Acta Radiologica 43 (2002) 207–212 Copyright C Acta Radiologica 2002

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AC TA R A D I O L O G I C A
ISSN 0284-1851

MR IMAGING, BONE SCINTIGRAPHY, AND

RADIOGRAPHY IN BONE STRESS INJURIES OF THE
PELVIS AND THE LOWER EXTREMITY

M. J. K1,2, H. K. P3, H. J. H4 and J. A. A1

1
Department of Radiology, Helsinki University Central Hospital, Helsinki, 2Research Center of Military Medicine, Helsinki,
3
Department of Surgery, Military Central Hospital, Helsinki and 4Diacor OY, Department of Clinical Physiology, Helsinki, Finland.

Abstract
Purpose: To compare MR imaging, radiography and bone scintigraphy in the Key words: Bones, stress injuries;
diagnosis of stress injuries to bones of the pelvis and lower extremity. fractures; MR imaging;
Material and Methods: Fifty consecutive conscripts with clinical signs of a radionuclides; radiography.
stress injury to bone underwent MR imaging and bone scintigraphy. Forty-
three patients also had radiographs available. Bone scintigraphy served as a Correspondence: Martti J. Kiuru,
gold standard. Kluuvintie 1 F 1, FIN-02180 Espoo,
Results: Compared to the bone scintigraphy, the sensitivity of radiography Finland.
was 56%, specificity 94%, accuracy 67%, positive predictive value (PPV) 95%, FAX π358 9 43 85 13 30.
and negative predictive value (NPV) 48%. The kappa value for radiography and
bone scintigraphy was fair (0.39). Correspondingly, the sensitivity of MR im- Accepted for publication 30 October
aging was 100%, specificity 86%, accuracy 95%, PPV 93% and NPV 100%. The 2001.
kappa value for MR imaging and bone scintigraphy was very good (0.89). MR
imaging depicted 3 bone stress injuries that were not visible on bone scinti-
graphy. Positive findings obtained from radiography correlated with MR signs
of fracture line or callus (p⬍0.001).
Conclusion: MR imaging is more sensitive than two-phase bone scintigraphy,
and MR imaging should be used as the gold standard in the assessment of
stress injuries of bone. Radiography reveals mainly the late phases of bone
stress injuries, such as stress fracture and callus.

Bone responds to normal stress by remodeling. imaging tool. In the early stages of these injuries,
With increasing stress, bone consecutively reacts the sensitivity of radiography may be as low as
with accelerated remodeling, accumulation of 10%, and 30–70% at follow-up (5, 12, 15, 17, 18).
microfractures, and stress fracture (4, 7, 23). J So far, the diagnosis has often been based on bone
et al. (7) showed that most of the stress-related in- scintigraphy, which is regarded as the gold stan-
juries diagnosed as stress fractures had no evidence dard (1). The sensitivity of bone scintigraphy has
of a fracture line and suggested that the term been considered to be nearly 100%, but the speci-
‘‘stress reaction’’ should be used. Stress injuries of ficity is considerably lower (11, 12, 20, 22).
bone are seen in healthy people who have recently According to some previous studies (1, 21, 22),
begun new and intensive physical activity (3, 16). MR imaging is as sensitive as bone scintigraphy in
The diagnosis of stress-related injuries to bones is the diagnosis of stress injuries to bone. Associated
based on the patient’s history of physical activity soft-tissue involvement can also be depicted in de-
and on radiological findings (1). tail due to the high contrast and spatial resolution
In the diagnosis of a stress-related injury to of MR imaging (1, 2). However, the superiority of
bone, radiography has been used as the primary two-phase bone scintigraphy over MR imaging in

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 M. J. KIURU ET AL.

revealing stress injuries to bones has also been re- presence of a focal, cortical and medullary zone
ported (6). of increased radionuclide uptake in both phases of
We wanted to compare the diagnostic values of bone scintigraphy. The bone scintigrams were
MR imaging and radiography to bone scinti- evaluated by an experienced nuclear medicine
graphy in bone stress injuries. physician who was aware of the suspected clinical
diagnosis but was blind to the findings obtained
from radiography and MR imaging.
Material and Methods
MR imaging was done on a 1.0 T unit (Signa
This study was performed at the Central Military Horizon, GE Medical Systems). Either a body coil
Hospital, Helsinki, Finland. The series consisted or a surface coil, suitable for imaging the painful
of 50 consecutive conscripts (8 female and 42 male; region was used. Routine coronal T1-weighted
aged 18–27 years; mean 20.1 years) who were re- spin-echo (SE) sequence images (TR/TE 600 ms/
ferred to orthopedic consultation due to stress-re- 19 ms, with 2 signals averaged, and a 256¿224 ma-
lated pain in the pelvis or in the lower extremities trix) were obtained followed by coronal and axial
during their military training. Forty-three of the T2-weighted fast spin-echo (FSE) sequences with
50 patients had undergone a conventional radio- fat suppression (3000–6200/75–80, with 2 signals
graphic examination at their primary health care averaged and a 512–256¿224 matrix). A coronal
unit before referred to our hospital. Nine of these STIR sequence was also used (5400/17, TI 140 ms,
43 patients had a clinical suspicion of two different with 2 signal averaged and a 256¿224 matrix). The
stress injuries to bone. Thus, a total of 52 radio- field of view (FOV) was 32–48¿24–48 cm, and the
graphic examinations were performed. The radio- slice thickness was 4.0–5.0 mm, with a 0.5- to 1.0-
graphs had been obtained within an average of 37 mm intersection gap. Two radiologists interpreted
days (range 5–120 days) after the onset of the the MR images in consensus. They were blind to
symptoms. The remaining 7 patients were referred the findings of radiography and bone scintigraphy.
to bone scintigraphy and MR imaging without any Edema of the bone marrow, periosteum, and
previous information on radiographs obtained in muscle surrounding the bones, as well as a fracture
the primary health care units. The gray cortex line and callus in the cortical bone, were the rel-
sign, endosteal callus, periosteal callus, and frac- evant MR signs which were recorded. Edema was
ture line were the radiographic signs of a stress in- represented as an intermediate signal intensity on
jury to bone. T1-weighted images, and as high signal intensity
In the Central Military Hospital all 50 patients on T2-weighted and STIR images. A fracture line
underwent bone scintigraphy and MR imaging. was a low signal intensity line on all MR images.
Bone scintigraphy was done in an average of 14 The stress injuries of bone were classified in MR
days (range 0–28 days) after the radiography. MR imaging as follows (9): Grade I: endosteal marrow
imaging was done within an average of 2 days edema, Grade II: periosteal edema and endosteal
(range 0–14) prior to or after bone scintigraphy. marrow edema, Grade III: muscle edema, perios-
The patients were informed, and the study was ap- teal edema, and endosteal marrow edema, Grade
proved by the Medical Ethics Committee of the IV: fracture line, and Grade V: callus, at the end-
hospital. osteal and/or periosteal surface of the cortical
Clinical examination included a careful history bone.
and palpation of the region that was claimed to be
painful. The movements of joints of the extremities
were tested and measured. The ability to walk
around and jump on one foot were examined. Lo- Table 1
cal tenderness at palpation and any other aberrant Distribution of 41 stress
observations were recorded. injuries in 32 patients
Two-phase bone scintigraphy was performed on Bone Cases, n
a Siemens Multispect 2 Dual Detector Gamma Sacral bone 5
Camera system. An average dose of 590 MBq Ischial bone 1
TechneScan HDP (oxidronate) (Mallinckrodt Pubic bone 2
Femur, neck 11
Medical B.V., Petten, The Netherlands) was in- Femur, shaft 3
jected into an antecubital vein. A high-resolution Femur, condyle 1
collimator was used. Blood-pool images were ob- Tibia, condyle 4
tained within 5 min of the injection and delayed Tibia, shaft 9
phase images 3 h after the injection. The diagnosis Calcaneus 5
Total 41
of an acute stress injury to bone was based on the

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 BONE STRESS INJURIES OF THE PELVIS AND LOWER EXTREMITY

Fig. 1. A 20-year-old male conscript

with unilateral pain in the left hip for 42
days. A) Negative radiography of the
left hip. B) Anterior (AP) and posterior
(PA) pelvis view on the bone scinti-
graphy showing no increased activity. C)
A coronal STIR (TR/TE/TI 5400/17/
140) MR image revealing high signal in-
tensity (»), indicating endosteal mar-
row edema in the left lower, medial bor-
der of the femoral neck.

The sensitivity, specificity, accuracy, positive pre- tivity of radiography was 56%, specificity 94%, ac-
dictive value (PPV) and negative predictive value curacy 67%, PPV 95% and NPV 48%. The k value
(NPV) were calculated for MR imaging and radi- for agreement between radiography and bone
ography. The k was used to measure the interrater scintigraphy was fair, 0.39 (pΩ0.0008).
agreement between bone scintigraphy and radi- When considering bone scintigraphy to be gold
ography and MR imaging. The k values for agree- standard, MR imaging revealed 38 true-positive,
ment were interpreted as follows: 0.0–0.2, poor; 18 true-negative, and 3 false-positive (Figs. 1–3)
0.21–0.4, fair; 0.41–0.6, moderate; 0.61–0.8, good; cases of stress injuries to bone. The sensitivity of
and 0.81–1.0, very good. Results of radiography MR imaging was 100%, specificity 86%, accuracy
findings were compared with MR findings. Sig- 95%, PPV 93%, and NPV 100%. The k value for
nificances of differences were assessed using the the agreement between MR imaging and bone
Fisher exact-probability test. In the statistical scintigraphy was very good, 0.89 (p⬍0.0001).
analysis, a significance level of 5% was chosen. In the 3 cases (Figs. 1–3) where the findings of
MR imaging and bone scintigraphy differed, 2
Results
cases involved the femoral neck and 1 case involved
the sacral bone. The first case was a 20-year-old
Bone scintigraphy was regarded as the gold stan- male with a stress injury of the femoral neck who
dard. A total of 41 stress injuries to bone were di- had had symptoms for 42 days before MR imaging
agnosed in 32 patients (Table 1), 9 patients had and bone scintigraphy that were performed on the
two different bone stress injuries simultaneously. same day (Fig. 1). The second case was a 20-year-
In the remaining 18 patients bone scintigraphy was old female with a stress injury of the femoral neck
normal. who had had symptoms for 39 days before MR
As compared with findings obtained from bone imaging. She underwent bone scintigraphy 3 days
scintigraphy, radiography depicted 20 true-posi- later (Fig. 2). The third case was a 20-year-old fe-
tive, 15 true-negative, 16 false-negative, and 1 false- male with a stress injury of the sacral bone who
positive cases of stress injuries to bone. The sensi- had had symptoms for 30 days before MR imaging

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 M. J. KIURU ET AL.

Fig. 2. A 20-year-old female conscript

with unilateral pain in the right hip for
39 days. A) Negative radiography of the
right hip. B) Anterior view of both hips
on bone scintigraphy showing no in-
creased activity. C) A coronal STIR
(TR/TE/TI 5400/17/140) MR image
revealing high signal intensity (»), indi-
cating endosteal marrow edema in the
right femoral neck.

and bone scintigraphy (Fig. 3). The onset of pain present in 30% to 70% of cases (5, 12, 15, 17,
was insidious in all 3 patients. 18). The sensitivity of 56% in the present study
There was a statistically significant difference is in agreement with these numbers because the
between the radiography findings when compared average duration of symptoms in our patients
to the MR imaging findings (p⬍0.001). The early was approximately 5 weeks. Although the com-
phases of the stress injuries were not reliably seen parison between radiography and MR imaging is
with radiography (Table 2). in favor of MR imaging due to the delay, radi-
ography depicted the late phases of bone stress
injuries reliably.
Discussion
For the early detection of bone stress injuries,
Clinical symptoms may vary depending on the bone scintigraphy has been an important imaging
phase of the pathophysiological spectrum in stress tool since the 1970s (25). It has a higher diagnostic
injuries to bone (1). Due to an often insidious on- value than radiography and it has been used if the
set of symptoms, previously published studies have radiographs were normal (1). Although cases of
shown that the clinical diagnosis of stress injuries false-negative bone scintigrams of bone stress in-
to bone is difficult, and the diagnosis should be juries have been reported, bone scintigraphy has
confirmed with imaging studies (19, 20). been considered to be the gold standard (8, 14, 24).
In the assessment of a bone stress-related in- In the present study we had 3 cases, where bone
jury, conventional radiography has been the pri- scintigraphy was normal but MR imaging revealed
mary imaging tool because it is widely available a stress injury to bone. Two of these cases con-
and relatively cheap. When obtained within 1 cerned the femoral neck and 1 case the sacral
week of the onset of pain, radiographic findings bone. Two of the previously published case reports
are usually ‘‘normal’’. A sensitivity of as low as on false-negative bone scintigraphy (8, 24) also in-
9.8% and a false-negative rate of 71% have been cluded femoral neck stress injuries. A missed stress
reported (12, 17). At follow-up radiography, the injury of the femoral neck may lead to a stress
diagnostic findings of stress injuries of bone are fracture and a complicated displaced fracture.

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 BONE STRESS INJURIES OF THE PELVIS AND LOWER EXTREMITY

Fig. 3. A 20-year-old female conscript

with unilateral pain in the right hip for
30 days. A) Negative radiography of the
pelvis. B) Anterior (AP) and posterior
(PA) pelvis view on bone scintigraphy
showing no increased activity. C) A T2-
weighted (TR/TE 6800/90) fat-sup-
pression coronal MR image revealing a
fracture line (»), and an irregular low
signal intensity in the right side of the
sacral bone surrounded with high signal
intensity, indicating endosteal marrow
edema.

Three-phase bone scintigraphy and single photon prove its diagnostic accuracy (1, 10, 13). In the
emission CT (SPECT) may improve the diagnostic present study MR imaging was more sensitive than
accuracy of stress injuries to bone (1). SPECT, bone scintigraphy in revealing stress injuries of
however, is not readily available for everyday clin- bone. We recommend that MR imaging should be
ical use. considered as the gold standard in the assessment
False MR imaging interpretations may be due of bone stress injuries.
to reader errors, suboptimal choice of imaging In conclusion, clinical diagnosis of bone stress in-
planes and sequences, inhomogeneities in fat-sup- juries is unreliable. MR imaging is more sensitive
pression, and partial volume effects (6). Different than two-phase bone scintigraphy, and MR im-
MR imaging techniques such as short tau inver- aging should be used as the gold standard in the
sion recovery (STIR) sequences and other fat-sup- assessment of stress injuries of bone. Radiography
pression techniques can be used to maximize the reveals mainly the late phases of bone stress in-
sensitivity of MR imaging and consequently to im- juries, such as stress fracture and callus.

Table 2
Correlation between the results of 52 radiographic examinations and the corresponding MR
findings in 43 patients
Radiography MR findings Cases,
n
Normal Stress injury of bone

Grade I Grade II Grade III Grade IV Grade V

Negative 15 7 6 1 2 0 31
Positive 1 1 4 4 8 3 21
Total 16 8 10 5 10 3 52

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 M. J. KIURU ET AL.

graphic uptake of 99mTc at non-painful sites in athletes

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