Should I Get an MRI for My Stress Fracture?

author : AMSSM
comments : 0
Member Question

I have a sharp pain in my leg. I feel this throughout my daily activities and while sitting at my desk as well. I can feel a slight jolt when walking (just less intense than when running).

The pain is on my left leg only, 2" up from ball of ankle and on the front of my shin towards the inside of leg.  The pain is concentrated but the "trigger area" is about the size of a baseball.  It does not feel like there is any meat or muscle between the area of pain and where I touch it.  There is sharp pain in a one inch area which is tender and unpleasant all around.  My other leg and rest of body is completely normal.

It sounds like I might have a stress fracture? I'm not sure that I want to spend the money on an MRI if the result is simply to rest (whether confirmed or suspected) as the treatment sounds the same with more money in my pocket.  I have no pain whatsoever when cycling.

I've had this pain but much less intense before, I usually give it a week and then it becomes tiny and insignificant.  It has been ongoing, progressively worse, and much much more intense the past few weeks.

What shall I do?  I have a marathon coming up in a few months.

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Answer from Ali Chisti, MS4, MPH and Melissa Novak, DO
Member AMSSM

This sounds like an overuse injury.  The key to management will really rely on having an accurate diagnosis.  Stress fractures are usually identified from a combination of a patient’s clinical history and radiographic confirmation.  Runners who complain of pain localized to a specific region in an extremity have a high probability of having a stress fracture.  If your leg is tender when you press on the site that is irritating you, then imaging should be done.  You wouldn’t have to jump straight to an MRI, instead an X-Ray would work to diagnose the stress fracture as long as you have had the pain for a minimum of two weeks and rule out other possible diagnoses.  An MRI would only be needed in the rare case that the lesion on the bone is indistinct, or really difficult to tell what it is (1).  Since we cannot image your leg through this discourse, I’ll tailor my recommendations with the assumption that we are dealing with a stress fracture.

Risk factors for running injuries include a history of a previous injury, competitive running, high weekly mileage (>25 miles per week), and abrupt increases in the intensity or duration of training.  Injuries are more likely to occur when the runner’s shoes are worn down, leading to the recommendation that shoes be replaced every six months or after 400 miles of use (1).  Many times, alignment abnormalities of the foot and adjacent joints are associated with increased frequency of injury. A high-arched foot (pes cavus) is rigid and tends to transmit impact up the leg. A flat foot (pes planus) leads to excessive pronation of the foot during running, which in turn increases stress on the medial structures of the ankle, shin, and knee. Orthotics may be helpful for either type of structural abnormality (1).  Women have been found to have 3.5 times the risk for stress fractures.  It is thought that this difference may be due to endocrine factors, eating disorders, differences in bone density and skeletal alignment (2), as well as the higher prevalence of osteoporosis among older women.  

The most commonly involved structures for stress fractures are the 2nd metatarsal head, tibia and fibula, which is likely for your injury as well.  Stress fractures occur from continued, repetitive stress that the normal remodeling of the bone cannot keep up with, leading to microfractures (1).  Initial symptoms in most athletes suggest medial tibial stress syndrome, or “shin splints” in the same region you described.  An X-Ray will help identify the most dreaded location for a stress fracture, the anterior cortex of the tibia.  Those fractures require an orthopedic referral due to their complex management, which may involve surgical intervention.  This type of stress fracture occurs in less than 5% of tibial stress fractures (3).

As you alluded to, the initial treatment for a stress fracture consists of rest and immobilization.  Stress fractures are frequently managed by primary care physicians.  If the fracture has a high risk of delayed healing or nonunion, then treatment should include a short period of non-weight-bearing and immobilization in a long air splint, knee splint, or hinged brace (4).  One of the key elements to a successful recovery is the implementation of a rehabilitation program.  Many times primary care physicians will refer the patient to a physical therapist for this.  The rehabilitation program should assess the cause of the injury, the nature of the injury, the symptoms and examination findings, preinjury activity level and patient goals for treatment, patient age, prior injuries and comorbidities (5).  A good rehabilitation plan will help the patient return quicker to the activity level they desire.  A typical plan has the patient returning to full intensity training between weeks 9 to 12.  The time it will take for your injury to heal properly will most likely conflict with your planned marathon.  I would recommend seeing your primary care physician or a non-operative sports medicine physician as soon as you can.  A good physical rehabilitation program will be a great aid to your successful recovery.

Ali Chisti, MS4, MPH
Oregon Health & Science University
Harvard School of Public Health

Ali Chisti is a 4th year medical student at the Oregon Health & Sciences University a Master of Public Health graduate from Harvard University, as well as an avid runner and competitive speedgolfer.

Melissa Novak, DO
Oregon Health & Science University
Sports Medicine

References:

1) Brown C.R., Jr. (2013). Chapter 72. Common Injuries from Running. In Imboden J.B., Hellmann D.B., Stone J.H. (Eds), CURRENT Rheumatology Diagnosis & Treatment, 3e. Retrieved January 23, 2014 from http://accessmedicine.mhmedical.com.liboff.ohsu.edu/content.aspx?bookid=506&Sectionid=42584963

2) Crossley K., et. al “Ground reaction forces, bone characteristics, and tibial stress fractures in male runners” Med Sci Sports Exerc 1999;31(8):1088

3) Hulkko, A., et. al “Stress fractures of the lower leg” Scand J Sports Sci 1987;9:1

4) Fields, K., et. al “Stress Fractures of the Tibia and Fibula” UpToDate

Accessed January 29, 2014 http://www.uptodate.com/contents/stress-fractures-of-the-tibia-and-fibula?source=search_result&search=stress+fracture&selectedTitle=2~92

5) O’connor, F.G., et. al Textbook of Running Injuries McGraw Hill, New York 2001

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date: February 13, 2014

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AMSSM

The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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