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CT and MR Imaging Findings in Athletes with Early Tibial Stress Injuries: Comparison with Bone Scintigraphy Findings and Emphasis on Cortical Abnormalities¹

¹ From the Departments of Radiological Sciences (M.G., F.M., E.S., G.A., S.V., A.B.) and Sport Medicine (D.B., L.M.), University of Messina, Policlinico "G. Martino," Via Consolare Valeria, 98100 Messina, Italy. Received March 1, 2004; revision requested May 11; final revision received August 16; accepted September 8. Address correspondence to F.M. (e-mail: fminutoli@unime.it).

View larger version (107K): [in a new window]   Figure 1. Transverse 2-mm-thick high-spatial-resolution CT section obtained at the level of the right midtibia in a healthy 26-year-old woman shows division of the tibial cortex into four parts. Note homogeneous attenuation of the tibial cortex. A = anterior cortex, L = lateral cortex, M = medial cortex, and P = posterior cortex.

View larger version (157K): [in a new window]   Figure 2. Coronal fast STIR MR image (3600/60/150) obtained in a 30-year-old male runner with serious tibial pain of 5 days duration shows hypointense transverse stress fracture (arrowhead) of cancellous bone of proximal tibial metaphysis and associated bone marrow (arrow) and periosteal edema.

View larger version (88K): [in a new window]   Figure 3a. Images obtained in a 23-year-old male runner with 18-day history of worsening pain in left tibia and 9-day history of slight pain in right tibia. (a) Transverse 2-mm-thick high-spatial-resolution CT scan of left midtibia demonstrates 3-mm resorption cavity (arrow) in posterior diaphyseal cortex. Areas of osteopenia (arrowheads) can be seen in both the posterior and the anterior cortices. (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) confirms presence of resorption cavity containing tissue with high signal intensity (arrowhead). Osteopenia is appreciable as round and linear areas of intermediate signal intensity in anterior cortex (small arrows). In addition, irregularity of subperiosteal bone of same cortex is clearly seen. Also, endosteal edema (large arrow) is present. (c) Transverse 2-mm-thick high-spatial-resolution CT scan of right midtibia reveals a geographic area of osteopenia in posterior cortex (black arrowheads). Also, subperiosteal cortical irregularity can be seen (white arrowheads). A minor degree of osteopenia (arrow) is present in anterior cortex. MR images (not shown) did not demonstrate these abnormalities. (d) Posterior 99mTc methylene diphosphonate scintigram shows slight uptake in posterior cortex of left tibial diaphysis (arrow). No abnormal uptake is visible in right tibia.

View larger version (138K): [in a new window]   Figure 3b. Images obtained in a 23-year-old male runner with 18-day history of worsening pain in left tibia and 9-day history of slight pain in right tibia. (a) Transverse 2-mm-thick high-spatial-resolution CT scan of left midtibia demonstrates 3-mm resorption cavity (arrow) in posterior diaphyseal cortex. Areas of osteopenia (arrowheads) can be seen in both the posterior and the anterior cortices. (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) confirms presence of resorption cavity containing tissue with high signal intensity (arrowhead). Osteopenia is appreciable as round and linear areas of intermediate signal intensity in anterior cortex (small arrows). In addition, irregularity of subperiosteal bone of same cortex is clearly seen. Also, endosteal edema (large arrow) is present. (c) Transverse 2-mm-thick high-spatial-resolution CT scan of right midtibia reveals a geographic area of osteopenia in posterior cortex (black arrowheads). Also, subperiosteal cortical irregularity can be seen (white arrowheads). A minor degree of osteopenia (arrow) is present in anterior cortex. MR images (not shown) did not demonstrate these abnormalities. (d) Posterior 99mTc methylene diphosphonate scintigram shows slight uptake in posterior cortex of left tibial diaphysis (arrow). No abnormal uptake is visible in right tibia.

View larger version (98K): [in a new window]   Figure 3c. Images obtained in a 23-year-old male runner with 18-day history of worsening pain in left tibia and 9-day history of slight pain in right tibia. (a) Transverse 2-mm-thick high-spatial-resolution CT scan of left midtibia demonstrates 3-mm resorption cavity (arrow) in posterior diaphyseal cortex. Areas of osteopenia (arrowheads) can be seen in both the posterior and the anterior cortices. (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) confirms presence of resorption cavity containing tissue with high signal intensity (arrowhead). Osteopenia is appreciable as round and linear areas of intermediate signal intensity in anterior cortex (small arrows). In addition, irregularity of subperiosteal bone of same cortex is clearly seen. Also, endosteal edema (large arrow) is present. (c) Transverse 2-mm-thick high-spatial-resolution CT scan of right midtibia reveals a geographic area of osteopenia in posterior cortex (black arrowheads). Also, subperiosteal cortical irregularity can be seen (white arrowheads). A minor degree of osteopenia (arrow) is present in anterior cortex. MR images (not shown) did not demonstrate these abnormalities. (d) Posterior 99mTc methylene diphosphonate scintigram shows slight uptake in posterior cortex of left tibial diaphysis (arrow). No abnormal uptake is visible in right tibia.

View larger version (102K): [in a new window]   Figure 3d. Images obtained in a 23-year-old male runner with 18-day history of worsening pain in left tibia and 9-day history of slight pain in right tibia. (a) Transverse 2-mm-thick high-spatial-resolution CT scan of left midtibia demonstrates 3-mm resorption cavity (arrow) in posterior diaphyseal cortex. Areas of osteopenia (arrowheads) can be seen in both the posterior and the anterior cortices. (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) confirms presence of resorption cavity containing tissue with high signal intensity (arrowhead). Osteopenia is appreciable as round and linear areas of intermediate signal intensity in anterior cortex (small arrows). In addition, irregularity of subperiosteal bone of same cortex is clearly seen. Also, endosteal edema (large arrow) is present. (c) Transverse 2-mm-thick high-spatial-resolution CT scan of right midtibia reveals a geographic area of osteopenia in posterior cortex (black arrowheads). Also, subperiosteal cortical irregularity can be seen (white arrowheads). A minor degree of osteopenia (arrow) is present in anterior cortex. MR images (not shown) did not demonstrate these abnormalities. (d) Posterior 99mTc methylene diphosphonate scintigram shows slight uptake in posterior cortex of left tibial diaphysis (arrow). No abnormal uptake is visible in right tibia.

View larger version (131K): [in a new window]   Figure 4a. Images obtained in a 22-year-old woman with left tibial pain of 20 days duration. (a) Transverse 2-mm-thick CT scan shows evident osteopenia (arrows) of the anterior tibial cortex. Some small resorption cavities (arrowheads) can be seen in both the anterior and the posterior cortices. (b) Transverse T2-weighted fast spin-echo MR image (5400/99) shows both osteopenia (arrows) and resorption cavities (arrowheads). Findings at scintigraphy were positive (not shown).

View larger version (124K): [in a new window]   Figure 4b. Images obtained in a 22-year-old woman with left tibial pain of 20 days duration. (a) Transverse 2-mm-thick CT scan shows evident osteopenia (arrows) of the anterior tibial cortex. Some small resorption cavities (arrowheads) can be seen in both the anterior and the posterior cortices. (b) Transverse T2-weighted fast spin-echo MR image (5400/99) shows both osteopenia (arrows) and resorption cavities (arrowheads). Findings at scintigraphy were positive (not shown).

View larger version (127K): [in a new window]   Figure 5. Transverse T2-weighted fast spin-echo MR image (5400/99) obtained in a 26-year-old male professional basketball player with tibial pain of 3 weeks duration shows multiple parallel striations (arrows) in the anterior tibial cortex. Small resorption cavities are visible in the posterior cortex.

View larger version (185K): [in a new window]   Figure 6a. Sagittal fast STIR MR images (3600/60/150) obtained in a 19-year-old female volleyball player with right tibial pain of 9 days duration. (a) MR image shows presence of bone marrow edema due to stress lesion in the distal diaphysis. In addition, periosteal edema (arrowheads) can be seen. Patient refused to rest, and symptoms rapidly worsened. (b) MR image obtained at the same level 1 week after that seen in a reveals wide spread of bone marrow edema. Moreover, periosteal edema is more evident.

View larger version (155K): [in a new window]   Figure 6b. Sagittal fast STIR MR images (3600/60/150) obtained in a 19-year-old female volleyball player with right tibial pain of 9 days duration. (a) MR image shows presence of bone marrow edema due to stress lesion in the distal diaphysis. In addition, periosteal edema (arrowheads) can be seen. Patient refused to rest, and symptoms rapidly worsened. (b) MR image obtained at the same level 1 week after that seen in a reveals wide spread of bone marrow edema. Moreover, periosteal edema is more evident.

View larger version (137K): [in a new window]   Figure 7a. MR images obtained in an 18-year-old man with left tibial pain of 3 weeks duration. (a) Transverse 3-mm-thick T1-weighted fast spin-echo MR image (680/12) obtained at the level of the left midtibia shows hypointense bone marrow edema (*). (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) obtained at the same level shows bone marrow edema (*) and periosteal edema (arrow) along the anterior and medial cortex.

View larger version (140K): [in a new window]   Figure 7b. MR images obtained in an 18-year-old man with left tibial pain of 3 weeks duration. (a) Transverse 3-mm-thick T1-weighted fast spin-echo MR image (680/12) obtained at the level of the left midtibia shows hypointense bone marrow edema (*). (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) obtained at the same level shows bone marrow edema (*) and periosteal edema (arrow) along the anterior and medial cortex.

View larger version (148K): [in a new window]   Figure 8a. MR images obtained in a 32-year-old male basketball player with left tibial pain of 2 weeks duration. (a) Transverse 3-mm-thick T1-weighted fast spin-echo MR image (680/12) allows depiction of nonspecific soft-tissue swelling (arrow) along anteromedial surface of upper diaphysis. Cortical bone appears normal. (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) demonstrates periosteal edema. Detached and thickened periosteum (arrow) can be seen as signal void line. No cortical abnormality is present.

View larger version (128K): [in a new window]   Figure 8b. MR images obtained in a 32-year-old male basketball player with left tibial pain of 2 weeks duration. (a) Transverse 3-mm-thick T1-weighted fast spin-echo MR image (680/12) allows depiction of nonspecific soft-tissue swelling (arrow) along anteromedial surface of upper diaphysis. Cortical bone appears normal. (b) Transverse 3-mm-thick fast STIR MR image (3600/60/150) demonstrates periosteal edema. Detached and thickened periosteum (arrow) can be seen as signal void line. No cortical abnormality is present.