Validation of the Shin Pain Scoring System: A Novel Approach for Determining Tibial Bone Stress Injuries

Journal of the Pediatric Orthopaedic Society of North America

Holtzman

Rizzone

et al. 2022

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Tibial bone stress injuries (BSIs) are common injuries experienced by active adolescent athletes. The current literature lacks consensus of BSI nomenclature and appropriate use of imaging modalities. Injury classification, severity, or grade may differ substantially according to imaging modalities used and location of injury. This leads to inconsistency in understanding prevalence of injury, communication of diagnosis and management, and can cause confusion for patients and their entourages. As such, the purpose of this Current Concept Review was to identify existing classification of atraumatic tibial pain/BSI, propose unifying nomenclature, and review imaging tools available to clinicians caring for young athletes. Limited literature was identified pertaining to adolescent aged athletes. Thus, we expanded our search to included adult literature and identified 32 publications for atraumatic tibial pain. Multiple grading scales and various imaging modalities were used in the literature highlighting a lack of consensus of terminology and imaging for formalizing diagnosis of BSI. Tibial BSI is common in athletes and has large discrepancies in reported incidence. Unified terminology and recommended imaging modalities for the adolescent athlete with these injuries would improve patient care and professional communication. We propose using “Bone Stress Injury” (BSI) to describe overuse injury of the tibia with associated physical examination findings. When needed for guidance of management, imaging can be used to confirm the diagnosis of BSI. Radiography is recommended as the first imaging modality, and MRI should be considered to confirm diagnosis and determine grade of injury.

Section: Bone Stress Injury Of the Tibiamentioning

confidence: 99%

“…64 Leg pain can be observed on clinical exam in adolescent athletes without corresponding changes on radiographs and MRI. 18,26,65 Clinicians must remember that MRI is not 100% sensitive. 66 The less-common longitudinal tibial stress fracture may also be seen on MRI but is frequently missed.…”

Section: Magnetic Resonance Imagingmentioning

confidence: 99%

Evaluation and Diagnosis of Tibial Bone Stress Injuries in Adolescents: Imaging and Nomenclature

Journal of the Pediatric Orthopaedic Society of North America

Holtzman

Rizzone

et al. 2022

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“…30 Physicians frequently find it difficult to make a formal diagnosis based on the clinical examination alone, as clinical tests are not both highly sensitive and specific. 32,33,37 Appropriate imaging can play an important role in confirming a diagnosis of tibial BSI, determining prognosis, and developing an individualized patient management strategy. X-rays are the most common type of examination in diagnostic imaging.…”

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confidence: 99%

“…30 Physicians frequently find it difficult to make a formal diagnosis based on the clinical examination alone, as clinical tests are not both highly sensitive and specific. 32,33,37…”

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confidence: 99%

Retrospective Review of Radiographic Imaging of Tibial Bony Stress Injuries in Adolescent Athletes With Positive MRI Findings: A Comparative Study

Sports Health: A Multidisciplinary Approach

King

Epstein

et al. 2022

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Background: It is difficult to diagnose and grade bony stress injury (BSI) in the athletic adolescent population without advanced imaging. Radiographs are recommended as a first imaging modality, but have limited sensitivity and, even when findings are present, advanced imaging is often recommended. Hypothesis: It was hypothesized that the significance of radiographs is underestimated for BSI in the adolescent with positive clinical examination and history findings. Study design: Case series Level of evidence: Level 4 Methods: A total of 80 adolescent athletes with a history of shin pain underwent clinical examination by an orthopaedic surgeon. On the day of clinical examination, full-length bilateral tibial radiographs and magnetic resonance imaging (MRI) scans were obtained. MRI scans were reviewed using Fredericson grading for BSI. At the completion of the study, radiographic images were re-evaluated by 2 musculoskeletal (MSK) radiologists, blinded to MRI and clinical examination results, who reviewed the radiographs for evidence of BSI. Radiographic results were compared with clinical examination and MRI findings. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated based on comparison with MRI. Results: All radiographs were originally read as normal. Of the tibia studied, 80% (127 of 160) showed evidence of BSI on MRI. None of the original radiographs demonstrated a fracture line on initial review by the orthopaedic surgeons. Retrospective review by 2 MSK radiologists identified 27% of radiographs (34 of 127) with evidence of abnormality, which correlated with clinical examination and significant findings on MRI. Review of radiographs found evidence of new bone on 0 of 28 Fredericson grade 0, 0 of 19 Fredericson grade I, 11 of 80 (13.7%) Fredericson grade II, 18 of 28 (64%) Fredericson grade III, and 5 of 5 (100%) Fredericson grade IV. Sensitivity of radiographs showed evidence of new bone on 27% (34 of 127) of initial radiographs, with presence more common with greater degree of BSI, as 23 of 33 (70%) were higher-grade injuries (III of IV) of BSI. Specificity and positive predictive value were 100%, while negative predictive value was 17%. Conclusion: These findings highlight the importance of initial radiographs in identifying high-grade BSI. As radiographs are readily available in most office settings of sports medicine physicians, this information can influence the management of adolescent athletic BSI without the need to delay treatment to obtain an MRI. Clinical Relevance: Adolescent athletes with radiographic evidence of BSI should be treated in a timely and more conservative manner, given the likelihood of higher-grade BSI. In addition, clinicians knowledgeable of the radiographic findings of high-grade BSI should feel more confident that a negative initial radiograph is not likely to be a high-grade BSI and can modify their treatment plans accordingly.

“…Lower leg pain is a common 1 presenting complaint among adolescent athletes. As many as 84% of these athletes identify as having bone stress injury (BSI), 21,24,35 with the most frequently reported site being the tibia. 18,23,32 Clinically, the cause of lower leg pain can be difficult to diagnose and troublesome to manage because of the wide range of potential diagnoses, 9,25 including BSI, exertional compartment syndrome, muscular, neurologic, and vascular injury.…”

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confidence: 99%

Evaluating the Clinical Tests for Adolescent Tibial Bone Stress Injuries

Sports Health: A Multidisciplinary Approach

Gatt

Bjornarra

et al. 2021

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Background: Tibial bone stress injuries are common among the athletic adolescent population. A thorough patient history and clinical examination are essential to identify the location and extent of injury. However, there has been little description or any validation of clinical tests to help guide clinicians. Consequently, a formal diagnosis is usually dependent on results from proper imaging. Hypothesis: Clinical examinations will be both highly sensitive and specific determining the incidence, grade, and location of tibial bone stress injury as compared with magnetic resonance imaging (MRI). Study Design: Case-control. Level of Evidence: Level 2. Methods: A total of 80 consecutive athletic adolescents, from various sports, with greater than 1-week history of shin pain were enrolled in this institutional review board–approved study. Exclusion criteria were age >19 years and history of traumatic injury. Patients underwent a standardized clinical examination, which included a fulcrum test (FT), tap/percussion test (TT), vibration test (VT) utilizing a 128-Hz tuning fork, weight bearing lunge test (WBLT) to determine degree of dorsiflexion range of motion (ROM), and vertical single leg hop test (VSLHT) for height, landing, and pain. Bilateral lower extremity MRI was completed on the same day as clinical evaluation and served as the injury reference. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate each clinical examination for its ability to identify a bone stress injury. Results: A total of 159 tibiae in 80 patients were evaluated. No single test or combination of tests was both highly sensitive and specific. Individual clinical tests demonstrated sensitivity ranging from 0.11 to 0.72 and specificity ranging from 0.37 to 0.93. The VSLHT noting an increase in pain was the most sensitive test (0.72; 95% CI, 0.62-0.78); however, its specificity was only 0.37 (95% CI, 0.19-0.55), with a PPV of 0.84 (95% CI, 0.78-0.91) and NPV of 0.20 (95% CI, 0.089-0.31). The WBLT demonstrated a mean ROM of 8 cm, with side-to-side differences (range 0-4 cm) not influencing incidence of injury. Combinations of tests demonstrated low sensitivity (0.03-0.40), with better specificity (0.63-1.0). When considering ability to identify higher grades of injury (grade III/IV), all tests had a high NPV indicating that if clinical tests were negative, there was a high likelihood that the patient did not have a grade III or IV injury. Conclusion: No single test or combination of tests was both highly sensitive and specific. Clinicians cannot solely rely on clinical examination for determining extent or severity of bone stress injury in the athletic adolescent population, but when combinations of tests are negative, there is likely not a high-grade bone stress injury. Clinical Relevance: Clinical tests utilized in the evaluation of adolescent tibial bone stress injury may help indicate the presence or absence of higher grade tibial bone stress injury.