Serial Ultrasonography for the Assessment of Healing of Lower Extremity Bone Stress Injury and Correlation With Return to Sport/Exercise.

ABSTRACT

BACKGROUND: Lower extremity bone stress injuries (BSIs) are common among athletes who participate in high-impact activities. Conventional imaging is limited in assessing healing of BSIs. HYPOTHESIS: Serial ultrasonography (US) can identify changes in appearance of lower extremity BSIs over time that can be correlated with symptoms and return to exercise/sport. STUDY DESIGN: Cohort observational study. LEVEL OF EVIDENCE Level 3. METHODS: Adults 18 to 50 years old with a recent exercise-associated BSI of distal tibia/fibula or metatarsals diagnosed by magnetic resonance imaging (MRI) were enrolled. US was performed every 2 weeks for 12 weeks. The sonographic appearance (soft tissue edema, periosteal reaction, hyperemia on power Doppler, callus) was correlated with the numerical rating scale (NRS) for pain and ability to return to sport/exercise. RESULTS: A total of 30 patients were enrolled (mean age, 35.3 ± 7.7 years; 21 [70.0%] female). The tibia was most frequently affected (n = 15, 50.0%), followed by metatarsals (n = 14, 46.7%) and fibula (n = 1, 3.3%). At week 4, 25 of 30 (83.3%) had at least 1 US finding associated with the BSI. The degree of hyperemia was correlated with NRS at weeks 4 and 6 (Spearman correlations [ρ] 0.45 [0.09, 0.69] and 0.42 [0.07, 0.67], respectively), as well as return to sport/exercise at week 6 (ρ -0.45 [-0.68, -0.09]). US soft tissue edema was also correlated with NRS at week 6 (ρ 0.38 [0.02, 0.65]). CONCLUSION: Serial US of lower extremity BSIs can provide objective measures of healing. US findings were correlated with clinical outcomes at multiple timepoints. CLINICAL RELEVANCE US may have advantages over conventional imaging for monitoring healing of lower extremity BSIs. Further research is needed to better understand the prognostic value of these sonographic indicators of BSI healing and role in assessing readiness for return to sport/exercise.