Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study.

OBJECTIVE: To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI). METHODS: A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv22 criteria were applied to classify MRI findings. RESULTS: Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77). CONCLUSIONS: USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.

Vitamin D for Improved Bone Health and Prevention of Stress Fractures: A Review of the Literature.

Vitamin D is a vital nutrient and hormone needed for many essential functions in overall health. There is growing literature examining the role of vitamin D not only in the general population but also in athletes. The most predominantly studied area of vitamin D pertains to bone health. Recently, there has been increased investigation into the relationship of vitamin D and stress fractures, including genetic polymorphisms, levels of 25-hydroxyvitamin D, and bioavailable vitamin D. This review will address the most recent developments of vitamin D research and its important role in bone health in athletes.

Winter Adaptive Sports Participation, Injuries, and Equipment.

As the participation rate and popularity of winter adaptive sports increases, understanding injury patterns and equipment is crucial for athletes, coaches, athletic trainers, sports physicians, prosthetists/orthotists, and all the staff involved. While the inaugural Winter Paralympics in 1976 had 17 participating countries, the most recent paralympic games in Pyeongchang, South Korea had >500 athletes from 49 different countries competing in 6 disciplines: alpine skiing, nordic skiing, sledge hockey, wheelchair curling, biathlon, and snowboarding. In this paper, we review participation rates, injury trends and equipment, with a focus on the 3 most popular events: alpine skiing, nordic skiing, and sledge hockey. Despite injury risk within this athletic community, there are documented advantages to physical movement, and for each individual the risks of injury have to be weighted with the benefits of competing. Overall, there is a need for educational efforts regarding the development, access, and participation to injury prevention programs with an integrated and multidisciplinary approach.

A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries.

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections.

OBJECTIVE: To systematically analyze published studies in regard to the comparative efficacy of particulate versus nonparticulate corticosteroids for cervical and lumbosacral epidural steroid injections (ESI) in reducing pain and improving function. TYPE: Systematic review. LITERATURE SURVEY: MEDLINE (Ovid), EMBASE, and Cochrane databases were searched from the period of 1950 to December 2015. METHODOLOGY: Criteria for inclusion in this review were (1) randomized controlled trials and (2) retrospective studies that compared particulate versus nonparticulate medication in fluoroscopically guided injections via a transforaminal (TF) or interlaminar (IL) approach. Each study was assigned a level of evidence (I-V) based on criteria for therapeutic studies. A grade of recommendation (A, B, C, or I) was assigned to each statement. Categorical analysis of the data was reported when available, with success defined by the minimal clinically important difference for appendicular radicular pain-a reduction of at least 2 on the visual analog scale. When data were available, additional categorical analysis included the proportion of individuals with a reduction in pain of at least 50%, 70%, or 75%. Follow-up was included at all reported intervals from 2 weeks to 6 months. SYNTHESIS: Three cervical ESI and 6 lumbar ESI studies were found to be suitable for review. Of the 3 cervical ESI studies, 2 were retrospective studies with grade III level of evidence and 1 was a randomized controlled trial with grade II evidence. Of 4 lumbar ESI studies that used a TF approach, the 2 randomized double-blinded controlled trials were grade I evidence and 2 retrospective studies were grade II and III level of evidence. One randomized controlled trial using the lumbar IL approach was level II evidence. One retrospective cohort study using the lumbar TF, IL and caudal approach was level III evidence. CONCLUSIONS: There is no statistically significant difference in terms of pain reduction or improved functional outcome between particulate and nonparticulate preparations in cervical ESI and, therefore, the authors recommend using nonparticulate steroid when performing cervical TFESI (Grade of Recommendation: B). In patients with lumbar radiculopathy due to stenosis or disk herniation, TFESI using particulate versus non-particulate is equivocal in reducing pain (Grade of Recommendation: B) and improving function (Grade of Recommendation: C) and therefore the authors recommend the use of nonparticulate steroids for lumbar TFESI in patients with lumbar radicular pain (Grade of Recommendation: B). There is insufficient information to make a recommendation of one steroid preparation over the other in lumbar ILESI (Grade of Recommendation: I). Given the lack of strong data favoring the efficacy of one steroid preparation over the other, and the potential risk of catastrophic complications, all of which have been reported with particulate steroids, nonparticulate steroids should be considered as first line agents when performing ESIs. LEVEL OF EVIDENCE: III.