July – Imaging

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    • #7629
      Laura Thornton

      A 25 year male direct access c/o subacute and worsening pain in his left anterior lower leg, referring from 1-2 inches below his knee into the dorsal surface of his ankle. He is currently training for the half-marathon and noticed in the past two weeks, the leg pain started gradually, but now is occurring earlier in his runs for the past week. His currently aggravating factors are mainly running, however if he is on his feet for awhile it can at times worsen mildly.

      Using this case or similar cases that you’ve seen in the clinic, please discuss your thought process regarding treatment approach and if recommended, any imaging referral.

      Hope everyone had a great holiday!

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    • #7631
      Jon Lester

      Due to the history provided above, I would suspect possibility of a stress fracture of (likely) the tibia due to the probable increase in training volume and locality of pain in this younger athlete. The worsening nature and pain onset with running/prolonged WB is concerning, especially knowing that he is DA (yay DA!). With a thorough objective exam, we could rule out lumbar spine or other orthopedic cause (i.e. MTSS, hip/knee referral) of his anterior shank symptoms. Likely he will have direct TTP over the tibia and the surrounding tissues if this region has a stress fracture. If so, or if the other objective findings warrant reasonable concern for a stress fracture, then my first thought would be to refer and treat this patient. Referral would be necessary immediately to confirm/rule out the fracture and determine the location (high or low vascularity) to decide on appropriate intervention. Radiography would likely be the first imaging of choice, however could lead to a false negative according to the research presented. If negative, a MRI would be the imaging of choice to rule in/out a stress fracture in this patient due to the high sensitivity and specificity of detection (94% and 97% respectively in a subject pool similar to current pt according to the study). If treatment is warranted, then addressing volume management would be high on my priority list. We could also address running mechanics, cadence, striking patterns, LQ strength/ROM, and other objective findings that could reduce the stress within the region of symptoms upon return to running. I have not seen any patients with this type of presentation, however this is how I would manage it based on the above description.

    • #7632
      Erik Kreil

      I agree with you Jon, stress fracture is on my list in addition to a number of other orthopedic conditions. More details to the history of injury could help push the needle a bit (his training volume, how many other races has he participated in, etc).. I like the treat and refer option here with XRAYs indicated as a first line of imaging, but what do you think about a f/u with ultrasonogrophy if XRAYs come back negative and PT isn’t demonstrating gain?

      My goal with concurrent PT would be to modify training volume as needed and modify contributing factors, if I’m really suspecting something that needs additional referral.

    • #7643

      Tibial stress fx would be higher up on my differential diagnosis list given the brief subjective report. I agree that more info based on training volume and progression of training would be helpful in how suspicious I am of a stress fx. Although it may not necessarily change anything on my differential list, I would ask some questions about any past running injuries, nutrition/diet, and if he participates in any weight training, as these factors could potentially lead to an increase in likelihood of stress fx.

      I think that the article’s flowchart is very helpful and to me makes a lot of logical sense for how to go about imaging. In this patient, I agree that I would recommend an x-ray first. If negative, I would treat for 2-3 weeks and then get a repeat x-ray. In the meantime I would speak to the referring physician about getting an MRI, so that this timeline isn’t dramatically lengthened. Since this region is not a high-risk site, I would not feel that an MRI is required immediately. Erik, I wouldn’t go the ultrasonography route at this point. I didn’t think the research was solid enough that I would recommend it before an MRI, as it has low specificity, so there could potentially be a false positive.

      As far as my treatment approach, if I am really thinking there is a high suspicion of a stress fracture, I would probably give the advice for cross-training so that he can continue to work on his CV endurance. I would also see if I could make any modifications to the LE chain that could change his pain. Based on this I would work on strengthening, motor control, etc of whatever extrinsic factors I felt I could improve. I just don’t think any modification would be powerful enough for me to recommend him continuing to run, especially since his symptoms have gotten worse enough to be aggravated with just prolonged standing. Do you guys agree with me on this, or would you try to work within his pain so that he can complete his half-marathon? I would just be worried about making his stress fracture worse and potentially lengthening his recovery time afterwards. I have literally never treated a runner at my clinic this year, so you all may have a different perspective than me on this.

    • #7644
      Erik Kreil

      Yeah, Jeff, I guess I was just thinking that if XRAYS come back negative and I’m still sniffing stress fracture (Failure of my treatment to provide relief, etc), then the article suggests US as a good method to more definitively rule out a diagnosis after a negative finding. Probably cheaper and more accessible (can PT offices do this?)..

    • #7645

      After investigating some I think I may refer ultrasound right away. This is a young man with a classic presentation of stress fracture. Why wait? If it looks like a duck and quacks like a duck, its probably duck. This area is a high risk area and this is a young healthy man I saw we skip the 85% negative x-ray and push for something better. I know its not easily that accessible but to me its the risk versus reward here and ultrasound is superior to x-ray for sure with less cost then MRI. I found this case report that I thought was interesting detecting a tibial stress fracture via ultrasound after negative x-ray. Whether this is right or not to me, it seems easy to go the protocol route. Try x-ray and conservative treatment but to me based on the presentation, patient, and location I would say the reward would be bigger her to go ultrasound referral if available.


      I’ve attached the article I mentioned above if anyone wants to see what the hallmark findings are for tibial stress fracture on an ultrasound are!

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    • #7647
      Cameron Holshouser

      First, I would like to know a better history – specifically with running
      – Too fast, too soon?
      – Novice runner?
      – Training program – safe mileage progression?
      – Where does he run (treadmill, outside, trails, hills)?
      – Shoes (any change, old?)
      – Hx of stress fx or shins splints

      Next, I would want to see if there is anything objectively that I could modify in regard to his tibial stress
      – Running form
      o Cadence – slow?
      o Heel strike – high angle of inclination?
      o Stiff lower extremity
      o Too much frontal plane motion
      – Foot posture
      o Cavus or planus foot
      o Dynamic foot posture
      o Potentially post or use an orthotic
      – Functional exam – weakness, dynamic control
      – Soft tissue restrictions – gastroc/deep extrinsic extensors/flexors

      So, there are plenty of things I would try first before referring out for imaging. It’s likely that he is having a stress reaction to his tibia. Why would we need costly imaging if we already know what is going on? However, what would change my imaging recommendation would be the severity and irritability. If he only had pain with running, I probably would not. If he was having significant pain with ADL’s then I would probably refer out for imaging. And, if he is going to continue to train for his race, then we need to make sure this stress reaction is not going to get worse (into grade III-IV).

      Would love to hear other’s thoughts on this.

      If imaging referral is needed, then I would express my concerns to the referring physician and let them make the decision. If I had to choose, I would recommend an MRI because it is the gold standard for stress fractures. MRI has high sensitivity and typically does not require additional further imaging because of its inclusiveness. I would still continue to see the patient in physical therapy to address his impairments while waiting on imaging.

    • #7648
      Aaron Hartstein

      Hi everyone,
      Nice discussion here. I appreciate all of your comments. I found the article useful in that it rearranged some prior thoughts of mine about the utility of a bone scan (being more Sn than Sp, in this review). Regarding the use of US by the PT in this case – while we certainly have the ability to use this tool and informally assess for this type of a lesion, creating a medical diagnosis or labeling the impairment as a stress fracture would be outside of our scope (and in theory, practicing medicine without a license to do so). Like anything else, it depends on the situation and the formality. For instance, we have one at school and often look at things informally, which could influence education, management, or when to refer out. But, this may not be the case in the clinic or if there was special interest from other stakeholders (consider a POPTS for instance, who has their own MRI machine). I found it interesting that Cameron was the only one to discuss the potential for an orthotic. I think conducting a non weight-bearing biomechanical exam on this patient would be highly relevant and a temporary orthotic or a modification to an old orthotic may be a way to provide some additional unloading in the short-term.

    • #7649
      Matt Fung

      I agree with everyone’s earlier remarks regarding wanting to know more information about the patients running history, running schedule etc. prior to jumping to immediately refer out for imaging.
      One thing I was considering which Cam touched upon was if I was suspecting potential tibial stress fx, being a low risk region, how much would an imaging confirmation change our initial POC with this patient? The articles discussion states …“When there is strong clinical suspicion of a low-risk stress fracture and initial radiographs are normal (eg,assumed false negative), imaging confirmation of a stress fracture is unlikely to alter patient management.”
      With this patient being DA it appears that his symptoms are getting worse and I would lean towards recommendations to modify activity including more cross training w/ dec running for the short term to see if that resulted in any improvements. If symptoms did not seem to improve I would push for an MRI depending on feasibility due to its high sensitivity and specificity to help confirm potential stress fx.

      I had a HS female runner come in a couple months back with c/o of anterior lower leg pain worse with her first few steps in running which improved as she ran more. Her sx ended up being more myofascial in nature as she overstrided and was a heavy heel striker. With this I feel it would be appropriate to have this patient run for us if he could tolerate to determine if there were any other running mechanics we can alter to decrease his symptoms irritability.

      I also had a HS basketball athlete present with lateral foot pain and a Dx of peroneal brevis tendonitis. Upon evaluation he was severely tender to palpation over his 5th met and 5th metatarsal stress fx was high on my list. However, prior to arrival MRI was performed and was negative. He was treated with walking boot prescribed by his orthopaedic and his symptoms improved with activity modifications and we progressed him accordingly.

    • #7655
      Laura Thornton

      There are a few main factors that really stick out to me to consider, being
      1) high vs. low risk classification
      2) stage of BSI in terms of severity and time since onset
      3) early detection

      Since this hasn’t been mentioned yet, I would push the importance of early detection with these stress injuries. This injury has been already 2 weeks old and most likely he has continued to train on top of an already developing stress injury. With respect to tissue healing timeframes for bone and the relative load is placed through the lower extremity, does the time from onset of symptoms change your treatment and/or imaging recommendations?

    • #7656
      Cameron Holshouser

      So, my first post was primarily looking at modifiable risk factors that I could alter to change the load due to my conservative PT bias. Yet after Laura’s point I started to do some more research to find out when is the best time to refer out for imaging. Based on the articles I read, this is the flow of potential stress fracture management that I came up with:

      1. Is this a high-risk stress fracture area? (femoral neck (tension-side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal 5th metatarsal, and great toe sesamoid)

      – “These locations all have a region of maximal tensile load in a zone of diminished blood flow that is vulnerable to stress injury, with suboptimal healing potential. Although HRSFs are relatively rare, they have important clinical relevance, because they can keep athletes from participating in sports for long periods of time and can cause significant morbidity if not properly treated. Athletes with HRSFs may require surgical intervention to return to play in a timely fashion. A high index of suspicion and early identification are critical to proper treatment and successful outcomes.” (McInnis 2016)

      2. Does the individual have a lot of risk factors for stress fractures?

      – Previous history of stress fracture and female sex are risk factors that are strongly supported by the data (Wright 2015)

      – Non-modifiable: Bone strength, genetic/nutritional factors, biomechanics, structure, physical fitness, sex, menstrual status

      – Modifiable: Training load, footwear, running surface, etc

      3. If suspicion is high for stress fracture, then refer out early for MRI. If there is a stress fracture present on MRI, determining the grade of stress fracture will determine the appropriate management.
      – MRI stress fracture grades (Nattiv 2015)

      Going back to the patient in this case. This has only been going on for 2 weeks. He has a high risk fracture location of anterior tibia. Yet, I would want to know more risk factors before referring to imaging.

      (McInnis 2016): High Risk Stress Fractures: Diagnosis and Management, PM R 2016, https://onlinelibrary.wiley.com/doi/full/10.1016/j.pmrj.2015.09.019

      (Wright 2015): Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis, BJSM 2015, https://bjsm.bmj.com/content/49/23/1517.long


    • #7660
      AJ Lievre

      32 year old Hispanic female (ESL) factory worker who complains of right upper trapezius region pain. Insidious onset 1 month ago. Pain is increased at work as her job requires repetitive lifting (3-5#) up to shoulder height for 10-12 hours shifts. The pain is constant and increases in intensity after 30-60 minutes of work. She works 3 days in a row and then has 4 days off. Her shoulder pain “barely” recovers by the time she gets back to work for her 3-day shift. Taking off of work is not an option for financial reasons.
      Overhead activity is her only aggravating factor and avoiding overhead activity eases her pain.
      Objectively her symptoms are reproduced when placing the upper trapezius on stretch, asking it to contract, elevation of the shoulder overhead and direct palpation to the upper trapezius. There is noticeable scapular dyskinesia with UE elevation. Inferior and posterior capsular tightness of the right GH joint found.
      Neuro is negative, cervical quadrants with OP and compression are negative.
      After 3 PT visits over 3 weeks, pain is no longer constant, and it takes 3 hours into her shift for the pain to begin.
      She goes back to primary care for follow-up and NP-C recommends the patient have cervical MRI and the patient agrees with POC. NP-C has the progress report of the patient’s status in PT.

      What is your role in this situation? How would you address this situation?

    • #7661
      Cameron Holshouser

      I think our role in this situation is to provide the patient with the most information that we can, and let the patient make the decision. Just because there is an order for an MRI, does not mean that she is required to have the MRI. I would first talk to the patient to see what the NP’s thoughts were with ordering an MRI. Then ask the patient about their thoughts regarding an MRI. I would then explain the objective and subjective success that she has made in physical therapy. Explain the negative findings of red flag and cervical testing (neuro/spurling’s). Explain the purpose of an MRI.

      – pro’s: more information, rule out red flags
      – con’s: irrelevant information, costs

      Then propose the idea to the patient of potentially getting the MRI in a couple of months if her pain is not getting better, but after completing 6-8 weeks of consistent physical therapy. See what the patient’s thoughts are with that plan. Maybe explain tissue healing timelines and how her job might continue to aggravate her pain so it might take longer to heal.

    • #7662
      Jon Lester

      I agree completely with you Cam. I think education is the most important aspect of care for this patient at their next PT session. Educating them on the rationale for MRI and making sure they are aware of them would be appropriate. Letting them know of the costs and that their presentation does not warrant the MRI is important for their ability of making an informed decision. The fear would be “finding something” on the MRI that is not related to their symptoms and having them “label themselves” as whatever the MRI says (e.g. “I have a disc bulge. That’s why my neck hurts”). The irrelevant information, as Cam suggested, could potentially lead to worsening of symptoms/presentation due to catastrophizing of pain due to something potentially unrelated and asymptomatic found on the MRI. Ultimately, it is the patient’s decision to make, but making them as informed as possible is the minimum of what should be done by us as one of their healthcare providers. Informing them of the objective improvement, subjectively improved tolerance to work, and the rationale for getting an MRI might sway their decision appropriately.

    • #7663
      Matt Fung

      Interesting scenario here especially with the patient only being seen for 3 visits and already being recommended for advanced imaging despite the initial findings and noted functional improvements and tolerance at work since beginning PT. I think Jon and Cam hit it on the head here where our role is to provide as much education we can to this patient so that they can make an informed decision on their next steps for care. For me I might be a little more aggressive on advising against pursuing an MRI especially due to her financial situation as it seems unnecessary at this time. I like your suggestion Cam of not completely shooting down the idea of an MRI but providing the alternative of giving PT a few more weeks/session to see how symptoms progress. I would also be sure to ask her more about her follow up with her NP-C to see what type of message was being passed along to her during her visit.

    • #7664
      Erik Kreil

      What do you guys think of additionally calling the NP-C with an open mind to ask what they’re seeing on their end that motivates the recommendation for an MRI? Do you guys have experience doing this?

    • #7666

      Erik, I was thinking the same thing. Although a proper PT cervical and neuro screen was performed to rule out a cervical referral, maybe the NP saw something in her exam that led her to making this decision. Although a PN was sent, who knows if the NP actually read it? I would call the NP and ask why the decision was made to order the MRI (if you could get access to this provider’s visit before making the call, that would be even better). I think first of all this is good for developing relationships with referral sources, and also may lead to a good conversation with the NP, likely displaying good clinical reasoning skills on your end for questioning the necessity of the MRI ordering, and demonstrating that improvements have been made with PT thus far.

      I do agree with everyone that my immediate reaction is to think the MRI is definitely unnecessary and if given would likely lead to pain catastrophizing, mis-education, and nocebo. In regards to patient education, hopefully by the third visit I would be able to use a test/treat/re-test to demonstrate and then further educate the patient that PT is and can continue to help the patient’s pain. I would educate the patient that an MRI will likely lead to injections and possibly surgery, and would stress that surgery would be a last-resort option, especially with her young age and occupational activities she has to perform.

      Lastly, like someone mentioned before, I would educate the patient on tissue healing times and time for muscles to hypertrophy and improve in strength so that the patient has realistic expectations for the time-line of the recovery process. I would also add that with the patient having to continue to her job requirements, that that will make the recovery time even longer – not to discourage the patient, but to make sure her expectations are realistic and you two are on the same page.

    • #7669
      Aaron Hartstein

      Nice work, everyone. Perhaps it is the content of my recent qualitative research and multicultural management coursework in my program, but I will add another perspective here, just for the sake of discussion. In working with individuals from this culture, it is important to understand their worldview and lived experience. Depending on her level of acculturation to Western beliefs and values, there may be conflicts related to traditional gender roles in her culture versus our more flexible and current Western views. Maybe she indicated that her symptoms were still there and requested the imaging herself, in attempt to expedite her recovery (from her perspective). Another factor to consider is the traditional view of fatalism (misfortune being inevitable and being resigned to it) in this culture. She may be happy going along passively with the NPs suggestion as a result of this perspective. From a holistic point of view, questioning her beliefs of about spirituality/religion may reveal something else to discuss or, better yet, leverage into your treatment approach. I know this is all a bit “touchy feely” in nature, but I thought it was interesting to assume that it was all driven by the NP and her decision making, when there could be another factor in the equation here. Just a thought.

    • #7670
      Jon Lester

      I think that’s a good point, Aaron. I definitely just assumed from AJ’s post that it was the NP that drove the bus, but I agree that this is not necessarily the case for all people that would be meeting with a health care provider. I guess that would be the first area to pursue if the patient was in front of you, by asking their opinion on the matter before shoving a bunch of education her way. I would have a hard time tying the religion/spirituality into the conversation, so it would be interesting to see how their perception of the situation appears from our perspective and allowing the amount and/or way of educating the patient to be dictated in part by that.

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