Tibial Stress Injury: Relationship of Radiographic, Nuclear Medicine Bone Scanning, MR Imaging, and CT Severity Grades to Clinical Severity and Time to Healing

Published Online:https://doi.org/10.1148/radiol.12102426

Although tibial stress injuries can be reliably graded by using existing schemes for the most accepted imaging modalities, only MR imaging severity bears any relationship to any clinically relevant phenomena, such as clinical severity or time to healing.


To examine the relationship between severity grade for radiography, triple-phase technetium 99m nuclear medicine bone scanning, magnetic resonance (MR) imaging, and computed tomography (CT); clinical severity; and recovery time from a tibial stress injury (TSI), as well as to evaluate interassessor grading reliability.

Materials and Methods

This protocol was approved by the Griffith University Human Research Ethics Committee, the Stanford University Panel on Human Subjects in Medical Research, the U.S. Army Human Subjects Research Review Board, and the Australian Defense Human Research Ethics Committee. Informed consent was obtained from all subjects. Forty subjects (17 men, 23 women; mean age, 26.2 years ±6.9 [standard deviation]) with TSI were enrolled. Subjects were examined acutely with standard anteroposterior and lateral radiography, nuclear medicine scanning, MR imaging, and CT. Each modality was graded by four blinded clinicians. Mixed-effects models were used to examine associations between image severity, clinical severity, and time to healing, with adjustments for image modality and assessor. Grading reliability was evaluated with the Cronbach α coefficient.


Image assessment reliability was high for all grading systems except radiography, which was moderate (α = 0.565–0.895). Clinical severity was negatively associated with MR imaging severity (P ≤ .001). There was no significant relationship between time to healing and severity score for any imaging modality, although a positive trend existed for MR imaging (P = .07).


TSI clinical severity was negatively related to MR imaging severity. Radiographic, bone scan, and CT severity were not related to time to healing, but there was a positive trend for MR imaging.

© RSNA, 2012


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Article History

Received December 14, 2010; revision requested January 28, 2011; revision received December 7; accepted December 29; final version accepted January 6, 2012.
Published online: June 2012
Published in print: June 2012