The Ability of Clinical Tests to Diagnose Stress Fractures: A Systematic Review and Meta-analysis
Schneiders AG, Sullivan SJ, Hendrick PA, Hones BD, McMaster AR, Sugden, BA, Tomlinson C. J Orthop Sports Phys Ther. 2012; 42(9): 760-771
As a clinician, early identification of stress fractures in patients is paramount to establishing a course of action for intervention and treatment. Unfortunately, without immediate access to medical imaging (e.g., magnetic resonance imaging [MRI], radiography, or scintigraphy) we often rely on subjective complaints, location of pain, details from the athlete’s training, medical history, and clinical examination tests despite little evidence to support their diagnostic ability. Schneiders et al performed a systematic review and meta-analysis on the literature involving the diagnostic efficacy of clinical tests for stress fractures. Utilizing eight electronic databases, the authors initially identified 9,321 studies published between January 1950 and June 2011 for possible inclusion. These studies specifically compared clinical tests to radiological imaging of lower extremity stress fractures. After review of each study’s title, abstract, and full texts (when available); the authors narrowed the pool to nine studies that underwent quality assessment using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Seven studies investigated therapeutic ultrasound and two studies investigated the use of a tuning fork to identify stress fracture in the lower extremity. MRI and scintigraphy were used as reference imaging to confirm the accuracy of these two clinical tests. The authors found that ultrasound had a pooled sensitivity (correctly identify with a stress fracture) of 64% and specificity (correctly identify absence of a stress fracture) of 63%. These results indicated a low to moderate ability for stress fracture diagnosis. Furthermore, ultrasound had a small positive likelihood ratio (probability of a positive test in someone with a stress fracture divided by the probability of positive test in someone who doesn’t get a stress fracture) of 2.09 and negative likelihood ratio of 0.35. For the two studies that investigated the use of tuning forks, a meta-analysis was not possible so each study was reported individually. Sensitivity/specificity and likelihood ratios presented by these studies were poor. Overall, this review did not support using ultrasound or tuning forks as a stand-alone diagnostic technique for stress fracture identification.
Stress fractures, particularly of the lower extremity, often lead to time-loss from sport or activity. Early intervention means altering activity and reducing physical stress on the lower body. The results of this systematic review and meta-analysis do not support the use of ultrasound and tuning forks for diagnosing stress fractures as standalone tools. Interestingly, Papalada et al found that therapeutic ultrasound may have the potential to assess lower extremity stress fractures. More research may be warranted to determine if there is an optimal ultrasound protocol for evaluating stress fractures. Until we know more, the clinician should rely on sound skills in obtaining a detailed history, patient reports of pain location and intensity, and cautionary use of clinical tests to confirm a decision of referral for physician evaluation and subsequent imaging. Is ultrasound or a tuning fork part of your evaluation currently? What clinical tests do you use to diagnose a stress fracture of the lower extremity?
Written By: Laura McDonald
Reviewed by: Jeffrey Driban
Related Posts:Schneiders AG, Sullivan SJ, Hendrick PA, Hones BD, McMaster AR, Sugden BA, & Tomlinson C (2012). The Ability of Clinical Tests to Diagnose Stress Fractures: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 42 (9), 760-71 PMID: 22813530