DOI:10.2214/AJR.07.3379
AJR 2008; 191:1412-1419
© American Roentgen Ray Society
Diagnostic Imaging in Athletes with Chronic Lower Leg Pain
Michele Gaeta1,
Fabio Minutoli1,
Silvio Mazziotti1,
Carmela Visalli1,
Sergio Vinci1,
Felice Gaeta2 and
Alfredo Blandino1
1 Department of Radiological Sciences, University of Messina, Policlinico
"G. Martino," Via Consolare Pompea 1871, 98165, Messina,
Italy.
2 Sport Medicine, Faculty of Motor Science, University of Messina, Policlinico
"G. Martino," Messina, Italy.
Received November 2, 2007;
accepted after revision June 3, 2008.
Address correspondence to S. Mazziotti
(smazziotti{at}unime.it).
Abstract
OBJECTIVE. Our purpose is to describe the imaging features in
athletes with chronic lower leg pain, emphasizing the role of MRI and CT,
which are the diagnostic tools with the highest sensitivity and specificity in
the differential diagnosis of lower leg pain. Moreover, a diagnostic algorithm
in patients with chronic lower leg pain is proposed.
CONCLUSION.Plain radiography has a low sensitivity but may reveal
tibial stress fractures, bone tumors, and soft-tissue calcification. CT and
MRI may be useful to better evaluate the abnormalities shown by plain
radiography.
Keywords: CT • lower leg pain • MRI
Introduction
Exercise-induced chronic leg pain is a common condition in compet itive and
recreational athletes. By definition, lower leg pain is pain between the knee
and ankle [1,
2]. The causes of chronic lower
leg pain in the athlete are numerous, and therefore the differential diagnosis
is quite broad (Appendix 1).
According to the literature, despite the wide range of potential diagnoses,
medial tibial stress syndrome and stress fractures are the most common sources
of exercise-induced chronic lower leg pain, followed by chronic exertional
compartment syndrome and popliteal nerve entrapment
[1–4].
Although a high index of suspicion, careful physical examination, and
detailed history are essential in athletes with chronic lower leg pain
[1–3],
"even for an astute clinician, distinction between the different medical
causes may be difficult given that many of their presenting features
overlap" [5].
Consequently, the role of diagnostic imaging remains fundamental in detecting
the cause of chronic lower leg pain.
The objectives of this article are to describe the imaging features in
athletes with chronic lower leg pain, emphasizing the roles of MRI and CT,
which are the diagnostic tools with the highest sensitivity and specificity in
the differential diagnosis of lower leg pain
[5,
6], and to propose a diagnostic
algorithm in patients with chronic lower leg pain.
Tibial Stress Injuries
Tibial stress injuries are by far the most common cause of lower leg pain
in athletes, accounting for up to 75% of exertional leg pain
[7]. Tibial stress injuries
include various types of bone lesions that represent a continuum of
abnormalities from asymptomatic osteopenia to fracture, all occurring in
response to abnormal repetitive stress applied to normal bone
[5–7].
This spectrum of lesions includes periostitis, cortical osteopenia, cancellous
bone, and cortical fractures, often associated with various degrees of
reactive soft-tissue and bone marrow edema
[5–7].
Although both proximal and distal metaphyses and the whole diaphysis can be
involved by stress injuries, such injuries more frequently occur in the cortex
of the distal two thirds of the tibia and cause a clinical syndrome known as
medial tibial stress syndrome or shin splints.
Periostitis can occur both as an isolated abnormality or in association
with bone stress injuries. Although a bone scan can be positive in this
condition, MRI is the most sensitive examination for diagnosing periostitis
[5]. Periostitis appears as a
soft-tissue edema near the cortex. Often, on STIR or fat-saturated T2-weighted
images, detached periosteum can be seen as a thin hypointensity surrounded by
hyperintense edema (Fig. 1A,
1B).
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Fig. 1A —Tibial periostitis in 32-year-old man who was professional
basketball player. Axial (A) and coronal (B) fast STIR images
show periosteal edema. Detached and thickened periosteum can be seen as
signal-void line (arrow).
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Fig. 1B —Tibial periostitis in 32-year-old man who was professional
basketball player. Axial (A) and coronal (B) fast STIR images
show periosteal edema. Detached and thickened periosteum can be seen as
signal-void line (arrow).
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Cortical lesions include osteopenia, cavitations, striations, and
fractures. Radiog raphy detects only a small number of cortical fractures. The
other cortical abnormalities and the majority of cortical fractures (up to
94%) remain undetected [8]
(Fig. 2A,
2B,
2C). Both MRI and CT have high
accuracy in detecting the spectrum of cortical abnormalities. MRI is the most
sensitive single diagnostic tool for patients with medial tibial stress
syndrome given its excellent soft-tissue contrast to show soft-tissue
abnormalities [5] (Figs.
3A,
3B and
4A,
4B). However, sometimes CT
permits the early diagnosis of cortical abnormalities not visible on MRI
[6] (Fig.
5A,
5B).
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Fig. 2A — Longitudinal tibial stress fracture in 34-year-old man who
was runner and had chronic medial tibial stress syndrome lasting 6 months.
Orthogonal radiograph obtained 10 days before MR and CT examinations does not
show fracture.
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Fig. 2B — Longitudinal tibial stress fracture in 34-year-old man who
was runner and had chronic medial tibial stress syndrome lasting 6 months.
Axial T2-weighted MR image shows longitudinal tibial stress fracture as
cortical hyperintense line. Hypointense calcified periosteal callus
(arrow) as well as bone marrow edema can also be seen.
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Fig. 2C — Longitudinal tibial stress fracture in 34-year-old man who
was runner and had chronic medial tibial stress syndrome lasting 6 months.
High-resolution CT image shows, with better advantage, longitudinal tibial
stress fracture with calcified periosteal callus (arrow).
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Fig. 3B —Medial tibial stress syndrome in 21-year-old man who was
runner. Three-dimensional CT reconstruction image of same patient confirms
evident osteopenia (arrows) of anterior and posterior tibial
cortices. Note normal density of fibula and lateral tibial cortices.
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Fig. 4A —Tibial stress injury in 27-year-old woman who was handball
player and had chronic leg pain. Fast STIR image shows both periosteal
(arrowheads) and bone marrow edema (asterisk) but not
fracture.
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Fig. 4B —Tibial stress injury in 27-year-old woman who was handball
player and had chronic leg pain. Axial turbo spin-echo T1-weighted image
confirms absence of cortical fracture. Bone marrow edema (asterisk)
and periostitis (arrowhead) are less conspicuously appreciable in
comparison with fast STIR image in A.
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Fig. 5A —Medial tibial stress syndrome in 20-year-old man who was
runner. High-resolution CT image reveals multiple areas of osteopenia and
cavities (arrows) of anterolateral tibial cortex representing stress
related lesions.
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Chronic Exertional Compartment Syndrome
Chronic exertional compartment syndrome is a cause for claudication in
athletes. It is caused by abnormally increased pressure within muscular
compartments that are enclosed by relatively noncompliant fasciae. Of the four
lower leg muscular compartments, anterior and lateral compartments are
affected more frequently than others (76%), followed by deep posterior (16%)
and posterior superficial (12%)
[9].
The diagnosis of chronic exertional compartment syndrome requires measuring
compartment pressure with a slit or weak catheter. However, some problems
exist: Pressure measurement is an invasive technique. Potential risks include
muscular hernia or neurovascular damage
[9]. Multiple compart ments are
affected in about half of chronic compartment syndrome cases and symptoms in
the bilateral legs occur in approximately 75% of cases
[10]. Chronic exertional
compartment syndrome may be complicated by the coexistence of periostitis and
tibial stress fracture, which cannot be diagnosed by compartment pressure
measurement.
MRI is a promising technique for non-invasive diagnosis of chronic
exertional compartment syndrome
[11,
12]. A recent work has shown
that the sensitivity of MRI in diagnosing chronic exertional compartment
syndrome was comparable to that of intracompartmental pressure measurement and
near-infrared spectroscopy
[11].
MRI must be performed immediately after exercise-inducing pain. MRI
findings in chronic exertional compartment syn drome include muscular
hyperintensity on T2-weighted or fast STIR images with or without muscular
swelling (Figs. 6 and
7). Inhomogeneous
hyperintensity within affected compartments can be seen
(Fig. 6). MRI may detect
involvement of more than one compartment
(Fig. 6) and concurrence of
medial tibial stress syndrome.
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Fig. 6 —Chronic compartment syndrome in 30-year-old man who was
runner. Fat-saturated T2-weighted axial MR image, obtained immediately after
exercise, shows evident edema of tibial anterior and deep posterior
compartment muscles (arrows). Slight, questionable hyperintensity can
be seen in other muscles of anterior compartment (arrowheads).
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Fig. 7 —33-year-old female long-distance runner with right lower leg
chronic exertional compartment syndrome lasting 3 months. Patient refused
catheter pressure measurement. Fat-suppressed T2-weighted axial MR image
obtained immediately after pain-inducing exercise shows swelling and
hyperintensity of anterior compartment muscles.
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Further studies are necessary to define the appropriate role of MRI in the
diagnostic algorithm of chronic exertional compartment syndrome. In the
meantime, MRI should be used as a problem-solving examination in confusing
circumstances, in patients refusing compartment pressure measurement, or in
patients with contraindication for compartment pressure measurement
(coagulation disorders).
Peripheral Neuropathy
Compression or nerve entrapment can lead to a functional disturbance or
pathologic change in the peripheral nerve of the lower leg causing lower leg
pain and muscular dysfunction. The superficial peroneal nerve and sural nerve
can be involved, but the most common cause of extraspinal neuropathic leg pain
is common peroneal nerve disease, which can be caused by trauma, compression,
and intrinsic abnormalities.
Although the diagnosis of common peroneal nerve injury is based initially
on electromyography, MRI plays an important complementary role in diagnosing
the cause of the nerve sufferance
[13]. Moreover, MRI can also
show muscular neurogenic edema in the subacute phase and atrophy with fatty
degeneration in the chronic phase of denervation
[14] (Fig.
8A,
8B).
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Fig. 8A —Chronic hypertrophic demyelinating neuropathy in 24-year-old
male basketball player. Axial T1-weighted turbo spin-echo image shows enlarged
common peroneal nerve (arrow) with loss of normal fascicular pattern.
Note slight fatty replacement because of early muscular atrophy of denervated
muscles.
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Fig. 8B —Chronic hypertrophic demyelinating neuropathy in 24-year-old
male basketball player. Fast STIR image shows enlarged and hyperintense common
peroneal nerve (arrow). Muscles of anterolateral and peroneal
compartments are diffusely hyperintense because of denervation.
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Muscular neurogenic edema appears on fast STIR and fat-saturated
T2-weighted turbo spin-echo images as a diffuse homogeneous hyperintensity
involving the muscles innervated by diseased nerve. Hyperintensity of
denervated muscles is usually seen after 2–3 weeks but can appear as
early as 4 days after acute traumatic denervation
[14]. Muscular neurogenic
atrophy with fatty infiltration due to long-standing denervation is well shown
by T1weighted MR images. This is important clinical information because
neurogenic atrophy is irreversible damage.
Peripheral Vascular Disease
Popliteal artery disease is an uncommon cause of intermittent claudication
of the lower leg in young athletes. The most common cause (up to 60%) is
popliteal artery entrapment syndrome, which typically occurs in young men
[15–17].
This syndrome is caused by anomalous musculature in the popliteal fossa, in
which the popliteal artery is entrapped
[15,
16] (Fig.
9A,
9B,
9C,
9D). Popliteal artery
entrapment syndrome may be complicated by thrombosis
[15] (Fig.
9A,
9B,
9C,
9D). Other rarer causes of
intermittent claudication in young athletes are adventitial cystic disease,
muscular fibrodysplasia, arteritis, and compression of the artery by exostosis
of the distal femur [17].
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Fig. 9A —19-year-old man who complained of right leg pain that
appeared with hard exercise and abated with rest. (Reprinted with permission
from [15], Utsunomiya D,
Sawamura T. Popliteal artery entrapment syndrome: noninvasive diagnosis by
MDCT and MRI. Australas Radiol 2007; 51[spec no]:B101–B103)
Occlusion of right popliteal artery is seen on 64-MDCT angiography image.
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Fig. 9B —19-year-old man who complained of right leg pain that
appeared with hard exercise and abated with rest. (Reprinted with permission
from [15], Utsunomiya D,
Sawamura T. Popliteal artery entrapment syndrome: noninvasive diagnosis by
MDCT and MRI. Australas Radiol 2007; 51[spec no]:B101–B103)
Delayed phase axial CT image of right popliteal fossa shows abnormal anatomy
in which medial head of gastrocnemius muscle (MHG) courses between thrombosed
popliteal artery (PA) and popliteal vein (PV).
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Fig. 9C —19-year-old man who complained of right leg pain that
appeared with hard exercise and abated with rest. (Reprinted with permission
from [15], Utsunomiya D,
Sawamura T. Popliteal artery entrapment syndrome: noninvasive diagnosis by
MDCT and MRI. Australas Radiol 2007; 51[spec no]:B101–B103) MR
angiography is comparable to CT angiography (A) in showing occlusion of
right popliteal artery.
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Fig. 9D —19-year-old man who complained of right leg pain that
appeared with hard exercise and abated with rest. (Reprinted with permission
from [15], Utsunomiya D,
Sawamura T. Popliteal artery entrapment syndrome: noninvasive diagnosis by
MDCT and MRI. Australas Radiol 2007; 51[spec no]:B101–B103)
Axial T2-weighted image also shows abnormal anatomy responsible for
entrapment. Black arrow indicates popliteal artery, white arrow indicates
popliteal vein, and arrowhead indicates medial head of gastrocnemius
muscle.
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The diagnosis of popliteal artery dis ease requires not only depiction of
arterial stenosis but also identification of the responsible disease. Although
arterial stenosis can be shown on conventional angiography and sonography, CT
and MRI are equally better in showing the cause of popliteal abnormalities
[15–17]
(Fig. 9A,
9B,
9C,
9D). However, MRI has some
advantages over CT, including lack of ionizing radiation and the need for
contrast material as well as higher soft-tissue contrast
[16].
Other Causes
Among the uncommon causes of chronic lower leg pain in athletes, a number
of soft-tissue and bone diseases should be considered, including tumors and
infection
[1–3],
tendinopathy of the proximal Achilles tendon (Fig.
10A,
10B), other more unusual
tendinopathies (Fig. 11A,
11B), interosseous membrane
injuries, and chronic bursitis (Fig.
12A,
12B).
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Fig. 10A —Tendinopathy in 38-year-old male long-distance runner.
Sagittal fast STIR image shows tendinopathy and partial tear (black
arrow) of Achilles tendon (white arrows). Edema of peritenoneum
(arrowheads) also can be seen.
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Fig. 10B —Tendinopathy in 38-year-old male long-distance runner.
T1-weighted axial turbo spin-echo image confirms enlargement of Achilles
tendon with marked medial hyperintensity (arrow) and posterior
peritenonitis (arrowheads).
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Fig. 11A —Calcification of interosseous membrane at insertion of tendon
of posterior tibial muscle in 29-year-old male professional soccer player
complaining of chronic pain of 1 year with recurrent episodes of acute pain.
Proton density–weighted fat-saturated axial image shows calcification
(arrow) of interosseous membrane at insertion of posterior (P) tibial
muscle. A = anterior tibial muscle.
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Fig. 11B —Calcification of interosseous membrane at insertion of tendon
of posterior tibial muscle in 29-year-old male professional soccer player
complaining of chronic pain of 1 year with recurrent episodes of acute pain.
Coronal T2-weighted fat-saturated turbo spin-echo image shows tendon
calcification (asterisk) and edema (arrow) of posterior
tibial muscle (P) at tendon–muscle junction. Muscle injury was probably
due to reduced elasticity of tendon–muscle junction in patient with
chronic overuse of muscle. Inflammation or recurrent strain can explain
muscular abnormalities.
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Fig. 12A —Chronic bursitis in 32-year-old male soccer player with
slight chronic pain and swelling on medial side of upper part of lower leg.
Axial T1-weighted turbo spin-echo image (A) and coronal fat-suppressed
T2-weighted turbo spin-echo image (B) show enlarged bursa
(arrowheads) containing multiple ossified loose bodies
(arrows). Bursitis is not anserine bursitis because it was located
superficial to pes anserinus tendons. This is adventitious bursa caused by
chronic friction from upper edge of stiff shin-guard.
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Fig. 12B —Chronic bursitis in 32-year-old male soccer player with
slight chronic pain and swelling on medial side of upper part of lower leg.
Axial T1-weighted turbo spin-echo image (A) and coronal fat-suppressed
T2-weighted turbo spin-echo image (B) show enlarged bursa
(arrowheads) containing multiple ossified loose bodies
(arrows). Bursitis is not anserine bursitis because it was located
superficial to pes anserinus tendons. This is adventitious bursa caused by
chronic friction from upper edge of stiff shin-guard.
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Diagnostic Algorithm
We propose a diagnostic algorithm for differential diagnosis in athletes
with chronic lower leg pain (Fig.
13). It is useful to remember that, according to Edwards et al.
[2], the first diagnostic step
is always represented by radiography. The advantages of radiography are low
cost, short imaging time, and easy execution. Radiography has a low
sensitivity but may reveal tibial stress fractures, bone tumors, and
soft-tissue calcification (calcific tendinitis, calcific soft-tissue tumors,
and so on). CT and MRI may be useful to better evaluate the abnormalities
shown by radiography.
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Abstract
Introduction
