The Ability of Clinical Tests to
Diagnose Stress Fractures: A Systematic Review and Meta-analysis

AG, Sullivan SJ, Hendrick PA, Hones BD, McMaster AR, Sugden, BA, Tomlinson C. J
Orthop Sports Phys Ther. 2012; 42(9): 760-771

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)
. 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
(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
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

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?

By:  Laura McDonald
by:  Jeffrey Driban


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