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Radiology Image: An athlete with pain

An athlete with pain

[headline_subtitle title=”” subtitle=”Can you solve the radiology image of this edition?”]
Patient data
  • Age: 19
  • Gender: Male
  • Medical history: None
  • Initial presentation: Patient is a professional athlete (100 metres sprint) who has been intensively training for the last 6-8 weeks. Acute onset of pain in the medial part of the right foot.

Question about the patient data.

X-ray of the foot

X-ray of the foot

X-ray of the foot

Question about the X-ray images.

MRI-scan of the foot

MRI-scan of the foot

MRI-scan of the foot

MRI-scan of the foot

MRI-scan of the foot

Question about the MRI and treatment.

S. Spijkers & M. Maas

Checklist Röntgen (Foot)

  1. Medial aspect (DP)
    1. 1st and 2nd metatarsals, check alignment and fractures
    2. Check the medial and intermediate cuneiform for fractures and/or dislocations
  2. Lateral aspect (oblique)
    1. 3rd, 4th and 5th metatarsals, check alignment and fractures
    2. Check lateral cuneiform for fractures and/or dislocations
    3. Navicular and cuboid, check for fractures
    4. Medial borders of 3rd metatarsal and lateral cuneiform should line up
  3. Bone review
    1. Check around the cortex of every bone
      1. Start proximally and work distally, medial to lateral
      2. Be sure to rule out periosteal bone formation
      3. Be sure to rule out any bone discontinuity
    2. Look for any bone that is not attached

Checklist MRI (Foot)

  1. Bone marrow: homogeneous black on T2 fat sat?
  2. Bone marrow: homogeneous white on T1?
  3. Soft tissue: all muscles normal at the side of the marked area of pain? ruptures?
  4. Osseous structures and articular surface: fractures? Alignment right? Osteochondral lesions?
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Stress fractures due to overuse are a common injury in athletes and military cadets. When a stress fracture is suspected, radiography is often the first diagnostic step to confirm the diagnosis and rule out other possible diagnoses. Since sensitivity ranges from 12% to 56%, conventional radiography is likely to result in false negatives. A negative radiograph should therefore always be followed by additional imaging. Literature shows that MRI is the most sensitive (68%-99%) and specific imaging test for stress fractures.

Since our patient is a professional athlete, excluding a stress fracture as cause of his pain is of crucial value for his training schedules and career. A 6-10 week period of rest is the treatment for a stress fracture, whereas when a low grade muscle injury is diagnosed, like in our patient, only 2-3 weeks rest are recommended.

Our patient was diagnosed with a first degree muscle injury (strain). On MR images this type of injury is visible as an intramuscular high intensity T2 signal. A feathery pattern around the myotendinous junction and adjacent muscles can be seen. The T1 weight images are often normal. Imaging findings and symptoms resolve completely over time.

Explanation of the images: Within the yellow circle a subtle high signal area is seen, meaning a strain of the muscle. All the bones are normal.

MRI-scan of the foot

MRI-scan of the foot

  1. Gaillard, F. (2017). Stress fractures | Radiology Reference Article | Radiopaedia.org. [online] Radiopaedia.org. Available here [Accessed 7 Jan. 2017].
  2. Lassus J, Tulikoura I, Konttinen YT, Salo J, Santavirta S. Bone stress injuries of the lower extremity: a review. Acta Orthop Scand 2002;73:359–68.
  3. Palmer WE, Kuong SJ, Elmadbouh HM. MR imaging of myotendinous strain. AJR Am J Roentgenol 1999; 173:703–709.
  4. nl. (2017). The Radiology Assistant : Muscle MR – traumatic changes. [online] Available here [Accessed 7 Jan. 2017].
  5. nl. (2017). The Radiology Assistant : Stress fractures. [online] Available here [Accessed 7 Jan. 2017].
  6. Robinson, P. (2010). Essential radiology for sports medicine. 1st ed. New York: Springer.
  7. Berger, FH, de Jonge, MC, Maas, M. Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. European Journal of Radiology 2007;62:16-26.

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