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Bone Stress Injuries Causing Exercise-Induced Knee Pain

Maria H. Niva, MD^*, Martti J. Kiuru, MD, PhD, MSc^*,,, Riina Haataja, MSc^,|| and Harri K. Pihlajamäki, MD, PhD^*,¶

From the ^* Research Institute of Military Medicine, Central Military Hospital, Helsinki, Finland, the Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland, the Tampere School of Public Health, University of Tampere, Tampere, Finland, the ^ll Research Unit, Tampere University Hospital, Tampere, Finland, and the ^¶ Department of Surgery, Central Military Hospital, Helsinki, Finland

Address correspondence to Martti J. Kiuru, MD, PhD, MSc, Topeliuksenkatu 5, PO Box 266, Helsinki, Finland 00029 HUS (e-mail: martti.kiuru{at}hus.fi).

Background: No comprehensive studies of bone stress injuries in the knee based on magnetic resonance imaging findings have been published.

Purpose: Assess the incidence, location, nature, and patterns of bone stress injuries in the knee in military conscripts with exercise-induced knee pain.

Study Design: Case series; Level of evidence, 4.

Methods: During a period of 70 months, 1330 patients with exercise-induced knee pain underwent magnetic resonance imaging of the knee. A total of 1577 knees were imaged; the images with bone stress injury findings were retrospectively reevaluated with respect to location and type of injury. The person-based incidence of bone stress injuries in the knee was calculated, based on the number of conscripts within the hospital’s catchment area.

Results: Of the 1330 patients, 88 (7%) met the inclusion criteria, and 141 bone stress injuries were found in the 110 knees imaged. The incidence of bone stress injuries was 103 per 100 000 person-years. Of the patients, 25% had bilateral bone stress injuries; 28% had 2 solitary bone stress injuries in the same knee simultaneously, all situated in the femoral condyle and tibial plateau. The most common anatomical location for a bone stress injury was the medial tibial plateau (31%), which was also the most typical location for a more advanced injury. After the commencement of military service, a bone stress injury in the medial tibial plateau caused knee pain earlier than did a bone stress injury elsewhere in the knee (P = .014).

Conclusion: The incidence of bone stress injuries in the knee with exercise-induced knee pain is relatively high in conscripts. Multiple and bilateral injuries can occur. For accurate diagnosis and to ensure appropriate treatment, magnetic resonance imaging is recommended as a routine imaging method when a physical activity can be regularly associated with the onset of symptoms.

Key Words: stress fracture • incidence • injury • knee • magnetic resonance imaging (MRI)