Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries.

backgroundA novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. HYPOTHESIS: A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. STUDY

designProspective cohort study. LEVEL OF EVIDENCE: Level 3.

methodsA total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated.

resultsOf the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance.

conclusionThe optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. CLINICAL RELEVANCE: For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.