Bone Stress Injuries Causing

Exercise-Induced Knee Pain

Maria H. Niva,* MD, Martti J. Kiuru,*†‡ MD, PhD, MSc, Riina Haataja,§ll 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 llResearch
¶
Unit, Tampere University Hospital, Tampere, Finland, and the Department of Surgery, Central
Military Hospital, Helsinki, Finland

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 imag-
ing 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.
Keywords: stress fracture; incidence; injury; knee; magnetic resonance imaging (MRI)

Bone stress injuries resulting from overuse are frequent
not only in athletes and in military trainees but also in
healthy people who have recently started a new or inten-
sive physical activity.10 However, reported cases of bone
stress injuries in the knee in young adults are rare; only
case reports have been previously published (Table 1).
The diagnosis of bone stress injury is based on a history
of increased physical activity and on imaging findings.1
‡
Address correspondence to Martti J. Kiuru, MD, PhD, MSc,
Topeliuksenkatu 5, PO Box 266, Helsinki, Finland 00029 HUS (e-mail:
martti.kiuru@hus.fi).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 34, No. 1
DOI: 10.1177/0363546505278699
© 2006 American Orthopaedic Society for Sports Medicine
The clinical diagnosis of bone stress injury is difficult,
and plain radiographs can produce false-negative find-
ings.5,11, 21,32,43,51 In bone scans, false-positive cases are
common, especially in the knee area, where osteonecrosis,
osteochondritis dissecans, or ligamentous injury can result
in abnormal uptake.8 One of the first choice diagnostic
modalities for stress-related bone changes 1,2,6,12,21,25,46 and
for the internal derangement of the knee joint is MRI.28,38
The purpose of the present study was to assess the inci-
dence, location, nature, and patterns of bone stress injuries
in physically active young adults based on MRI.
MATERIALS AND METHODS
This retrospective study took place in the Central Military
Hospital in Helsinki, Finland. It involved 1577 knees of

78
Vol. 34, No. 1, 2006 Bone Stress Injuries Causing Exercise-Induced Knee Pain 79

TABLE 1
Reported Cases of Knee Stress Fractures (SF) in Previous Studiesa

Duration of
Patients, SF, Symptom Before Diagnosis
Author Year Location of SF n n Bilateral Activity Age Gender Radiology of SF

Milgrom et al33 1986 Medial femoral condyle 3 3 – Military 18 3m 8, 9, 12 wk BS

Weber49 1988 Femoral metaphysis- 1 1 – Tennis 15 m 4 wk R
epiphyses
Boden and Speer7 1997 Femoral condyle 1 1 – Baseball, 19 m 10 wk MRI
basketball
Yasuda et al53 1992 Supracondylar femur 1 1 – Rugby 15 m NA R, BS
Muralikuttan and 1999 Supracondylar femur 2 2 – Military 19, 18 2m 1d R
Sankarart-
Kutty36
Glorioso et al14 2002 Supracondylar femur 2 2 – Running 19, 37 2f 4 wk MRI
Geslien et al13 1976 Tibial plateau NA 73 51 Military 17-30 NA 0-2 wk R, BS
Engber11 1977 Medial tibial plateau 36 57 21 NA 17-35 36 m 20-50 d R
Vossinakis and 2000 Medial tibial plateau 1 1 – Running 38 m 20 wk MRI
Tasker51
Hensal et al16 1983 Patella 1 2 1 Basketball 17 m 0d R
Jerosch et al18 1989 Patella 1 1 – Recreational 20 m 1-2 d R
sports
Teitz and 1992 Patella 2 2 – Ski instruction, 23, 36 m, f 1 mo, 1 mo R
Harrington47 belly dancing
Orava et al37 1996 Patella 5 5 – Sports 21 2 m, 3 f 2-8 mo R, BS
Mason et al26 1996 Patella 3 3 – Running, 48, 15, 23 m, 2 f 2 y, 2 mo R
gymnastics,
basketball
Mayers et al29 2001 Patella 1 1 – Football 21 m NA R
a
m, male; f, female; NA, not available; R, radiograph; BS, bone scan; MRI, magnetic resonance imaging.

1330 consecutive military conscripts (34 women, 1296
men; age range, 17-29 years; mean, 20 years), who during
a period of 70 months, beginning in 1997, underwent MRI
because of stress-related knee pain. The conscripts were
referred to the Central Military Hospital for an
orthopaedic surgeon’s consultation because exercise-
induced knee pain had disturbed their military training.
The inclusion criteria for the present study were exercise-
induced knee pain during the military service, a physical
examination by an orthopaedic surgeon in the Central
Military Hospital, a negative finding on a plain radiograph
taken in the primary military health care unit, and a find-
ing on an MRI of a bone stress injury. The exclusion crite-
ria were infection and a known recent trauma involving
the knee. The original medical records and MRIs of
patients meeting these inclusion and exclusion criteria
were reviewed and retrieved. The study was approved by
the Medical Ethics Committee of the institution.
Physical examination by the orthopaedic surgeon
involved careful history taking and palpation. The range of
movement (extension-flexion) and the ligamentous stability
(anterior-posterior and side stability) of both knee joints
were examined. Skin changes were recorded. The ability to
walk and to jump on 1 foot was examined, and any other
aberrant observations were recorded. The symptomatic
knees, based on patient history and on physical examina-
tion, underwent MRI.
The MRI scans were performed with a 1.0 T scanner
(Sigma Horizon, GE Medical Systems, Milwaukee, Wis). A
knee coil with a field of view of 10 to 16 cm was used. Slice
thickness was 3 to 4 mm, with a 0.5-mm or 1.0-mm inter-
section gap. Sagittal proton density spin-echo sequence
images with fat suppression (repetition time/echo time =
3400 ms/17 ms, with 2 signals averaged and a 256 × 256
[516] matrix) or sagittal T1-weighted spin-echo sequence
images (repetition time/echo time = 680 ms/11 ms, with
2 signals averaged and a 256 × 256 [512] matrix) were
obtained. T2-weighted fast spin-echo sequences with fat
suppression were obtained in the axial images (repetition
time/echo time = 2560 ms/85 ms, with 2 signals averaged
and a 256 × 256 [512] matrix) and in the coronal images
(repetition time/echo time = 4000-4600 ms/72-90 ms, with
2 signals averaged and a 256 × 256 [512] matrix).
Two musculoskeletal radiologists reevaluated the MRIs
retrospectively and independently, without knowledge of
the clinical data. In case of disagreement of the interpre-
tation, a third musculoskeletal radiologist interpreted the
MRI. The MRIs of the knees were analyzed for bone stress
injury location and bone stress injury type. Bone stress
injuries were graded as follows 22: grade I, endosteal mar-
row edema; grade II, periosteal edema and endosteal mar-
row edema; grade III, muscle edema, periosteal edema,
and endosteal marrow edema; grade IV, fracture line; and
grade V, callus in cortical bone. Internal derangement of
the knee was recorded.
All Finnish men become liable for a 6-, 9-, or 12-month-
long military service at the age of 18. Within the service area
of the hospital, the total exposure time for the population at
80 Niva et al
Figure 1. A 20-year-old male conscript suffering from left
knee pain for 41 days. A, coronal T2-weighted fat saturated
MRI reveals a high signal intensity indicating endosteal bone
marrow edema both in the medial femoral condyle and in the
medial tibial plateau (arrows). A tiny intraosseous fracture
line is visible (arrowhead). B, axial T2-weighted fat saturated
MRI demonstrates not only endosteal edema (arrow) but also
periosteal edema (arrowhead) in the medial tibial plateau.
Figure 2. A 22-year-old male conscript suffering from right
knee pain for 14 days. A, coronal T2-weighted fat saturated
MRI demonstrates a fracture line (arrowheads) with associated
bone marrow edema of the medial tibial plateau. B, sagittal
T1-weighted image indicates a nearly horizontal, posteriorly
wide, slightly irregular line of reduced signal intensity (arrow-
heads) in the proximal medial tibia around the epiphysial line.
risk during the study period was 85 318 person-years. This
number was calculated by registering the dates of entry
and transfer or discharge of every conscript in the catch-
ment area of the hospital. The catchment area was clearly
defined. The Mann-Whitney U test was used to test the
differences in the continuous skewed data between groups.
Differences in cross tables were determined using the
Fisher exact test. The limit for significance was set equal
to .05. Data analysis was performed using SPSS/Win (ver-
sion 11.0, SPSS Inc, Chicago, Ill).
RESULTS
Based on MRI, 88 (1 woman, 87 men; age range, 19-29
years; mean, 21 years) of the 1330 patients had 141 bone
stress injuries in the knee. Of the 113 knees in these 88
patients that underwent MRI, bone stress injuries were
The American Journal of Sports Medicine
Figure 3. A 20-year-old male conscript suffering from right
knee pain for 14 days. Coronal T2-weighted fat saturated
MRI indicating a transverse supracondylar femoral fracture
line (arrows) with associated bone marrow edema and soft
tissue edema.
seen in 110 knees, and 3 knees appeared normal. Of the
1577 knees that underwent MRI, at least 1 bone stress
injury occurred in 7% (110 of 1577) of the cases; internal
derangement—meniscal lesions, ligamentous injuries,
patellar chondromalacia, osteochondritis dissecans, and
plicae—occurred in 8.6% (135 of 1577) of the cases; and in
84.3% (1329 of 1577) of the knees, there were no aberrant
findings. The incidence of conscripts having sustained a
bone stress injury in the knee was 103 per 100 000 person-
years. Of the 88 patients, 53% had 1 bone stress injury, and
47% had 2 or more solitary bone stress injuries either in
one or both knees. Altogether, 55% (77 of 141) of bone
stress injuries occurred in the right knee and 45% (64 of
141) in the left knee.
After the commencement of military training, the median
time for an orthopaedic consultation was 42 days (range,
11-207 days; n = 43 knees) in patients with bone stress
injury in the medial tibial plateau and 59 days (range, 7-
280 days; n = 70 knees) in patients with bone stress injury
in another location (P = .014). In all 88 patients, the mean
duration of knee pain before MRI was 55.6 days (median,
48.5 days; range, 13-180 days; n = 92 knees with pain data
Vol. 34, No. 1, 2006 Bone Stress Injuries Causing Exercise-Induced Knee Pain 81

Figure 4. A 19-year-old male conscript suffering from left knee pain for 21 days. A and B, sagittal and coronal T2-weighted fat
saturated MRI reveal a high signal intensity indicating endosteal bone marrow edema of patella (arrows). C, axial proton density
image demonstrates not only endosteal edema and periosteal edema but also soft tissue edema (grade III) (arrow).

TABLE 2
medial tibial plateau, and 1 (5%) had bilateral supra-
Anatomical Locations and Magnetic Resonance Imaging
condylar bone stress injuries. Two solitary bone stress
(MRI) Grades (I-V) of Bone Stress Injuries
injuries in the same knee simultaneously were found in 25
MRI Grade of Bone Stress Injury patients (28%; 29 knees, 4 bilateral), and all these cases
involved the tibial and femoral condyles. The most com-
Grade Grade Grade Grade Grade Locations, mon combinations of anatomical locations involving the
Location I II III IV V no. % same knee were medial tibial plateau with medial femoral
Femur
condyle (11 patients, 13 knees) (Figure 1), entire tibial
Supracondylar 1 1 – 3 1 6 4 plateau with entire femoral condyle (7 patients, 8 knees),
Medial condyle 25 1 – 2 – 28 20 and entire tibial plateau with medial femoral condyle (5
Lateral condyle 1 – – – – 1 1 patients, 6 knees). The most common anatomical location
Medial and for bone stress injury was the medial tibial plateau (43 of
lateral condyles 11 – – – – 11 8 141; 31%), which was also the most typical location for a
Tibia fracture line (67%) (Table 2, Figure 2). Of all 141 bone
Medial plateau 14 2 1 26 – 43 31 stress injuries, 83 (59%) were in the tibial plateau, 7 (5%)
Lateral plateau 5 – – 1 – 6 4 were in the proximal tibial shaft, 40 (28%) were in the
Medial and
femoral condyles, and 6 (4%) were in the femoral supra-
lateral plateaus 31 – – 3 – 34 24
Proximal shaft 1 – – 4 2 7 5
condylar area (Figure 3). None of the fracture lines of the
Patella 3 2 – – – 5 4 condylar bone stress injuries extended into the articular
Total no. surface. There were no fibular bone stress injuries. Of the
of grades 92 6 1 39 3 141 141 bone stress injuries, bone marrow edema was exhibited
Percentage 65 4 1 28 2 100 in 65% of the cases. Patellar bone stress injuries were low
grades (Figure 4). In the 25 patients with 2 bone stress
injuries in the same knee simultaneously, no relationship
between the anatomical locations and the grades was
observed. Based on the MRIs of these 88 patients, 12
available). The median time to diagnosis of the bone stress
patients had a simultaneous intra-articular abnormality
injury by MRI after entering military service was 72 days
in the same knee as the bone stress injury: 6 patients had
(range, 21-319 days; n = 110 knees). There were no indi-
a meniscal tear, 2 patients had patellar chondromalacia,
vidual clinical findings found to be specifically related to
and 4 patients had a medial synovial plica.
bone stress injuries in the knee.
Both knees were imaged in 25 patients (28%) because of
bilateral knee pain. Twenty-two patients (25%) had bilat- DISCUSSION
eral bone stress injuries, giving them the incidence of 26
per 100 000 person-years. Of these 22 patients, 13 (59%) In the present study, as compared with the previous liter-
had bilateral bone stress injuries in varying anatomical ature (Table 1), a surprisingly high proportion, almost a
locations, 8 (36%) had bone stress injuries in the bilateral tenth of conscripts, had a bone stress injury in the knee as
82 Niva et al
a cause of exercise-induced knee pain. The incidence of
bone stress injury to the knee among Finnish military con-
scripts is 103 per 100 000 person-years. This incidence is
representative of the general conscript population during
military service. Previous studies concerning knee bone
stress injuries have been mainly case reports, and conse-
quently, the real incidence is unknown. The reports on the
general incidence of all lower extremity bone stress
injuries have varied from 2% to 31%.3,4,19,31,33,42
In the present study, the exercise-induced knee pain and
bone stress injuries appeared mainly during the basic
training period, that is, the first 3 months of military serv-
ice. This finding is in agreement with the findings of pre-
vious studies on bone stress injuries involving lower
extremities.13,15,31,33,35,36,42 The abrupt increase in the
intensity or duration of training, to which the trainees are
often not accustomed in civilian life, is usually reported.11,13,35
In this study, after the commencement of military training,
the conscripts with bone stress injuries in the medial tib-
ial plateau sought medical advice about 2 weeks earlier
than did patients with bone stress injuries in other
anatomical locations. In a study by Engber et al,11 the
delay between the inception of knee pain and the time
when medical advice was sought was even shorter, a mean
of 9 days (range, 3-50 days).
In this study, a quarter of all patients had a bilateral
knee bone stress injury. The proportion of the bilateral
bone stress injuries involving the medial tibial plateau,
47%, was lower than in earlier reports,11,13 in which the
proportions were 74% and 70%, respectively. Depending on
the determination of the bone stress injury, the proportion
of bilateral bone stress injuries may have increased if the
pain-negative knees had also undergone MRI and bone
stress injuries had been calculated. However, an intense
isotope accumulation in the medial tibial plateau in
asymptomatic patients has also been considered to indi-
cate an early physiological abnormality, a stress-related
bone remodeling, and, therefore, a false-positive.11 The
finding in the present study that about one third of the
patients had 2 bone stress injuries in the same knee simul-
taneously seems to represent a very unusual combination
of bone stress injuries in previously healthy individuals
because we found no similar references in the English lit-
erature.
The weightbearing stress in the proximal tibia is
thought to be greatest in the medial and posterior parts of
the bone.40 In the shaft, the thick cortex handles most of
the stress, whereas in the ends of the long bones, the can-
cellous trabeculae handle much of the weightbearing
stress.43 In this study, the medial tibial plateau was the
most common anatomical location involved with bone
stress injury, accounting for about one third of all loca-
tions. In more than half of the cases, the location was
exhibited by a fracture line surrounded by bone marrow
edema. An explanation for this anatomical location may be
found in the varying individual biomechanical factors23
and in the differences in exercise, terrain, and genetic fac-
tors as well. It is possible that with a larger female popu-
lation, the number and distribution of bone stress injuries
might have been different. Variation in the results of the
The American Journal of Sports Medicine
previous studies (female recruits showed a greater risk
and incidence as well as a different distribution of stress
fracture than did male recruits) probably reflects not only
the differences in the composition of each case series but
also the differences in the biomechanical features and
endocrine factors. 3,7,9,27,41,48
Military recruits with a running background had fewer
stress fractures,15 whereas conscripts with multiple bone
stress fractures had not participated in sports before their
military service.30 In a recent report by Hohmann et al,17
MRIs of the hips and knees in long-distance runners dis-
played no bone marrow edema or periosteal stress reac-
tions before and after a marathon race. It was thought that
the runners’ long-lasting training history compensated for
the extreme demands.
The study of choice for evaluating the trabecular bone of
the condyles is MRI.7 It is usually adequate for making a
distinction between a spontaneous osteonecrosis and an
insufficiency stress fracture in the medial femoral condyle
and in the medial tibial plateau.44,52 On an MRI, a highly
sensitive early sign of a stress-related bone stress injury is
the endosteal marrow edema, whereas the only specific
MRI finding for a bone stress injury is a fracture line.25 In
this study, about two thirds of all bone stress injuries,
regardless of the anatomical location, appeared as grade I.
However, a bone marrow edema is a nonspecific finding
that can also be evident in bone bruises, infections, malig-
nancies, and in asymptomatic physically active per-
sons.2,20,39,44,46,50 In the present study, the differentiation
between bone stress injuries and bone bruises was made
on the basis of a negative trauma history.
The diagnosis of internal derangement of the knee
has commonly been used as a name for the condition of
the painful knee joint. In the literature review, we were
not able to find any reference to an association between
bone stress injury and internal derangement of the knee
joint in young adults to support the findings of the pres-
ent study. It remains unclear whether the meniscal tears
observed in this study as causing medial knee pain
might have had an effect in the development of bone
stress injuries or whether those tears were such as found
by MRI in approximately one third of the patients without
knee complaints.8,24 In the present study, however, nei-
ther subchondral marrow edema nor sclerosis was seen
adjacent to the ruptured menisci or chondral changes, as
is usually the case with transient posttraumatic abnor-
malities.34
The typical diagnostic features in young adults with
bone stress injuries are unaccustomed or unusual activity
preceding localized pain with insidious onset, worsening of
pain with progressive activity, and relief of pain by
rest.7,11,15,19 The proximity of a bone stress injury to the
knee joint can confuse the clinical diagnosis with a lesion
within a joint 11,51; medial knee pain can raise a suspicion
of a rupture of the medial meniscus.31,51 In conclusion, a
typical patient history without recent trauma, unclear
findings in the physical examination, and negative plain
radiograph results should emphasize MRI as the diagnos-
tic method for bone stress injuries before an arthroscopic
procedure is performed.
Vol. 34, No. 1, 2006
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