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Significance of tibial MRI findings of special forces recruits at the onset of their training
  1. Charles Milgrom1,
  2. N Tsur2,
  3. I Eshed3,
  4. Y Milgrom4,
  5. S Beyth4,
  6. E Spitzer5,
  7. I Gofman2 and
  8. A S Finestone6
  1. 1Military Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel
  2. 2Medical Corps, Israel Navy, Tel Aviv, Israel
  3. 3Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
  4. 4Internal Medicine and Orthopaedic Surgery, Hebrew University Hadassah Medical School, Jerusalem, Israel
  5. 5Medical Corps, Israel Defense Forces, Tel Aviv, Israel
  6. 6Orthopaedics, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
  1. Correspondence to Professor Charles Milgrom, Military Medicine, Hebrew University Hadassah Medical School, Jerusalem 911200, Israel; charlesm{at}


Introduction MRI is commonly used to evaluate medial tibial stress syndrome (MTSS), based on grading assessments developed in civilian populations. When MTSS represents stress fracture, rest is required to allow for bone remodelling to occur. False positive evaluations can lead to unnecessary recruit attrition.

Methods Thirty randomly selected new recruits to a special forces training unit underwent MRI of their tibias using the T2-Dixon sequence at the onset of training. Evaluation was according to the Fredericson MTSS grading system. Prior to undergoing MRI, anthropomorphic measurements, a survey of sports history and an orthopaedic examination of subject tibias were performed. Orthopaedic follow-up was through 11 weeks of training.

Results Medial periosteal oedema without the presence of bone marrow oedema, corresponding to a grade 1 stress reaction, was present on MRI in 10 recruits (17 tibias). In only one case did the periosteal oedema include the posterior aspect of the medial cortex where medial tibial stress fractures usually occur. Tibial tenderness was present in seven tibias on examination done just prior to the MRI studies, but none were symptomatic and only one had periosteal oedema present on MRI, but without anatomical correlation between the site of the tenderness and the periosteal oedema. During subsequent training, five tibias in four recruits developed pain and tenderness. Two had periosteal oedema in their prior MRIs, but the location did not coincide anatomically with that of the tibial tenderness. The time from stopping sports before induction and the presence of periosteal oedema was not significant.

Conclusion Periosteal oedema, one of the hallmarks used in MRI grading systems to evaluate MTSS, was found to have a 37.7% false positive rate for anatomically corresponding tibial tenderness at the time of the examination and during subsequent training, indicating the grading systems’ low utility for the military.

  • Orthopaedic sports trauma
  • Trauma management
  • Magnetic resonance imaging
  • Adult orthopaedics

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. Not applicable.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. Not applicable.

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  • Contributors CM planned the study, participated in the data collection, prepared the original manuscript draft and is the study guarantor. NT coordinated the study within the military unit and was responsible for the IDF ethics committee submission and approval. IE was responsible for the design of the MRI protocol and performing MRI readings. YM contributed to data analysis, study logistics and manuscript reviewing and editing. SB was responsible for the HMO ethics committee submission and approval and in-hospital logistics. ES performed the initial orthopaedic stress fracture examinations and participated in the orthopaedic follow-up. IG was the unit medical doctor and performed and documented recruit primary medical care. ASF planned the study, performed data analysis and performed orthopaedic follow-up and manuscript preparation.

  • Funding The study was supported by internal funding from the Hadassah Medical Organization (#8528183).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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