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X ray detail
Lateral X Ray
Biopsy of a stress fracture is best avoided ( healing callus from the fracture can easily be misdiagnosed as malignant osteoid). Make the diagnosis on other imaging modalities if possible. A normal ESR and blood count should rule out Osteitis as a cause of the sclerosis.
If the plain film turns out to be negative, which is quite frequently the case, than consider either an MRI or bone scintigraphy to further evaluate the clinical finding.
MRI can easily detect minor stress reactions such as bone contusions. . If in addition the typical linear low signal component is identified, then the classic criteria for a stress fracture are present In addition, MRI is sensitive enough to detect further malignant entities causing a marrow replacement, which would make the bone prone to insufficiency fracture.
Another approach can be 3-phase skeletal scintigraphy with 99mTc MDP. It is important to image the contralateral normal side as well. The first phase of the study is the dynamic phase, and rapid sequence dynamic images are obtained for approximately 1 minute. The second phase is the blood pool phase. Static planar images are obtained immediately after the dynamic images. The third phase images consist of static planar images obtained 2-3 hours later.