The sensitivity and specificity of therapeutic ultrasound to diagnose stress fractures of the lower limb were classed as low to moderate (seven studies 333 participants) pooled sensitivity was 64% (95% CI 55 to 73), pooled specificity was 63% (95% CI 54 to 71). However, in all studies, the reference standard was independent of the index test and described in sufficient detail to permit its replication most studies clearly reported uninterpretable and/or intermediate test results. ![]() Two studies had a significantly long time between the index and reference tests (therefore the pathology may have changed between tests), the index test was not clearly described in all studies,and it was unclear in most studies whether the index test and reference test were undertaken without the examiner's knowledge of the other test results. The reference standard varied between studies. Many of the studies did not clearly specify selection criteria for participants. Seven studies investigated therapeutic ultrasound two studies investigated tuning fork tests to diagnose stress fractures of the lower limb. Nine diagnostic accuracy studies were included in the review including 420 participants. Two reviewers independently assessed studies for inclusion, with disagreements resolved by consultation with a third reviewer. ![]() Precise definitions of positive index tests varied between studies (full details given in review). The reference standard was scintigraphy, roentgenogram, MRI or a combination of these tests. Assessors included sonography technicians, physiotherapists, a nuclear medicine physician, a radiologist and other clinicians not otherwise specified. Index tests assessed were ultrasound (most used a 3cm head and intensity up to 2.0W/cm 2, 30 second application, where reported) or tuning fork (128Hz to 512Hz). Participants included soldiers or military basic trainees, athletes, and runners with symptoms of stress fracture of the tibia or fibula or knee pain. Most studies included both men and women with average age ranging from 19 to 31 years, where reported. Studies had to be published as full reports before June 2011 to be eligible for inclusion. ![]() Studies that specifically assessed pathological stress fractures were excluded. Studies had to include only lower-limb stress fractures, and not impose an age restriction for participants. Studies had to report or allow computation of sensitivity, specificity and likelihood ratios. Diagnostic accuracy studies of one or more clinical tests, compared against a radiological reference test, for the examination of suspected stress fractures were eligible for inclusion.
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