Publications

INTRODUCTION: Bone stress injuries (BSIs) are common overuse injuries in athletes and are associated with prolonged recovery and high rates of reinjury. Despite their clinical importance, there is no consensus on how to define or assess BSI healing. Clinical, functional and imaging outcomes for BSI healing are used inconsistently across studies, limiting comparability and the development of evidence-based return-to-sport guidelines. This study aims to identify and characterise candidate outcomes for assessing BSI healing in runners, including their time course and variability across function, imaging and clinical domains.

METHODS AND ANALYSIS: This is a 1 year, multi-site prospective cohort study of male and female runners with a recent MRI-confirmed BSI of the tibia, metatarsals, femoral neck or sacrum. We will enrol participants across four clinical and academic research sites in the USA and Canada, within 3 weeks of diagnostic MRI and follow them longitudinally for 1 year through recovery, return to sport and full sport participation. Candidate outcomes for BSI healing include time to pain-free functional milestones (eg, hopping, jogging), completion of a return-to-run protocol, medical clearance for unrestricted activity, and changes in MRI grade and clinical severity scores. Secondary and exploratory measures include training patterns, wearable-derived activity and sleep metrics, biomechanical assessments, and serum proteomic profiles. We will use descriptive statistics to characterise the time course and variability of candidate outcomes. We will explore associations between outcomes and subsequent BSIs within 1 year using regression models.

ETHICS AND DISSEMINATION: This study has received institutional review board approval at all participating institutions. We will obtain written informed consent from all participants prior to any study procedures (and assent with parental consent for minors). We will disseminate results through peer-reviewed publications and scientific conferences.

BACKGROUND: While ultra-high-resolution (UHR) photon-counting detector CT (PCD-CT) shows promising agreement with high resolution peripheral quantitative CT for bone microarchitecture evaluation, clinical translation requires balancing noise, resolution, and dose. Conventional optimization relies on objective metrics and may not reflect task-based perception. A hybrid approach integrating objective and subjective assessment may better guide the development of clinically robust PCD-CT UHR bone imaging protocols.

PURPOSE: To apply a hybrid objective-subjective approach to optimize PCD-CT UHR bone imaging protocol at clinically acceptable dose levels.

METHODS: Four cadaveric specimens (one lumbar vertebra and three proximal femora) along with the Mindways phantom (Model 3), were imaged with PCD-CT (NAEOTOM Alpha.Peak VB20, Siemens Healthineers) at 120kVp. Six total acquisitions were performed at three dose levels, IQ-75 (3.0-4.3mGy), IQ-150 (6.0-8.6mGy), and IQ-450 (17.9-25.7mGy) across two pitch settings (0.35 and 0.85). For each acquisition, images were reconstructed using three kernels (Br76, Br89, Br98) and two levels of Quantum Iterative Reconstruction (QIR2 and QIR4), yielding 35 unique protocols. Protocol performance was evaluated using both objective and subjective assessment. Objective metrics included SNR, CNR, and task-based transfer function (TTF) f50 for spatial resolution. Task-based protocol performance was independently assessed by four radiologists using a 5-point Likert scale for cortical sharpness, trabecular visibility, and noise. Statistical analysis for SNR, CNR, TTF-f50 and Likert ratings were performed, and heatmaps were generated to evaluate protocol performance. Interrater reliability was assessed using a two-way random-effects, absolute-agreement intraclass correlation coefficient (ICC).

RESULTS: SNR and CNR were highest with Br76 kernel, QIR4, and highest exposure (IQ-450), while noise was lowest for Br76, increased with sharper kernels (Br89, Br98) and lower IQ, and was markedly reduced with QIR4; pitch had minimal impact (figures 1, 2). Variance analysis showed that QIR had the greatest impact (η² = 0.54, 0.52), followed by kernel (η² = 0.29, 0.32) and IQ (η² = 0.09, 0.08), while pitch had no significant effect. For Br76, TTF-f50 was consistently higher with QIR2 than QIR4 (1.62 vs 1.36 at IQ-75, pitch 0.85), with minimal dependence on IQ and pitch. Consistently, Br76 achieved the highest scores (mean Likert 4.2), outperforming Br89 (3.88) and Br98 (3.02), with scores improving with increasing IQ and at QIR2, and minimal impact from pitch. Interrater reliability was excellent (ICC = 0.92).

CONCLUSION: Br76 provided the best objective-subjective performance for trabecular bone assessment, with QIR4 minimizing noise and maximizing SNR/CNR, while QIR2 better preserved spatial resolution; pitch had no significant effect. Protocol optimization of PCD-CT for UHR imaging of trabecular bone at a clinically acceptable radiation dose is essential to unlock its full potential in clinical research.

OBJECTIVE: To gain insight into higher fracture risk in individuals with type 2 diabetes, we determined the association of type 2 diabetes glycemic status and severity with longitudinal changes in peripheral bone density and microarchitecture.

RESEARCH DESIGN AND METHODS: We conducted a longitudinal study of 769 participants from the Framingham Study who underwent high-resolution, peripheral, quantitative computed tomography (HR-pQCT) at the tibia and radius, in 2012-2016 and 2021-2023 (mean 8-year follow-up). Linear regression models estimated mean 8-year percent changes in bone measures, across indicators of diabetes severity, adjusting for age, sex, weight, and height.

RESULTS: The mean age was 67 ± 7 years, and 59% of participants were women. More than half (57%) were normoglycemic (fasting plasma glucose [FPG] <100 mg/dL, not on any treatment), 31% had prediabetes (100 ≤ FPG ≤125 mg/dL), and 12% had type 2 diabetes (FPG >125 mg/dL or on treatment). Adjusted mean percent changes in HR-pQCT bone measures were similar across diabetes severity, including glycemic status, use of diabetes medications, duration of diabetes, and HbA1c. For example, cortical volumetric bone mineral density at the radius changed by -1.50% (95% CI -2.43, -0.56) in type 2 diabetes and -1.96% (-2.53, -1.39), in prediabetes, compared with -2.42% (-2.86, -1.97) in normoglycemia (reference group; all P > 0.05).

CONCLUSIONS: The magnitude of peripheral bone loss over 8 years did not differ between individuals with type 2 diabetes and those with normoglycemia, suggesting that bone deterioration alone does not explain the higher fracture risk in older adults with type 2 diabetes. Future studies should address other contributors to skeletal fragility.