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Milgrom and Finestone, 2008

Milgrom and Finestone, 2008

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01/29/2013

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How
Stress
Fracture
Incidence
WasLowered
in
the
Israeli
Army:
A
25-yr
Struggle
AHARON
FINESTONE'
andCHARLES
MILGROM
2
1
The
Foot
and
Ankle
Unit,
OrthopaedicDepartment,
Assaf
Harofeh
Medical
Center,
Zerijffin,
ISRAEL;
and
2
Department
of
Orthopaedic
Surgery,
The
Hadassah-Hebrew
University
Medical Center,Ein
Kerem,
Jerusalem,
ISRAEL
ABSTRACT
FINESTONE,
A., and C.
MILGROM.,HowStress FractureIncidence
Was
Lowered
in the Israeli
Army:A 25-yr Struggle.
Med.
Sci.
Sports
Exerc.,
Vol.
40,
No.
lIS,
pp.
S623-S629,
2008.
In
1983,
a
31%
incidence
of
stress
fractures was
found among
Israelibasicinfantryrecruits.
Purpose:
Thepurpose
of
thisarticle
is
to chronicle the efforts
of
he
Israeli
DefenseForces to
lower
the
stress fracture
incidence
and
to
present newdatashowing howreduction
was
finally achieved.
Methods:
A
historicalreview
of
the stepstaken
overthe
past
25
yr
to decreasestress
fracture
incidence
inthe Israeli
Army
is
presented:
risk
factors for stress
fracture
were identified
to
createa
risk profile
and facilitate
screening
of
recruits;
modifications
in army
shoeswere
made;
shock attenuatingorthoses
and
biomechanicalorthoses
of
variouscompositions were
used;
and the bisphosphonaterisedronate
was
administered
to
recruitsbefore
and
duringbasictraining. Inthelatestintervention, the combinedeffect
of
a minimumnightly
sleep
requirement
(6
h
a
night)
anda
decreasein
recruits' cumulative marchingand running
onthe
incidence
of
stress
fractures was
evaluatedamong
2761infantry
recruits.
Results: A
stress
fracture risk
profile
was
developed.
It
allows
a
recruit's
stressfracture
risk
to
be
calculated before
infantry
training. Shoemodifications, orthoses,and pharmacologicaltreatment
with
risedronate were not-effective
in
lowering
the
incidence
of
stress
fractures.
The minimum
sleep
regimen
and
thereduced cumulativemarching
lowered the
incidence
of
stress
fracturesby
62%
(from
30.8%
to
11.6%)
and decreased their severity
as
comparedwiththe
1983
baselinestudy.
Conclusion:
Afterfailing in prior interventions,a more
than60%
decrease
in
stress
fracture
incidence
was
achieved by enforcing
a
minimum sleep .regimenand
loweringthe
cumulativemarching duringinfantry training.
These
ýchanges
didnot affect the quality
of
the
training or
the
soldiers' combatreadiness.
Key
Words:
BONE,
FATIGUE FRACTURE,INTERVENTION,RISKFACTOR,MILITARY,SLEEP DEPRIVATION
The
goal
of
infantry training
is
to
produce
a
combat
soldier. Physical
performance,endurance,
mental
conditioning,
andcombat
skills
must be builtat
a
minimum
risk
of
injury.
Most
of
the
injuries
sustained
by
infantrytrainees
are
secondary
to
overuseandnot
to
acute
trauma.
In
the
first Israeli
prospective
study
of
the
epidemiology
of
overuseinjuries amonginfantry recruits
in1983,
an alarming
31%
incidence
of
stressfractures was
found
during
14
wk
of
infantry basic
training
(20).
Subsequentstudies,usingthe samematerialsand methods,foundtheincidence
to
be
in the range
of
23%
to
24%
(18,27).
These findingsspurred effortsto find waystodecreasetheincidence
of
stressfractures.
The purpose
of
this
article
is
to chronicle the effortsmadeby the Israeli
Defense
Forces over thepast two decadestolowerthe incidence
of
stressfractures amonginfantrysoldiers and
topresent
new
data
showing how
reductionwas finally achieved.
Address
for correspondence:CharlesMilgrom, M.D., Department
of
Orthopaedics,Hadassah
University
Hospital, Ein Kerem,P.O. Box
12000,
Jerusalem 91120,
Israel;E-mail:
charles.milgrom@ekmd.huji.ac.il.0195-9131/08/401IS-S623/0MEDICINE
&
SCIENCE
IN
SPORTS
&
EXERCISE_Copyright
©
2008by
the
AmericanCollege
of
Sports MedicineDOI: l0.1249/MSS.0b013e3181892dc2
STEPS
TAKEN
TOLOWER
THE
INCIDENCE
OF
STRESS
FRACTURES
I.
Identification
of
potential
risk
and
preventive
factors
for
stress
fracture
The
firststep toward thelowering
of
theincidence
of
stress fractures was
to
identify
possiblerisk
factors
for
theirdevelopment(9,11).
In
spite
of
a
high
incidence
of
overuse
injuries,
most infantryrecruits finishtheir basic trainingwithout injury.It
was
thoughtthat thosewho sustained
stressfractures
mighthave
eitherintrinsic anatomic
or
physiological
factors
and/or
deficienciesin
their
lifestyle
such
as lack
of
physical
activity beforearmy service, whichincreasedthe risk
for
stressfracture.
In
an initial
study,before beginning
basic
training,
infantry recruitswere assessed
for
factors consideredto
have
a
possiblerelationshipwith
the incidence
of
stressfractures
(11).
Some
of
thefactors studiedwere chosenbasedon
priorpublished
articles (15,24,26), others due
to
biomechanical considerations.Recruitswere
then
followedduring
14
wk
of
basictraining andwere actively examinedbya team
of
physiciansevery2or
3
wk
for
the
presence
of
overuseinjuries.
Recruits
suspected
of
having
stress
fracture
underwentbone
scintigraphyevaluation.
Narrow
tibiaswere found
to
be
a
risk
factor
for
both
tibial and femoralstress fractures(Table
1).
Thebasis
for
the associationbetween
bonesize
and the risk
for
stress
S623
 
TABLE
1.
Overall
incidence
of
stress
fracturesamong
infantry
recruitsaccording
to
tibial
bone
width.*
%
of
soldiers
without
stress
fractures
%
ofsoldierswith
stress
fractures
Bone
Width
ý
Narrow
BoneWide
Bone
Stress
Fractures
(Width
_<26
mm)(Width
>26
mm)
TotalNumber
of
soldiers
69
(58.0)
130 (76.9)199
(69.1)v:dthout
stress
fractures
(%)
Number
of
soldiers50(42.0)39
(23.1)
89(30.9)
with
stress
fractures
(%)
Total
j19
169
288
*
Pvilue
<
0.01
fracture
canbe
found
in
basicengineeringstrength
calculations.
Diaphyseal
bone
canbe
idealized
as
a
cylinder.
For
suchaconstruct,the
bending
strength
is
proportional
totheareamomerlt
of
inertia,therotationalstrength
is
proportional
to
the
polar
area
of
inertia,and
the
compressionstrength
is
proportional
tothecross-sectional
area.
Thepolar
and
the
area
moments
of
inertia
are
proportionaltotheradipstothefourth
power
(r
4
),
andthecross-sectionalarea
is
proportionaltothe
radius
tothesecond
power
(r
2
).
Practicallyand
assuming
thesamematerialproperties,thismeans
that
if
thediameter
of
a
bone
increasesfrom
2
to2.5
cm,
then
the
bending
andtherotationalstrengthincreasesby
126%
and thecompressionstrengthincreases
by
51%.
Externalrotation
of
thehipgreaterthan
650
was
found
tobe ariskfactor
for
stressfractures(9,14)(Table
2).
The
basisfor
this
association
is
notknown.Narrow
tibial
bone
size
(11,12)
andhighexternalrotation
of
thehip
(11,14)are
independent
riskfactors
for
stressfracture.
Their
risk
is
cumulative.
Combining
themallows
for
effectivepr6filing
of
recruitsat
highrisk
forstressfractureduringinfantrybasictraining(Fig.
1).
Recruitswithtruepesplanus
are
routinely
not
admittedintoIsraeliarmyinfantryservice..Whenfootarchheightwasclassifiedintocategories
of
lowernormal,normal,
and
high
arch,lownormalarchwas
found
to
be
a
protectivefactbr
for
stressfracturesin
basic
training
(13).
The
arch
typd
was
assessed
off
weight
bearing.
A
10%
incidence
of
stressfractureswasfound
among
recruitswithlow
normalfoot
arches
as
opposed
to39.6%incidenceamongthosewithhigharches
(P
<
0.05).Recruits
whose
footarchesweredefined
as
averagehad
a
31.3%incidence.Recruits'agewasfound
to
be
a
risk
factor
for
stressfracturesduringinfantrybasictraining.Recruitswho
were
TABLE
2.
Overall
incidence
of
stress
fractures
among
infantry
recruitsaccording
to
externalrotation
of
the
hip.*
Hip
ExternalRotation
Stress
Fractures
<65*>65*
Total
,Nurpber
of
soldiers
149
(75.3)
47
(56.0)196(69.5)without
stress
fractures
(%)
Number
of
soldiers
49
(24.7)37
(44.0)
86
(30.5)
with
stress
fractures
(%)
Total
198
84
282
Pvilue
<0.005.
Bone
width:5
26
omm
FIGURE
I-Cumulative
stress
fracturerisk
of
tibial
bone
width
andexternal
rotationof
the
hip.
,younger
hada
higher
incidence
of
stressfractures.Riskdecreased
by
28%
for
everyyearincrease
of
agebetween
17
and26
years
(17).
This
associationcan
be
explainedbythe
fact
thatthe
bone
reaches
its
maximumstrengthattheage
of
25
to
26years.
Thetype
of
physical
activity
of
recruitsbeforemilitaryinductionwas
a
major
determinant
for
stressfracture
risk
in
basictraining.
It
was
found
that
recruits
whohad
playedbasketball
with
a
frequencythreetimes
a
weekormore,
for
at
least
2
yr
before
military
induction,had
a
low
risk
for
stressfractures
in
basictraining(Table
3)
(21,22).
Long-
distance
running
was
not
protective.
The
explanation
is
thatwhereaslong-distance
running
involvestherepetition
of
the
samestride.patternoverandoveragain,basketball
isan
activitywithmultipleforcevectors.
Assuming
Wolff's
law
is
true,basketball
wouldbe
expectedtostrengthen
bone
againstforcesin
multiple
directionsand
runningonly
tostrengthen
it
for
a
limited
number
of
forcevectors.
When
infantry
basic
traineeswerefollowed
throughtheirsubsequentyear
of
infantryservice,aninterestingobservation
was
made.Recruitswho
sustained
femoralstressfractures
in
infantrybasictraining
werelfound
tobe
at a25%
higher
risktosustainstressfracturesin
futuretrainingwhen
compared
with
recruitswhodid
not
sustainstressfracturesinbasictraining.
However,
thisassociationwas
notfound
to
be
true
for
tibial
or
metatarsalstressfractures
(10).
Tibialbonemineral
content
and
bone
density
as
well
as
body
habitusaccording
to
heathcarter
somatotypeswere
notfound
to
be
relatedtotheincidence
of
stressfracture.
Prebasic
:•training
aerobicphysicalfitnesswas
notfound
to
be
relatedtotheincidence
of
stressfractures
(11).
The
studyandidentification
:of
riskfactorsallowed
us
to
build
a
profile
of
aninfantryrecruit
with
a
low
risk
for
stressfracture.Heshould
havewidebones,
a
low
range
of
hipexternalrotation,
a
low-normalfootarch,
bebeyond
his
teens
in
age,and
haveplayed
basketball
regularlyformore
than2
yr.
Unfortunately,
this
profile
is
more
of
theoreticalthan
of
practicaluse.
Motiv&ted,
physically
andmentallycapablecandidates
for
infantryor special
training
forcesare
http://www.acsm-msse.org
S624
Official
Journal
of
the
American
College
of
Sports
Medicine
 
TABLE
3.
Incidence
of
stress
fractures among recruits who
played
ball
sports
for
2 yr before induction
into
the army and
those
who
did
not
play.
1988 19901995Played
Did
Not
Play Played
Did
Not
Play Played
Oid
Not
Play
Site
(N=
129),
%
(N
m
53),
%
PValue
(N
=
90),
%
(N
=
304),
%
PValue
(N=
55),
%
(N
=
277),
%
PValue
Tibia
4.7 23.2
0.001
12.2 20.7 0.07
3.6 14.8
0.024
Femur
7.8
10.7 0.363
1.1
6.9
0.035
0
10.1
0.014
All
13.228.9
0.001
16.7 26.97 0.046 3.6 18.8 0.05
not
in
an
excess.
Soeven
if
a
candidate
has
a
40%risk forstressfracture,he
still
has
a 60%
chance
of
not
developing
a
stress
fracture
in
infantrytraining.
Eliminating
such
a
candidate
a
priori
from
infantryservice would
not
seem
to be warranted.
II.
Modifications
in
footwear
The
next effort
to
lower
the incidence
of
stress fracturescentered
on
shoe gear and orthoses.
It
was thought
thattraining with shoegear
that
had improved
shock
absorption
at
the foot ground interface could lower the incidence
of
stress fractures.
If
this hypothesis were true, it would havebeen
possible
to
lower theincidence
of
stress fractureswithoutany changes inthe training.
A
series
of
prospectivestudieswere carriedout
to
study
this hypothesis.
Inthe
first
study, the effect
of
training
in
basketball shoesinstead
of
traditional army shoes was studied.
Before
the
beginning
of
the
training, two
pairs
of
modified basketballshoes were given
at
random
to187
of
the recruits.
The
other
203
recruits received standard lightweight infantry
boots.The
soldiers were
not
allowedtochange shoe gear until
the
end
of
their training. Initially, the basketball shoes
were
judged
by
the
soldiers
to
be more comfortable than armyshoes. Once
it
rained, the soldiers changed their appraisal.The
areas
padding for
comfort absorbed water, and theshoes became heavy and damp.
During the
14
wk
of
training,
93
(24%)
of
390 recruits had sustaineda
total
of
140
stress fractures
(18).
Recruits training
in
a modifiedbasketball shoe had a statistically significant lower
inci-
dence
of
metatarsal stress fractures
(P
=
0.03)
and non-
stress-fracture-related
footoveruse injuries
(P
=
0.001)
compared
with
recruits
using
standardinfantry
boots,buttheir
overall incidence
of
overuse injuries was
not
reduced.
Foot
orthoses
are
devices that helpthefoot
to
function
better.
Theymay bedividedinto
four
basic types: devicesthat
reduce
impact and cushion the foot,
arch
supports,those used
to
relieve
pressure,
andbiomechanical,custom-fabricated shoe orthotics
that
are
designed
to
bring
the foot
into
proper
alignment
as it
strikesthe ground and therebyimprove function.
The first
foot orthoses
studied
were
prefabricated,
composed
of
a
polyolefin
modulecovered with cambrel.
The
heel,
posted
in
3'
of
varus, was composed
of
PPT®(open
cell
urethane
foam)covered
with
a
protective plate.This
orthotic was designed
to
serve both
as
a shock
absorber
and
as
an arch
support.
In
a
prospective
random-ized study (27),
113
recruits
using
theorthoticdevice
were
compared with
a
control group
of
152
without
devices. Theeffect
of
the orthotic device on the incidence
of
stress
fractures was evaluated separately
for
soldiers with high
arch
feet and soldiers with low-normal arch feet. In
the
higharch
population,the
femoral stress
fracture
incidence
was
5.1%
among
thesubjects wearing
the
device and
15.5%
among those not usingit
(P
<
0.003).In thelow
arch
population,
an opposite trendwas observed.
The
femoralfracture incidence among soldiers
using
the devicewas7.9%, whereas in
the nonusers it
was
2.6%.
No
significantdifferencesin the incidence
of
tibial and metatarsalstressfractureswerefound between soldierswho
did
andwho
did
not
use the
device in either group, high or low foot
arch.
It
was then
thought
that a custom biomechanical orthotic
mightbe
moreeffective
in
lowering the incidence
of
stressfractures.
In
a
subsequent
study
(7),
infantryrecruits
were
randomly assignedto three groups. Thesubjectsinthe
first
groupweregiven semirigid biomechanical orthotics made
of
polypropylene.The
subjects
in
thesecond groupreceivedsoft biomechanical orthotics fabricated from three layers
of
polyurethane
of
differentdensity(grades
80
upper
layer,
60
middle
layer, and
80
lower
layer).
The
subjects
who
formedthethird group were controls and were
not
givenorthotics.
Recruits
were reviewed biweekly during
14
wk
of
basictraining.The incidence
of
stress
fractures was
10.7%
for
the
soft
biomechanical
orthotic,
15.7%
for
thesemirigidbiomechanical
orthotic,
and
27%
for the
control group.
According
tothe per-protocol analysis, thesedifferencesweresignificant
but
not
by
intention-to-treat analysis. The
soft biomechanical orthoticswere
better
tolerated
byrecruits than the semirigid devices. It seemed that we might
have
found
a
simple meansto
lower
the incidence
of
stressfractures.
To
confirm these findings, an additional prospectivestudy wasdone.
Eight
hundredand
seventy-four
infantry
recruits were randomized into four orthotic groups:
soft
custom, soft prefabricated, semirigid biomechanical,
and
semirigid prefabricated
(8).
The
effects
of
theorthoticdevices on
the
incidence
of
stress fractures, ankle sprains,and foot problems were studied during
14
wk
of
basic
training.
There was a significant dropout from the
study
due
to
discomfortwiththeorthotics.
A
statistically significantlylower
number
of
recruits,given
soft
prefabricated orthoses,finished
basic
trainingin
their
assigneddevices (53%) than
that
inthesoft custom group (72%),
in
the semirigidbiomechanical group (75%), and in the semirigid prefabri-cated group
(82%)
(P
=
0.003). There was no statisticallysignificaht difference in the overall incidence
of
stress
LOWERING
THE
INCIDENCE
OF
STRESS
FRACTURES
Medicine
&
Science
in
Sports
&
Exercise,,
,
S625

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