Stress fractures in military recruits:​ a prospective study showing an unusually high incidence

Milgrom, C.<sup>1</sup>; Giladi, M.<sup>2</sup>; Stein, M.<sup>3</sup>; Kashtan, H.<sup>4</sup>; Margulies, J. Y.<sup>1</sup>; Chisin, R.<sup>5</sup>; Steinberg, R.<sup>6</sup>; Aharonson, Z.<sup>3</sup>

Affiliations

¹Department of Orthopaedic Surgery, Hadassah University Hospital, P0 Box 12000, Em Kerem, 91 120 Jerusalem, Israel

²Department of Internal Medicine, Tel-Aviv Medical Centre. Ichilov Hospital, Tel-Aviv 64239, Israel

³Israel Defence Forces, Medical Corps, Israel, Military POB 02149

⁴Department of Surgery, Tel-Aviv Medical Centre, Ichilov Hospital, Tel-Aviv 64239, Israel

⁵Department of Nuclear Medicine, Hadassah University Hospital, P0 Box 12000, Em Kerem, 91 120 Jerusalem, Israel

⁶Osteoporosis Institute, Jerusalem, Israel

Abstract

In a prospective study of 295 male Israeli military recruits a 31% incidence of stress fractures was found. Eighty per cent of the fractures were in the tibial or femoral shaft, while only 8% occurred in the tarsus and metatarsus. Sixty-nine per cent of the femoral stress fractures were asymptomatic, but only 8% of those in the tibia. Even asymptomatic stress fractures do, however, need to be treated. Possible explanations for the unusually high incidence of stress fractures in this study are discussed.

Links

DOI: 10.1302/0301-620X.67B5.4055871

PubMed: 4055871

WoS: A1985AUK9000011

Cited By (37)

Year	Entry
2014	Cooper MT. Stress fractures of the foot and ankle. In: Philbin TM, ed. Sports Injuries of the Foot: Evolving Diagnosis and Treatment. New York, NY: Springer; 2014:105-128.
2006	Robling AG, Castillo AB, Turner CH. Biomechanical and molecular regulation of bone remodeling. Annu Rev Biomed Eng. 2006;8:455-498.
1997	Mori S, Harruff R, Ambrosius W, Burr DB. Trabecular bone volume and microdamage accumulation in the femoral heads of women with and without femoral neck fractures. Bone. December 1997;21(6):521-526.
2021	Fioravanti G, Hua PQ, Tomlinson RE. The TrkA agonist gambogic amide augments skeletal adaptation to mechanical loading. Bone. June 2021;147:115908.
2022	O'Leary TJ, Izard RM, Tang JCY, Fraser WD, Greeves JP. Sex differences in tibial adaptations to arduous training: an observational cohort study. Bone. July 2022;160:116426.
1992	Frost HM. Perspectives: bone's mechanical usage windows. Bone Miner. December 1992;19(3):257-271.
2008	Edwards WB, Gillette JC, Thomas JM, Derrick TR. Internal femoral forces and moments during running: implications for stress fracture development. Clin Biomech (Bristol, Avon). December 2008;23(10):1269-1278.
1989	Jones BH, Harris JM, Vinh TN, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev. January 1989;17(1):379-422.
1997	Burr DB. Bone, exercise, and stress fractures. Exerc Sport Sci Rev. January 1997;25(1):171-194.
2010	Gu YD, Ren XJ, Li JS, Lake MJ, Zhang QY, Zeng YJ. Computer simulation of stress distribution in the metatarsals at different inversion landing angles using the finite element method. Int Orthop. June 2010;34(5):669-676.
2006	Mohsin S, O'Brien FJ, Lee TC. Osteonal crack barriers in ovine compact bone. J Anat. January 2006;208(1):81-89.
1989	Milgrom C, Gildadi M, Simkin A, Rand N, Kedem R, Kashtan H, Stein M, Gomori M. The area moment of inertia of the tibia: a risk factor for stress fractures. J Biomech. 1989;22(11-12):1243-1248.
2002	Arndt A, Ekenman I, Westblad P, Lundberg A. Effects of fatigue and load variation on metatarsal deformation measured in vivo during barefoot walking. J Biomech. May 2002;35(5):621-628.
2007	Milgrom C, Radeva-Petrova DR, Finestone A, Nyska M, Mendelson S, Benjuya N, Simkin A, Burr D. The effect of muscle fatigue on in vivo tibial strains. J Biomech. 2007;40(4):845-850.
2016	Derrick TR, Edwards WB, Fellin RE, Seay JF. An integrative modeling approach for the efficient estimation of cross sectional tibial stresses during locomotion. J Biomech. February 8, 2016;49(3):429-435.
1999	Donahue SW, Sharkey NA. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg. September 1999;81A(9):1236-1244.
1990	Burr DB, Milgrom C, Boyd RD, Higgins WL, Robin G, Radin EL. Experimental stress fractures of the tibia: biological and mechanical aetiology in rabbits. J Bone Joint Surg. May 1990;72B(3):370-375.
2005	Tommasini SM, Nasser P, Schaffler MB, Jepsen KJ. Relationship between bone morphology and bone quality in male tibias: implications for stress fracture risk. J Bone Miner Res. August 2005;20(8):1372-1380.
2021	O'Leary TJ, Wardle SL, Gifford RM, Double RL, Reynolds RM, Woods DR, Greeves JP. Tibial macrostructure and microarchitecture adaptations in women during 44 weeks of arduous military training. J Bone Miner Res. July 2021;36(7):1300-1315.
1998	Boyce TM, Fyhrie DP, Glotkowski MC, Radin EL, Schaffler MB. Damage type and strain mode associations in human compact bone bending fatigue. J Orthop Res. May 1998;16(3):322-329.
2017	Cresswell EN. Spatial Regulation of Bone Formation in Functional Adaptation of Cancellous Bone [PhD thesis]. Ithaca, NY: Cornell University; May 2017.
2008	Tommasini SM. Phenotypic Integration Contributes to Skeletal Functionality and Fragility [PhD thesis]. New York, NY: The City University of New York; 2008.
2020	Ellison MA. Beam Theory and Finite Element Approaches to Modelling the Stresses in the Second Metatarsal During Running [PhD thesis]. Exeter, UK: University of Exeter; March 2020.
2019	Bakr M. Parathyroid Hormone Effect on Facilitating Stress Fracture Repair [PhD thesis]. Brisbane, Australia: Griffith University; July 2019.
2009	Edwards WB. Internal Structural Loading of the Lower Extremity During Running: Implications for Skeletal Injury [PhD thesis]. Iowa State University; 2009.
2008	Booker WA. Forgiveness of Genetic Variation: Functional Interactions Among Bone Traits in the Distal Femoral Epiphysis [Master's thesis]. Mount Sinai School of Medicine; 2008.
2008	Courtland H-W. Intra-Species Variation in Skeletal Mechanical Function is Achieved Through Genetic Regulation of Both the Quality and Morphology of Bone [PhD thesis]. Mount Sinai School of Medicine; 2008.
2008	Herman BC. Osteocytes and Activation of Bone Remodeling [PhD thesis]. Mount Sinai School of Medicine; 2008.
2011	Ross RD. Functionalized Gold Nanoparticles as Damage-Specific X-Ray Computed Tomography Contrast Agents in Bone Tissue [PhD thesis]. University of Notre Dame; November 2011.
1997	Flynn TW. Tibial Flexural Wave Propagation Velocity in Vivo: Methodological Considerations in the Analysis of Bone Quality [PhD thesis]. State College, PA: Pennsylvania State University; August 1997.
2006	Xie L. Low Level Mechanical Vibrations Enhance Musculoskeletal Accretion in Growing Mice [PhD thesis]. Stony Brook, NY: Stony Brook University; December 2006.
2008	Mulvihill BMC. Computational Investigation Into the Mechanoregulation of Osteoporosis [PhD thesis]. Trinity College Dublin; December 2008.
2017	Fung A. Experimental Validation of Finite Element Predicted Bone Strain in the Human Metatarsal [Master's thesis]. Calgary, AB: University of Calgary; April 2017.
1987	Stover SM. Dorsal Metacarpal Disease in Thoroughbred Horses: Relationship to the Development of the Third Metacarpal Bone [PhD thesis]. Davis, University of California; 1987.
1999	Donahue SW. Bone Strain and Microdamage At Stress Fracture Sites in Human Metatarsals [PhD thesis]. Davis, University of California; 1999.
2009	Crowell HP III. Gait Retraining for the Reduction of Lower Extremity Loading [PhD thesis]. University of Delaware; Winter 2009.
2019	Martig S. Compressive Fatigue Life and Micromorphology of Equine Metacarpal Subchondral Bone [PhD thesis]. University of Melbourne; June 2019.