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Abbott A, Wang C, Stamm M, Mulcahey MK. Part II: Risk Factors for Stress Fractures in Female Military Recruits. Mil Med 2023; 188:93-99. [PMID: 35253041 DOI: 10.1093/milmed/usac033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Stress fractures (SFx) represent a significant proportion of injuries in military recruits internationally. Stress fractures disproportionately affect female recruits, a disparity that has similarly been consistently demonstrated in female athletes. Stress fractures result in medical morbidity, financial burden, and medical discharge from military service. This review presents current literature regarding SFx risk factors to identify and/or mitigate in this high-risk population. METHODS A literature review was conducted using PubMed to find relevant articles. We utilized keywords stress fracture, military, recruits, female, risk factors, modifiable, non-modifiable, overuse, nutrition, and/or prevention. Articles older than 10 years (published before 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review. RESULTS Modifiable risk factors for SFx include nutritional deficiency, especially of iron, vitamin D, and possibly calcium, poor physical fitness, suboptimal training programming for injury development and recovery, load carriage, and military footwear. Non-modifiable risk factors include female sex, greater height, lower weight and body mass index in females but lower or higher weight and body mass index in males, lower body fat percentage, and lower bone mineral density. In addition, menstrual dysfunction, low energy availability, later age at menarche, and iron deficiency pose unique risks to female recruits. Preventive measures include leadership education, programs with recovery considerations, and risk factor screening. CONCLUSION This review, Part II of a two-part series, guides multidisciplinary management of military recruits, especially females, who are at risk for developing SFx. Unique nuances of the military recruit require specific knowledge to reduce high incidence rates of injury internationally.
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Affiliation(s)
- Alexandra Abbott
- Department of Pediatrics, University of California, Los Angeles, CA 90095, USA
| | - Cindy Wang
- Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Michaela Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
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Abbott A, Wang C, Stamm M, Mulcahey MK. Part I: Background and Clinical Considerations for Stress Fractures in Female Military Recruits. Mil Med 2023; 188:86-92. [PMID: 35253062 DOI: 10.1093/milmed/usac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Stress fractures (SFx) represent a significant proportion of musculoskeletal injuries in military recruits internationally. Incidence rates as high as 40% have been reported, varying by country and branch of military cohorts. Tibial SFx are the most common, followed by other lower extremity sites, and are related to the emphasis on running during training. SFx disproportionately affect female recruits, similarly to a disparity demonstrated in female athletes. METHODS A literature review of articles relevant to our review was conducted using PubMed, utilizing keywords stress fracture, military, recruits, diagnosis, management, treatment, prevention, epidemiology, background, and/or female. Articles older than 10 years old (prior to 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review. RESULTS SFx can cause medical morbidity and financial burden and can require discharge from military service. SFx management in the military has cost the United States approximately $100 million annually, which may be underestimated due to lost duty hours or medical discharge with resulting compensation. However, SFx incidence rates have been demonstrated to be reducible with concerted efforts in military cohorts. CONCLUSION This review, Part I of a two-part series, provides updated information for multidisciplinary management of SFx in female military recruits. There are many similarities to management in athletes, but unique nuances of the military recruit require specific knowledge to reduce the high incidence rates of injury.
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Affiliation(s)
- Alexandra Abbott
- Department of Pediatrics, University of California, Los Angeles, CA 90095, USA
| | - Cindy Wang
- Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Michaela Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
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Rhon DI, Greenlee TA, Dickens JF, Wright AA. Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review. Orthop J Sports Med 2021; 9:23259671211053034. [PMID: 34805422 PMCID: PMC8600561 DOI: 10.1177/23259671211053034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Female servicemembers sustain higher rates of lower extremity injuries as
compared with their male counterparts. This can include intra-articular
pathology in the hip. Female patients are considered to have worse outcomes
after hip arthroscopy for femoroacetabular impingement and for hip labral
repair. Purpose: To (1) compare published rates of hip arthroscopy between male and female
military servicemembers and (2) determine if there are any sex-based
differences in outcomes after hip arthroscopy in the military. Study Design: Systematic review; Level of evidence, 3. Methods: We reviewed the literature published from January 1, 2000, through December
31, 2020, to identify studies in which hip arthroscopy was performed in
military personnel. Clinical trials and cohort studies were included. The
proportion of women within each cohort was identified, and results of any
between-sex analyses were reported. Results: Identified were 11 studies that met established criteria. Studies included
2481 patients, 970 (39.1%) of whom were women. Surgery occurred between
January 1998 and March 2018. Despite women accounting for approximately 15%
of the active-duty military force, they represented 39.1% (range,
25.7%-57.6%) of patients undergoing hip arthroscopy. In most cases, there
were no differences in self-reported outcomes (pain, disability, and
physical function), return to duty, or medical disability status based on
sex. Conclusion: Women account for approximately 15% of the military, but they made up 40% of
patients undergoing hip arthroscopy. Outcomes were not different between the
sexes; however, definitive conclusions were limited by the heterogeneity of
outcomes, missing data, lack of sex-specific subgroup analyses, and zero
studies with sex differences as the primary outcome. A proper understanding
of sex-specific outcomes after hip arthroscopy will require a paradigm shift
in the design and reporting of trials in the military health system.
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
| | - Jonathan F Dickens
- Uniformed Services University of Health Sciences, Bethesda, Maryland, USA.,Department of Sports Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,John A. Feagin Jr Sports Medicine Fellowship, Keller Army Community Hospital, West Point, New York, USA
| | - Alexis A Wright
- School of Medicine, Tufts University, Boston, Massachusetts, USA
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Barbeau P, Michaud A, Hamel C, Rice D, Skidmore B, Hutton B, Garritty C, da Silva DF, Semeniuk K, Adamo KB. Musculoskeletal Injuries Among Females in the Military: A Scoping Review. Mil Med 2021; 186:e903-e931. [PMID: 33367692 DOI: 10.1093/milmed/usaa555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/04/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Musculoskeletal injuries (MSKi) are a common challenge for those in military careers. Compared to their male peers, reports indicate that female military members and recruits are at greater risk of suffering MSKi during training and deployment. The objectives of this study were to identify the types and causes of MSKi among female military personnel and to explore the various risk factors associated with MSKi. MATERIALS AND METHODS A scoping review was conducted over a 4-month time frame of English language, peer-reviewed studies published from 1946 to 2019. Search strategies for major biomedical databases (e.g., MEDLINE; Embase Classic + Embase; and the following EBM Reviews-Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment, and the NHS Economic Evaluation Database) were developed by a senior medical information specialist and included 2,891 titles/abstracts. Study selection and data collection were designed according to the Population, Concept, and Context framework. Studies were included if the study population provided stratified data for females in a military context. RESULTS From a total of 2,287 citations captured from the literature searches, 168 peer-reviewed publications (144 unique studies) were eligible for inclusion. Studies were identified from across 10 countries and published between 1977 and 2019. Study designs were primarily prospective and retrospective cohorts. Most studies assessed both prevalence/incidence and risk factors for MSKi (62.50%), with few studies assessing cause (13.69%). For MSKi of female recruits compared to active female members, the prevalence was higher (19.7%-58.3% vs. 5.5%-56.6%), but the incidence (0.02%-57.7% vs. 13.5%-71.9%) was lower. The incidence of stress fractures was found to be much higher in female recruits than in active members (1.6%-23.9% vs. 2.7%). For anthropometric risk factors, increased body fat was a predictor of MSKi, but not stress fractures. For physiological risk factors for both female military groups, being less physically fit, later menarche, and having no/irregular menses were predictors of MSKi and stress fractures. For biomechanical risk factors, among female recruits, longer tibial length and femoral neck diameter increased the risk of stress fractures, and low foot arch increased risk of an ankle sprain. For female active military members, differences in shoulder rotation and bone strength were associated with risk of MSKi. For biological sex, being female compared to male was associated with an increased risk of MSKi, stress fractures, and general injuries. The consequences of experiencing MSKi for active military included limited duties, time off, and discharge. For recruits, these included missed training days, limited duty days, and release. CONCLUSIONS This scoping review provides insight into the current state of the evidence regarding the types and causes of MSKi, as well as the factors that influence MSKi among females in the military. Future research endeavors should focus on randomized controlled trials examining training paradigms to see if women are more susceptible. The data presented in the scoping review could potentially be used to develop training strategies to mitigate some of the identified barriers that negatively impact women from pursuing careers in the military.
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Affiliation(s)
- Pauline Barbeau
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Alan Michaud
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Candyce Hamel
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Danielle Rice
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Becky Skidmore
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Brian Hutton
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Chantelle Garritty
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Danilo F da Silva
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Kevin Semeniuk
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Kristi B Adamo
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Yadav A, Maheshwari V, Porwal N, Gadhavi R, Kushwaha A. Pattern of injuries sustained during training: A retrospective record-based study. JOURNAL OF MARINE MEDICAL SOCIETY 2021. [DOI: 10.4103/jmms.jmms_34_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Celtikci E, Yakar F, Celtikci P, Izci Y. Relationship between individual payload weight and spondylolysis incidence in Turkish land forces. Neurosurg Focus 2019; 45:E12. [PMID: 30544316 DOI: 10.3171/2018.8.focus18375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 08/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to investigate the relationship between lumbar spondylolysis and payload weight between different combat units of Turkish land forces (TLF).METHODThe authors reviewed clinical and radiological data of the military personnel with low-back pain (LBP) admitted to their clinic between July 2017 and July 2018. Age, BMI, average payload weight, and military service unit were recorded. CT scans were evaluated for pars interarticularis fractures and spondylolisthesis, whereas MRI studies were evaluated for spondylolisthesis, Modic-type endplate changes, or signal loss on T2-weighted images compatible with disc degeneration.RESULTFollowing exclusion, a total of 642 all-male military personnel were included. Of these personnel, 122 were commandos, 435 were infantry, and 85 were serving in the artillery units. Bilateral pars interarticularis fracture was noted in 42 commandos (34.42%) and 2 infantrymen (0.45%). There was no spondylolysis in the artillery units. There was no multiple-level spondylolysis and the most common level of spondylolysis was L5. Commandos had a significantly higher incidence of spondylolysis and more average payload weight (p < 0.001). Twelve patients (27.2%) with spondylolysis had accompanying MRI pathologies at the same level, whereas 32 patients (72.7%) had no accompanying MRI pathologies.CONCLUSIONSIncreased payload weight in military personnel is associated with spondylolysis, and commandos in the TLF have significantly heavier payloads, which causes an increased rate of spondylolysis compared to other units. Additionally, spondylolysis without adjacent-level changes on MRI could be undiagnosed. LBP in active military personnel who have a history of carrying heavy payloads should be evaluated extensively with both MRI and CT scans.
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Affiliation(s)
- Emrah Celtikci
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara.,2Department of Neurosurgery, Kars Harakani State Hospital, Kars
| | - Fatih Yakar
- 2Department of Neurosurgery, Kars Harakani State Hospital, Kars
| | - Pinar Celtikci
- 3Department of Radiology, Kars Harakani State Hospital, Kars; and
| | - Yusuf Izci
- 4Department of Neurosurgery, University of Health Sciences, Gulhane Education and Research Hospital, Ankara, Turkey
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