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Miller Olson E, Sainani KL, Dyrek P, Bakal D, Miller K, Carlson JL, Fredericson M, Tenforde AS. The association between overuse and musculoskeletal injuries and the female athlete triad in Division I collegiate athletes. PM R 2024. [PMID: 38837318 DOI: 10.1002/pmrj.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 03/06/2024] [Accepted: 03/25/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Although the female athlete triad (Triad) has been associated with increased risk of bone-stress injuries (BSIs), limited research among collegiate athletes has addressed the associations between the Triad and non-BSI injuries. OBJECTIVE To elucidate the relationship between Triad and both BSI and non-BSI in female athletes. DESIGN Retrospective cohort study. SETTING Primary and tertiary care student athlete clinic. PARTICIPANTS National Collegiate Athletic Association Division I female athletes at a single institution. INTERVENTION Participants completed a pre-participation questionnaire and dual-energy x-ray absorptiometry, which was used to generate a Triad cumulative risk assessment score (Triad score). The number of overuse musculoskeletal injuries that occurred while the athletes were still competing collegiately were identified through chart review. MAIN OUTCOME MEASURE BSI and non-BSI were treated as count variables. The association between BSI, non-BSI, and Triad score was measured using Poisson regression to calculate rate ratios. RESULTS Of 239 athletes, 43% of athletes (n = 103) sustained at least one injury. Of those, 40% (n = 95) sustained at least one non-BSI and 10% (n = 24) sustained at least one BSI over an average follow-up 2.5 years. After accounting for sport type (non-lean, runner, other endurance sport, or other lean advantage sport) and baseline age, we found that every additional Triad score risk point was associated with a significant 17% increase in the rate of BSI (rate ratio [RR] 1.17, 95% confidence interval [CI] 1.03-1.33; p = .016). However, Triad score was unrelated to non-BSI (1.00, 95% CI 0.91-1.11; p = .99). Compared with athletes in non-lean sports (n = 108), athletes in other lean advantage sports (n = 30) had an increased rate of non-BSI (RR: 2.09, p = .004) whereas distance runners (n = 46) had increased rates of BSI (RR: 7.65, p < .001) and non-BSI (RR: 2.25, p < .001). CONCLUSIONS Higher Triad score is associated with an increased risk of BSI but not non-BSI in collegiate athletes.
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Affiliation(s)
- Emily Miller Olson
- Department of Orthopedic Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Kristin L Sainani
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Paige Dyrek
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - David Bakal
- Department of Orthopedic Surgery, Division of Sports Medicine, University of California San Diego, La Jolla, California, USA
| | - Kenneth Miller
- Department of Physical Medicine and Rehabilitation, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Jennifer L Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael Fredericson
- Department of Orthopedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, Stanford, California, USA
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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Eastman K, O’Leary TJ, Carswell A, Walsh N, Izard R, Fraser W, Greeves J. Distal Tibial Bone Properties and Bone Stress Injury Risk in Young Men Undergoing Arduous Physical Training. Calcif Tissue Int 2023; 113:317-328. [PMID: 37481657 PMCID: PMC10449708 DOI: 10.1007/s00223-023-01111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/22/2023] [Indexed: 07/24/2023]
Abstract
Trabecular microarchitecture contributes to bone strength, but its role in bone stress injury (BSI) risk in young healthy adults is unclear. Tibial volumetric BMD (vBMD), geometry, and microarchitecture, whole-body areal BMD, lean and fat mass, biochemical markers of bone metabolism, aerobic fitness, and muscle strength and power were measured in 201 British Army male infantry recruits (age 20.7 [4.3] years, BMI 24.0 ± 2.7 kg·m2) in week one of basic training. Tibial scans were performed at the ultra-distal site, 22.5 mm from the distal endplate of the non-dominant leg using High Resolution Peripheral Quantitative Computed Tomography (XtremeCT, Scanco Medical AG, Switzerland). Binary logistic regression analysis was performed to identify associations with lower body BSI confirmed by MRI. 20 recruits (10.0%) were diagnosed with a lower body BSI. Pre-injured participants had lower cortical area, stiffness and estimated failure load (p = 0.029, 0.012 and 0.011 respectively) but tibial vBMD, geometry, and microarchitecture were not associated with BSI incidence when controlling for age, total body mass, lean body mass, height, total 25(OH)D, 2.4-km run time, peak power output and maximum dynamic lift strength. Infantry Regiment (OR 9.3 [95%CI, 2.6, 33.4]) Parachute versus Line Infantry, (p ≤ 0.001) and 2.4-km best effort run time (1.06 [95%CI, 1.02, 1.10], p < 0.033) were significant predictors. Intrinsic risk factors, including ultradistal tibial density, geometry, and microarchitecture, were not associated with lower body BSI during arduous infantry training. The ninefold increased risk of BSI in the Parachute Regiment compared with Line Infantry suggests that injury propensity is primarily a function of training load and risk factors are population-specific.
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Affiliation(s)
- Katharine Eastman
- Norwich Medical School, University of East Anglia, Norwich, UK
- Army Health and Performance Research, Army Headquarters, Andover, UK
- HQ DPHC, Coltman House, DMS Whittington, Lichfield, WS14 9PY UK
| | - Thomas J. O’Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK
- Division of Surgery and Interventional Science, UCL, London, UK
| | | | - Neil Walsh
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Rachel Izard
- Science and Technology Commissioning, Defence Science and Technology, Porton Down, Salisbury, UK
| | - William Fraser
- Norwich Medical School, University of East Anglia, Norwich, UK
- Departments of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Julie Greeves
- Norwich Medical School, University of East Anglia, Norwich, UK
- Army Health and Performance Research, Army Headquarters, Andover, UK
- Division of Surgery and Interventional Science, UCL, London, UK
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Bozzini BN, Nguyen VT, Reynoso MC, Guerriere KI, Walker LA, Taylor KM, Foulis SA, Bouxsein ML, Hughes JM, Popp KL. The Risk of Menstrual Dysfunction Increases for Women during U.S. Army Basic Combat Training. Med Sci Sports Exerc 2023; 55:1533-1539. [PMID: 37057721 DOI: 10.1249/mss.0000000000003183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
PURPOSE To determine whether changes in menstruation develop in female trainees during BCT and whether changes in body mass, body composition and/or physical activity are associated with menstrual interruption during BCT. METHODS Female trainees grouped according to self-reported menstrual status in the 12 months before BCT as having regular cycles (RC; n = 352) or MD ( n = 97) completed height, body mass, and body composition assessments and questionnaires before and after BCT. Fisher's exact test and Mann-Whitney U test were used to compare between-group differences in categorical and continuous variables, respectively. Among RC trainees, odds ratios were calculated to examine the influence of changes in body mass, lean mass, and fat mass on a trainee's likelihood to miss a period during BCT. RESULTS There were no differences in race, height, body mass, body mass index, or physical activity history at pre-BCT between RC and MD ( P > 0.05). Overall, 86% of trainees experienced changes to menstruation during BCT. RC were more likely than MD to have at least one period during BCT (81% vs 69%, respectively, P = 0.01). Among RC, gaining more body mass and lean mass and losing less fat mass were associated with increased odds of missing a period during BCT. CONCLUSIONS These findings demonstrate that most female trainees experience menstrual changes during BCT. Menstrual cycle interruptions do not appear to align with loss of body or fat mass.
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Affiliation(s)
- Brittany N Bozzini
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | - Vy T Nguyen
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | - Marinaliz C Reynoso
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | - Katelyn I Guerriere
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | - Leila A Walker
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | - Kathryn M Taylor
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | - Stephen A Foulis
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
| | | | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA
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Dyches KD, Friedl KE, Greeves JP, Keller MF, McClung HL, McGurk MS, Popp KL, Teyhen DS. Physiology of Health and Performance: Enabling Success of Women in Combat Arms Roles. Mil Med 2023; 188:19-31. [PMID: 37490562 DOI: 10.1093/milmed/usac256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 02/28/2022] [Accepted: 08/16/2022] [Indexed: 07/27/2023] Open
Abstract
INTRODUCTION The modern female soldier has yet to be fully characterized as she steps up to fill new combat roles that have only recently been opened to women. Both U.S. and U.K. military operational research efforts are supporting a science-based evolution of physical training and standards for female warfighters. The increasing representation of women in all military occupations makes it possible to discover and document the limits of female physiological performance. METHOD An informal Delphi process was used to synthesize an integrated concept of current military female physiological research priorities and emerging findings using a panel of subject matter experts who presented their research and perspectives during the second Women in Combat Summit hosted by the TriService Nursing Research Program in February 2021. RESULTS The physical characteristics of the modern soldier are changing as women train for nontraditional military roles, and they are emerging as stronger and leaner. Capabilities and physique will likely continue to evolve in response to new Army standards and training programs designed around science-based sex-neutral requirements. Strong bones may be a feature of the female pioneers who successfully complete training and secure roles traditionally reserved for men. Injury risk can be reduced by smarter, targeted training and with attention directed to female-specific hormonal status, biomechanics, and musculoskeletal architecture. An "estrogen advantage" appears to metabolically support enhanced mental endurance in physically demanding high-stress field conditions; a healthy estrogen environment is also essential for musculoskeletal health. The performance of female soldiers can be further enhanced by attention to equipment that serves their needs with seemingly simple solutions such as a suitable sports bra and personal protective equipment that accommodates the female anatomy. CONCLUSIONS Female physiological limits and performance have yet to be adequately defined as women move into new roles that were previously developed and reserved for men. Emerging evidence indicates much greater physical capacity and physiological resilience than previously postulated.
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Affiliation(s)
- Karmon D Dyches
- Military Operational Medicine Research Program, U.S. Army Medical Research and Development Command, Fort Detrick, MD 21702, USA
| | - Karl E Friedl
- Biophysics and Biomedical Modeling Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Julie P Greeves
- Department of Army Health and Performance Research (AHPR), British Army, Andover, Hampshire SP11 8HT, UK
| | - Margaux F Keller
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Holly L McClung
- Biophysics and Biomedical Modeling Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Michael S McGurk
- Research and Analysis Directorate, U.S. Army Center for Initial Military Training, Fort Eustis, VA 23604, USA
| | - Kristin L Popp
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Deydre S Teyhen
- Chief, U.S. Army Medical Specialist Corps, U.S. Army Medical Command, Falls Church, VA 22042, USA
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O'Leary TJ, Coombs CV, Perrett C, Double RL, Keay N, Wardle SL, Greeves JP. Menstrual Function, Eating Disorders, Low Energy Availability, and Musculoskeletal Injuries in British Servicewomen. Med Sci Sports Exerc 2023; 55:1307-1316. [PMID: 36893306 DOI: 10.1249/mss.0000000000003154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
PURPOSE This study aimed to investigate associations between menstrual function, eating disorders, and risk of low energy availability with musculoskeletal injuries in British servicewomen. METHODS All women younger than 45 yr in the UK Armed Forces were invited to complete a survey about menstrual function, eating behaviors, exercise behaviors, and injury history. RESULTS A total of 3022 women participated; 2% had a bone stress injury in the last 12 months, 20% had ever had a bone stress injury, 40% had a time-loss musculoskeletal injury in the last 12 months, and 11% were medically downgraded for a musculoskeletal injury. Menstrual disturbances (oligomenorrhea/amenorrhea, history of amenorrhea, and delayed menarche) were not associated with injury. Women at high risk of disordered eating (Female Athlete Screening Tool score >94) were at higher risk of history of a bone stress injury (odds ratio (OR; 95% confidence interval (CI)), 2.29 (1.67-3.14); P < 0.001) and time-loss injury in the last 12 months (OR (95% CI), 1.56 (1.21-2.03); P < 0.001) than women at low risk of disordered eating. Women at high risk of low energy availability (Low Energy Availability in Females Questionnaire score ≥8) were at higher risk of bone stress injury in the last 12 months (OR (95% CI), 3.62 (2.07-6.49); P < 0.001), history of a bone stress injury (OR (95% CI), 2.08 (1.66-2.59); P < 0.001), a time-loss injury in the last 12 months (OR (95% CI), 9.69 (7.90-11.9); P < 0.001), and being medically downgraded with an injury (OR (95% CI), 3.78 (2.84-5.04); P < 0.001) than women at low risk of low energy availability. CONCLUSIONS Eating disorders and risk of low energy availability provide targets for protecting against musculoskeletal injuries in servicewomen.
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Affiliation(s)
| | - Charlotte V Coombs
- Army Health and Performance Research, Army Headquarters, Andover, UNITED KINGDOM
| | - Caitlin Perrett
- Division of Surgery and Interventional Science, UCL, London, UNITED KINGDOM
| | - Rebecca L Double
- Army Health and Performance Research, Army Headquarters, Andover, UNITED KINGDOM
| | - Nicky Keay
- Division of Medicine, UCL, London, UNITED KINGDOM
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Poh PYS, Sessoms PH, Haluch KS, Trone DW. Assessing Injury Susceptibility at Marine Corps Recruit Depot, San Diego, California. J Strength Cond Res 2023; 37:1530-1536. [PMID: 36728010 DOI: 10.1519/jsc.0000000000004407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Poh, PYS, Sessoms, PH, Haluch, KS, and Trone, DW. Assessing injury susceptibility at Marine Corps Recruit Depot, San Diego, California. J Strength Cond Res 37(7): 1530-1536, 2023-Marine Corps Recruit Depot (MCRD) recruits undergo demanding training. Musculoskeletal injury (MSKI) accounts for attrition and graduation delays. Functional tests, such as Functional Movement Screen (FMS), Y-Balance Test-Lower Quarter (YBT-LQ), and ankle dorsiflexion range of motion (AD-ROM), may identify individuals at greater MSKI risk. This study tested the hypothesis that functional assessments may inform injury prediction. Male recruits ( N = 407; mean ± SD : age, 20 ± 2 years) performed baseline functional tests. Marine Corps Recruit Depot staff tracked MSKI and graduation outcomes. The chi-square test of independence (individual FMS exercises) and Mann-Whitney U (FMS composite score) test examined the relationship between FMS and MSKI incidence. One-way analysis of variance compared YBT-LQ and AD-ROM with MSKI incidence. Twelve recruits (3%) incurred a lower extremity MSKI and were dropped. Of those 12, 9 had a delayed graduation, and 3 separated from enlistment. The level of significance was set at p < 0.10 to identify between-group differences (yes-MSKI vs. no-MSKI). Functional movement screen composite score ( p = 0.064), hurdle step ( p = 0.059), and trunk stability ( p = 0.001) were lower in yes-MSKI. Y-Balance Test-Lower Quarter anterior direction difference between legs ( p = 0.011) and AD-ROM right side ( p = 0.055) was greater in yes-MSKI. Odds ratios (OR) were calculated using cut-off scores, with strong odds of sustaining MSKI with FMS trunk stability score <2 (OR: 7.56, 95% confidence interval [CI]: [2.32, 24.61]) and YBT-LQ anterior difference >6.25 cm (OR: 6.38, 95% CI: [1.98, 20.55]). Recruits who incurred MSKI had scores that indicated lesser mobility and stability of the lower extremity, providing preliminary evidence that when assessed together, FMS, YBT-LQ, and AD-ROM, may have predictive value for identifying those at MSKI risk.
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Affiliation(s)
- Paula Y S Poh
- Leidos, Inc., Reston, Virginia
- Warfighter Performance Department, Naval Health Research Center, San Diego, California
| | - Pinata H Sessoms
- Warfighter Performance Department, Naval Health Research Center, San Diego, California
| | - Kathrine S Haluch
- Warfighter Performance Department, Naval Health Research Center, San Diego, California
- Eagle Applied Sciences, LLC, San Antonio, Texas; and
| | - Daniel W Trone
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
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Popp KL, Outerleys J, Gehman S, Garrahan M, Rudolph S, Loranger E, Ackerman KE, Tenforde AS, Bouxsein ML, Davis IS. Impact loading in female runners with single and multiple bone stress injuries during fresh and exerted conditions. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:406-413. [PMID: 35218949 DOI: 10.1016/j.jshs.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/25/2021] [Accepted: 01/13/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND Bone stress injuries (BSIs) are common in female runners, and recurrent BSI rates are high. Previous work suggests an association between higher impact loading during running and tibial BSI. However, it is unknown whether impact loading and fatigue-related loading changes discriminate women with a history of multiple BSIs. This study compared impact variables at the beginning of a treadmill run to exertion and the changes in those variables with exertion among female runners with no history of BSI as well as among those with a history of single or multiple BSIs. METHODS We enrolled 45 female runners (aged 18-40 years) for this cross-sectional study: having no history of diagnosed lower extremity BSI (N-BSI, n = 14); a history of 1 lower extremity BSI (1-BSI, n = 16); and diagnosed by imaging, or a history of multiple (≥3) lower extremity BSIs (M-BSI, n = 15). Participants completed a 5-km race speed run on an instrumented treadmill while wearing an Inertial Measurement Unit. The vertical average loading rate (VALR), vertical instantaneous loading rate (VILR), vertical stiffness during impact via instrumented treadmill, and tibial shock determined as the peak positive tibial acceleration via Inertial Measurement Unit were measured at the beginning and the end of the run. RESULTS There were no differences between groups in VALR, VILR, vertical stiffness, or tibial shock in a fresh or exerted condition. However, compared to N-BSI, women with M-BSI had greater increase with exertion in VALR (-1.8% vs. 6.1%, p = 0.01) and VILR (1.5% vs. 4.8%, p = 0.03). Similarly, compared to N-BSI, vertical stiffness increased more with exertion among women with M-BSI (-0.9% vs. 7.3%, p = 0.006) and 1-BSI (-0.9% vs. 1.8%, p = 0.05). Finally, compared to N-BSI, the increase in tibial shock from fresh to exerted condition was greater among women with M-BSI (0.9% vs. 5.5%, p = 0.03) and 1-BSI (0.9% vs. 11.2%, p = 0.02). CONCLUSION Women with 1-BSI or M-BSIs experience greater exertion-related increases in impact loading than women with N-BSI. These observations imply that exertion-related changes in gait biomechanics may contribute to risk of BSI.
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Affiliation(s)
- Kristin L Popp
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA; Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA.
| | - Jereme Outerleys
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, MA 02138, USA
| | - Sarah Gehman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Margaret Garrahan
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Sara Rudolph
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Elizabeth Loranger
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA; Department of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, MA 02138, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 , USA; Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Irene S Davis
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, MA 02138, USA
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Syrop I, Fukushima Y, Mullins K, Raiser S, Lawley R, Bosshardt L, Finlay A, Ray J, Fredericson M. Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2885-2896. [PMID: 35316862 DOI: 10.1002/jum.15977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 02/02/2022] [Accepted: 02/05/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI). METHODS A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv22 criteria were applied to classify MRI findings. RESULTS Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77). CONCLUSIONS USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.
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Affiliation(s)
- Isaac Syrop
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Yaeko Fukushima
- Department of Physical Medicine and Rehabilitation, Kansai Medical University, Osaka, Japan
| | - Kevin Mullins
- Department of Physical Medicine and Rehabilitation, UC Davis, Davis, CA, USA
| | - Sara Raiser
- Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | - Richard Lawley
- Sports Medicine, Orthopedic Centers of Colorado, Denver, CO, USA
| | | | - Andrea Finlay
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Michael Fredericson
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, CA, USA
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Rosenthal MD, Rauh MJ, Cowan JE. Prospective Assessment of Clinical Tests Used to Evaluate Tibial Stress Fracture. Orthop J Sports Med 2022; 10:23259671221122356. [PMID: 36147792 PMCID: PMC9486277 DOI: 10.1177/23259671221122356] [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: 05/28/2022] [Accepted: 06/09/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Tibial stress fracture (SFx) is the most common SFx of the lower extremity.
Presently, diagnostic accuracy of clinical examination techniques for tibial
SFx remains suboptimal. Purpose: To assess the diagnostic effectiveness of 5 clinical tests for tibial SFx
individually versus a test item cluster. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 50 patients with tibial pain (17 with bilateral symptoms) were
assessed with 5 clinical examination tests (tibial fulcrum test, focal
tenderness to palpation, heel percussion test, therapeutic ultrasound test,
and 128-Hz tuning fork test) before they underwent diagnostic imaging
(radionuclide bone scan). The application of the clinical tests was
counterbalanced to minimize the likelihood of carryover effects. Patients
provided a pain rating immediately before and after the application of each
clinical test. Results: The prevalence of tibial SFx among the study participants was 52.2%. High
levels of specificity were produced by the therapeutic ultrasound test
(93.8%), tuning fork test (90.6%), and percussion test (90.6%). The fulcrum
test had moderate to high specificity (84.4%). All tests demonstrated low
levels of sensitivity, with the highest levels found for focal tenderness to
palpation (48.6%) and fulcrum (45.7%). The fulcrum test provided the highest
positive likelihood ratio (2.93), followed by the therapeutic ultrasound
test (2.30). The fulcrum test had the lowest negative likelihood ratio
(0.64), with the focal tenderness to palpation and tuning fork tests having
negative likelihood ratios >1.0. Combinations of these clinical tests did
not improve the prediction of tibial SFx above that observed among the
individual tests. Conclusion: The clinical tests evaluated were generally highly specific, but all had low
sensitivity. The fulcrum test provided the highest level of diagnostic
accuracy; however, it was inadequate for definitive clinical management.
Combining tests did not improve the diagnostic accuracy of tibial SFx.
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Affiliation(s)
| | | | - James E Cowan
- US Army-Baylor University, Fort Sam Houston, San Antonio, Texas, USA
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Li N, Zhang Y, Hou S. Stress exposure status and associated factors among Chinese People's Armed Police personnel: A cross-sectional study. Front Psychiatry 2022; 13:1000981. [PMID: 36405900 PMCID: PMC9669384 DOI: 10.3389/fpsyt.2022.1000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND MG (Mass gathering) deployment is one of the primary duties of Chinese People's Armed Police (PAP) personnel. Due to prolonged and repeated deployments in difficult conditions and harsh climates, military personnel are exposed to multiple stressors. OBJECTIVES This study aims to understand the stress exposure status of armed police personnel during MG deployment and to explore its influencing factors. METHODS A cross-sectional study was conducted among PAP in 2021. We used a cluster random sampling to select 960 PAP personnel. Binary logistic regression was used to examine whether the stress exposure status was associated with factors such as demographics, health service utilization, and MG deployment. RESULTS Among 960 PAP personnel,83% of PAP personnel participated in MG in the past month, and 23.1% of PAP personnel suffered stress. The chi-square test showed that there were significant differences in MG'cycle time (p < 0.05). The binary logistic regression results showed that satisfaction with medical skills (p = 0.008), satisfaction with health environment (p = 0.031), satisfaction with medicine (OR = 0.640, 95%CI:0.436,0.938), and seeking health services (OR = 5.36, 95%CI:2.316,12.402) were associated with stress exposure status. However, age, and length of military service did not have any association with the stress exposure status of PAP personnel in this study. CONCLUSION This study demonstrated that stress exposure status among PAP personnel was associated with MG deployment, and health service utilization. These findings can help policy-makers and clinicians to relieve the stress of the armed police personnel, as well as provide a basis for developing military health service security plans.
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Affiliation(s)
- Nan Li
- College of Management and Economics, Tianjin University, Tianjin, China
| | - Yongzhong Zhang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
| | - Shike Hou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
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11
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Lennox GM, Wood PM, Schram B, Canetti EFD, Simas V, Pope R, Orr R. Non-Modifiable Risk Factors for Stress Fractures in Military Personnel Undergoing Training: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:422. [PMID: 35010681 PMCID: PMC8744653 DOI: 10.3390/ijerph19010422] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022]
Abstract
A fracture, being an acquired rupture or break of the bone, is a significant and debilitating injury commonly seen among athletes and military personnel. Stress fractures, which have a repetitive stress aetiology, are highly prevalent among military populations, especially those undergoing training. The primary aim of this review is to identify non-modifiable risk factors for stress fractures in military personnel undergoing training. A systematic search was conducted of three major databases to identify studies that explored risk factors for stress fractures in military trainees. Critical appraisal, data extraction, and a narrative synthesis were conducted. Sixteen articles met the eligibility criteria for the study. Key non-modifiable risk factors identified were prior stress fracture and menstrual dysfunction, while advancing age and race other than black race may be a risk factor. To reduce the incidence of stress fractures in military trainees, mitigating modifiable risk factors among individuals with non-modifiable risk factors (e.g., optimising conditioning for older trainees) or better accommodating non-modifiable factors (for example, extending training periods and reducing intensity to facilitate recovery and adaptation) are suggested, with focus on groups at increased risk identified in this review.
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Affiliation(s)
- Grace M. Lennox
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
| | - Patrick M. Wood
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
| | - Ben Schram
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
| | - Elisa F. D. Canetti
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
| | - Vini Simas
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
| | - Rodney Pope
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
- School of Community Health, Charles Sturt University, Albury-Wodonga, NSW 2640, Australia
| | - Robin Orr
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
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12
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Sammito S, Hadzic V, Karakolis T, Kelly KR, Proctor SP, Stepens A, White G, Zimmermann WO. Risk factors for musculoskeletal injuries in the military: a qualitative systematic review of the literature from the past two decades and a new prioritizing injury model. Mil Med Res 2021; 8:66. [PMID: 34886915 PMCID: PMC8662851 DOI: 10.1186/s40779-021-00357-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Musculoskeletal injuries (MSkIs) are a leading cause of health care utilization, as well as limited duty and disability in the US military and other armed forces. MSkIs affect members of the military during initial training, operational training, and deployment and have a direct negative impact on overall troop readiness. Currently, a systematic overview of all risk factors for MSkIs in the military is not available. METHODS A systematic literature search was carried out using the PubMed, Ovid/Medline, and Web of Science databases from January 1, 2000 to September 10, 2019. Additionally, a reference list scan was performed (using the "snowball method"). Thereafter, an international, multidisciplinary expert panel scored the level of evidence per risk factor, and a classification of modifiable/non-modifiable was made. RESULTS In total, 176 original papers and 3 meta-analyses were included in the review. A list of 57 reported potential risk factors was formed. For 21 risk factors, the level of evidence was considered moderate or strong. Based on this literature review and an in-depth analysis, the expert panel developed a model to display the most relevant risk factors identified, introducing the idea of the "order of importance" and including concepts that are modifiable/non-modifiable, as well as extrinsic/intrinsic risk factors. CONCLUSIONS This is the qualitative systematic review of studies on risk factors for MSkIs in the military that has attempted to be all-inclusive. A total of 57 different potential risk factors were identified, and a new, prioritizing injury model was developed. This model may help us to understand risk factors that can be addressed, and in which order they should be prioritized when planning intervention strategies within military groups.
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Affiliation(s)
- Stefan Sammito
- Section Experimental Aerospace Medicine Research, German Air Force Centre of Aerospace Medicine, Flughafenstraße 1, 51147 Cologne, Germany
- Occupational Medicine, Faculty of Medicine, Otto-Von-Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Vedran Hadzic
- Faculty of Sport, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Thomas Karakolis
- Defence Research and Development Canada, Toronto, ON M3K 2C9 Canada
| | - Karen R. Kelly
- Warfighter Performance, Naval Health Research Center, San Diego, CA 92106-3599 USA
| | - Susan P. Proctor
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760 USA
- Research Service, VA Boston Healthcare System, Boston, MA 02130 USA
| | - Ainars Stepens
- Centre for Military Medicine Research, Riga Stradins University, Riga, 1007 Latvia
| | - Graham White
- Human and Social Sciences Group, Defense Science and Technology Laboratory, Portsdown Hill Road, Fareham, PO17 6AD UK
| | - Wes O. Zimmermann
- Department of Military Sports Medicine, Royal Netherlands Army, 3584 AB Utrecht, The Netherlands
- Department of Military/Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814 USA
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13
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Wardle SL, O'Leary TJ, McClung JP, Pasiakos SM, Greeves JP. Feeding female soldiers: Consideration of sex-specific nutrition recommendations to optimise the health and performance of military personnel. J Sci Med Sport 2021; 24:995-1001. [PMID: 34452842 DOI: 10.1016/j.jsams.2021.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 12/25/2022]
Abstract
Appropriate nutrition recommendations are required to optimise the health and performance of military personnel, yet limited data are available on whether male and female military personnel have different nutrition requirements. OBJECTIVES To consider the evidence for sex-specific nutrition requirements to optimise the health and performance of military personnel. DESIGN Narrative review. METHODS Published literature was reviewed, with a focus on sex-specific requirements, in the following areas: nutrition for optimising muscle mass and function, nutrition during energy deficit, and nutrition for reproductive and bone health. RESULTS There are limited data on sex differences in protein requirements but extant data suggest that, despite less muscle mass, on average, in women, sex-specific protein feeding strategies are not required to optimise muscle mass in military-aged individuals. Similarly, despite sex differences in metabolic and endocrine responses to energy deficit, current data do not suggest a requirement for sex-specific feeding strategies during energy deficit. Energy deficit impairs health and performance, most notably bone and reproductive health and these impairments are greater for women. Vitamin D, iron and calcium are important nutrients to protect the bone health of female military personnel due to increased risk of stress fracture. CONCLUSIONS Women have an increased incidence of bone injuries, less muscle mass and are more susceptible to the negative effects of energy deficit, including compromised reproductive health. However, there are limited data on sex differences in response to various nutrition strategies designed to improve these elements of health and performance. Future studies should evaluate whether sex-specific feeding recommendations are required.
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Affiliation(s)
- Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, United Kingdom; Division of Surgery and Interventional Science, University College London, United Kingdom.
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, United Kingdom; Division of Surgery and Interventional Science, University College London, United Kingdom
| | - James P McClung
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, United States of America
| | - Stefan M Pasiakos
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, United States of America
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, United Kingdom; Division of Surgery and Interventional Science, University College London, United Kingdom; Norwich Medical School, University of East Anglia, United Kingdom
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14
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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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15
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Warden SJ, Edwards WB, Willy RW. Preventing Bone Stress Injuries in Runners with Optimal Workload. Curr Osteoporos Rep 2021; 19:298-307. [PMID: 33635519 PMCID: PMC8316280 DOI: 10.1007/s11914-021-00666-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 02/07/2023]
Abstract
Bone stress injuries (BSIs) occur at inopportune times to invariably interrupt training. All BSIs in runners occur due to an "error" in workload wherein the interaction between the number and magnitude of bone tissue loading cycles exceeds the ability of the tissue to resist the repetitive loads. There is not a single optimal bone workload, rather a range which is influenced by the prevailing scenario. In prepubertal athletes, optimal bone workload consists of low-repetitions of fast, high-magnitude, multidirectional loads introduced a few times per day to induce bone adaptation. Premature sports specialization should be avoided so as to develop a robust skeleton that is structurally optimized to withstand multidirectional loading. In the mature skeleton, optimal workload enables gains in running performance but minimizes bone damage accumulation by sensibly progressing training, particularly training intensity. When indicated (e.g., following repeated BSIs), attempts to reduce bone loading magnitude should be considered, such as increasing running cadence. Determining the optimal bone workload for an individual athlete to prevent and manage BSIs requires consistent monitoring. In the future, it may be possible to clinically determine bone loads at the tissue level to facilitate workload progressions and prescriptions.
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Affiliation(s)
- Stuart J Warden
- Department of Physical Therapy, School of Health & Human Sciences, Indiana University, 1140 W. Michigan St., CF-124, Indianapolis, IN, 46202, USA.
- Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, IN, USA.
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
| | - W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Richard W Willy
- School of Physical Therapy & Health Sciences, University of Montana, Missoula, MT, USA
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16
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Risk factors for musculoskeletal injuries in military personnel: a systematic review with meta-analysis. Int Arch Occup Environ Health 2021; 94:1173-1189. [PMID: 33987772 DOI: 10.1007/s00420-021-01700-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/25/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate the risk factors for musculoskeletal injuries in military personnel. METHODS A systematic literature search was carried out in August 2019 and updated in July 2020 without language or time filters. The inclusion criteria were prospective studies that investigated the risk factors for injuries in military personnel. Only risk factors analyzed by at least ten studies were selected for the meta-analysis. For data analysis, the RevMan5.3 program was used to compare the number of participants with injuries between high- or low-risk groups. The measurement of dichotomous variables was one of the selected parameters for the analysis, as well as the Mantel-Haenszel statistical method, random-effects model, and analysis with a relative risk (RR) and 95% confidence interval for the included studies. RESULTS A total of 2,629 studies were identified through databases. Thirty-four studies met the inclusion criteria. The groups considered at risk were the oldest [RR = 1.22; (95% CI 1.06-1.41)], with overweight or obesity [RR = 1.27; (95% CI 1.08-1, 48)], with previous injuries [RR = 1.15; (95% CI 1.01-1.30)], and with the worst performance in running tests of 1,600-3,200 m [RR = 1.87; (95% CI 1.28-2.71)]. Gender, ethnicity, and smoking were not associated with injuries. However, a subgroup analysis showed that among studies with a follow-up of fewer than 12 months, women presented RR = 2.44 (95% CI 1.65-3.60) more likely to develop injuries. CONCLUSION Age, overweight or obesity, previous injuries, and performance in the 1600-3200 m run are associated with an increased risk of injury in the military.
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Kardouni JR, McKinnon CJ, Taylor KM, Hughes JM. Timing of stress fracture in soldiers during the first 6 career months: a retrospective cohort study. J Athl Train 2021; 56:465003. [PMID: 33975344 PMCID: PMC8675322 DOI: 10.4085/1062-6050-0380.19] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Stress fractures (SF) are injuries that can result from beginning new or higher volume physical training regimens. The pattern of clinical presentation of SF over time after individuals start a new or more demanding physical training regimen is not well defined in medical literature. OBJECTIVE Report trends in the clinical presentation of stress fractures over the first six month of soldiers' time in the service. DESIGN Retrospective Cohort study Setting: This study was conducted using medical encounter and personnel data from U.S. Army soldiers during the first 6 months of their career. PARTICIPANTS U.S. Army soldiers beginning their careers from 2005-2014 (N=701,027). DATA COLLECTION AND ANALYSIS Weekly SF numbers and incidence were calculated overall, as well as by sex, over the first 6 months of military service. RESULTS SF diagnoses (N=14,155) increased steeply in weeks 3 and 4, with a peak in the overall incidence of SF diagnoses occurring during weeks 5-8. Although clinical incidence of stress fracture generally decreased beyond 8 weeks, incident lower extremity stress fractures continued to present for over 20 weeks. The hazard ratio (HR) for SF among women compared to men was 4.14 (95% CI = [4.01, 4.27]). CONCLUSIONS Across the 6-month study period, women showed over 4 times greater hazard for stress fracture. The results also suggest that health care providers should be particularly vigilant for stress fractures within 3 weeks after the beginning of a new or higher intensity exercise regimen. The incidence of SF may continue to climb for several weeks. Even as stress fracture incidence declines, it should be noted that these injuries may also continue to appear clinically even several months after a change in activity or training.
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Affiliation(s)
- Joseph R Kardouni
- 1U.S. Army Forces Command, Fort Bragg, NC, 28310
- 2U.S. Army Research Institute of Environmental Medicine, Military Performance Division, Natick, MA 01760
- E-mail correspondence may be directed to the authors at the following addresses: Joseph R. Kardouni - , Julie M. Hughes - , Craig J. McKinnon - , Kathryn M. Taylor -
| | - Craig J McKinnon
- 2U.S. Army Research Institute of Environmental Medicine, Military Performance Division, Natick, MA 01760
- E-mail correspondence may be directed to the authors at the following addresses: Joseph R. Kardouni - , Julie M. Hughes - , Craig J. McKinnon - , Kathryn M. Taylor -
| | - Kathryn M Taylor
- 2U.S. Army Research Institute of Environmental Medicine, Military Performance Division, Natick, MA 01760
- E-mail correspondence may be directed to the authors at the following addresses: Joseph R. Kardouni - , Julie M. Hughes - , Craig J. McKinnon - , Kathryn M. Taylor -
| | - Julie M Hughes
- 2U.S. Army Research Institute of Environmental Medicine, Military Performance Division, Natick, MA 01760
- E-mail correspondence may be directed to the authors at the following addresses: Joseph R. Kardouni - , Julie M. Hughes - , Craig J. McKinnon - , Kathryn M. Taylor -
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18
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Staab JS, Kolb AL, Tomlinson RE, Pajevic PD, Matheny RW, Hughes JM. Emerging evidence that adaptive bone formation inhibition by non-steroidal anti-inflammatory drugs increases stress fracture risk. Exp Biol Med (Maywood) 2021; 246:1104-1111. [PMID: 33641442 DOI: 10.1177/1535370221993098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There is mounting evidence suggesting that the commonly used analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), may inhibit new bone formation with physical training and increase risk of stress fractures in physically active populations. Stress fractures are thought to occur when bones are subjected to repetitive mechanical loading, which can lead to a cycle of tissue microdamage, repair, and continued mechanical loading until fracture. Adaptive bone formation, particularly on the periosteal surface of long bones, is a concurrent adaptive response of bone to heightened mechanical loading that can improve the fatigue resistance of the skeletal structure, and therefore may play a critical role in offsetting the risk of stress fracture. Reports from animal studies suggest that NSAID administration may suppress this important adaptive response to mechanical loading. These observations have implications for populations such as endurance athletes and military recruits who are at risk of stress fracture and whose use of NSAIDs is widespread. However, results from human trials evaluating exercise and bone adaptation with NSAID consumption have been less conclusive. In this review, we identify knowledge gaps that must be addressed to further support NSAID-related guidelines intended for at-risk populations and individuals.
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Affiliation(s)
- Jeffery S Staab
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Alexander L Kolb
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Ryan E Tomlinson
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | | | - Ronald W Matheny
- Military Operational Medicine Research Program, Fort Detrick, MD 21702, USA
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
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19
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Popp KL, Ackerman KE, Rudolph SE, Johannesdottir F, Hughes JM, Tenforde AS, Bredella MA, Xu C, Unnikrishnan G, Reifman J, Bouxsein ML. Changes in Volumetric Bone Mineral Density Over 12 Months After a Tibial Bone Stress Injury Diagnosis: Implications for Return to Sports and Military Duty. Am J Sports Med 2021; 49:226-235. [PMID: 33259223 DOI: 10.1177/0363546520971782] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone stress injuries (BSIs) occur in up to 20% of runners and military personnel. Typically, after a period of unloading and gradual return to weightbearing activities, athletes return to unrestricted sports participation or military duty approximately 4 to 14 weeks after a BSI diagnosis, depending on the injury location and severity. However, the time course of the recovery of the bone's mechanical competence is not well-characterized, and reinjury rates are high. PURPOSE To assess the bone microarchitecture and volumetric bone mineral density (vBMD) over 12 months after a tibial BSI diagnosis. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS We enrolled 30 female athletes from the local community (aged 18-35 years) with a tibial BSI (grade ≥2 of 4 on magnetic resonance imaging) for this prospective observational study. Participants completed a baseline visit within 3 weeks of the diagnosis. At baseline and 6, 12, 24, and 52 weeks after the BSI diagnosis, we collected high-resolution peripheral quantitative computed tomography scans of the ultradistal tibia (4% of tibial length) of the injured and uninjured legs as well as pain and physical activity assessment findings. RESULTS From baseline to 12 weeks after the diagnosis, total, trabecular, and cortical vBMD declined by 0.58% to 0.94% (P < .05 for all) in the injured leg. Total and trabecular vBMD also declined by 0.61% and 0.67%, respectively, in the uninjured leg (P < .05 for both). At 24 weeks, mean values for all bone parameters were nearly equivalent to baseline values, and by 52 weeks, several mean values had surpassed baseline values. Of the 30 participants, 10 incurred a subsequent BSI during the course of the study, and 1 of these 10 incurred 2 subsequent BSIs. Participants who suffered an additional BSI were younger and had a later age of menarche, a greater incidence of previous fractures, and lower serum parathyroid hormone levels (P < .05 for all). CONCLUSION Bone density declined in both the injured and the uninjured legs and, on average, did not return to baseline for 3 to 6 months after a tibial BSI diagnosis. The observed time to the recovery of baseline vBMD, coupled with the high rate of recurrent BSIs, suggests that improved return-to-sports and military duty guidelines may be in order.
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Affiliation(s)
- Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sara E Rudolph
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fjola Johannesdottir
- Harvard Medical School, Boston, Massachusetts, USA.,Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Adam S Tenforde
- Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Chun Xu
- Biotechnology High Performance Computing Software Applications Institute, Department of Defense, Frederick, Maryland, USA
| | - Ginu Unnikrishnan
- Biotechnology High Performance Computing Software Applications Institute, Department of Defense, Frederick, Maryland, USA
| | - Jaques Reifman
- Biotechnology High Performance Computing Software Applications Institute, Department of Defense, Frederick, Maryland, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Fenn BP, Song J, Casey J, Waryasz GR, DiGiovanni CW, Lubberts B, Guss D. Worldwide epidemiology of foot and ankle injuries during military training: a systematic review. BMJ Mil Health 2020; 167:131-136. [PMID: 33168697 DOI: 10.1136/bmjmilitary-2020-001591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Musculoskeletal foot and ankle injuries are commonly experienced by soldiers during military training. We performed a systematic review to assess epidemiological patterns of foot and ankle injuries occurring during military training. METHODS A review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search, done on 14 February 2019, resulted in 1603 reports on PubMed, 565 on Embase and 3 on the Cochrane Library. After reading the remaining full-text articles, we included 91 studies. RESULTS Among a population of 8 092 281 soldiers from 15 countries, 788 469 (9.74%) foot and ankle injuries were recorded. Among the 49 studies that reported on length of training, there were 36 770/295 040 (18.17%) injuries recorded among women and 248 660/1 501 672 (16.56%) injuries recorded among men over a pooled mean (±SD) training period of 4.51±2.34 months. Ankle injuries were roughly 7 times more common than foot injuries, and acute injuries were roughly 24 times more common than non-acute injuries. Our findings indicated that, during a 3-month training period, soldiers have a 3.14% chance of sustaining a foot and ankle injury. The incidence of foot or ankle injury during military parachutist training was 3.1 injuries per thousand jumps. CONCLUSIONS Our findings provide an overview of epidemiological patterns of foot and ankle injuries during military training. These data can be used to compare incidence rates of foot and ankle injuries due to acute or non-acute mechanisms during training. Cost-effective methods of preventing acute ankle injuries and non-acute foot injuries are needed to address this problem.
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Affiliation(s)
- Brian P Fenn
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J Song
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J Casey
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G R Waryasz
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - C W DiGiovanni
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - B Lubberts
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - D Guss
- Massachusetts General Hospital, Boston, Massachusetts, USA
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O'Leary TJ, Wardle SL, Greeves JP. Energy Deficiency in Soldiers: The Risk of the Athlete Triad and Relative Energy Deficiency in Sport Syndromes in the Military. Front Nutr 2020; 7:142. [PMID: 32984399 PMCID: PMC7477333 DOI: 10.3389/fnut.2020.00142] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022] Open
Abstract
Military personnel experience energy deficit (total energy expenditure higher than energy intake), particularly during combat training and field exercises where exercising energy expenditures are high and energy intake is reduced. Low energy availability (energy intake minus exercising energy expenditure expressed relative to fat free mass) impairs endocrine function and bone health, as recognized in female athletes as the Female Athlete Triad syndrome. More recently, the Relative Energy Deficiency in Sport (RED-S) syndrome encompasses broader health outcomes, physical and cognitive performance, non-athletes, and men. This review summarizes the evidence for the effect of low energy availability and energy deficiency in military training and operations on health and performance outcomes. Energy availability is difficult to measure in free-living individuals but doubly labeled water studies demonstrate high total energy expenditures during military training; studies that have concurrently measured energy intake, or measured body composition changes with DXA, suggest severe and/or prolonged energy deficits. Military training in energy deficit disturbs endocrine and metabolic function, menstrual function, bone health, immune function, gastrointestinal health, iron status, mood, and physical and cognitive performance. There are more data for men than women, and little evidence on the chronic effects of repeated exposures to energy deficit. Military training impairs indices of health and performance, indicative of the Triad and RED-S, but the multi-stressor environment makes it difficult to isolate the independent effects of energy deficiency. Studies supplementing with energy to attenuate the energy deficit suggest an independent effect of energy deficiency in the disturbances to metabolic, endocrine and immune function, and physical performance, but randomized controlled trials are lacking.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom.,Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom.,Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom.,Division of Surgery and Interventional Science, UCL, London, United Kingdom.,Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Whittle RS. Distance travelled by military recruits during basic training is a significant risk factor for lower limb overuse injury. BMJ Mil Health 2020; 168:343-348. [PMID: 32487672 DOI: 10.1136/bmjmilitary-2020-001445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Military initial training results in a high incidence of lower limb overuse injuries (stress fractures and medial tibial stress syndrome). This study aimed to determine whether the distance travelled by recruits, both on and off duty, was a risk factor for overuse injury. METHODS 14 male airborne infantry recruits from three training platoons carried global positioning system receivers throughout the first 19 weeks of basic military training. Total distance travelled each day was recorded. This was compared with time of clinical manifestation of 52 lower limb overuse injuries (stress fractures and medial tibial stress syndrome) collected from the 276 airborne infantry recruits in the period immediately preceding the study. RESULTS Recruits travelled significantly farther than the UK average male population in 17 of 18 measured weeks. Pearson correlation between distance travelled per week and injuries was not significant (p=0.4448); however, correlation between distance travelled per week and injuries two weeks later was significant (p=0.0263). A generalised linear model found distance travelled as a significant covariate (p=0.0144) to the expected number of injuries two weeks later. CONCLUSION Recruits travel long distances during basic training, particularly in the first few weeks when they are not yet conditioned. This distance travelled is likely a contributing risk factor to the high incidence of overuse injuries seen during training, and strategies to reduce this distance should be explored.
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Affiliation(s)
- Richard S Whittle
- Department of Aerospace Engineering, Texas A&M University, College Station, Texas, USA .,British Army, London, UK
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Geometric and "True" Densitometric Characteristics of Bones in Athletes with Stress Fracture and Menstrual Disturbances: A Systematic Review. Sports Med 2020; 49:1059-1078. [PMID: 31041601 DOI: 10.1007/s40279-019-01109-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Stress fractures can lead to short- and long-term consequences, impacting participation in sport and general health. Recognizing which skeletal characteristics render bones susceptible to stress fracture may aid stress-fracture prevention. Menstrual disturbances among exercising women are a known risk factor for stress fracture; therefore, assessing skeletal commonalities between women with stress fractures and women with menstrual disturbances may increase our understanding of why menstrual disturbances put athletes at greater risk for stress fracture. Three-dimensional (3D) bone imaging tools provide detailed information about volumetric bone mineral density (vBMD) and bone structure that cannot be obtained using traditional two-dimensional (2D) techniques. OBJECTIVES This systematic review serves to: (1) evaluate the current literature available on vBMD, bone geometry, and bone structure in exercising women with menstrual disturbances and exercising women with stress fractures, and (2) assess the common skeletal characteristics between both conditions. Our aim is to reveal bone properties beyond 2D areal BMD that may indicate increased susceptibility to stress fracture among exercising women with menstrual disturbances. SEARCH METHODS A search of the PubMed/Medline database was completed in May 2018. ELIGIBILITY CRITERIA Eligible articles included those that reported vBMD, bone geometry, or bone structure obtained from 3D imaging techniques or estimated from 2D imaging techniques. Only studies conducted in premenopausal exercising women and girls who had a stress fracture, a menstrual disturbance, or both were included. RESULTS Twenty-four articles met the inclusion criteria. Bone area and cortical thickness at the tibia were identified as altered both in women with menstrual disturbances and in women with stress fractures; however, there was inconsistency in the results observed for all bone parameters. The majority of skeletal parameters of the lower extremities were not significantly different between exercising women with and without stress fractures and between those with and without menstrual disturbances. DISCUSSION Most studies were moderate or low quality based on study design, and only one article combined both conditions to explore vBMD and bone geometry in athletes with menstrual disturbances and a history of stress fracture. These findings highlight the need for more skeletal research on the intersection of these health conditions in exercising women. The lack of observed differences in skeletal parameters suggests that risk factors other than bone geometry and structure may be the primary causes of stress fracture in these women.
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Fallowfield JL, Leiper RG, Shaw AM, Whittamore DR, Lanham-New SA, Allsopp AJ, Kluzek S, Arden NK, Sanchez-Santos MT. Risk of Injury in Royal Air Force Training: Does Sex Really Matter? Mil Med 2020; 185:170-177. [PMID: 30137495 DOI: 10.1093/milmed/usy177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/01/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Musculoskeletal injuries are common during military and other occupational physical training programs. Employers have a duty of care to reduce employees' injury risk, where females tend to be at greater risk than males. However, quantification of principle co-factors influencing the sex-injury association, and their relative importance, remain poorly defined. Injury risk co-factors were investigated during Royal Air Force (RAF) recruit training to inform the strategic prioritization of mitigation strategies. MATERIAL AND METHODS A cohort of 1,193 (males n = 990 (83%); females n = 203 (17%)) recruits, undertaking Phase-1 military training, were prospectively monitored for injury occurrence. The primary independent variable was sex, and potential confounders (fitness, smoking, anthropometric measures, education attainment) were assessed pre-training. Generalized linear models were used to assess associations between sex and injury. RESULTS In total, 31% of recruits (28% males; 49% females) presented at least one injury during training. Females had a two-fold greater unadjusted risk of injury during training than males (RR = 1.77; 95% CI 1.49-2.10). After anthropometric, lifestyle and education measures were included in the model, the excess risk decreased by 34%, but the associations continued to be statistically significant. In contrast, when aerobic fitness was adjusted, an inverse association was identified; the injury risk was 40% lower in females compared with males (RR = 0.59; 95% CI: 0.42-0.83). CONCLUSIONS Physical fitness was the most important confounder with respect to differences in males' and females' injury risk, rather than sex alone. Mitigation to reduce this risk should, therefore, focus upon physical training, complemented by healthy lifestyle interventions.
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Affiliation(s)
- Joanne L Fallowfield
- Environmental Medicine and Sciences Division, Institute of Naval Medicine, Crescent Road, Alverstoke, Hampshire PO12 2DL, UK
| | - Rachel G Leiper
- Regional Medical Centre, RAF Halton, Aylesbury, Bucks HP22 5PG, UK
| | - Anneliese M Shaw
- Environmental Medicine and Sciences Division, Institute of Naval Medicine, Crescent Road, Alverstoke, Hampshire PO12 2DL, UK
| | - David R Whittamore
- Nutritional Sciences Department, Faculty of Health and Medical Sciences, University of Surrey, Guilford, Surrey GU2 7XH, UK
| | - Susan A Lanham-New
- Nutritional Sciences Department, Faculty of Health and Medical Sciences, University of Surrey, Guilford, Surrey GU2 7XH, UK
| | - Adrian J Allsopp
- Environmental Medicine and Sciences Division, Institute of Naval Medicine, Crescent Road, Alverstoke, Hampshire PO12 2DL, UK
| | - Stefan Kluzek
- Arthritis Research UK Sports, Exercise and Osteoarthritis Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford OX3 7LD, UK
| | - Nigel K Arden
- Arthritis Research UK Sports, Exercise and Osteoarthritis Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford OX3 7LD, UK.,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton SO17 1BJ, UK.,Sydney Medical School, Edward Ford Building A27, The University of Sydney, NSW 2006, Australia
| | - Maria T Sanchez-Santos
- Arthritis Research UK Sports, Exercise and Osteoarthritis Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford OX3 7LD, UK
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A Profile of Injuries Sustained by Firefighters: A Critical Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16203931. [PMID: 31623104 PMCID: PMC6843477 DOI: 10.3390/ijerph16203931] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 01/09/2023]
Abstract
Firefighters, along with other tactical personnel, are at a high risk of work-related physical injury above that of the private sector. The aim of this critical narrative review was to identify, critically appraise and synthesise key findings from recent literature investigating firefighting musculoskeletal injuries to inform injury reduction programs. The methodological approach (search terms, databases, etc.) was registered with PROSPERO and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality was assessed using the Downs and Black checklist with scores graded according to the Kennelly grading system. Levels of evidence were ranked according to the Australian National Health and Medical Research Council. Of the 8231 studies identified, 17 met the criteria for inclusion. The methodological quality of the studies was ‘fair’ with a level of evidence of III-2. Reported injury rates ranged from 9% to 74% with the lower extremities and back the leading aggregated bodily sites of injury. Sprains and strains were the leading nature of musculoskeletal injury, often caused by slips, trips and falls, although muscle bending, lifting and squatting or muscle stressing were also prevalent. This review may inform injury reduction strategies and given that injuries reported in firefighters are similar to those of other tactical populations, safety processes to mitigate injuries may be of benefit across the tactical spectrum.
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Tomes CD, Sawyer S, Orr R, Schram B. Ability of fitness testing to predict injury risk during initial tactical training: a systematic review and meta-analysis. Inj Prev 2019; 26:67-81. [DOI: 10.1136/injuryprev-2019-043245] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/03/2019] [Accepted: 06/09/2019] [Indexed: 11/04/2022]
Abstract
ObjectiveTactical personnel (Military, Law Enforcement, Emergency Responders) require physical fitness levels sufficient for training and occupational duty. Physical conditioning aimed at increasing fitness levels during training presents an injury risk, but unfit trainees may struggle to meet occupational performance standards, further increasing injury risk to themselvesor others. Therefore, the aim of this review was to determine if fitness, asquantified by tactical fitness tests, effectively predicts injury risk during training.MethodsLiterature databases were search and relevant articles extracted. 27 Publications were included for qualitative review and seven studies reporting a timed run were included in meta-analysis.ResultsThe combined risk ratio was 2.34 (95% CI 2.02 to2.70). Muscular endurance tests were less conclusive in their predictive abilities. Functional strength or power tests were effective predictors, but few studies reported on strength or power, indicating a need for further study inthis area.ConclusionsThe meta-analysis results are supported by the occupational relevance of run tests; tactical trainees are required to perform frequent bouts of distance weight bearing activity. However, given the diverse physical requirements of tactical personnel, measures of strength and power should alsobe evaluated, especially given their effectiveness in the studies that included these measures.
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Vitamin D and foot and ankle trauma: An individual or societal problem. Foot (Edinb) 2019; 39:100-105. [PMID: 31026676 DOI: 10.1016/j.foot.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/04/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Vitamin D deficiency is a worldwide health concern. Hypovitaminosis D may adversely affect recovery from bone injury. The authors aimed to perform an audit of the Vitamin D status of patients in three centres in the United Kingdom presenting with foot and ankle osseous damage. METHODS Serum 25-hydroxyvitamin-D (vitamin D) levels were obtained in patients presenting with imaging confirmed foot and ankle osseous trauma. Variables including age, gender, ethnicity, location, season, month, anatomical location and type of bone injury were recorded. RESULTS 308 patients were included from three different centres. 66.6% were female. The average age was 47.7 (range; 10-85). The mean hydroxyvitamin-D levels were 52.0 nmol/L (SD 28.5). 18.8% were grossly deficient, 23.7% deficient, 34.7% insufficient and 22.7% within normal range. 351 separate bone injuries were identified of which 104 were categorised as stress reactions, 134 as stress fractures, 105 as fractures and 8 non-unions. Age, gender, anatomical location and fracture type did not statistically affect vitamin D levels. Ethnicity did affect Vitamin D levels: non-Caucasians mean levels were 32.4 nmols/L compared to Caucasian levels of 53.2 nmol/L (p=0.0026). CONCLUSION Only 18.8% of our trauma patients had a normal Vitamin D level and 22.7% were grossly deficient. Patient age, gender, anatomical location and injury type did not statistically affect vitamin D levels. No difference between trauma and elective patients were found. Hypovitaminosis D is a problem of society in general rather than specific to certain foot and ankle injury patterns or particular patient groups sustaining trauma. LEVEL OF EVIDENCE 2b.
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Müller-Schilling L, Gundlach N, Böckelmann I, Sammito S. Physical fitness as a risk factor for injuries and excessive stress symptoms during basic military training. Int Arch Occup Environ Health 2019; 92:837-841. [PMID: 30895369 DOI: 10.1007/s00420-019-01423-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 03/12/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of basic military training (BMT) is to enable the recruited soldiers to acquire basic military skills and develop the required physical fitness. This training is accompanied by heightened physical stress and the risk of injury and excessive stress symptoms (I&ESS). The objective of this study was to examine the extent to which the level of physical fitness at the beginning of BMT affects the incidence of I&ESS and resultant absence from duty. METHODS The data of a total of 774 subjects (age 20.5 ± 2.2) from 8 subsequent BMT quarters were analysed. The medical diagnoses made during the consulting hours of the unit physicians were reviewed for I&ESS and the kinds of injuries incurred and the sick leave pronounced were documented. The level of physical fitness per quarter was then categorised by means of the total numbers of points achieved during the standard basic fitness test (BFT). This categorisation was finally used as a basis for an analysis of the lost days in relation to the level of physical fitness. RESULTS 255 of the 774 subjects (32.9%) suffered an I&ESS. 60% of all the I&ESS were located at lower extremity. There was a significant increase in the length of absence from duty among the group with the lowest level of physical fitness. CONCLUSIONS The analysis revealed that the level of physical fitness at the beginning of BMT has a significant influence on the length of absence from duty due to I&ESS. Moreover, 60% of the injuries were lower extremity injuries, which show the specific significance they have for limitations during BMT. Overall, this reveals the necessity for appropriate preventive measures (additional fitness training, adjustment of requirements) to be implemented so that recruits with a low level of fitness can complete BMT with as few injuries as possible.
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Affiliation(s)
- Lisa Müller-Schilling
- Department I Internal Medicine, Bundeswehr Hospital Berlin, Berlin, Germany.,Department of Occupational Medicine, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Nils Gundlach
- Medical Clinic Rotenburg (Wümme), Rotenburg (Wümme), Germany
| | - Irina Böckelmann
- Department of Occupational Medicine, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Stefan Sammito
- Department of Occupational Medicine, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany. .,Bundeswehr Medical Service Headquarters, Section VI 3.3 Occupational Health Management System, Sports and Nutrition Medicine, Von-Kuhl-Straße 50, 56070, Koblenz, Germany.
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Heller R, Stammers H. Running to breaking point? The relationship between 1.5-mile run time and injury risk in female recruits during British Army basic training. BMJ Mil Health 2019; 166:e3-e7. [DOI: 10.1136/jramc-2018-001012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/04/2022]
Abstract
IntroductionThe 1.5-mile best-effort run is used in the British Army to assess the fitness of all recruits and trained service personnel by means of the physical fitness assessment (PFA). The 1.5-mile run is a basic measure of fitness and slower times have been associated with an increased risk of musculoskeletal injury (MSkI), particularly during this early stage of training. The aim of this study was to establish whether 1.5-mile run times were associated with subsequent MSkIs among female recruits during their 14-week basic training.MethodRetrospective data were analysed from female recruits who had undertaken basic military training between June 2016 and October 2017. This included retrieving the results of their week 1 PFA; recording the type, cause and week of MSkI if they had sustained one; and noting down their outcome from basic training. Run times were statistically analysed in relation to MSkI occurrence of 227 female recruits using binomial logistic regression with an accepted alpha level of p value <0.05.Results1.5-mile run time predicted risk of MSkI (χ2 (1)=12.91, p<0.0005) in female recruits. The mean run time for injury-free recruits was faster than for injured recruits (12 min 13 s compared with 12 min 43 s). Every 10 s increase in run time was associated with an 8.3% increase in risk of injury.ConclusionSlower 1.5-mile best-effort run time, as a surrogate of aerobic fitness, is associated with increased risk of MSkI in female recruits during basic training.
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Injuries of the adolescent girl athlete: a review of imaging findings. Skeletal Radiol 2019; 48:77-88. [PMID: 30123946 DOI: 10.1007/s00256-018-3029-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 07/03/2018] [Accepted: 07/09/2018] [Indexed: 02/02/2023]
Abstract
With the rising participation of girls in sports at both the recreational and elite levels, there has also been increased awareness of injuries common in this athlete population. Anatomic differences between boys and girls cause girl athletes to be predisposed to certain injuries. Certain behavioral patterns, such as eating disorders, also cause problems specific to girl athletes that may result in injury. Imaging plays a large role in diagnosis and ongoing management, but there has been only scant literature dedicated to the specific topic of imaging in girl athletes. The purpose of this article is to review the imaging findings and recommendations for injuries and other conditions affecting the adolescent girl athlete. This article first provides an overview of the key anatomic differences between boys and girls, including both static and dynamic factors, as well as non-anatomic differences, such as hormonal factors, and discusses how these differences contribute to the injury patterns that are seen more typically in girls. The article then reviews the imaging findings in injuries that are commonly seen in girl athletes. There is also a discussion of the "female athlete triad," which consists of osteoporosis, disordered eating, and amenorrhea, and the role of imaging in this condition.
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Flanagan SD, Krajewski KT, Sinnott AM, Johnson CD, Eagle SR, LaGoy AD, Beckner ME, Beethe AZ, Turner R, Lovalekar MT, Dunn-Lewis C, Connaboy C, Nindl BC. Prediction of exertional lower extremity musculoskeletal injury in tactical populations: protocol for a systematic review and planned meta-analysis of prospective studies from 1955 to 2018. Syst Rev 2018; 7:244. [PMID: 30580762 PMCID: PMC6304230 DOI: 10.1186/s13643-018-0883-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 11/13/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Musculoskeletal injuries (MSI) represent more than half of all injuries in tactical populations (i.e., military service and public safety workers including police, firefighters, emergency medical services (EMS)). Most lower extremity MSIs result from physical exertion during training, occupational tasks, and recreation. Such exertional lower extremity injuries (ELEI) produce a significant human and financial cost. Accordingly, significant efforts have been made to identify sensitive, specific, and reliable predictors of ELEI. There is a need to synthesize and evaluate the predictive value of risk factors for ELEI while addressing the influence of occupation, sex, exposure, injury characteristics, and study quality. Therefore, the purpose of this systematic review and planned meta-analysis is to evaluate risk factors for ELEI in tactical populations. METHODS After the development of a search strategy, comprehensive searches will be conducted in MEDLINE, EMBASE, Cochrane, and CINAHL databases. Articles will be screened with a multi-user process and delimited to prospective comparative cohort studies that directly measure injury occurrence in the target population(s). Extracted data will be synthesized and assessed for reporting bias, meta-bias, and overall quality, with subgroup analyses to determine the influence of participant, injury, and exposure characteristics in addition to study quality. DISCUSSION This systematic review and planned meta-analysis will comprehensively evaluate ELEI risk factors. Information gained will inform injury prevention protocols, facilitate the use of improved measurements, and identify requirements for future research. TRIAL REGISTRATION The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 3 Jan 2018 (registration number CRD42018056977 ).
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Affiliation(s)
- Shawn D. Flanagan
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Kellen T. Krajewski
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Aaron M. Sinnott
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Caleb D. Johnson
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Shawn R. Eagle
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Alice D. LaGoy
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Meaghan E. Beckner
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Anne Z. Beethe
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Rose Turner
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA USA
| | - Mita T. Lovalekar
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Courtenay Dunn-Lewis
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
- Department of Health and Physical Activity, School of Education, University of Pittsburgh, Pittsburgh, PA USA
| | - Chris Connaboy
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
| | - Bradley C. Nindl
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA USA
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Can anthropometric, body composition, and bone variables be considered risk factors for musculoskeletal injuries in Brazilian military students? BMC Musculoskelet Disord 2018; 19:377. [PMID: 30326875 PMCID: PMC6192153 DOI: 10.1186/s12891-018-2292-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 10/03/2018] [Indexed: 01/08/2023] Open
Abstract
Background Musculoskeletal injuries are the main cause of premature discharge from military service and can sometimes lead to permanent disabilities. Some intrinsic risk factors are well discussed in the literature. However, the relation between body composition variables and the risk for musculoskeletal injury is not well known or recognized. Methods This prospective study evaluated 205 Brazilian military students. At the beginning of military service, health status and sports experience prior to military service were registered. Anthropometric variables were evaluated, and bone and body composition variables were measured using dual-energy X-ray absorptiometry. The occurrence of musculoskeletal injuries throughout the year was registered at the military physiotherapy service. At the end of 1 year of follow-up, risk factors were analysed by comparing the variables between the injured and non-injured students. Results No difference in previous health status was found between injured and non-injured groups, whereas sports experience prior to military service was identified as a protective factor (Odds Ratio (OR) 0.323; 95% CI: 0.108–0.968; p = 0.044). Anthropometric, bone, and body composition variables could not be identified as risk factors for musculoskeletal injuries in Brazilian military students. Conclusion Anthropometric, bone, and body composition variables could not be considered risk factors for musculoskeletal injuries in Brazilian military students.
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Fukushima Y, Ray J, Kraus E, Syrop IP, Fredericson M. A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2297-2307. [PMID: 29655254 DOI: 10.1002/jum.14588] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/26/2017] [Accepted: 12/27/2017] [Indexed: 06/08/2023]
Abstract
Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.
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Affiliation(s)
- Yaeko Fukushima
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California, USA
| | - Jeremiah Ray
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California, USA
| | - Emily Kraus
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California, USA
| | - Isaac P Syrop
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California, USA
| | - Michael Fredericson
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California, USA
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Prevalence of Indicators of Low Energy Availability in Elite Female Sprinters. Int J Sport Nutr Exerc Metab 2018; 28:490-496. [PMID: 29757049 DOI: 10.1123/ijsnem.2017-0397] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Low energy availability (LEA), and subsequent relative energy deficiency in sport, has been observed in endurance, aesthetic, and team sport athletes, with limited data on prevalence in athletes in short-burst activities such as sprinting. We examined prevalence of signs and symptoms of LEA in elite female sprinters at the start of the training season (PRE), and at the end of a 5-month indoor training period (POST). Four of 13 female sprinters (31%) presented at PRE testing with at least one primary (amenorrhea, low bone mineral density, low follicle-stimulating hormone, luteinizing hormone, or estradiol, resting metabolic rate ≤29 kcal/kg fat-free mass, Low Energy Availability in Females Questionnaire score ≥8) and one secondary indicator of LEA (fasting blood glucose <4 mmol/L, free triiodothyronine <3.5 pmol/L, ferritin <25 μg/L, low-density lipoprotein cholesterol >3.0 mmol/L, fasting insulin <20 pmol/L, low insulin-like growth factor-1, systolic blood pressure <90 mmHg, and/or diastolic blood pressure <60 mmHg). At POST, seven out of 13 athletes (54%) presented with at least one primary and one secondary indicator of LEA, three of whom had also presented with indicators of LEA at PRE. Five out of 13 (39%) athletes had previous stress fracture history, though this was not associated with current indicators of LEA (PRE: r = .52, p = .07; POST: r = -.07, p = .82). In conclusion, elite female sprinters may present with signs and symptoms of LEA, even after off-season rest. Medical and coaching staff should be aware of the signs and symptoms of LEA and relative energy deficiency in sport and should include appropriate screening and intervention strategies when working with sprinters.
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Brumitt J, Heiderscheit BC, Manske RC, Niemuth PE, Mattocks A, Rauh MJ. Preseason Functional Test Scores Are Associated With Future Sports Injury in Female Collegiate Athletes. J Strength Cond Res 2018; 32:1692-1701. [DOI: 10.1519/jsc.0000000000002243] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Knapik JJ, Sharp MA, Montain SJ. Association between stress fracture incidence and predicted body fat in United States Army Basic Combat Training recruits. BMC Musculoskelet Disord 2018; 19:161. [PMID: 29788936 PMCID: PMC5964907 DOI: 10.1186/s12891-018-2061-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/25/2018] [Indexed: 01/10/2023] Open
Abstract
Background A stress fracture (SF) is a highly debilitating injury commonly experienced in United States Army Basic Combat Training (BCT). Body fat (BF) may be associated with this injury but previous investigations (in athletes) have largely used SF self-reports and lacked sufficient statistical power. This investigation developed an equation to estimate %BF and used that equation to examine the relationship between %BF and SF risk in BCT recruits. Methods Data for the %BF predictive equation involved 349 recruits with BF obtained from dual-energy X-ray absorptiometry. %BF was estimated using body mass index (BMI, weight/height2), age (yr), and sex in the entire population of BCT recruits over an 11-year period (n = 583,651). Medical information was obtained on these recruits to determine SF occurrence. Recruits were separated into deciles of estimated %BF and the risk of SFs determined in each decile. Results The equation was %BF = − 7.53 + 1.43 ● BMI + 0.13 ● age − 14.73 ● sex, with sex either 1 for men or 0 for women (r = 0.88, standard error of estimate = 4.2%BF). Among the men, SF risk increased at the higher and lower %BF deciles: compared to men in the mean %BF decile, the risk of a SF for men in the first (lowest %BF) and tenth (highest %BF) decile were 1.27 (95%confidence interval (95%CI) = 1.17–1.40) and 1.15 (95%CI = 1.05–1.26) times higher, respectively. Among women, SF risk was only elevated in the first %BF decile with risk 1.20 (95%CI = 1.09–1.32) times higher compared to the mean %BF decile. Conclusions Low %BF was associated with higher SF risk in BCT; higher %BF was associated with higher SF risk among men but not women.
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Affiliation(s)
- Joseph J Knapik
- US Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA.
| | - Marilyn A Sharp
- US Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA
| | - Scott J Montain
- US Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA
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The effect of hormone therapy on bone mineral density and cardiovascular factors among Iranian female athletes with amenorrhea/oligomenorrhea: A randomized clinical trial. Med J Islam Repub Iran 2018; 32:27. [PMID: 30159278 PMCID: PMC6108246 DOI: 10.14196/mjiri.32.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Indexed: 12/12/2022] Open
Abstract
Background: Functional hypothalamic menstrual disorder (FHMD) has a destructive effect on the athlete's bone mineral density and cardiovascular system. Utilizing hormone replacement therapy to treat FHMD in athletes is controversial. This study was conducted to examine the effect of hormone therapy on bone density and the cardiovascular system of professional female athletes with FHMD. Methods: In this study, 18 female athletes with at least a 2- year history of FHMD were recruited in a 9-month single blind randomized clinical intervention (RCT) and randomly classified into 2 groups: the oral contraceptive pills (OCP) group, who received a lowdose combined oral contraceptive (OC) containing 30 µg ethinyl estradiol and 150 µg levonorgestrel (n= 10), and the control group (n= 8). Bone mineral densitometry (BMD) and certain cardiovascular risk factors were measured before and after the 9-month trial. The Chi square test was used to compare the quantitative and qualitative results. Results: Bone mineral density did not change significantly in either group. Very low density lipoprotein (VLDL) (p= 0.035) and Apolipoprotein B (Apo B) (p= 0.04) reduced significantly in the OCP group. An increase was observed in the serum levels of Apolipoprotein A (Apo A) (p= 0.01) in the control group. Changes in the Apo B to Apo A ratio was significant in both groups (OCP group: p= 0.018, control group: p= 0.040). No significant changes were observed in the other measured factors. Conclusion: Although the administration of estrogen did not significantly increase bone mineral density, it had positive effects on the cardiovascular system and lipid profile.
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Bedno SA, Nelson DA, Kurina LM, Choi YS. Gender differences in the associations of body mass index, physical fitness and tobacco use with lower extremity musculoskeletal injuries among new US Army soldiers. Inj Prev 2018; 25:295-300. [PMID: 29572263 DOI: 10.1136/injuryprev-2017-042669] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/27/2018] [Accepted: 03/03/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Musculoskeletal (MSK) injuries are a leading cause of morbidity among US Army soldiers, especially among women and the newly enlisted. While extremes of body mass index (BMI), low physical fitness and tobacco use have been identified as risk factors, no prior studies have determined the combined effects of these risk factors or tested for gender differences in the associations. METHODS We conducted a retrospective cohort study utilising the Stanford Military Data Repository to study all enlisted soldier accessions to the US Army between January 2011 and January 2014, with follow-up through December 2014 (n=238 772). We used discrete-time logistic regression to test for associations between demographic, socioeconomic and health behaviour-related predictors and incident lower extremity injuries. We included interaction terms to test for gender differences. RESULTS Among men, there were greater adjusted odds of injury among underweight (OR 1.27), overweight (OR 1.14) and obese soldiers (OR 1.54) (all p<0.001) relative to normal-weight soldiers. No statistically significant differences in the odds of injury on the basis of BMI were observed for female soldiers. Physical fitness was a significantly stronger predictor of injury for female as compared with male soldiers, while the association between tobacco use and injury was stronger for men (OR 1.47) than for women (OR 1.30) (p<0.001 for both). CONCLUSION This is the largest known study to simultaneously assess important, modifiable musculoskeletal injury risk factors and to test for gender differences in these associations. These findings provide critical gender-related nuances for clinicians and leaders seeking to reduce the risk of these problems.
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Affiliation(s)
- Sheryl A Bedno
- Department of Preventive Medicine, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - D Alan Nelson
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Lianne M Kurina
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Y Sammy Choi
- Departments of Medicine and Pediatrics, Womack Army Medical Center, Fort Bragg, North Carolina, USA
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TORNBERG ÅSAB, MELIN ANNA, KOIVULA FIONAMANDERSON, JOHANSSON ANDERS, SKOUBY SVEN, FABER JENS, SJÖDIN ANDERS. Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes. Med Sci Sports Exerc 2017; 49:2478-2485. [DOI: 10.1249/mss.0000000000001383] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jones BH, Hauret KG, Dye SK, Hauschild VD, Rossi SP, Richardson MD, Friedl KE. Impact of physical fitness and body composition on injury risk among active young adults: A study of Army trainees. J Sci Med Sport 2017; 20 Suppl 4:S17-S22. [DOI: 10.1016/j.jsams.2017.09.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/19/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
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Tirosh O, Orland G, Eliakim A, Nemet D, Steinberg N. Tibial impact accelerations in gait of primary school children: The effect of age and speed. Gait Posture 2017; 57:265-269. [PMID: 28683418 DOI: 10.1016/j.gaitpost.2017.06.270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/07/2017] [Accepted: 06/26/2017] [Indexed: 02/02/2023]
Abstract
Tibial stress fractures are associated with increased lower extremity loading at initial foot-ground contact, reflected in high peak positive acceleration (>8g) of the tibia in adults. There is no reported data on peak positive acceleration of the tibia in children during walking and running. The aim of this study was to establish tibial peak positive acceleration responses in children across a range of age and gait speeds. Twenty-four children aged 8.5±1.4years with no known gait pathology comprised two age groups; Young (7-9year, n=12) and Older (10-12 years, n=12). Wireless Inertial Measurement Unit comprising a tri-axial accelerometer was securely taped to the anteromedial aspect of the distal tibia to measure peak positive acceleration responses while walking and running on the treadmill at 3 different speeds (20% below baseline, baseline, and 20% above baseline). Results showed significant increase in peak positive acceleration with increased gait speed and greater variability in young children compared to older children. The study suggests that ground impact in walking, but not running, is mature by age 7 years. Future studies should explore strategies using peak positive acceleration responses to monitor ground impact during sport activities and its application in gait retraining.
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Affiliation(s)
- Oren Tirosh
- School of Health Sciences, Swinburne University of Technology, 6 Luton Lane, Hawthorn, Victoria, 3122, Australia.
| | - Guy Orland
- The Wingate College of Physical Education and Sports Sciences at the Wingate Institute, Israel
| | - Alon Eliakim
- Child Health and Sport center, Pediatric Department, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Dan Nemet
- Child Health and Sport center, Pediatric Department, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Nili Steinberg
- The Wingate College of Physical Education and Sports Sciences at the Wingate Institute, Israel
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Bulathsinhala L, Hughes JM, McKinnon CJ, Kardouni JR, Guerriere KI, Popp KL, Matheny RW, Bouxsein ML. Risk of Stress Fracture Varies by Race/Ethnic Origin in a Cohort Study of 1.3 Million US Army Soldiers. J Bone Miner Res 2017; 32:1546-1553. [PMID: 28300324 DOI: 10.1002/jbmr.3131] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 03/08/2017] [Accepted: 03/12/2017] [Indexed: 11/11/2022]
Abstract
Stress fractures (SF) are common and costly injuries in military personnel. Risk for SF has been shown to vary with race/ethnicity. Previous studies report increased SF risk in white and Hispanic Soldiers compared with black Soldiers. However, these studies did not account for the large ethnic diversity in the US military. We aimed to identify differences in SF risk among racial/ethnic groups within the US Army. A retrospective cohort study was conducted using data from the Total Army Injury and Health Outcomes Database from 2001 until 2011. SF diagnoses were identified from ICD-9 codes. We used Cox-proportional hazard models to calculate time to SF by racial/ethnic group after adjusting for age, education, and body mass index. We performed a sex-stratified analysis to determine whether the ethnic variation in SF risk depends on sex. We identified 21,549 SF cases in 1,299,332 Soldiers (more than 5,228,525 person-years of risk), revealing an overall incidence rate of 4.12 per 1000 person-years (7.47 and 2.05 per 1000 person-years in women and men, respectively). Using non-Hispanic blacks as the referent group, non-Hispanic white women had the highest risk of SF, with a 92% higher risk of SF than non-Hispanic black women (1.92 [1.81-2.03]), followed by American Indian/Native Alaskan women (1.72 [1.44-1.79]), Hispanic women (1.65 [1.53-1.79]), and Asian women (1.32 [1.16-1.49]). Similarly, non-Hispanic white men had the highest risk of SF, with a 59% higher risk of SF than non-Hispanic black men (1.59 [1.50-1.68]), followed by Hispanic men (1.19 [1.10-1.29]). When examining the total US Army population, we found substantial differences in the risk of stress fracture among racial/ethnic groups, with non-Hispanic white Soldiers at greatest risk and Hispanic, American Indian/Native Alaskan, and Asian Soldiers at an intermediate risk. Additional studies are needed to determine the factors underlying these race- and ethnic-related differences in stress fracture risk. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Lakmini Bulathsinhala
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Julie M Hughes
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Craig J McKinnon
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Joseph R Kardouni
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Katelyn I Guerriere
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Ronald W Matheny
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA.,Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Department of Orthopedic Surgery, Harvard Medical School, Boston MA, USA
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Lisman PJ, de la Motte SJ, Gribbin TC, Jaffin DP, Murphy K, Deuster PA. A Systematic Review of the Association Between Physical Fitness and Musculoskeletal Injury Risk: Part 1—Cardiorespiratory Endurance. J Strength Cond Res 2017; 31:1744-1757. [DOI: 10.1519/jsc.0000000000001855] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gifford RM, Reynolds RM, Greeves J, Anderson RA, Woods DR. Reproductive dysfunction and associated pathology in women undergoing military training. J ROY ARMY MED CORPS 2017; 163:301-310. [DOI: 10.1136/jramc-2016-000727] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/15/2016] [Accepted: 01/27/2017] [Indexed: 01/07/2023]
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A Profile of Injuries Sustained by Law Enforcement Officers: A Critical Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14020142. [PMID: 28165373 PMCID: PMC5334696 DOI: 10.3390/ijerph14020142] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/17/2017] [Accepted: 01/24/2017] [Indexed: 02/07/2023]
Abstract
Due to the unpredictable, varied and often physical nature of law enforcement duties, police officers are at a high risk of work-related physical injury. The aim of this critical narrative review was to identify and synthesize key findings of studies that have investigated musculoskeletal injuries sustained by law enforcement officers during occupational tasks. A systematic search of four databases using key search terms was conducted to identify potentially relevant studies, which were assessed against key inclusion and exclusion criteria to determine studies to be included in the review. Included studies were critically appraised and the level of evidence determined. Relevant data were extracted, tabulated and synthesized. The 16 identified studies ranged in percentage quality scores from 25.00% to 65.00%, with a mean score of 41.25% and high interrater agreement in scores reflected in a Cohen’s Kappa coefficient, κ = 0.977. The most common body site of injury was the upper extremity, the most common injury types were soft-tissue sprains and strains and the most common cause of injury was a non-compliant offender, often involving assault. However, there was limited peer reviewed research in this area and the published research had a narrow focus and was of low to fair methodological quality.
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Nye NS, Covey CJ, Sheldon L, Webber B, Pawlak M, Boden B, Beutler A. Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries. Sports Health 2017; 8:278-283. [PMID: 26945021 PMCID: PMC4981068 DOI: 10.1177/1941738116635558] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Lower extremity stress fractures among athletes and military recruits cause significant morbidity, fiscal costs, and time lost from sport or training. During fiscal years (FY) 2012 to 2014, 1218 US Air Force trainees at Joint Base San Antonio-Lackland, Texas, were diagnosed with stress fracture(s). Diagnosis relied heavily on bone scans, often very early in clinical course and often in preference to magnetic resonance imaging (MRI), highlighting the need for an evidence-based algorithm for stress injury diagnosis and initial management. EVIDENCE ACQUISITION To guide creation of an evidence-based algorithm, a literature review was conducted followed by analysis of local data. Relevant articles published between 1995 and 2015 were identified and reviewed on PubMed using search terms stress fracture, stress injury, stress fracture imaging, and stress fracture treatment. Subsequently, charts were reviewed for all Air Force trainees diagnosed with 1 or more stress injury in their outpatient medical record in FY 2014. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS In FY 2014, 414 trainees received a bone scan and an eventual diagnosis of stress fracture. Of these scans, 66.4% demonstrated a stress fracture in the symptomatic location only, 21.0% revealed stress fractures in both symptomatic and asymptomatic locations, and 5.8% were negative in the symptomatic location but did reveal stress fracture(s) in asymptomatic locations. Twenty-one percent (18/85) of MRIs performed a mean 6 days (range, 0- 21 days) after a positive bone scan did not demonstrate any stress fracture. CONCLUSION Bone stress injuries in military training environments are common, costly, and challenging to diagnose. MRI should be the imaging study of choice, after plain radiography, in those individuals meeting criteria for further workup.
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Affiliation(s)
- Nathaniel S. Nye
- 559th Trainee Health Squadron, Joint Base San Antonio–Lackland, Texas
| | - Carlton J. Covey
- Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lucas Sheldon
- 59th Radiology Squadron, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio–Lackland, Texas
| | - Bryant Webber
- 559th Trainee Health Squadron, Joint Base San Antonio–Lackland, Texas
| | - Mary Pawlak
- 559th Trainee Health Squadron, Joint Base San Antonio–Lackland, Texas
| | | | - Anthony Beutler
- Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Zimmermann WO, Helmhout PH, Beutler A. Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces. J ROY ARMY MED CORPS 2016; 163:94-103. [DOI: 10.1136/jramc-2016-000635] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/26/2016] [Accepted: 05/29/2016] [Indexed: 01/28/2023]
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Chen TL, An WW, Chan ZYS, Au IPH, Zhang ZH, Cheung RTH. Immediate effects of modified landing pattern on a probabilistic tibial stress fracture model in runners. Clin Biomech (Bristol, Avon) 2016; 33:49-54. [PMID: 26945721 DOI: 10.1016/j.clinbiomech.2016.02.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/12/2016] [Accepted: 02/17/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tibial stress fracture is a common injury in runners. This condition has been associated with increased impact loading. Since vertical loading rates are related to the landing pattern, many heelstrike runners attempt to modify their footfalls for a lower risk of tibial stress fracture. Such effect of modified landing pattern remains unknown. This study examined the immediate effects of landing pattern modification on the probability of tibial stress fracture. METHODS Fourteen experienced heelstrike runners ran on an instrumented treadmill and they were given augmented feedback for landing pattern switch. We measured their running kinematics and kinetics during different landing patterns. Ankle joint contact force and peak tibial strains were estimated using computational models. We used an established mathematical model to determine the effect of landing pattern on stress fracture probability. FINDINGS Heelstrike runners experienced greater impact loading immediately after landing pattern switch (P<0.004). There was an increase in the longitudinal ankle joint contact force when they landed with forefoot (P=0.003). However, there was no significant difference in both peak tibial strains and the risk of tibial stress fracture in runners with different landing patterns (P>0.986). INTERPRETATION Immediate transitioning of the landing pattern in heelstrike runners may not offer timely protection against tibial stress fracture, despite a reduction of impact loading. Long-term effects of landing pattern switch remains unknown.
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Affiliation(s)
- T L Chen
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - W W An
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Z Y S Chan
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - I P H Au
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Z H Zhang
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - R T H Cheung
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong.
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