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Zhu B, Zhao F, Qin X, Jiang H, Yao Z. Multiple stress fractures: A case report and discussion. Radiol Case Rep 2024; 19:3656-3660. [PMID: 38983284 PMCID: PMC11228661 DOI: 10.1016/j.radcr.2024.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 07/11/2024] Open
Abstract
Stress fracture is the result of bone destruction with prolonged and repetitive loading. It usually occurs among various groups, including athletes, military recruits, and others. Early stress fractures often undergo undiagnosed or misdiagnosed because of atypical symptoms and effective medical examination. Here, we report a rare clinical case about the multiple stress fractures in one adolescent. Expect for the pathological biopsy, it hardly gets confirm diagnosis. With the increasing population of sports lover, healthcare institutions should be enhanced their understanding of stress fractures and enable effective management at an early stage.
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Affiliation(s)
- Bitao Zhu
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Fei Zhao
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Xiabing Qin
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Heng Jiang
- Department of anesthesiology, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
| | - Zhongjun Yao
- Department of Orthopedic, The Taihe Hospital, Affiliated Hospital of Hubei University of Medicine, PR China
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2
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Sekel NM, Lovalekar M, Koltun KJ, Bird MB, Forse JN, Martin BJ, Nindl BC. Micronutrient Status During Military Training and Associations With Musculoskeletal Health, Injury, and Readiness Outcomes. Int J Sport Nutr Exerc Metab 2024:1-9. [PMID: 39168457 DOI: 10.1123/ijsnem.2024-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVE Micronutrient status, specifically vitamin D and iron, represent modifiable factors for optimizing military readiness. The primary purpose of this investigation was to determine associations between micronutrient deficiency (i.e., iron status and 25-hydroxy-vitamin D [25(OH)D]) and operationally relevant outcomes (i.e., skeletal health, musculoskeletal injury) at baseline and post-10 weeks of arduous military training. METHODS A total of 227 (177 men, 50 women) Marine Officer Candidates School (OCS) candidates who completed OCS training with complete data sets were included in this analysis. Vitamin D and iron status indicators were collected at two timepoints, pre (baseline) and post OCS. Musculoskeletal outcomes at the mid- and proximal tibial diaphysis were assessed via peripheral quantitative computed tomography. RESULTS Micronutrient status declined following OCS training in men and women and was associated with musculoskeletal outcomes including greater bone strength (strength strain index) at the mid-diaphysis site in those with optimal status (M = 38.26 mm3, SE = 15.59) versus those without (M = -8.03 mm3, SE = 17.27). In women (p = .037), endosteal circumference was greater in the deficient group (M = 53.26 mm, SE = 1.19) compared with the optimal group (M = 49.47 mm, SE = 1.31) at the proximal diaphysis. In men, greater baseline hepcidin concentrations were associated with an increased likelihood of suffering musculoskeletal injury during training. CONCLUSIONS Vitamin D and iron status declined over the course of training, suggesting impaired micronutrient status. Differences in musculoskeletal outcomes by micronutrient group suggests optimal vitamin D and ferritin concentrations may exert beneficial effects on bone fatigability and fracture reduction during military training.
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Affiliation(s)
- Nicole M Sekel
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mita Lovalekar
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kristen J Koltun
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew B Bird
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer N Forse
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Martin
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bradley C Nindl
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
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3
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Kasper KB, Cockerell M, Escamilla C, Gonzalez R. Multivitamin Compliance Reduces Injuries of Female Recruits at Air Force Basic Training: A Randomized Controlled Cohort Study. Mil Med 2024; 189:93-98. [PMID: 39160796 DOI: 10.1093/milmed/usae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 02/06/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Department of the Air Force basic military training (BMT) is the 7.5-week initial entry training for all enlisting U.S. Air Force and Space Force recruits. Overuse musculoskeletal injuries (MSKI) during training threaten success in BMT, and trainees with nutritional deficiencies are at higher risk. Several efforts are made at BMT to mitigate these issues to help trainees graduate on time, such as the distribution of multivitamins (MVI) to female recruits. However, trainee compliance with the prescribed MVI has been reported to be low, calling into question the effectiveness of this intervention. This study evaluated the effect of briefing modality offered to these trainees at the time of distribution on educational effectiveness, MVI compliance, and injury rates. MATERIALS AND METHODS This was a randomized controlled cohort study of BMT female trainees. Subjects included all female trainees of a single iteration of BMT concurrently completing training within the same squadron. At the outset of training, cohorts were randomly educated in one of two ways regarding the provided MVI. The control cohort (n = 80) was presented with the standard educational video created by BMT-registered dietitians, while the test cohort (n = 79) was presented the video and then also briefed in-person by a group of subject matter experts. At the end of BMT, the trainees completed a questionnaire regarding their knowledge, confidence, and compliance with the MVI. Additionally, a routinely collected training database was queried and analyzed for differences in injuries and training outcomes using the chi-squared test with significance set to α ≤ 0.05. RESULTS Although both cohorts found their educational presentation useful, the "in-person" cohort reported significantly higher compliance rates and were found to be diagnosed with MSKI and bone stress injuries at significantly lower rates (43% and 66% relative risk reductions, respectively). CONCLUSIONS Education to female BMT trainees regarding the MVI, which included a face-to-face discussion with subject matter experts, resulted in greater compliance and reduced incidence of MSKI and bone stress injury, compared to a video prepared by registered dietitians alone. Such educational approaches should continue to be strived for in this and other military population health measures. This study's implication of MVI efficacy for injury risk reduction in female trainees should be further studied, verified, and improved upon in this and other populations.
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Affiliation(s)
- Korey B Kasper
- 559th Trainee Health Squadron, JBSA-Lackland, TX 78236, USA
| | | | - Clarissa Escamilla
- 37th Training Wing, Human Performance Directorate, JBSA-Lackland, TX 78236, USA
| | - Richard Gonzalez
- 37th Training Wing, Human Performance Directorate, JBSA-Lackland, TX 78236, USA
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Hollabaugh WL, Hymel A, Pennings JS, Clark DE, Soslow JH, Karpinos AR. Vitamin D Status and Cardiovascular Disease in College Athletes After SARS-CoV-2 Infection. Clin J Sport Med 2024:00042752-990000000-00211. [PMID: 38980665 DOI: 10.1097/jsm.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/10/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE To evaluate the association between vitamin D status and CV disease after COVID-19 in college athletes. DESIGN Retrospective cohort study. SETTING National College Athletic Association Division-I college athletes from a single academic institution. PATIENTS A total of 157 athletes (60 female; median age: 20 years) from 9 sports with a positive SARS-CoV-2 test, cardiac magnetic resonance imaging (CMR), and vitamin D level. INDEPENDENT VARIABLES Serum 25-hydroxyvitamin D level (primary); age, sex (regression models). MAIN OUTCOMES MEASURES Differences in age, sex, race, ethnicity, myocarditis, pericarditis, and CMR metrics by vitamin D status were analyzed. Regression models were used to assess the relationship between vitamin D status and CMR metrics accounting for age and sex. RESULTS Low vitamin D (LVD) was found in 33 (21.0%) of athletes, particularly Black males (P < 0.001). Athletes with LVD had higher biventricular and lower mid-ventricular extracellular volumes, but these differences were not significant when corrected for age and sex. Athletes with LVD had higher left ventricle (LV) mass (P < 0.001) and LV mass index (P = 0.001) independent of age and sex. Differences in global circumferential strain were noted but are likely clinically insignificant. Vitamin D status did not associate with myocarditis and pericarditis (P = 0.544). CONCLUSIONS LVD is common in athletes, particularly in Black males. Although athletes with LVD had higher LV mass, cardiac function and tissue characterization did not differ by vitamin D status. Future studies are needed to determine if the differences in LV mass and LV mass index by vitamin D status are clinically significant. This study suggests that vitamin D status does not impact the development of myocarditis or pericarditis after COVID-19 infection.
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Affiliation(s)
- William L Hollabaugh
- Division of Sports Medicine, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alicia Hymel
- Division of Sports Medicine, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacquelyn S Pennings
- Division of Sports Medicine, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel E Clark
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jonathan H Soslow
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Ashley R Karpinos
- Division of Sports Medicine, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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5
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Michelson JD. Considerations Regarding Vitamin D in Foot and Ankle Treatment and Surgery. Orthop Clin North Am 2024; 55:383-392. [PMID: 38782509 DOI: 10.1016/j.ocl.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Although the impact that vitamin D has on bone healing is uncertain in foot and ankle (F&A) surgery, there is support for vitamin D supplementation (2000 IU/day) with calcium (1 g/day) to promote bone healing. Although orthopedic F&A surgeons are frequently the first provider to detect the harbingers of osteoporosis by the occurrence of fragility fractures, this should trigger referral to the appropriate specialist for assessment and treatment. There is circumstantial evidence suggesting a role of hypovitaminosis D in bone marrow edema syndrome and possibly osteochondritis dissecans. There should be a low threshold for assessing vitamin D levels in such patients.
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Affiliation(s)
- James D Michelson
- Orthopaedic Surgery, Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Stafford Hall 418, 95 Carrigan Drive, Burlington, VT 05401, USA.
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Fallowfield JL, McClung JP, Gaffney-Stomberg E, Probert B, Peterson R, Charlebois A, Boilard H, Carins J, Kilding H. Nutrition as a military capability to deliver human advantage: more people, more ready, more of the time. BMJ Mil Health 2024:e002738. [PMID: 38942432 DOI: 10.1136/military-2024-002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/22/2024] [Indexed: 06/30/2024]
Abstract
Soldiers must achieve high-level mission-preparedness to endure extended periods of physical and cognitive activity, with unpredictable recovery, in all environments. Nutrition provides the foundation for health and performance. Militaries have not maximised the strategic and financial value that considering nutrition as a military capability could deliver. A whole system approach to military nutrition, based on the prepare-perform-recover human capability cycle phases, is presented. Trainee nutrition requirements, through to very-high-readiness forces undertaking arduous roles at reach, must be specifically addressed. Promoting military performance diets in the prepare phase, through practitioner-supported nutrition education and food provision, will ensure mission readiness and mitigate ill health. Delivering nutrition in field settings in the perform phase-through smaller/lighter, nutritionally optimised rations and smart packaging technologies-will improve utility and minimise waste. Strategic dietary supplement use can provide a mission performance-enhancing adjunct to a food-first philosophy. Impact value chain analysis of military nutrition capability investments could support cost-benefit measurement.
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Affiliation(s)
| | - J P McClung
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | | | - B Probert
- Defence Science and Technology Group, Launceston, Tasmania, Australia
| | - R Peterson
- Defence Science and Technology Group, Launceston, Tasmania, Australia
| | - A Charlebois
- Department of National Defence, CANSOFCOM, Ottawa, Ontario, Canada
| | - H Boilard
- Strategic Joint Staff, Department of National Defence, Ottawa, Ontario, Canada
| | - J Carins
- Griffith University, Brisbane, Queensland, Australia
| | - H Kilding
- Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand
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7
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Tenforde AS, Ackerman KE, Bouxsein ML, Gaudette L, McCall L, Rudolph SE, Gehman S, Garrahan M, Hughes JM, Outerleys J, Davis IS, Popp KL. Factors Associated With High-Risk and Low-Risk Bone Stress Injury in Female Runners: Implications for Risk Factor Stratification and Management. Orthop J Sports Med 2024; 12:23259671241246227. [PMID: 38779133 PMCID: PMC11110515 DOI: 10.1177/23259671241246227] [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: 09/11/2023] [Accepted: 10/24/2023] [Indexed: 05/25/2024] Open
Abstract
Background Bone stress injury (BSI) is a common overuse injury in active women. BSIs can be classified as high-risk (pelvis, sacrum, and femoral neck) or low-risk (tibia, fibula, and metatarsals). Risk factors for BSI include low energy availability, menstrual dysfunction, and poor bone health. Higher vertical load rates during running have been observed in women with a history of BSI. Purpose/Hypothesis The purpose of this study was to characterize factors associated with BSI in a population of premenopausal women, comparing those with a history of high-risk or low-risk BSI with those with no history of BSI. It was hypothesized that women with a history of high-risk BSI would be more likely to exhibit lower bone mineral density (BMD) and related factors and less favorable bone microarchitecture compared with women with a history of low-risk BSI. In contrast, women with a history of low-risk BSI would have higher load rates. Study Design Cross-sectional study; Level of evidence, 3. Methods Enrolled were 15 women with a history of high-risk BSI, 15 with a history of low-risk BSI, and 15 with no history of BSI. BMD for the whole body, hip, and spine was standardized using z scores on dual-energy x-ray absorptiometry. High-resolution peripheral quantitative computed tomography was used to quantify bone microarchitecture at the radius and distal tibia. Participants completed surveys characterizing factors that influence bone health-including sleep, menstrual history, and eating behaviors-utilizing the Eating Disorder Examination Questionnaire (EDE-Q). Each participant completed a biomechanical assessment using an instrumented treadmill to measure load rates before and after a run to exertion. Results Women with a history of high-risk BSI had lower spine z scores than those with low-risk BSI (-1.04 ± 0.76 vs -0.01 ± 1.15; P < .05). Women with a history of high-risk BSI, compared with low-risk BSI and no BSI, had the highest EDE-Q subscores for Shape Concern (1.46 ± 1.28 vs 0.76 ± 0.78 and 0.43 ± 0.43) and Eating Concern (0.55 ± 0.75 vs 0.16 ± 0.38 and 0.11 ± 0.21), as well as the greatest difference between minimum and maximum weight at current height (11.3 ± 5.4 vs 7.7 ± 2.9 and 7.6 ± 3.3 kg) (P < .05 for all). Women with a history of high-risk BSI were more likely than those with no history of BSI to sleep <7 hours on average per night during the week (80% vs 33.3%; P < .05). The mean and instantaneous vertical load rates were not different between groups. Conclusion Women with a history of high-risk BSI were more likely to exhibit risk factors for poor bone health, including lower BMD, while load rates did not distinguish women with a history of BSI.
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Affiliation(s)
- Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Logan Gaudette
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Lauren McCall
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara E Rudolph
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Gehman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret Garrahan
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Jereme Outerleys
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Irene S Davis
- School of Physical Therapy Tampa, University of South Florida, Florida, USA
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- Oak Ridge Associated Universities, Oak Ridge, Tennessee, USA. A.S.T., K.E.A., and M.L.B. contributed equally to this study. I.S.D. and K.L.P. contributed equally to this study
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8
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DeFoor MT, Mullin EP, Cuenca RA, Pierrie SN. Distal Femoral Stress Fractures Has High Operation Rates in Adolescent and Young Adult Athletes. J Pediatr Orthop 2024; 44:e439-e445. [PMID: 38506233 DOI: 10.1097/bpo.0000000000002661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Although stress fractures of the distal femur are rare, symptoms can overlap with other peri-articular knee pathology, delaying diagnosis. Untreated stress fractures have the potential to progress into completed fractures with a higher likelihood for requiring surgery and longer recovery times in otherwise healthy adolescents and young adults. This case series represents the largest cohort of adolescent athletes with distal femoral stress fractures who presented with activity-related knee pain. METHODS Patients treated nonoperatively and operatively for metaphyseal distal femur stress fractures at a tertiary referral center over a four-year period were retrospectively identified from the medical record. RESULTS Eight patients (mean age 16.8 y; range 14 to 22 y; 87.5% male; mean body mass index [BMI] 20.9) with a total of 10 distal femur stress fractures were identified. All patients were involved in competitive sports or military training. There was an average of 3.8 encounters with a medical provider between presentation with activity-related knee pain and diagnosis with distal femur stress fracture. All except 1 patient (87.5%) were initially incorrectly diagnosed with another type of peri-articular knee pathology. Six stress fractures (60%) were treated conservatively with protected weight bearing, activity modification, and gradual return to activity. Four completed stress fractures (40%) required operative fixation-3 healed uneventfully, while 1 had an asymptomatic delayed union. Vitamin D insufficiency (<30 ng/mL) was identified in 7 of 8 patients (87.5%) and 3 patients (37.5%) had an underweight BMI (<18.5). The mean clinical follow-up was 13.1 weeks (range, 2.8 to 32.0 wk). CONCLUSIONS High clinical suspicion for distal femoral stress fractures is needed to avoid misdiagnosis or delayed diagnosis in young, active individuals with activity-related knee pain refractory to conservative management. In this patient population, activity-related knee pain recalcitrant to activity modification, rest, and physical therapy warrants further workup with magnetic resonance imaging and orthopaedic evaluation. Though rare, misdiagnosis can result in catastrophic fractures with prolonged rehabilitation needs. An open line of communication and streamlined access for referral between primary care providers and orthopaedic surgeons is critical in preventing misdiagnosis and delayed treatment. Furthermore, the treatment of concomitant metabolic disorders and nutritional deficiency should not be neglected when treating distal femoral stress fractures. LEVEL OF EVIDENCE Level-IV (case series).
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Affiliation(s)
- Mikalyn T DeFoor
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Edmund P Mullin
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Rachel A Cuenca
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Sarah N Pierrie
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center
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9
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Wherry SJ. Calcium balance: considerations for the bone response to exercise. J Bone Miner Res 2024; 39:191-192. [PMID: 38484138 DOI: 10.1093/jbmr/zjae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 04/21/2024]
Affiliation(s)
- Sarah J Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC) , VA Eastern Colorado Health Care System, Aurora, CO 80045, United States
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10
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Jacob G, Shimomura K, Nakamura N. Biologic therapies in stress fractures: Current concepts. J ISAKOS 2024:S2059-7754(24)00078-6. [PMID: 38631518 DOI: 10.1016/j.jisako.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
Stress fractures, a common overuse injury in physically active individuals, present a significant challenge for athletes and military personnel. Patients who sustain stress fractures have demanding training regimes where periods of rest and immobilisation have unacceptable negative consequences on sports goals and finances. Aside from being an overuse injury, there are various contributing risk factors that put certain individuals at risk of a stress fracture. The main two being nutritional deficiencies and hormonal variations, which have significant effects on bone metabolism and turnover. Historically, treatment of stress fractures focused on conservative strategies such as rest and immobilisation. Calcium and vitamin D deficiencies have been closely linked to stress fractures and so over time supplementation has also played a role in treatment. With the introduction of biologics into orthopaedics, newer treatment strategies have been applied to accelerate fracture healing and perhaps improve fracture callus quality. If such therapies can reduce time spent away from sport and activity, it would be ideal for treating stress fractures. This article aims to offer insights into the evolving landscape of stress fracture management. It investigates the pre-clinical evidence and available published clinical applications. Though fracture healing is well understood, the role of biologics for fracture healing is still indeterminate. Available literature for the use of biologic therapies in stress fractures are restricted and most reports have used biologics as a supplement to surgical fixation in subjects in studies that lack control groups. Randomised control trials have been proposed and registered by a few groups, with results awaited. Assessing individuals for risk factors, addressing hormonal imbalances and nutritional deficiencies seems like an effective approach to addressing the burden of stress fractures. We await better designed trials and studies to accurately determine the clinical benefit of adding biologics to the management of these injuries.
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Affiliation(s)
- George Jacob
- Department of Orthopaedic Surgery, Lakeshore Hospital, Cochin, India
| | - Kazunori Shimomura
- Department of Rehabilitation, Kansai University of Welfare Sciences, Osaka, Japan; Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Norimasa Nakamura
- Institute for Medical Science in Sports, Osaka Health Science University, Osaka, Japan; Global Centre for Medical Engineering and Informatics, Osaka University, Osaka, Japan.
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11
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Raiser SN, Schroeder AN, Lawley RJ, Tenforde AS. Bone health and the masters runner. PM R 2024; 16:363-373. [PMID: 38532664 DOI: 10.1002/pmrj.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 03/28/2024]
Abstract
Masters runners are often defined as those ages 35 years and older who train and compete in running events. These runners represent a growing population of the overall running community and experience running-related injuries including bone stress injuries (BSIs). Similar to younger runners, health considerations in masters runners include the goal to optimize bone health with focus on mitigating age-associated loss of bone strength and preventing BSIs through a combination of ensuring appropriate physical activity, optimizing nutrition, and correcting faulty biomechanics. Importantly, BSIs in masters runners may include characteristics of both overuse injury from insufficient recovery and failure of bone weakened by age-related loss of bone (insufficiency fractures). This narrative review covers the limited available research on strategies to optimize bone health in masters runners. Applying knowledge on masters athletes and extrapolating from other populations, we propose strategies on treatment and prevention of BSIs. Finally, the review highlights gaps in knowledge that require further age-specific discoveries to advance treatment and prevention.
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Affiliation(s)
- Sara N Raiser
- Department of Physical Medicine & Rehabilitation, University of Virginia, Charlottesville, Virginia, USA
| | - Allison N Schroeder
- Department of Orthopedics, University Hospitals and Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Lawley
- Department of Physical Medicine & Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - Adam S Tenforde
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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12
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Gaffney-Stomberg E, Nakayama AT, Lutz LJ, McClung JP, O'Brien KO, Staab JS. Load carriage exercise increases calcium absorption and retention in healthy young women. J Bone Miner Res 2024; 39:39-49. [PMID: 38630876 DOI: 10.1093/jbmr/zjad003] [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: 07/12/2023] [Revised: 10/16/2023] [Accepted: 12/05/2023] [Indexed: 04/19/2024]
Abstract
Aerobic exercise reduces circulating ionized Ca (iCa) and increases parathyroid hormone (PTH), but the cause and consequences on Ca handling are unknown. The objective of this study was to determine the effects of strenuous exercise on Ca kinetics using dual stable Ca isotopes. Twenty-one healthy women (26.4 ± 6.7 yr) completed a randomized, crossover study entailing two 6-d iterations consisting of either 60 min of treadmill walking at 65% VO2max wearing a vest weighing 30% body weight on study days 1, 3, and 5 (exercise [EX]), or a rest iteration (rest [REST]). On day 1, participants received intravenous 42Ca and oral 44Ca. Isotope ratios were determined by thermal ionization mass spectrometry. Kinetic modeling determined fractional Ca absorption (FCA), Ca deposition (Vo+), resorption (Vo-) from bone, and balance (Vbal). Circulating PTH and iCa were measured before, during, and after each exercise/rest session. Data were analyzed by paired t-test or linear mixed models using SPSS. iCa decreased and PTH increased (P < .001) during each EX session and were unchanged during REST. On day 1, urinary Ca was lower in the EX pool (25 ± 11 mg) compared to REST (38 ± 16 mg, P = .001), but did not differ over the full 24-h collection (P > .05). FCA was greater during EX (26.6 ± 8.1%) compared to REST (23.9 ± 8.3%, P < .05). Vbal was less negative during EX (-61.3 ± 111 mg) vs REST (-108 ± 23.5 mg, P < .05), but VO+ (574 ± 241 vs 583 ± 260 mg) and VO- (-636 ± 243 vs -692 ± 252 mg) were not different (P > .05). The rapid reduction in circulating iCa may be due to a change in the miscible Ca pool, resulting in increased PTH and changes in intestinal absorption and renal Ca handling that support a more positive Ca balance.
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Affiliation(s)
- Erin Gaffney-Stomberg
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, United States
| | - Anna T Nakayama
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, United States
| | - Laura J Lutz
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, United States
| | - James P McClung
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, United States
| | - Kimberly O O'Brien
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14850, United States
| | - Jeffery S Staab
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, United States
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13
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Sotos-Prieto M, Rodriguez-Artalejo F, Fung TT, Meyer HE, Hu FB, Willett WC, Bhupathiraju SN. Plant-Based Diets and Risk of Hip Fracture in Postmenopausal Women. JAMA Netw Open 2024; 7:e241107. [PMID: 38421643 PMCID: PMC10905300 DOI: 10.1001/jamanetworkopen.2024.1107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/14/2024] [Indexed: 03/02/2024] Open
Abstract
Importance Previous research has found that vegetarian diets are associated with lower bone mineral density and higher risk of fractures, but these studies did not differentiate the quality of the plant-based foods. Objective To examine the association between the quality of plant-based diets (not necessarily vegan but also omnivorous) and hip fracture risk among postmenopausal women in the Nurses' Health Study. Design, Setting, and Participants This cohort study analyzed data from 70 285 postmenopausal women who participated in the US Nurses' Health Study from 1984 through 2014. Data were analyzed from January 1 to July 31, 2023. Main outcomes and Measures Hip fractures were self-reported on biennial questionnaires. Diet was assessed every 4 years using a validated semiquantitative food frequency questionnaire. Plant-based diet quality was assessed using 2 previously established indices: the healthful Plant-Based Diet Index (hPDI), for which healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea or coffee) received positive scores, whereas less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, and sweets or desserts) and animal foods received reversed scores; and the unhealthful Plant-Based Diet Index (uPDI), for which positive scores were given to less healthy plant foods and reversed scores to healthy plant and animal foods. Quintile scores of 18 food groups were summed, with a theoretical range for both indices of 18 to 90 (highest adherence). Cox proportional hazards regression with time-varying covariates was used to compute hazard ratios (HRs) and 95% CIs for hip fracture. Results In total, 70 285 participants (mean [SD] age, 54.92 [4.48] years; 100% White women) were included, and 2038 cases of hip fracture were ascertained during the study and for up to 30 years of follow-up. Neither the hPDI (HR for highest vs lowest quintile, 0.97 [95% CI, 0.83-1.14]) nor the uPDI (HR for highest vs lowest quintile, 1.02 [95% CI, 0.87-1.20]) for long-term diet adherence was associated with hip fracture risk. However, when examining recent intake for the highest vs lowest quintiles, the hPDI was associated with 21% lower risk of hip fracture (HR, 0.79 [95% CI, 0.68-0.92]; P = .02 for trend), and the uPDI was associated with 28% higher risk (1.28 [95% CI, 1.09-1.51]; P = .008 for trend). Conclusions and Relevance Findings of this cohort study indicated that long-term adherence to healthful or unhealthful plant-based diets as assessed by hPDI and uPDI scores was not associated with hip fracture risk. Future research should clarify whether the associations observed with recent dietary intake are due to short-term effects of these dietary patterns, reverse causality, or both.
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Affiliation(s)
- Mercedes Sotos-Prieto
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
- CIBERESP (CIBER of Epidemiology and Public Health), Madrid, Spain
- IMDEA-Food Institute, Campus of International Excellence and University of Madrid and Spanish National Research Council (CEI UAM-CSIC), Madrid, Spain
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Fernando Rodriguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
- CIBERESP (CIBER of Epidemiology and Public Health), Madrid, Spain
- IMDEA-Food Institute, Campus of International Excellence and University of Madrid and Spanish National Research Council (CEI UAM-CSIC), Madrid, Spain
| | - Teresa T. Fung
- Department of Nutrition, Simmons University, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Haakon E. Meyer
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Frank B. Hu
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Walter C. Willett
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Shilpa N. Bhupathiraju
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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14
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Tong EYH, Jeong SJ, Farook MZ, Volpin A. Multifocal stress fractures in a patient with rheumatoid arthritis. BMJ Case Rep 2024; 17:e254840. [PMID: 38290983 PMCID: PMC10828864 DOI: 10.1136/bcr-2023-254840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Abstract
Stress fractures are often associated to activities that requires repetitive stress such as running. However, insufficiency-type stress fractures can also occur in patients with risk factors such as rheumatoid arthritis. Diagnosis of stress fracture would require a thorough clinical evaluation along with radiological imaging. However, this may be difficult due to how it mimics other musculoskeletal problems. The case of a woman in her 60s presenting with 2 months of severe ipsilateral right knee and ankle pain is used as an example. Based on initial clinical assessment and plain radiograph, her provisional diagnosis was osteoarthritis or inflammatory arthritis secondary to rheumatoid disease. However, MRI scan revealed that she had multifocal stress fractures in her knee, ankle and foot. Hence, we hope that this case study can allow clinicians to consider multifocal stress fracture as a possible diagnosis in patients with risk factors and to have lower threshold in performing MRI scans.
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Affiliation(s)
| | | | | | - Andrea Volpin
- Trauma and Orthopaedics, Dr Gray's Hospital, Elgin, Moray, UK
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15
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Grabia M, Perkowski J, Socha K, Markiewicz-Żukowska R. Female Athlete Triad and Relative Energy Deficiency in Sport (REDs): Nutritional Management. Nutrients 2024; 16:359. [PMID: 38337644 PMCID: PMC10857508 DOI: 10.3390/nu16030359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
The female athlete triad (TRIAD) is a spectrum of disorders involving low energy availability (LEA), low bone mineral density, and menstrual disorders. It is increasingly common to use the term 'relative energy deficiency in sport' (RED), emphasising the extensive impact of LEA on the body. The aim of this narrative review was to gather original research encompassing female athletes across various sports as well as to collect findings on the potential of a nutrition-focused approach to prevent or treat the aforementioned disorders. A comprehensive search was conducted in PubMed and Scopus. Several challenges were identified regarding the adequacy of the energy availability, protein, and carbohydrate requirements in the diets of female athletes. Moreover, insufficient intake of vitamin D has been observed across all athlete groups studied. This insufficiency also extends to the average requirement for Ca, Mg, the Ca/P ratio, Zn, and Fe. To address those concerns, a nutritional approach is proposed in the latter part of this review. The factors that can improve the absorption of micronutrients have also been discussed. The TRIAD/REDs affect an ever-growing number of women and require appropriate therapeutic management, particularly through nutritional care. Therefore, cooperation within an interdisciplinary team comprising a physician, nutritionist, physiotherapist, and psychologist is crucial.
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Affiliation(s)
- Monika Grabia
- Department of Bromatology, Faculty of Pharmacy with the Division of Laboratory Medicine, Medical University of Białystok, 2D Mickiewicza Street, 15-222 Białystok, Poland (K.S.)
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16
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Wyatt PB, Reiter CR, Satalich JR, O’Neill CN, Edge C, Cyrus JW, O’Connell RS, Vap AR. Effects of Vitamin D Supplementation in Elite Athletes: A Systematic Review. Orthop J Sports Med 2024; 12:23259671231220371. [PMID: 38188620 PMCID: PMC10768611 DOI: 10.1177/23259671231220371] [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: 05/27/2023] [Accepted: 07/31/2023] [Indexed: 01/09/2024] Open
Abstract
Background Deficiency in vitamin D has been shown to increase the risk of injury. Purpose To synthesize current placebo-controlled randomized trials investigating the effect of vitamin D supplementation in elite athletes on (1) aerobic capacity; (2) anaerobic measures, such as strength, speed, and anaerobic power; (3) serum biomarkers of inflammation; and (4) bone health. Study Design Systematic review; Level of evidence, 1. Methods A literature search was conducted on November 30, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included were randomized, placebo-controlled studies of longer than 2 weeks on subjects with active participation in organized sport. Excluded were nonrandomized controlled trial study designs, vitamin D administration routes other than oral, studies that did not use vitamin D supplementation as the sole intervention, and studies with nonathletic or military populations. Results Out of 2331 initial studies, 14 studies (482 athletes) were included. Of the 3 studies that assessed aerobic capacity, 2 demonstrated significantly greater improvements in maximal oxygen uptake and physical working capacity-170 (P < .05) in supplemented versus nonsupplemented athletes. Measurements of anaerobic power and strength were consistently increased in supplemented groups compared with nonsupplemented groups in 5 out of the 7 studies that assessed this. Of the 6 studies that assessed sprint speed, 4 found no significant difference between supplemented and nonsupplemented groups. Aside from 1 study that found significantly lower interleukin-6 levels in supplemented athletes, measures of other inflammatory cytokines were not affected consistently by supplementation. The 4 studies that assessed markers of bone health were conflicting regarding benefits of supplementation. One study found demonstrated improvements in bone mineral density in response to supplementation (P = .02) compared with control whereas another found no significant difference between supplemented and nonsupplemented groups. However, in 3 other studies, serum biomarkers of bone turnover such as bone-specific alkaline phosphatase, parathyroid hormone, and N-terminal telopeptide appeared to be higher in subjects with lower serum vitamin D levels (P < .05). Conclusion Results of this systematic review indicated that the greatest benefit of vitamin D supplementation in elite athletes may be improving aerobic endurance, anaerobic power, and strength. More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in this population.
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Affiliation(s)
- Phillip B. Wyatt
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Charles R. Reiter
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - James R. Satalich
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Conor N. O’Neill
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Carl Edge
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - John W. Cyrus
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Robert S. O’Connell
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Alexander R. Vap
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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17
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Yan X, Lu E, Song Z, Wu Y, Sha X. Development and In Vivo Evaluation of a Novel Vitamin D3 Oral Spray Delivery System. Pharmaceutics 2023; 16:25. [PMID: 38258036 PMCID: PMC10819964 DOI: 10.3390/pharmaceutics16010025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
Developing drugs that are highly selective to host tissues but are the least toxic remains one of the most difficult challenges in cancer treatment. Recent studies have shown that tumor cells from a variety of sources can express vitamin D3 receptors and that the response to vitamin D3 and its analogs is prone to growth arrest and cell death. However, conventional vitamin D3 drug formulations lack dose control and cannot target specific cells or tissues. The aim of this study was to prepare vitamin D3 nanospray for inhalation delivery route. This study evaluated the physical properties of the formulation (particle size distribution and biological stability), the total number of sprays per bottle, the spray volume per spray, and the loading variance of the spray. The optimized vitamin D3 spray formula is easy to spray, has fewer drips, and has a fast drying time. It can be stored for 3 months at 37 ± 2 °C temperature, 75 ± 5% relative humidity, and away from light, and can maintain biological stability. This study showed that compared with traditional nasal sprays, the spray has a larger fan angle (82.1 degrees) and beam width (104.88 mm), more symmetrical spray on both sides of the spray column, a faster coverage of the administration site, and a wider range, which is suitable for inhalation delivery routes.
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Affiliation(s)
- Xin Yan
- Key Laboratory of Smart Drug Delivery, Ministry of Education, School of Pharmacy, Fudan University, Shanghai 201203, China; (X.Y.); (E.L.)
| | - Enhao Lu
- Key Laboratory of Smart Drug Delivery, Ministry of Education, School of Pharmacy, Fudan University, Shanghai 201203, China; (X.Y.); (E.L.)
| | - Zhuo Song
- Shanghai JiaLanHai NanoTechnology Group Co., Ltd., Shanghai 200335, China; (Z.S.); (Y.W.)
| | - Yuexing Wu
- Shanghai JiaLanHai NanoTechnology Group Co., Ltd., Shanghai 200335, China; (Z.S.); (Y.W.)
| | - Xianyi Sha
- Key Laboratory of Smart Drug Delivery, Ministry of Education, School of Pharmacy, Fudan University, Shanghai 201203, China; (X.Y.); (E.L.)
- The Institutes of Integrative Medicine, Fudan University, Shanghai 200040, China
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18
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Bullock GS, Dartt CE, Ricker EA, Fallowfield JL, Arden N, Clifton D, Danelson K, Fraser JJ, Gomez C, Greenlee TA, Gregory A, Gribbin T, Losciale J, Molloy JM, Nicholson KF, Polich JG, Räisänen A, Shah K, Smuda M, Teyhen DS, Allard RJ, Collins GS, de la Motte SJ, Rhon DI. Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review. Inj Prev 2023; 29:461-473. [PMID: 37620010 DOI: 10.1136/ip-2023-044905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities. METHODS A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified. RESULTS From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions. CONCLUSION Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.
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Affiliation(s)
- Garrett S Bullock
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Centre for Sport, Exercise, and Osteoarthritis, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Carolyn E Dartt
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Emily A Ricker
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Joanne L Fallowfield
- Environmental Medicine and Sciences Division, Institute of Naval Medicine, Gosport, UK
| | - Nigel Arden
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
- University of Southampton MRC Lifecourse Epidemiology Centre, Southampton, UK
| | - Daniel Clifton
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Kerry Danelson
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - John J Fraser
- Directorate for Operational Readiness & Health, Naval Health Research Center, San Diego, California, USA
| | - Christina Gomez
- College of Health Sciences, Western University of Health Sciences, Pomona, California, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Alexandria Gregory
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Timothy Gribbin
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Justin Losciale
- Department of Rehabilitation, The University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Joseph M Molloy
- Office of the Army Surgeon General, Falls Church, Virginia, USA
| | - Kristen F Nicholson
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Julia-Grace Polich
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anu Räisänen
- Department of Physical Therapy Education, Oregon, College of Health Sciences, Western University of Health Sciences, Lebanon, Oregon, USA
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Karishma Shah
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Michael Smuda
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Deydre S Teyhen
- Army Medical Specialist Corps Chief, Office of the Army Surgeon General, Falls Church, Virginia, USA
| | - Rhonda J Allard
- Learning Resource Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Sarah J de la Motte
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
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Ross JA, Heebner NR. No pain, no gain: The military overtraining hypothesis of musculoskeletal stress and injury. Physiother Theory Pract 2023; 39:2289-2299. [PMID: 35695302 DOI: 10.1080/09593985.2022.2082346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 04/16/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022]
Abstract
The purpose of this manuscript is to present a model of military overtraining and subsequent injury, discharge, and disability. Military training and combat operations are physically and physiologically demanding, placing great strain on the musculoskeletal system of warfighters. Non-battle musculoskeletal injuries (MSKI) are common and present a serious threat to operational readiness in today's military. MSKI risk stratification and prevention are an active area of research and is steeped in the background of sports science. Here, a model is proposed that incorporates the theory of General Adaptation Syndrome to describe how military training stressors may exceed that of training in traditional athletics and may induce sub-optimal training stressors. Positive feedback loops are discussed to explain how military overtraining (MOT) creates a system of ever-increasing stressors that can only be fully understood in the greater context of all environmental factors leading to overtraining. The Military Overtraining Hypothesis (MOTH) is proposed as a model that encapsulates the elevated MSKI risk in combat arms and other operational military personnel as an effort to broaden understanding of multifactorial military MSKI etiologies and as a tool for researchers and commanders to contextualize MSKI research and risk mitigation interventions.
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Affiliation(s)
- Jeremy A Ross
- Sports Medicine Research Institute, University of Kentucky, Lexington USA
| | - Nicholas R Heebner
- Sports Medicine Research Institute, University of Kentucky, Lexington USA
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20
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Kawashima I, Hiraiwa H, Ishizuka S, Oba H, Sakaguchi T, Idota M, Kawai R, Tsukahara T, Imagama S. Displaced tibial and fibular stress fractures in a female elite pole-vaulter with menstrual dysfunction, vitamin D deficiency, and high serum pentosidine. J Orthop Sci 2023; 28:1513-1517. [PMID: 34794859 DOI: 10.1016/j.jos.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/31/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Itaru Kawashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Hideki Hiraiwa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Shinya Ishizuka
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takefumi Sakaguchi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masaru Idota
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Ryosuke Kawai
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Takashi Tsukahara
- Department of Orthopaedic Surgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu, Gifu, 500-8523, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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21
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Solberg A, Reikvam H. Iron Status and Physical Performance in Athletes. Life (Basel) 2023; 13:2007. [PMID: 37895389 PMCID: PMC10608302 DOI: 10.3390/life13102007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/20/2023] [Accepted: 09/23/2023] [Indexed: 10/29/2023] Open
Abstract
Iron is an important mineral in the body, essential for muscle function and oxygen transport. Adequate levels of iron in the blood are necessary for athletes, as iron-deficiency anemia can reduce physical performance. Several studies have investigated iron status and supplementation in iron-deficient athletes, and determined how physical strain can change iron balance and markers related to iron status. The question of how to influence and optimize iron status, as well as other markers that can affect iron metabolism, has been less thoroughly investigated. Therefore, the aim of this review is to take a closer look at the importance of iron values, iron markers, and factors that can change iron metabolism for physical performance and the extent to which physical performance can be influenced in a positive or negative way. A systematic search of the PubMed database was performed, with the use of « iron» or «iron deficiency» or «hemoglobin» AND «athletes» AND «athletic performance» as a strategy of the search. After the search, 11 articles were included in the review after the application of inclusion and exclusion criteria. Major findings include that iron supplementation had the best effect in athletes with the lowest iron status, and effects on physical performance were mostly achieved in those who were originally in a deficit. Iron supplementation could be beneficial for optimal erythropoietic response during altitude training, even in athletes with normal iron stores at baseline, but should be performed with caution. Alteration of the hepcidin response can affect the use of existing iron stores for erythropoiesis. Energy intake, and the amount of carbohydrates available, may have an impact on the post-exercise hepcidin response. Optimal vitamin D and B12 levels can possibly contribute to improved iron status and, hence, the avoidance of anemia.
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Affiliation(s)
- Andrea Solberg
- Faculty of Medicine, University of Bergen, 5007 Bergen, Norway;
| | - Håkon Reikvam
- Institute of Clinical Science, Faculty of Medicine, University of Bergen, 5007 Bergen, Norway
- Clinic for Medicine, Haukeland University Hospital, 5009 Bergen, Norway
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22
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Carswell AT, O'Leary TJ, Swinton P, Jackson S, Tang JC, Oliver SJ, Izard RM, Walsh NP, Fraser WD, Greeves JP. Vitamin D Metabolites Are Associated With Musculoskeletal Injury in Young Adults: A Prospective Cohort Study. J Bone Miner Res 2023; 38:1453-1464. [PMID: 37526272 DOI: 10.1002/jbmr.4890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/06/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
The relationship between vitamin D metabolites and lower body (pelvis and lower limb) overuse injury is unclear. In a prospective cohort study, we investigated the association between vitamin D metabolites and incidence of lower body overuse musculoskeletal and bone stress injury in young adults undergoing initial military training during all seasons. In 1637 men and 530 women (aged 22.6 ± 7.5 years; body mass index [BMI], 24.0 ± 2.6 kg/m- 2 ; 94.3% white ethnicity), we measured serum 25-hydroxyvitamin D (25(OH)D) and 24,25-dihydroxyvitamin D (24,25(OH)2 D) by high-performance liquid chromatography tandem mass spectrometry, and 1,25-dihydroxyvitamin D (1,25(OH)2 D) by immunoassay during week 1 of training. We examined whether the relationship between 25(OH)D and 1,25(OH)2 D:24,25(OH)2 D ratio was associated with overuse injury. During 12 weeks of training, 21.0% sustained ≥1 overuse musculoskeletal injury, and 5.6% sustained ≥1 bone stress injury. After controlling for sex, BMI, 2.4 km run time, smoking, bone injury history, and Army training course (Officer, standard, or Infantry), lower body overuse musculoskeletal injury incidence was higher for participants within the second lowest versus highest quartile of 24,25(OH)2 D (odds ratio [OR] = 1.62; 95% confidence interval [CI] 1.13-2.32; p = 0.009) and lowest versus highest cluster of 25(OH)D and 1,25(OH)2 D:24,25(OH)2 D (OR = 6.30; 95% CI 1.89-21.2; p = 0.003). Lower body bone stress injury incidence was higher for participants within the lowest versus highest quartile of 24,25(OH)2 D (OR = 4.02; 95% CI 1.82-8.87; p < 0.001) and lowest versus highest cluster of 25(OH)D and 1,25(OH)2 D:24,25(OH)2 D (OR = 22.08; 95% CI 3.26-149.4; p = 0.001), after controlling for the same covariates. Greater conversion of 25(OH)D to 24,25(OH)2 D, relative to 1,25(OH)2 D (ie, low 1,25(OH)2 D:24,25(OH)2 D), and higher serum 24,25(OH)2 D were associated with a lower incidence of lower body overuse musculoskeletal and bone stress injury. Serum 24,25(OH)2 D may have a role in preventing overuse injury in young adults undertaking arduous physical training. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.
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Affiliation(s)
- Alexander T Carswell
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Thomas J O'Leary
- Army Health and Performance Research, Army HQ, Andover, UK
- Division of Surgery and Interventional Science, UCL, London, UK
| | - Paul Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Sarah Jackson
- Army Health and Performance Research, Army HQ, Andover, UK
| | - Jonathan Cy Tang
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- Departments of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Rachel M Izard
- Defence Science and Technology, Porton Down, Ministry of Defence, Salisbury, UK
| | - Neil P Walsh
- Faculty of Science, Liverpool John Moores University, Liverpool, UK
| | - William D Fraser
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- Departments of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital, Norwich, UK
| | - Julie P Greeves
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- Army Health and Performance Research, Army HQ, Andover, UK
- Division of Surgery and Interventional Science, UCL, London, UK
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23
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Ding Y, Yang Y, Xu F, Tan Z, Liu X, Shao X, Kang F, Yan Z, Luo E, Wang J, Luo Z, Cai J, Jing D. Early protection against bone stress injuries by mobilization of endogenous targeted bone remodeling. iScience 2023; 26:107605. [PMID: 37664634 PMCID: PMC10470328 DOI: 10.1016/j.isci.2023.107605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/29/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Abstract
Bone stress injuries are common overuse injuries, especially in soldiers, athletes, and performers. In contrast to various post-injury treatments, early protection against bone stress injuries can provide greater benefit. This study explored the early protection strategies against bone stress injuries by mobilization of endogenous targeted bone remodeling. The effects of various pharmaceutical/biophysical approaches, individual or combinational, were investigated by giving intervention before fatigue loading. We optimized the dosage and administration parameters and found that early intervention with pulsed electromagnetic field and parathyroid hormone (i.e., PEMF+PTH) resulted in the most pronounced protective effects among all the approaches against the bone stress injuries. In addition, the mechanisms by which the strategy mobilizes targeted bone remodeling and enhances the self-repair capacity of bone were systematically investigated. This study proposes strategies to reduce the incidence of bone stress injuries in high-risk populations (e.g., soldiers and athletes), particularly for those before sudden increased physical training.
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Affiliation(s)
- Yuanjun Ding
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Yongqing Yang
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Fei Xu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Zhifen Tan
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Xiyu Liu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Xi Shao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Fei Kang
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zedong Yan
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Erping Luo
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Jing Wang
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhuojing Luo
- Institute of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jing Cai
- College of Basic Medicine, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Da Jing
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
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24
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Hua Y, Li Y, Zhou J, Fan L, Huang F, Wu Z, Xue H, Yang B, Chen P, Rui Y, Tian Y, Moayyeri A, Libanati C, Du W. Mortality following fragility hip fracture in China: a record linkage study. Arch Osteoporos 2023; 18:105. [PMID: 37498371 DOI: 10.1007/s11657-023-01304-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
Mortality risk declined over time. Patients with fragility hip fracture experienced an approximate ninefold excess mortality, peaking shortly after fracture, in comparison with that of the general population. Continuous efforts in lowering the occurrence of hip fracture have the potential to improve the survival of the elderly population in China. PURPOSE Hip fractures in older adults often lead to an elevated risk of death. However, few studies investigated mortality risk following hip fracture in mainland China. This retrospective cohort study aimed to evaluate the crude mortality and excess mortality after fragility hip fractures in Lishui residents aged 50 years and older. METHODS Patients having a fragility hip fracture between October 2013 and August 2019 were identified from the Lishui District Inpatient Data Collection and followed up until August 2020. Death information was ascertained from the linked death registry records. We calculated the follow-up mortality rate and corresponding 95% confidence intervals (CIs) as well as the standard mortality ratios (SMRs) in comparison with the mortality rates of Lishui residents. RESULTS During the study period, a total of 808 patients (63.4% females) with an average age of 75 years were admitted for fragility hip fractures. The 1st, 2nd, and 3rd year follow-up mortality rates were 16.51, 6.06, and 5.03 per 100 person-year, respectively. The SMRs were 8.46 (6.94, 9.97), 5.74 (4.86, 6.63), and 4.63 (3.98, 5.27) for the 1st, 2nd, and 3rd year following fragility hip fracture. CONCLUSION Although mortality risk declined over time, patients with fragility hip fracture experienced an approximate ninefold excess mortality, peaking shortly after fracture, in comparison with that of the general population. Continuous efforts in lowering the occurrence of hip fracture have the potential to improve the survival of the elderly population in China.
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Affiliation(s)
- Yiwen Hua
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China
| | - Ying Li
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China
| | | | - Lijun Fan
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China
| | - Feng Huang
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China
| | - Zhanpo Wu
- Department of Trauma Orthopedics, Lishui Renmin Hospital & Zhongda Hospital, Nanjing, China
| | - Hui Xue
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China
| | - Bingquan Yang
- Department of Trauma Orthopedics, Lishui Renmin Hospital & Zhongda Hospital, Nanjing, China
| | - Ping Chen
- Lishui Smart City Operating Command Center, Nanjing, China
| | - Yunfeng Rui
- Department of Trauma Orthopedics, Lishui Renmin Hospital & Zhongda Hospital, Nanjing, China
| | - Yong Tian
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China
| | | | | | - Wei Du
- School of Public Health, Southeast University, Gulou District, 87 Dingjiaqiao, Nanjing, 210000, Jiangsu, China.
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25
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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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26
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Sundaramurthy A, Tong J, Subramani AV, Kote V, Baggaley M, Edwards WB, Reifman J. Effect of stride length on the running biomechanics of healthy women of different statures. BMC Musculoskelet Disord 2023; 24:604. [PMID: 37488528 PMCID: PMC10364351 DOI: 10.1186/s12891-023-06733-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/17/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Tibial stress fracture is a debilitating musculoskeletal injury that diminishes the physical performance of individuals who engage in high-volume running, including Service members during basic combat training (BCT) and recreational athletes. While several studies have shown that reducing stride length decreases musculoskeletal loads and the potential risk of tibial injury, we do not know whether stride-length reduction affects individuals of varying stature differently. METHODS We investigated the effects of reducing the running stride length on the biomechanics of the lower extremity of young, healthy women of different statures. Using individualized musculoskeletal and finite-element models of women of short (N = 6), medium (N = 7), and tall (N = 7) statures, we computed the joint kinematics and kinetics at the lower extremity and tibial strain for each participant as they ran on a treadmill at 3.0 m/s with their preferred stride length and with a stride length reduced by 10%. Using a probabilistic model, we estimated the stress-fracture risk for running regimens representative of U.S. Army Soldiers during BCT and recreational athletes training for a marathon. RESULTS When study participants reduced their stride length by 10%, the joint kinetics, kinematics, tibial strain, and stress-fracture risk were not significantly different among the three stature groups. Compared to the preferred stride length, a 10% reduction in stride length significantly decreased peak hip (p = 0.002) and knee (p < 0.001) flexion angles during the stance phase. In addition, it significantly decreased the peak hip adduction (p = 0.013), hip internal rotation (p = 0.004), knee extension (p = 0.012), and ankle plantar flexion (p = 0.026) moments, as well as the hip, knee, and ankle joint reaction forces (p < 0.001) and tibial strain (p < 0.001). Finally, for the simulated regimens, reducing the stride length decreased the relative risk of stress fracture by as much as 96%. CONCLUSIONS Our results show that reducing stride length by 10% decreases musculoskeletal loads, tibial strain, and stress-fracture risk, regardless of stature. We also observed large between-subject variability, which supports the development of individualized training strategies to decrease the incidence of stress fracture.
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Affiliation(s)
- Aravind Sundaramurthy
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, FCMR-TT, 504 Scott Street, Fort Detrick, MD, 21702-5012, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, 20817, USA
| | - Junfei Tong
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, FCMR-TT, 504 Scott Street, Fort Detrick, MD, 21702-5012, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, 20817, USA
| | - Adhitya V Subramani
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, FCMR-TT, 504 Scott Street, Fort Detrick, MD, 21702-5012, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, 20817, USA
| | - Vivek Kote
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, FCMR-TT, 504 Scott Street, Fort Detrick, MD, 21702-5012, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, 20817, USA
| | - Michael Baggaley
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, T2N 1N4, Canada
- The McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, T2N 1N4, Canada
- The McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Jaques Reifman
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, FCMR-TT, 504 Scott Street, Fort Detrick, MD, 21702-5012, USA.
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27
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Zalneraitis BH, Huuki E, Benavides LC, Benavides JM. Relation of Vitamin D Level, BMI, and Location of Lower Extremity Stress Fractures in Military Trainees. Mil Med 2023; 188:e1970-e1974. [PMID: 36004444 DOI: 10.1093/milmed/usac258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/14/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Military trainees are at an increased risk of stress fractures. Vitamin D availability is known to play an important role in both fracture prevention and healing. The purpose of this investigation was to assess 25-hydroxy vitamin D (25(OH)D) levels in soldiers with confirmed lower extremity stress fractures and assess the predictors of fracture location. MATERIALS AND METHODS Following Institutional Review Board approval, military trainees at a large training base presenting to the orthopedic clinic with a radiographically verified stress fracture were identified. Demographic data and 25(OH)D levels were collected. A descriptive analysis was performed in regard to patient age, body mass index (BMI), and 25(OH)D level. Interactions between variables were assessed using one-way analysis of variance for four fracture location groups (femoral neck, femoral shaft, tibial shaft, and foot and ankle). Bivariate correlations were examined between age, BMI, and vitamin D level. RESULTS A total of 155 lower extremity stress fractures were identified in 144 males and 11 females over 30 months. The mean age was 22.7 ± 4.85 years. The majority (60.7%) of fractures were located in the femoral neck. The average 25(OH)D level was 26.8 ± 8.37 ng/mL. Overall, 26% (N = 41) of enrolled patients had normal 25(OH)D levels, 48% (N = 74) had insufficient 25(OH)D levels, and 26% (N = 40) had deficient 25(OH)D levels. Patients with femoral neck fractures and tibial shaft fractures had significantly lower BMI than patients with foot and ankle fractures (23.3 vs. 27.7, P < .001 and 24.2 vs. 27.7, P = .003, respectively). Patients with foot and ankle fractures had significantly lower 25(OH)D levels than patients with femoral shaft fractures (21.1 vs. 30.1, P = .02). There were no significant findings regarding age and fracture location. Age correlated positively (but weakly) with BMI (0.338, P < .001). There was no correlation between age and vitamin D level or BMI and vitamin D level. CONCLUSION Overall, 74% of patients in military training with lower extremity stress fractures had insufficient or deficient levels of 25(OH)D, highlighting a persistent area of concern in this population. Patients with femoral neck and tibial shaft stress fractures had significantly lower BMI than patients with foot and ankle stress fractures. This suggests that in stress fracture-prone patients, BMI may play a role in predicting fracture location.
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Affiliation(s)
- B Holt Zalneraitis
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Elizabeth Huuki
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Linda C Benavides
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Jerome M Benavides
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
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28
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Coombs CV, Wardle SL, Shroff R, Eisenhauer A, Tang JCY, Fraser WD, Greeves JP, O'Leary TJ. The effect of calcium supplementation on calcium and bone metabolism during load carriage in women: protocol for a randomised controlled crossover trial. BMC Musculoskelet Disord 2023; 24:496. [PMID: 37328859 DOI: 10.1186/s12891-023-06600-w] [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: 02/17/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Military field exercises are characterised by high volumes of exercise and prolonged periods of load carriage. Exercise can decrease circulating serum calcium and increase parathyroid hormone and bone resorption. These disturbances to calcium and bone metabolism can be attenuated with calcium supplementation immediately before exercise. This randomised crossover trial will investigate the effect of calcium supplementation on calcium and bone metabolism, and bone mineral balance, during load carriage exercise in women. METHODS Thirty women (eumenorrheic or using the combined oral contraceptive pill, intrauterine system, or intrauterine device) will complete two experimental testing sessions either with, or without, a calcium supplement (1000 mg). Each experimental testing session will involve one 120 min session of load carriage exercise carrying 20 kg. Venous blood samples will be taken and analysed for biochemical markers of bone resorption and formation, calcium metabolism, and endocrine function. Urine will be collected pre- and post-load carriage to measure calcium isotopes for the calculation of bone calcium balance. DISCUSSION The results from this study will help identify whether supplementing women with calcium during load carriage is protective of bone and calcium homeostasis. TRIAL REGISTRATION NCT04823156 (clinicaltrials.gov).
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Affiliation(s)
- Charlotte V Coombs
- Army Health and Performance Research, Army Headquarters, Andover, SP11 8HT, UK
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, SP11 8HT, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, London, UK
| | | | | | | | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, SP11 8HT, UK
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, SP11 8HT, UK.
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29
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Greeves JP, Beck B, Nindl BC, O'Leary TJ. Current risks factors and emerging biomarkers for bone stress injuries in military personnel. J Sci Med Sport 2023:S1440-2440(23)00075-0. [PMID: 37188615 DOI: 10.1016/j.jsams.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 04/01/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Bone stress injuries (BSIs) have plagued the military for over 150 years; they afflict around 5 to 10% of military recruits, more so in women, and continue to place a medical and financial burden on defence. While the tibia generally adapts to the rigours of basic military training, the putative mechanisms for bone maladaptation are still unclear. METHODS This paper provides a review of the published literature on current risk factors and emerging biomarkers for BSIs in military personnel; the potential for biochemical markers of bone metabolism to monitor the response to military training; and, the association of novel biochemical 'exerkines' with bone health. RESULTS The primary risk factor for BSI in military (and athletic) populations is too much training, too soon. Appropriate physical preparation before training will likely be most protective, but routine biomarkers will not yet identify those at risk. Nutritional interventions will support a bone anabolic response to training, but exposure to stress, sleep loss, and medication is likely harmful to bone. Monitoring physiology using wearables-ovulation, sleep and stress-offer potential to inform prevention strategies. CONCLUSIONS The risk factors for BSIs are well described, but their aetiology is very complex particularly in the multi-stressor military environment. Our understanding of the skeletal responses to military training is improving as technology advances, and potential biomarkers are constantly emerging, but sophisticated and integrated approaches to prevention of BSI are warranted.
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Affiliation(s)
- Julie P Greeves
- Army Health and Performance Research, Army HQ, Andover, United Kingdom; Norwich Medical School, University of East Anglia, United Kingdom; Division of Surgery and Interventional Science, UCL, United Kingdom.
| | - Belinda Beck
- School of Health Sciences and Social Work, Griffith University, Australia; The Bone Clinic, Australia.
| | - Bradley C Nindl
- School of Health and Rehabilitation Sciences, University of Pittsburgh, United States.
| | - Thomas J O'Leary
- Army Health and Performance Research, Army HQ, Andover, United Kingdom; Division of Surgery and Interventional Science, UCL, United Kingdom.
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Evaluation of the Association of VDR rs2228570 Polymorphism with Elite Track and Field Athletes' Competitive Performance. Healthcare (Basel) 2023; 11:healthcare11050681. [PMID: 36900688 PMCID: PMC10001357 DOI: 10.3390/healthcare11050681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
The present study aimed to examine the vitamin D receptor (VDR), rs2228570 polymorphism, and its effect on elite athletes' performance. A total of 60 elite athletes (31 sprint/power and 29 endurance) and 20 control/ physically inactive, aged 18-35, voluntarily participated in the study. The International Association of Athletics Federations (IAAF) score scale was used to determine the performance levels of the athletes' personal best (PB). Whole exome sequencing (WES) was performed by the genomic DNA isolated from the peripheral blood of the participants. Sports type, sex, and competitive performance were chosen as the parameters to compare within and between the groups by linear regression models. The results showed no statistically significant difference between the CC, TC, and TT genotypes within and between the groups (p > 0.05). Additionally, our results underlined that there were no statistically significant differences for the association of rs2228570 polymorphism with PBs within the groups of the (p > 0.05) athletes. The genetic profile in the selected gene was similar in elite endurance, sprint athletes, and in controls, suggesting that rs2228570 polymorphism does not determine competitive performance in the analyzed athlete cohort.
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Musculoskeletal Injury Risk in a Military Cadet Population Participating in an Injury-Prevention Program. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020356. [PMID: 36837558 PMCID: PMC9961050 DOI: 10.3390/medicina59020356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
Background and Objectives: Musculoskeletal injuries are a major health hazard among military personnel. Previous research has proposed several exercise-based strategies for prevention. The purpose of this study was to investigate the effect of an exercise-based injury-prevention program on the incidence of musculoskeletal injury, motor performance and psychosocial status. Materials and Methods: Thirty-six Estonian Military Academy cadets were randomly assigned into either an intervention or control group. The intervention group followed a neuromuscular exercise-based injury-prevention warm-up program, three times per week for 6 months. The control group continued with the usual warm-up. The main outcome measure was injury incidence during the study period. Additionally, evaluation of isokinetic lower-extremity strength, postural sway, physical fitness and psychosocial status was included pre- and post-intervention. Results: During the 6-month study period, the musculoskeletal injury incidence was 43% in the intervention group and 54% in the control group (RR = 0.8; 95% CI = 0.41 to 1.99). The noted 20% risk reduction was not statistically significant (p = 0.59). Furthermore, there were no statistically significant differences between the intervention and control group in motor performance or psychosocial status measures. Conclusions: In conclusion, no effect of the exercise-based injury-prevention program on injury risk, motor performance or psychosocial status could be detected.
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Nutritional Strategies in the Rehabilitation of Musculoskeletal Injuries in Athletes: A Systematic Integrative Review. Nutrients 2023; 15:nu15040819. [PMID: 36839176 PMCID: PMC9965375 DOI: 10.3390/nu15040819] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
It is estimated that three to five million sports injuries occur worldwide each year. The highest incidence is reported during competition periods with mainly affectation of the musculoskeletal tissue. For appropriate nutritional management and correct use of nutritional supplements, it is important to individualize based on clinical effects and know the adaptive response during the rehabilitation phase after a sports injury in athletes. Therefore, the aim of this PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science PERSiST-based systematic integrative review was to perform an update on nutritional strategies during the rehabilitation phase of musculoskeletal injuries in elite athletes. After searching the following databases: PubMed/Medline, Scopus, PEDro, and Google Scholar, a total of 18 studies met the inclusion criteria (Price Index: 66.6%). The risk of bias assessment for randomized controlled trials was performed using the RoB 2.0 tool while review articles were evaluated using the AMSTAR 2.0 items. Based on the main findings of the selected studies, nutritional strategies that benefit the rehabilitation process in injured athletes include balanced energy intake, and a high-protein and carbohydrate-rich diet. Supportive supervision should be provided to avoid low energy availability. The potential of supplementation with collagen, creatine monohydrate, omega-3 (fish oils), and vitamin D requires further research although the effects are quite promising. It is worth noting the lack of clinical research in injured athletes and the higher number of reviews in the last 10 years. After analyzing the current quantitative and non-quantitative evidence, we encourage researchers to conduct further clinical research studies evaluating doses of the discussed nutrients during the rehabilitation process to confirm findings, but also follow international guidelines at the time to review scientific literature.
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Ihekweazu C. Is Coffee the Cause or the Cure? Conflicting Nutrition Messages in Two Decades of Online New York Times' Nutrition News Coverage. HEALTH COMMUNICATION 2023; 38:260-274. [PMID: 34519247 DOI: 10.1080/10410236.2021.1950291] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Two-thirds of US adults report hearing news stories about diet and health relationships daily or a few times a week. These stories have often been labeled as conflicting. While public opinion suggests conflicting nutrition messages are widespread, there has been limited empirical research to support this belief. This study examined the prevalence of conflicting information in online New York Times' news articles discussing published nutrition research between 1996-2016. It also examined the contextual differences that existed between conflicting studies. The final sample included 375 news articles discussing 416 diet and health relationships (228 distinct relationships). The most popular dietary items discussed were alcoholic beverages (n = 51), vitamin D (n = 26), and B vitamins (n = 23). Over the 20-year study period, 12.7% of the 228 diet and health relationships had conflicting reports. Just under three-fourths of the conflicting reports involved changes in study design, 79% involved changes in study population, and 31% involved changes in industry funding. Conflicting nutrition messages can have negative cognitive and behavioral consequences for individuals. To help effectively address conflicting nutrition news coverage, a multi-pronged approach involving journalists, researchers, and news audiences is needed.
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Weinstein Y, Ovadia Y, Weinstein B, Weinstein A. The Effects of Amorphous Calcium Carbonate (ACC) Supplementation on Resistance Exercise Performance in Women. Nutrients 2023; 15:nu15030538. [PMID: 36771244 PMCID: PMC9919417 DOI: 10.3390/nu15030538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
The effects of 9 weeks of amorphous calcium carbonate (ACC) supplementation (1000 mg/day) and resistance exercise training (RT) on one repetition maximum (1-RM) values were tested. Thirty-one women (33.1 ± 7.3 y) were randomly assigned into a supplement (ACC, n = 14) or a placebo (PL, n = 17) group. On day 1 and following 9 weeks of intervention, the participants underwent anthropometric measurements and filled out a food frequency questionnaire (FFQ) and sports injuries questionnaires. 1-RM values were measured for the back squat and bench press exercises. All the participants significantly (p = 0.01) improved their mean back squat and bench press 1-RM values (time effect). While no between-group difference was observed in the bench press 1-RM values, the ACC groups' mean post-pre bench press 1-RM differences (Δ1-RM) were significantly higher than in the PL group, expressed in kg (p = 0.049), per body mass (p = 0.042), or per lean body mass (p = 0.035). No significant interaction was observed for time X group effect (p = 0.421). No differences (within- or between-groups) were observed in the anthropometric values or in the questionnaires' results. ACC supplementation revealed an ergogenic effect by augmenting the improvement of maximum amount generated force, which can possibly be attributed to the calcium and/or the carbonate components.
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Affiliation(s)
- Yitzhak Weinstein
- Department of Nutritional Sciences, Tel-Hai Academic College, Kiryat Shmone 1220800, Israel
- Correspondence:
| | - Yarden Ovadia
- Department of Nutritional Sciences, Tel-Hai Academic College, Kiryat Shmone 1220800, Israel
| | - Bar Weinstein
- Department of Statistics and Operations Research, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ayelet Weinstein
- Department of Nutritional Sciences, Tel-Hai Academic College, Kiryat Shmone 1220800, Israel
- Department of Sports Medicine and Research, Wingate Institute, Netanya 4290200, Israel
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Abbott A, Wang C, Stamm M, Mulcahey MK. Part II: Risk Factors for Stress Fractures in Female Military Recruits. Mil Med 2023; 188:93-99. [PMID: 35253041 DOI: 10.1093/milmed/usac033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Stress fractures (SFx) represent a significant proportion of injuries in military recruits internationally. Stress fractures disproportionately affect female recruits, a disparity that has similarly been consistently demonstrated in female athletes. Stress fractures result in medical morbidity, financial burden, and medical discharge from military service. This review presents current literature regarding SFx risk factors to identify and/or mitigate in this high-risk population. METHODS A literature review was conducted using PubMed to find relevant articles. We utilized keywords stress fracture, military, recruits, female, risk factors, modifiable, non-modifiable, overuse, nutrition, and/or prevention. Articles older than 10 years (published before 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review. RESULTS Modifiable risk factors for SFx include nutritional deficiency, especially of iron, vitamin D, and possibly calcium, poor physical fitness, suboptimal training programming for injury development and recovery, load carriage, and military footwear. Non-modifiable risk factors include female sex, greater height, lower weight and body mass index in females but lower or higher weight and body mass index in males, lower body fat percentage, and lower bone mineral density. In addition, menstrual dysfunction, low energy availability, later age at menarche, and iron deficiency pose unique risks to female recruits. Preventive measures include leadership education, programs with recovery considerations, and risk factor screening. CONCLUSION This review, Part II of a two-part series, guides multidisciplinary management of military recruits, especially females, who are at risk for developing SFx. Unique nuances of the military recruit require specific knowledge to reduce high incidence rates of injury internationally.
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Affiliation(s)
- Alexandra Abbott
- Department of Pediatrics, University of California, Los Angeles, CA 90095, USA
| | - Cindy Wang
- Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Michaela Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
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MAMI T, MAYUMI K, TAKAYUKI N, JUN S. Outcomes of vitamin D3 supplementation on serum 25-hydroxy vitamin D in male runners: a randomized controlled trial. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2023. [DOI: 10.23736/s0393-3660.22.04781-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
Stress fractures are a common injury that present in athletes because of the high intensity and repetitive nature of many sports. These injuries require a high index of suspicion in the treating clinician to allow for timely management. Though most low-risk fractures heal well with conservative management, high-risk stress fractures as well as any fracture in the elite athlete may warrant surgical intervention as well as an augmented treatment and rehabilitation regimen.
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Affiliation(s)
- Eric Shi
- Sutter East Bay Medical Foundation, 20101 Lake Chabot Road, Castro Valley, CA 94546, USA.
| | - Lawrence M Oloff
- Sutter Health Palo Alto Medical Foundation, Callan Boulevard, Daly City, CA 94015, USA
| | - Nicholas W Todd
- Sutter Health Palo Alto Medical Foundation, 701 East El Camino Real, Mountain View, CA 94040, USA
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Rips L, Toom A, Kuik R, Varblane A, Mölder H, Tammaru M, Kull M, Ööpik V, Kartus JT, Gapeyeva H, Rahu M. Seven-month wintertime supplementation of 1200 IU vitamin D has no effect on hand grip strength in young, physically active males: A randomized, controlled study. J Int Soc Sports Nutr 2022; 19:437-454. [PMID: 35875694 PMCID: PMC9302007 DOI: 10.1080/15502783.2022.2100718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background Study Design Methods Results Conclusion
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Affiliation(s)
- Leho Rips
- Tartu University Hospital, Sports Medicine and Rehabilitation Clinic, Tartu, Estonia
- University of Tartu, Department of Sports Medicine and Rehabilitation, Institute of Clinical Medicine, Faculty of Medicine, Tartu, Estonia
| | - Alar Toom
- Central Finland Central Hospital, Department of Orthopaedics, Jyväskylä, Finland
| | - Rein Kuik
- Tartu University Hospital, Sports Medicine and Rehabilitation Clinic, Tartu, Estonia
| | - Ahti Varblane
- Estonian National Defence College, Centre of Military Disaster Medicine, Tartu, Estonia
| | - Hanno Mölder
- Medical Centre of the 2nd Infantry Brigade CSS Battalion, Estonian Defence Forces, Võru, Estonia
| | - Marika Tammaru
- East-Tallinn Central Hospital, Research Department, Tallinn, Estonia
| | - Mart Kull
- Viljandi Hospital, Jämejala Viljandi, Estonia
| | - Vahur Ööpik
- University of Tartu, Institute of Sport Sciences and Physiotherapy, Tartu, Estonia
| | - Jüri-Toomas Kartus
- Tartu University Hospital, Sports Medicine and Rehabilitation Clinic, Tartu, Estonia
- University of Tartu, Department of Sports Medicine and Rehabilitation, Institute of Clinical Medicine, Faculty of Medicine, Tartu, Estonia
- University of Gothenburg, Institute of Clinical Siences, Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Gapeyeva
- University of Tartu, Institute of Sport Sciences and Physiotherapy, Tartu, Estonia
- East-Tallinn Central Hospital, Clinic of Medical Rehabilitation, Tallinn, Estonia
| | - Madis Rahu
- Tartu University Hospital, Sports Medicine and Rehabilitation Clinic, Tartu, Estonia
- University of Tartu, Department of Sports Medicine and Rehabilitation, Institute of Clinical Medicine, Faculty of Medicine, Tartu, Estonia
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Vitamin D Supplementation and Its Impact on Different Types of Bone Fractures. Nutrients 2022; 15:nu15010103. [PMID: 36615761 PMCID: PMC9824692 DOI: 10.3390/nu15010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Vitamin D helps to balance the levels of calcium and phosphorus to maintain proper bone structure. It is also involved in essential biological roles and displays a wide spectrum of potential benefits in the human body. Since there are many types of fractures that occur at specific ages and due to different circumstances, the influence of vitamin D on the frequency of a particular fracture may differ. Thus, the authors investigated the possible preventive effect of vitamin D on the risks of vertebral fractures, hip fractures, stress fractures and pediatric fractures. Additional aspects of vitamin D, especially on recuperation after injures and its impact on the severity of particular fractures, were also discussed. It was suggested that vitamin D supplementation may contribute to a reduction in hip fracture risk due to reduced bone turnover, decreased frequency of falls and improved muscle function. Furthermore, vitamin D appears to lower the risk of stress fractures in athletes and military recruits. Due to a nonunified protocol design, presented investigations show inconsistencies between vitamin D supplementation and a decreased risk of vertebral fractures. However, a vitamin D preventive effect on pediatric fractures seems to be implausible.
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Costa TMDRL, Borba VZC, Correa RGP, Moreira CA. Stress fractures. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:765-773. [PMID: 36382766 PMCID: PMC10118812 DOI: 10.20945/2359-3997000000562] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot adapt quickly enough, leading to microdamage and fracture. The etiology is multifactorial with numerous risk factors involved. Diagnosis of SF can be achieved by identifying intrinsic and extrinsic factors, obtaining a good history, performing a physical exam, and ordering laboratory and imaging studies (magnetic resonance imaging is the current gold standard). Relative energy deficiency in sport (RED-S) is a known risk factor. In addition, for women, it is very important know the menstrual status to identify long periods of amenorrhea in the past and the present. Early detection is important to improve the chance of symptom resolution with conservative treatment. Common presentation involves complaints of localized pain, with or without swelling, and tenderness on palpation of bony structures that begins earlier in training and progressively worsens with activity over a 2- to 3-week period. Appropriate classification of SF based on type, location, grading, and low or high risk is critical in guiding treatment strategies and influencing the time to return to sport. Stress injuries at low-risk sites are typically managed conservatively. Studies have suggested that calcium and vitamin D supplementation might be helpful. Moreover, other treatment regimens are not well established. Understanding better the pathophysiology of SFs and the potential utility of current and future bone-active therapeutics may well yield approaches that could treat SFs more effectively.
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Divergent effects of sex and calcium/vitamin D supplementation on serum magnesium and markers of bone structure and function during initial military training. Br J Nutr 2022; 128:1730-1737. [PMID: 34814952 PMCID: PMC9592948 DOI: 10.1017/s0007114521004669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Maintaining Mg status may be important for military recruits, a population that experiences high rates of stress fracture during initial military training (IMT). The objectives of this secondary analysis were to (1) compare dietary Mg intake and serum Mg in female and male recruits pre- and post-IMT, (2) determine whether serum Mg was related to parameters of bone health pre-IMT, and (3) whether Ca and vitamin D supplementation (Ca/vitamin D) during IMT modified serum Mg. Females (n 62) and males (n 51) consumed 2000 mg of Ca and 25 μg of vitamin D/d or placebo during IMT (12 weeks). Dietary Mg intakes were estimated using FFQ, serum Mg was assessed and peripheral quantitative computed tomography was performed on the tibia. Dietary Mg intakes for females and males pre-IMT were below the estimated average requirement and did not change with training. Serum Mg increased during IMT in females (0·06 ± 0·08 mmol/l) compared with males (-0·02 ± 0·10 mmol/l; P < 0·001) and in those consuming Ca/vitamin D (0·05 ± 0·09 mmol/l) compared with placebo (0·001 ± 0·11 mmol/l; P = 0·015). In females, serum Mg was associated with total bone mineral content (BMC, β = 0·367, P = 0·004) and robustness (β = 0·393, P = 0·006) at the distal 4 % site, stress-strain index of the polaris axis (β = 0·334, P = 0·009) and robustness (β = 0·420, P = 0·004) at the 14 % diaphyseal site, and BMC (β = 0·309, P = 0·009) and stress-strain index of the polaris axis (β = 0·314, P = 0·006) at the 66 % diaphyseal site pre-IMT. No significant relationships between serum Mg and bone measures were observed in males. Findings suggest that serum Mg may be modulated by Ca/vitamin D intake and may impact tibial bone health during training in female military recruits.
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Griffis CE, Pletta AM, Mutschler C, Ahmed AE, Lorimer SD. Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries. Clin Orthop Relat Res 2022; 480:2111-2119. [PMID: 35901437 PMCID: PMC9555899 DOI: 10.1097/corr.0000000000002304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 06/09/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lower extremity stress fractures result in lost time from work and sport and incur costs in the military when they occur in service members. Hypovitaminosis D has been identified as key risk factor in these injuries. An estimated 33% to 90% of collegiate and professional athletes have deficient vitamin D levels. Other branches of the United States military have evaluated the risk factors for stress fractures during basic training, including vitamin D deficiency. To the best of our knowledge, a study evaluating the correlation between these injuries and vitamin D deficiency in US Navy recruits and a cost analysis of these injuries has not been performed. Cutbacks in military medical staffing mean more active-duty personnel are being deferred for care to civilian providers. Consequently, data that previously were only pertinent to military medical providers have now expanded to the nonmilitary medical community. QUESTIONS/PURPOSES We therefore asked: (1) What proportion of US Navy recruits experience symptomatic lower extremity stress fractures, and what proportion of those recruits had hypovitaminosis vitamin D on laboratory testing? (2) What are the rehabilitation costs involved in the treatment of lower extremity stress fractures, including the associated costs of lost training time? (3) Is there a cost difference in the treatment of stress fractures between recruits with lower extremity stress fractures who have vitamin D deficiency and those without vitamin D deficiency? METHODS We retrospectively evaluated the electronic medical record at Naval Recruit Training Command in Great Lakes, IL, USA, of all active-duty males and females trained from 2009 until 2015. We used ICD-9 and ICD-10 diagnosis codes to identify those diagnosed with symptomatic lower extremity stress fractures. Data collected included geographic region of birth, preexisting vitamin D deficiency, vitamin D level at the time of diagnosis, medical history, BMI, age, sex, self-reported race or ethnicity, hospitalization days, days lost from training, and the number of physical therapy, primary care, and specialty visits. To ascertain the proportion of recruits who developed symptomatic stress fractures, we divided the number of recruits who were diagnosed with a stress fracture by the total number who trained over that span of time, which was 204,774 individuals. During the span of this study, 45% (494 of 1098) of recruits diagnosed with a symptomatic stress fracture were female and 55% (604 of 1098) were male, with a mean ± SD age of 24 ± 4 years. We defined hypovitaminosis D as a vitamin D level lower than 40 ng/mL. Levels less than 40 ng/mL were defined as low normal and levels less than 30 ng/mL as deficient. Vitamin D levels were obtained at the discretion of the individual treating provider without standardization of protocol. Cost was defined as physical therapy visits, primary care visits, orthopaedic visits, diagnostic imaging costs, laboratory costs, hospitalizations, if applicable, and days lost from training. Diagnostic studies and laboratory tests were incorporated as indirect costs into initial and follow-up physical therapy visits. Evaluation and management code fee schedules for initial visits and follow-up visits were used as direct costs. We obtained these data from the Centers for Medicare & Medicaid Services website. Per capita cost was calculated by taking the total cost and dividing it by the study population. Days lost from training is based on a standardized government military salary of recruits to include room and board. RESULTS We found that 0.5% (1098 of 204,774) of recruits developed a symptomatic lower extremity stress fracture. Of the recruits who had vitamin D levels drawn at the time of stress fracture, 95% (416 of 437 [95% confidence interval (CI) 94% to 98%]; p > 0.99) had hypovitaminosis D (≤ 40 ng/mL) and 82% (360 of 437 [95% CI 79% to 86%]; p > 0.99) had deficient levels (≤ 30 ng/mL) on laboratory testing, when evaluated. The total treatment cost was USD 9506 per recruit. Days lost in training was a median of 56 days (4 to 108) for a per capita cost of USD 5447 per recruit. Recruits with deficient vitamin D levels (levels ≤ 30 ng/mL) incurred more physical therapy treatment costs than did those with low-normal vitamin D levels (levels 31 to 40 ng/mL) (mean difference USD 965 [95% CI 2 to 1928]; p = 0.049). CONCLUSION The cost of lost training and rehabilitation associated with symptomatic lower extremity stress fractures represents a major financial burden. Screening for and treatment of vitamin D deficiencies before recruit training could offer a cost-effective solution to decreasing the stress fracture risk. Recognition and treatment of these deficiencies has a role beyond the military, as hypovitaminosis and stress fractures are common in collegiate or professional athletes. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Clare E Griffis
- Naval Medical Center Portsmouth, Portsmouth, VA, USA
- Captain James A. Lovell Federal Health Care Center, North Chicago, IL, USA
| | - Aileen M Pletta
- Naval Special Warfare Center, San Diego, CA, USA
- Captain James A. Lovell Federal Health Care Center, North Chicago, IL, USA
| | - Christian Mutschler
- Navy Medicine Readiness and Training Command Camp Pendleton, Oceanside, CA, USA
| | - Anwar E Ahmed
- Uniformed Service University of the Health Sciences/Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MS, USA
| | - Shannon D Lorimer
- Naval Medical Center Portsmouth, Portsmouth, VA, USA
- Captain James A. Lovell Federal Health Care Center, North Chicago, IL, USA
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Schowalter S, Le B, Creps J, McInnis KC. Rib Fractures in Professional Baseball Pitchers: Mechanics, Epidemiology, and Management. Open Access J Sports Med 2022; 13:89-105. [PMID: 36248020 PMCID: PMC9563740 DOI: 10.2147/oajsm.s288882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022] Open
Abstract
Pitching is a complex kinetic chain activity requiring the transfer of energy from the lower body, through the core and trunk, and finally through the arm to generate explosive acceleration of the baseball. As a result, large forces are generated in the trunk musculature and rib attachments from the late cocking phase of pitching through deceleration. The repetitive cumulative load and high pitch velocities put professional pitchers at risk of rib stress fracture. Given the potential for a prolonged recovery course and high rate of recurrence, early recognition of rib bone stress injury is critical to optimize care. Identifying torso strength imbalances, suboptimal pitching biomechanics (such as late or inadequate pelvic rotation), as well as metabolic deficiencies that may adversely affect bone health are essential to expedite safe return to play and prevent future injury. In this review, we discuss risk factors, mechanism of injury, typical clinical presentation, diagnostic imaging findings, and propose treatment and prevention strategies for rib stress fractures in overhand pitchers.
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Affiliation(s)
- Sean Schowalter
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA, USA,Correspondence: Sean Schowalter, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA, Tel +1 617 952 5000, Email
| | - Bryan Le
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - James Creps
- Sports Medicine Service, Boston Red Sox, Boston, MA, USA
| | - Kelly C McInnis
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA, USA,Division of Sports Medicine, Massachusetts General Hospital, Boston, MA, USA
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Rothschild CE. Exercise Considerations for the Masters Female Athlete. Strength Cond J 2022. [DOI: 10.1519/ssc.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wilson-Barnes SL, Lanham-New SA, Lambert H. Modifiable risk factors for bone health & fragility fractures. Best Pract Res Clin Rheumatol 2022; 36:101758. [PMID: 35750569 DOI: 10.1016/j.berh.2022.101758] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Osteoporosis is an ageing disorder characterised by poor microstructural architecture of the bone and an increase in the risk of fragility fractures, which often leads to hospitalisation and eventually a loss of mobility and independence. By 2050, it is estimated that more than 30 million people in Europe will be affected by bone diseases, and European hospitalisation alone can approximately cost up to 3.5 billion euros each year [1]. Although inherited variation in bone mineral density (BMD) is pre-determined by up to 85% [2], there is a window of opportunity to optimise BMD and reduce fracture risk through key modifiable lifestyle factors during the life course. An optimal diet rich in micronutrients, such as calcium, vitamin D, and potassium, has long been considered an important modifiable component of bone health, which is attributed to their direct roles within bone metabolism. Recently, there has been emerging evidence to suggest that protein and even an adequate intake of fruit and vegetables may also play an important role in improving BMD [3,4]. Maintaining a physically active lifestyle is not only protective from non-communicable diseases such as cardiovascular disease but it also has been shown to lessen the risk of fractures later in life, thereby making it an imperative modifiable factor for bone health, particularly as it also supports peak bone mass attainment during childhood/adolescence and can facilitate the maintenance of bone mass throughout adulthood [5]. Other key lifestyle factors that could be potentially modified to reduce the risk of osteoporosis or osteoporotic fractures later in life include smoking status, alcohol intake, and body composition [6]. Therefore, the principle aim of this review is to highlight the recent evidence pertaining to modifiable lifestyle factors that contribute to optimal bone health and the prevention of fragility fractures in later life.
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Affiliation(s)
- Saskia L Wilson-Barnes
- Department of Nutritional Sciences, School of Biosciences & Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK.
| | - Susan A Lanham-New
- Department of Nutritional Sciences, School of Biosciences & Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Helen Lambert
- Department of Nutritional Sciences, School of Biosciences & Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
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Tenforde AS, DeLuca S, Wu AC, Ackerman KE, Lewis M, Rauh MJ, Heiderscheit B, Krabak BJ, Kraus E, Roberts W, Troy KL, Barrack MT. Prevalence and factors associated with bone stress injury in middle school runners. PM R 2022; 14:1056-1067. [PMID: 34251763 DOI: 10.1002/pmrj.12673] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Bone stress injury (BSI) in youth runners is clinically important during times of skeletal growth and is not well studied. OBJECTIVE To evaluate the prevalence, anatomical distribution, and factors associated with running-related BSI in boy and girl middle school runners. DESIGN Retrospective cross-sectional study. SETTING Online survey distributed to middle school runners. METHODS Survey evaluated BSI history, age, grade, height, weight, eating behaviors, menstrual function, exercise training, and other health characteristics. MAIN OUTCOME MEASUREMENTS Prevalence and characteristics associated with history of BSI, stratified by cortical-rich (eg, tibia) and trabecular-rich (pelvis and femoral neck) locations. PARTICIPANTS 2107 runners (n = 1250 boys, n = 857 girls), age 13.2 ± 0.9 years. RESULTS One hundred five (4.7%) runners reported a history of 132 BSIs, with higher prevalence in girls than boys (6.7% vs 3.8%, p = .004). The most common location was the tibia (n = 51). Most trabecular-rich BSIs (n = 16, 94% total) were sustained by girls (pelvis: n = 6; femoral neck: n = 6; sacrum: n = 4). In girls, consuming <3 daily meals (odds ratio [OR] = 18.5, 95% confidence interval [CI] = 7.3, 47.4), eating disorder (9.8, 95% CI = 2.0, 47.0), family history of osteoporosis (OR = 6.9, 95% CI = 2.6, 18.0), and age (OR = 1.6, 95% CI = 1.0, 2.6) were associated with BSI. In boys, family history of osteoporosis (OR = 3.2, 95% CI = 1.2, 8.4), prior non-BSI fracture (OR = 3.2, 95% CI = 1.6, 6.7), and running mileage (OR = 1.1, 95% CI = 1.0, 1.1) were associated with BSI. Participating in soccer or basketball ≥2 years was associated with lower odds of BSI for both sexes. CONCLUSION Whereas family history of osteoporosis and prior fracture (non-BSI) were most strongly related to BSI in the youth runners, behaviors contributing to an energy deficit, such as eating disorder and consuming <3 meals daily, also emerged as independent factors associated with BSI. Although cross-sectional design limits determining causality, our findings suggest promoting optimal skeletal health through nutrition and participation in other sports including soccer and basketball may address factors associated with BSI in this population.
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Affiliation(s)
- Adam S Tenforde
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie DeLuca
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander C Wu
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Kathryn E Ackerman
- Harvard Medical School, Boston, Massachusetts, USA
- Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Margo Lewis
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Mitchell J Rauh
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Bryan Heiderscheit
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin, USA
| | - Brian J Krabak
- Rehabilitation, Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Emily Kraus
- Stanford Children's Orthopedic and Sports Medicine Center, Stanford University, Stanford, California, USA
| | - William Roberts
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Karen L Troy
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
| | - Michelle T Barrack
- Department of Family and Consumer Sciences, California State University, Long Beach, California, USA
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Høeg TB, Olson EM, Skaggs K, Sainani K, Fredericson M, Roche M, Kraus E. Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners. Clin J Sport Med 2022; 32:375-381. [PMID: 34232162 DOI: 10.1097/jsm.0000000000000956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD). DESIGN Multiyear cross-sectional study. SETTING One hundred-mile ultramarathon. PARTICIPANTS Competing runners were recruited in 2018 and 2019. ASSESSMENT OF RISK FACTORS Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only). MAIN OUTCOME MEASURE A Triad Cumulative Risk Assessment Score was calculated for each participant. RESULTS One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk. CONCLUSIONS Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.
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Affiliation(s)
- Tracy Beth Høeg
- Department of Physical Medicine & Rehabilitation School of Medicine, University of California-Davis, Sacramento, California.,Northern California Orthopaedic Associates, Grass Valley, California
| | - Emily Miller Olson
- Stanford Department of Orthopaedic Surgery, Stanford University, Palo Alto, California; and
| | - Kira Skaggs
- Stanford Department of Orthopaedic Surgery, Stanford University, Palo Alto, California; and
| | - Kristin Sainani
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Michael Fredericson
- Stanford Department of Orthopaedic Surgery, Stanford University, Palo Alto, California; and
| | - Megan Roche
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Emily Kraus
- Stanford Department of Orthopaedic Surgery, Stanford University, Palo Alto, California; and
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Examination of Amorphous Calcium Carbonate on the Inflammatory and Muscle Damage Response in Experienced Resistance Trained Individuals. Nutrients 2022; 14:nu14091894. [PMID: 35565859 PMCID: PMC9106048 DOI: 10.3390/nu14091894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
The effect of 3 weeks of amorphous calcium carbonate (ACC) supplementation (2000 mg per day) was examined on the recovery response to resistance exercise. Thirty men were randomized into a supplement (ACC) or placebo (PL) group. Following supplementation, participants performed six sets of 10 repetitions in the bench press (BP) and incline BP exercises, using 80% of maximal strength. Participants returned 24 (T4) and 48 h (T5) later and performed six sets of the BP exercise. Significant decreases in the number of repetitions (p < 0.001), peak power (p < 0.001), and mean power (p = 0.009) were noted over time, but no significant interactions were observed (p > 0.05). Magnitude-based inference analysis (MBI) indicated that the change in repetitions was possibly beneficial for ACC at T4 and likely beneficial at T5. No significant interaction was noted for general soreness (p = 0.452), but a trend toward an interaction was observed in upper body soreness (p = 0.089). Confidence intervals for mean percent change scores indicated significant differences between the groups at T4 and T5, and MBI analysis indicated that ACC was very likely or likely to be beneficial for reducing soreness at those time points. In conclusion, ACC supplementation may have a potential beneficial effect in attenuating the decline in performance, which is possibly due to the carbonate component.
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Hoenig T, Ackerman KE, Beck BR, Bouxsein ML, Burr DB, Hollander K, Popp KL, Rolvien T, Tenforde AS, Warden SJ. Bone stress injuries. Nat Rev Dis Primers 2022; 8:26. [PMID: 35484131 DOI: 10.1038/s41572-022-00352-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 01/11/2023]
Abstract
Bone stress injuries, including stress fractures, are overuse injuries that lead to substantial morbidity in active individuals. These injuries occur when excessive repetitive loads are introduced to a generally normal skeleton. Although the precise mechanisms for bone stress injuries are not completely understood, the prevailing theory is that an imbalance in bone metabolism favours microdamage accumulation over its removal and replacement with new bone via targeted remodelling. Diagnosis is achieved by a combination of patient history and physical examination, with imaging used for confirmation. Management of bone stress injuries is guided by their location and consequent risk of healing complications. Bone stress injuries at low-risk sites typically heal with activity modification followed by progressive loading and return to activity. Additional treatment approaches include non-weight-bearing immobilization, medications or surgery, but these approaches are usually limited to managing bone stress injuries that occur at high-risk sites. A comprehensive strategy that integrates anatomical, biomechanical and biological risk factors has the potential to improve the understanding of these injuries and aid in their prevention and management.
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Affiliation(s)
- Tim Hoenig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Boston, MA, USA.,Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Belinda R Beck
- School of Health Sciences & Social Work, Griffith University, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Gold Coast, Queensland, Australia.,The Bone Clinic, Brisbane, Queensland, Australia
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School and Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David B Burr
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA.,Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,U.S. Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S Tenforde
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, USA.
| | - Stuart J Warden
- Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA. .,Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, IN, USA. .,La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
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50
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Hixon KR, Miller AN. Animal models of impaired long bone healing and tissue engineering- and cell-based in vivo interventions. J Orthop Res 2022; 40:767-778. [PMID: 35072292 DOI: 10.1002/jor.25277] [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: 08/02/2021] [Revised: 12/05/2021] [Accepted: 01/16/2022] [Indexed: 02/04/2023]
Abstract
Bone healing after injury typically follows a systematic process and occurs spontaneously under appropriate physiological conditions. However, impaired long bone healing is still quite common and may require surgical intervention. Various complications can result in different forms of impaired bone healing including nonunion, critical-size defects, or stress fractures. While a nonunion may occur due to impaired biological signaling and/or mechanical instability, a critical-size defect exhibits extensive bone loss that will not spontaneously heal. Comparatively, a stress fracture occurs from repetitive forces and results in a non-healing crack or break in the bone. Clinical standards of treatment vary between these bone defects due to their pathological differences. The use of appropriate animal models for modeling healing defects is critical to improve current treatment methods and develop novel rescue therapies. This review provides an overview of these clinical bone healing impairments and current animal models available to study the defects in vivo. The techniques used to create these models are compared, along with the outcomes, to clarify limitations and future objectives. Finally, rescue techniques focused on tissue engineering and cell-based therapies currently applied in animal models are specifically discussed to analyze their ability to initiate healing at the defect site, providing information regarding potential future therapies. In summary, this review focuses on the current animal models of nonunion, critical-size defects, and stress fractures, as well as interventions that have been tested in vivo to provide an overview of the clinical potential and future directions for improving bone healing.
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Affiliation(s)
- Katherine R Hixon
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA.,Thayer School of Engineering, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
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