Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Military/ Police boots and tibial stress fractures- is there a link?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Pod on sea, Aug 9, 2012.

  1. Pod on sea

    Pod on sea Active Member

    Members do not see these Ads. Sign Up.
    Does anyone know of any research/evidence re the wearing of heavy boots for long periods, running in them whilst carrying heavy equipment and firearms predisposing to tibial stress fractures in someone who is a marked overpronator (or even someone with no biomechanical anomalies). Any leads/ help much appreciated.
    Thank you.
  2. davidh

    davidh Podiatry Arena Veteran

    Try Google Scholar.

    I'm unaware of any research which shows evidence of increased tibial stress factures due to military/police boots.
  3. Boots n all

    Boots n all Well-Known Member

    You may find tibial injury is just related to the running for long periods whilst carrying heavy equipment and firearms, rather than anything to do with the supportive ankle boots?

    The Boots just happen to be worn by both.

    How much do the boots in question weigh? do they actually weigh that much more?
  4. SFRrepeat

    SFRrepeat Welcome New Poster

    I'm a newbie so bear with me here. I served in the U.S. military a couple years ago, so this may be a bit dated. In the last 10 years the typical Army boots have changed from being a more stiffer supporting surrounding the ankle up to the mid tib-fibs to being more flimsy in these areas. The first type are the regular, black army standard issue. The 2nd newer type are the "deserts". There are all sorts of variations, stores like "Ranger Joe's" or any old army/navy surplus can give you an idea. Common in my day were standard issue and Jungle Boots. Each set of boots came with an "orthosis" that was standard issue and still is today.

    If you are looking for extended marching with high loads start with most of the military schools such as Airborne, Ranger, Special Forces etc. One of the greatest ways to get rid of some of my classmates was marching and running with heavy loads. 2 or 3 weeks of this, and then you jump out of a plane a couple times. You can guess what kind of injuries we usually saw. These were also men that were used to running anywhere from 30-40 miles a week in normal running shoes, and then put into these environments with a brand new set of boots that they were not accustomed to and hadn't broken in.

    If there's not any research I always thought this would be a great thing to invest some time in. After reading through the forum I sent a few calls out to some of the people I still know that are in charge of testing the military boots and are in medical support for those schools above that maybe able to get some further info for you.
  5. Craig Payne

    Craig Payne Moderator

    I not aware of any research and did 2yrs ago worked on a major report for the military on boots. Its also about the magnitude of the load that the carry over the distances they travel ... its that simple.
  6. SFRrepeat

    SFRrepeat Welcome New Poster

    Yes, I figured there wasn't any research and it's a shame. Had a couple friends fail a few courses because of injuries. Thanks for the feedback.

    Craig do have any idea what type of boots were used? How long of distances? The amount of weight? Were they in formation, walking, or running? Any idea of terrain they covered? In what kind of shape were the test subjects?

    I'm still going to see if any of my leads have anything or if there is anything that might be of interest. The only reason is that for the first two weeks of Airborne is when I remember the most leg injuries. And that was because we were running in tight formations, for extended periods of time (2-5 hours?), it was done on asphault/cement, but we were without any type of gear.
  7. SFRrepeat

    SFRrepeat Welcome New Poster

    Another question, what kind of foot exam did you perform in the military report? The U.S. military had a nasty habit of handing out boots and shoes without any kind of adequate physical exam in my time, causing a severe mismatch of foot type to boot.
  8. Pod on sea

    Pod on sea Active Member

    Good point, and thank you, Craig. You have a knack for simplifying things, and I like simple!
  9. Here:

    Bensel CK, Kish RN. Lower extremity disorders among men and women in Army basic training and effects of two types of boots. (Technical report Natick TR-83/026). Natick, MA: US Army Natick Research and Development Laboratories, 1983.

    Bensel CK. The effects of tropical and leather combat boots on lower extremity disorder among U.S. Marine Corps recruits. (Technical report no. 76-49-CEMEL). Natick, MA: US Army Natick Research and Development Laboratories, 1976.
  10. Pod on sea

    Pod on sea Active Member

    Wey hey, brilliant! Thank you Simon.
  11. CEM

    CEM Active Member

    One thing that is interesting is our military (in the UK) will give a pair of decent boots to anyone with foot pain who reports to the med centre, they normally suggest Altberg or Lowa costing in excess of £100 a pair, the standard issue boot currently costs less than £20 a pair, has a lousy midsole and a sock liner which resembles a cheese grater (the mesh is supposed to allow moisture to drain from under the foot, it hasn't changed (from what i have been told) since WW2.

    So is there is link between military boots and tibial stress fractures? not sure! But one thing is for sure poor quality boots are probably involved in some way shape or form.
  12. Craig Payne

    Craig Payne Moderator

    The report we worked on was commissioned by the Army due to ongoing complaints from diggers. We visited bases around the country; talked to diggers and medical personal; reviewed the literature and reports on military footwear for other countries and forces; looked at the training routines and loads carried; poured over the anonymous written complaints on boots going back over 5 yrs; reviewed the boot fitting processes and issuing of boots policies; looked at injury risk factor studies; integrated that with the research on running shoes; talked to competing manufacturers of military boots, as well as other footwear manufacturers; did bench testing on a range of boots; and some limited in vivo testing; and had to tread lightly due to political sensitives, dealing with the 'no it alls, and not to mention the commercial in confidence issues we had access to.

    It was a major undertaking and cost the govt a lot of $. The highlight for me was meeting and talking to all the diggers who had recently returned from Iraq & Afghanistan.

    Basically the problem came down to the lack of choice soldiers had. There was only one brand/model that they could wear. That has now changed and they can use a wider range/choice of boots along with a better fitting process and boot allocation policy. Personally, I got myself a pair of Danner's, which is not one they previously had access to.
  13. I did a review study, about 20 years ago, for the California Department of Forestry to try and determine why their female firefighters were getting injured much more than their male counterparts while in the rugged backcountry fighting fires here in California. What I found was that women were being given smaller men's boots since there were no provision to use a boot manufacturer that had women's sizes. It seems that once women were given appropriately fitting boots, the injury rates went down.

    When I did my student externship at Fort Ord in Monterey, California in 1982, the US army had already started to allow the recruits to run in traditional running shoes versus being required to always run in their military issue boots. The recruits I talked to thought that this change to running shoes had helped them stay healthier.

    Simon's paper he referenced (see attached) looks like it covers the multifactorial causes of stress fractures fairly well (thanks for that one Simon). You must always remember that, just like in our discussions on whether barefoot or minimalist shoes or more traditional running shoes are more likely to cause injury, stress fractures are not simply just due to the shoes being worn. More times than not, stress fractures are more related to doing too much, too fast and too soon in these military recruits (especially for those who were not runners or athletically active before entering the military) than to whether they are wearing boots or some other type of shoe to run in.

    One must also remember that, in regards to stress fractures in long bones such a metatarsals, tibias and fibulas, that the bending moments on the bone are the most likely cause of these injuries and reducing these bending moments with foot orthoses, strengthening or gait retraining may be one of the most productive methods of reducing the frequency of stress fractures of the metatarsals, tibia and fibula. Therefore, if you see a patient with a metatarsal, tibia or fibular stress fracture, think increased bending strain, versus tension, compression or torsional strain, as being the most likely cause of the fatigue fracture of the bone.


  14. Pod on sea

    Pod on sea Active Member

    Thanks Kevin. Would Tib varum be likely to increase bending moments or is it more about knee and ankle ROM/stiffness?
  15. yes..
  16. An increased tibial varum would tend to increase the ground reaction force (GRF) on the lateral forefoot during the first half of support phase of running so that would tend to increase the valgus tibial bending moments. In addition, a decrease in subtalar joint pronation range of motion, an increase in rearfoot varus deformity and an increase in inverted forefoot deformity would also tend to increase the GRF on the lateral forefoot during running. Other factors influencing bending moments would be the weight, speed and running style of the runner with an increased weight, increased speed and more forefoot striking pattern theoretically causing increase tibial bending moments. Factors increasing valgus bending strains on the medial tibial cortex would include thinner tibias (i.e. decrease cross sectional area of tibia) and decreased tibial bone density.

    Hope this helps.
  17. Rick K.

    Rick K. Active Member

    Don't recall any published study, but there were cohort comparisons for infantry basic trainee companies at Ft. Benning, GA in the early 1980's that involved division into 2 groups - 1. running with standard issue combat boots, 2. running with running shoes of choice. Showed huge reduction of injuries in group using running shoes and that opened up the change from running in boots to running in training/running shoes. My shaky recollection is it was really pushed by a retiring infantry training brigade commander and he asked podiatry service at Martin Army Hospital to give him something to stand on scientifically. This colonel had nothing to lose, since his career was over, but he sure made a big difference in injuries over the years.
  18. Pod on sea

    Pod on sea Active Member

    I started this thread as I have a patient in the British police, affected by tib fractures who was riot trained then went on to firearms duty. The choice of boots was either Altbergs or Hi-Tec Magnums, and he chose the Altbergs as colleagues had said the Hi-Tecs were not as good. There doesn't seem to have been any guidance re choice. The boots were replaced every 18 months to 2 years, which sounds a long time to me. The fractures occurred whilst he was in the firearms dept., his kit weighed 4 stone in total. I posed the initial question as Police/Military as I had a feeling there had been some research done on military recruits, and my thought was that the demands, boots and weight of kit would be similar, but does anyone have any experience of these injuries re Police or any knowledge about the Police boots?
  19. CEM

    CEM Active Member

    The boot he is using if Altberg will be a model called the peacemaker it has a pretty strong mid-sole and a reasonable level of cushioning, so in theory is pretty suitable for what he is doing in terms of footwear. I would 100% choose the Altberg over pretty much any other boot out there.

    The patients biomechanics, are however another thing and from what you have said i would think that he may have similar issues whatever the boot unless there is some other intervention in terms of orthoses / muscle strengthening etc
  20. Blaise Dubois

    Blaise Dubois Active Member

    But not injuries
  21. Not in isolation.
  22. Blaise Dubois

    Blaise Dubois Active Member

    can you explain please
  23. Dr. Steven King

    Dr. Steven King Well-Known Member


    The US Department of Defense and Army's Medical Research and Materials Command is currently testing for this. DiaPedia LLC was granted the phase 2 award and we will be excited to see what Dr. Peter Cavanagh and his team have invented and researched.

    http://www.diapedia.com/DIApedia personnel.htm


    SITIS Archives - Topic Details
    Program: SBIR
    Topic Num: A11-109 (Army)
    Title: Advanced Composite Insoles for the Reduction of Stress Fractures
    Research & Technical Areas: Biomedical


    Acquisition Program: Office of the Principal Assistant for Acquisition
    Objective: To develop a composite boot orthotic that will decrease the risk of musculoskeletal overuse injuries and increase ambulatory performance by reducing loading rates, while increasing energy storage and energy return.

    Description: Musculoskeletal injuries of the lower legs are a primary problem in military populations. Injury rates during military training range from 1-16%, and up to 30% in elite infantry units (1). Specific injuries include stress syndrome, muscle sprains, ankle sprains, knee pain, and metatarsal stress fractures (2). Some of the risk factors associated with high injury rates include high running mileage and high amounts of weekly exercise, both examples of movements where an individual is exposed to high repetitive impact forces. Footwear selection plays a major role in the injury risk of the musculoskeletal system. Current military boot applications require stiff thick sole and midsole materials to protect from puncture wounds. Heavy rubber and rigid polyurethane foams are used in most military boots. Under impact testing, military footwear (jungle and leather combat boots) has been shown to have less shock-absorbing capabilities than traditional footwear (3). As a result, extra layers of soft foam have been needed in boots as insoles to reduce repetitive impact shock and stress fractures. Although these materials provide some protection against excessive impact, they also increase the weight and height of the footwear. An increase in boot height can have a negative effect on balance and increase peak pressures in sensitive areas of the foot, both which can increase the risk of injury. An increase in boot weight will speed up the onset of fatigue on an individual, again increasing the risk of injury through the increase of inadvertent falls as a result of a Warfighter’s failing to lift their feet to avoid obstacles on an uneven terrain. In summary, the current military boot contains a cushioning system which causes excessive stress on the metatarsal heads, ankle and knee joints. Efforts to mitigate this lack of cushioning increase the weight of the boot (4), which can be correlated to increased fatigue, which can lead to inadvertent falls and more injuries. The challenge is to find an innovative solution that will decrease the risk of musculoskeletal overuse injuries and increase ambulatory performance by reducing loading rates, while increasing energy storage and energy return. Advanced lightweight composite materials, such as carbon fibre and Kevlar have proven to protect our vehicles and soldiers as shielding and personal body armour. The objective is to develop and test advanced composite orthotic designs that will reduce loading rates, while increasing energy storage and energy return, all while lowering the overall weight of the footwear.

    PHASE I: Phase I will include multiple concept designs and development of a working orthotic and synergistic “boot housing.” The prototype will be supported with an analysis of the predicted biomechanical performance benefits, such as the reduction of internal load and the increased energy return of the orthotic. Performance considerations for the orthotic should include: 1) outperforming ASTM F2412-05 puncture standards; 2) reducing outsole and midsole weight of combat boots by >10%; 3) reducing injury risk by >10%; 3) a significant decrease in oxygen consumption; 4) be fire retardant; and 5) increase subjective comfort ratings by 10% when compared to traditional combat boot. Phase I will also include a feasibility evaluation that will address practical factors, such as useful life expectancy of the orthotic, and manufacturing costs.

    PHASE II: Finalize Phase I design and perform multiple biomechanical evaluations of the different prototypes, which may result in revisions to the prototype. Specific biomechanical testing will include: 1) muscle activation (EMG); 2) kinetics & kinematics (e.g., joint angles, angular displacements, and moments); 3) pressure distribution; 4) oxygen consumption (VO2); 5) impulse; 6) comfort; and 7) impact testing. Revised prototypes will be further assessed using biomechanical methods for validation and functional effectiveness. A prospective study will also be executed to add credibility to the reduction of injury risk claims. Sourcing solutions for mass production should also be validated in this Phase.

    PHASE III: The end result of Phase-I/Phase-II research efforts will validate applications and further develop synergistic orthotic boot coverings (uppers and soles). The advanced orthotic system and accompanying boot and shoe systems will be integrated into the current service uniforms for the military and paramilitary government entities including all branches of the military, Homeland Security, fire and police departments, and NASA. The commercial applications will continue with incorporation of orthotic technology in prosthetics, braces, and crutch systems used for the treatment of neurologic and diabetic wounds by the Veterans Administration and general public.

    References: 1. Kenton R. Kaufman PhD, Stephanie Brodine MD, and Richard Shaffer PhD. Military training-related injuries: Surveillance, research, and prevention. American Journal of Preventive Medicine. Volume 18, Issue 3, Supplement 1, April 2000, Pages 54-63. 2. Hinz P, Henningsen A, Matthes G, Jäger B, Ekkernkamp A, Rosenbaum D. Analysis of pressure distribution below the metatarsals with different insoles in combat boots of the German Army for prevention of march fractures. Gait Posture. 2008 Apr;27(3):535-8. 3. Williams, Karen M. ; Brodine, S. K. ; Shaffer, R. A. ; Hagy, J. ; Kaufman, K. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA. Biomechanical Properties of Infantry Combat Boot Development. National technical Information Service, US department of Commerce, 1997. 4. 2000: Stefanyshyn D J; Nigg B M, Energy aspects associated with sport shoes. Sportverletzung Sportschaden : Organ der Gesellschaft für Orthopädisch-Traumatologische Sportmedizin 2000;14(3):82-9.

    Keywords: Combat Boots, Advanced Composite Materials, Injury Risk, Energy Return, Biomechanics, Stress Fractures
  24. Yep, no problem. Bending moment in isolation is not necessarily a good predictor of injuries, one needs to consider other factors such as cross sectional area of the bone, mineralisation etc. Moreover, the paper I posted above talks about the multifactorial nature of pathogenesis and the various predictors of tibial stress fracture.
  25. 5,4,3,2,1.. and here comes Dr Steven King to post something about his foot orthoses design and a cheesy tag-line to boot... lets see if he can resist.

Share This Page