Risk factors for tibial stress fractures

NewsBot · Sep 10, 2008

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Biomechanical predictors of retrospective tibial stress fractures in runners.
Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS.
J Biomech. 2008;41(6):1160-5.

Both kinematics and kinetics of the lower limb have been shown separately to be related with a history of tibial stress fractures (TSFs) in female runners. However, it is likely that these factors interact together to increase the risk of a TSF. This study was conducted to determine which combination of kinematic and kinetic factors are the best predictors of retrospective TSF in female distance runners. Total 30 female runners who had previously sustained a TSF were recruited, along with an age and mileage matched control group (n=30). Subjects ran overground at 3.7m/s while kinematic and kinetic data were recorded. Five trials from each subject were used for data analysis and ensemble means were calculated for both groups. The kinematic variables of peak hip adduction (HADD), peak knee internal rotation (KIR) and knee adduction (KADD), peak rearfoot eversion (RFEV) were entered into a binary logistic regression along with the kinetic variables of vertical instantaneous load rate (VILR) and absolute free moment (FM). The variables HADD, FM and RFEV were able to correctly predict a history of TSF in 83% of cases. Increases in HADD, FM and RFEV (odds ratios of 1.29, 1.37 and 1.18) were associated with an elevated risk of having a history of TSF. The addition of VILR, KIR and KADD did not improve the ability to predict previous injury. Based on these results, HADD, FM and RFEV appear to be the most important of the variables of interest in terms of predicting retrospective TSF in female runners.
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Admin2 · Sep 11, 2008

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Other threads on stress fractures

NewsBot · Oct 14, 2008

Prediction Model for Stress Fracture in Young Female Recruits during Basic Training.

Moran DS, Israeli E, Evans RK, Yanovich R, Constantini N, Shabshin N, Merkel D, Luria O, Erlich T, Laor A, Finestone A.
Med Sci Sports Exerc. 2008 Oct 8. [Epub ahead of print]

PURPOSE:: To develop a new prediction model for stress fractures (SF) in female recruits during basic training (BT) to identify risk factors and to try to prevent orthopedic injuries.

METHODS:: Measurements and data collection were taken from three companies of gender-integrated recruited units before the BT program (a total of 227 females and 83 males). Measurements included anthropometric variables, blood samples for hematology profile and markers for bone metabolism, fitness tests, bone quality (peripheral quantitative computed tomography), nutritional and activity habits, psychological assessment, and medical evaluation. SF were diagnosed during BT by bone scintigraphy and/or magnetic resonance imaging.

RESULTS:: All collected measurements were used to construct a new prediction model for the 27 and 192 female soldiers found with and without stress fracture, respectively. There were no SF in the male soldiers. The model successfully predicts 76.5% of the female soldiers with and without stress fractures (SF) as follows:pSF = -13.98 + 0.079 Ht - 0.014 Fe + 0.464 BUR - 0.105 BMI + 0.035 Ferritin,where PSF is the SF prediction according to the log odds(SF); odds(SF) is the ratio between probability of SF existence and nonexistence; Ht is the height (cm); BUR is a subjective assessment of burnout on a scale of 1 to 7; Fe is the iron blood level (mug.dL); ferritin is the iron storage level (ng.mL); and BMI is the body mass index (kg.m).

CONCLUSION:: A young female recruited to an integrated light combat unit is at risk for stress fracture if she is tall, lean, feels "burnout," has iron deficiency, and is at the high end of the normal ferritin range. However, further evaluation is required in different populations, conditions, and training programs to evaluate these results.
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NewsBot · Oct 14, 2008

How Stress Fracture Incidence Was Lowered in the Israeli Army: A 25-yr Struggle.
Finestone A, Milgrom C.
Med Sci Sports Exerc. 2008 Oct 8. [Epub ahead of print]

In 1983, a 31% incidence of stress fractures was found among Israeli basic infantry recruits.

PURPOSE:: The purpose of this article is to chronicle the efforts of the Israeli Defense Forces to lower the stress fracture incidence and to present new data showing how reduction was finally achieved.

METHODS:: A historical review of the steps taken over the past 25 yr to decrease stress fracture incidence in the Israeli Army is presented: risk factors for stress fracture were identified to create a risk profile and facilitate screening of recruits; modifications in army shoes were made; shock attenuating orthoses and biomechanical orthoses of various compositions were used; and the bisphosphonate risedronate was administered to recruits before and during basic training. In the latest intervention, the combined effect of a minimum nightly sleep requirement (6 h a night) and a decrease in recruits' cumulative marching and running on the incidence of stress fractures was evaluated among 276 infantry recruits.

RESULTS:: A stress fracture risk profile was developed. It allows a recruit's stress fracture risk to be calculated before infantry training. Shoe modifications, orthoses, and pharmacological treatment with risedronate were not effective in lowering the incidence of stress fractures. The minimum sleep regimen and the reduced cumulative marching lowered the incidence of stress fractures by 62% (from 30.8% to 11.6%) and decreased their severity as compared with the 1983 baseline study.

CONCLUSION:: After failing in prior interventions, a more than 60% decrease in stress fracture incidence was achieved by enforcing a minimum sleep regimen and lowering the cumulative marching during infantry training. These changes did not affect the quality of the training or the soldiers' combat readiness.
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NewsBot · Apr 21, 2010

Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture.
Milner CE, Hamill J, Davis IS.
J Orthop Sports Phys Ther. 2010 Feb;40(2):59-66.

STUDY DESIGN: Cross-sectional controlled laboratory study.

OBJECTIVES: To investigate the kinematics of the hip, knee, and rearfoot in the frontal and transverse planes in female distance runners with a history of tibial stress fracture.

BACKGROUND: Tibial stress fractures are a common overuse injury in runners, accounting for up to half of all stress fractures. Abnormal kinematics of the lower extremity may contribute to abnormal musculoskeletal load distributions, leading to an increased risk of stress fractures.

METHODS: Thirty female runners with a history of tibial stress fracture were compared to 30 age-matched and weekly-running-distance-matched control subjects with no previous lower extremity bony injuries. Kinematic and kinetic data were collected using a motion capture system and a force platform, respectively, as subjects ran in the laboratory. Selected variables of interest were compared between the groups using a multivariate analysis of variance (MANOVA).

RESULTS: Peak hip adduction and peak rearfoot eversion angles were greater in the stress fracture group compared to the control group. Peak knee adduction and knee internal rotation angles and all joint angles at impact peak were similar between the groups.

CONCLUSION: Runners with a previous tibial stress fracture exhibited greater peak hip adduction and rearfoot eversion angles during the stance phase of running compared to healthy controls. A consequence of these mechanics may be altered load distribution within the lower extremity, predisposing individuals to stress fracture.
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NewsBot · Nov 10, 2015

From LER:
Tibial stress fractures: an evidence-based approach

NewsBot · Jan 8, 2016

Four biomechanical and anthropometric measures predict tibial stress fracture: a prospective study of 1065 Royal Marines
Michael Nunns, Carol House, Hannah Rice, Mohammod Mostazir, Trish Davey, Victoria Stiles, Joanne Fallowfield, Adrian Allsopp, Sharon Dixon
Br J Sports Med doi:10.1136/bjsports-2015-095394

Background Tibial stress fractures (TSFs) cause a significant burden to Royal Marines recruits. No prospective running gait analyses have previously been performed in military settings.

Aim We aimed to identify biomechanical gait factors and anthropometric variables associated with increased risk of TSF.

Methods 1065 Royal Marines recruits were assessed in week 2 of training. Bilateral plantar pressure and three-dimensional lower limb kinematics were obtained for barefoot running at 3.6 m/s, providing dynamic arch index, peak heel pressure and lower limb joint angles. Age, bimalleolar breadth, calf girth, passive hip internal/external range of motion and body mass index (BMI) were also recorded. 10 recruits who sustained a TSF during training were compared with 120 recruits who completed training injury-free using a binary logistic regression model to identify injury risk factors.

Results 4 variables significantly (p<0.05) predicted increased risk of TSF (ORs and 95% CI): smaller bimalleolar width (0.73, 0.58 to 0.93), lower BMI (0.56, 0.33 to 0.95), greater peak heel pressure (1.25, 1.07 to 1.46) and lower range of tibial rotation (0.78, 0.63 to 0.96).

Summary Reduced impact attenuation and ability to withstand load were implicated in tibial stress fracture risk.
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NewsBot · Feb 9, 2016

PUBLIC RELEASE: 9-FEB-2016
Link between stress fracture injuries and genes found
UNIVERSITY OF LIVERPOOL

In a paper published in The Official Journal of the International Purine Club University of Liverpool researchers have successfully identified how certain genes can contribute towards a person's susceptibility to stress fracture injuries. This research provides a platform for further research into providing a personalised health approach to this common sports injury.

A stress fracture is a fatigue-induced fracture of the bone caused by repeated pressure over time. Unlike normal fractures, stress fractures are the result of accumulated trauma from repeated mechanical usage, such as running or jumping. As such, stress fractures are common injuries for athletes and military personnel. The effect of heavy repeated mechanical usage causes an amalgamation of micro-damage in bone. The body responds to this through a process known as 'bone remodelling', in which damaged bone is removed and healthy bone is deposited. Bone remodelling occurs continuously through our lives and helps us keep our bones healthy.

Derby Professor of Anatomy and Cell Biology Jim Gallagher and his team at the University's Institute of Ageing and Chronic Disease aimed to identify the contribution a specific gene had to stress fracture injuries in two groups of volunteers made up of military recruits and elite athletes. The researchers evaluated the contribution the specific gene, P2X7R, had on the volunteers. In the past they showed that mutations in this gene are associated with low lumbar spine bone mineral density and accelerated bone loss in post-menopausal women.

New research area

Professor Jim Gallagher said: "The genetic predisposition to develop a stress fracture is still a relatively new research area and our understanding of the risks that predispose individuals to develop a stress fracture is still very limited.

"The study found that two specific variations within the gene were associated with stress fracture injuries in healthy, exercising individuals. The precise mechanism by which these variations may influence stress fracture risk is unknown but may include decreased sensitivity of bone to mechanical loading or adverse changes to specific bone cells.

"The findings are the first to demonstrate an independent association between stress fracture injury and specific variations in purinergic receptor genes. This work builds on pioneering basic laboratory research over several years in which we first showed that purinergic receptors are expressed in bone cells and that they regulate the response of bone to mechanical loading.

"Further work with a larger sample group is needed to explain the mechanisms at work and to help us develop preventative measures and more suitable personalised treatments.
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NewsBot · Feb 9, 2016

Functional polymorphisms in the P2X7 receptor gene are associated with stress fracture injury
Ian Varley, Julie P. Greeves , Craig Sale, Eitan Friedman, Daniel S. Moran, Ran Yanovich, Peter J. Wilson, Alison Gartland, David C. Hughes and 4 more
Purinergic Signalling; pp 1-11; 29 January 2016

Military recruits and elite athletes are susceptible to stress fracture injuries. Genetic predisposition has been postulated to have a role in their development. The P2X7 receptor (P2X7R) gene, a key regulator of bone remodelling, is a genetic candidate that may contribute to stress fracture predisposition. The aim of this study is to evaluate the putative contribution of P2X7R to stress fracture injury in two separate cohorts, military personnel and elite athletes. In 210 Israeli Defense Forces (IDF) military conscripts, stress fracture injury was diagnosed (n = 43) based on symptoms and a positive bone scan. In a separate cohort of 518 elite athletes, self-reported medical imaging scan-certified stress fracture injuries were recorded (n = 125). Non-stress fracture controls were identified from these cohorts who had a normal bone scan or no history or symptoms of stress fracture injury. Study participants were genotyped for functional SNPs within the P2X7R gene using proprietary fluorescence-based competitive allele-specific PCR assay. Pearson’s chi-squared (χ 2) tests, corrected for multiple comparisons, were used to assess associations in genotype frequencies. The variant allele of P2X7R SNP rs3751143 (Glu496Ala—loss of function) was associated with stress fracture injury, whilst the variant allele of rs1718119 (Ala348Thr—gain of function) was associated with a reduced occurrence of stress fracture injury in military conscripts (P < 0.05). The association of the variant allele of rs3751143 with stress fractures was replicated in elite athletes (P < 0.05), whereas the variant allele of rs1718119 was also associated with reduced multiple stress fracture cases in elite athletes (P < 0.05). The association between independent P2X7R polymorphisms with stress fracture prevalence supports the role of a genetic predisposition in the development of stress fracture injury.
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NewsBot · Feb 24, 2016

Immediate effects of modified landing pattern on a probabilistic tibial stress fracture model in runners
T.L. Chen, W.W. An, Z.Y.S. Chan, I.P.H. Au, Z.H. Zhang, R.T.H. Cheung
Clinical Biomechanics; Article in Press

Highlights
•Heelstrikers experience lower impact loading after landing pattern switch.
•Longitudinal ankle joint contact force is increased when heelstrikers land with forefoot.
•Immediate landing pattern switch does not change peak tibial strains.
•Immediate landing pattern switch does not lower the risk of tibial stress fracture.
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Background
Tibial stress fracture is a common injury in runners. This condition has been associated with increased impact loading. Since vertical loading rates are related to the landing pattern, many heelstrike runners attempt to modify their footfalls for a lower risk of tibial stress fracture. Such effect of modified landing pattern remains unknown. This study examined the immediate effects of landing pattern modification on the probability of tibial stress fracture.

Methods
Fourteen experienced heelstrike runners ran on an instrumented treadmill and they were given augmented feedback for landing pattern switch. We measured their running kinematics and kinetics during different landing patterns. Ankle joint contact force and peak tibial strains were estimated using computational models. We used an established mathematical model to determine the effect of landing pattern on stress fracture probability.

Findings
Heelstrike runners experienced greater impact loading immediately after landing pattern switch (P < 0.004). There was an increase in the longitudinal ankle joint contact force when they landed with forefoot (P = 0.003). However, there was no significant difference in both peak tibial strains and the risk of tibial stress fracture in runners with different landing patterns (P > 0.986).

Interpretation
Immediate transitioning of the landing pattern in heelstrike runners may not offer timely protection against tibial stress fracture, despite a reduction of impact loading. Long term effects of landing pattern switch remains unknown.
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NewsBot · Dec 4, 2020

Medial tibial stress fracture diagnosis and treatment guidelines
Charles Milgrom et al
Source

Objectives
To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol.
Design
Prospective cohort study.
Methods
429 elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis.
Results
31 out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p = 0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10 cm in length. Tibial pain scores were not predictive of stress fracture.
Conclusions
This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.
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NewsBot · Dec 17, 2023

Effects of Running in Minimal, Maximal and Conventional Footwear on Tibial Stress Fracture Probability: An Examination Using Finite Element and Probabilistic Analyses
Jonathan Sinclair and Paul John Taylor
Computation 2023, 11(12), 248; https://doi.org/10.3390/computation11120248

This study examined the effects of minimal, maximal and conventional running footwear on tibial strains and stress fracture probability using finite element and probabilistic analyses. The current investigation examined fifteen males running in three footwear conditions (minimal, maximal and conventional). Kinematic data were collected during overground running at 4.0 m/s using an eight-camera motion-capture system and ground reaction forces using a force plate. Tibial strains were quantified using finite element modelling and stress fracture probability calculated via probabilistic modelling over 100 days of running. Ninetieth percentile tibial strains were significantly greater in minimal (4681.13 με) (p < 0.001) and conventional (4498.84 με) (p = 0.007) footwear compared to maximal (4069.65 με). Furthermore, tibial stress fracture probability was significantly greater in minimal footwear (0.22) (p = 0.047) compared to maximal (0.15). The observations from this investigation show that compared to minimal footwear, maximal running shoes appear to be effective in attenuating runners’ likelihood of developing a tibial stress fracture.
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