Fundamental differences in axial and appendicular bone density in stress fractured and uninjured Royal Marine recruits — A matched case–control study

Davey, T. F.; Lanham-New, Susan A; Shaw, A. M.; Cobley, R.; Allsopp, Adrian; Hajjawi, Mark; Arnett, Timothy R.; Taylor, P; Cooper, Cyrus; Fallowfield, Joanne L.

doi:10.1016/j.bone.2014.12.018

Cited by 33 publications

(29 citation statements)

References 37 publications

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“…However, this is not the case in individuals who begin training with a narrower tibial diaphysis, as indicated by lower CSA at the 38% site in our participants suffering tibial injury and in stress fracture cases of Royal Marine trainees [63]. The 38% site corresponds to the narrowest point of the tibial shaft (Table 1) [51] with lowest lateral bending strength [61] and high compressive and tensile stresses experienced during human locomotion [47].…”

Section: Discussionmentioning

confidence: 74%

Increased density and periosteal expansion of the tibia in young adult men following short-term arduous training

Izard¹,

Fraser

Negus³

et al. 2016

Bone

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2 AbstractPurpose: Few human studies have reported early structural adaptations of bone to weightbearing exercise, which provide a greater contribution to improved bone strength than increased density. This prospective study examined site-and regional-specific adaptations of the tibia during arduous training in a cohort of male military (infantry) recruits to better understand how bone responds in vivo to mechanical loading.Methods: Tibial bone density and geometry were measured in 90 British Army male recruits (ages 21 + 3 y, height 1.78 ± 0.06 m, body mass 73.9 + 9.8 kg) in weeks 1 (Baseline) and 10 of initial military training. Scans were performed at the 4%, 14%, 38% and 66% sites, measured from the distal end plate, using pQCT (XCT2000L, Stratec Pforzheim, Germany).Customised software (BAMPack, L-3 ATI) was used to examine whole bone cross-section and regional sectors. T-tests determined significant differences between time points (P<0.05).Results: Bone density of trabecular and cortical compartments increased significantly at all measured sites. Bone geometry (cortical area and thickness) and bone strength (i, MM i and BSI) at the diaphyseal sites (38 and 66%) were also significantly higher in week 10. Regional changes in density and geometry were largely observed in the anterior, medial-anterior and anterior-posterior sectors. Calf muscle density and area (66% site) increased significantly at week 10 (P<0.01). Conclusions:In vivo mechanical loading improves bone strength of the human tibia by increased density and periosteal expansion, which varies by site and region of the bone.These changes may occur in response to the nature and distribution of forces originating from bending, torsional and shear stresses of military training. These improvements are observed early in training when the osteogenic stimulus is sufficient, which may be close to the fracture threshold in some individuals.3

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Section: Discussionmentioning

confidence: 74%

Increased density and periosteal expansion of the tibia in young adult men following short-term arduous training

Izard¹,

Fraser

Negus³

et al. 2016

Bone

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“…Thus, the reasons for disparities in stress fracture risk by race/ethnic origin are incompletely understood but may, in part, be explained by differences in bone mass, microarchitecture, and strength. Low areal bone mineral density (aBMD), tibial trabecular volumetric BMD (vBMD), and cortical area are associated with increased stress fracture risk among military personnel . Consistent with their lower risk of stress fracture, studies have routinely demonstrated higher BMD and more favorable bone microarchitecture among black individuals .…”

Section: Discussionmentioning

confidence: 99%

Risk of Stress Fracture Varies by Race/Ethnic Origin in a Cohort Study of 1.3 Million US Army Soldiers

Bulathsinhala

Hughes

McKinnon

et al. 2017

Journal of Bone and Mineral Research

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Stress fractures (SF) are common and costly injuries in military personnel. Risk for SF has been shown to vary with race/ethnicity. Previous studies report increased SF risk in white and Hispanic Soldiers compared with black Soldiers. However, these studies did not account for the large ethnic diversity in the US military. We aimed to identify differences in SF risk among racial/ethnic groups within the US Army. A retrospective cohort study was conducted using data from the Total Army Injury and Health Outcomes Database from 2001 until 2011. SF diagnoses were identified from ICD-9 codes. We used Cox-proportional hazard models to calculate time to SF by racial/ethnic group after adjusting for age, education, and body mass index. We performed a sex-stratified analysis to determine whether the ethnic variation in SF risk depends on sex. We identified 21,549 SF cases in 1,299,332 Soldiers (more than 5,228,525 person-years of risk), revealing an overall incidence rate of 4.12 per 1000 person-years (7.47 and 2.05 per 1000 person-years in women and men, respectively). Using non-Hispanic blacks as the referent group, non-Hispanic white women had the highest risk of SF, with a 92% higher risk of SF than non-Hispanic black women (1.92 [1.81-2.03]), followed by American Indian/Native Alaskan women (1.72 [1.44-1.79]), Hispanic women (1.65 [1.53-1.79]), and Asian women (1.32 [1.16-1.49]). Similarly, non-Hispanic white men had the highest risk of SF, with a 59% higher risk of SF than non-Hispanic black men (1.59 [1.50-1.68]), followed by Hispanic men (1.19 [1.10-1.29]). When examining the total US Army population, we found substantial differences in the risk of stress fracture among racial/ethnic groups, with non-Hispanic white Soldiers at greatest risk and Hispanic, American Indian/Native Alaskan, and Asian Soldiers at an intermediate risk. Additional studies are needed to determine the factors underlying these race- and ethnic-related differences in stress fracture risk. © 2017 American Society for Bone and Mineral Research.

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“…Recruits at greater risk may have already sustained an injury prior to week-21, when the protocol activity for this study took place, and as such would have been excluded from the study. However, stress fractures tend to occur later throughout the Royal Marine training programme than other military training programmes (Davey et al 2015), thus the volunteer recruits likely provided a useful representation.…”

Section: Rice Et Al Published In Ergonomics 27 July 2016mentioning

confidence: 99%

“…Royal Marine recruits (United Kingdom) have a high rate of lower limb stress fracture, with the tibia and metatarsals the most commonly fractured sites (Davey et al 2015). Mechanisms by which load carriage activities may increase the risk of lower limb stress fracture are unclear.…”

Section: Introductionmentioning

confidence: 99%

Influence of a 12.8-km military load carriage activity on lower limb gait mechanics and muscle activity

Rice

Fallowfield²,

Allsopp³

et al. 2016

Ergonomics

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The high stress fracture occurrence in military populations has been associated with frequent load carriage activities. This study aimed to assess the influence of load carriage and of completing a load carriage training activity on gait characteristics. Practitioner Summary:This study identified gait changes due to load carriage and after a military load carriage training activity. Such activities are associated with lower limb stress fractures. A prepost study design was used. Gait mechanics changed to a greater extent when carrying load, than after completion of the activity when assessed without load.

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Fundamental differences in axial and appendicular bone density in stress fractured and uninjured Royal Marine recruits — A matched case–control study

Cited by 33 publications

References 37 publications

Increased density and periosteal expansion of the tibia in young adult men following short-term arduous training

Increased density and periosteal expansion of the tibia in young adult men following short-term arduous training

Risk of Stress Fracture Varies by Race/Ethnic Origin in a Cohort Study of 1.3 Million US Army Soldiers

Influence of a 12.8-km military load carriage activity on lower limb gait mechanics and muscle activity

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