Identifying Factors That Contribute to Adolescent Bony Stress Injury in Secondary School Athletes: A Comparative Analysis With a Healthy Athletic Control Group

Abstract

Background:Bony stress injuries (BSIs) are common among adolescents involved in high school sports. A better understanding of factors that contribute to adolescent BSI is needed to target preventative measures.Hypothesis:Individuals who suffer a BSI will demonstrate significant differences in training methods, sleep, diet, and history of injury compared with a healthy, noninjured control group.Study Design:Descriptive epidemiologic study.Methods:Data from the National High School Stress Fracture Registry (NHSSFR), an internet-based adolescent BSI survey, were used to identify variables reported with adolescent (13-18 years of age) BSI. These findings were compared with a survey of 100 (50 males, 50 females) healthy athletic controls to identify significant differences between healthy adolescents and those with BSI.Results:A total of 346 stress fractures were reported in 314 (206 females, 108 males) athletes within the NHSSFR. Comparison with healthy control participants demonstrated multiple significant findings. In particular, body mass index was significantly lower for patients with BSI injury compared with controls ( P < 0.001). Patients slept significantly less than the control group (7.2 vs 7.95 hours; F = 34.41; P < 0.001). Females also slept significantly less hours than males (7.2 vs 7.63 hours; F = 11.02; P < 0.001). Fifty-eight percent of those who reported a BSI did not engage in any weight training. Those with a BSI had significantly higher average stress ratings than control participants (1.67 vs 1.42; P < 0.001), and females also rated their stress levels significantly higher than males (1.8 vs 1.38; P < 0.001). A significant difference between patients with any BSI and control participants existed for history of “shin splints” (Pearson χ2= 28.31; P < 0.001), and females also expressed having shin pain lasting for longer than 4 weeks (Pearson χ2= 8.12; P < 0.001) and more often (Pearson χ2= 5.84; P = 0.02) than males. There was also a significant difference between patients with BSI and control subjects regarding dairy intake (2.25 vs 2.69; F = 6.43; P = 0.01).Conclusion:Findings revealed significant differences between those who reported a BSI relative to healthy athletic adolescents. These differences included body mass index, prior history of shin splints, involvement in weight training, amount of sleep, daily stress, and dairy intake. Preventive measures should be developed to address these areas to reduce the incidence of BSIs in the adolescent population.

Risk Factors, Diagnosis and Management of Bone Stress Injuries in Adolescent Athletes: A Narrative Review

“…Longitudinal studies investigating high school athletes report that the preponderance of stress fractures (63%) occur in girls and that female athletes experience higher grades of stress fracture than males [ 16 , 50 , 75 ]. A higher incidence of female BSI than male is prevalent across a wide variety of sports at the high school and collegiate levels [ 15 , 16 ].…”

“…Disturbed sleep patterns in the adolescent athlete due to training commitments, social habits, academic requirements and use of technological devices affect physiological recovery and thus may predispose to injury [ 102 ]; however, self-reported sleep and stress levels appear to be better in elite athletes than age- and sex-matched non-athletes [ 103 ]. However, general psychological stress and poor sleep was associated with BSI in adolescent girls [ 75 ] and adolescents who have less than eight hours of sleep per night over an extended period are more likely to experience general injury [ 104 ]. A large-scale military study found that introducing a minimum sleep regimen (6 h) reduced incidence of stress fractures in new Israeli recruits (minimum age 18) from 31% to 11% [ 105 ].…”

“…Others have observed positive changes to BMD over longer training periods (9–15 months) of jumping and resistance exercise [ 161 , 162 , 163 , 164 , 165 ]. Additional benefits of ongoing resistance training over multiple years or sporting seasons have not been explicitly investigated, yet it has been observed that 58% of high school athletes who sustained BSI over a two-year period did not partake in weight training, which may suggest a protective effect [ 75 ]. Results from a study of the Brazilian martial art Capoeira plus jumping in pre-pubertal children revealed a positive effect on BMD, and one year after withdrawal those differences between exercising and non-exercising groups remained [ 166 , 167 ].…”

“…Long term, this form of calcium depletion will reduce bone mass and strength, therefore ensuring adequate dietary calcium is an intuitive strategy to prevent BSI. The efficacy of calcium and vitamin D intake and supplementation to reduce BSI is has not been established beyond observation studies that have determined associations rather than causation [ 18 , 75 ].…”

Training Load Capacity, Cumulative Risk, and Bone Stress Injuries: A Narrative Review of a Holistic Approach

“…In a study of 95 endurance sport athletes who self-reported their sleep time over a 2-week period, those who slept <7 h/day were at a 51% increased risk of new injury, whereas athletes who slept >7 h/day reduced new injury risk by 37% (Johnston et al, 2020). Specific to BSI, in a population of 314 adolescent high school athletes who experienced 346 BSIs over a 2-year period, those with BSI reported sleeping less than those without a BSI (7.2 vs. 7.95 h/day) (Nussbaum et al, 2019). Figure 1, reprinted from Swanson et al (2018) with permission, demonstrates the complex, yet important, intersection between sleep and bone health.…”