Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries

Abstract

BackgroundLower 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/purposesWe 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?MethodsWe 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 st...

CORR Insights®: Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries

“…In an article in this month’s Clinical Orthopaedics and Related Research , Griffis et al [3] reported on the prevalence and added costs of stress fractures in correlation with a deficiency in vitamin D among United States Navy recruits. Their study found that a substantial proportion of stress fractures among these recruits correlated with low vitamin D levels, and this proportion was associated with greater direct and indirect costs.…”

“…Unfortunately, in preventing and treating osteoporosis and fragility fractures, the clinically beneficial and low-cost effects of vitamin D supplementation pale compared with those of widely advertised and more expensive medications, such as bisphosphonates. Fortunately, analyses with specific attention to bone health are offering perspectives and strategies to improve overall healthcare quality and rein in attendant costs [1, 3].…”

“…More broadly, the interplay between prevention and mitigation of poor bone health is complicated, and healthcare policy should seek to maximize quality and minimize costs. Griffis et al [3] highlighted the low costs of vitamin D compared with the considerable costs of treatment. Unfortunately, in preventing and treating osteoporosis and fragility fractures, the clinically beneficial and low-cost effects of vitamin D supplementation pale compared with those of widely advertised and more expensive medications, such as bisphosphonates.…”

“…Focused studies like the one by Griffis et al [3] and others that assess specific, achievable endpoints can give us some practical direction for everyday patient care. Because the peak bone mass typically occurs in people who are in their 20s and 30s, targeting younger patients in order to supplement their vitamin D intake may more substantially improve bone health, with potentially longer-lasting effects into later adulthood.…”