Activity levels as a risk factor to lower limb stress fractures
Date First Published:
July 13, 2015
Last Updated:
July 13, 2015
Report by:
Alexander Bulcock, Medical Student (University of Manchester)
Search checked by:
Alexander Bulcock, University of Manchester
Three-Part Question:
In [patients with below knee bony pain] are [current levels of activity or previous levels of
activity] a [greater risk factor for lower limb stress fractures]
Clinical Scenario:
A 24 year old female presents to the emergency department with atraumatic bony pain in her left foot. She tells you that she is a keen runner and is in the process of training for a marathon. You wonder if her previous activity levels or current increase in activity are a greater risk factor for a stress fracture.
Search Strategy:
Ovid MEDLINE(R) 1946 to July Week 1 2015
Search Details:
(exp Tibia/ OR exp Fibula/ OR lower limb.mp. OR exp Lower extremity/ OR exp Foot/ OR exp Foot Bones/) AND (exp Fractures, Stress/ OR exp Athletics Injuries/ OR fatigue fracture.mp. OR stress syndrome.mp. ) AND (exp Exercise/ OR exp Physical Fitness/ OR physical activity.mp.) AND (exp Risk Factors/) Limit (English language AND humans AND all adults (19 plus))
Outcome:
24 Hits and 11 Relevancies
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Previous injuries and some training characteristics predict running-related injuries in recreational runners: a prospective cohort study. Hespanhol Junior LC 2013 Brazil | 200 Recreational runners | Prospective cohort study to determine two factors, What is the incidence of running related injuries and what factors contribute towards this. | Level of activity relevant risk factor | Minimal impact 1.01 probability | Low follow up levels Only 12 weeks of review Simple methodology. |
| High impact training | 1.46 probability of stress fracture | ||||
| Risk factors and prognostic indicators for medial tibial stress syndrome. Moen MH 2012 Netherlands | 35 Dutch Male military recruits | Case-control study to assess risk factors for MTSS and prognostic factors | Risk factor for stress fracture | BMI significant risk | Poor description of methodology Small population group Assessed MTSS not stress fractures Aimed to assess risk factors but very specific measurements/only measured physical internal risk factors not external risk factors. No intervention |
| Training habits and injuries of masters' level football players: a preliminary report. Newsham-West R 2009 New Zealand | 199 masters level football players ages 40-49 years | Descriptive cross-sectional study in order to profile training habits and related injuries in football players | Activity acted as a risk factor | 1-4 hours of training per week risk factor | Not related to running Didn’t define what the injuries were Didn’t have a follow up Poor methodology |
| Number of lower limb stress fractures | 64 injuries/100 players 67.3% occurred during games | ||||
| Contributing factors to medial tibial stress syndrome: a prospective investigation. Hubbard TJ 2009 USA | 146 healthy collegiate athletes | Descriptive cross-sectional study to assess risk factors for MTSS | Activity levels relevant risk factor | Control = 8.8 years/ 26.5 miles per week MTSS = 5.3 years/ 27.1 miles per week | Focused on intrinsic factors not extrinsic factors in methodology yet mentioned in results No focus on athletics activity Poor follow up |
| Risk factors for lower extremity injuries among male marathon runners Marienke Van Middelkoop 2008 Netherlands | 1500 recreational runners 694 responded to questionnaire |
Questionnaire based descriptive cross-sectional study to identify risk factors for lower extremity injuries in runners | Activity levels relevant risk factor | Running less than 40km per week was protective >60 km per week = 21.3% Number of races participated in 0-3 = 0.39 p-value/ >11 = 0.08 p-value | Large study design may limit specifics of study |
| Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review Bobbie RN van Gent 2009 Netherlands | Review article | To present an overview of published reports describing the incidence of various running injuries of the lower extremities | Activity levels relevant risk factor | Training frequency was a significant risk factor of overall injury RR=3.68 Increase of training of 1d/w also had OR = 1.19 Distance had an increased risk of lower limb injuries between OR= 1.6- 7.4 | No clear focus aims of study Looked at overall injuries not specific injuries and did not clarify these |
| Kinetic asymmetry in female runners with and without retrospective tibial stress fractures Rebecca Avrin Zifchock 2006 USA | 49 Runners 25 control and 24 who had injuries |
Controlled Trial with 3 aims 1. To compare kinetic symmetry in healthy runners 2. compare kinetic SI values between runners who have 1 injury 3. Compare affected to unaffected leg kinetic values |
Activity levels relevant risk factor | 104 monthly miles in control group 115 monthly miles in group with Tibial Stress Fracture Speed relevant 3.7m/s in control group 3.8m/s in TSF group | Running not relevant to subject aims |
| Predictors of Stress Fracture Susceptibility in Young Female Recruits Richard A. Shaffer 2006 USA | 2962 female Marine Corps recruits | Cohort Study to identify risk factors for stress fractures at boot camps. | Activity levels relevant risk factor | Low aerobic fitness and no menses in past year significantly increased risk factors Slowest time AOR = 3.54% | Didn’t explain times of aerobic fitness Not accurate measurements |
| Evaluation of lower extremity overuse injury potential in runners ALAN Hreljac 2000 USA | 40 runners- 16 female and 24 male divided into 2 groups |
Cohort study to identify biomechanical and anthropometric variables that contribute to overuse injuries in runners | Risk factor for stress fracture | Biomechanical factors more significant than external factors | Small population size Not much follow up |
| Activity levels relevant risk factor | No | ||||
| The effect of leg strength on the incidence of lower extremity overuse injuries during military training Jay R Hoffman 1999 Israel | 136 male military recruits | Cohort study to examine the effects of pre-induction strength and fitness levels on the incidence of lower extremity overuse injuries | Activity levels relevant risk factor | 58.8% participated in no physical conditioning prior to training in this group 11% received stress fractures Compared with the physical active group only 7% suffered stress fractures Those who had competitive sports background suffered no fractures | Unable to access tables of data Good study design Poor follow up Relatively small sample size No clear definition of aerobic fitness |
| Stress fractures in female army recruits: implications of bone density, calcium intake, and exercise Alana D Cline 1998 USA | 127 female soldiers: 78 control/ 49 confirmed stress fracture |
Case control study to identify characteristic and factors associated with increased risk for stress fractures in military women | Activity levels relevant risk factor | Leisure activity energy expenditure (kcal/day) tended toward association with lower stress fracture risk as expenditure level increased (p=0.06) | Full text not available Self-reporting may not be accurate |
Author Commentary:
10 Studies discussed the link between exercise and an increased risk of lower limb stress fractures
Of these 10
2 stated that exercise activity was of no or little statistical significance
4 suggested that increased exercise was protective
4 suggested that consistent low levels of exercise were protective
All suggested that acute short term increases in exercise were likely to increase risk
All suggested that previous injury to the lower limb was a significant risk factor
2 studies suggested that BMI was the current most dangerous risk factor.
Of these 10
2 stated that exercise activity was of no or little statistical significance
4 suggested that increased exercise was protective
4 suggested that consistent low levels of exercise were protective
All suggested that acute short term increases in exercise were likely to increase risk
All suggested that previous injury to the lower limb was a significant risk factor
2 studies suggested that BMI was the current most dangerous risk factor.
Bottom Line:
Acute episodes of increased activity, such as training for upcoming races or major competitions produce the most significant risk factor for potential lower limb stress fractures.
References:
- Hespanhol Junior LC. Previous injuries and some training characteristics predict running-related injuries in recreational runners: a prospective cohort study.
- Moen MH. Risk factors and prognostic indicators for medial tibial stress syndrome.
- Newsham-West R. Training habits and injuries of masters' level football players: a preliminary report.
- Hubbard TJ. Contributing factors to medial tibial stress syndrome: a prospective investigation.
- Marienke Van Middelkoop. Risk factors for lower extremity injuries among male marathon runners
- Bobbie RN van Gent. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review
- Rebecca Avrin Zifchock. Kinetic asymmetry in female runners with and without retrospective tibial stress fractures
- Richard A. Shaffer. Predictors of Stress Fracture Susceptibility in Young Female Recruits
- ALAN Hreljac. Evaluation of lower extremity overuse injury potential in runners
- Jay R Hoffman. The effect of leg strength on the incidence of lower extremity overuse injuries during military training
- Alana D Cline. Stress fractures in female army recruits: implications of bone density, calcium intake, and exercise