Search

To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol.Prospective cohort study.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, tenderness1/3 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.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 ≤10cm in length. Tibial pain scores were not predictive of stress fracture.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.

Background: Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study’s purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers. Methods: We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year. Results: Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa ( P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s ( P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics. Conclusion: This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence. Level of Evidence: Level III, retrospective case series of prospectively collected data.

There is a known variance in the incidence and anatomical site of tibial stress fractures among infantry recruits and athletes who train according to established uniform training programs. To better understand the biomechanical basis for this variance, we conducted in vivo axial strain measurements using instrumented bone staples affixed in the medial cortex, aligned along the long axis of the tibia at the level of the mid and distal third of the bone in four male subjects. Strain measurements were made during treadmill walking, treadmill running, drop jumps from a 45 cm height onto a force plate and serial vertical jumps on a force plate. Significance levels for the main effects of location, type of activity and their interaction were determined by quasi-parametric methodologies. Compared to walking, running and vertical jumping peak axial tensile strain (με) was 1.94 (p = 0.009) and 3.92 times (p

Background The reported prevalence of spondylolysis (SL) in the adult population is 6–7%. Data concerning adolescent-onset spondylolisthesis (SLS) and the impact of certain activities on it is scarce. We examined the risk of clinical progression of SL and SLS as a function of primary severity and occupational strain among military recruits. Methods Based on the Israel defense Force (IDF) central human resources database, we identified 1521 18-year-old males inducted to the IDF with SL/SLS between the late nineteen nineties and early two-thousands. We followed changes in the SL/SLS status during the 3 years of obligatory military service. Disease severity was classified as Cat2: radiological findings of SL without clinical findings; Cat3: painful SL or asymptomatic grade 1 SLS; Cat4: grade 1 SLS with pain; Cat5: Grade 2 SLS. The soldiers were subdivided into the following occupational categories: administrative, combat, maintenance, and driving. The purpose was to compare the progression rates in different medical categories and job assignments. Results There were 162 recruits in Cat2, 961 in Cat3, and 398 recruits in Cat4. The overall progression rate to Cat5 (grade 2 SLS) was 1.02%. Significant progression rates were seen amongst administrative soldiers with a relatively higher risk of progression from Cat4 (painful-grade-1 SLS: 2.2%) vs. Cat3 (asymptomatic SLS: 0.5%, relative risk = 4.7, p Conclusion Progression of SL/SLS was highest in Cat4, i.e. for recruits already diagnosed with painful SLS (i.e. with a more severe baseline disorder). Progression did not correlate with military occupation. We recommend further follow-up studies that include, aside from progression rates, incidence rates of newly diagnosed grade 2 SL during military service.

PURPOSE OF REVIEW: Tendinopathy describes a combination of pain, swelling, and impaired performance of the tendon and around structures. There are various treatment options for tendinopathy with unclear efficacy. Dry needling involves inserting needles into the affected tendon, and it is thought to disrupt the chronic degenerative process and encourage localized bleeding and fibroblastic proliferation. The purpose of this review is to review the use of dry needling as a treatment modality for tendinopathy. RECENT FINDINGS: The effectiveness of dry needling for treatment of tendinopathy has been evaluated in 3 systematic reviews, 7 randomized controlled trials, and 6 cohort studies. The following sites were studied: wrist common extensor origin, patellar tendon, rotator cuff, and tendons around the greater trochanter. There is considerable heterogeneity of the needling techniques, and the studies were inconsistent about the therapy used after the procedure. Most systematic reviews and randomized controlled trials support the effectiveness of tendon needling. There was a statistically significant improvement in the patient-reported symptoms in most studies. Some studies reported an objective improvement assessed by ultrasound. Two studies reported complications. SUMMARY: Current research provides initial support for the efficacy of dry needling for tendinopathy treatment. It seems that tendon needling is minimally invasive, safe, and inexpensive, carries a low risk, and represents a promising area of future research. In further high-quality studies, tendon dry needling should be used as an active intervention and compared with appropriate sham interventions. Studies that compare the different protocols of tendon dry needling are also needed.

Background Tibial stress fractures in military recruits occur beginning with the fourth week of training. In and ex vivo tibial strain experiments indicate that the repetitive mechanical loading during this time may not alone be sufficient to cause stress fracture. This has led to the hypothesis that the development of tibial stress fracture is mediated by the bone remodeling response to high repetitive strains. This study assesses the differences in the strain and angle of the principal strain during military field activities versus common civilian activities. Methods In vivo strain measurements were made from a rosette strain gauge bonded to the midshaft of the medial tibia. Measurements of principal strains and their angles were made while performing level and inclined walking and running on an asphalt surface, while fast walking up and down stairs, while performing a standing vertical jump and while zig-zag running up and down a 30° inclined dirt hill. Findings The angle of the principal strain varied little (5.40° to +2.74°) during activities performed on engineered surfaces. During zig-zag running on a dirt hill the strain levels were higher (maximum shear = 4290 μe). At the pivot points of zig-zag running the angle of the principal strain varied between −115° to −123° downhill and between −32.8° to −51° uphill. Interpretation Activities that mimic those performed by infantry recruits on irregular hilly surfaces result in higher tibial strains and have more variation in principal strain angles than activities of ordinary civilian life performed on engineered surfaces.

Background: Foot ulcers carry considerable morbidity in patients with peripheral neuropathy and frequently lead to foot amputation. The purpose of this study was to present our experience treating recalcitrant ulcers underlying the hallux interphalangeal joint in patients with diabetes mellitus (DM)–related neuropathy with a first metatarsophalangeal (MTPJ1) resection arthroplasty. Methods: We retrospectively reviewed the computerized medical files of patients with diabetic neuropathy treated with a MTPJ1 resection arthroplasty. We performed 28 arthroplasties on 20 patients with a mean age of 59 years. The patients had a diagnosis of DM for a mean of 10.7 years. Of the ulcers, 26 were grade 1A ulcers, and 2 were grade 2A ulcers (University of Texas score); the ulcer’s mean age was 5.4 months. The mean dorsiflexion of the hallux before surgery was 46 degrees. Results: The primary ulcer recovered in a mean of 3.1 weeks. Major complications (wound dehiscence and infection) occurred in 6 of 28 operations. Patients returned to normal activity 4 weeks after all procedures except in the 6 patients with dehiscence. In a subgroup of patients with follow-up longer than a year, the ulcer recurred after 4 of 18 arthroplasties (22%) between 3 and 12 months due to postoperative hallux rigidus. In the remaining 14 of 18 arthroplasties (78%), there was no recurrence during a mean follow-up of 26 months. Conclusion: MTPJ1 resection arthroplasty may be considered in a patient with resistant plantar hallux ulcerations, even in the absence of hallux rigidus. As with all operations on neuropathic feet in patients with DM, the surgeon and the patient should be aware that there is a significant likelihood of complications, but most are treatable. Level of Evidence: Level IV, case series.

Diabetic foot ulcers are frequently related to elevated pressure under a bony prominence. Conservative treatment includes offloading with orthopaedic shoes and custom made orthotics or plaster casts. While casting in plaster is usually effective in achieving primary closure of foot ulcers, recurrence rates are high. Minimally invasive surgical offloading that includes correction of foot deformities has good short and long term results. The surgery alleviates the pressure under the bony prominence, thus enabling prompt ulcer healing, negating the patient’s dependence on expensive shoes and orthotics, with a lower chance of recurrence. The purpose of this protocol is to compare offloading surgery (percutaneous flexor tenotomy, mini-invasive floating metatarsal osteotomy or Keller arthroplasty) to non-surgical treatment for patients with diabetic foot ulcers in a semi-crossover designed RCT. One hundred patients with diabetic neuropathy related foot ulcers (tip of toe ulcers, ulcers under metatarsal heads and ulcers under the hallux interphalangeal joint) will be randomized (2:3) to a surgical offloading procedure or best available non-surgical treatment. Group 1 (surgery) will have surgery within 1 week. Group 2 (controls) will be prescribed an offloading cast applied for up to 12 weeks (based on clinical considerations). Following successful offloading treatment (ulcer closure with complete epithelization) patients will be prescribed orthopaedic shoes and custom made orthotics. If offloading by cast for at least 6 weeks fails, or the ulcer recurs, patients will be offered surgical offloading. Follow-up will take place till 2 years following randomization. Outcome criteria will be time to healing of the primary ulcer (complete epithelization), time to healing of surgical wound, recurrence of ulcer, time to recurrence and complications. The high recurrence rate of foot ulcers and their dire consequences justify attempts to find better solutions than the non-surgical options available at present. To promote surgery, RCT level evidence of efficacy is necessary. Israel MOH_2017–08-10_000719. NIH: NCT03414216 .

Background Episodes of low back pain (LBP) are very common among workers. A number of occupational risk factors have been shown to increase the risk for LBP. One of these risk factors is exposure to whole body vibration, which is a known characteristic in driving professions. The aim of this study was to assess the impact of driving on LBP amongst young professional drivers. Methods This is an historical-prospective cohort study based on the Israel Defense Forces (IDF) database of male soldiers drafted between the years 1997–2006. Subjects’ medical history with specific reference to LBP medical history, clinical and radiographic findings were taken as part of the recruitment process to the IDF. The study group included subjects (n = 80,599) from three occupational groups: administrative units (AU), car drivers (CD) and truck drivers (TD) that were followed for 3 years. The incidence and recrudescence rates of LBP were calculated based on standardized LBP severity tiers. Results The total incidence rate for LBP was 0.65%, 0.7% and 0.34% for AU, CD and TD respectively. In a comparison between subjects without a history of LBP (category 1) to subjects with a history of LBP without clinical findings (category 2) and subjects with a history of LBP with mild clinical / radiographic findings (category 3), the relative risk (RR) for severe LBP exacerbation was 1.4 (p

Context: Lower extremity movement patterns have been implicated as a risk factor for various knee disorders. Ankle-dorsiflexion (DF) range of motion (ROM) has previously been associated with a faulty movement pattern among healthy female participants. Objective: To determine the association between ankle DF ROM and the quality of lower extremity movement during the lateral step-down test among healthy male participants. Design: Cross-sectional study. Setting: Training facility of the Israel Defense Forces. Patients or Other Participants: Fifty-five healthy male Israeli military recruits (age = 19.7 ± 1.1 years, height = 175.4 ± 6.4 cm, mass = 72.0 ± 7.6 kg). Intervention(s): Dorsiflexion ROM was measured in weight-bearing and non–weight-bearing conditions using a fluid-filled inclinometer and a universal goniometer, respectively. Lower extremity movement pattern was assessed visually using the lateral step-down test and classified categorically as good or moderate. All measurements were performed bilaterally. Main Outcome Measure(s): Weight-bearing and non–weight-bearing DF ROM were more limited among participants with moderate quality of movement than in those with good quality of movement on the dominant side (P = .01 and P = .02 for weight-bearing and non–weight-bearing DF, respectively). Non–weight-bearing DF demonstrated a trend toward a decreased range among participants with moderate compared with participants with good quality of movement on the nondominant side (P = .03 [adjusted P = .025]). Weight-bearing DF was not different between participants with good and moderate movement patterns on the nondominant side (P = .10). Weight-bearing and non–weight-bearing ankle DF ROM correlated significantly with the quality of movement on both sides (P < .01 and P < .05 on the dominant and nondominant side, respectively). Conclusions: Ankle DF ROM was associated with quality of movement among healthy male participants. The association seemed weaker in males than in females.

Background: Whether the human Achilles tendon undergoes hypertrophic changes as measured by an increase in cross-sectional area, in response to endurance training exercise remains in question. We investigated the hypothesis that transition from civilian life through 6 months of elite infantry training would induce adaptive Achilles tendon hypertrophy. Methods: Seventy-two new elite infantry recruits had the cross-sectional area of their Achilles tendons measured at a point 2.5 cm proximal to the Achilles insertion by ultrasound before beginning elite infantry training. Measurements were repeated by the same ultrasonographer for those recruits who were still in the training program at 6 months. Prior to beginning the study the intraobserver reliability of the ultrasonographer’s Achilles tendon measurements was calculated (intraclass correlation coefficient = .96). Fifty-five recruits completed 6 months of training. Results: The mean cross-sectional area of their right Achilles tendon increased from 47.0 ± 11.2 to 50.2 ± 9.6 mm2 ( P = .037) and the left Achilles tendon from 47.2 ± 8.9 to 51.1 ± 8.3 mm2 ( P = .013). The change in cross-sectional area did not correlate with subject height, weight, prior sport history, or jumping and running abilities. Conclusions: An abrupt stimulus of 6 months of elite infantry training was adequate to induce hypertrophic changes in the Achilles tendon. This is the first human prospective study showing an increase in the Achilles tendon cross-sectional area in response to rigorous endurance type training. The finding supports the hypothesis that the Achilles tendon in response to sufficiently high and sustained loading can remodel its morphological properties and thereby strengthen itself. Level of Evidence: Level II, etiology study.

Background: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. Methods: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. Results: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). Conclusion: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. Level of Evidence: Level IV, retrospective case series.

Background: Most previous studies on hallux valgus focused on the possible relationship between this deformity and muscles and/or ligaments in the foot and lower leg. Very little is known about the relationship between hallux valgus and alignment of the proximal joints. The aims of the present study were to determine the extent to which lower extremity alignment characteristics of the hip, knee, ankle, and foot were related to the manifestation of hallux valgus and to identify variables predicting its development in women. Methods: A group of 25 women with hallux valgus and 24 control women, age 51 to 80 years, were interviewed and screened for the current study. Measurements recorded were hallux valgus angle; intermetatarsal angle; a set of body physique measures (eg, height); range of motion at the hip, knee, ankle, and foot joints; general hypermobility; lower extremity alignment (eg, tibiofemoral angle); and 9 anatomical anomalies (eg, knee valgus/varum). Results: Women with hallux valgus manifested notably higher range of motion at their joints, different lower extremity alignment, higher prevalence of general joint hypermobility, and higher prevalence of anatomical anomalies compared with controls. Estimated marginal means for most joint range of motion and lower extremity alignment measurements were notably higher for the hallux valgus group. Conclusion: Lower extremity alignment and joint range of motion were correlated with hallux valgus. Future studies could possibly identify anatomic risk factors for the development of hallux valgus, nonsurgical methods of prevention and adjunctive surgical methods of treatment. Level of Evidence: Level III, comparative case series.

Background context Back problems are reported with increasing frequency in adults and adolescents. Most information is from self-reported questionnaires or studies with small sample sizes. Reports were usually focused on specific diseases and biased toward overdiagnosis. Purpose To assess the prevalence of common back disorders among a large cohort of 17-year-old males and females recruited by the Israel Defense Forces (IDF). Study design A retrospective cross-sectional prevalence study. Patient sample Seventeen-year-old Israeli male and female military recruits reporting as directed by the IDF for preinduction medical examination between January 01, 1998 and December 31, 2006. Outcome measures Military functional limitation Grades 1 to 7 per diagnosis category. Methods Military recruits were examined and classified based on medical and orthopedic diagnoses. They were referred for orthopedic consultation as necessary. Four orthopedic classifications were used: spinal deformity (including kyphosis and scoliosis), back pain (including neck and radicular syndromes), spondylolysis/olisthesis, and limitations resulting from trauma or spinal surgery. Data were coded into a central database, and descriptive statistics are presented. Results The overall prevalence of back disorders among 828,171 17-year-old military recruits (61.5% male) was 16.8%. Back disorders resulting in significant functional limitation were diagnosed in 0.8% of recruits. The most prevalent diagnoses were spinal deformities (kyphosis and scoliosis, females 11.9%, males 11.5%) and back pain (females 3.0%, males 5.6%). Most of these diagnoses were rated as mild. Conclusions When using objective criteria, overall back disorders in a large population of 17-year-old recruits were 17%, considerably lower than most reports. Back morbidity severe enough to prevent combat duty occurred at a rate of less than 1%, suggesting that serious back morbidity is not a frequent finding in this age group. Level of evidence Symptom prevalence study, Level III.

This study aimed to measure ambulation in infantry army basic training, and to evaluate if covering more distance can explain stress fractures in a stressor-stress model. Forty-four male combat recruits (18.7 ± 0.7 years) participated in a 6-month rigorous high intensity combat training program. Baseline data included anthropometric measurements, VO(2)max, and psychological questionnaires. Actual distance covered was measured using a pedometer over an 11-week training period. Psychological questionnaires were repeated after 2 months. Sixteen recruits were diagnosed with stress fractures by imaging (SFi = 36.4%). Statistical analysis included comparing measured variables between SFi and those without stress fractures (NSF). The recruits covered 796 ± 157 km, twofold the distance planned of 378 km (P

Background: In a previous military study a custom-made tri-layer polyurethane shoe orthotic was shown to be effective in lowering the incidence of stress fractures in infantry recruits. Stress fractures are caused by repetitive high strains. Objective: To compare the effect of tri-layer polyurethane orthotics with other types of orthotics on in vivo strains at sites where stress fractures are common. Design: Subjects underwent surgical implantation of strain gauged staples to the dorsal surface of the midshaft 2nd metatarsal and to the medial surface of the midshaft tibia. Setting: University Hospital. Patients: Two male members of the research staff aged 40 and 54. Measurements: In vivo simultaneous peak-to-peak axial compression-tension strains during treadmill walking at 5 km/h while wearing standard army boots and Nike Air Max running shoes with and without either a non custom pre-fabricated orthotic with a three-quarter length thermocork module, a semirigid custom-made orthotic, with a three-quarter ...

We undertook a prospective study in 51 male patients aged between 17 and 27 years to ascertain whether immobilisation after primary traumatic anterior dislocation of the shoulder in external rotation was more effective than immobilisation in internal rotation in preventing recurrent dislocation in a physically active population. Of the 51 patients, 24 were randomised to be treated by a traditional brace in internal rotation and 27 were immobilised in external rotation of 15° to 20°. After immobilisation, the patients undertook a standard regime of physiotherapy and were then assessed clinically for evidence of instability. When reviewed at a mean of 33.4 months (24 to 48) ten from the external rotation group (37%) and ten from the internal rotation group (41.7%) had sustained a futher dislocation. There was no statistically significant difference (p = 0.74) between the groups. Our findings show that external rotation bracing may not be as effective as previously reported in preventing recurrent anterior dislocation of the shoulder.

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.

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 (microg x dL); ferritin is the iron storage level (ng x mL); and BMI is the body mass index (kg x 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. Language: en

Background context Special Forces training is even more demanding than that of elite athletes. The training includes grueling physical activity and periods of sleep deprivation. The soldiers routinely carry heavy loads up to 40% of their body weight on their backs while running and marching for distances up to 90 km. Purpose Our purpose was to find out if Special Forces recruits are able to complete the preparatory Navy Seals training program without sustaining magnetic resonance imaging (MRI) signs of overuse or irreversible injury to their backs. Study design/setting Prospective cohort study. We performed MRI scans before and after 14 weeks of Navy Seals preparatory training course. Patient sample Ten soldiers underwent MRI of their lumbar sacral spines and right knees before and after the completion of Navy Seals preparatory training. Outcome measures Physiologic measures. Lumbar sacral spine and knee MRI tests were performed before and after the training to identify changes in the spinal discs, facet joints, pars interarticularis, vertebral bodies, knee articular cartilage, ligaments, knee menisci, and the presence or absence of soft tissue and/or bone edema. Methods We investigated the difference in spine and knee pathology before and after a 14-week Navy Seals preparatory training course by using MRI criteria. The recruits participating in the study were monitored for acute and overuse injuries every 3 to 4 weeks. Results Before the training, seven out of ten spine MRI scans were normal. Two showed small L5–S1 disc bulges, one of them with concomitant Scheuermann's disease. Another soldier's MRI showed L1–L4 mild Scheuermann's disease. Follow-up MRI showed no spinal changes. Before the training, one knee had a small lateral femoral condyle cartilage lesion. Nine of ten knees had prepatellar swelling, five had increased joint fluid, and two bone edema. Follow-up magnetic resonance imaging showed improvement in the prepatellar swelling in eight soldiers, no change in one soldier, and increased knee effusion and a new medial femoral condyle bone edema in another. The lateral femoral condyle lesion remained unchanged. Conclusions According to MRI criteria, the soldiers in this study completed the 14-week training, which involved loading of their spines far beyond the levels recommended by the US National Institute for Occupational Safety and Health without sustaining irreversible damage to their spines or knees. Although the subjects' knees showed signs of overuse injury, their backs did not.

Objective: To examine whether dynamic parameters of foot pronation are risk factors for the development of stress fractures of the femur and tibia. Design: Observational prospective study. Setting: Infantry basic training course. Participants: 473 recruits evaluated for stress fractures of the femur and tibia every 2 weeks during 14 weeks of infantry basic training. The final analysis included 405 recruits. Assessment of Risk Factors: Two weeks before commencement of training, the recruits were evaluated during treadmill walking for their subtalar joint kinematics. Five independent variables were measured bilaterally: maximal pronation angle during the stance, pronation range of motion, time from heel strike to maximum pronation, pronation mean angular velocity, and time to maximum pronation as a percent of the total stance time. Main Outcome Measurements: Stress fractures of the femur and tibia. These were considered positive only when proven by imaging. Results: Ten percent of the participants were diagnosed with stress fractures of the femur and tibia. Recruits with longer duration of foot pronation had reduced odds ratio to develop this injury. Conclusions and Clinical Relevance: Longer duration of foot pronation may have a protective effect from stress fractures of the femur and tibia. This finding may promote the understanding of stress fracture pathomechanism, assist in the identification of subjects with increased risk who need augmented monitoring throughout training, and assist in future planning of impact reducing aids.

Stress fracture is a common musculoskeletal problem affecting athletes and soldiers. Repetitive high bone strains and strain rates are considered to be its etiology. The strain level necessary to cause fatigue failure of bone ex vivo is higher than the strains recorded in humans during vigorous physical activity. We hypothesized that during fatiguing exercises, bone strains may increase and reach levels exceeding those measured in the non-fatigued state. To test this hypothesis, we measured in vivo tibial strains, the maximum gastrocnemius isokinetic torque and ground reaction forces in four subjects before and after two fatiguing levels of exercise: a 2km run and a 30km desert march. Strains were measured using strain-gauged staples inserted percutaneously in the medial aspect of their mid-tibial diaphysis. There was a decrease in the peak gastrocnemius isokinetic torque of all four subjects' post-march as compared to pre-run (p=0.0001), indicating the presence of gastrocnemius muscle fatigue. Tension strains increased 26% post-run (p=0.002, 95 % confidence interval (CI) and 29% post-march (p=0.0002, 95% CI) as compared to the pre-run phase. Tension strain rates increased 13% post-run (p=0.001, 95% CI) and 11% post-march (p=0.009, 95% CI) and the compression strain rates increased 9% post-run (p=0.0004, 95% CI) and 17% post-march (p=0.0001, 95% CI). The fatigue state increases bone strains well above those recorded in rested individuals and may be a major factor in the stress fracture etiology.

Excessive foot pronation has been considered to be related to anterior knee pain. We undertook a prospective study to test the hypothesis that exertional anterior knee pain is related to the static and dynamic parameters of foot pronation. Two weeks before beginning basic training lasting for 14 weeks, 473 infantry recruits were enrolled into the study and underwent two-dimensional measurement of their subtalar joint displacement angle during walking on a treadmill. Of the 405 soldiers who finished the training 61 (15%) developed exertional anterior knee pain. No consistent association was found between the incidence of anterior knee pain and any of the parameters of foot pronation. While a statistically significant association was found between anterior knee pain and pronation velocity (left foot, p = 0.05; right foot, p = 0.007), the relationship was contradictory for the right and left foot. Our study does not support the hypothesis that anterior knee pain is related to excessive foot pronation.

Strains applied to bone can stimulate its development and adaptation. High strains and rates of strain are thought to be osteogenic, but the specific dose response relationship is not known. In vivo human strain measurements have been performed in the tibia to try to identify optimal bone strengthening exercises for this bone, but no measurements have been performed in the distal radial metaphysis, the most frequent site of osteoporotic fractures. Using a strain gauged bone staple, in vivo dorsal metaphyseal radial strains and rates of strain were measured in ten female patients during activities of daily living, standard exercises and falls on extended hands. Push-ups and falling resulted in the largest compression strains (median 1345 to 3146 με, equivalent to a 0.1345% to 0.3146% length change) and falling exercises in the largest strain rates (18 582 to 45 954 με/s). On the basis of their high strain and/or strain rates these or variations of these exercises may be appropriate for distal radial metaphyseal bone strengthening.

STUDY DESIGN Randomized controlled trial. OBJECTIVES To determine if the use of custom shoe orthoses can lessen the incidence of weight bearing-induced back pain. SUMMARY OF BACKGROUND DATA The scientific basis for the use of orthoses to prevent back pain is based principally on studies that show that shoe orthoses can attenuate the shock wave generated at heel strike. The repetitive impulsive loading that occurs because of this shock wave can cause wear of the mechanical structures of the back. Previous randomized studies showed mixed results in preventing back pain, were not blinded, and used orthoses for only short periods of time. METHODS A total of 404 eligible new infantry recruits without a history of prior back pain were randomly assigned to received either custom soft, semirigid biomechanical, or simple shoe inserts without supportive or shock absorbing qualities. Recruits were reviewed biweekly by an orthopaedist for back signs and symptoms during the course of 14 weeks of basic training RESULTS The overall incidence of back pain was 14%. By intention-to treat and per-protocol analyses, there was no statistically significant difference between the incidence of either subjective or objective back pain among the 3 treatment groups. Significantly more recruits who received soft custom orthoses finished training in their assigned orthoses (67.5%) than those who received semirigid biomechanical orthoses (45.5%) or simple shoe inserts (48.6%), P = 0.001. CONCLUSIONS The results of this study do not support the use of orthoses, either custom soft or semirigid biomechanical, as prophylactic treatment for weight bearing-induced back pain. Custom soft orthoses had a higher utilization rate than the semirigid biomechanical or simple shoe inserts. The pretraining physical fitness and sports participation of recruits were not related to the incidence of weight bearing-induced back pain.

Background: Foot orthoses are widely prescribed both to treat existing pathological conditions and to prevent overuse injuries, but little is known about the effect of their material composition and fabrication technique on patient comfort and the incidence of overuse injuries. Materials and Methods: The acceptance rates and comfort scores of soft custom, soft prefabricated, semirigid biomechanical, and semirigid prefabricated orthoses and their effect on the incidence of stress fractures, ankle sprains, and foot problems were studied in a prospective, randomized, single-blinded clinical trial among 874 infantry recruits during basic training. Results: A statistically significantly lower number of recruits given soft prefabricated orthoses (53%) finished basic training in their assigned devices than in the soft custom group (72%), in the semirigid biomechanical group (75%), and in the semirigid prefabricated group (82%) ( p = .003). For recruits who finished training in their assigned orthoses, the soft custom (3.54) and soft prefabricated (3.43) orthoses had significantly higher comfort scores than the semirigid biomechanical (3.23) and prefabricated (3.17) orthoses, ( p = .0001). There was no statistically significant difference in the incidence of stress fractures, ankle sprains, or foot problems between recruits using the different types of orthoses. Conclusions: These findings suggest that if a foot orthosis is being dispensed as prophylaxis for overuse injuries in an active, healthy population, there is little justification for prescribing semirigid biomechanical orthoses. Their cost is high compared to other types of orthoses, without an advantage in comfort or a reduction in stress fractures, ankle sprains, and foot problems.

Instrumented bone staples were first introduced as an alternative to surface-mounted strain gauges for use in human in vivo bone strain measurements because their fixation to bone is secure and requires not only minimally invasive surgery. Bench-top bone bending models have shown that the output from strain gauged bone staples compares favorably to that of traditional mounted gauges. However their within- and across-subject performance at sites typically instrumented in vivo has never been examined. This study used seven human cadaver lower extremities with an age range of 23-81 years old and a dynamic gait simulator to examine and compare axial strains in the mid tibial diaphysis and on the dorsal surface of the second metatarsal as measured simultaneously with strain gauged bone staples and with traditional surface-mounted gauges. Rosette configurations were used at the tibial site for deriving principal compression and tension, and shear strains. Axial outputs from the two gauge types demonstrated strong linear relationships for the tibia (r(2)=0.78-0.94) and the second metatarsal (r(2)=0.96-0.99), but coefficients (slopes) for the relationship were variable (range 7-20), across subjects and across sites. The apparent low reliability of strain gauged staples may be explained by the fact that both strain gauged staples and surface strain gauges are inexact to some degree, do not measure strains from exactly the same areas and strain gauged staples reflect surface strains as well as deformations within the cortex. There were no relationships for the principal tibia compression, tension or shear strain measurements derived from the two rosette gauge types, reflecting the very different anatomical areas measured by each of the constructs in this study. Strain gauged bone staples may be most useful in comparing relative axial intra-subject differences between activities, but inter-subject variability may require larger sample sizes to detect differences between populations.

In a prospective study of risk factors for Achilles tendinopathy among four induction cycles of infantry recruits, 95 out of 1405 recruits, (6.8%) were found to suffer from Achilles tendinopathy. In more than 94% of the cases, the tendinopathy was considered to be paratendinitis. Training season had a statistically significant effect on the incidence of Achilles paratendinitis with 3.6% suffering in the summer and 9.4% in the winter ( p = .001). This increased risk for Achilles paratendinitis in cold weather outdoor training can be explained by a fall in temperature of the Achilles paratenon whose membranes are rich in mucopolysaccharides and serve as a lubricant for gliding of the tendon and epitenon. Decreased temperature may increase the viscosity of the lubricant and thereby increases friction and risk for Achilles paratendinitis. This same relationship illustrates why “warming up” before exercising may be important in lowering the incidence of Achilles paratendinitis.

Repetitive high bone strain and/or strain rates, such as those that occur during running, contribute to stress fractures as well as promoting maintenance of or increase in bone mass. Kinematic differences are known to exist between overground and treadmill running and these may be reflected in different bone strains and strain rates during the two running techniques.To measure in vivo strains and strain rates in human tibia during treadmill and overground running and determine if there are significant differences in strain and strain rate levels between the two running techniques.A strain gauged bone staple was mounted percutaneously along the axial direction in the mid diaphysis of the medial tibia in three subjects, and in vivo tibial strains were measured during treadmill and overground running at 11 km/h.Axial compression strains (p0.0001), tension strains (p0.001), compression strain rates (p0.0001), and tension strain rates (p0.0001) were 48-285% higher during overground running than during treadmill running.On the basis of lower in vivo strains and strain rates, treadmill runners are at lower risk of developing tibial stress fractures, but less likely to achieve tibial bone strengthening, than overground runners.

Human in vivo tibial strains during vigorous walking have not been found to exceed 1200 microstrains. These values are below those found in ex vivo studies (>3000 microstrains) to cause cortical bone fatigue failure, suggesting that an intermediate bone remodeling response may be associated with tibial stress fractures. Metatarsal stress fractures, however, often develop before there is time for such a response to occur. Simultaneous in vivo axial strains were measured at the mid diaphysis of the second metatarsal and the tibia in two subjects. Peak axial metatarsal compression strains and strain rates were significantly higher than those of the tibia during treadmill walking and jogging both barefoot and with running shoes and during simple calisthenics. During barefoot treadmill walking metatarsal compression strains were greater than 2500 microstrains. During one- and two-leg vertical jumps and broad jumping, both metatarsal compression and tension strains were >3000 microstrains. Compression and tension strains in the metatarsus unlike those of the tibia may be sufficiently high even during moderate exertional activities to cause fatigue failure of bone secondary to the number of loading cycles without an intermediate bone remodeling response.

Background Achilles tendinopathy (AT) is a prevalent condition among runners and military personnel. Although ankle dorsiflexion (DF) range of motion (ROM) as measured with the knee bent has not been previously associated with AT, the literature concerning its role is limited. In addition, the role of lower extremity movement pattern in the pathogenesis of AT has not been studied prospectively. The purpose of this study was to further explore the role of ankle DF ROM as measured with the knee bent and that of lower extremity movement pattern as risk factors for mid-portion AT. Methods Seventy healthy male military recruits (mean ± SD age, height and body mass of 19.6 ± 1.0 years, 176.0 ± 10.0 cm, and 71.5 ± 7.4 kg) participated in this study. Ankle DF ROM as measured with the knee bent in weight-bearing (WB) and non-weight-bearing (NWB), as well as lower extremity quality of movement during a lateral step down (LSD) test were measured at baseline. Participants were then followed for a 6-month period of army basic training with recording of the development of AT. Results Five participants developed AT during training. Participants that developed AT had a more limited NWB ankle DF ROM (27.40 versus 21.10, p = 0.025). The quality of lower extremity movement did not differ between injured and uninjured participants (p = 0.361). Conclusions A more limited ankle DF ROM as measured in NWB with the knee bent increases the risk of developing AT among military recruits taking part in intensive physical training.

To test the hypothesis that shoe sole composition can affect the level of bone strain and strain rates that contribute to the development of stress fractures, in vivo tibial strain measurements were made during treadmill walking while wearing four shoes which differed only in their sole composition. Soles of 65 Shore A polyurethane with an embedded heel air cell had significantly lower compression and shear strains and shear strain rates than soles of 65, 75 and a composite of 40/65 Shore A polyurethane with no embedded air cells. A sole composed of 65 Shore A polyurethane with an embedded air cell can potentially be protective against stress fracture in a walking shoe.

This study, encompassing 2591 Israeli soldiers, characterized Israeli soldiers with stress fractures to profile individuals who are prone to experience stress fractures: 318 with clinically and scintigraphically proven high grade stress fractures; 237 soldiers with symptoms but with normal scintigraphy; and 2036 soldiers with no symptoms. Soldiers with high grade stress fractures weighed less (68.4 +/- 7.9 kg versus 70.5 +/- 12.4 kg), smoked less, and reported fewer previous stress fractures, had fewer reports of stress fractures in their family histories, and had fewer incidences of bone diseases than did control subjects. Serum levels of bone specific alkaline phosphatase and osteocalcin were elevated in patients with high grade stress fractures compared with control subjects with no symptoms: 37.6 versus 26.2 units/L, and 10.8 versus 8.8 ng/mL, respectively. Levels of 25-hydroxy vitamin D were lower in patients with high grade stress fractures (25.3 ng/mL) than in control subjects (29.8 ng/mL). This study revealed that several parameters can distinguish soldiers with high grade stress fractures, but their predictive value and precise pathogenetic role remain unclear.

The computerized database of the Israeli Defence Forces Medical Corps monitors recurrent shoulder dislocations before citizens are eligible for military induction, during the years of regular military service, and during the time of eligibility for reserve army service. With the computerized database of the Israeli Defence Forces Medical Corps, between the years of 1978 to 1995 the prevalence rate of subjects with recurrent shoulder dislocations less than or equal to 21 years of age was found to be 19.7 of 10,000 for men and 5.01 of 10,000 for women. The prevalence rate of subjects with a history of shoulder dislocations in the male population between the ages of 22 and 33 years was 42.4 of 10,000. Forty-four percent were judged to be sufficiently unstable to warrant surgery, but only 55% of these actually underwent surgery. These epidemiologic data may be important if arthroscopic shoulder surgery is being considered after a first shoulder dislocation. (J Shoulder Elbow Surg 1998;7:621-4)

Background: Foot ulcers have been implicated as a causative factor in diabetic foot amputations. The purpose of this study was to evaluate treating foot ulcers in patients with diabetes by percutaneous tenotomy. Methods: We retrospectively reviewed the computerized medical files of 83 patients treated for foot ulcers by percutaneous tenotomies. Results were analyzed on the basis of indication and per patient. Results: The 83 patients had 160 tenotomies for 4 indications: 103 tip-of-toe ulcers (treated by flexor digitorum longus tenotomy), 26 cock-up/dorsal ulcers (extensor digitorum longus tenotomy), 21 kissing ulcers (extensor digitorum longus and/or flexor digitorum longus tenotomies), and 10 plantar metatarsal ulcers (extensor digitorum longus with or without flexor digitorum longus tenotomy). Healing at 4 weeks was 98%, 96%, 81%, and 0%, respectively. The complication rate was very low, with the exception of “transfer lesions,” where an adjacent toe became involved and needed subsequent tenotomy in 8% of tip-of-toe ulcers. Conclusions: Percutaneous tenotomy was an effective and safe method for treating toe ulcers in neuropathic patients. It was not effective in treating plantar metatarsal ulcers. Level of Evidence: Level IV, case series.

Background Excessive shoe heel abrasion is of concern to patients, parents and shoe manufacturers, but little scientific information is available. The purpose of this study was to describe the phenomenon in a group of infantry recruits performing similar physical activity, and search for biomechanical factors that might be related. Methods Seventy-six subjects (median age 19) enrolled. Pre-training parameters measured included height, weight, tibial length, foot arch height and foot progression angle. Digital plantar pressure maps were taken to calculate arch indexes. Shoe heel abrasion was assessed manually after 14 weeks of training with different-sized clock transparencies and a calliper. Results Outsole abrasion was posterolateral, averaging 12 degrees on each shoe. The average heel volume that was eroded was almost 5 cm3. The angle of maximum wear was related to right foot progression angle (r = 0.27, p = 0.02). Recruits with lateral ankle sprains had higher angles of maximal abrasion (17° versus 10°, p = 0.26) and recruits with lateral heel abrasion had more lateral ankle sprains (14% versus 3%, p = 0.12). Conclusion While shoe heel wear affects many people, very little has been done to measure it. In this study in healthy subjects, we found the main abrasion to be posterolateral. This seems to be related to foot progression angle. It was not related to hindfoot valgus/varus or other factors related to subtalar joint motion. These findings do not warrant modification of subtalar joint motion in order to limit shoe heel abrasion.

The purpose of the study was to develop a simple prediction model for stress fractures (SFs) in young male recruits to identify risk factors for SF. Data were collected from 57 young (18.5 ± 0.5 years) male athletes before elite combat basic training (BT). Measurements included anthropometric variables, blood samples, fitness tests, bone quality (peripheral quantitative computed tomography [pQCT]), psychological assessment, nutritional habits, and history of physical activity. A medical evaluation was done periodically. The SFs were clinically diagnosed during the 1-year training and thereafter confirmed by bone scintigraphy. Three "simple to monitor" variables were found to be significantly (p0.05) related to SF occurrence during basic and advanced training: aerobic training frequency, aerobic training duration, and waist circumference. From these 3 variables, a new model was constructed that successfully predicted 85% of the soldiers with (n = 23) and without (n = 34) SF as follows:(Equation is included in full-text article.)where PSF is the stress fracture prediction according to the Log Odds (SF), Odds(SF) is the ratio between the probability of SF existence and nonexistence, ATn is the aerobic training (times per week), ATt is the aerobic training duration (minutes per week), and waist is the circumference (centimeters). This model was validated on a different database taken from another 59 elite combat recruits before BT and successfully predicted 76.5% of the soldiers with SF (n = 22) and without SF (n = 37). A young male recruit for elite combat unit is at a greater risk of developing SF if, before entering BT, he trained aerobically2 times per week with each training40 minutes and has a waist circumference of75 cm. However, further evaluation is required for different combat recruits, ages, and training programs to validate these results.

Background: The training of elite infantry recruits takes a year or more. Stress fractures are known to be endemic in their basic training and the clinical presentation of tibial, femoral, and metatarsal stress fractures are different. Stress fracture incidence during the subsequent progressively more demanding training is not known. The study hypothesis was that after an adaptation period, the incidence of stress fractures during the course of 1 year of elite infantry training would fall in spite of the increasingly demanding training. Materials and Methods: Seventy-six male elite infantry recruits were followed for the development of stress fractures during a progressively more difficult training program composed of basic training (1 to 14 weeks), advanced training (14 to 26 weeks), and unit training (26 to 52 weeks). Subjects were reviewed regularly and those with clinical suspicion of stress fracture were assessed using bone scan and X-rays. Results: The incidence of stress fractures was 20% during basic training, 14% during advanced training and 23% during unit training. There was a statistically significant difference in the incidence of tibial and femoral stress fractures versus metatarsal stress fractures before and after the completion of phase II training at week 26 ( p = 0.0001). Seventy-eight percent of the stress fractures during phases I and II training were either tibial or femoral, while 91% of the stress fractures in phase III training were metatarsal. Prior participation in ball sports ( p = 0.02) and greater tibial length ( p = 0.05) were protective factors for stress fracture. Conclusion: The study hypothesis that after a period of soldier adaptation, the incidence of stress fractures would decrease in spite of the increasingly demanding elite infantry training was found to be true for tibial and femoral fractures after 6 months of training but not for metatarsal stress fractures. Further studies are required to understand the mechanism of this difference but physicians and others treating stress fractures should be aware of this pattern. Level of Evidence: IV, Case Series

Background The treatment options for a first traumatic shoulder dislocation in a young patient are either nonoperative care or primary surgery. It would be valuable to find patient-specific assessments that could predict the risk for redislocation in these patients and thereby identify those who would benefit from primary surgery. Hypothesis The supine apprehension test, performed after completion of physical therapy in first traumatic shoulder dislocators, can predict risk for redislocation. Patients with a positive test would be at very high risk for redislocation and therefore would be candidates for primary surgery. Study Design Cohort study (prognosis); Level of evidence, 2. Methods Men aged 17 to 27 years who sustained first traumatic shoulder dislocations were treated in a shoulder immobilizer for 4 weeks and then treated according to a physical therapy protocol. At the 6-week follow-up, an anterior apprehension test was performed to assess risk of redislocation. Follow-up of patients was done at 3 months, 6 months, 1 year, and 2 years. Follow-up continued yearly for up to another 2 years. Results Fifty-two men with a mean age of 20.3 years (standard deviation, 2.5) participated. Seventy-nine percent were combat soldiers. Twenty-four participants (46.2%) sustained redislocation. The minimum follow-up period was 24 months (range, 24-48 months; mean, 39.6 months). Redislocations were sustained in 36.8% of participants with negative apprehension tests and 71.4% with positive tests (P = .03). The odds ratio was 4.285 (95% confidence interval, 1.129-16.266). The sensitivity of the apprehension test was 41.7% and the specificity was 85.7%. Conclusion The anterior apprehension test performed 6 to 9 weeks after a first traumatic dislocation is not a definitive tool to predict risk for recurrent dislocation. It can, however, categorize patients into groups at higher and lower risk for recurrence. The redislocation rate found in this study is less than that of previous reports.

Study Design. Comparative knowledge survey. Objective. This study compared the knowledge of orthopaedic surgeons and family practitioners in managing simple low back pain (LBP) with reference to currently published guidelines. Summary of Background Data. LBP is the most prevalent of musculoskeletal conditions. It affects nearly everyone at some point in time and about 4% to 33% of the population at any given point. Treatment guidelines for LBP should be based on evidence-based medicine and updated to improve patient management and outcome. Studies in various fields have assessed the impact of publishing guidelines on patient management, but little is known about the physicians' knowledge of the guidelines. Methods. Orthopedic surgeons and family practitioners participating in their annual professional meetings were requested to answer a questionnaire regarding the management of simple low back pain. Answers were scored based on the national guidelines for management of low back pain. Results. One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners' score (69.7) was significantly higher than the orthopaedists' score (44.3) (P< 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclooxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs. Significantly less importance was attributed to patient encouragement and reassurance by the orthopaedists as compared with family physicians. Conclusion. Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners. Although the importance of publishing guidelines and keeping them up-to-date and relevant for different disciplines in different countries cannot be overstressed, disseminating the knowledge to clinicians is also very important to ensure good practice.

PURPOSE: The purpose of this prospective study was to investigate the epidemiology of overuse injuries and to identify common risk factors for stress fractures among female and male recruits in a new light infantry basic training designed to minimize the incidence of overuse injuries. METHODS: Study subjects were male and female recruits in the 16-wk light infantry basic training. A control group of noncombat female medics whose military service did not include demanding physical activities was recruited to assess the female recruits' preinduction physical preparedness. Pretraining survey of all participants' medical and sports participation histories was conducted. Anthropometric measurements were performed. Subjects were followed every 3 wk for overuse injuries. Stress fractures were diagnosed by radiography or scintigraphy. RESULTS: Ninety-nine female recruits, 36 male recruits, and 55 controls participated. Although 31% of the controls reported regular preinduction sports participation, less than 25% of both male and female recruits did. Stress fractures incidence was 0% among males and controls but 12% among female recruits (P = 0.03). The mean body mass index of female recruits with stress fractures was 19.2 +/- 2.6 versus 22.5 +/- 3.3 kg x m of female recruits without stress fractures (P = 0.02, odds ratio = 1.397, 95% confidence interval = 1.065-1.833). No statistically significant difference was found between female and male military trainees in the incidence of other overuse injuries, but there was a statistical trend (P = 0.07) for more back pain among females. CONCLUSIONS: Lower body mass index was the only variable identified as a risk factor for stress fractures among female recruits in the present study. It does not explain the markedly different response of female and male recruits' bones to the low demand training. There may be an intrinsic difference between male and female bone resistance to fatigue. Language: en

The Karakal is an existing light infantry unit consisting of both female and male fighters (predominantly female). This was the first Israel Defense Forces study to assess and to evaluate the dietary intake among male and female recruit fighters in comparison to nonfighters from preinduction through Army Basic Training (ABT).One company of Karakal recruits plus a control group of female medics were assessed for dietary intake at three time points: day of recruitment, 2 months into ABT, and at the end of 4 months ABT, using validated Food Frequency Questionnaires. Means of dietary intake were presented and compared with the Military Dietary Reference Intakes (MDRI).This study included 92 Karakal females (KF), 33 Karakal males (KM), and 48 control females (CF) aged 18-19 yr. Mean energy and calcium intakes at preinduction for KF were 90% and 71% of MDRI, respectively. These values were significantly lower than CF values (108% and 88%). Both groups of females consumed 57% of vitamin D. The KM intakes were similarly deficient. At preinduction, deficiencies were greater among recruits who first volunteered for 1 yr of national service (NS). During ABT, average dietary intakes decreased in all groups. Values for KF and CF were as follows: energy intake = 80% and 71%, respectively; Ca = 61% and 49%, respectively; Zn = 71% and 57%, respectively; and vitamin D = 34% and 24%, respectively. The diet of all groups met the MDRI requirements for protein, vitamin B6, and vitamin B12.Karakal fighters' food consumption during ABT did not meet most MDRI nutrient requirements. Females entering the army directly from a home environment began with a nutritional status that met MDRI requirements, unlike those inducted after 1 yr of NS away from home. Deficiencies need further investigation as they may have a negative impact on soldiers' health and physical performance.

Background: This study was designed to assess the effectiveness of a method of off-loading large neuropathic ulcers of the hindfoot and midfoot. The device used is composed of a fiberglass cast with a metal stirrup and a window around the ulcer. Methods: A retrospective study of 14 diabetic and nondiabetic patients was performed. All had chronic plantar hindfoot or midfoot neuropathic ulcers that failed to heal with conventional treatment methods. A fiberglass total contact cast with a metal stirrup was applied. A window was made over the ulcer to allow daily ulcer care. Results: The average duration of ulcer before application of the metal stirrup was 26 + 13.2 (range 7 to 52) months. The ulcer completely healed in 12 of the 14 patients treated. The mean time for healing was 10.8 weeks for midfoot ulcers and 12.3 weeks for heel ulcers. Complications developed in four patients: three developed superficial wounds and one developed a full-thickness wound. In three of these four patients, local wound care was initiated, and the stirrup cast was continued to complete healing of the primary ulcer. Conclusions: A fiberglass cast with a metal stirrup is an effective off-loading device for midfoot and hindfoot ulcers. It is not removable and does not depend on patient compliance. The window around the ulcer allows for daily wound care, drainage of the ulcer and the use of vacuum-assisted closure (VAC) treatment. The complication rate is comparable to that of total contact casting.

BackgroundBiomechanical orthoses have been shown to lower stress fracture incidence in infantry recruits. However, these results may not be applicable to running athletes.HypothesisTraining in either running shoes or military boots with custom biomechanical shoe orthoses lessens tibial bone strains and strain rates during walking and running.Study DesignRandomized controlled laboratory study.MethodsIn vivo strain measurements were made in nine subjects to determine whether the use of biomechanical orthoses lowers tibial strains during both walking and running and whether such lowering depends on the type of shoe worn. Measurements were made during treadmill walking at 5 km/hr and then during serial 2-km treadmill runs at 13 km/hr with running shoes, with and without the orthoses, and during serial 1-km runs with army boots, with and without the orthoses.ResultsWhen soft or semirigid biomechanical orthoses were worn with boots, the tibial peak-to-peak strains were significantly lowered. Soft orthoses also significantly lowered the tension and compression strain rates when worn with boots. During running, semirigid orthoses significantly increased the compression and tension strain rates when worn with boots.ConclusionsThe use of biomechanical orthoses may be warranted for tibial stress fracture prevention during training in which boots are worn and that mostly involves walking, but they are not warranted for activities that primarily involve running or are performed in running shoes.

Background—Bone must have sufficient strength to withstand both instantaneous forces and lower repetitive forces. Repetitive loading, especially when bone strain and/or strain rates are high, can create microdamage and result in stress fracture Aim—To measure in vivo strains and strain rates in human tibia during high impact and moderate impact exercises. Methods—Three strain gauged bone staples were mounted percutaneously in a rosette pattern in the mid diaphysis of the medial tibia in six normal subjects, and in vivo tibial strains were measured during running at 17 km/h and drop jumping from heights of 26, 39, and 52 cm. Results—Complete data for all three drop jumps were obtained for four of the six subjects. No statistically significant differences were found in compression, tension, or shear strains with increasing drop jump height, but, at the 52 cm height, shear strain rate was reduced by one third (p = 0.03). No relation was found between peak compression strain and calculated drop jump energy, indicating that subjects were able to dissipate part of the potential energy of successively higher drop jumps by increasing the range of motion of their knee and ankle joints and not transmitting the energy to their tibia. No statistically significant differences were found between the principal strains during running and drop jumping from 52 cm, but compression (p = 0.01) and tension (p = 0.004) strain rates were significantly higher during running. Conclusions—High impact exercises, as represented by drop jumping in this experiment, do not cause higher tibial strains and strain rates than running and therefore are unlikely to place an athlete who is accustomed to fast running at higher risk for bone fatigue. Key Words: bone; strain; biomechanics; stress fractures; impact

In three prospective epidemiologic studies of the effect of pre-military-induction sport activities on the incidence of lower extremity stress fractures during infantry basic training, recruits who played ball sports (principally basketball) regularly for at least 2 years before basic training had a significantly lower incidence of stress fractures (13.2%, 16.7%, and 3.6% in the three studies, respectively) than recruits who did not play ball sports (28.9%, 27%, and 18.8%, respectively). Preinduction running was not related to the incidence of stress fracture. To assess the tibial strain environment during these sport activities, we made in vivo strain measurements on three male volunteers from the research team. Peak tibial compression and tension strain and strain rates during basketball reached levels 2 to 5.5 times higher than during walking and about 10% to 50% higher than during running. The high bone strain and strain rates that occurred in recruits while playing basketball in the years before military induction may have increased their bone stiffness, according to Wolff's Law. The stiffer bone could tolerate higher stresses better, resulting in lower strains for a given activity and a lower incidence of stress fractures during basic training.