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Does the use of orthotics prevent tibial stress fractures in marching activities? A review of the literature.

Introduction

Stress fractures can occur during physical activities that repeatedly apply load and stress on the bone, particularly in the lower extremities. If the bone is unable to adapt to the stress, the subsequent microdamage may potentially lead to partial or complete stress fractures (Bennel & Brukner, 2002). Running and marching apply repeated load and stress on the lower extremities and can result in stress fractures (Jones, Thacker, Gilchrist, Kimsey & Sosin, 2002). Tibial stress fracture has clinical significance, particularly in military recruits and athletes. Stress fractures are typically seen in the first 10-12 days of training, and take approximately 10-12 weeks to heal (Hume et al., 2008; Armstrong et al., 2004; Milner, 2010). Although stress fracture can occur in any bone, it is most commonly seen in the tibia (Bennel & Brukner, 2002; Snyder et al., 2009). The objective of this review is to determine if orthotics could be used to prevent or minimize tibial stress fractures in individuals engaged in marching activities.

Incidence of Stress Fractures

The incidence of stress fractures varies among available studies, the majority of which have been conducted in the military. The incidence ranges from 1% to 5% for males and 3.5% to 21% for females in basic military training (Jones, et al., 2002). The incidence of stress fractures have been 0.84.0% for males and 3.0-5.7% for females among Marine recruits within 12 weeks of the basic training (Jones, et al., 2002). Among infantry soldiers, the annual stress fracture incidence for males has been 6.9% (Jones, et al., 2002). In a systematic review of the literature conducted by Snyder, et al. (2009), the stress fracture incidence among military soldiers was 1.0-1.7% and 1.0-2.6% among National Collegiate Athletic Association (NCAA) athletes (Snyder, et al., 2009).

Stress Fractures in Military Marching Bands

Few studies have examined the incidence rates of stress fractures that are seen in individuals participating in marching bands. A study of the Michigan Marching Band found that 85% of injuries occurred in the lower extremity during one season although the number of stress fractures was not reported (Mehler, et al. 1996). Kilanowski (2008) found that "high-step marching, a rigorous training schedule, inadequate practice or performing shoes, and marching on inappropriate surfaces are factors which can contribute to injuries in the bones of the lower extremities among individuals participating in marching bands (Kilanowski, 2008). The incidence is significant because the majority of fractures that present with short-duration symptoms will take four to eight weeks to heal (Bennel & Brukner, 2002). The treatment of stress fractures can be implemented in two phases. These phases involve modified activity and the reintroduction of physical activity, respectively, leading to the return to sports activities (Bennel & Brukner, 2002). The time needed for the treatment and recovery from stress fractures can have negative impact on the affected individuals. Stress fractures that are incurred by individuals in the military can cause a loss of duty and/or practice time, inability to fully participate in marching activities and may face potential discharge from the military (Jones, et al., 2002).

Therefore, individuals engaged in marching activities would benefit from strategies to prevent or minimize stress fractures. Calcium supplementation, preparatory exercise programs, changes in training strategies, modification of shoes, and the use of orthotics are strategies currently employed to prevent or minimize stress fractures (Snyder, et al., 2009).

The Role of Foot and Ankle Orthotics

The foot and ankle are the bases of support both for balance and walking activities. During gait, the foot acts as shock absorber, terrain-conformer, and propulsion component (Kisner & Colby, 2007). According to Genova and Gross (2000), abnormal pronation within the foot has been implicated in numerous lower extremity pathologies including pelvic and hip dysfunction, knee pain, bunions, shin splints, stress fractures, arthritis, and tendonitis. Since excessive pronation has been implicated with numerous lower extremity pathologies, foot orthotics are often considered for reducing the magnitude of injury (Genova & Gross, 2000).

An orthotic may be fabricated with a post or wedge applied to the forefoot, rearfoot or both. In patients with calcaneal eversion during the stance phase of gait, a rearfoot post may be applied to place the calcaneous in neutral position (Genova & Gross, 2000). In patients with forefoot varus or valgus malalignment, a forefoot wedge may be applied to place the forefoot in neutral position (Genova & Gross, 2000). These modifications are made in an attempt to improve the effectiveness of the subtalar and midtarsal joints and to minimize stresses directed on the lower extremity soft tissues (Genova & Gross, 2000). Therefore, foot orthotics have been found to decrease the calcaneal eversion angle at heel rise by more than two inches (Genova & Gross, 2000). Clinically, this slight change often results in a reduction or complete resolution of symptoms of the foot or lower extremity (Genova & Gross, 2000).

Previous studies have examined various preventive strategies, including the use of orthotic inserts to minimize stress fractures in military and athletic populations (Jones, et al., 2002; Hume, et al., 2008; Snyder, et al., 2009; Gardner, et al., 1988). A review of the literature has suggested that the application of foot orthotics would be beneficial to recreational and competitive athletes engaged in repetitive and high impact activities (Lockard, 1988). To date, no studies have been conducted to evaluate the role of orthotics for preventing stress fractures during marching activities. Two predominant populations engaged in marching activities are military service members and marching bands. Within these populations, the literature review was conducted to answer the question, "Does the use of orthotics prevent or minimize tibial stress fractures in individuals engaged in marching activities?"

Methods

In order to identify articles relevant to the prevention of stress fractures by the use of orthotics in marching activities, a review of the available literature was conducted by using the following search engines: Academic Search Premier, Google Scholar, Ovid, CINAHL, and APTA Open Door. The keywords included tibial stress fractures, orthotics, marching injuries, biomechanics, treatment, pathology, insoles, and prevention. Articles were included in the review if they met one or more of the following criteria:

* The content was relevant to the use of orthotics in the prevention, alleviation and treatment of stress fractures.

* The study investigated the role of orthotics and the biomechanics of the foot and the lower extremity.

Articles that did not meet any of the above criteria were excluded from the review.

Results

Eleven research articles were reviewed that met the criteria. Of these articles, two were systematic reviews, two literature reviews and a controlled trial, which directly investigated the use of orthotics for preventing stress fractures (Jones, et al., 2002; Hume, et al., 2008; Snyder, et al., 2009; Gardner, et al., 1988; Lockard, 1988). Six articles contained information on orthotics, stress fractures, and marching activities. The information was useful in making a clinical decision for or against the use orthotics for preventing stress fractures in marching athletes. Table 1 represents the citations of the five articles that were directly linked to the use of orthotics in preventing stress fractures.

Systematic Reviews

The first systematic review conducted by Jones, et al. (2002) found favorable outcomes for the use of orthotics for preventing stress fractures and reported that shock absorbant boot insoles might be beneficial for preventing stress fractures in military recruits. In addition to orthotics, this review identified significant risk factors for the development of stress fractures. These factors included female gender, age, lower bone density and indices of bone strength, low aerobic fitness, low physical activity, cigarette smoking, and excessive running activity. The review also indicated that reducing the amount of running and other weight-bearing activities can reduce stress fractures.

The second systematic review found that a statistically significant reduction in the stress fracture incidence was associated with the addition of an orthosis in one of the studies. When the data were pooled from the five studies for the analysis, the researchers found that the outcomes were only promising if an orthotic shoe insert was used (Snyder, et al., 2009).

Nonsystematic Reviews and Controlled Trial

The first literature review directly investigated the use of orthotics for preventing stress fractures found favorable outcomes with the use of customized semi-rigid and soft foot orthotics. The review also determined that semi-rigid foot orthoses could be used to treat and prevent posterior tibial stress fractures (Hume et al., 2008). The second review also found that the use of orthotics is beneficial as a means of shock absorption for the foot in athletes engaged in high impact sports activities and indicated that orthotics could be used to correct the malalignments of the foot joints (Lockard, 1988). On the other hand, the controlled trial concluded that shock absorbers or insoles may not be beneficial in preventing stress fractures (Gardner et al., 1988).

Discussion

Stress fractures are a common overuse injury seen in individuals engaged in marching activities. This review of the literature was conducted to examine the body of the available evidence for the use of orthotics as a preventive measure against tibial stress fractures secondary to marching activities. Four studies concluded that the use of orthotics was beneficial in the prevention or reduction of tibial stress fractures associated with marching activities. On the other hand, the controlled trial did not favor the use of orthotics to prevent stress fractures. Interestingly, this study was included in both of the systematic reviews that supported the use of orthotics (Jones et al., 2002; Snyder et al., 2009).

The supporting literature suggests that a soft insert is preferable to a semirigid or rigid insert in order to decrease trauma to the tibia due to heel strikes during marching (Lockard, 1988). Individuals engaged in these activities who wear shoes that significantly absorb the shock due to heel strike and reduce loading of the tibia are less likely to suffer microdamages that result in stress fractures. Semirigid and rigid shoe inserts can be used to align the feet in the best position for weight bearing, i.e., a neutral position of the subtalar joint with maximal eversion of the midtarsal joints (Lockard, 1988). Correcting the malignment with orthotics can relieve the stress on the tibia thereby preventing or at least minimizing the risk of developing stress fractures (Lockard, 1988).

Currently, the quality and amount of research to address stress fractures and the associated risks are limited (Jones et al., 2002; Hume et al., 2008; Snyder at al., 2009). The following factors that could have affected the quality of studies used in this review of the literature included:

* Differences in diagnostic techniques to identify stress fractures (e.g., radiographs vs. bone scans).

* Lack of data on the duration and/or intensity of the physical and marching activities that were associated with stress fractures.

* Inadequate study design, randomization process, and statistical analyses.

(Jones, Thacker, Gilchrist, Kimsey & Sosin, 2002; Hume et al., 2008; Snyder, Deangelis, Koester, Spindler & Dunn, 2009).

Conclusion

Based on the literature reviewed, we concluded that the use of orthotics may prove beneficial in preventing tibial stress fractures during marching activities. This strategy helps to prevent lost service time due to stress fractures and it does not require additional changes to the training regimen. In addition, attention should be paid to muscle strengthening and stretching, proper nutrition, progressive exercise programs, appropriate therapeutic modalities, and proper shoes in outlining strategies aimed at preventing or minimizing the risk of tibial stress fractures. Some factors that may contribute to the development of stress fractures include muscle fatigue and weakness (primarily tibialis anterior), improper training methods, footwear, problem with lower limb alignment, muscle length and joint mobility, menstrual status, bone density and dietary intake (Bennel & Brukner, 2002; Gefen, 2002). Finally, further quality research is needed to elucidate treatment protocols that prevent or minimize stress fractures during marching activities.

References

Armstrong, D.W., Rue, J.P., Wickens, J.H., & Frassica, F.J. (2004). Stress fracture injury in young military men and women. Official journal of the International Bone and Mineral Society, (35), 806-816.

Bennell, K. & Brukner, P. (2002). How should you treat a stress fracture? In D. MacAuley and T. Best (Eds.), Evidence-based Sports Medicine. London, England: BMJ Books, 491-517.

Dutton, M. (2008). Orthopaedic examination, evaluation, and intervention. New York: McGraw-Hill Companies, Inc.

Gardner, L.I., Dziados, J.E., Jones, B.H., Brundage, J.F., Harris, J.M., Sullivan, R. & Gill, P. (1988). Prevention of lower extremity stress fractures: A controlled trial of a shock absorbent insole. American Journal of Public Health, 78, 1563-1567.

Gefen, A. (2002). Biomechanical analysis of fatigue-related foot injury mechanisms in athletes and recruits during intensive marching. Medical and Biological Engineering and Computing, 40, 302-310

Genova, J.M. & Gross, M.T. (2000). Effect of orthotics on calcaneal eversion during standing and treadmill walking for subjects with abnormal pronation. Journal of Orthopaedic and Sports Physical Therapy. 30(11), 664-675.

Glaros, S. (2003). All evidence is not created equal: a discussion of levels of evidence. PT Magazine, Retrieved from http://www.apta.org/AM/Template.cfm?Section=AdvanceSearch&TEMPLATE=/CM/ HTMLDisplay.cfm&CONTENTID=37998.

Hume, P., Hopkins, W., Rome, K., Maulder, P., Coyle, G. & Nigg, B. (2008). Effectiveness of foot orthoses for treatment and prevention of lower limb injuries. Sports Medicine, 38(9), 759-779

Jones, B.H., Thacker, S.B., Gilchrist, J., Kimsey, C.D. & Sosin, D.M. (2002). Prevention of lower extremity stress fractures in athletes and soldiers: A systematic review. Epidemiologic Reviews, 24(2), 228-247.

Kilanowski, J.F. (2008). Marching athletes: Injuries and illnesses at band camp. American Journal of Maternal Child Nursing, 33(6), 338-345.

Kisner, C. & Colby, L. (2007). Therapeutic exercise: foundations and techniques. Philadelphia: F.A. Davis Company.

Lockard, M.A. (1988). Foot orthoses. Physical Therapy, 68(12), 1866-1873.

Mehler, A.S., Brink, D.S., Eickmeier, K.M., Hesse, D.F. & McGuire, J.W. (1996). Marching band injuries. A one-season survey of the University of Michigan Marching Band. Journal of the American Podiatric Medical Association, 86(9), 407-413.

Milner, C.E. Gait biomechanics and tibial stress fracture in runners. Retrieved from http://w4.ub.uni-konstanz.de/cpa/article/viewFile/3040/2847. Accessed February 17, 2010.

Snyder, R.A., DeAngelis, J.P., Koester, M.C., Spindler, K.P. & Dunn, W.R. (2009). Does shoe insole modification prevent stress fractures? A Systematic Review. Hospital for Special Surgery Journal, (5), 92-98.

Tim Stewart

Physical Therapy Student

Department of Physical Therapy

Tennessee State University

Lee Houchin

Physical Therapy Student

Department of Physical Therapy

Tennessee State University

Deborah Edmondson, Ed.D., PT

Associate Professor

Department of Physical Therapy

Tennessee State University
TABLE 1
The reviewed literature and levels of evidence.

                                                            * Evidence
Study Title                                                 Level

Snyder RA, DeAngelis JP, Koester MC, Spindler KP, Dunn      Level 1
WR. Does Shoe Insole Modification Prevent Stress
Fractures? A Systematic Review. Hospital for Special
Surgery Journal. 2009;5:92-98.

Jones BH, Thacker SB, Gilchrist J, Kimsey CD, Sosin DM.     Level 3
Prevention of Lower Extremity Stress Fractures in
Athletes and Soldiers: A Systematic Review. Epidemiologic
Reviews. 2002;24:228-247.

Hume P, Hopkins W, Rome K, Maulder P, Coyle G, Nigg B.      Level 3
Effectiveness of Foot Orthoses for Treatment and
Prevention of Lower Limb Injuries. Sports Medicine.
2008;38(9):759-779

Gardner L, Dziados J, Jones B, et al. Prevention of lower   Level 1
extremity stress fractures: A controlled trial of a shock
absorbent insole. American Journal of Public Health.
1988;78:1563-1567.

Lockard MA. Foot Orthoses. Physical Therapy Journal.        Level 3
1988;68:1866-1873

* The levels of evidence are based on
Sackett's ranking method (Glaros, 2003).
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Author:Stewart, Tim; Houchin, Lee; Edmondson, Deborah
Publication:Journal of the National Society of Allied Health
Article Type:Report
Date:Mar 22, 2011
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