Previous Article Next Article Injury timeOn 1 Apr 2001 in Personnel Today Comments are closed. Overuse injuries are the major cause of days lost during military trainingbut they are not always easy to spot. Advice on diagnosis, treatment andprevention is given, by Susan GregoryIntroduction Bassingbourn Barracks is an initial training regiment for the Army. Thereare approximately 1,500 recruits undertaking their Phase 1 basic training atany one time. Overuse injuries, particularly in the lower limbs, are the majorcause of days lost during military training and one of the most common of theseinjuries is stress fracture1. Background Initial training is for 11 weeks and many recruits find the discipline andarduous exercise regimes hard to settle into and decide to leave. Recruits who are injured during the course of their training at Bassingbournare transferred into the rehabilitation platoon. Running, according to Bruknerand colleagues2, is the major cause of tibial stress fractures. Although stressfractures can occur at any time they are most commonly seen in week five. Definition Stress fractures are the result of repetitive abnormal or excessive loadingof bone. The fractures can be partial or complete resulting from repeatedstress that is lower than that required to fracture the bone in a single load3.Bone is a living tissue and has the ability to remodel and adapt to thephysical stresses imposed upon it. Increases in bone mass appear to beinfluenced by the type of exercise training performed. This stress reaction can be graded from normal remodelling (grade 0) tostress fracture (grade 4), with mild, moderate and severe stress reaction inbetween. Risk factors Risk factors for any injury may be classified as extrinsic or intrinsic.Injuries occur as a result of the sum of various extrinsic or intrinsic factorsat any given point in time. In military studies female recruits have a higher risk of stress fracturesthan male recruits with similar training volumes. Schaffer and colleagues’recent study4 revealed that 21.6 per cent of high-risk individuals experiencedmore than three times as many stress fractures as low-risk individuals. Thissuggests that the risk of stress fractures is increased by poor physicalfitness and low levels of physical activity prior to entry into training. Specific aspects of the training regime can influence stress fracturedevelopment and military studies have shown that modifying the training candecrease their incidence. These interventions include rest periods, eliminationof running and marching on concrete, and a reduction of high- impact activity.These may reduce stress fractures by allowing time for bone microdamage to berepaired and by decreasing the load applied to bone. Athletic footwear, insoles and orthotics aim to attenuate the shock ofground contact and to control motion of the foot and ankle. Surprisingly, a newform of infantry boot produced the lowest strains compared to various sportsshoes, despite the relatively higher weight and sole durometry of the boot6. Signs and symptoms – Local redness and/or swelling. – Local bony tenderness. – Antalgic gait. – History of a gradual onset of pain first noted during/after strenuousexercise. – Pain gradually progressing during non-sports activities, or at rest,leading to reduced activity. – Typically, a recent change in the training regime either with increasedactivity or mileage. – A focal, isolated site of pain. – Pain that is mild at rest but is exacerbated on the first loading of thelimb. – Sliding a vibrating tuning fork along the skin will severely exacerbatethe pain in a localised area at the site of a stress fracture. Nursing model Within the medical centre at Bassingbourn there are no set models in use toassess and plan care. Each nurse develops his or her own method of assessmentand examination within a general framework of guidelines and protocols. Case study The client is referred to as Barry, not his real name, in order to ensuremedical confidentiality. Barry is 17 years of age. He completed eight weeks of basictraining and presented to the medical centre with left shin pain. Inspection of both lower limbs including the knee, ankle and lumbar spine,will indicate any focus of deformity, swelling or redness. Red streaks above anarea of swelling with associated warmth point to infection. Inspection of thefoot for any areas of broken skin may identify a source of contamination. Stress fractures can be so localised that a point of maximal tenderness can becovered with a single finger. Multiple stress fractures are possible in thesame limb. Left shin pain Barry admitted during questioning that he had been suffering from shin painfor six weeks. He did not want to miss any of his training and decided to tryand cope with the problem. The pain however has worsened, with Barryexperiencing pain on initial weight bearing at the start of the day. On examination of both of Barry’s legs he was found to be tender over theleft tibia. There was no obvious sign of injury or trauma. In view of thelength of time Barry had been experiencing pain, and because of its worseningnature, it was important not to delay treatment further. Barry was excusedboots, issued with crutches to ensure no further weight bearing on the leftleg, and referred to the Senior Medical Officer. Barry was given a full examination by the SMO who gave a provisionaldiagnosis of left tibia stress fracture. He was referred to physiotherapy andto the sports medicine department at Addenbrookes Hospital for a bone scan andadvice regarding his future management. Barry was transferred to Aisne Platoon (rehabilitation). Due to Barrysuffering pain and having difficulty in mobilising the SMO admitted him to theward at the medical centre for rest and observation. Health care pathway A health care pathway demonstrates the multi-professional approach taken inBarry’s care and treatment indicating at what stage in the process outsideagencies were involved. These agencies were: – Physiotherapy – Bone Scan – Army welfare – Family doctor – Rehabilitation Interdisciplinary teamwork involves all team members at formal team meetingsand is explicitly patient centred, focused on what the patient needs ratherthan what the individual therapist can do. For these meetings to be successfuleach member of the team has to have an understanding of the techniques used byothers, accepting some overlapping of roles. Physiotherapy Early treatment has been demonstrated by research3 to be a key factor inreturning to full fitness. Physiotherapy is available to military personnel onsite daily. A pneumatic leg brace was applied to Barry’s lower left leg.Swenson and colleagues7 highlight the use of an “Aircast” brace inreducing the amount of time taken to return to full training. Barry wasinstructed to carry on using crutches. Ice therapy and short wave pulsedtreatment was given on six occasions. Progress of a stress fracture is monitored clinically. Patients can resumeactivities when healing is evident, that is, when they are pain free duringactivities of daily living and there is no local tenderness. Return to activityis gradual. Bone scan Barry’s bone scan confirmed a “grossly abnormal” increased traceruptake in the posteromedial aspect of the left tibia at the junction of theproximal with the distal. The appearance was consistent with a high gradestress fracture. Two weeks sick leave was agreed and Barry’s family doctor wasinformed of the diagnosis, treatment and medication to date. Rehabilitation On return from sick leave Barry was seen by the SMO. Now relatively painfree he was discharged from the ward and transferred back into Aisne Platoon tocommence his rehabilitation. Phase 1 Barry was allowed to perform normal activities of daily living. Aerobicfitness was maintained by cycling. As Barry was pain free at rest, activerehabilitation was undertaken in the form of a gradual return to weight bearingexercise, from walking through to jogging in trainers. Once Barry was able tojog pain free in trainers, without carrying any weight, he was able to passinto Phase 2. Phase 2 Physical fitness in Phase 2 rehabilitation is of utmost importance. Herejogging increased to running at normal pace, with physical training exercisesand marching. If at any time Barry had experienced pain he would have beenreturned to Phase 1 training, as stress fractures can recur. Barry’s progress throughout rehabilitation was closely monitored by thephysical fitness team, physiotherapists and the medical team. Barry reportedweekly to the occupational health nurse with progress reports. With full agreement of the rehabilitation team Barry was considered fit,allowing him to return to full training. Barry passed his test with no pain. OH nurses are in a unique position to understand clients’ illness/disabilitybecause of their familiarity of the workplace setting and training schedules. Conclusions Stress fractures represent a significant cause of sickness absence during militaryrecruits’ basic training. The financial implications of lost training days,medical discharges and potential litigation is considerable. All staff need to be aware of the implications of delayed treatment whenassessing recruits presenting with limb pain or injury. Careful questioning andhistory taking in an initial assessment is of great importance as some recruitsmay be unwilling to admit to having pain. This is usually borne out of a fearof being taken out of training. Health promotion and education can raise awareness of the importance ofseeking advice early. Awareness of any possible contributing factors along withrecognition of the signs and symptoms of chronic injuries such as stressfractures may reduce the incidence. Recommendations It is suggested that the following research-based recommendations regardingthe prevention and treatment of stress fractures should be implemented. – Potential recruits should be made more aware of the physical demands ofbasic training at pre-selection interviews and at recruitment centres. – Prior to enlistment, candidates should be given a training schedule tofollow to improve their physical fitness and activity level. – Recruits should perform alternative aerobic exercise with low impactloading for one week after week 2 or 3 of their basic training5. – Alternative exercise such as swimming or cycling should be added into theweekly training schedule instead of running5. – The training programme needs to be reviewed if there is an increased incidenceof stress fractures in any one part of the schedule. – Nursing staff need to be aware of the signs and symptoms of stressfractures and the importance of early diagnosis and treatment by continualeducation. – Health education needs to be increased to the recruits when they arestarting basic training to alert them to seek advice early with regard to painor difficulties with the training programme. References 1. Hoffman J, Chapnik L, Shamis A. (1999a) The effect of leg strength on theincidence of lower extremity overuse injuries during military training.Military Medicine; 164(2): 153-6. 2. Brukner P, Bradshaw C, Bennell K. (1998a) Managing common stressfractures, let risk level guide treatment. The Physician and Sports Medicine;26(8): 40. 3. Brukner P, Bradshaw C, Bennell K. (1998b) Managing common stressfractures, let risk level guide treatment. The Physician and Sports Medicine;26(8): 39-47. 4. Schaffer RA, Brodine SK, Almeida SA et al. (1999) Use of simple measuresof physical activity to predict stress fractures in young men undergoing arigorous physical training program. American Journal Epidemiology; 149: 236-42.5. Bennell K, Matheson G, Meeuwisse W, Brukner P. (1999) Risk factors forstress fractures. Sports Medicine; 28(2): 91-122. 6. Milogram C, Burr D, Fyhrie D, et al. (1996) The effect of shoe gear onhuman tibial strains recorded during dynamic loading: a pilot study. Foot andAnkle 17: 667-71. 7. Swenson EJ, DeHaven KE, Sebastianelli WJ, et al. (1997) The effect of apneumatic leg brace on return to play in athletes with tibial stress fractures.American Journal of Sport Medicine; 25: 322. The author is one of nine nurses working in the medical centre atBassingbourn Barracks which is an initial training regiment for the Army. Related posts:No related photos.