This document discusses a preliminary study conducted on US Navy recruits with multiple stress fractures who underwent CT bone densitometry scans. The study found that 58% of recruits with multiple stress fractures had osteopenia, and osteopenia was more common in Asian/Pacific Islander recruits and male recruits. The study concludes that CT bone densitometry may be a useful tool to identify insufficiency as a contributing factor to stress fractures in military recruits, as many cases of osteopenia were identified that otherwise would have been overlooked. However, more research is still needed to fully understand risk factors and how to treat recruits identified as osteopenic.

1. Stress Fractures
CT Bone Densitometry in patients
with Multiple Stress Fractures:
Preliminary Data
LT Rowland J. Rivero, DO
LCDR Richard G. Schuster, DO
LT Sean Swiatkowski, DO
LT Philip D. Davis, PA-C
LT John J. Kim, DPM
CDR (RET) David Petty, MD
James Kedrow, PA-C
Art Studabaker, DPM
Sports Medicine and Rehabilitation Therapy Clinic

2. Agenda
• Stress Fractures
– History
– Types
– Causes
– Diagnoses
• History
• Physical Exam
• Radiographs
– Treatment
• CT Bone Density In
Patients with Multiple
Stress Fractures

3. History of Stress Fractures
• 1855 Britehaup, German Military Surgeon
– Foot Swelling after marching
– “Inflammation of the Tendon Sheath”
• 1897 Stechhow
– Classified first stress fracture of a metatarsal

4. Stress Fracture: AKA
• March Foot
• March Fracture
• Fatigue Fracture
• Spontaneous Fracture
• Crack Fracture
• Pseudofracture
• Deutschländer’s Disease
• Pied Force

5. Stress Fracture Types
• Fatigue Fractures
– Abnormal Stress on normal bone
– Increased activity
– Repeated activity
• Insufficiency Fractures
– Normal Stress on Abnormal Bone
– Osteoporosis
– Disease States

6. Causes of Stress Fractures
• Compressive Forces: Wt Bearing Areas
– MTP, Tib Plafond, Fem. Condyles
• Tensile Forces: Areas under tension on Wt.
Bearing
– Lateral Femoral Neck
– Anterior Tibia
– Pubic Ramus

7. Stress Fracture
Diagnosis

8. History
• Pain with Insidious Onset
• 3-4 weeks of symptoms
• Resolves with rest
• Progressively longer intervals for pain to
resolve

9. Physical Exam
• Point Tenderness at site of fracture
• NO Physical Deformity
– May have redness and swelling at site
• +/- pain with vibratory/percussion initiated
distal to fracture site
• +/- Fulcrum
• +/- Patricks Sign (Figure 4)

10. Radiographic Studies
• Plain Film Radiographs
– Unicortical Disruption
– Periosteal Reaction
– Callous Formation
• Bone Scan
– Focal Increased Radioisotope Uptake
– Better sensitivity than plain films

11. Radiographs: Periosteal Reaction

12. Radiograph: Callous

13. Radiographs: Sclerosis

14. Bone Scan

15. Bone Scan

16. Bone Scan

17. Treating Stress Fractures
• Relative Rest
– Protect
– Prevent Progression
• Pain Control
• Continue
Cardiovascular
Exercise
– Swimming
– Cycling
• Advance Wt-Bearing
as tolerated
– PAIN FREE
– Build Slowly
• Eventually Return to
Full Duty.
• Duration 4-8 weeks

18. Sports Medicine and
Rehabilitation Therapy NHGL
• Phase I
– Upper Body Only
• Phase II
– Add Cycling and
Swimming
• Phase III
– Add Stair Stepper
• Phase IV
– Add Treadmill
• 1-2 weeks per phase
• Helps Keep tabs on
progress.
• Weekly Meetings with
Recruit Division
Commander
– Overall wellness
– Behavior/Discipline
– Therapy Compliance

19. Recruit Training Command
• Keep Recruit with Division
– Increase morale
– Motivation
– Decreased Attrition
• Recruit Convalescent Unit
– When Division Leaves
– Pending Medical Board Results

20. Preliminary Data
CT Bone Densitometry in patients
with Multiple Stress Fractures
LT Rowland J. Rivero, DO
LCDR Richard G. Schuster, DO
LT Sean Swiatkowski, DO
LT Philip D. Davis, PAC
CDR (RET) David Petty, MD
James Kedrow, PAC
LT John J. Kim, DPM
Art Studabaker, DPM
Sports Medicine and Rehabilitation Therapy Clinic

21. Introduction
• First described in Military Personnel
• Continue to cause morbidity in Naval
Recruits
– 1-3 in 4000
– 60% Separated from the Navy in 2000

22. “May Day”
• May 2001
• 20 year old Female Recruit with 6 areas of
uptake on Bone Scan
• Division Officer Decision:
– Bone Density on this Patient
• Osteoporosis T Score of -2.52
* Patient was evaluated by Bone
Density Dexa scan of the Spine

23. “May Day”
• Division Officer Policy Decision:
– Bone Density on all Multiple Stress Fractures
– Find out how many Osteopenics were being
missed.
– Arbitrary Standard: More than 1 stress fracture
– Consider Calcium Replacement
– Consider Birth Control Pills
– Consider alendronate therapy

24. Division Officer Policy Decision
• CT Bone Density Evaluation.
– Owned by the Hospital (Cheap)
– San Francisco Studies by Dr. Cann
• Established Age Matched Bone Densities

25. Purpose
• To determine if a correlation exists
between bone density and multiple stress
fractures in United States Navy Recruits.
• Review the CT Bone Densitometry Policy of
the SMART Clinic.
• Convince Director of Ancillary Services that
these studies do not waste OPTAR $$.

26. Methods
• Patient presented to Sports Medicine Clinic.
• Diagnosed with Multiple Stress Fractures
– Physical Exam
– Verified with Plain Films or Bone Scan
• By SMART Team policy:
– CT Bone Density

27. Methods
• Demographic Information
– From Composite Healthcare System (CHCS)
– Information is entered into CHCS upon
in-processing to the Recruit Training Command
(RTC)

28. Stress Fractures by Gender
0
10
20
30
40
50
60
70
Patients
Single
Multiple
Single 29 37
Multiple 10 28
Male Female
26%
74%
57%
43%
104 Total Stress Fractures
Jun 2001 - Jan 2002
39
65

29. Multiple Stress Fractures by Gender
26%
74%
Male
Female
10
28

30. Multiple Stress Fractures by Race
52%
32%
3%
13%
Asian/Pacific Islander
Black
White
Other
20
12
01
05

31. Osteopenia Overall
58%
42%
Osteopenia
Non Osteopenia
22
16

32. Osteopenia in Males
80%
20%
Osteopenia
Non Osteopenia
8
2

33. Osteopenia in Females
50%50%
Osteopenia
Non Osteopenia
14
14

34. Bone Denisty of Recruits with Multiple Stress Fractures
29%
29%
16%
26%
Mild Osteopenia
Moderate Osteopenia
Normal
Above Mean
11
11
06
10

35. Multiple Stress Fractures in Asian/Pacific
Islanders by Gender
60%
40%
Female
Male
12
08

36. Total Osteopenia in Asian/Pacific Islanders
70%
30%
Osteopenia
Normal
14
06

37. CT Bone Densities in Overall Asian/Pacific Islanders with
Multiple Stress Fractures
25%
45%
10%
20%
Mild Osteopenia
Moderate Osteopenia
Above Mean
Normal
5
9
2
4

38. Osteopenia of Female Asian/Pacific
Islanders
58%
42%
Osteopenia
Normal
7
5

39. Bone Densities of Female Asian/Pacific
Islanders
17%
42%8%
33%
Mild Osteopenia
Moderate Osteopenia
Above Mean
Normal
2
5
1
4
Bone Densities of Female Asian/Pacific
Islanders
17%
42%8%
33%
Mild Osteopenia
Moderate Osteopenia
Above Mean
Normal
2
5
1
4

40. Osteopenia of Male Asian/Pacific Islanders
87%
13%
Osteopenia
Normal
7
1

41. Bone Densities of Male
Asian/Pacific Islanders
38%
49%
13% 0%
Mild Osteopenia
Moderate Osteopenia
Above Mean
Normal
3
4
1
0

42. Osteopenia in Blacks Overall
33%
67%
Osteopenia
Normal
4
8

43. Bone Densities in Black Patients with
Multiple Stress Fractures
33%
0%
17%
50%
Mild Osteopenia
Moderate Osteopenia
Normal
Above Mean
*Only one Black Male in
Study (Above mean)
4
0
2
5

44. Osteopenia in Other/Non
Specified Races
60%
40%
Osteopenia
Normal
3
2

45. Bone Densities in Other/Non
Specified Races
40%
20%
40%
0%
Mild Osteopenia
Moderate Osteopenia
Above Mean
Normal
2
1
2
0

46. Results Recap
• Osteopenia in 58% of patients with Multiple
Stress Fractures.
• 52% of patients with Multiple Stress
Fractures were Asian/Pacific Islander.
• Asian/Pacific Islanders had “worse” bone
densities.
• Males with multiple stress fractures may
have a higher osteopenia rate than females.
• Blacks had Increased Bone densities.

47. Conclusions:
• CT Bone Densitometry MAY be a useful
Study.
• May be a component of Insufficiency that
has been overlooked in Military Recruits
with Stress Fracture.

48. Fatigue Stress Fractures Insufficiency Stress Fractures

49. Fatigue Stress Fractures Insufficiency Stress Fractures

50. Questions Still to be Answered
• Risk Factors:
– Tobacco Use
– Alcohol Use
– Sex
– Age
– Anatomic Risk Factors
– Diet and Activities Before Boot Camp

51. Questions Still To Be Answered
• Role of Calcium Loss and Supplementation
• Role of alendronate in this child-bearing
population
• Is there an outcome difference in patients
with multiple stress fractures with low bone
density vice patients with normal bone
density?

52. Questions?
R. J. Rivero, LT, MC, USNR
rjrivero@grl10.med.navy.mil