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BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2018

Open Access 01-12-2018 | Research article

Association between stress fracture incidence and predicted body fat in United States Army Basic Combat Training recruits

Authors: Joseph J. Knapik, Marilyn A. Sharp, Scott J. Montain

Published in: BMC Musculoskeletal Disorders | Issue 1/2018

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Abstract

Background

A stress fracture (SF) is a highly debilitating injury commonly experienced in United States Army Basic Combat Training (BCT). Body fat (BF) may be associated with this injury but previous investigations (in athletes) have largely used SF self-reports and lacked sufficient statistical power. This investigation developed an equation to estimate %BF and used that equation to examine the relationship between %BF and SF risk in BCT recruits.

Methods

Data for the %BF predictive equation involved 349 recruits with BF obtained from dual-energy X-ray absorptiometry. %BF was estimated using body mass index (BMI, weight/height2), age (yr), and sex in the entire population of BCT recruits over an 11-year period (n = 583,651). Medical information was obtained on these recruits to determine SF occurrence. Recruits were separated into deciles of estimated %BF and the risk of SFs determined in each decile.

Results

The equation was %BF = − 7.53 + 1.43 ● BMI + 0.13 ● age − 14.73 ● sex, with sex either 1 for men or 0 for women (r = 0.88, standard error of estimate = 4.2%BF). Among the men, SF risk increased at the higher and lower %BF deciles: compared to men in the mean %BF decile, the risk of a SF for men in the first (lowest %BF) and tenth (highest %BF) decile were 1.27 (95%confidence interval (95%CI) = 1.17–1.40) and 1.15 (95%CI = 1.05–1.26) times higher, respectively. Among women, SF risk was only elevated in the first %BF decile with risk 1.20 (95%CI = 1.09–1.32) times higher compared to the mean %BF decile.

Conclusions

Low %BF was associated with higher SF risk in BCT; higher %BF was associated with higher SF risk among men but not women.
Literature
1.
Reinker KA, Ozburne S. A comparison of male and female orthopedic pathology in basic training. Milit Med. 1979;144:532–6.CrossRef
2.
Brudvig TGS, Gudger TD, Obermeyer L. Stress fractures in 295 trainees: a one-year study of incidence as related to age, sex, and race. Milit Med. 1983;148:666–7.CrossRef
3.
Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic risk factors for exercise-related injuries among male and female Army trainees. Am J Sports Med. 1993;21:705–10.CrossRefPubMed
4.
Bensel CK, Kish RN. Lower extremity disorders among men and women in Army basic training and effects of two types of boots. Natick: U.S. Army Natick Research and Development Laboratories Technical TR-83/026 TR-83/026; 1983.
5.
Westphal KA, Friedl KE, Sharp MA, King N, Kramer TR, Reynolds KL, Marchitelli LJ. Health, performance and nutritional status of U.S. Army women during basic combat training. Natick: U.S. Army Research Institute of Environmental Medicine Technical Report Number T96–2; 1995.
6.
Pester S, Smith PC. Stress fractures of the lower extremities of soldiers in basic training. Orthop Rev. 1992;21:297–303.PubMed
7.
Knapik JJ, Montain SJ, McGraw S, Grier T, Ely M, Jones BH. Stress fracture risk factors in basic combat training. Int J Sports Med. 2012;33:940–6.CrossRefPubMed
8.
Hauret KG, Shippey DL, Knapik JJ. The physical training and rehabilitation program: duration of rehabilitation and final outcome of injuries in basic combat training. Milit Med. 2001;166:820–6.CrossRef
9.
Mattila VM, Niva M, Kiuru M, Pihlajmaki H. Risk factors for bone stress injuries: a follow-up study of 102,515 person-years. Med Sci Sports Exerc. 2007;39:1061–6.CrossRefPubMed
10.
Macleod MA, Houston AS, Sanders I, Anagnostopoulos C. Incidence of trauma related to stress fractures and shin splints in male and female Army recruits: retrospective case study. Br Med J. 1999;318:29.CrossRef
11.
Protzman RR, Griffis CC. Comparative stress fracture incidence in males and females in equal training environments. Athl Train. 1977;12:126–30.
12.
Lappe JM, Stegman MR, Recker RR. The impact of lifestyle factors on stress fractures in female Army recruits. Osteopros Int. 2001;12:35–42.CrossRef
13.
Gardner LI, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, Gill P. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988;78:1563–7.CrossRefPubMedPubMedCentral
14.
Kelly EW, Johnson SR, Cohen ME, Shaffer R. Stress fractures of the pelvis in female navy recruits: an analysis of possible mechanisms of injury. Milit Med. 2000;165:142–6.CrossRef
15.
Friedl KE. Body composition and military performance: origins of the Army standards. In: Marriott BM, Grumstrup-Scott J, editors. Body composition and military performance. Washington, DC: National Academy Press; 1992. p. 31–55.
16.
Beck TJ, Ruff CB, Mourtada FA, Shaffer RA, Maxwell-Williams K, Kao GL, Sartoris DJ, Brodine S. Dual energy X-ray absorptiometry derived structural geometry for stress fracture prediction in male US marine corps recruits. J Bone Mineral Res. 1996;11:645–53.CrossRef
17.
Giladi M, Milgrom C, Simkin A, Danon Y. Stress fractures. Identifiable risk factors. Am J Sports Med. 1991;19:647–52.CrossRefPubMed
18.
Finestone A, Shlamkovitch N, Eldad A, Laor A, Danon YL, Milgrom C. Risk factors for stress fractures among Israeli infantry recruits. Milit Med. 1991;156:528–30.CrossRef
19.
Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fractures in young female recruits. Am J Sports Med. 2006;34:108–15.CrossRefPubMed
20.
Valimaki VV, Alfthan E, Lehmuskallio E, Loyttyniemi E, Sah T, Suominen H, Valimakii MJ. Risk factors for clinical stress fractures in male military recruits: a prospective cohort study. Bone. 2005;37:267–73.CrossRefPubMed
21.
Givon U, Friedman E, Reiner A, Vered I, Finestone A, Shemer J. Stress fractures in the Israeli defense forces from 1995 to 1996. Clin Orthop Relat Res. 2000;373:227–32.CrossRef
22.
Duckham RL, Peirce N, Meyer C, Summers GD, Cameron N, Brooke-Wavell K. Risk factors for stress fractures in female endurance athletes: a cross-sectional study. BMJ Open. 2012;2:e001920.CrossRefPubMedPubMedCentral
23.
Wakamatsu K, Sakuraba K, Suzuki Y, Maruyama A, Tsuchiya Y, Shikakura J, El O. Association between stress fracture and bone metabolism/quality markers in lacrosse players. Open Access J Sports Med. 2012;3:67–71.PubMedPubMedCentral
24.
Bennell KL, Malcolm SA, Thomas SA, Ebeling PR, McCrory PR, Wark JD, Brukner PD. Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Clin J Sports Med. 1995;5:229–35.CrossRef
25.
Schnackenburg KE, MacDonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc. 2011;43:2110–9.CrossRefPubMed
26.
Knapik JJ, Burse RL, Vogel JA. Height, weight, percent body fat and indices of adiposity for young men and women entering the U.S. Army. Aviat Space Environ Med. 1983;54:223–31.PubMed
27.
Roche AF, Siervogel RM, Chumlea WM, Webb P. Grading body fatness from limited anthropometric data. Am J Clin Nutr. 1981;34:2831–8.CrossRefPubMed
28.
Deurenberg P, Weststrate JA, Seidell JC. Body mass index as a measure of body fatness: age- and sex-specific prediction formulas. Brit J Nutr. 1991;65:105–14.CrossRefPubMed
29.
Gallagher D, Visser M, Supulveda D, Pierson RN, Harris T, Heymsfield SB. How useful is body mass index for comparison of body fat across age, sex and ethnic groups. Am J Epidemiol. 1996;143(3):228–39.CrossRefPubMed
30.
Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PA, Sakamoto Y. Healthy percent body fat ranges: an approach for developing guidelines on body mass index. Am J Clin Nutr. 2000;72:694–701.CrossRefPubMed
31.
Jackson AS, Stanforth PR, Gagnon J, Rankinen T, Leon AS, Rao DC, Skinner JS, Bouchard C, Wilmore JH. The effect of sex, age, and race on estimating percentage of body fat from body mass inde: the heritage family study. Int J Obes. 2002;26:789–96.CrossRef
32.
Pasco JA, Nicholson GC, Brennan SL, Kotowicz MA. Prevalence of obesity and the relationship between the body mass index and body fat: cross-sectional, population-based data. PLoS One. 2012;7(1):e29580.CrossRefPubMedPubMedCentral
33.
Gomez-Ambrosi J, Silva C, Galofre JC, Escalada J, Santos S, Millan D, Vila N, Ibanez P, Gil MJ, Valenti V, et al. Body mass index classification misses subjects with increased cardiometabolic risk factors related to elevated adiposity. Int J Obes. 2012;36:286–94.CrossRef
34.
Fernandez JR, Heo M, Heymsfield SB, Pierson RN, Pi-Sunyer FX, Wang ZM, Wang J, Hayes M, Allison DB, Gallagher D. Is percent body fat differentially related to body mass index in Hispanic Americans, African Americans, and European Americans? Am J Clin Nutr. 2003;77:71–5.CrossRefPubMed
35.
Rauh MJ, Macera CA, Trone DW, Shaffer RA, Brodine SK. Epidemiology of stress fracture and lower-extremity overuse injuries in female recruits. Med Sci Sports Exerc. 2006;38:1571–7.CrossRefPubMed
36.
Sharp MA, Knapik JJ, Patton JF, Smutok MA, Hauret K, Chervak M, Ito M, Mello RP, Frykman PN, Jones BH. Physical fitness of soldiers entering and leaving basic combat training. Natick: US Army Research Institute of Environmental Medicine Technical Report Number T00–13; 2000.CrossRef
37.
Nana A, Slater GJ, Stewart AD, Burke LM. Methodological review: using dual-energy X-ray absorptiometry (DXA) for the assessment of body composition in athletes and active people. Int J Sports Nutr Exerc Metabol. 2014;24:196–215.CrossRef
38.
Knapik JJ, Montain SJ, McGraw SM, Grier T, Ely MR, Jones BH. Risk factors for stress fractures in basic combat training. Int J Sports Med. 2012;33:940–6.CrossRefPubMed
39.
Holiday DB, Ballard JE, Mckeown BC. PRESS-related statistics: regression tools for cross-validation and case diagnostics. Med Sci Sports Exerc. 1995;27:612–20.CrossRefPubMed
40.
41.
Khosla S, Oursler MJ, Monroe DG. Estrogens and the skeleton. Trends Endrocriol Metab. 2012;23(11):576–81.CrossRef
42.
Li J, Papadopoulos V, Vihma V. Steroid biosynthesis in adipose tissue. Steroids. 2015;103:89–104.CrossRefPubMed
43.
Chumlea WC, Wisemandle W, Guo SS, Siervogel RM. Relations between frame size and body composition and bone mineral status. Am J Clin Nutr. 2002;75:1012–6.CrossRefPubMed
44.
Trotter M, Broman GE, Peterson RR. Densities on bones of white and negro skeletons. J Bone Joint Surg Am. 1960;42A:50–8.CrossRef
45.
Bachrach LK, Hastie T, Wang MC, Narssimhan R, Marcus R. Bone mineral acquisition in healthy Asian, hispanic, black and caucasian youth: a longitudinal study. J Clin Endocrinol Metab. 1999;84:4702–12.PubMed
46.
Nelson DA, Barondess DA, Hendrix SL, Beck TJ. Cross-sectional geometry, bone strength, and bone mass in the proximal femur in black and white postmenopausal women. J Bone Mineral Metabol. 2000;15:1992–7.CrossRef
47.
Ettinger B, Sidney S, Cummings SR, Libanati C, Bikle DD, Tekawa IS, Tolan K, Steiger P. Racial differences in bone mineral density between young adult black and white subjects persist after adjustment for anthropometric, lifestyle, and biochemical differences. J Clin Endocrinol Metab. 1997;82:429–34.PubMed
48.
Knapik JJ, Sharp MA, Canham-Chervak M, Hauret K, Patton JF, Jones BH. Risk factors for training-related injuries among men and women in basic combat training. Med Sci Sports Exerc. 2001;33:946–54.CrossRefPubMed
49.
Jackson AS, Pollock ML, Ward A. Generalized equations for predicting body density of women. Med Sci Sports Exerc. 1980;12:175–82.PubMed
50.
Jackson AS, Pollock ML. Generalized equations for predicting body density of men. Brit J Nutr. 1978;40:497–504.CrossRefPubMed
Metadata
Title
Association between stress fracture incidence and predicted body fat in United States Army Basic Combat Training recruits
Authors
Joseph J. Knapik
Marilyn A. Sharp
Scott J. Montain
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2018
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/s12891-018-2061-3

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