Injury time

Overuse injuries are the major cause of days lost during military training
but they are not always easy to spot. Advice on diagnosis, treatment and
prevention is given, by Susan Gregory

Introduction

Bassingbourn Barracks is an initial training regiment for the Army. There
are approximately 1,500 recruits undertaking their Phase 1 basic training at
any one time. Overuse injuries, particularly in the lower limbs, are the major
cause of days lost during military training and one of the most common of these
injuries is stress fracture1.

Background

Initial training is for 11 weeks and many recruits find the discipline and
arduous exercise regimes hard to settle into and decide to leave.

Recruits who are injured during the course of their training at Bassingbourn
are transferred into the rehabilitation platoon. Running, according to Brukner
and colleagues2, is the major cause of tibial stress fractures. Although stress
fractures can occur at any time they are most commonly seen in week five.

Definition

Stress fractures are the result of repetitive abnormal or excessive loading
of bone. The fractures can be partial or complete resulting from repeated
stress 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 the
physical stresses imposed upon it. Increases in bone mass appear to be
influenced by the type of exercise training performed.

This stress reaction can be graded from normal remodelling (grade 0) to
stress fracture (grade 4), with mild, moderate and severe stress reaction in
between.

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 factors
at any given point in time.

In military studies female recruits have a higher risk of stress fractures
than male recruits with similar training volumes. Schaffer and colleagues’
recent study4 revealed that 21.6 per cent of high-risk individuals experienced
more than three times as many stress fractures as low-risk individuals. This
suggests that the risk of stress fractures is increased by poor physical
fitness and low levels of physical activity prior to entry into training.

Specific aspects of the training regime can influence stress fracture
development and military studies have shown that modifying the training can
decrease their incidence. These interventions include rest periods, elimination
of running and marching on concrete, and a reduction of high- impact activity.
These may reduce stress fractures by allowing time for bone microdamage to be
repaired and by decreasing the load applied to bone.

Athletic footwear, insoles and orthotics aim to attenuate the shock of
ground contact and to control motion of the foot and ankle. Surprisingly, a new
form of infantry boot produced the lowest strains compared to various sports
shoes, 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 strenuous
exercise.

– Pain gradually progressing during non-sports activities, or at rest,
leading to reduced activity.

– Typically, a recent change in the training regime either with increased
activity or mileage.

– A focal, isolated site of pain.

– Pain that is mild at rest but is exacerbated on the first loading of the
limb.

– Sliding a vibrating tuning fork along the skin will severely exacerbate
the 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 to
assess and plan care. Each nurse develops his or her own method of assessment
and 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 ensure
medical confidentiality. Barry is 17 years of age. He completed eight weeks of basic
training 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 an
area of swelling with associated warmth point to infection. Inspection of the
foot 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 be
covered with a single finger. Multiple stress fractures are possible in the
same limb.

Left shin pain

Barry admitted during questioning that he had been suffering from shin pain
for six weeks. He did not want to miss any of his training and decided to try
and cope with the problem. The pain however has worsened, with Barry
experiencing 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 the
left tibia. There was no obvious sign of injury or trauma. In view of the
length of time Barry had been experiencing pain, and because of its worsening
nature, it was important not to delay treatment further. Barry was excused
boots, issued with crutches to ensure no further weight bearing on the left
leg, and referred to the Senior Medical Officer.

Barry was given a full examination by the SMO who gave a provisional
diagnosis of left tibia stress fracture. He was referred to physiotherapy and
to the sports medicine department at Addenbrookes Hospital for a bone scan and
advice regarding his future management.

Barry was transferred to Aisne Platoon (rehabilitation). Due to Barry
suffering pain and having difficulty in mobilising the SMO admitted him to the
ward at the medical centre for rest and observation.

Health care pathway

A health care pathway demonstrates the multi-professional approach taken in
Barry’s care and treatment indicating at what stage in the process outside
agencies were involved. These agencies were:

– Physiotherapy

– Bone Scan

– Army welfare

– Family doctor

– Rehabilitation

Interdisciplinary teamwork involves all team members at formal team meetings
and is explicitly patient centred, focused on what the patient needs rather
than what the individual therapist can do. For these meetings to be successful
each member of the team has to have an understanding of the techniques used by
others, accepting some overlapping of roles.

Physiotherapy

Early treatment has been demonstrated by research3 to be a key factor in
returning to full fitness. Physiotherapy is available to military personnel on
site daily. A pneumatic leg brace was applied to Barry’s lower left leg.
Swenson and colleagues7 highlight the use of an "Aircast" brace in
reducing the amount of time taken to return to full training. Barry was
instructed to carry on using crutches. Ice therapy and short wave pulsed
treatment was given on six occasions.

Progress of a stress fracture is monitored clinically. Patients can resume
activities when healing is evident, that is, when they are pain free during
activities of daily living and there is no local tenderness. Return to activity
is gradual.

Bone scan

Barry’s bone scan confirmed a "grossly abnormal" increased tracer
uptake in the posteromedial aspect of the left tibia at the junction of the
proximal with the distal. The appearance was consistent with a high grade
stress fracture. Two weeks sick leave was agreed and Barry’s family doctor was
informed of the diagnosis, treatment and medication to date.

Rehabilitation

On return from sick leave Barry was seen by the SMO. Now relatively pain
free he was discharged from the ward and transferred back into Aisne Platoon to
commence his rehabilitation.

Phase 1

Barry was allowed to perform normal activities of daily living. Aerobic
fitness was maintained by cycling. As Barry was pain free at rest, active
rehabilitation was undertaken in the form of a gradual return to weight bearing
exercise, from walking through to jogging in trainers. Once Barry was able to
jog pain free in trainers, without carrying any weight, he was able to pass
into Phase 2.

Phase 2

Physical fitness in Phase 2 rehabilitation is of utmost importance. Here
jogging increased to running at normal pace, with physical training exercises
and marching. If at any time Barry had experienced pain he would have been
returned to Phase 1 training, as stress fractures can recur.

Barry’s progress throughout rehabilitation was closely monitored by the
physical fitness team, physiotherapists and the medical team. Barry reported
weekly 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/disability
because of their familiarity of the workplace setting and training schedules.

Conclusions

Stress fractures represent a significant cause of sickness absence during military
recruits’ 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 when
assessing recruits presenting with limb pain or injury. Careful questioning and
history taking in an initial assessment is of great importance as some recruits
may be unwilling to admit to having pain. This is usually borne out of a fear
of being taken out of training.

Health promotion and education can raise awareness of the importance of
seeking advice early. Awareness of any possible contributing factors along with
recognition of the signs and symptoms of chronic injuries such as stress
fractures may reduce the incidence.

Recommendations

It is suggested that the following research-based recommendations regarding
the prevention and treatment of stress fractures should be implemented.

– Potential recruits should be made more aware of the physical demands of
basic training at pre-selection interviews and at recruitment centres.

– Prior to enlistment, candidates should be given a training schedule to
follow to improve their physical fitness and activity level.

– Recruits should perform alternative aerobic exercise with low impact
loading for one week after week 2 or 3 of their basic training5.

– Alternative exercise such as swimming or cycling should be added into the
weekly training schedule instead of running5.

– The training programme needs to be reviewed if there is an increased incidence
of stress fractures in any one part of the schedule.

– Nursing staff need to be aware of the signs and symptoms of stress
fractures and the importance of early diagnosis and treatment by continual
education.

– Health education needs to be increased to the recruits when they are
starting basic training to alert them to seek advice early with regard to pain
or difficulties with the training programme.

References

1. Hoffman J, Chapnik L, Shamis A. (1999a) The effect of leg strength on the
incidence of lower extremity overuse injuries during military training.
Military Medicine; 164(2): 153-6.

2. Brukner P, Bradshaw C, Bennell K. (1998a) Managing common stress
fractures, let risk level guide treatment. The Physician and Sports Medicine;
26(8): 40.

3. Brukner P, Bradshaw C, Bennell K. (1998b) Managing common stress
fractures, 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 measures
of physical activity to predict stress fractures in young men undergoing a
rigorous physical training program. American Journal Epidemiology; 149: 236-42.

5. Bennell K, Matheson G, Meeuwisse W, Brukner P. (1999) Risk factors for
stress fractures. Sports Medicine; 28(2): 91-122.

6. Milogram C, Burr D, Fyhrie D, et al. (1996) The effect of shoe gear on
human tibial strains recorded during dynamic loading: a pilot study. Foot and
Ankle 17: 667-71.

7. Swenson EJ, DeHaven KE, Sebastianelli WJ, et al. (1997) The effect of a
pneumatic 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 at
Bassingbourn Barracks which is an initial training regiment for the Army.

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