The relationship between lower-extremity stress fractures and the ground reaction force: A systematic review

  • Author Footnotes
    1 Both authors have equally contributed to this manuscript and should therefore be considered as joint first authors.
    Amir Abbas Zadpoor
    Correspondence
    Corresponding author.
    Footnotes
    1 Both authors have equally contributed to this manuscript and should therefore be considered as joint first authors.
    Affiliations
    Department of Biomechanical Engineering, Delft University of Technology (TU Delft), Mekelweg 2, Delft 2628 CD, The Netherlands
    Search for articles by this author
  • Author Footnotes
    1 Both authors have equally contributed to this manuscript and should therefore be considered as joint first authors.
    Ali Asadi Nikooyan
    Footnotes
    1 Both authors have equally contributed to this manuscript and should therefore be considered as joint first authors.
    Affiliations
    Department of Biomechanical Engineering, Delft University of Technology (TU Delft), Mekelweg 2, Delft 2628 CD, The Netherlands
    Search for articles by this author
  • Author Footnotes
    1 Both authors have equally contributed to this manuscript and should therefore be considered as joint first authors.

      Abstract

      Background

      Lower-limb stress fracture is one of the most common types of running injuries. There have been several studies focusing on the association between stress fractures and biomechanical factors. In the current study, the ground reaction force and loading rate are examined. There is disagreement in the literature about whether the history of stress fractures is associated with ground reaction forces (either higher or lower than control), or with loading rates.

      Methods

      A systematic review of the literature was conducted on the relationship between the history of tibial and/or metatarsal stress fracture and the magnitude of the ground reaction force and loading rate. Fixed-effect meta-analysis techniques were applied to determine whether or not the ground reaction force and/or loading rate are different between the stress fracture and control groups.

      Findings

      Thirteen articles were identified through a systematic search of the literature. About 54% of these articles reported significantly different vertical ground reaction force and/or loading rate between the stress fracture and control groups. Other studies (~46%) did not observe any significant difference between the two groups.
      Meta-analysis results showed no significant differences between the ground reaction force of the lower-limb stress fracture and control groups (P>0.05). However, significant differences were observed for the average and instantaneous vertical loading rates (P<0.05).

      Interpretation

      The currently available data does not support the hypothesis that there is a significant difference between the ground reaction force of subjects experiencing lower-limb stress fracture and control groups. Instead, the vertical loading rate was found to be significantly different between the two groups.

      Keywords

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      References

        • Arangio G.A.
        • Beam H.
        • Kowalczyk G.
        • Salathe E.P.
        Analysis of stress in the metatarsals.
        Foot and Ankle Surgery. 1998; 4: 123-128
        • Beck T.J.
        • Ruff C.B.
        • Mourtada F.A.
        • Shaffer R.A.
        • Maxwell Williams K.
        • Kao G.L.
        • et al.
        Dual-energy X-ray absorptiometry derived structural geometry for stress fracture prediction in male US Marine Corps recruits.
        Journal of Bone and Mineral Research. 1996; 11: 645-653
        • Beck T.J.
        • Ruff C.B.
        • Shaffer R.A.
        • Betsinger K.
        • Trone D.W.
        • Brodine S.K.
        Stress fracture in military recruits: gender differences in muscle and bone susceptibility factors.
        Bone. 2000; 27: 437-444
        • Bennell K.
        • Crossley K.
        • Jayarajan J.
        • Walton E.
        • Warden S.
        • Kiss Z.S.
        • et al.
        Ground reaction forces and bone parameters in females with tibial stress fracture.
        Medicine and Science in Sports and Exercise. 2004; 36: 397-404
        • Bischof J.E.
        • Abbey A.N.
        • Chuckpaiwong B.
        • Nunley J.A.
        • Queen R.M.
        Three-dimensional ankle kinematics and kinetics during running in women.
        Gait and Posture. 2010;
        • Borenstein M.
        • Hedges L.V.
        • Higgins J.P.T.
        • Rothstein H.R.
        Introduction to meta-analysis.
        Wiley, Chippenham2009
        • Brukner P.
        • Bradshaw C.
        • Khan K.
        • White S.
        • Crossley K.
        Stress fractures: a review of 180 cases.
        Clinical Journal of Sport Medicine. 1996; 6: 85
        • Brukner P.
        • Bradshaw C.
        • Bennell K.
        Managing common stress fractures: let risk level guide treatment.
        The Physician and sportsmedicine. 1998; 26: 39
        • Carter D.R.
        • Hayes W.C.
        Compact bone fatigue damage: a microscopic examination.
        Clinical Orthopaedics and Related Research. 1977; 127: 265-274
        • Cavanagh P.R.
        • Lafortune M.A.
        Ground reaction forces in distance running.
        Journal of Biomechanics. 1980; 13: 397-406
        • Clarke T.E.
        • Frederick E.C.
        • Hamill C.L.
        The effects of shoe design parameters on rearfoot control in running.
        Medicine and Science in Sports and Exercise. 1983; 15: 376-381
        • Creaby M.W.
        • Dixon S.J.
        External frontal plane loads may be associated with tibial stress fracture.
        Medicine and Science in Sports and Exercise. 2008; 40: 1669-1674
        • Crossley K.
        • Bennell K.L.
        • Wrigley T.
        • Oakes B.W.
        Ground reaction forces, bone characteristics, and tibial stress fracture in male runners.
        Medicine and Science in Sports and Exercise. 1999; 31: 1088-1093
        • Davis I.F.
        • Milner C.E.
        • Hamill J.F.
        Does increased loading during running lead to tibial stress fractures? a prospective study.
        Medicine and Science in Sports and Exercise. 2004; 36: S58
      1. De Winter, J.C.F., Dodou, D., Mulder, M., submitted for publication. Training effectiveness of whole body flight simulator motion: a meta-analysis. Ergonomics.

        • Dixon S.J.
        • Creaby M.W.
        • Allsopp A.J.
        Comparison of static and dynamic biomechanical measures in military recruits with and without a history of third metatarsal stress fracture.
        Clinical Biomechanics. 2006; 21: 412-419
        • Ferber R.
        • McClay-Davis I.
        • Hamill J.
        • Pollard C.D.
        • McKeown K.A.
        Kinetic variables in subjects with previous lower extremity stress fractures.
        Medicine and Science in Sports and Exercise. 2002; 34: S5
        • Fredericson M.
        • Jennings F.
        • Beaulieu C.
        • Matheson G.O.
        Stress fractures in athletes.
        Topics in Magnetic Resonance Imaging. 2006; 17: 309-325
        • Friedl K.
        • Nuovo J.
        • Patience T.
        • Dettori J.
        Factors associated with stress fracture in young army women: indications for further research.
        Military Medicine. 1992; 157: 334
        • Giladi M.
        • Milgrom C.
        • Simkin A.
        • Stein M.
        • Kashtan H.
        • Margulies J.
        • et al.
        Stress fractures and tibial bone width. A risk factor.
        Journal of Bone and Joint Surgery. 1987; British Volume 69: 326
        • Gottschall J.S.
        • Kram R.
        Ground reaction forces during downhill and uphill running.
        Journal of Biomechanics. 2005; 38: 445-452
        • Grimston S.K.
        • Engsberg J.R.
        • Kloiber R.
        • Loiber R.
        • Hanley D.A.
        Bone mass, external loads, and stress fractures in female runners.
        Journal of Applied Biomechanics. 1991; 7: 293-302
        • Grimston S.K.
        • Nigg B.M.
        • Fisher V.
        • Ajemian S.V.
        External loads throughout a 45 minute run in stress fracture and non-stress fracture runners.
        Journal of Biomechanics. 1994; 27: 668
        • James S.
        • Bates B.
        • Osternig L.
        Injuries to runners.
        The American Journal of Sports Medicine. 1978; 6: 40
        • Jones B.
        • Bovee M.
        • Harris J.
        • Cowan D.
        Intrinsic risk factors for exercise-related injuries among male and female army trainees.
        The American Journal of Sports Medicine. 1993; 21: 705
        • Jorgensen U.
        Body load in heel-strike running—the effect of a firm heel counter.
        American Journal of Sports Medicine. 1990; 18: 177-181
        • Kowal D.
        Nature and causes of injuries in women resulting from an endurance training program.
        The American Journal of Sports Medicine. 1980; 8: 265
        • Liu W.
        • Nigg B.M.
        A mechanical model to determine the influence of masses and mass distribution on the impact force during running.
        Journal of Biomechanics. 2000; 33: 219-224
        • Logan S.
        • Hunter I.
        • Hopkins J.T.
        • Feland J.B.
        • Parcell A.C.
        Ground reaction force differences between running shoes, racing flats, and distance spikes in runners.
        Journal of Sports Science and Medicine. 2010; 9: 147-153
        • Macera C.A.
        • Pate R.R.
        • Powell K.E.
        • Jackson K.L.
        • Kendrick J.S.
        • Craven T.E.
        Predicting lower-extremity injuries among habitual runners.
        Archives of internal medicine. 1989; 149: 2565-2568
        • Matheson G.
        • Clement D.
        • McKenzie D.
        • Taunton J.
        • Lloyd-Smith D.
        • MacIntyre J.
        Stress fractures in athletes: a study of 320 cases.
        The American Journal of Sports Medicine. 1987; 15: 46
        • McBryde Jr, A.
        Stress fractures in runners.
        Clinics in sports medicine. 1985; 4: 737
        • Milgrom C.
        • Giladi M.
        • Simkin A.
        • Rand N.
        • Kedem R.
        • Kashtan H.
        • et al.
        An analysis of the biomechanical mechanism of tibial stress-fractures among Israeli infantry recruits—a prospective-study.
        Clinical Orthopaedics and Related Research. 1988; 231: 216-221
        • Milner C.E.
        • Davis I.S.
        • Hamill J.
        Free moment as a predictor of tibial stress fracture in distance runners.
        Journal of Biomechanics. 2006; 39: 2819-2825
        • Milner C.E.
        • Ferber R.
        • Pollard C.D.
        • Hamill J.
        • Davis I.S.
        Biomechanical factors associated with tibial stress fracture in female runners.
        Medicine and Science in Sports and Exercise. 2006; 38: 323-328
        • Mizrahi J.
        • Verbitsky O.
        • Isakov E.
        Fatigue-related loading imbalance on the shank in running: a possible factor in stress fractures.
        Annals of Biomedical Engineering. 2000; 28: 463-469
        • Munro C.F.
        • Miller D.I.
        • Fuglevand A.J.
        Ground reaction forces in running: a reexamination.
        Journal of Biomechanics. 1987; 20: 147-155
        • Pester S.
        • Smith P.
        Stress fractures in the lower extremities of soldiers in basic training.
        Orthopaedic Review. 1992; 21: 297
        • Pohl M.B.
        • Mullineaux D.R.
        • Milner C.E.
        • Hamill J.
        • Davis I.S.
        Biomechanical predictors of retrospective tibial stress fractures in runners.
        Journal of Biomechanics. 2008; 41: 1160-1165
        • Queen R.M.
        • Abbey A.N.
        • Chuckpaiwong B.
        • Nunley J.A.
        Plantar loading comparisons between women with a history of second metatarsal stress fractures and normal controls.
        American Journal of Sports Medicine. 2009; 37: 390-395
        • Rauh M.J.
        • Macera C.A.
        • Trone D.W.
        • Shaffer R.A.
        • Brodine S.K.
        Epidemiology of stress fracture and lower-extremity overuse injury in female recruits.
        Medicine and Science in Sports and Exercise. 2006; 38: 1571-1577
        • Ross R.
        • Allsopp A.
        Stress fractures in royal marines recruits.
        Military Medicine. 2002; 167: 560-565
        • Schaffler M.B.
        • Radin E.L.
        • Burr D.B.
        Mechanical and morphological effects of strain rate on fatigue of compact bone.
        Bone. 1989; 10: 207-214
        • Seebeck P.
        • Thompson M.S.
        • Parwani A.
        • Taylor W.R.
        • Schell H.
        • Duda G.N.
        Gait evaluation: a tool to monitor bone healing?.
        Clinical Biomechanics. 2005; 20: 883-891
        • Soutaslittle R.W.
        • Beavis G.C.
        • Verstraete M.C.
        • Markus T.L.
        Analysis of foot motion during running using a joint coordinate system.
        Medicine and Science in Sports and Exercise. 1987; 19: 285-293
        • Stergiou N.
        • Bates B.T.
        • James S.L.
        Asynchrony between subtalar and knee joint function during running.
        Medicine and Science in Sports and Exercise. 1999; 31: 1645-1655
        • Taunton J.
        • Clement D.
        • Webber D.
        Lower extremity stress fractures in athletes.
        Physician Sportsmed. 1981; 9: 77-86
        • Walter S.D.
        • Hart L.E.
        • McIntosh J.M.
        • Sutton J.R.
        The Ontario cohort study of running-related injuries.
        Archives of internal medicine. 1989; 149: 2561-2564
        • Wheat J.S.
        • Bartlett R.M.
        • Milner C.E.
        • Mullineaux D.R.
        The effect of different surfaces on ground reaction forces during running: a single-individual design approach.
        Journal of Human Movement Studies. 2003; 44: 353-364
        • Zadpoor A.A.
        • Nikooyan A.A.
        A mechanical model to determine the influence of masses and mass distribution on the impact force during running—a discussion.
        Journal of Biomechanics. 2006; 39: 388-390
        • Zadpoor A.A.
        • Nikooyan A.A.
        Modeling muscle activity to study the effects of footwear on the impact forces and vibrations of the human body during running.
        Journal of Biomechanics. 2010; 43: 186-193
        • Zadpoor A.A.
        • Nikooyan A.A.
        • Arshi A.R.
        A model-based parametric study of impact force during running.
        Journal of Biomechanics. 2007; 40: 2012-2021
        • Zifchock R.A.
        • Davis I.
        • Hamill J.
        Kinetic asymmetry in female runners with and without retrospective tibial stress fractures.
        Journal of Biomechanics. 2006; 39: 2792-2797