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Meta-Analysis
. 2005 Apr 18;2005(2):CD000450.
doi: 10.1002/14651858.CD000450.pub2.

Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults

K Rome  1 , H H G Handoll, R Ashford
Affiliations
Meta-Analysis

Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults

K Rome et al. Cochrane Database Syst Rev. .

Abstract

Background: Stress reaction in bone, which may proceed to a fracture, is a significant problem in military recruits and in athletes, particularly long distance runners.

Objectives: To evaluate the evidence from randomised controlled trials of interventions for prevention or management of lower-limb stress fractures and stress reactions of bone in active young adults.

Search strategy: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (April 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to September week 1, 2004), EMBASE, CINAHL, Index to UK Theses, reference lists of relevant articles and contacted trialists.

Selection criteria: Any randomised or quasi-randomised trials evaluating interventions for preventing or treating lower limb stress reactions of bone or stress fractures in active young adults.

Data collection and analysis: We independently selected trials for inclusion, assessed trial quality and extracted data. Only limited data pooling was undertaken.

Main results: We included 16 trials. All 13 prevention trials involved military recruits undergoing training. Participants of two of the three treatment trials were military personnel. Ten prevention trials tested the effects of various foot inserts and other footwear modifications. While pooling of data was not possible, the four trials evaluating the use of "shock-absorbing" boot inserts versus control found fewer stress injuries of the bone in their intervention groups. However, the only trial showing a significant benefit lacked important information about trial design. A key issue in several trials was the acceptability, in terms of practicality and comfort, of the boot inserts. Two cluster-randomised prevention trials found no significant effect of leg muscle stretching during warm up before exercise. Pooled data from three small but very different trials testing the use of pneumatic braces in the rehabilitation of tibial stress fractures showed a significant reduction in the time to recommencing full activity (weighted mean difference -33.39 days, 95% confidence interval -44.18 to -22.59 days). These results were highly heterogeneous (I squared = 90%), which is likely to reflect the underlying differences of the trials, including differences in the control group interventions and definitions of outcomes.

Authors' conclusions: The use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures in military personnel. There is insufficient evidence to determine the best design of such inserts but comfort and tolerability should be considered. Rehabilitation after tibial stress fracture may be aided by the use of pneumatic bracing but more evidence is required to confirm this.

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Conflict of interest statement

None known

Figures

1.1
1.1. Analysis
Comparison 1 Prevention: insoles/orthotics versus control (no insole), Outcome 1 Participants sustaining stress injury of bone.
1.2
1.2. Analysis
Comparison 1 Prevention: insoles/orthotics versus control (no insole), Outcome 2 Participants sustaining stress injury of bone (by site).
1.3
1.3. Analysis
Comparison 1 Prevention: insoles/orthotics versus control (no insole), Outcome 3 Participants sustaining an injury.
2.1
2.1. Analysis
Comparison 2 Prevention: cushioned (urethrane or special grid‐like mesh) versus standard insoles, Outcome 1 Participants sustaining stress reaction of bone (by site).
2.2
2.2. Analysis
Comparison 2 Prevention: cushioned (urethrane or special grid‐like mesh) versus standard insoles, Outcome 2 Participants attending medical facility for lower‐limb disorder.
2.3
2.3. Analysis
Comparison 2 Prevention: cushioned (urethrane or special grid‐like mesh) versus standard insoles, Outcome 3 Participants with activity restriction due to lower‐limb disorder.
2.4
2.4. Analysis
Comparison 2 Prevention: cushioned (urethrane or special grid‐like mesh) versus standard insoles, Outcome 4 Medical discharge due to lower‐limb disorder.
2.5
2.5. Analysis
Comparison 2 Prevention: cushioned (urethrane or special grid‐like mesh) versus standard insoles, Outcome 5 Participants rating their insoles as uncomfortable.
3.1
3.1. Analysis
Comparison 3 Prevention: visco‐elastic polymer versus mesh (standard) insoles (exploratory analysis), Outcome 1 Participants sustaining stress injury of bone.
3.2
3.2. Analysis
Comparison 3 Prevention: visco‐elastic polymer versus mesh (standard) insoles (exploratory analysis), Outcome 2 Participants sustaining stress injury of bone in the foot.
4.1
4.1. Analysis
Comparison 4 Prevention: orthotics (semi‐rigid or soft foot) versus mesh (standard) insoles, Outcome 1 Participants sustaining stress injury of bone.
4.2
4.2. Analysis
Comparison 4 Prevention: orthotics (semi‐rigid or soft foot) versus mesh (standard) insoles, Outcome 2 Participants sustaining stress injury of bone (by site).
4.3
4.3. Analysis
Comparison 4 Prevention: orthotics (semi‐rigid or soft foot) versus mesh (standard) insoles, Outcome 3 Early dissatisfaction with orthotic/insole (reason for drop out).
5.1
5.1. Analysis
Comparison 5 Prevention: urethrane versus special grid‐like mesh insoles, Outcome 1 Participants sustaining stress reaction of bone (by site).
5.2
5.2. Analysis
Comparison 5 Prevention: urethrane versus special grid‐like mesh insoles, Outcome 2 Participants attending medical facility for lower‐limb disorder.
5.3
5.3. Analysis
Comparison 5 Prevention: urethrane versus special grid‐like mesh insoles, Outcome 3 Participants with activity restriction due to lower‐limb disorder.
5.4
5.4. Analysis
Comparison 5 Prevention: urethrane versus special grid‐like mesh insoles, Outcome 4 Medical discharge due to lower‐limb disorder.
5.5
5.5. Analysis
Comparison 5 Prevention: urethrane versus special grid‐like mesh insoles, Outcome 5 Participants rating their insoles as uncomfortable.
6.1
6.1. Analysis
Comparison 6 Prevention: semi‐rigid versus soft foot orthotics, Outcome 1 Participants sustaining stress injury of bone.
6.2
6.2. Analysis
Comparison 6 Prevention: semi‐rigid versus soft foot orthotics, Outcome 2 Participants sustaining stress injury of bone (by site).
6.3
6.3. Analysis
Comparison 6 Prevention: semi‐rigid versus soft foot orthotics, Outcome 3 Early dissatisfaction with orthotic (reason for drop out).
7.1
7.1. Analysis
Comparison 7 Prevention: custom‐made versus prefabricated soft foot orthoses, Outcome 1 Participants sustaining stress injury of bone in the foot.
7.2
7.2. Analysis
Comparison 7 Prevention: custom‐made versus prefabricated soft foot orthoses, Outcome 2 Participants sustaining foot overuse injuries.
7.3
7.3. Analysis
Comparison 7 Prevention: custom‐made versus prefabricated soft foot orthoses, Outcome 3 Participants failing to complete training in allocated insoles.
8.1
8.1. Analysis
Comparison 8 Prevention: custom‐made mechanical versus prefabricated semi‐rigid foot orthoses, Outcome 1 Participants sustaining stress injury of bone in the foot.
8.2
8.2. Analysis
Comparison 8 Prevention: custom‐made mechanical versus prefabricated semi‐rigid foot orthoses, Outcome 2 Participants sustaining foot overuse injuries.
8.3
8.3. Analysis
Comparison 8 Prevention: custom‐made mechanical versus prefabricated semi‐rigid foot orthoses, Outcome 3 Participants failing to complete training in allocated insoles.
9.1
9.1. Analysis
Comparison 9 Prevention: modified basketball shoe versus standard infantry boot, Outcome 1 Participants sustaining stress injury of bone.
9.2
9.2. Analysis
Comparison 9 Prevention: modified basketball shoe versus standard infantry boot, Outcome 2 Participants sustaining stress injury of bone (by site).
9.3
9.3. Analysis
Comparison 9 Prevention: modified basketball shoe versus standard infantry boot, Outcome 3 Participants sustaining overuse injuries.
10.1
10.1. Analysis
Comparison 10 Prevention: pre‐exercise stretching (exploratory analysis), Outcome 1 All stress fractures.
10.2
10.2. Analysis
Comparison 10 Prevention: pre‐exercise stretching (exploratory analysis), Outcome 2 Stress fractures (by site).
10.3
10.3. Analysis
Comparison 10 Prevention: pre‐exercise stretching (exploratory analysis), Outcome 3 All lower limb injuries.
11.1
11.1. Analysis
Comparison 11 Prevention: calcium supplementation versus placebo, Outcome 1 Participants sustaining stress fractures.
11.2
11.2. Analysis
Comparison 11 Prevention: calcium supplementation versus placebo, Outcome 2 Participants sustaining stress fractures (by site).
11.3
11.3. Analysis
Comparison 11 Prevention: calcium supplementation versus placebo, Outcome 3 Participants sustaining an injury.
12.1
12.1. Analysis
Comparison 12 Treatment: rehabilitation in a pneumatic air brace versus control (no brace), Outcome 1 Time to resuming light activity.
12.2
12.2. Analysis
Comparison 12 Treatment: rehabilitation in a pneumatic air brace versus control (no brace), Outcome 2 Time to return to full activity/training.
12.3
12.3. Analysis
Comparison 12 Treatment: rehabilitation in a pneumatic air brace versus control (no brace), Outcome 3 Medical discharge from army.
See this image and copyright information in PMC

Update of

Comment in

References

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