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Diagnosis of Stress fractures in military trainees: a large-scale cohort
  1. Michael Shapiro1,2,3,
  2. K Zubkov2 and
  3. R Landau2,4
  1. 1Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
  2. 2Israel Defense Forces Medical Corps, Ramat Gan, Israel
  3. 3Department of Internal Medicine T, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  4. 4Internal Medicine D, Chaim Sheba medical center, Tel Hashomer, Israel
  1. Correspondence to Dr R Landau, Medical corps, IDF, Tel Aviv 61909, Israel; regev.landau{at}


Introduction The Israel Defense Forces (IDF) has strict protocols for the diagnosis and treatment of stress fractures wherein diagnosis is clinical with imaging used for persistent symptoms only. The purpose of this study was to examine the incidence of clinical and radiological stress fractures during IDF combat training.

Methods Medical records of all soldiers enlisted to combat training between 2014 and 2017 were scanned for the diagnosis of stress fractures. We examined the imaging tests ordered (plain radiographs and bone scans) and their results and the time between the clinical diagnosis to imaging tests.

Results During 4 years, 62 371 soldiers (10.1% women) had started combat training, and 3672 of them (5.9%) were diagnosed with clinical stress fractures. Radiographs were ordered for 53.5% of those diagnosed, of whom 29.7% also had a bone scan. Some 42% of radiographs were taken within 21 days. Radiographs were positive for stress fractures in 11.1% of tests. Bone scans showed evidence of stress fractures in 49.7%, of which 49.2% diagnosed stress fractures in multiple bones.

Conclusion The high percentage of negative radiographs may indicate towards alternative causes for symptoms. Performing the radiograph before or after 21 days did not affect workup results diverting from current belief that later radiographs will be more sensitive. Multiple stress fractures are a common finding, indicating that the increased training load puts the whole musculoskeletal system at increased risk for injury. Research results may necessitate a revision of clinical guidelines for the diagnosis of stress fractures in military trainees.

  • adult orthopaedics
  • musculoskeletal disorders
  • sports medicine
  • nuclear radiology
  • diagnostic radiology

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  • Contributors MS: obtained the data from the medical record, designed the model and the computational framework, and analysed the data; participated in interpretation of results and writing the manuscript. KZ: assisted in interpretation of the results, participated in writing the manuscript. RL: was involved in data analysis, participated in interpretation of results, wrote the manuscript and prepared it for submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval IDF Medical Corps IRB number 2022-2019.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement No data are available. The data for this research were obtained from the IDF electronic medical records with the help of the data analysis branch. Due to its source in a military data base, information cannot be made available to other researches.

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