How stress fracture incidence was lowered in the Israeli army: a 25-yr struggle.

UNLABELLED: In 1983, a 31% incidence of stress fractures was found among Israeli basic infantry recruits.
PURPOSE: The purpose of this article is to chronicle the efforts of the Israeli Defense Forces to lower the stress fracture incidence and to present new data showing how reduction was finally achieved.
METHODS: A historical review of the steps taken over the past 25 yr to decrease stress fracture incidence in the Israeli Army is presented: risk factors for stress fracture were identified to create a risk profile and facilitate screening of recruits; modifications in army shoes were made; shock attenuating orthoses and biomechanical orthoses of various compositions were used; and the bisphosphonate risedronate was administered to recruits before and during basic training. In the latest intervention, the combined effect of a minimum nightly sleep requirement (6 h a night) and a decrease in recruits' cumulative marching and running on the incidence of stress fractures was evaluated among 276 infantry recruits.
RESULTS: A stress fracture risk profile was developed. It allows a recruit's stress fracture risk to be calculated before infantry training. Shoe modifications, orthoses, and pharmacological treatment with risedronate were not effective in lowering the incidence of stress fractures. The minimum sleep regimen and the reduced cumulative marching lowered the incidence of stress fractures by 62% (from 30.8% to 11.6%) and decreased their severity as compared with the 1983 baseline study.
CONCLUSION: After failing in prior interventions, a more than 60% decrease in stress fracture incidence was achieved by enforcing a minimum sleep regimen and lowering the cumulative marching during infantry training. These changes did not affect the quality of the training or the soldiers' combat readiness.