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Part II: Risk Factors for Stress Fractures in Female Military Recruits.

INTRODUCTION
Stress fractures (SFx) represent a significant proportion of injuries in military recruits internationally. Stress fractures disproportionately affect female recruits, a disparity that has similarly been consistently demonstrated in female athletes. Stress fractures result in medical morbidity, financial burden, and medical discharge from military service. This review presents current literature regarding SFx risk factors to identify and/or mitigate in this high-risk population.


METHODS
A literature review was conducted using PubMed to find relevant articles. We utilized keywords stress fracture, military, recruits, female, risk factors, modifiable, non-modifiable, overuse, nutrition, and/or prevention. Articles older than 10 years (published before 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review.


RESULTS
Modifiable risk factors for SFx include nutritional deficiency, especially of iron, vitamin D, and possibly calcium, poor physical fitness, suboptimal training programming for injury development and recovery, load carriage, and military footwear. Non-modifiable risk factors include female sex, greater height, lower weight and body mass index in females but lower or higher weight and body mass index in males, lower body fat percentage, and lower bone mineral density. In addition, menstrual dysfunction, low energy availability, later age at menarche, and iron deficiency pose unique risks to female recruits. Preventive measures include leadership education, programs with recovery considerations, and risk factor screening.


CONCLUSION
This review, Part II of a two-part series, guides multidisciplinary management of military recruits, especially females, who are at risk for developing SFx. Unique nuances of the military recruit require specific knowledge to reduce high incidence rates of injury internationally.