Knowledge Assessment of Stress Bone Fractures among Soldiers in Saudi Arabia

Background: Stress fractures are well perceived in military preparing and athletes. Aside from knowledge of the frequency of these fractures and their impact on the economy and lost training hours, there are just a few studies in Saudi Arabia that show the real incidence of these fractures. The precise incidence must be known in order to provide recommendations for future preventative initiatives. This study aims to assess the knowledge of stress fractures among Saudi soldiers. Methodology: An observational cross-sectional study was conducted in medical centers; these centers are located in Saudi Arabia on male and female patients of all ages who are in Saudi military society to assess the knowledge of stress fractures among Saudi military society. Data collection was done by questionnaire that distributed between Saudi soldiers. Data was entered and analyzed using (SPSS) program, version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Original Research Article Albaker et al.; JPRI, 33(54B): 32-40, 2021; Article no.JPRI.77706 33 Results: Of all 1178 studied participants, 51.5% aged between 2030 years old. 91.7% were males. 47.5% of all participants had never heard of stress fractures before, 26.2% heard about it when joined military and 17.4% heard about it before joining the military field. 20.8% of all participants had stress fractures before, 10.4% were diagnosed through x-rays and medical history with the doctor, 4.6% were diagnosed through medical history only, and 2.4% diagnosed themselves. 85.3% of all participants agreed that stress fractures occur due to repetitive loading on the bones, 76.6% agreed that predominance of stress fractures of the lower extremities, over fractures of the upper extremities, 67.6% reported that stress fractures can be treated with painkillers, physiotherapy and reduce the risk and 78.6% agreed that stress fractures can be prevented by wearing appropriate footwear. Conclusion: Participants and relatively good knowledge of stress fractures. Knowledge of stress fracture was significantly associated with years of experience of participants, military sector, and residence area in the kingdom.


INTRODUCTION
Stress fractures are well perceived in military preparing and athletes, with the primary detailed case being recognized in 1855 by Breithaupt and the first imaging of a stress fracture recorded by Stechow in 1897 [1].
Fractures, occurring mostly in weight-bearing bones as a consequence of repetitive and immoderate efforts, which might also additionally development to a entire fracture if left untreated. [2] This harm happens as a result of tall numbers of occurrences of patterned overburdening of concentrated lower than the greatest bone quality, on non-pathological bone tissue [3]. SFs have been detailed in about any bone within the limits [2]. Accurate diagnosis for stress fractures is dependent on the anatomical space. Regardless, early recognition is that the optimum goal to attenuate the potential for microfractures to become macro fractures [4]. Special tests and treatment regimes, however, square measure similar among most stress fractures with resolution between 4weeks to a year [4].
The first description of stress fractures was by Prussian military physician called Breithaupt in 1855, he described soldiers with oedematous painful feet. Then, in 1897 Stechow found an evidence of fractures on imaging, so he called these fractures by "march fractures" [3,5]. The incidence of stress fractures among military recruits has been estimated to be in the range of 1.9%-31% [6]. In other studies, reported in India the incidences were 11.4% and 7.04% in two different military training centers, The occurrence of SFs was higher during their initial training period and reached its peak at 12 weeks of training [7]. Despite the fact that the clinical prevalence of stress fractures decreased after 8 weeks, incident lower limbs stress fractures persisted for over 20 weeks [8]. Actually, the incidence of stress fractures were higher in female soldiers than men [6].
The incidence of sustained stress fractures in military recruits may be as excessive as 12%, compared with a charge of 21.1% of elite athletes and 1% of the overall populace [1]. In the USA, the incidence of stress fractures in military recruits during training has been estimated to be in the range of 0.9%-12.3% Stress fractures in military recruits during training are estimated to occur in the range of 0.9 percent to 12.3 percent in the United States [9]. Most bones have reported cases of stress fractures, but the lower extremities have the highest prevalence. In a study of 320 athletes, the tibia (49.1%), tarsals (25.3%), and metatarsals (8.8%) were the most frequently involved bones affected by a stress fracture have been reported in most bones, but the lower extremities have the highest occurrence. The tibia (49.1%), tarsals (25.3%), and metatarsals (8.8%) were the most commonly involved bones damaged by a stress fracture in a sample of 320 athletes [10]. The incidence of SFs ranges from 1.5% to 31% depending on the population studied and the occurrence of SFs varies from 1.5% to 31% relying at the populace studied [5]. The number of studies on stress fractures in Saudi Army recruits is minimal, particularly in terms of invalidments. Furthermore, data on the actual occurrence is necessary to establish a foundation for future prevention initiatives and to improve the overall health of the troops. Aside from knowledge of the frequency of these fractures and their impact on the economy and lost training hours, there are just a few studies in Saudi Arabia that show the real incidence of these fractures. The precise incidence must be known in order to provide recommendations for future preventative initiatives [7].

Study Objective
To assess the knowledge of stress fractures among Saudi soldiers.

Study Design
This is an observational cross-sectional study was conducted in military medical centers, in different areas of Saudi Arabia, during the period from July to November, 202.

Subjects and Sample Size
Study included 1178 male and female patients of all ages who are in Saudi military society, who had stress fracture, to assess the knowledge of stress fractures among Saudi military society. The sample size was estimated using the Qualtrics calculator with a confidence level of 95%.

Exclusion criteria
Exclusion criteria are as follow: (1) Not a soldier (2) No previous history of stress fractures.

Data Collection and Study Tool
Data collection was done by questionnaire that distributed between Saudi soldiers. The questionnaire contains demographic data such as age, region, education level, profession, and how long in occupation. The participants were asked if they hearing about stress fractures (SF), if they recognize stress fractures in military, where the predominance of stress fractures, most cause of stress fractures. Also, they were asked if the pain & swelling are symptoms of SF, treatment and prevention of stress fractures.

Analysis and Entry Data
Data was entered on the computer using the "Microsoft Office Excel Software" program (2016) for windows. Data was then transferred to the Statistical Package of Social Science Software (SPSS) program, version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) to be statistically analyzed.

RESULTS
Of all 1178 studied participants, 51.5% aged between 20-30 years old, 24.2% aged between 31-40 years old and 13.8% aged between 41-50 years old. 91.7% were males. 24.8% live in the western region and 23.8% live in the southern area of the kingdom. 40.2% had university education, and 34.8% had secondary school education. 43% of all participants work in the ministry of Interior (Public Security), 37.4% work in ministry of Defense while 13.1% work in ministry of National Guard. Regarding years of experience, 34.5% were employed for more than 10 years, 31.7% were less than 5 years, while 19.9% had 5-10 years of experience.
According to Table ( Regarding knowledge of diagnosis method; half of participants reported medical history, X-ray, MRI, or bone scan, 11.8% reported patient history only, and 33.8% didn't know. Only 73.8% agreed that stress fractures are well recognized in military armies and athletes.

DISCUSSION
Stress fractures occur when bone, typically in the lower extremities, is subjected to repeated mechanical stress that results in microscopic fractures. They often occur when the frequency or degree of physical activity is significantly increased [11]. The threshold value of stress that places an individual bone at high risk for stress fracture has not been identified. The activities involved in the diverse types of military training may put personnel at different injury risks. The most frequently reported cause of these fractures is repetitive weight-bearing activities such as running and marching, a recent increase in physical activity, beginning of a new activity or some other change in their routine can also result in increase of these fractures [12].
Due to the repetitive nature of military training, stress fractures common in members of the military. From 2009 to 2012, US military members had 5.69 stress fractures per 1000 person-years [13]. In our study, 20.8% of all participants had stress fractures before. However, in India two studies by Agrawal PK and Dash N et al., reported high incidence of 11.4% and 7.04% in two different military training centers [14,15]. Another study reported 15% incidence of SFs which far exceeds those figures or those reported from any previous study [15].
In our study,76.6% of participants agreed that predominance of stress fractures of the lower extremities, over fractures of the upper extremities. Previous studies reported most common stress fractures in decreasing order of occurrence are the tibia (23.6%), tarsal navicular (17.6%), metatarsals (16.2%), femur (6.6%), and pelvis (1.6%) [16]. Another previous study reported that commonest site involved in our cases was tibia (87.66%) followed by fibula and metatarsal [17]. The distribution of sites of SF was similar to the study by Singh SC, et al., [18]. However, in contrast Alexander M Wood et al., reported metatarsals as the most common site for stress fracture [19] The majority (75%) of fatigue fractures detected in another cohort study were located in the tibial shaft or metatarsals [20]. This finding is consistent with those of previous studies of both Finnish athletes and conscripts [21,22]. In a previous study of US Marine Corps recruits, bone stress injuries were less commonly detected in the pelvis, hip, thigh, and knee [23].
The pathophysiology of a stress fracture is usually related to repetitive loading of the bone that leads to an imbalance between the micro damaged bone and the processes of bone remodelling and repair. Several risk factors, including reduced body weight, decreased body mass index, increased height (or tallness), poor physical condition, low bone mineral density and high serum parathyroid hormone levels have been suggested as being associated with the development of stress fractures. In addition, indirect evidence supports the existence of genetic factors in the pathogenesis of stress fractures [24]. This was in agreement with most participants' knowledge as 76.3% agreed that most common cause of stress fractures is repetitive weight-bearing activities.
Symptom includes pain which increases on bearing weight and swelling. Typical findings include localized tenderness, swelling and erythema. Preliminary diagnosis of these fractures is through history assessment and clinical diagnosis. 77.2% of our participants agreed that pain and swelling a symptom of stress fractures.
Radiological diagnosis provides a reliable confirmation of these fractures and site associated. SFs may heal completely, slowly or incompletely. In our study, of all participants who had stress fracture,10.4% were diagnosed through x-rays and medical history with the doctor, 4.6% were diagnosed through medical history only, and 2.4% diagnosed themselves.
Regarding knowledge of diagnosis method, half of participants reported medical history, X-ray, MRI, or bone scan, 11.8% reported patient history only, and 33.8% didn't know. Only 73.8% agreed that stress fractures are well recognized in military armies and athletes. Giladi et al. [25] advocate a high clinical index of suspicion and early referral for MRI to enable prompt diagnosis among at-risk populations, though definitive evidence is lacking as to whether early diagnostic MRI has significant effect on rehabilitation time from injury and further research into this is necessary.
According to our results, 67.6% reported that stress fractures can be treated with painkillers, physiotherapy and reduce the risk and 78.6% agreed that stress fractures can be prevented by wearing appropriate footwear. Prevention, however difficult is the best approach for avoiding SFs. Treatment strategies includes early identification of the symptoms, early diagnosis, a sufficiently long training pause and in special cases consultation of experts in the field. Surgical treatment may be needed in some cases [26].

CONCLUSION
Participants and relatively good knowledge of stress fractures. Knowledge of stress fracture was significantly associated with years of experience of participants, military sector, and residence area in the kingdom. The cornerstone in avoiding SF is prevention. Education of trainees, trainers and instructors, modification in training procedures, use of better equipments can reduce occurrence of these fractures. Early reporting to hospital and treatment is also necessary as it can help in early return to full activity.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
Informed consent was obtained from all participants included in the study.

ETHICAL APPROVAL
The was approved from the research ethics committee of Majmaah University, with ethical approval number (MUREC-October.28/COM-2021/9-2).