Prospective study of biomechanical risk factors for second and third metatarsal stress fractures in military recruits



      This prospective study investigated anatomical and biomechanical risk factors for second and third metatarsal stress fractures in military recruits during training.


      Prospective cohort study.


      Anatomical and biomechanical measures were taken for 1065 Royal Marines recruits at the start of training when injury-free. Data included passive range of ankle dorsi-flexion, dynamic peak ankle dorsi-flexion and plantar pressures during barefoot running. Separate univariate regression models were developed to identify differences between recruits who developed second (n = 7) or third (n = 14) metatarsal stress fracture and a cohort of recruits completing training with no injury (n = 150) (p < 0.05). A multinomial logistic regression model was developed to predict the risk of injury for the two sites compared with the no-injury group. Multinomial logistic regression results were back transformed from log scale and presented in Relative Risk Ratios (RRR) with 95% confidence intervals (CI).


      Lower dynamic arch index (high arch) (RRR: 0.75, CI: 0.63–0.89, p < 0.01) and lower foot abduction (RRR: 0.87, CI: 0.80–0.96, p < 0.01) were identified as increasing risk for second metatarsal stress fracture, while younger age (RRR: 0.78, CI: 0.61–0.99, p < 0.05) and later peak pressure at the second metatarsal head area (RRR: 1.19, CI: 1.04–1.35, p < 0.01) were identified as risk factors for third metatarsal stress fracture.


      For second metatarsal stress fracture, aspects of foot type have been identified as influencing injury risk. For third metatarsal stress fracture, a delayed forefoot loading increases injury risk. Identification of these different injury mechanisms can inform development of interventions for treatment and prevention.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Science and Medicine in Sport
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ross R.A.
        • Allsopp A.
        Stress fractures in Royal Marines recruits.
        Mil Med. 2002; 167: 560-565
        • Taunton J.E.
        • Ryan M.B.
        • Clement D.B.
        • et al.
        A retrospective case-control analysis of 2002 running injuries.
        Br J Sports Med. 2002; 36: 95-101
        • Giladi M.
        • Ahronson Z.
        • Stein M.
        • et al.
        Unusual distribution and onset of stress fractures in soldiers.
        Clin Orthop Relat Res. 1985; 192: 142-146
        • Davey T.
        • Lanham-New S.
        • Shaw A.
        • et al.
        Fundamental differences in axial and appendicular bone density in stress fractured and uninjured Royal Marine recruits — a matched case-control study.
        Bone. 2015; 73: 120-126
        • Wood A.
        • Hales R.
        • Keenan A.
        • et al.
        Incidence and time to return to training for stress fractures during military basic training.
        J Sports Med. 2014; 2014: 1-5
        • Arangio G.A.
        • Beam H.
        • Kowalczyk G.
        • et al.
        Analysis of stress in the metatarsals.
        Foot Ankle Surg. 1998; 4: 123-128
        • Hughes L.
        Biomechanical analysis of the foot and ankle for predisposition to developing stress fractures.
        J Orthop Sports Phys Ther. 1985; 7: 96-101
        • Simkin A.
        • Leichter I.
        • Giladi M.
        • et al.
        Combined effect of foot arch structure and an orthotic device on stress fractures.
        Foot Ankle. 1989; 10: 25-29
        • Giladi M.
        • Milgrom C.
        • Stein M.
        • et al.
        The low arch, a protective factor in stress fractures: a prospective study of 295 military recruits.
        Orthop Rev. 1985; 14: 709-712
        • Dixon S.J.
        • Creaby M.W.
        • Allsopp A.J.
        Comparison of static and dynamic biomechanical measures in military recruits with and without a history of third metatarsal stress fracture.
        Clin Biomech. 2006; 21: 412-419
        • Nunns M.
        • House C.
        • Rice H.
        • et al.
        Four biomechanical and anthropometric measures predict tibial stress fracture: a prospective study of 1065 Royal Marines.
        Br J Sports Med. 2016; 50: 1206-1210
        • Bennell K.
        • Khan K.
        • Matthews B.
        • et al.
        Hip and ankle range of motion and hip muscle strength in young female ballet dancers and controls.
        Br J Sports Med. 1999; 33: 340-346
        • White H.
        A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity.
        Econometrica. 1980; 48: 817-830
        • Huber P.J.
        The behavior of maximum likelihood estimates under nonstandard conditions.
        in: Presented at: Fifth Berkeley Symposium on Mathematical Statistics and Probability, Berkeley, CA1967
        • Willems T.M.
        • De Clercq D.
        • Delbaere K.
        • et al.
        A prospective study of gait related risk factors for exercise-related lower leg pain.
        Gait Posture. 2006; 23: 91-98
        • Queen R.M.
        • Abbey A.N.
        • Chuckpaiwong B.
        • et al.
        Plantar loading comparisons between women with a history of second metatarsal stress fractures and normal controls.
        Am J Sports Med. 2009; 37: 390-395
        • Griffin N.L.
        • Richmond B.G.
        Cross-sectional geometry of the human forefoot.
        Bone. 2005; 37: 253-260
        • Redmond A.C.
        • Crosby J.
        • Ouvrier R.A.
        Development and validation of a novel rating system for scoring standing foot posture: the foot posture index.
        Clin Biomech. 2006; 21: 89-98
        • Sun P.-C.
        • Shih S.-L.
        • Chen Y.-L.
        • et al.
        Biomechanical analysis of foot with different foot arch heights: a finite element analysis.
        Comput Methods Biomech Biomed Eng. 2011; 15: 563-569
        • De Cock A.
        • Willems T.
        • Witvrouw E.
        • et al.
        A functional foot type classification with cluster analysis based on plantar pressure distribution during jogging.
        Gait Posture. 2006; 23: 339-347
        • Rolian C.
        • Lieberman D.E.
        • Hamill J.
        • et al.
        Walking, running and the evolution of short toes in humans.
        J Exp Biol. 2009; 212: 713-721
        • Simpson K.J.
        • Jiang P.
        Foot landing position during gait influences ground reaction forces.
        Clin Biomech. 1999; 14: 396-402
        • Milgrom C.
        • Finestone A.
        • Shlamkovitch N.
        • et al.
        Youth is a risk factor for stress fracture. A study of 783 infantry recruits.
        J Bone Jt Surg Br Vol. 1994; 76-B: 20-22
        • Nunns M.
        • Stiles V.
        • Dixon S.J.
        The effects of standard issue Royal Marine recruit footwear on risk factors associated with third metatarsal stress fractures.
        Footwear Sci. 2012; : 59-70