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Does Shoe Insole Modification Prevent Stress Fractures? A Systematic Review

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HSS Journal

Abstract

Stress fractures can be debilitating in athletes and military personnel. Insoles may lower stress fracture rates by improving biomechanics, lessening fatigue, and attenuating impact. The objective of this study was to systematically review the best evidence on the use of insoles as a method of stress fracture prevention in a high-risk population. Using MEDLINE, Cochrane, Current Controlled Trials, UK National Research Register, ScienceDirect, CINAHL, and EMBASE, a review of randomized (level I) and quasi-randomized (level II) controlled trials was performed using an insole as the intervention and stress fracture incidence as the primary outcome measure. Five trials were included, and a random effects model was used to generate a summary estimate and an overall odds ratio. One study found a significant reduction in overall stress fracture incidence using a semirigid insole, while four studies found no overall reduction in military personnel. However, when the data are pooled, orthotic use was beneficial. When stratified by site, there was a reduction in femoral and tibial stress fracture incidence. Shoe insoles may reduce the overall femoral and tibial stress fracture incidence during military training. It is unclear if the use of insoles would prevent stress fractures in athletes. Additional studies are necessary to determine the efficacy of insoles in an athletic population.

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Acknowledgments

The authors would like to acknowledge Tara Holmes, Lynn Cain, and Teresa Chipps for their editorial assistance.

Author information

Authors and Affiliations

  1. Vanderbilt University School of Medicine, Nashville, TN, USA

    Rebecca A. Snyder MD

  2. Vanderbilt Sports Medicine Center, Nashville, TN, USA

    Joseph P. DeAngelis MD, Kurt P. Spindler MD & Warren R. Dunn MD, MPH

  3. Center for Health Services Research, Vanderbilt University Medical Center, 6000 Medical Center East, North Tower 1215 21st Avenue South, Nashville, TN, 37232-8300, USA

    Warren R. Dunn MD, MPH

  4. Slocum Orthopedic Center, Eugene, OR, USA

    Michael C. Koester MD, ATC

Authors
  1. Rebecca A. Snyder MD
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  2. Joseph P. DeAngelis MD
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  3. Michael C. Koester MD, ATC
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  4. Kurt P. Spindler MD
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  5. Warren R. Dunn MD, MPH
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Corresponding author

Correspondence to Warren R. Dunn MD, MPH.

Additional information

Level of evidence: Level II systematic review.

The project described was supported by Grant # 5K23AR052392-02 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (Dunn, Warren R.) and a Pfizer Scholars Grant in Clinical Epidemiology (Dunn, Warren R.).

Appendix. Rationale for exclusion of individual manuscripts

Appendix. Rationale for exclusion of individual manuscripts

  1. 1.

    Simkin et al. 1989—this study was excluded as it uses the same data as the study of Milgrom et al. in 1985 [24, 28].

  2. 2.

    Milgrom et al. 1992—this study was excluded because it does not meet inclusion criteria. The intervention in this study was not an insole, but a basketball shoe [10].

  3. 3.

    Ekenman et al. 2002—this study was excluded because it does not meet inclusion criteria. Stress fracture incidence is not included as an outcome measure. Instead, the primary outcome measure was reported as “in vivo strain measurement”, as determined by in vivo bone staples and strain gauges [19].

  4. 4.

    Larsen et al. 2002—this study was excluded because it does not meet inclusion criteria. Stress fracture incidence is not included as an outcome measure. Outcome measures included self-reported “back problems”, “knee problems”, “shin splints”, “achilles tendonitis”, “sprained ankle”, and “other lower extremity problems” [22].

  5. 5.

    Finestone et al. 2004—this study was excluded because it does not meet inclusion criteria. Within the study design, there was no control group. The study compared outcomes among subjects wearing custom soft orthoses, soft prefabricated orthoses, semirigid biomechanical orthoses, and semirigid prefabricated orthoses [33]. However, there was no control group in which no insoles or standard orthoses were used.

  6. 6.

    Smith et al. 1985—this study was excluded because it does not meet inclusion criteria. The authors used the terminology “tibial stress” as a primary outcome measure, which may indicate stress fractures or tibial stress reactions [16]. Because stress fracture incidence was not specifically reported as an outcome measure, it was excluded.

  7. 7.

    Mundermann et al. 2001—this study was excluded because it does not meet inclusion criteria. The study does not clearly report stress fractures as an outcome measure. The primary outcome measure was described using the terminology “stress fracture or pain” [15]. Because the authors grouped pain with stress fractures, no clear stress fracture incidence could be determined.

  8. 8.

    Withnall et al. 2006—this study was excluded because it does not meet inclusion criteria. The primary outcome reported in this study was “any lower limb injury” [25]. Stress fracture incidence was not reported as an outcome measure.

  9. 9.

    Hinz et al. 2007—this study was excluded because it did not meet inclusion criteria. The primary outcome measure was “peak pressure under metatarsal heads” [21]. Stress fracture incidence was not reported as an outcome measure.

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Snyder, R.A., DeAngelis, J.P., Koester, M.C. et al. Does Shoe Insole Modification Prevent Stress Fractures? A Systematic Review. HSS Jrnl 5, 92–98 (2009). https://doi.org/10.1007/s11420-009-9114-y

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  • DOI: https://doi.org/10.1007/s11420-009-9114-y

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