The burden and management of sports-related musculoskeletal injuries and conditions within the US military

Sex- and age-related differences in kinetics and tibial accelerations during military-relevant movement tasks in U.S. Army trainees

Lower extremity injuries are prevalent in military trainees, especially in female and older trainees. Modifiable factors that lead to higher injury risk in these subgroups are not clear. The purpose of this study was to identify whether external loading variables during military-relevant tasks differ by age and sex in U.S. Army trainees. Data was collected on 915 trainees in the first week of Basic Combat Training. Participants performed running and ruck marching (walking with 18.1 kg pack) on a treadmill, as well as double-/single-leg drop landings. Variables included: vertical force loading rates, vertical stiffness, first peak vertical forces, peak vertical and resultant tibial accelerations. Comparisons were made between sexes and age groups (young, ≤19 years; middle, 20-24 years; older, ≥25 years). Significant main effects of sex were found, with females showing higher vertical loading rates during ruck marching, and peak tibial accelerations during running and ruck marching (p ≤ 0.03). Males showed higher vertical stiffness during running and peak vertical tibial accelerations during drop landings (p < 0.01). A main effect of age was found for vertical loading rates during running (p = 0.03), however no significant pairwise differences were found between age groups. These findings suggest that higher external loading may contribute to higher overall injury rates in female trainees. Further, higher stiffness during running may contribute to specific injuries, such as Achilles Tendinopathy, that are more prevalent in males. The lack of differences between age groups suggests that other factors contribute more to higher injury rates in older trainees.

Overview of Navy Medicine's Limited Duty Patient Population

INTRODUCTION

U.S. Navy Medicine's temporary limited duty (LIMDU) program is the primary vehicle for managing the medical care and subsequent career outcomes of the ill and injured active component (AC) Sailors and Marines to ensure a medically ready force. Before the LIMDU Sailor and Marine Readiness Tracker System (SMART) came online, it was very difficult to examine LIMDU program administration metrics, patients' experiences during LIMDU, and their subsequent health and career outcomes. This study examined the LIMDU patient population's demographic, military career, and LIMDU-specific characteristics; identified characteristics that differed significantly by military service; and evaluated potentially modifiable factors associated with patient outcomes.

MATERIALS AND METHODS

A comprehensive SMART extract was used to identify all AC Sailors and Marines in active LIMDU status between October 1, 2016, and September 30, 2019. The SMART extract was merged with comprehensive administrative military personnel data by patient identifiers to create a longitudinal dataset and to conduct descriptive statistics, bivariate, and multivariate logistic regression analyses for this study. The sample included 26,591 AC Sailors and Marines with complete SMART and military personnel records who ended LIMDU on or before September 30, 2019.

RESULTS

During the study's 3-year period, Navy Medicine's rate of initial LIMDU entry by AC personnel increased each year from 2,041 in FY2017 to 2,424 in FY2019 per 100,000 personnel. At the time of initial entry, most LIMDU patients were male (76%), E4-E6 paygrades (54%), and had a single diagnosis recorded in their SMART records (66%). Pain patients (23%) constituted the largest diagnostic group, followed closely by musculoskeletal patients (23%), and then mental and behavioral health patients (20%). Variables that might reflect administration practices of the program did not differ significantly by service, suggesting good internal standardization of LIMDU administration across Navy Medicine. However, bivariate and multivariate analyses identified significant differences by service for almost all personal demographic, LIMDU-specific, and post-LIMDU military career sample characteristics measured at the last LIMDU close date or later. Study results suggested that the Navy and Marine Corps referred Sailors and Marines to start LIMDU for different medical reasons; to receive care from different military treatment facilities; to close LIMDU with different final actions; and to experience different post-LIMDU career outcomes.

CONCLUSION

Navy Medicine's SMART data is an important new resource for LIMDU program evaluation and population-level patient research, despite the data limitations and concerns identified and addressed by this study. The study results provide a baseline empirical understanding about the LIMDU patient population. Further research is necessary to interrogate the validity of these results over a longer period and to initiate other lines of inquiry. While the construction of the larger project's LIMDU patient population longitudinal dataset required a significant initial investment, future dividends from ongoing work are anticipated. Results derived from verified SMART data will benefit Navy Medicine, operational commands, and LIMDU patients alike by informing continuing efforts to improve patient health and career outcomes, identify and implement best clinical and administrative practices, and optimize force readiness.

Associations Between Rank, Sex, and Parity With Musculoskeletal Injuries Sustained During Annual Military Physical Fitness Test

ABSTRACT

Edwards, CM, da Silva, DF, Puranda, JL, Souza, SCS, Semeniuk, K, and Adamo, KB. Associations between rank, sex, and parity with musculoskeletal injuries sustained during annual military physical fitness test. J Strength Cond Res 38(2): 367-373, 2024-Musculoskeletal injuries pose a significant threat to the well-being of military personnel. Attempts to use physical employment standard test results as predictors of injury are underway, but little is known about injuries sustained during the tests. This study sought to identify body regions most likely to be reported as injured during the annual Canadian Armed Forces (CAF) physical fitness evaluation. In addition, sex, rank, and parity status are explored as possible associated factors for injury. A total of 1,796 actively serving CAF members were categorized by sex (1,030 male participants; 766 female participants), rank (1,142 Non-Commissioned Members [NCM]; 638 Officers), and parity (314 parous female participants; 435 nulliparous female participants). Sex, rank, and parity were associated with body regions reportedly injured during an annual CAF fitness assessment (significance p ≤ 0.05). When compared with male participants, female participants were more likely to be injured {aOR: 1.797 (95% [confidence interval] CI: 1.45-2.23)} and more prone to injury of the wrist (adjusted odds ratio [aOR]: 1.933 [95% CI: 1.20-3.12]), hip (aOR: 3.445 [95% CI: 2.07-5.728]), or lower back (aOR: 1.55 [95% CI: 1.18-2.04]). Non-Commissioned Members were more likely to injure the neck (aOR: 2.14 [95% CI: 1.18-3.88]) or shoulder (aOR: 2.03 [95% CI: 1.31-3.15]), when compared with Officers. Parous female participants reported pelvis/abdomen injury at a higher rate than the nulliparous group (5 vs. 1.7%, p = 0.019). Injuries sustained during an annual CAF fitness assessment differ based on sex, rank, and parity. Canadian Armed Forces female participants, NCM, and parous female participants may require specific physical fitness support in preparation for the annual physical fitness test.

Timing of Outcomes and Expectations After Knee Surgery in the US Military: A Systematic Review

CONTEXT

Knee injury and subsequent surgery are widespread in the military setting. Associations between knee surgery and expected outcomes over time have not been consolidated and characterized systematically by procedure type across the body of literature, and the temporal expectations of these outcomes remain unclear.

OBJECTIVE

To summarize common postoperative follow-up times and associated outcomes that determine clinical or surgical failure in US service members after elective knee surgery.

DATA SOURCES

A systematic search was conducted with 3 bibliographic databases of published research reports from 2010 through 2021.

STUDY SELECTION

Studies in US military service members undergoing elective knee surgery, with a minimum of 1-year follow-up, and reporting on a functional/occupational outcome were included. Three reviewers screened all abstracts and full-text articles to determine eligibility.

STUDY DESIGN

Systematic review of longitudinal cohort studies.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

Extracted data included military demographics, surgical procedure variables, surveillance period, and outcome measures. The Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development, and Evaluation approach were used to determine study quality and risk of bias.

RESULTS

A total of 22 studies (mean follow-up time of 40.7 months) met the inclusion criteria. For cruciate ligament repair, approximately one-third of patients required a second surgery or were medically separated from military service by 2 years from surgery; 100% were reinjured by 4 years, and 85% sustained a new injury within 5 years of surgery. For meniscal repair, nearly one-third of patients were medically separated, and half were placed on activity restrictions within 3 years of surgery. For articular cartilage repair, within 5 years, 39% of patients required a second surgery, 30% were placed on activity restrictions, and 36% were medically separated. For patellar repair, 37% of patients were medically separated and over half were placed on activity restrictions within 5 years.

CONCLUSION

Common knee surgeries can have long-term implications for military careers that may not become apparent with shorter follow-up periods (<2 years). When longer surveillance periods are used (eg, up to 5 years), additional surgical procedures are more common and the likelihood of being injured or medically separated from military service is higher.

Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review

INTRODUCTION

Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities.

METHODS

A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified.

RESULTS

From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions.

CONCLUSION

Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Musculoskeletal Complaint Epidemiology in Australian Special Operation Forces Trainees

INTRODUCTION

Elite military trainees are burdened by high numbers of musculoskeletal (MSK) injuries and are a priority military population for injury prevention. This research aims to describe the MSK complaint epidemiology of trainees undertaking special forces (SF) training in the Australian Defence Force (ADF). One barrier to accurate injury surveillance in military populations is that traditional surveillance methods rely on personnel engaging with the military healthcare system to collect injury data. This approach is likely to underestimate the injury burden as it is known that many military personnel, particularly trainees, avoid reporting their injuries because of various motives. Subsequently, the insights from surveillance systems may underestimate the injury burden and limit the ability to inform prevention requirements. This research aims to actively seek MSK complaint information directly from trainees in a sensitive manner to mediate injury-reporting behaviors.

MATERIALS AND METHODS

This descriptive epidemiology study included two consecutive cohorts of ADF SF trainees from 2019 to 2021. Musculoskeletal data items and their respective recording methods were based on international sports injury surveillance guidelines and adapted to a military context. Our case definition encompassed all injuries or physical discomforts as recordable cases. A unit-embedded physiotherapist retrospectively collected MSK complaint data from selection courses and collected prospective data over the training continuum. Data collection processes were external to the military health care system to mediate reporting avoidance and encourage injury reporting. Injury proportions, complaint incidence rates, and incidence rate ratios were calculated and compared between training courses and cohorts.

RESULTS

In total, 334 MSK complaints were reported by 103 trainees (90.4%), with a complaint incidence rate of 58.9 per 1,000 training weeks (95% CI, 53.0-65.5). Of these MSK complaints, 6.4% (n = 22) resulted in time loss from work. The lumbar spine (20.6%, n = 71) and the knee (18.9%, n = 65) were the most frequently affected body parts. Most of the MSK complaints were reported during selection courses (41.9%), followed by field survival and team tactics (23.0%) and urban operations courses (21.9%). Physical training accounted for 16.5% of complaints. Fast-roping training was associated with more severe MSK complaints.

CONCLUSIONS

Musculoskeletal complaints are highly prevalent in ADF SF trainees. Complaints are more frequently reported in selection and qualification training courses than in physical training. These activities are priorities for focused research to understand injury circumstances in ADF elite training programs to inform injury prevention strategies. A strength of our study is the data collection methods which have provided greater MSK complaint information than past research; however, much work remains in conducting consistent and accurate surveillance. Another strength is the use of an embedded physiotherapist to overcome injury-reporting avoidance. Embedded health professionals are recommended as continued practice for ongoing surveillance and early intervention.

Musculoskeletal Injury Concealment in the Reserve Officers' Training Corps: A Survey of Cadets' Reporting Behaviors

BACKGROUND

Among service members, musculoskeletal injuries threaten military readiness and place a substantial burden on medical and financial resources. Emerging research suggests that service members regularly conceal injuries, especially in training environments. The Reserve Officers' Training Corps (ROTC) is a critical training environment for future U.S. military commissioned officers. Training activities expose cadets to a high risk of injury while in the ROTC. The purpose of this study was to explore injury-reporting behaviors in cadets and factors associated with injury concealment.

MATERIALS AND METHODS

We invited Army, Air Force, and Naval cadets from six host universities participating in officer training to complete an online, self-reported survey regarding injury reporting and concealment. Cadets answered questions about pain or injuries experienced during officer training. Survey questions pertained to an injury's anatomic location, onset, severity, functional limitations, and whether or not the injury had been reported. Cadets also selected factors that influenced the decision to report or conceal injuries from predetermined lists in a "choose any" fashion. A series of χ2 tests of independence compared the relationship between injury reporting and other injury characteristics for each individual injury.

RESULTS

One hundred fifty-nine cadets (121 Army, 26 Air Force, and 12 Naval) completed the survey. Eighty-five cadets disclosed a total of 219 injuries. Two-thirds of injuries (144/219) were concealed. Twenty-six percent of participants (22/85) reported all injuries, whereas the remainder (63/85, 74%) had at least one concealed injury. In relation to injury reporting/concealment, there was a weak association with injury onset (χ21 = 4.24, P = .04, V = 0.14), a moderate association with anatomic location (χ212 = 22.64, P = .03, V = 0.32), and relatively strong associations with injury severity (χ23 = 37.79, P < .001, V = 0.42) and functional limitations (χ23 = 42.91, P < .001, V = 0.44).

CONCLUSIONS

Two-thirds of injuries went unreported in this sample of ROTC cadets. Functional limitations, symptom severity, and injury onset may be the largest factors that influence the decision to report or conceal musculoskeletal injuries. This study establishes the foundation for researching injury reporting in cadets and adds to the existing military evidence on the topic.

Simultaneous Arthroscopic Rotator Cuff Repair and Glenoid Microfracture in Active-Duty Military Patients Younger Than 50 Years: Outcomes at Midterm Follow-up

Background

While concomitant full-thickness rotator cuff tears and glenoid osteochondral defects are relatively uncommon in younger patients, military patients represent a unique opportunity to study this challenging injury pattern.

Purpose/Hypothesis

To compare the outcomes of young, active-duty military patients who underwent isolated arthroscopic rotator cuff repair (ARCR) with those who underwent ARCR plus concurrent glenoid microfracture (ARCR+Mfx). It was hypothesized that ARCR+Mfx would produce significant improvements in patient-reported outcome measures.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective analysis of consecutive active-duty military patients from a single base who underwent ARCR for full-thickness rotator cuff tears between January 2012 and December 2020. All patients were <50 years and had minimum 2-year follow-up data. Patients who underwent ARCR+Mfx were compared with those who underwent isolated ARCR based on the visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion.

Results

A total of 88 patients met the inclusion criteria for this study: 28 underwent ARCR+Mfx and 60 underwent isolated ARCR. The mean final follow-up was 74.11 ± 33.57 months for the ARCR+Mfx group and 72.87 ± 11.46 months for the ARCR group (P = .80). There were no differences in baseline patient characteristics or preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all). However, the ARCR+Mfx group had significantly worse VAS pain (1.89 ± 2.22 vs 1.03 ± 1.70; P = .05), SANE (85.46 ± 12.99 vs 91.93 ± 12.26; P = .03), and ASES (86.25 ± 14.14 vs 92.85 ± 12.57; P = .03) scores. At the final follow-up, 20 (71.43%) patients in the ARCR+Mfx group and 53 (88.33%) patients in the ARCR group were able to remain on unrestricted active-duty military service (P = .05).

Conclusion

Concomitant ARCR+Mfx led to statistically and clinically significant improvements in patient-reported outcome measures at the midterm follow-up. However, patients who underwent ARCR+Mfx had significantly worse outcomes and were less likely to return to active-duty military service than those who underwent isolated ARCR. The study findings suggest that ARCR+Mfx may be a reasonable option for young, active patients who are not candidates for arthroplasty.

Predicting Postoperative Injury and Military Discharge Status After Knee Surgery in the US Army

BACKGROUND

Researchers have assessed postoperative injury or disability predictors in the military setting but typically focused on 1 type of surgical procedure at a time, used relatively small sample sizes, or investigated mixed cohorts with civilian populations.

PURPOSE

To identify the relationship between baseline variables and injury incidence or military discharge status in US Army soldiers after knee surgery.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were obtained from a repository containing personnel, performance, and medical records for all active-duty US Army soldiers. Multivariate logistic regressions were used to estimate the effects of numerous variables on postoperative injury or on medical discharge. Variable selection and model validation were conducted using the k-fold method.

RESULTS

A total of 7567 soldiers underwent knee surgery between 2017 and 2019. Meniscal procedures were the most common type of surgery (39%), and approximately 71% of the cohort had a postoperative injury. Significant predictors for sustaining a postoperative injury included having a previous nonknee injury (odds ratio [OR], 1.5), female sex (OR, 1.3), and Black race (OR, 1.2). Within 4 years after surgery, 17% of soldiers were discharged from the military because of knee-related disability. Significant predictors for discharge from duty included enlisted rank (OR, 2.3), recent fitness test failure (OR, 1.9), number of previous knee surgeries (OR, 1.7), and having a previous nonknee injury (OR, 1.6).

CONCLUSION

After knee surgery, nearly three-fourths of the soldiers in this cohort sustained a postoperative injury and almost one-fifth of soldiers were medically discharged from the military within 4 years. This study identified variables that indicate statistically increased risk for these postoperative outcomes and highlighted potentially modifiable factors.

Simultaneous Arthroscopic Glenohumeral Stabilization and Glenoid Microfracture in Young, Active-Duty Military Patients: Outcomes at 5-Year Follow-up

Background

Glenohumeral instability represents a common cause of shoulder pain and disability among active-duty members of the military and is associated with the development of glenoid osteochondral defects.

Purpose

To report clinical outcomes and survivorship after combined microfracture of isolated chondral lesions of the glenoid and labral repair among young, active-duty military patients and to compare outcomes with those of patients who underwent isolated shoulder stabilization.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 31 active-duty military patients aged <40 years who underwent simultaneous microfracture of chondral lesions of the glenoid and labral repair for shoulder instability between January 2011 and January 2017 (microfracture group) and 209 patients without chondral defects who underwent shoulder stabilization during the same time period (instability group). Preoperative and 5-year postoperative outcomes (range of motion [ROM], visual analog scale [VAS] for pain, Single Assessment Numeric Evaluation [SANE] score, American Shoulder and Elbow Surgeons [ASES] shoulder score, and Rowe instability score) were compared within and between groups, and separate subgroup analyses were performed to determine whether variant of instability and dominant-shoulder involvement were associated with worse outcomes.

Results

The mean follow-up was significantly longer for the microfracture group versus the instability group (95.58 ± 23.12 vs 83.38 ± 25.93 months; P = .014). Age and sex distributions were similar between groups. In both groups, there was significant pre- to postoperative improvement on all outcomes scores (P = .0001 for all). When compared with the instability cohort, microfracture patients had significantly worse postoperative VAS pain (2.65 ± 1.78 vs 1.55 ± 1.92; P = .003), SANE (79.13 ± 14.43 vs 91.23 ± 13.20; P < .0001), and ASES (79.90 ± 13.87 vs 89.03 ± 14.28; P = .001) scores, as well as decreased ROM in forward flexion (151.29° ± 11.76° vs 155.48° ± 10.3°; P = .039) and external rotation (63.65° ± 8.34° vs 65.17° ± 0.64°; P = .010). At latest follow-up, 58% of microfracture patients had returned to active-duty military service compared with 93.78% of isolated instability patients (P < .0001).

Conclusion

Combined microfracture and arthroscopic labral repair produced modest, albeit statistically significant, improvements in patient-reported outcome measures and may be a reasonable treatment option for patients with chondral lesions who are not candidates for arthroplasty. However, microfracture patients had significantly worse outcomes than patients who underwent stabilization without concomitant chondral defects.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival

Background

To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid.

Methods

All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes.

Results

The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients.

Conclusion

Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

Osteoarthritis Risks and Sports: An Evidence-based Systematic Review

PURPOSE

Regular sports activities are associated with multiple physical and psychological health benefits. However, sports also may lead to injuries and the development of osteoarthritis (OA). This systematic review investigated the association between sports activity, sports type, and the risk of developing OA.

METHODS

A systematic review was performed by assessing studies that have investigated the risk of OA development in sports. Data extracted included general information, study design, number of participants, related body mass index, sports type, and assessment of OA. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 63 studies were included in this systematic review. The overall Newcastle-Ottawa Scale score was 6.46±1.44 demonstrating a good methodological quality of the articles included in the present study. A total of 628,036 participants were included, with a mean follow-up of 8.0±8.4 years. The mean age of the included athletes was 45.6±15.8, with a mean body mass index of 24.9±2.3 kg/m 2 .

CONCLUSION

Football and soccer players seem to be at higher risk for the development of OA, although the injury status of the joint should be considered when assessing the risk of OA. High equipment weight and increased injury risk also put military personnel at a higher risk of OA, although elite dancing leads to more hip labral tears. Femoroacetabular impingement was also often diagnosed in ice-hockey players and ballet dancers.

Epidemiology of Ankle Sprain in the Active-Duty Military Population

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Ankle sprain is one of the most prevalent injuries within the military population, resulting in health-care costs, time away from active duty, and negative impacts on overall readiness.

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Female service members appear to be more likely to sustain ankle sprains than male service members.

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There is a need for additional research on prevention methods and rehabilitation programs for ankle sprains in the military population because the rate of ankle sprain in this population exceeds that in populations with less physically demanding lifestyles. Consequently, low-cost prevention strategies could yield substantial benefits.

Utilization of the Department of Defense Peer-Reviewed Orthopaedic Research Program (PRORP): Combating Musculoskeletal Disease With PRORP

INTRODUCTION

Established in 2009, the Department of Defense (DoD) Peer-Reviewed Orthopaedic Research Program (PRORP) is an annual funding program for orthopaedic research that seeks to develop evidence for new clinical practice guidelines, procedures, technologies, and drugs. The aim was to help reduce the burden of injury for wounded Service members, Veterans, and civilians and to increase return-to-duty and return-to-work rates. Relative to its burden of disease, musculoskeletal injuries (MSKIs) are one of the most disproportionately underfunded conditions. The focus of the PRORP includes a broad spectrum of MSKI in areas related to unique aspect of combat- and some noncombat-related injuries. The PRORP may serve as an important avenue of research for nonmilitary communities by offering areas of shared interests for the advancement of military and civilian patient cohort MSKI care. The purpose of this study was to provide a descriptive analysis of the DoD PRORP, which is an underrecognized but high value source of research funding for a broad spectrum of both combat- and noncombat-related MSKIs.

METHODS

The complete PRORP Funding Portfolio for FY2009-FY2017 was obtained from the Congressionally Directed Medical Research Programs (CDMRP), which includes 255 awarded grants. Information pulled from the CDMRP included awardee descriptors (sex, education level, affiliated institution type, research specialty, and previous award winner [yes/no]) and grant award descriptors (grant amount, year, primary and secondary awarded topics, research type awarded, and mechanism of award). Distribution statistics were broken down by principal investigator specialty, sex, degree, organization type, research type, mechanism, and research topics. Distribution and statistical analysis was applied using R software version 3.6.3.

RESULTS

From FY2009 to 2017, $285 million was allocated for 255 PRORP-funded research studies. The seven major orthopaedic subspecialties (foot and ankle, hand, musculoskeletal oncology, pediatrics, spine, sports medicine, and trauma) were represented. Trauma and hand subspecialists received the largest amount of funding, approximately $28 (9.6%) and $22 million (7.1%), respectively. However, only 22 (8.6%) and 26 (10.2%) of the primary investigators were trauma and hand subspecialists, respectively. The primary research categories were diverse with the top five funded PRORP topics being rehabilitation ($53 million), consortia ($39 million), surgery ($37 million), device development ($30 million), and pharmacology ($10 million).

DISCUSSION

The CDMRP funding represents an excellent resource for orthopaedic medical research support that includes trauma and nontrauma orthopaedic conditions. This study serves to promote and communicate the missions of the PRORP both within and beyond the DoD to raise awareness and expand access of available funding for orthopaedic focused research.

SIGNIFICANCE/CLINICAL RELEVANCE

A likelihood exists that this project will provide sustained and powerful influence on future research by promoting awareness of orthopaedic funding sources.

LEVEL OF EVIDENCE

Level III.

Improving musculoskeletal injury surveillance methods in Special Operation Forces: A Delphi consensus study

Musculoskeletal injury mitigation is a priority in military organisations to protect personnel health and sustain a capable workforce. Despite efforts to prevent injury, inconsistencies exist in the evidence used to support these activities. There are many known limitations in the injury surveillance data reported in previous Special Operation Forces (SOF) research. Such studies often lack accurate, reliable, and complete data to inform and evaluate injury prevention activities. This research aimed to achieve expert consensus on injury surveillance methods in SOF to enhance the quality of data that could be used to inform injury prevention in this population. A Delphi study was conducted with various military injury surveillance stakeholders to seek agreement on improving surveillance methods in SOF. Iterative questionnaires using close and open-ended questions were used to collect views about surveillance methods related to injury case definitions and identifying essential and optional data requirements. Consensus was predefined as 75% group agreement on an item. Sixteen participants completed two rounds of questionnaires required. Consensus was achieved for 17.9% (n = 7) of questions in the first-round and 77.5% (n = 38) of round two questions. Several challenges for surveillance were identified, including recording injury causation, SOF personnel's injury reporting behaviours influencing accurate data collection, and surveillance system infrastructure limitations. Key military injury surveillance stakeholders support the need for improved data collection to enhance the evidence that underpins injury prevention efforts. The consensus process has resulted in preliminary recommendations to support future SOF injury surveillance.

The Impact of Musculoskeletal Injuries Sustained in Road Traffic Crashes on Work-Related Outcomes: A Systematic Review

Musculoskeletal injuries occur frequently after road traffic crashes (RTCs), and the effect on work participation is not fully understood. The primary aim of this review was to determine the impact of sustaining a musculoskeletal injury during an RTC on the rate of return to work (RTW), sick leave, and other work outcomes. The secondary aim was to determine factors associated with these work-related outcomes. An electronic search of relevant databases to identify observational studies related to work and employment, RTC, and musculoskeletal injuries was conducted. Where possible, outcome data were pooled by follow-up period to answer the primary aim. Fifty-three studies were included in this review, of which 28 were included in meta-analyses. The pooled rate of RTW was 70% at 1 month, 67% at 3 months, 76% at 6 months, 83% at 12 months, and 70% at 24 months. Twenty-seven percent of participants took some sick leave by one month follow-up, 13% by 3 months, 23% by 6 months, 36% by 12 months, and 22% by 24 months. Most of the factors identified as associated with work outcomes were health-related, with some evidence also for sociodemographic factors. While 70% of people with RTC-related musculoskeletal injury RTW shortly after accident, many still have not RTW two years later.

Mental and physical health, and long-term quality of life among service members injured on deployment

Background

More than 52,000 casualties have been documented in post-9/11 conflicts. Service members with extremity injuries (EIs) or traumatic brain injury (TBI) may be at particular risk for long-term deficits in mental and physical health functioning compared with service members with other injuries.

Methods

The present study combined medical records with patient reports of mental health and health-related quality of life (HRQOL) for 2,537 service members injured in overseas contingency operations who participated in the Wounded Warrior Recovery Project. Combined parallel-serial mediation models were tested to examine the pathways through which injury is related to mental and physical health conditions, and long-term HRQOL.

Results

Results revealed that injury was indirectly related to long-term HRQOL via its associations with physical health complications and mental health symptoms. Relative to TBI, EI was associated with a higher likelihood for a postinjury diagnosis for a musculoskeletal condition, which were related to lower levels of later posttraumatic stress disorder (PTSD) symptoms, and higher levels of physical and mental HRQOL. Similarly, EI was related to a lower likelihood for a postinjury PTSD diagnosis, and lower levels of subsequent PTSD symptoms, and therefore higher physical and mental HRQOL relative to those with TBI. Despite this, the prevalence of probable PTSD among those with EI was high (35%). Implications for intervention, rehabilitation, and future research are discussed.

Managing Complex Peripheral Nerve Injuries Within the Military Health System: A Multidisciplinary Approach to Treatment, Education, and Research at Walter Reed National Military Medical Center

INTRODUCTION

Peripheral nerve injuries are a leading cause of disability within the Military Health System (MHS) patient population. Many peripheral nerve injuries (PNIs) are amenable to therapeutic intervention but require a timely diagnosis and prompt referral to a specialty center capable of intervention, as functional outcomes are directly related to the duration between injury and intervention. Even when appropriately identified, PNI management in the MHS is often challenged by the lack of an established pathway for care coordination and a limited awareness of available diagnostic and therapeutic resources. To address these potential shortcomings, the Walter Reed National Military Medical Center Peripheral Nerve Program (WRNMMC PNP) in Bethesda, MD, has been established to provide comprehensive, multidisciplinary care to peripheral nerve-injured patients across the MHS. Additionally, the WRNMMC PNP provides graduate medical education training in PNI management for multiple residency and fellowship programs, and it facilitates critical peripheral nerve research to advance knowledge within the field.

MATERIALS AND METHODS

A retrospective review of all patients evaluated by the WRNMMC PNP between December 2015 and April 2019 was conducted in order to identify pertinent patient demographic information, referral patterns, and PNI etiology data.

RESULTS

The WRNMMC PNP evaluated 356 patients consisting of active duty, dependents, retirees, and Veterans Affairs patients during the designated study period. These patients were referred by providers from more than nine different specialties from 78 commands across eight countries. The majority of these patients (222 patients) were referred for traumatic PNI. The WRNMMC PNP has also evaluated and treated patients with PNIs stemming from congenital and compressive etiologies. One hundred and one patients referred during this period were treated with surgery, while the remainder were managed through nonoperative means.

CONCLUSIONS

The WRNMMC PNP facilitates comprehensive, patient-centered care for PNI patients within the MHS. Moreover, the program helps to prepare the next generation of providers for evaluating and treating PNI patients through its involvement with graduate medical education training. It also conducts critical peripheral nerve research and lays the foundation for collaborations with other institutions involved with peripheral nerve research. In the years ahead, the WRNMMC PNP aims to expand its outreach and capabilities within the MHS through more expansive use of telemedicine consultation and the establishment of satellite peripheral nerve clinic sites.

Soldier-Centered Care: A Concept Analysis

INTRODUCTION

It is critical for the U.S. Army Medical Department to acknowledge the distinctive medical needs of soldiers and conceptualize soldier-centered care as a unique concept. In addition to the nationally recognized standards of patient-centered care, soldier-centered care includes provisions for the priorities of soldier health and wellness, injury prevention, illness and injury management, and the preservation of physical performance and medical readiness. The development of soldier-centered care as a distinctive concept may strengthen the evidence base for interventions that support improvements to soldier care and thus, enhance health outcomes specific to soldiers. The purpose of this article is to analyze the concept of soldier-centered care, clarify the meaning of soldier-centered care, and propose a theoretical definition.

METHODS

Rodgers' evolutionary concept analysis method was used to search and analyze the literature for related terms, attributes, antecedents, and consequences and to create a theoretical definition for soldier-centered care.

RESULTS

The results of this concept analysis indicated that soldier-centered care is realized through the presence of nine attributes: operational alignment of care, provider and support staff therapeutic competence, management of transitions and care coordination, technology and accessibility, management of limited and lost work days, trust and expectation management, leadership support, continuity, and access to care. Soldier-centered care is focused on health and wellness promotion, disease and injury prevention, and early diagnosis and treatment of acute injuries in the primary care setting to facilitate timely injury recovery, reduce reinjury, and prevent long-term disabilities. The result of soldier-centered care is enhanced physical performance, medical readiness, and deployability for soldiers. Based on the literature analysis, the following theoretical definition of soldier-centered care is proposed: Soldier-centered care is individualized, comprehensive healthcare tailored to the soldier's unique medical needs delivered by a care team of competent primary care providers and support staff who prioritize trust and expectation management, operational alignment of care, leadership support, care coordination, and the management of limited and lost workdays through the use of evidence-based practice approaches that employ innovative information technology to balance access to care and continuity.

CONCLUSIONS

The concept of soldier-centered care often emerges in discussions about optimal physical performance and medical readiness for soldiers. Although soldier-centered care and patient-centered care have similar conceptual underpinning, it is important to clarify the unique physical and medical requirements for soldiers that differentiate soldier-centered care from patient-centered care. Implementing the defining attributes of soldier-centered care in the U.S. Army primary care setting may improve the quality of care and health outcomes for soldiers. When defining performance metrics for primary care models of care, the U.S. Army Medical Department must consider assessing outcomes specific to the soldier population. Developing empirical indicators for the attributes of soldier-centered care will support meaningful testing of the concept.

Incidence and Mechanisms of Musculoskeletal Injuries in Deployed Navy Active Duty Service Members Aboard Two U.S. Navy Air Craft Carriers

INTRODUCTION

This brief report describes the number and nature of cases of musculoskeletal pain and injury among sailors and marines presenting to the ship's physical therapist during recent, respective deployments of two U.S. Navy aircraft carriers.

MATERIALS AND METHODS

The case definition for this study was cases of work-limiting medical complaints involving the musculoskeletal system presenting, or referred, to the ship's physical therapy services for evaluation and treatment. The population for this study was drawn from ship's company from two Nimitz class carriers on their respective deployments. Potential subjects were recruited at their index visit for their complaint. Participants completed a survey of their symptoms while at the ship's medical department. Data for analysis consist of counts of cases, body part affected, self-reported mechanism of injury, age, and gender of the subject. Data were analyzed by generating descriptive tables.

RESULTS

One hundred ninety-seven cases were captured across the two carriers. Injury to the low back was the most frequent (34%), followed by shoulder (25%) and knee (15%). Twenty one cases (11%) were reported to be exacerbation of previous injuries and the rest new injuries. Of the 176 new injury cases, 93 (53%) were of an insidious onset and the remainder had a specific, identifiable onset. Of the 82 cases with a specific identifiable onset, 38 cases (46%) occurred during participation in sport and exercise activity on board ship, and the remainder of the cases occurred during the performance of duty-related work. None of the cases required evacuation off of the ship.

CONCLUSION

Care should be used interpreting the results since participants were volunteers and a small proportion of eligible subjects chose not to participate in the study. Nevertheless, our data are generally consistent with other studies of musculoskeletal injury on board U.S. Navy ships and are useful for health care planning purposes and for planning for future studies that may take place on board U.S. Navy vessels. The novel and important finding of this study suggests that sports and exercise activity on board ship may warrant a new area of attention for safety.

Factors Associated With Progression to Surgical Intervention for Lumbar Disc Herniation in the Military Health System

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To determine surgery-free survival of patients receiving conservative management of lumbar disc herniation (LDH) in the military healthcare system (MHS) and risk factors for surgical intervention.

SUMMARY OF BACKGROUND DATA

Radiculopathy from LDH is a major cause of morbidity and cost.

METHODS

The Military Data Repository was queried for all patients diagnosed with LDH from FY2011-2018; the earliest such diagnosis in a military treatment facility (MTF) was kept for each patient as the initial diagnosis. Follow-up time to surgical intervention was defined as the time from diagnosis to first encounter for lumbar microdiscectomy or lumbar decompression in either a MTF or in the civilian sector. The Military Data Repository was also queried for history of tobacco use at any time during MHS care, age at the time of diagnosis, sex, MHS beneficiary category, and diagnosing facility characteristics. Multivariable Cox proportional hazards models were used to evaluate the associations of patient and diagnosing facility characteristics with time to surgical intervention.

RESULTS

A total of 84,985 MHS beneficiaries including 62,771 active duty service members were diagnosed with LDH in a MTF during the 8-year study period. A total of 10,532 (12.4%) MHS beneficiaries, including 7650 (10.9%) active duty, failed conservative management onto surgical intervention with lumbar microdiscectomy or lumbar decompression. Median follow-up time of the cohort was 5.2 (interquartile range 2.6, 7.5) years. Among all healthcare beneficiaries, several patient-level (younger age, male sex, and history of tobacco use) and facility-level characteristics (hospital vs. clinic and surgical care vs. primary care clinic) were independently associated with higher risk of surgical intervention.

CONCLUSION

LDH compromises military readiness and negatively impacts healthcare costs. MHS beneficiaries with LDH have a good prognosis with approximately 88% of patients successfully completing conservative management. However, strategies to improve outcomes of conservative management in LDH should address risks associated with both patient and facility characteristics.Level of Evidence: 4.

Physical Performance Measures of Flexibility, Hip Strength, Lower Limb Power, and Trunk Endurance in Healthy Navy Cadets: Normative Data and Differences Between Sex and Limb Dominance

ABSTRACT

Lopes, TJA, Simic, M, Alves, DdS, Bunn, PdS, Rodrigues, AI, Terra, BdS, Lima, MdS, Ribeiro, FM, Vilão, P, and Pappas, E. Physical performance measures of flexibility, hip strength, lower limb power, and trunk endurance in healthy navy cadets: Normative data and differences between sex and limb dominance. J Strength Cond Res 35(2): 458-464, 2021-The objectives were to provide normative data on commonly used physical performance tests that may be associated with musculoskeletal injuries in Navy cadets and assess for sex and limb dominance differences. A large cohort of Navy cadets were assessed for physical performance tests of flexibility (ankle dorsiflexion range of motion and sit and reach), isometric hip strength, lower limb power (single-leg hop), and trunk endurance (plank and side plank tests). Besides providing normative data tables, sex and limb dominance differences were assessed by a 2-way mixed analysis of variance. A total of 545 Brazilian Navy cadets (394 men) representing 79% of the cadets in the Academy participated. Normative reference values were reported as mean ± SD, 95% confidence interval and percentiles. For tests of muscle strength, power, and endurance, men performed better than women (p < 0.001). For flexibility tests, women achieved greater distances than men for the sit and reach test (p < 0.001), but no difference for ankle dorsiflexion (p = 0.51). Overall, there were no clinically relevant differences between limbs. In conclusion, normative data for commonly used physical performance tests were provided. Although no clinically relevant side-to-side differences were found, men presented higher values for lower limb strength and power, as well as trunk endurance than women, whereas women demonstrated increased flexibility. Valuable normative data are provided to professionals who work with young, active populations from the injury prevention or rehabilitation perspective because the current study may help professionals to identify athletes or cadets whose performance is outside the normative values and may be at risk for injury.

Musculoskeletal injury in military Special Operations Forces: a systematic review

INTRODUCTION

Special Operations Forces conduct military activities using specialised and unconventional techniques that offer a unique and complementary capability to conventional forces. These activities expose Special Operations Forces personnel to different injury risks in comparison with personnel in the conventional forces. Consequently, different injury patterns are expected in this population. The purpose of this research is to establish high-level evidence informing what is known about musculoskeletal injury epidemiology in Special Operations Forces.

METHODS

A systematic review was conducted using three online databases to identify original studies reporting musculoskeletal injury data in Special Operations Forces. A critical appraisal tool was applied to all included studies. Descriptive data were extracted for demographics, study design details and injuries (eg, injury frequency, injury type, body part injured, activity, mechanism, severity). Results were narratively synthesised.

RESULTS

Twenty-one studies were included. Trainees conducting qualification training had the highest injury frequency, up to 68% injured in a training period. The ankle, knee and lumbar spine were the most common body parts affected. Parachuting caused the most severe injuries. Physical training was the most common activity causing injury, accounting for up to 80% of injuries. Running and lifting were common injury mechanisms. Injury causation information was frequently not reported. Partially validated surveillance methods limited many studies.

CONCLUSIONS

Injuries are prevalent in Special Operation Forces. Future research should prioritise identifying injury causation information that supports prevention. Focus on improving surveillance methods to enhance the accuracy and comparison of results across cohorts is also recommended.

Hyperbaric Oxygen Therapy in Sports Musculoskeletal Injuries

Hyperbaric oxygen therapy (HBOT) is a well-established treatment for a variety of conditions. Hyperbaric oxygen therapy is the administration of 100% oxygen breathing in a pressure vessel at higher than atmospheric pressure (1 atmosphere absolute = 101 kPa). Typically, treatment is given daily for between 1 and 2 h at pressures of 2.0 to 2.8 ATA, depending on the indication. Sporting injuries are often treated over 3 to 10 sessions. Hyperbaric oxygen therapy has been documented to be effective and is approved in 14 medical indications by the Undersea and Hyperbaric Medical Society, including, but not limited to, carbon monoxide poisoning, compromised skin grafts and flaps, crush injuries, necrotizing soft tissue infections, and nonhealing ulcers with arterial insufficiencies. Recently, HBOT for sports musculoskeletal injuries is receiving increased attention. Hyperbaric oxygen therapy may allow injured athletes to recover faster than normal rehabilitation methods. Any reduction in collegiate and professional athletes' rehabilitation period can be financially significant for top-level sports teams; however, further research is required to confirm HBOT's benefits on sports musculoskeletal injuries. The purpose of this review to discuss the current understanding of HBOT as a treatment modality for common musculoskeletal injuries in sport medicine. Moreover, we will highlight the advantages and disadvantages of this modality, as well as relevant clinical and research applications.

Effects of Linear Periodization Training on Performance Gains and Injury Prevention in a Garrisoned Military Unit

PURPOSE

Performing well in combat requires military service members to be in peak physical shape. Although each branch of the United States military has fitness guidelines and assessments, there are no exact prescriptions for physical training programs. The absence of a standardised approach may lead to suboptimal physical performance and increased risk of musculoskeletal injury. To address this gap, we evaluated the feasibility of a pilot combat conditioning program based on linear periodisation.

METHODS

Twenty-nine garrisoned US Marine Corps service members (25 men, 4 women; 23.5±4.4 years) enrolled in our 11-week conditioning program that was supervised by a strength and conditioning professional. Military-specific (physical/combat fitness tests) and general (treadmill-based maximal exercise test) assessments were performed at baseline and 11 weeks. Training and injury logs were maintained throughout the duration of the program.

RESULTS

Approximately 80% (23/29) of service members completed the entire program. Cardiorespiratory fitness (Peak VO^2; +8.10±10.9%; p=0.011), upper-body strength (pull-ups; +47.0±58.2%; p<0.001) and core strength (abdominal crunches; +9.2±23.3%; p=0.029) significantly increased from pre- to post-training. No statistically significant improvement or worsening was noted in any other performance assessment measure. Eight (28%) participants reported minor musculoskeletal concerns, of which only one required medical attention (injury rate 1.3 injuries/100 person-months).

CONCLUSION

A protocolised linear periodisation training program was feasible and demonstrated improvements in fitness in a group of garrisoned Marines with low injury rates. Other military units may benefit from a similar approach.

Epidemiology and Financial Burden of Musculoskeletal Injuries as the Leading Health Problem in the Military

INTRODUCTION

Musculoskeletal injuries (MSIs) have direct impact on occupational readiness and task performance in military populations. Until this date, no epidemiologic data have been published concerning MSI incidence in the Netherlands Armed Forces (NAF). The aim of this study was to assess the MSI incidence and related costs in the NAF.

METHODS

In this descriptive epidemiologic study, we collected injury surveillance data from the electronic patient records of multiple military units of the NAF. Using data of all new consultations with a military physician from January 1, 2014 to December 31, 2016, we calculated MSI incidence rates per 100 person-years, with a 95% confidence interval (CI). Physician care costs were determined based on the number of physician consults and the charge per appointment. We used two methods to determine productivity costs; the top-down microcosting method and the friction cost method.

RESULTS

Our study sample included 22% (n = 8,847) of the total NAF population of 2016 (n =40,178). In this sample, consultations of MSIs accounted for 23.2% (n = 7,815) of all new consultations (n = 33,666). MSI incidence rates per unit ranged from 12.5 to53.3 per 100 person-years. In the total sample, MSI incidence rates were highest in the back (6.73, 95% CI 6.39-7.10), knee (5.04, 95% CI 4.74-5.35), and foot (4.79, 95% CI 4.50-5.10). The estimated costs for physician visits for MSIs in our sample were €0.69 million. Limited duty days accounted for €1.10 million productivity costs using top-down microcosting method.

CONCLUSION

Our study provided evidence that MSIs result in substantial financial burden. Injuries of the back, knee, and foot account for the majority of demands on curative care for MSIs.

Blood Flow Restriction Therapy: From Development to Applications

Blood flow restriction (BFR) has been shown to produce beneficial adaptations to skeletal muscle. These adaptations have been documented in the civilian and military populations. BFR therapy may provide patients a safe method to begin strength training at earlier stages of rehabilitation to allow for earlier and more effective return to activity and improved military readiness. The purpose was to review BFR therapy physiology, complications, side effects, standardized treatment algorithms, and long-term patient outcomes.

Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task

Painful and disabling musculoskeletal disorders remain prevalent. In rats trained to perform repetitive tasks leading to signs and dysfunction similar to those in humans, we tested whether manual therapy would prevent the development of the pathologies and symptoms. We collected behavioral, electrophysiological, and histological data from control rats, rats that trained for 5 weeks before performing a high-repetition high-force (HRHF) task for 3 weeks untreated, and trained rats that performed the task for 3 weeks while being treated 3x/week using modeled manual therapy (MMT) to the forearm (HRHF + MMT). The MMT included bilateral mobilization, skin rolling, and long axis stretching of the entire upper limb. High-repetition high-force rats showed decreased performance of the operant HRHF task and increased discomfort-related behaviors, starting after training. HRHF + MMT rats showed improved task performance and decreased discomfort-related behaviors compared with untreated HRHF rats. Subsets of rats were assayed for presence or absence of ongoing activity in C neurons and slow Aδ neurons in their median nerves. Neurons from HRHF rats had a heightened proportion of ongoing activity and altered conduction velocities compared with control and MMT-treated rats. Median nerve branches in HRHF rats contained increased numbers of CD68 macrophages and degraded myelin basic protein, and showed increased extraneural collagen deposition, compared with the other groups. We conclude that the performance of the task for 3 weeks leads to increased ongoing activity in nociceptors, in parallel with behavioral and histological signs of neuritis and nerve injury, and that these pathophysiologies are largely prevented by MMT.

Joint Space Narrowing in Patients with Femoroacetabular Impingement: A Matched Cohort Study of Military versus Civilian Patients

Introduction

Decreased hip joint space has been associated with poorer outcomes after hip arthroscopy. The purpose of this study was to determine if a difference exists in hip joint degenerative findings in military versus civilian patients with FAI.

Methods

A single surgeon’s case series was reviewed to identify all patients undergoing primary hip arthroscopy for treatment of FAI. All active duty military personnel were included in the study group. A cohort of civilian patients matched for age, gender, lateral center edge (LCE) angle, and alpha angle was identified and included as the control group. The hip joint space was measured at the medial and lateral extents of the acetabular sourcil and the center of the sourcil. The Tonnis grade for osteoarthritis was recorded for each patient. Labral tear size as well as femoral head and acetabular chondromalacia grading were obtained from operative records.

Results

A total of 229 patients that underwent primary hip arthroscopy for FAI were identified. 46(20.1%) were active duty military personnel. A well-matched cohort of 46 civilian patients was identified. There was no statistical difference in age (35.0, 34.7 years), gender (31 males, 15 females in both groups), BMI (26.8, 27.6), LCE angle (31.0, 31.5), and alpha angle (64.9, 64.9) between the civilian and military groups. Joint space was narrower in the military group in each of the three measured locations (Superomedial 3.8 mm vs 4.2 mm, p = 0.025; Superior 4.0 mm vs 4.4 mm, p = 0.013; Superolateral 4.4 mm vs 4.9 mm, p = 0.043).

Conclusion

Military patients with FAI may have increased joint space narrowing compared to otherwise similar civilian patients. Femoral and acetabular chondromalacia are found in similar frequencies in military and civilian populations, however the grading system utilized accounts for the presence but not the size of high grade lesions.

Level of Evidence

Level 3.

Epidemiology of musculoskeletal injuries among US Air Force Special Tactics Operators: an economic cost perspective

Objectives

Musculoskeletal injuries (MSI) are an important concern in military populations. The purpose of this study was to describe the burden of MSI and associated financial cost, in a sample of US Air Force Special Operations Command Special Tactics Operators.

Methods

In this cross-sectional study, medical records of the Operators were reviewed during the years 2014–2015. MSI that occurred during a 1-year period prior to the date of review were described. MSI attributes described included incidence, anatomic location, cause, activity when MSI occurred, type and lifetime cost of MSI estimated using the Web-based Injury Statistics Query and Reporting System.

Results

A total of 130 Operators participated in the study (age: 29.1±5.2 years). The 1-year cumulative incidence of MSI was 49.2 injured Operators/100 Operators/year. The most frequent anatomic location and sublocation for MSI were the lower extremity (40.9% of MSI) and shoulder (20.9%), respectively. Lifting was a common cause of MSI (21.8%). A large per cent of MSI (55.5%) occurred while Operators were engaged in either physical or tactical training. Common MSI types were pain/spasm/ache (44.5%). Many MSI (41.8%) were classified as potentially preventable by an injury prevention training programme. The total lifetime cost of these MSI was estimated to be approximately US$1.2 million.

Conclusion

MSI are an important cause of morbidity and financial cost in this sample of Air Force Special Tactics Operators. There is a need to develop a customised injury prevention programme to reduce the burden and cost of MSI in this population.

Physical Therapists Forward Deployed on Aircraft Carriers: A Retrospective Look at a Decade of Service

Introduction

Navy physical therapists (PTs) have been a part of ship's company aboard Aircraft Carriers since 2002 due to musculoskeletal injuries being the number one cause of lost duty time and disability. This article describes a decade of physical therapy services provided aboard aircraft carriers.

Materials and Methods

A retrospective survey was conducted to evaluate the types of services provided, volume of workload, value of services provided, and impact of PTs on operational readiness for personnel aboard Naval aircraft carriers. Thirty-four reports documenting workload from PTs stationed onboard aircraft carriers were collected during the first decade of permanent PT assignment to aircraft carriers.

Results

This report quantifies a 10-yr period of physical therapy services (PT and PT Technician) in providing musculoskeletal care within the carrier strike group and adds to existing literature demonstrating a high demand for musculoskeletal care in operational platforms. A collective total of 144,211 encounters were reported during the 10-yr period. The number of initial evaluations performed by the PT averaged 1,448 per assigned tour. The average number of follow-up appointments performed by the PT per tour was 1,440. The average number of treatment appointments per tour provided by the PT and PT technician combined was 1,888. The average number of visits per patient, including the initial evaluation, was 3.3. Sixty-five percent (65%) of the workload occurred while deployed or out to sea during training periods. It was estimated that 213 medical evacuations were averted over the 10-yr period. There were no reports of adverse events or quality of care reviews related to the care provided by the PT and/or PT technician. Access to early PT intervention aboard aircraft carriers was associated with a better utilization ratio (lower average number of visits per condition) than has been reported in prior studies and suggests an effective utilization of medical personnel resources.

Conclusions

The impact of Navy PTs serving afloat highlights the importance of sustaining these billets and indicates the potential benefit of additional billet establishment to support operational platforms with high volumes of musculoskeletal injury. Access to early PT intervention can prevent and rehabilitate injuries among operational forces, promote human performance optimization, increase readiness during war and peace time efforts, and accelerate rehabilitation from neuromusculoskeletal injuries. With the establishment of Electronic Health Records within all carrier medical groups a repeat study may provide additional detail related to musculoskeletal injuries to guide medical planners to staff sea-based operational platforms most effectively to care for the greatest source of battle and disease non-battle injuries and related disability in the military.

Extremity War Injuries XII: Homeland Defense as a Translation of War Lessons Learned

The 12th Extremity War Injuries Symposium focused on issues related to the transitions in medical care that are occurring as the focus of the war on terror changes. The symposium highlighted the results of Department of Defense-funded research in musculoskeletal injury, the evolution of combat casualty care, and the readiness of the fighting force. Presentations and discussions focused on force readiness of both troops and their medical support as well as the maintenance of the combat care expertise that has been developed during the previous decade of conflict.

Abdominal Circumference Versus Body Mass Index as Predictors of Lower Extremity Overuse Injury Risk

BACKGROUND

Abdominal circumference (AC) is superior to body mass index (BMI) as a measure of risk for various health outcomes. Our objective was to compare AC and BMI as predictors of lower extremity overuse injury (LEOI) risk.

METHODS

Retrospective review of electronic medical records of 79,868 US Air Force personnel over a 7-year period (2005-2011) for incidence of new LEOI. Subjects were stratified by BMI and AC. Injury risk for BMI/AC subgroups was calculated using Kaplan-Meier curves and Cox proportional-hazards regression. Receiver operating characteristic curves with area under the curve were used to compare each model's predictive value.

RESULTS

Cox proportional-hazards regression showed significant risk association between elevated BMI, AC, and all injury types, with hazard ratios ranging 1.230-3.415 for obese versus normal BMI and 1.665-3.893 for high-risk versus low-risk AC (P < .05 for all measures). Receiver operating characteristic curves with area under the curve showed equivalent performance between BMI and AC for predicting all injury types. However, the combined model (AC and BMI) showed improved predictive ability over either model alone for joint injury, overall LEOI, and most strongly for osteoarthritis.

CONCLUSIONS

Although AC and BMI alone performed similarly well, a combined approach using BMI and AC together improved risk estimation for LEOI.

Comprehensive biomechanical characterization of feet in USMA cadets: Comparison across race, gender, arch flexibility, and foot types

Lower extremity musculoskeletal injuries are common, complex, and costly problems. Literature supports associations between static foot structure and dynamic foot function, as well as between overuse injury and demographic characteristics. Previous studies failed to provide a comprehensive biomechanical foot characteristics of at-risk military personnel. In this study, foot structure, function, and arch height flexibility (AHF) were objectively measured in 1090 incoming cadets (16.3% female, mean age of 18.5years and BMI of 24.5kg/m²) of the United States Military Academy at the start of their training. A Generalized Linear Model with an identity link function was used to examine the effects of race, gender, foot types, and AHF while accounting for potential dependence in bilateral data. Planus and flexible feet independently demonstrated over-pronation, as measured by reduced Center of Pressure Excursion Index (CPEI). When comparing across race, Black participants showed a significantly lower arch height index (AHI), a larger malleolar valgus index (MVI), and a higher prevalence of pes planus (91.7% versus 73.3% overall). However, Asian participants with flexible arches, rather than Black with low arch, displayed over-pronation in gait. Females showed no significant difference in standing AHI and MVI but demonstrated a significantly greater AHF and a reduced CPEI than male participants. This was the first large scale investigation that comprehensively characterized biomechanical foot in a cohort of young at-risk individuals with lower limb musculoskeletal injuries. Long-term goal is to examine the relationship between these biomechanical features and injuries, ultimately to develop effective preventive measures.

Effect of a Lower Extremity Preventive Training Program on Physical Performance Scores in Military Recruits

Peck, KY, DiStefano, LJ, Marshall, SW, Padua, DA, Beutler, AI, de la Motte, SJ, Frank, BS, Martinez, JC, and Cameron, KL. Effect of a lower extremity preventive training program on physical performance scores in military recruits. J Strength Cond Res 31(11): 3146-3157, 2017-Exercise-based preventive training programs are designed to improve movement patterns associated with lower extremity injury risk; however, the impact of these programs on general physical fitness has not been evaluated. The purpose of this study was to compare fitness scores between participants in a preventive training program and a control group. One thousand sixty-eight freshmen from a U.S. Service Academy were cluster-randomized into either the intervention or control group during 6 weeks of summer training. The intervention group performed a preventive training program, specifically the Dynamic Integrated Movement Enhancement (DIME), which is designed to improve lower extremity movement patterns. The control group performed the Army Preparation Drill (PD), a warm-up designed to prepare soldiers for training. Main outcome measures were the Army Physical Fitness Test (APFT) raw and scaled (for age and sex) scores. Independent t tests were used to assess between-group differences. Multivariable logistic regression models were used to control for the influence of confounding variables. Dynamic Integrated Movement Enhancement group participants completed the APFT 2-mile run 20 seconds faster compared with the PD group (p < 0.001), which corresponded with significantly higher scaled scores (p < 0.001). Army Physical Fitness Test push-up scores were significantly higher in the DIME group (p = 0.041), but there were no significant differences in APFT sit-up scores. The DIME group had significantly higher total APFT scores compared with the PD group (p < 0.001). Similar results were observed in multivariable models after controlling for sex and body mass index (BMI). Committing time to the implementation of a preventive training program does not appear to negatively affect fitness test scores.

Mitigating the risk of musculoskeletal injury: A systematic review of the most effective injury prevention strategies for military personnel

OBJECTIVES

To update the current injury prevention strategy evidence base for making recommendations to prevent physical training-related musculoskeletal injury.

DESIGN

We conducted a systematic review to update the evidence base on injury prevention strategies for military personnel.

METHODS

Literature was systematically searched and extracted from five databases, and reported according to PRISMA guidelines. Sixty one articles meeting the inclusion criteria and published during the period 2008-2015 were selected for systematic review.

RESULTS

The retrieved articles were broadly categorised into six injury prevention strategies; (1) conditioning, (2) footwear modifications, (3) bracing, (4) physical activity volume, (5) physical fitness, and (6) leadership/supervision/awareness. The majority of retrieved articles (n=37 (of 61) evaluated or systematically reviewed a conditioning intervention of some nature. However, the most well-supported strategies were related to reducing physical activity volume and improving leadership/supervision/awareness of injuries and injury prevention efforts.

CONCLUSIONS

Several injury prevention strategies effectively reduce musculoskeletal injury rates in both sexes, and many show promise for utility with military personnel. However, further evaluation, ideally with prospective randomised trials, is required to establish the most effective injury prevention strategies, and to understand any sex-specific differences in the response to these strategies.

Oleanolic Acid Enhances Mesenchymal Stromal Cell Osteogenic Potential by Inhibition of Notch Signaling

Oleanolic acid (OA), a pentacyclic triterpenoid, has been shown to modulate multiple signaling pathways in a variety of cell linages. But the mechanisms underlying OA-mediated mesenchymal stromal cell (MSC) osteogenic differentiation are not known. In this study, we examined effects of OA on cell viability, osteogenic differentiation in MSCs, and the involvement of Notch and BMP signaling. OA induced bone marrow derived MSC differentiation towards osteoprogenitor cells and inhibited Notch signaling in a dose dependent manner. Constitutive activation of Notch signaling fully blocked OA induced MSC osteogenic differentiation. The expression level of early osteogenic marker genes, ALP, Runx2, and type I collagen, which play a critical role in MSC to osteoblast transition and servers as a downstream target of BMP signaling, was significantly induced by OA. Furthermore, BMP2 mediated MSC osteogenic differentiation was significantly enhance by OA treatment, indicating a synergistic effect between BMP2 and OA. Our results suggest that OA is a promising bioactive agent for bone tissue regeneration, and inhibition of Notch signaling is required for its osteogenic effects on MSCs.

Knowledge mapping visualization analysis of the military health and medicine papers published in the web of science over the past 10 years

BACKGROUND

Military medicine is a research field that seeks to solve the medical problems that occur in modern war conditions based on public medicine theory.

METHODS

We explore the main research topics of military health and medical research in the web of science™ core collection (WoSCC) from 2007 to 2016, and the goal of this work is to serve as a reference for orientation and development in military health and medicine. Based on CiteSpace III, a reference co-citation analysis is performed for 7921 papers published in the WoSCC from 2007 to 2016. In addition, a cluster analysis of research topics is performed with a comprehensive analysis of high-yield authors, outstanding research institutions and their cooperative networks.

RESULTS

Currently, the research topics in military health and medicine mainly focus on the following seven aspects: mental health diagnoses and interventions, an army study to assess risk and resilience in service members (STARRS), large-scale military action, brain science, veterans, soldier parents and children of wartime, and wound infection. We also observed that the annual publication rate increased with time. Wessely S, Greenberg N, Fear NT, Smith TC, Smith B, Jones N, Ryan MAK, Boyko EJ, Hull L, and Rona RJ were the top 10 authors in military health and medicine research. The top 10 institutes were the Uniformed Services University of the Health Sciences, the United States Army, the United States Navy, Kings College London, Walter Reed National Military Medical Center, Boston University, Walter Reed Army Institute of Research, Walter Reed Army Medical Center, Naval Health Research Center, and the VA Boston Healthcare System.

CONCLUSIONS

We are able to perform a comprehensive analysis of studies in military health and medicine research and summarize the current research climate and the developmental trends in the WoSCC. However, further studies and collaborations are needed worldwide. Overall, our findings provide valuable information and new perspectives and shape future research directions for further research in the area of military health and medicine.

Extremity War Injuries XI: Maintaining Force Readiness During an Era of Military Transition

The symposium Extremity War Injuries XI focused on issues related to the transitions in medical care that are occurring as the focus of the war on terror changes. Titled "Maintaining Force Readiness During an Era of Military Transition," this year's symposium highlighted the results of Department of Defense-funded research in musculoskeletal injury, the evolution of combat casualty care, and the readiness of the fighting force. The issues highlighted related to the force readiness of both troops and their medical support as well as the maintenance of the combat care expertise that has been developed during the last decade of conflict. As always, participants in breakout sessions addressed the research gaps in the topics discussed.

A Porcine Urinary Bladder Matrix Does Not Recapitulate the Spatiotemporal Macrophage Response of Muscle Regeneration after Volumetric Muscle Loss Injury

Volumetric muscle loss (VML) results in irrecoverable loss of muscle tissue making its repair challenging. VML repair with acellular extracellular matrix (ECM) scaffolds devoid of exogenous cells has shown improved muscle function, but limited de novo muscle fiber regeneration. On the other hand, studies using minced autologous and free autologous muscle grafts have reported appreciable muscle regeneration. This raises the fundamental question whether an acellular ECM scaffold can orchestrate the spatiotemporal cellular events necessary for appreciable muscle fiber regeneration. This study compares the macrophage and angiogenic responses including the remodeling outcomes of a commercially available porcine urinary bladder matrix, MatriStem™, and autologous muscle grafts. The early heightened and protracted M1 response of the scaffold indicates that the scaffold does not recapitulate the spatiotemporal macrophage response of the autograft tissue. Additionally, the scaffold only supports limited de novo muscle fiber formation and regressing vessel density. Furthermore, scaffold remodeling is accompanied by increased presence of transforming growth factor and α-smooth muscle actin, which is consistent with remodeling of the scaffold into a fibrotic scar-like tissue. The limited muscle formation and scaffold-mediated fibrosis noted in this study corroborates the findings of recent studies that investigated acellular ECM scaffolds (devoid of myogenic cells) for VML repair. Taken together, acellular ECM scaffolds when used for VML repair will likely remodel into a fibrotic scar-like tissue and support limited de novo muscle fiber regeneration primarily in the proximity of the injured musculature. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel.

Incidence and Characteristics of Meniscal Injuries in Cadets at a Military School, 2013-2015

CONTEXT

 Meniscal injury is common among military service members.

OBJECTIVE

 To examine the incidence and characteristics of meniscal injuries in cadets at a single military institution between 2013 and 2015.

DESIGN

 Cohort study.

SETTING

 Meniscal-injury data were collected at the Center of Rehabilitation Training, the People's Liberation Army University of Science and Technology.

PATIENTS OR OTHER PARTICIPANTS

 A total of 2479 cadets participating in physical activities between 2013 and 2015.

MAIN OUTCOME MEASURE(S)

 Injury rates, injury proportions by body mass index, risk ratios (RRs), and injury proportion ratios were reported with 95% confidence intervals (CIs).

RESULTS

 The overall incidence rate was 10.08 (95% CI = 6.84, 14.84) per 1000 person-years. A multiple-comparisons test revealed differences in the relative injury rate in overweight or obese cadets versus normal-weight cadets and underweight cadets (χ² = 8.98, P = .01). No differences were found between injured normal-weight cadets and underweight cadets (P = .66, RR = 1.39, 95% CI = 0.32, 6.06) or between injured overweight or obese cadets and injured underweight cadets (P = .24, RR = 0.42, 95% CI = 0.09, 1.91). The absolute injury rate was higher for overweight and obese cadets compared with normal-weight cadets (P < .01, RR = 0.30, 95% CI = 0.13, 0.69). The overall proportional distribution for patterns of injury was 2:1 (medial to lateral) for meniscal injuries. Grade 2 injuries were the most common.

CONCLUSIONS

 The high frequency and level of severity of meniscal injuries may negatively affect the readiness and health of cadets. High body mass index was a risk factor for meniscal injury.

Medical causes of temporary or definitive leaves from a French counterterrorist unit pre-internship

INTRODUCTION

Each year, the French Special Weapons And Tactics team, Groupe d'Intervention de la Gendarmerie Nationale, recruits new members through a physically demanding 8-week selection process. The goal of this study is to estimate the incidence and the causes for temporary or final interruptions during this process for medical reasons.

SUBJECTS, MATERIAL AND METHODS

All of the candidates for the November 2015 selection process were included in this prospective study. The number and reasons for temporary or final interruptions were documented by military general practitioners.

RESULTS

The applicants were 48 law enforcement professionals (2 women, mean age 29.4 years, range 22-35). In 14 cases, a temporary interruption was required and in five cases the selection process prematurely ended. Fifty-two per cent of the temporary interruptions were due to sprains, tendinopathies, fractures or muscle tears, 11% were due to burns, wounds or subcutaneous bruises, 16% were due to cranial trauma and 21% were due to medical causes.

DISCUSSION

The high prevalence of minor traumatology that we observed is similar to the ones observed in other cohorts describing initial training for military personnel in the conventional forces. However, the presence of other pathologies in our study, such as cranial trauma or medical causes, is due to the specificity of this internship selection granting access to an elite unit.

Is High-Intensity Functional Training (HIFT)/CrossFit Safe for Military Fitness Training?

High-intensity functional training (HIFT) is a promising fitness paradigm that gained popularity among military populations. Rather than biasing workouts toward maximizing fitness domains such as aerobic endurance, HIFT workouts are designed to promote general physical preparedness. HIFT programs have proliferated as a result of concerns about the relevance of traditional physical training (PT), which historically focused on aerobic condition via running. Other concerns about traditional PT include: (1) the relevance of service fitness tests given current combat demands, (2) the perception that military PT is geared toward passing service fitness tests, and (3) that training for combat requires more than just aerobic endurance. Despite its' popularity in the military, concerns have been raised about HIFT's injury potential, leading to some approaches being labeled as "extreme conditioning programs" by several military and civilian experts. Given HIFT programs' popularity in the military and concerns about injury, a review of data on HIFT injury potential is needed to inform military policy. The purpose of this review is to: (1) provide an overview of scientific methods used to appropriately compare injury rates among fitness activities and (2) evaluate scientific data regarding HIFT injury risk compared to traditional military PT and other accepted fitness activities.

Osteoarthritis and the Tactical Athlete: A Systematic Review

OBJECTIVE

 Although tactical athletes (eg, military service members, law enforcement personnel, fire fighters) are exposed to several known risk factors, it remains unclear if they are at increased risk for osteoarthritis (OA). The purpose of this systematic review was to investigate the association between serving as a tactical athlete and the incidence and prevalence of OA.

DATA SOURCES

 We completed a comprehensive systematic literature search in November 2014 using 12 bibliographic databases (eg, PubMed, Ovid, SportDiscus) supplemented with manual searches of reference lists.

STUDY SELECTION

 Studies were included if they met the following criteria: (1) an aim of the study was to investigate an association between tactical athletes and OA; (2) the outcome measure was radiographic OA, clinical OA, total joint replacement, self-reported diagnosis of OA, or placement on a waiting list for a total joint replacement; (3) the study design was a cohort study; and (4) the study was written in English.

DATA EXTRACTION

 One investigator extracted data from articles that met all inclusion criteria (eg, group descriptions, measures of disease burden, source of nonexposed controls).

DATA SYNTHESIS

 Twelve articles met the inclusion criteria and described retrospective cohort studies. Firefighters, active-duty military service members, and veteran military parachutists consistently had a higher incidence or prevalence of knee, hip, or any OA diagnosis (4 studies). Active-duty pilots and veteran military parachutists may have a higher prevalence of spine OA, but this was not statistically significant (2 studies). Occupational risk factors for OA among tactical athletes include rank and branch of military service. The risk of OA among individuals who completed mandatory national military service remains unclear (6 studies).

CONCLUSIONS

 The incidence of OA among tactical athletes appears to be significantly higher when compared with nonexposed controls. Further research is needed to specifically identify modifiable risk factors within this high-risk population to develop and implement effective risk-reduction strategies.

The Effects of an Injury Prevention Program on Landing Biomechanics Over Time

BACKGROUND

Knowledge is limited regarding how long improvements in biomechanics remain after completion of a lower extremity injury prevention program.

PURPOSE

To evaluate the effects of an injury prevention program on movement technique and peak vertical ground-reaction forces (VGRF) over time compared with a standard warm-up (SWU) program.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 1104 incoming freshmen (age range, 17-22 years) at a military academy in the United States volunteered to participate. Participants were cluster-randomized by military company to either the Dynamic Integrated Movement Enhancement (DIME) injury prevention program or SWU. A random subsample of participants completed a standardized jump-landing task at each time point: immediately before the intervention (PRE), immediately after (POST), and 2 (POST2M), 4 (POST4M), 6 (POST6M), and 8 months (POST8M) after the intervention. VGRF data collected during the jump-landing task were normalized to body weight (%BW). The Landing Error Scoring System (LESS) was used to evaluate movement technique during the jump landing. The change scores (Δ) for each variable (LESS, VGRF) between the group's average value at PRE and each time point were calculated. Separate univariate analyses of variance were performed to evaluate group differences.

RESULTS

The results showed a greater decrease in mean (±SD) VGRF in the DIME group compared with the SWU group at all retention time points: POST2M (SWU [Δ%BW], -0.13 ± 0.82; DIME, -0.62 ± 0.91; P = .001), POST4M (SWU, -0.15 ± 0.98; DIME,-0.46 ± 0.64; P = .04), POST6M (SWU, -0.04 ± 0.96; DIME, -0.53 ± 0.83; P = .004), and POST8M (SWU, 0.38 ± 0.95; DIME, -0.11 ± 0.98; P = .003), but there was not a significant improvement in the DIME group between PRE and POST8M (Δ%BW, -0.11 ± 0.98). No group differences in Δ LESS were observed.

CONCLUSION

The study findings demonstrated that an injury prevention program performed as a warm-up can reduce vertical ground-reaction forces compared with a standard warm-up but a maintenance program is likely necessary in order for continued benefit.

CLINICAL RELEVANCE

Injury prevention programs may need to be performed constantly, or at least every sport season, in order for participants to maintain the protective effects against injury.

Seven steps for developing and implementing a preventive training program: lessons learned from JUMP-ACL and beyond

Musculoskeletal injuries during military and sport-related training are common, costly and potentially debilitating. Thus, there is a great need to develop and implement evidence-based injury prevention strategies to reduce the burden of musculoskeletal injury. The lack of attention to implementation issues is a major factor limiting the ability to successfully reduce musculoskeletal injury rates using evidence-based injury prevention programs. We propose 7 steps that can be used to facilitate successful design and implementation of evidence-based injury prevention programs within the logical constraints of a real-world setting by identifying implementation barriers and associated solutions. Incorporating these 7 steps along with other models for behavioral health interventions may improve the overall efficacy of military and sport-related injury prevention programs.