Content uploaded by Veronique Hauschild
Author content
All content in this area was uploaded by Veronique Hauschild on May 25, 2016
Content may be subject to copyright.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx
fracture and possibly requiring surgical intervention.10
While we found a meaningful decrease in the number of
observed femoral shaft stress fractures, our study was
likely underpowered, given the inability to show statisti-
cal signicance. Our study was limited to one installa-
tion, JBSA Fort Sam Houston, and only extends to the 6
months immediately prior to and after implementation
of the PRT program. A larger cohort could be derived
from including more installations or from examining a
longer period around the time of implementation.
In addition to an underpowered study, there are other
limitations. The PRT program was only implemented
for the Army recruits at JBSA Fort Sam Houston. As we
collected no demographic information on the subjects,
permanent party (nontrainee), Air Force, or Navy per-
sonnel that are also trained at JBSA Fort Sam Houston
could be included despite not participating in the PRT
program. Because the TMC is the entry point to the
Military Health System for recruits, we are condent
that we captured all recruits save those that presented
primarily to the Emergency Department (ED). However,
any post-ED follow up is performed at the TMC, regard-
less of subspecialty referral by the ED. All recruits are
seen at this one TMC. We recognize that we could have
missed stress fractures of individuals who chose not to
seek treatment or delayed presentation until outside the
study window. Furthermore, we would miss additional
stress fracture diagnoses made following specialty care
evaluation because initial evaluation by the primary care
provider would have had a different ICD-9 code. Finally,
given such as short study window, we could have missed
potential seasonal variations similar
to those seen in other injury patterns.
conclusion
Our study demonstrated a decline in
the diagnosis of lower extremity stress
fractures in the 6 months following the implementation
of the Army PRT program. This included a decrease in
femoral neck stress fractures, which can be associated
with worse outcomes. Continued investigation is war-
ranted considering the high cost of training dollars lost
to injury, treatment, and discharge of recruits early in
their military training.
references
1. US Government Accountability Ofce. Military
Attrition: DOD Could Save Millions by Better
Screening Enlisted Personnel. Washing ton, DC: US
Government Accountability Ofce; January 1997.
GAO/NSIAD-97-39. Available at: http://www.gao.
gov/assets/160/155698.pdf. Accessed July 24, 2014.
2. Pope RP, Herbert R, Kirwan JD, Graham BJ. Pre-
dicting attrition in basic military training. Mil Med.
1999;164(10):710 -714.
3. Booth-Kewley S, Larson GE, Ryan MA. Predictors
of Navy attrition. I. Analysis of 1-year attrition. Mil
Med. 2002;167(9):760-769.
4. Reis JP, Trone DW, Macera CA, Rauh MJ. Factors
associated with discharge during Marine Corps ba-
sic training. Mil Med. 20 07;172(9):936-941.
5. Talcott GW, Haddock CK, Klesges RC, Lando H,
Fiedler E. Prevalence and predictors of discharge
in United States Air Force basic military training.
Mil Med. 1999;164(4):269-274.
6. Knapik JJ, Canham-Chervak M, Hauret K, Hoede-
becke E, Laurin MJ, Cuthie J. Discharges during
U.S. Army basic training: injury rates and risk fac-
tors. Mil Med. 2001;16 6(7 ):641- 6 47.
Table 3. Data of observed lower ex-
tremity stress fractures displayed by
region and group. Negative percent-
age change represents a decline in
the number of lower extremity stress
fractures observed. Positive percent-
age change represents an increase in
the number of lower extremity stress
fractures obser ved.
Group
1
Group
2
Change
%
P
Value
Pelvis 0 0 0 %N/A
Thigh 69 35 -49.3%P<.001
Leg 61 65 6.6%P=.720
Foot 104 74 -28.8%P=.023
Tot al 234 174 -25.2%P=.002
Distribution of diagnosed stress fractures by month for the study period April 2010
through March 2011.
Metatarsals
Tarsals
Tibia/Fibula
Femoral shaft
Femoral neck
20
0
40
50
30
60
10
Apr 10
May 10
Jun 10
Jul 10
Aug 10
Sep 10
Oct 10
Nov 10
Dec 10
Jan 11
Feb 11
Mar 11
Before PRT After PRT
OBSERVED RATES OF LOWER EXTREMITY STRESS FRACTURES AFTER IMPLEMENTATION OF THE
ARMY PHYSICAL READINESS TRAINING PROGRAM AT JBSA FORT SAM HOUSTON
January – March 2016 9
THE ARMY MEDICAL DEPARTMENT JOURNAL
7. Gemmell IM. Injuries among female army re-
cruits: a conict of legislation. J R Soc Med.
20 02 ;95 (1) :23 -27.
8. Snoddy RO Jr, Henderson JM. Predictors
of basic infantry training success. Mil Med.
1994;159(9):616- 62 2.
9. Knapik JJ, Rieger W, Palkoska F, Van Camp S,
Darakjy S. United States Army physical readi-
ness training: rationale and evaluation of the
physical training doctrine. J Strength Cond Res.
2009;23(4):1353-1362.
10. Boden BP, Osbahr DC. High-risk stress fractures:
evaluation and treatment. J Am Acad Orthop Surg.
Nov-D ec 2000;8(6):34 4 -353.
Authors
CPT Chalupa is a physician assistant with the Orthopae-
dic Surgery Service, Department of Orthopaedics and
Rehabilitation, Brooke Army Medical Center, JBSA Fort
Sam Houston, Texas.
Mr Aberle is Chief, McWethy Troop Medical Clinic,
JBSA Fort Sam Houston, Texas.
LTC (P) Johnson is Chairman, Department of Orthopae-
dics and Rehabilitation, Brooke Army Medical Center,
JBSA Fort Sam Houston, Texas.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx
Unintended injuries, in particular physical training-re-
lated injuries, continue to be one of the most signicant
threats to US military readiness.1 As many of these inju-
ries are considered preventable, this study was undertak-
en to help determine what additional information might
contribute to reducing these injuries in the US Army.
historicAl revi ew
Common musculoskeletal and orthopedic injuries (ie,
strains, sprains, joint derangements, and stress frac-
tures) are the leading threat to the medical readiness of
our troops.1 Almost 50% of all service members experi-
ence one or more injuries annually.2 Each year, these in-
juries limit physical ability and cause disability among
active duty service members, resulting in millions of
medical encounters, lost or restricted duty days, and
medical expenses.1,3-6 These injuries, predominantly of
the back, knees, and lower extremities, are most often
due to repetitive overuse, not from acute trauma.1,3-5 ,7-10
In fact, over half of these injuries result from unit or per-
sonal physical training activities like running or sports.2
Even during wartime operations, medical air evacua-
tions are more often for nonbattle injuries such as those
caused by sports and physical training than for injuries
resulting from combat.11
This problem has persisted for decades.12,13 In 1992, an
estimated 450,000 outpatient medical encounters re-
sulted in several million days of restricted duty.13 In
2012, 2.2 million Department of Defense (DoD) mili-
tary medical encounters resulted from these same types
of musculoskeletal injuries, resulting in an estimated
25 million limited duty days.1 The Army accounts for
about 40%—the largest portion—of these days of lim-
it e d duty.1,4 It has been estimated that a 1% reduction
in incidence of lower back pain could translate to the
retention of thousands of trained Soldiers, avoidance of
countless lost training hours, and signicant cost sav-
ings through fewer disability payments and less con-
sumption of medical care.13
The continued high incidence of these common inju-
ries is, in part, because Soldiers must routinely conduct
physical training. Physical training is the cornerstone
to enhancing physical tness and overall human per-
formance. Yet physical training and optimizing human
physical performance includes minimizing injury. Sci-
entic study and injury surveillance data have helped
to identify risk factors and evaluate the effectiveness of
some tactics for reducing these injuries.14 -19 Risks and
interventions associated with running mileage, training
programs, stretching, footwear, various braces (such as
ankle, back, knee), gender, age, and medication use have
been and continue to be investigated. In some cases,
current evidence provides insights into training modi-
cations that could reduce injuries. In other cases, scien-
tic investigation has shown that evidence is inadequate
to prove the benets of some interventions. In fact, some
scientic evidence shows that not all injury prevention
(IP) tactics once believed to be effective are actually
helpful. In reality, some may increase injury risks.3 Un-
fortunately, anecdotal information often drives risk pre-
vention decisions.
scope of this effort
Investigators at the US Army Public Health Center (Pro-
visional)* (USAPHC(P)) theorized that a lack of aware-
ness and confusion about risk factors and effective
physical training techniques may be contributing to this
persistent injury problem. In order to guide the develop-
ment of IP educational materials to increase awareness
and correct misinformation, a voluntary survey tool was
used to assess current awareness about IP topics and
identify specic information needs and interests among
Army audiences.
Methods
A group of health analysts, health educators, and stat-
isticians experienced with survey tools developed a
What Soldiers Know and Want to Know
About Preventing Injuries: A Needs Survey
Regarding a Key Threat to Readiness
Veronique D. Hauschild, MPH
Anna Schuh, PhD
Bruce H. Jones, MD, MPH
*Formerly the US Army Public Health Command.
January – March 2016 11
THE ARMY MEDICAL DEPARTMENT JOURNAL
29-question survey.20 The survey,
designed to be anonymous, focused
on unintentional musculoskeletal in-
juries, but also included some ques-
tions about heat and cold injuries.
Data requirements were balanced
with the desire to limit the time bur-
den for respondents. Survey topics
included demographics and job roles,
personal injury history (past 12
months), awareness of injury effects,
risk factors, interventions, leader-
ship perspectives (for nonsupervi-
sor responders), and IP interests (ie,
activities, injury types, and infor-
mation sources and formats). Prior
to disseminating the survey, docu-
mentation was submitted for review
through the USAPHC(P) Human
Protection Review Board. The collection of person-
ally identiable information was avoided through pre-
established, broad categories provided in demographic
questions.
The survey was delivered using the Vovici software
application (Vovici is now Verint Enterprise Edition
(Verint Systems Inc, Melville, NY)). The voluntary on-
line survey was dispersed to Army audiences through
several venues between July 9 and August 26, 2014 (6½
weeks). Venues included postings on Army medical and
nonmedical social media sites, websites, and
through mass Army (S-1 Net) and individual
emails. Posting of the survey link was vol-
untary for the proponent organizations. All
responses were received in a protected data
archive only accessible by selected project
investigators.
To assess general awareness of the problem,
4 evidence-based statements regarding most
common musculoskeletal injuries within the
Army and leading causes of these injuries
were provided for respondents to indicate
their level of agreement (on a 5- point scale
from Strongly Agree to Strongly Disagree).
Respondents also scored the effects of vari-
ous risk factors and prevention measures
for musculoskeletal injuries by indicating
whether they believed the measures decrease
risk, neither increase/decrease risk, increase
risk, or whether the respondent was not sure.
The “correctness” of statements were evalu-
ated based on previously published scientic
evidence,1,5 ,11 including a systematic review
of physical training injury interven-
tion conducted by DoD experts.3 In
addition, respondents were asked to
choose activities about which they
were most interested in receiving
IP information. Sixteen options (in-
cluding “other”) were provided with
the instruction to select all that apply.
Responders who were not healthcare
providers/educators were asked 4
questions regarding their experi-
ences or beliefs regarding their lead-
ership’s support or interest in injury
prevention. Other questions included
asking respondents about preferred
format and venue for obtaining ad-
ditional IP information, and an open
ended question for any additional
comments.
Data analyses were conducted using IBM SPSS Statis-
tics 21.0 and Microsoft Excel 2010. Only respondents
who fully completed all questions were included in the
nal analysis. Quantied results were presented as fre-
quencies and percentiles. Data cleaning of narrative
free-text responses was completed by 2 investigators
who separately reviewed all individual responses to de-
termine whether responses could be grouped with pre-
established response categories or into any newly cre-
ated categories.
Table 1. Demographics of Respondents
Completing Survey (N=685).
Total Military Civilian
Affiliation
Military 5 27 ( 7 7%)
Civilian 158 (23 %)
Gender
Male 4 67 (6 8 %) 377 90
Female 21 8 (3 2%) 150 68
Age (year s)
<20 10 (1%) 9 1
21-3 0 13 1 (19 %) 123 8
31-40 192 (28%) 179 13
41-50 205 (30%) 165 40
>50 14 7 ( 2 2%) 51 96
Job Field
Medical 265 (39%) 235 30
Nonmedical 42 0 (61%) 292 128
Figure 1. Percentage distribution of injury causes among respondents who
reported injury (n=360) in response to the following question:
What was the cause of your most severe injury in the past 12 months?
A B C D E F G H I J
10%
20%
0%
15%
5%
25%
35%
30%
A. Running F. Parachuting
B. E xercise other than running G. Combat training/obstacle course
C. Lift/push/pull H. Road marching
D. Sports I. Motor vehicle/motorcycle
E. Slip/trip/fall J. Other (variety of activities: general
everyday tasks; pushing/pull/lifting
items)
12 http://www.cs.amedd.army.mil/amedd_journal.aspx
results
General and Demographics
The survey was initiated by 926 persons and fully com-
pleted by 685 respondents. The average time taken to
complete the survey was 14 minutes. A comparison
of the respondents who completed the survey (685)
versus those who did not (241) revealed no signicant
differences.
Table 1 summarizes key demographic characteristics.
Most respondents (77%) were Army personnel (62%
ofcers, 38% enlisted). More men (68%) than women
(32%) responded. Very few responders were under 20
years of age, most falling between 21-50 years of age.
Of the military respondents, almost half were of medi-
cal areas of concentration or military occupational spe-
cialties. Of these, the largest portions were physician
assistants (32%), followed by physical therapists (18%).
Nonmedical military personnel included chemical, bio-
logical, radiological and nuclear specialists, infantry,
military intelligence, ordnance, and others.
Over half (53%) of respondents reported musculoskel-
etal injuries in the previous 12 months that affected
their physical ability to do daily tasks or exercises. Of
these, 61% were described as primarily associated with
overuse. The most common cause reported was running
(34%), as shown in Figure 1.
Knowledge and Awareness
The ndings for musculoskeletal injuries are presented
in Table 2. The responses of all medical respondents (ie,
healthcare/educator providers) followed the same trends
as the overall trends for all respondents, with slightly
more accurate answers and slightly fewer unsure re-
sponses. Most respondents (62% to 78%) correctly
chose “strong” or “very strong” agreement with each of
the 4 evidence-based statements regarding the general
magnitude and types of the injury problem. However,
7% to 14% disagreed with each question, and 11% to
23% neither agreed nor disagreed. Respondents were
less likely to identify “correct” for responses pertaining
to musculoskeletal injury risk factors and interventions
than for those pertaining to heat and cold injury (data
not shown). Responses for risk factors that were most
incorrect included the increased risks that are associated
with low body mass index (BMI), high exibility, and
smoking. For interventions, higher percentages of incor-
rect responses were found regarding the effectiveness of
ankle braces and cotton socks, and the lack of IP effec-
tiveness that has been shown with back braces, stretch-
ing, the use of anti-inammatories prior to exercise, and
wearing of minimalist running shoes.
Injury Prevention Interests
Figure 2 presents the types of activities about which
respondents were most interested in receiving IP infor-
mation. Respondents chose an average of 5 activities
(mean 4.98, SD 2.84). Despite some minor variations,
activity interests were very similar between medical
and nonmedical responders.20 Write-in responses for
“other” activities not listed included yoga, biking, and
soccer. Sprains/strains/torn muscles and tendonitis/bur-
sitis were most frequently selected as being of interest
by both those personnel not in the health community
(78% and 74%, respectively) and healthcare/educators
(84% and 88%, respectively). Of next greatest interest
to both groups were torn ligaments (56% for those not
in the health community and 59% of those from health
elds) and fractures (48% and 54%). Other types of inju-
ries of interest identied in free-text responses included
chronic conditions such as arthritis.
A common topic appearing in free-text comments con-
cerned overtraining, along with requests for more de-
tailed guidance regarding athletic form and technique.
Some respondents noted that because physical train-
ing is integral to optimizing Army readiness, Soldiers
should be treated more as athletes and coaching or pro-
fessional guidance about injury prevention should be
provided. Likewise, many free-text responses requested
guidance concerning the prevention of re-injury. One
suggestion made by a few respondents was to provide
guidance or training specically to unit leaders so they
would not require injured or formerly injured personnel
to participate in activities that are likely to result in re-
injury. Of the 265 healthcare/health educator respond-
ers, 81% indicated that they would like products to help
communicate information about risk factors and IP tac-
tics to their patients/customers.
Perceptions of Leadership and Medical Roles
The experiences or beliefs those not in the health com-
munity (providers and/or educators) regarding their lead-
ership’s support or interest in IP are shown in Figure 3.
Only a slight majority (37% to 44%, depending on the
statement) described positive leadership emphasis/sup-
port. Approximately a third (25% to 35%) had neutral
perceptions and just under a third (22% to 32%) had neg-
ative views regarding their leadership’s emphasis on and
support for IP. Responses for all 4 questions correlated
strongly with one another (P<.01, correlation >0.74 to
0.83; a strongly agree for one question correlated with a
strongly agree for other questions). In addition, approxi-
mately one-third of respondents provided an additional
written response to the last question of the survey, which
was an open-ended request for any additional thoughts.
WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:
A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 13
THE ARMY MEDICAL DEPARTMENT JOURNAL
Figure 2. Percentage distribution of respondents’ choices of activities for which they were most interested in receiving
information related to injury prevention. Note: Since each respondent was allowed to select all activities that apply, the
sum of percentages displayed exceeds 100%.
10%
20%
0%
60%
50%
70%
80%
40%
30%
A KB LC MD NE OF PG H I J
A. Running I. Motor vehicle/motorcycle accident s
B. Weight training (free weights, weight machines) J. Basketball
C. Agility, calisthenics, stretching K. Snow Sports (skiing, snowboarding)
D. Ex treme conditioning (CrossFit, P90Xm etc) L. Parachuting
E. Road marching M. Football
F. Heat N. Softball/baseball
G. Cold O. Other
H. Work related falling/tripping P. Racquet sports (racquetball, tennis)
Examples of comments written by respondents in the free-text area of the injury prevention survey.
“Changing the mentality of injury is a must within the military. Many of my patients report injuries weeks/
months/years after the initial injury and the damage has been exacerbated from continued use…. Teaching peo-
ple that it’s okay to seek help because no one is Superman would do wonders for maintaining the ghting force
as a whole.”
“Most of patients that I see are musculoskeletal due to overuse (overtraining). One of the biggest things I see
is the leadership not taking care of their ‘Joes’ and allowing them to modify their training according to their
injury.”
“Leaders need to be educated. They play a direct role in helping the junior Soldiers prevent and recover from
injury. In many cases common sense is lacking....”
By far, the most frequently raised issue was concerns
with leadership. Some examples of such responses are
shown below. Despite awareness of the magnitude of
the musculoskeletal injury problem, free-text responses
suggested that many believe that such injuries are inher-
ent to a Soldier’s job, and are even a way to “screen out
the weak.” Specic concerns cited include the need for
better unit leader IP training, specically among Drill
Sergeants and First Sergeants. Responders indicated
that this was necessary to change what was described
as a “suck it up” and “no pain is no gain” attitude and to
improve awareness about the negative effect of training-
related injuries on Army readiness. Inadequate time and
guidance for reconditioning and recovery, especially af-
ter a prole, was also described as exacerbating the in-
jury problem. Leaders were described as being unaware
of the magnitude of the adverse impacts that uninten-
tional injuries have on the Army, and not recognizing
what they can do to reduce these injuries. Suggestions
included leader IP training, mentorship, and certication.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx
Another major topic cited in free-text responses de-
scribed a systemic lack of credibility in the Army Medi-
cal Prole system, particularly among unit leaders. Re-
spondents indicated that although inconsistencies and
misuse of the current Medical Prole system were due
in part to individual Soldiers’ motivations, some respon-
dents suggested problems within the medical commu-
nity itself. Specically, inadequately or inconsistently
supported diagnoses, inconsistencies in work and physi-
cal training restrictions, and the lack of specic reha-
bilitation guidance were cited as areas that could be
improved.
coMMent
The size of the response to the voluntary survey was
larger than expected and thus was considered a positive
Table 2. Distribution by percentage of respondents’ beliefs on musculoskeletal injury risks and interventions.
Factors/interventions that: %N [685 total respondents]
%n [268 healthcare/educators]
Increase Risk Of Injury*Decrease Risk Neither
more nor less
Increase Risk*Not Sure
Increased running mileage 2%
2%
15%
10%
80%
86%
3%
2%
Dehydration 1%
1%
7%
8%
89%
90%
2%
2%
Prior injury 1%
1%
4%
2%
94%
97%
2%
0%
Cigarette smoking 1%
1%
16%
8%
75%
89%
9%
2%
High flexibility 71%
59%
16%
19%
10%
20%
3%
2%
Very thin body type 6%
5%
56%
53%
25%
33%
13%
9%
Does Not Decrease
Or May Increase Risk*
Decrease Risk Neither
more nor less*
Increase Risk*Not Sure
Back brace/lif t belt
(for job or weight training)
56%
44%
23%
33%
13%
18%
8%
4%
Over-the-counter anti-inflammatories
before workouts
19%
16%
39%
48%
26%
26%
16%
10%
Stretching before exercise 58%
41%
27%
38%
12%
19%
3%
2%
Reduce Risk*Decrease Risk*Neither
more nor less
Increase Risk Not Sure
Ankle brace (for basketball, parachuting) 61%
59%
22%
27%
9%
9%
8%
5%
Cotton socks 22%
20%
57%
62%
8%
9%
13%
8%
Does Not Either Decrease
Or Increase Risk*
Decrease Risk Neither
more nor less*
Increase Risk Not Sure
Minimalist running shoes 5%
5%
22%
25%
58%
58%
15%
12%
Effect On Risk Not Evident/Is Variable*Decrease Risk Neither
more nor less
Increase Risk Not Sure*
Fatigue/lack of sleep 1%
1%
5%
3%
91%
95%
2%
1%
Older age (> 40 years) 1%
1%
16%
15%
80%
83%
2%
1%
Male 6%
9%
63%
58%
20%
26%
11%
7%
Energy or dietary supplements 3%
2%
27%
28%
56%
61%
13%
9%
Older running shoes 1%
0%
6%
7%
91%
92%
2%
0%
*Current assessment of scientic evidence per Bullock et al3
Key concerns
Topic for improved education given more than 10% incorrect responses
WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:
A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 15
THE ARMY MEDICAL DEPARTMENT JOURNAL
indication of interest in this topic. Though the respon-
dents included civilians, the large portion of military
personnel provides an indication of the knowledge and
interests of the overall active duty Soldier population.
This is supported in part by the similarities in the in-
jury experience of the respondents to prior studies of
specic Army Soldier populations. These prior studies
have shown that, like the survey respondents, about one
half of personnel are injured each year, and that leading
causes of these injuries include running, nonrunning ex-
ercise, and sports.2 ,17,18
While most respondents demonstrated a fairly accurate
awareness regarding the general magnitude of this Army
injury problem, approximately one third either disagree
or are neutral to acknowledgement of the documented
evidence. This suggests a majority are aware of the prob-
lem. In addition, respondents indicated through free-text
responses that there remains a common belief that these
injuries are inherently “part of the job” and thus cannot
be prevented. They indicate that part of this problem is
many unit leaders may be unaware of the adverse im-
pacts that training-related overuse injuries have on Army
readiness or how they can help reduce these injuries.
The current level of awareness is further exacerbated
by confusion about certain risk factors and effective
techniques to prevent common musculoskeletal inju-
ries among both nonmedical and medical respondents.
Awareness of risk factors and interventions was greater
for heat and cold injuries (not addressed in this article),
perhaps due to existing policies requiring annual heat
and cold injury prevention training and strict account-
ability for such injuries.23,24 Though the overall magni-
tude of musculoskeletal injuries in the Army is much
greater than that of heat and cold injuries, current poli-
cies do not require injury prevention training either an-
nually or at any level of a Soldier’s basic, advanced, spe-
cialized or leadership development. Scientically-sup-
ported educational products are needed to increase the
broader Army community’s knowledge of injury causes,
risk factors, and the effectiveness of interventions.
These products must provide adequate details for medi-
cal personnel to educate patients, and be straightforward
enough for their patients (Soldiers) to understand.
Key Activities of Interest
Injury prevention education and training needs can be
framed in the context of specic activities that cause
or contribute to common injuries. Key activities identi-
ed by respondents as top interests largely mirrored top
causes of their own injuries (Figure 1) as well as top
causes attributed to overall injuries to Army personnel2:
My leadership be-
lieves injuries can
be prevented and
makes it a priority.
22%
44%
34%
I am kept informed
about the key types
and risks of injuries
in our unit/workforce.
32%
31%
37%
I am provided
information to help
reduce injuries (my
own and/or others).
32%
25%
43%
My leadership
models injury
prevention efforts.
27%
35%
38%
Strongly disagree/Disagree
Strongly agree/Agree
Neither agree nor disagree
Figure 3. Percentage distribution of respondents’ perceptions
of leadership interest in injury prevention.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx
Running. Consistent with prior Army studies,8 ,11,17,19 run-
ning was the most common cause of injury cited by sur-
vey respondents and was the IP topic of greatest interest.
Though numerous respondents specically desired more
information about how to run correctly, evidence does
not support a single “one-size ts all” running style or
technique that will reduce injury. However, information
on risk factors and guidance about proper conditioning
and avoidance of over-training problems can be provid-
ed through educational materials.
Weight-training and Extreme Conditioning. Respondents
also desired information regarding proper form and
technique to minimize injury associated with weight
training and extreme conditioning. While some educa-
tion products can be developed to advise against certain
techniques, specically trained and certied personnel
trainers are recommended to give proper individualized
instruction for these activities, especially for persons
who have had prior injury.
Agility, Cross-training, and Stretching. Many respondents
recognized the importance of a mixed exercise program
and desired additional information about cross training
and warm-up techniques. For example, information is
desired to explain different types of stretching tech-
niques (ie, static versus dynamic) with guidance as to
when and how to incorporate them into a training pro-
gram.
Road Marches. About half of the respondents desired ad-
ditional IP guidance for minimizing injuries resulting
from road marches. The scientic research on this mili-
tary training activity topic25,26 may provide information
for better educational products that describe key risk
factors and injury types, with suggestions to minimize
risks.
Risk factors and Interventions
Of the risk factors and interventions identied in this
survey, the topics considered of greatest importance are
those for which the majority of respondents exhibited
lowest awareness as indicated by incorrect responses
regarding the degree of risk associated with risk factors
and interventions. While future study of effective inter-
ventions is still needed, increased awareness of current
evidence is warranted for topics such as:
Body Type and Injury Risk. Many respondents (56%) were
under the incorrect impression that a thin body type
does not affect injury risk, and another 6% thought that
it would even reduce risk. However, while poor tness
and high BMI have been shown by some to increase the
risk of injury,9 current evidence shows that low BMI
will also increase risk to injuries especially stress frac-
tures.17-19 Products should be developed to help dispel
myths that thinner means healthier.
Flexibility and Stretching. Though evidence has shown
exibility to be a bimodal risk factor (ie, those with low
as well as those with high exibility are at increased
risk of injury),9,18,19 71% of respondents believed that
having high exibility decreases risk. In addition, while
most respondents (58% total, 41% healthcare/educators)
consider stretching prior to exercise to be a means of
decreasing the risk of injury, the science is inadequate
to support this.3 Current data is rather mixed. The com-
plexity of variables include different types of stretch-
ing (eg, static versus dynamic), different body types and
exibility levels, and different exercise regimens.3, 27-29
Given the unknowns, current expert guidance is to
avoid static stretching prior to exercise and instead use
dynamic and whole body warm-up techniques. Target
audiences should be made aware of the variables and
unknowns.
Footwear. Responses show confusion regarding risks re-
sulting from use of cotton socks, minimalist shoes, and
older running shoes. For example, the use of minimalist
shoes (shoes with limited sole and “zero drop” heel to
toe support) has been a popular trend in the past few
years. While marketers have purported these shoes re-
duce injury risk, a majority of our survey respondents
(58%) indicated they believe that minimalist shoes in-
crease the risk of musculoskeletal injury. Evidence does
not indicate they increase or decrease risk of injury
compared to other shoe types.30 ,31 Products that clarify
existing evidence and dispel myths on these topics are
needed.
Braces. Many respondents (56% total, 44% health care/
educators) considered back braces/belts to be a means
of decreasing injury risk. However, substantial evidence
indicates that they do not reduce risk, and both military
policy and national guidance advise against their use.3
This is especially important since concerns suggest
a potential for increased risk due to use. On the other
hand, the use of ankle braces to prevent injuries in bas-
ketball and parachuting has been strongly supported by
scientic evidence.3,8 ,33-3 6 Products that clarify effective-
ness of different types of personal equipment in risk re-
duction are needed.
Enhancing Unit Leadership Awareness
Essential elements of IP include leadership awareness,
interest, and activity.3 Consistent with prior evaluation,13
the respondents in this survey pointed to leadership at the
small unit level as frequently encouraging overtraining
WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:
A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 17
THE ARMY MEDICAL DEPARTMENT JOURNAL
(especially with running) and marginalizing those who
are proled or injured. Suggestions indicate that these
leaders, who have direct oversight of physical training,
would benet from additional education, motivation,
and/or policy requirements to prioritize IP objectives.
As many unit leaders may not be reached without a di-
rect mandate through their chain of command, respon-
dent suggestions included requiring IP training or “IP
certication” for leaders. A proponent agency with the
authority to implement mandated training would help to
effectively implement this recommendation.
Medical Profile Improvements
Based on responses from this survey and consistent with
a prior study,13 the lack of consistent documentation of
diagnoses and rehabilitation procedures in Army Medi-
cal Proles are still a problem. This may be part of the
reason that unit leaders ignore or marginalize those on a
prole and may not allow adequate recovery. This lack
of consistency may also encourage misuse of the Army
Medical Prole system. While policies and guidance
cannot address all Soldiers’ motivational differences,
guidelines for documentation of prole determinations
and inclusion of detailed rehabilitation and recondition-
ing procedures could improve the validity and credibil-
ity of medical proles. This, in turn, could reduce the
number of re-injuries and incidence of chronic injuries
in what is a relatively young population.
Limitations
As it is not possible to determine the number of persons
who were aware of the survey, response rates could not
be estimated. A comparison of demographic data from
this survey to that of the overall Army active duty popu-
lation (eg, 86.4% male, 13.6% female; source: Armed
Forces Health Surveillance data, 2013) shows the lim-
ited sample of respondents is not a cross-sectional rep-
resentation of the Army. In addition, almost half of the
respondents were from areas of concentration or mili-
tary occupational specialties related to medicine, which
is a much more substantial representation than that of
the overall Army. However, the medical respondents
referred to problems and interests on behalf of their
patients, which at least indirectly represent the broad-
er Army population. In addition, injury experiences of
overall respondents reected trends similar to that of the
broader Army.2 ,15 -17 In addition, medical professionals
are more likely to inuence the IP knowledge.
conclusion
Considering the long-standing magnitude of a prob-
lem that has been documented for decades, awareness
among Soldiers regarding physical training injuries and
prevention could be improved. The ndings of this sur-
vey indicate that many personnel desire additional in-
formation. Scientically supported consumer-oriented
educational materials can empower individuals to help
reduce common musculoskeletal injuries in the Army.
Products should address both knowledge gaps as well as
topics of particular interest to the audience. To achieve
a population-level reduction in injuries, improvements
in leadership awareness and possibly even policy-level
accountability are needed. Because lack of awareness
among unit leaders may inhibit Army human perfor-
mance optimization, they should be a key audience for
future IP educational efforts. The Army medical com-
munity can also become better partners with its opera-
tional and Soldier training counterparts. This includes
nding ways to improve the medical prole system to
mitigate the occurrence of re-injuries and ensure the
most effective rehabilitation, as well as assisting with
future IP awareness and education.
AcknowledgMents
We thank K. D. Deaver, MPH, E. J. Pfau, MPH, M. O.
Stephen, MPH, M. Swantkowski-Hughes, MS, and S.
Hall of the USAPHC(P) for their assistance with survey
development.
references
1. Nindl BC, Williams TJ, Deuster PA, Butler NL,
Jones BH. Strategies for optimizing military physi-
cal readiness and preventing musculoskeletal inju-
ries in the 21st century. US Army Med Dep J. Octo-
ber-December 2013:7-23.
2. Loringer K, Bedno S, Hauret K, Jones B, Kao T,
Mallon T. Injuries from Participation in Sports,
Exercise, and Recreational Activities Among Ac-
tive Duty Service Members. Aberdeen Proving
Ground, MD: US Army Public Health Command;
2011. Injury Prevention Report No. 12-HF-0DPT.
Available at: http://www.dtic.mil/dtic/tr/fulltext/u2/
a560733.pdf. Accessed November 19, 2015.
3. Bullock S, Jones Bh, Gilchrist J, Marshall SW.
Prevention of physical training-related injuries:
recommendations for the military and other active
populations based on expedited systematic reviews.
Am J Prev Med. 2010 ;38(su ppl 1):S156-S181.
4. Jones BH, Canham-Chervak M, Sleet DA. An ev-
idence-based public health approach to injury pri-
orities recommendations for the US military. Am J
Prev Med. 2 010;38(s uppl 1):S1-S10.
5. Ruscio BA, Jones BH, Bullock SH, et al. A process
to identify military injury prevention priorities
based on injury type and limited duty days. Am J
Prev Med. 2010;38(suppl 1):S19-S33.
