© Springer Science+Business Media New York 2016
Kenneth L. Cameron and Brett D. Owens (eds.)Musculoskeletal Injuries in the Military10.1007/978-1-4939-2984-9_44. Sports and Exercise-Related Injuries in the Military
(1)
Evans Army Community Hospital, Ft Carson, 8441 Old Exchange Drive, 80920 Colorado Springs, CO, USA
(2)
Moncrief Army Community Hospital, Ft Jackson, 155 Granbury Lane, 29229 Columbia, SC, USA
(3)
Joint Base Elmendorf-Richardson, 1267B Airborne Dr, 99505 Anchorage, AK, USA
Keywords
MilitaryInjurySportAthleticFitnessIntroduction
Sports participation is a common method for military members to sustain and enhance physical fitness. The Army and Navy service academies entered intercollegiate sports competition in the late 1800s with a limited number of participants. After the Spanish-American War in 1898, the entire military began to embrace sports for soldier entertainment, enhanced morale, and improved fitness [1]. As time progressed, the role of sports participation moved from unorganized games to military-sponsored sports programs. While the benefits of sports participation are well known in terms of fitness and morale, the negative impacts in terms of injury and reduced readiness require further attention.
American military service members are required to perform a variety of tasks in the most difficult conditions imaginable. While technological advances have changed the manner in which war is conducted, the strength and stamina of individuals continue to be the foundation of American military power. Mental and physical toughness are requisite traits in the profession of arms, and sports participation and physical training are important tools in developing these traits. Douglas McArthur famously stated that “upon the fields of friendly strife are sown the seeds that, upon other fields, on other days, will bear the fruits of victory.” As a result, formal physical training programs integrating competitive and recreational sports are commonplace within the military to maintain the physical and mental aspects of readiness. While these physical activities can enhance readiness through fitness, camaraderie, and esprit de corps, they also predispose participants to the risk of musculoskeletal injury. Just as weapon systems are constantly being developed, issues that affect personnel readiness also continue to evolve and deserve further attention and research.
Hemorrhage from extremity injuries remains a leading cause of combat death [2]. As a direct result, military combat casualty care is heavily focused on controlling hemorrhage from vascular injury. This training coupled with the forward positioning of surgical teams, improvements in body armor, and advanced aeromedical evacuation have resulted in the lowest ratio of injured to killed service members in the history of warfare [3]. While these advancements in combat casualty care are remarkable, nonoccupational injuries exist as a more insidious medical concern that is degrading military readiness [4]. While unintentional musculoskeletal injuries do not normally affect life and limb, these injuries do result in lost duty time that strains the personnel readiness of military units and the military medical system [5]. Recent surveillance studies indicate that preventable non-battle injuries involving sports and physical training are the leading cause of medical evacuation from Iraq and Afghanistan [6].
Sports and fitness -related injuries are the leading cause of outpatient medical visits in the US military [7, 8]. When considering all aspects of medical complaints, unintentional injury results in the greatest negative impact on military readiness [9]. While military service members and civilian athletes require enhanced levels of physical fitness for job performance, maintaining that fitness requires participation in activities that can potentially lead to injury. In this chapter, we will discuss the epidemiology of sports and fitness injuries in the military, report on proven methods to reduce injuries, and highlight emerging trends in fitness development that will undoubtedly impact medical readiness in the future.
Sports Injury Surveillance and Epidemiology in the Military
Military studies conducted from training schools , individual units, and service-wide populations clearly demonstrate that musculoskeletal injuries resulting from physical training are a leading cause of outpatient medical visits [–9 12]. While sports participation outside of mandatory physical training is not required, there are many opportunities, both formal and informal, for military members to participate. In the early 1900s, the Army Morale, Welfare and Recreation (MWR) division was established to build, operate, and maintain gyms and other fitness facilities on military installations. Since then, the MWR and similar organizations have continued to develop and improve sports and fitness opportunities for troops at home and while deployed. Most military installations have gymnasiums, courts, and fields for a wide variety of sports participation. Most installations have voluntary unit intramural sports leagues including flag football, basketball, soccer, volleyball, and softball. The intramural league is a friendly installation-wide program open to military members and their spouses. In addition to these outside voluntary leagues, sports activities are also routinely incorporated into mandatory unit fitness training .
The Armed Forces Sports (AFS) program is another opportunity provided for military members to train and compete in the highest levels of sports competition. This program was officially established in 1948 and paved the way for military personnel to have the opportunity to train and compete for national, Olympic, and international competitions, such as the International Military Sports Council (CISM) World Military Championships. “The AFS program offers 25 men and women team and individual sports; annually conducts 16 Armed Forces Sports Championships and 9 qualifying events/trial camps; participates in 9 U.S. national championships and 16 CISM Military World Championships. In 2012, 21 military service members participated in the London Olympic Games. The selection of the US delegation for national and international events occurs at the annual Armed Forces Championship or through a qualification process such as a trial camp” [13].
The army soldier athletics program, introduced in May 2013, is separate from the intramural leagues and pits battalions against one another in a semiannual competition. The goal is to increase the level of competition with a soldier-only program to recognize the best soldier-athletes. The events include men’s and women’s basketball, volleyball, soccer, flag football, softball, and cross-county along with coed combative teams. The battalion teams compete for installation level championships and the winners continue on to regional tournaments and conclude at the Chief of Staff of the Army Sports Championships. “The Army Sports Program embodies key elements of comprehensive soldier fitness—building physical fitness, strengthening resilience, fostering teamwork and camaraderie—while ultimately offering soldiers positive activity choices during discretionary times, thereby reducing soldier opportunities to engage in high-risk opportunities,” read the operations order signed by Lt. Gen. Mike Ferriter, commander of Installation Management Command [14].
The heavy emphasis on sports participation can lead to many positive effects such as increased morale, camaraderie, and fitness, but there is also a negative side. As mentioned earlier, sports and physical training injuries are a major reason for medical evacuation [6]. Many other studies also highlight the impact of injury during sports participation in a military population. In 2010, Burnham et al. analyzed injuries from basketball, flag football, and softball reported to the US Air Force (USAF) safety center between 1993 and 2002 [15−17]. They reported basketball as the sport causing most injuries during the 10 year study period. Interestingly, they also noted that basketball is the most popular sport in the USAF. Injuries related to basketball participation ranked 4th overall for total workdays lost, which included injuries not related to sports participation. The most common mechanism of injury was landing awkwardly from a jump (26 %) followed by landing on another player’s foot (17 %). Softball was the sport with the second most injuries that led to a lost workday and 5th overall on the list. The most common mechanism of injury was sliding (23 %) followed by being hit by a ball (20 %). Flag football was the sport with the third most injuries and 8th overall on the list with the most common mechanism being contact with another player (42 %) followed by falling while running (14 %) .
In agreement with these findings, softball, basketball, and football were the sports with the largest number of injuries in other military studies as well [7, 11]. Burnham et al. [15−17] also discussed potential ways to prevent or reduce injuries in these sports. These prevention strategies include training to improve balance, using ankle braces, implementing and enforcing rules, performing appropriate warm up and preseason conditioning, along with utilizing more safety equipment (helmets, eye and mouth guards, etc). Research demonstrates that training can improve jump-landing mechanics associated with knee anterior cruciate ligament (ACL) injury, which potentially leads to decreased risk of ACL tear during sports participation [18]. Monetary cost and time seem to be the main barriers to implementation of these prevention strategies. Although making sports participation safer can be more expensive in the short-term, these strategies are arguably cheaper in the long run if they reduce the number of workdays lost or result in fewer medical evacuations during military deployments.
The financial impact of sports injuries can range from lost training days to surgery and subsequent rehabilitation if serious enough. Some sports-related injuries may also lead to disability discharge and impact long-term health-related quality of life. It is estimated that approximately $2 billion per year are spent on managing injuries to the ACL of the knee alone [19]. Considering that over 70 % of ACL injuries are of the noncontact variety, it seems that many of these may be preventable [19]. A 6-year study looking at hospitalizations due to sports injuries in the Army showed that they accounted for 29,435 lost work days each year with a rate of 38 and 18 per 10,000 for men and women respectively [7]. The knee was by far the most frequently injured body part with fractures being the most common injury. The knee is the most common body part injured in modern day sports; as many as 40 % of sports injuries are knee injuries [16, 20]. Knowledge of injury patterns common for each sport, and risk factors common to sports participants can allow medical personnel and team leaders to apply interventions to diminish the injury risk .
Military athletes are routinely involved in a variety of sports dependent on personal interest, season, facilities, and training calendar. There are risk factors specific to each sport that play a role in injury development. These extrinsic risk factors can be identified ahead of participation and in many cases mitigated to reduce injury risk. In addition to the sport itself, the athlete can also possess certain intrinsic risk factors that predispose them to injury. While intrinsic factors cannot be changed, they can be identified and taken into account when counseling athletes on sports participation. Examining intrinsic and extrinsic injury risk factors for specific sports, and athletes in general, can help identify areas that are amenable to change with appropriate injury-reduction programs.
Factors Associated with Musculoskeletal Injury During Sports Participation in the Military
Risk factors for sports injuries in the military and civilian populations are quite similar, as sports themselves have inherent risks that contribute to their injury patterns. There are several published studies identifying risk factors [20−26] and incidence rates [20, 21, 23−25, 27−29] of injury during sports and exercise participation in the military. In the civilian setting, there are similar reports on injury patterns, risk factors, and incidence rates in the literature [30]. Regardless of whether a risk factor is intrinsic or extrinsic, whether a risk factor is modifiable or not may be more important in developing and implementing potential injury prevention practices [31]. In the coming sections, we will compare the extrinsic and intrinsic risk factors for injury in civilian sports settings to military sports settings. Throughout the course of this discussion we will focus on conceptualizing these risk factors and the clinical relevance of this classification for sports and exercise-related injury prevention [31].
Extrinsic Risk Factors
Extrinsic risk factors for injury during sports participation are not inherent to the individual participant. Extrinsic factors that are specific to military units and military occupations can be more difficult to comprehend. Reducing these extrinsic risk factors is a relatively simple process in theory, but in practice there are many unique military obstacles to implementation. Equipment, playing surface, coaching, and rules enforcement are known extrinsic factors associated with sports injury [30]. In a military setting, mitigating these risk factors can be difficult as sports and physical training are often secondary concerns behind mission-specific training.
Military units vary from location to location by the type of unit, operational tempo, and training cycle. There may be a time during the year when a military unit is training at a high operational pace in preparation for an upcoming deployment, prolonged field training exercise (FTX), or skills validation assessment. Some unit leaders believe that offering a sports activity during physical training can be a way to reward soldiers for their hard work and give them a break from the normal rigors of physical training. This practice is also common when a unit returns from a deployment or long field training exercise. While commanders may feel that unit sports participation is a reward for a job well done, the risk of injury is higher due to lower levels of conditioning and fitness. The unit operational tempo is a modifiable extrinsic risk factor for sports injury. Commanders must be aware of this risk and produce a physical training plan accordingly. Furthermore, taking steps to ensure that known risk factors are accounted for when adding sports to the training calendar is critical in mitigating these risks .
Another extrinsic risk factor for sports injury is the use of appropriate safety equipment. In collegiate and professional athletics , it is mandatory for safety equipment to be utilized. For instance, in American football it is unheard of for a player to participate without a helmet or shoulder pads [32]. During military training , a soldier would never conduct a mission without appropriate protective equipment including a ballistic vest, helmet, or weapon. However, when these same soldiers participate in an organized game of flag football, they often wear their normal running shoes. Not wearing appropriate footwear greatly increases the risk of slipping and twisting injuries. The same footwear issue is present when military members participate in other sports as well. Wearing running shoes while playing basketball or softball can also lead to lower extremity injury. Running is perhaps the most popular military sport, and multiple studies indicate that appropriate footwear can help reduce injury. In the basic training environment, running injuries have been investigated in multiple settings with inappropriate footwear being cited as a significant contributing factor [33, 34].
The playing surface is another extrinsic modifiable risk factor for injury in the military setting. Typically, military sports are played in any available open space. These include grassy areas never designed or inspected for organizational sports use, and even large areas of concrete such as empty parking lots. Flag football participation by military personnel results in a considerable injury rate [16]. A major factor in many of these injuries revolves around the playing surface. Often times, open areas on military installations serve multiple purposes, are not level, and are filled with tire ruts and other obstacles that are not easily seen. Combining a poor playing surface with inappropriate equipment only increases the risk of injury. Commanders and unit leaders should take appropriate steps to ensure that appropriate facilities are available for organized sports activities that are added to the training calendar. Furthermore, unit leaders should ensure that the facilities are inspected for potential hazards prior to engaging in sports activities, and any noted deficiencies should be addressed to reduce injury risk .
In addition to equipment and playing surface, the lack of appropriate officiating and coaching are also risk factors for injury. It is common practice for military units to play a particular sport during unit physical training without a trained official. Military units also lack trained coaches or conditioning staff to ensure that members are prepared for sport participation. If the sport is conducted as part of a daily physical training program, there may be no officials or coaches and the responsibility lies with the participants to control the game. With this, it is fairly common for games to become increasingly competitive and physical. This style of play, that is often void of fundamentals and performed by unconditioned participants, creates an environment of increased injury risk. Planning sports activities where the rules of engagement are clarified prior to participation, and assigning personnel to monitor the rules during play, are relatively simple steps that can be taken by unit leaders to enhance the safety of these activities and reduce injury risk .
Intrinsic Factors
Intrinsic risk factors are those that are particular to the individual athlete. In some instances these factors may be modifiable; regardless, intrinsic risk factors require identification and subsequent mitigation if appropriate. Hamstring injuries are very common among sports participants and the risk factors for hamstring injury are widely published [35, 36]. Among the intrinsic risk factors, some of the most widely reported are age, flexibility, strength, fitness, and past history of injury [35, 36]. These intrinsic risk factors exist for military members participating in sports and physical training as well.
The first factor to consider is the overall fitness level of the sports participant. One might assume that a high level of fitness is required to join and remain in the military. While there are fitness requirements for military service, these requirements vary from service to service and the enforcement of these standards can vary from unit to unit. As a result, there are individuals in the military that do not meet height/weight or basic fitness standards. Military research indicates that current fitness levels can be a significant risk factor for future injury during military training [23−25]. Increasing the fitness level of military recruits prior to entry into their initial training can reduce the rate of musculoskeletal injury [29, 37]. Identifying members that possess an inadequate level of aerobic fitness and enforcing standards in place concerning passing fitness tests can also ensure that poor fitness becomes less of an impact on injury in the military. A factor often associated with low levels of aerobic fitness is obesity which can also increase the risk of injury [28, 38].
Obesity is another intrinsic risk factor for military and civilian athletes alike [30]. While there are height and weight standards across the military, the enforcement of these standards often varies from unit to unit. Fitness levels and obesity are both modifiable risk factors that are constantly measured as part of the normal unit physical training plan [28]. Identifying these individuals and implementing a plan for improvement prior to unit sports participation is vital to preventing musculoskeletal injury. Another easily identifiable risk factor for injury is history of previous injury.
History of a prior musculoskeletal injury is one of the major predisposing non-modifiable risk factors for injury development [39, 40]. While there is no consensus answer as to why this risk factor exists, one theory is that athletes return to sports prior to fully recovering from their previous injury [40−45]. Athletes or military members with a history of prior injury can be assessed by the sports medical staff to determine any rehabilitative needs prior to sports participation. In the military setting, recovery from injury is often focused on being cleared to participate in unit physical training and complete the mandatory physical fitness tests. These fitness tests are not sports-specific, so significant strength, mobility, or motor control deficits can still exist despite being cleared for full participation in military physical training. While past history of injury is not a modifiable risk factor, the intrinsic deficits that remain after injury may be modifiable, if identified. Furthermore, secondary prevention becomes much more important in military service members with a history of musculoskeletal injury .
Age is another intrinsic risk factor for sports injury development [46, 47]. While the youngest members of the military can be of a similar age to many civilian college athletes, the more experienced members of the military often approaches 45–50 years of age. Increasing years of experience are often associated with promotion and career advancement. Not surprisingly, a higher enlisted rank is found to correlate with increased injury during deployment [48]. Age may also be associated with the type of sports-related injuries experienced by military service members. A recent review reported that acute traumatic joint injuries and fractures seem to be more common in younger military service members, and the risk of these injuries decreases with increasing age. Conversely, the risk for chronic overuse injuries, injuries to the fibrocartilage in the knee and shoulder, and degenerative joint disease and osteoarthritis (OA) is lowest in younger age groups and increases with increasing age [49]. While age is not a modifiable risk factor for injury, it is an easily identifiable risk factor. Unit leaders must decide if the benefits of sports participation are worth the increased risk of injury for their more seasoned military members.
The final intrinsic risk factors to be discussed here include strength, flexibility, and neuromuscular control [50]. Arguably the most important aspect of physical training is the warm-up and cool-down periods. In the military setting, these are often neglected due to time constraints. Strength training in the military is often left to the individual members. Group strength training is rarely performed. When strength training is integrated into a fitness plan, the focus is on fitness test performance and not sports-specific skills. The concept of neuromuscular control has received considerable attention in the civilian sports medicine research literature. Not only is neuromuscular control a known risk factor for injury, integrating an intervention program to improve neuromuscular control can reduce injury risk specifically in the knee [51]. As noted previously, the knee is one of the most common sites for sports-related injury among military service members .
With all of the risk factors for injury discussed, the largest contributor to injury in the military population may be inadequate planning and execution, which can clearly be modified with appropriate command interest and support. A published physical training plan can ensure that participants arrive in the appropriate footwear. Inspecting the playing area prior to the day of competition can identify environmental risks for injury. Ensuring that all participants know the rules of engagement prior to participating in sports activities and that someone is designated to ensure these rules are followed to mitigate injury risk are all important strategies that can make sports participation safer in military populations. Appropriate planning can also help reduce the role that fatigue plays in injury production [23]. There are several studies looking at professional sports teams that identify fatigue as a significant intrinsic risk factor for various injuries [52−56]. Understanding the role of fatigue in a military setting may be best illustrated with an example. A service member on deployment may conduct daily patrols for 12–18 h per day carrying equipment that may exceed 85 pounds. In addition to the physical stresses associated with these missions, there are also significant mental stressors that can lead to fatigue and lack of focus. Upon return to their base, these military members may engage in a sporting activity to help recovery mentally from these stressful missions. Participating in a disorganized sports activity, while physically and mentally fatigued, can increase the risk of musculoskeletal injury.
The majority of research studies focusing on sports injury prevention and management involve civilian athletes at the collegiate and professional levels. Military health-care providers specializing in the delivery of sports medicine, including physical therapists, orthopedists, and sports-trained physicians routinely integrate these research findings into the evaluation and management of injured soldiers. Advancements in the care of civilian athletic populations can have direct implications in the management of military athletes. Looking at the spectrum of care provided to civilian athletes, and comparing that level of care to that provided to military athletes might offer some insight into the management of military sports and fitness injuries.
In 2003, a collegiate football player competing for a nationally ranked university created a national controversy when responding to a question regarding his aggressive style of play. While his language was a bit more colorful than described here, the essence of his response included references to protecting yourself from other players attempting to harm you, competing in a war, and being a soldier on the playing field. His comments came at a time when American military members were involved in actual combat operations in both Afghanistan and Iraq. His realization that college athletics are not combat operations, along with words of advice from the university leadership, resulted in an immediate apology. This was not the first or last reference credited to athletes at all levels of competition alluding to battles occurring on the playing field. We provide care for civilian athletes in a manner consistent with their required level of performance when they step onto these proverbial battlefields. How can we provide that same level of care to military members whose ultimate performance is judged on actual battlefields? Perhaps the answer lies in integrating a civilian model of sports care for our military members [49].
Civilian athletes are afforded structured training programs specific for their sport, top notch training facilities, and readily available access to high quality sports medicine assets that are typically co-located in the training environment. Military service members are constantly preparing for situations where much more is at stake than a simple win or loss. The high rate of sports and fitness injuries prevalent in the military indicates a need to alter the model of health care provided to our military athletes [57]. While personnel and training issues represent seemingly insurmountable obstacles to implementation, integrating aspects of sports care proven effective in the civilian community can only help to improve upon musculoskeletal injury rates observed in the military environment.
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