Injury Prevention

Injuries are unfortunate events that physically active people face. But to be sure, the benefits of physical activity and leading a healthy lifestyle far outweigh these risks.

Would you rather exercise and occasionally have some knee or back pain OR be sedentary and get Type II Diabetes? Which also tends to come with a side of chronic knee and back pain secondary to being overweight/obese and inactive! No thanks.

Injuries can be prevented in Soldiers on an individual basis by managing your weight, training single-leg exercises, and ensuring you have proper form while exercising. From a unit perspective, it’s critical to program injury prevention into your PRT sessions. They’re challenging and have many benefits, injury prevention is only one.

Are Injuries a Problem in the Army?

Absolutely.

As a Physical Therapist (PT) I can affirm that my job is safe and my field is growing.

According to the most recent Health of the Force Report (2019), 53% of Soldiers suffered a new injury last year. Between 7-12% of active duty Soldiers were nondeployable, mostly due to medical conditions.

Breaking that down further, 63% of females reported an acute injury, and 55% of females reported at least one overuse injury. 52% of males reported an acute injury and 43% reported an overuse injury.

Notice the pattern? Nearly half of Soldiers are dealing with a new injury or condition on top of their old chronic condition. That’s a problem.

Soldiers attended nearly 2 million medical appointments and lost nearly 10 million duty days. It’s a miracle we get anything done at all! 😉

While I love job security I love the thought of working my way out of a job even more! Unfortunately, as it stands right now, I’m going to be working overtime toward both of those ends at the rate we’re going.

So what are injuries and how do we prevent them?

What are Injuries?

Injuries generally come in two types: Traumatic and Atraumatic.

Traumatic Injuries

Traumatic injuries are also known as acute injuries. These often occur when someone suffers a slip, fall, or is hit, causing acute pain.

Acute injuries are typically quite painful and obvious. As a PT, when I ask a patient what caused their pain and they tell me about one specific incident in one moment when their pain began, I know they had an acute injury.

Acute injuries are more likely to be associated with significant pain and potential tissue damage. Fortunately, only about 1/3 of all injuries suffered by Soldiers in a given year are acute, traumatic injuries.

Common acute injuries that Soldiers face while exercising are:

• back muscle spasms (very painful, no tissue damage)
• ankle sprains (very painful, mild-moderate-severe tissue damage)
• shoulder dislocations (extremely painful, sometimes with tissue damage)
• tearing an Anterior Cruciate Ligament (ACL) in the knee (sometimes painful, often with tissue damage)
• hamstring strains (i.e. a “pulled” hamstring) (often quite painful, occasional tissue damage)

There are obviously many types of acute injuries that Soldiers suffer while training. As I have the chance I’ll add articles on specific conditions and their proper rehabilitation to help guide you on your journey to recovery if you’ve suffered an injury.

If you suffer an acute injury I encourage you to rehab it all the way! The worst part of acute injuries in the military is when they turn chronic… which they will if you don’t take care of them!

A sidebar to the leaders reading this…

Take care of your Soldiers!!! This is on you. Ensure they’re going to medical and getting the appropriate care. Ensure they have the time to do their rehab. You want your Soldier back, I get it. But you want 100% of your Soldier back, not 75%. Boost your unit’s morale by showing them that you care. Maybe you’ll motivate your Soldiers to return to duty quicker…

One more thing – lead by example. When you’re injured don’t hide it. Rest, rehab, and return to duty publicly just like you want your Soldiers to. Don’t hide out secretly on profile while beating yourself up at PRT every morning instead of rehabbing and modifying your workout and then telling everyone how the Army has broken you.

Unless someone is injured in combat or a training exercise, the Army doesn’t break anyone. But poor leaders do!!!

So, with that being said how’s the health of your Soldiers right now?

Consider that their health reflects more on your leadership than what you’re likely acknowledging. Lead from the front. Provide your Soldiers with the opportunity to rehab and then hold them accountable for doing their rehab and improving in line with what their medical provider thinks they should.

At the very least, never read a profile looking for loopholes. If you spend time looking for loopholes around a profile imagine what you could do if you spent your time holding your Soldier accountable for doing their rehab the right way…

Atraumatic Injuries

Back to injuries. Fortunately, traumatic/acute injuries aren’t that common in the military.

Unfortunately, atraumatic injuries are!

Atraumatic injuries are what we call overuse conditions. Overuse injuries account for 71% of all injuries/pains/conditions seen in the Army.

The worst part about this is this: as the name atraumatic implies, there was no trauma, there was never that one-time thing that happened that caused your pain.

Overuse injuries should not happen.

Proper training programs significantly decrease overuse conditions.

Another sidebar to leaders…

Once again, this comes back to leadership. Who’s leading your PRT? Are they knowledgeable? Competent? Do they look the part? Do they act the part? If not, you’re winging it. That’s not going to get it done.

If your unit has a high rate of overuse injuries then your training isn’t working. In fact, it’s the opposite, it’s working against you.

Analyze what you’ve been doing and implement some changes. If you’re unfamiliar or uncomfortable with this use the training program that you can download from the Home page.

Send your most motivated and dedicated leaders to the Master Fitness Trainer Course. Reach out to your local PT. Find a SME to help you develop a program that meets your needs, prepares your Soldiers to pass the ACFT, and reduces acute and overuse injuries.

Can Injuries be Prevented?

There is literally TONS of research on this and the answer is, yes!

There are two key ways to go about reducing the injuries in your formation:

1. Develop a PRT program that incorporates injury prevention through both proper planning and exercise selection
2. Identify those Soldiers in your ranks that are at increased risk of injury and have them work specifically on those risk factors

Developing a Comprehensive PRT Program that Prevents Injuries

This is the second goal of this entire website; the first being to pass and excel on the ACFT!

This is where most people get lost so I’ve taken the liberty to develop a couple of different PRT programs.

The most comprehensive one is a 6-month PRT program that is meant to be repeated after every ACFT event, assuming they’re six months apart.

The second one is a 10-week program that is more of a getting started guide.

But I will say that while I developed these to the best of my knowledge and ability there is no one best training program.

How to use these programs

Honestly, the best training program is the one that’s based on scientific research, incorporates some aspect of periodization, provides progressive overload, and that you’ll stick to.

Consistency is key. You’ll be better off sticking with a mediocre program than jumping from the best program to a better program to a better one, etc.

So feel free to download one of the programs I’ve provided and tweak it to meet your needs and intent for your PRT program.

The key components of all programs are:

• Emphasizing proper technique
• Optimal exercise selection (the ones with the most benefits, think efficiency)
• Progressive overload
• Some aspect of Periodization (I recommend block periodization)

So modify the exercises as desired based on equipment availability, skill level of the PRT leader, and time available for PRT.

Identifying which Soldiers are at increased risk of injury

I mentioned this at the very top, but remember that ALL Soldiers are at risk of injury. Injuries are an unfortunate inherent aspect of being physically active and working a physically demanding job.

Yet, while we’re all at risk there are significant ways we can decrease that risk. At the unit level, it involves the proper PRT program as described above. On the individual level, it involves identifying which Soldiers are at increased risk of injury beyond that of the normal risk level.

Two studies on Soldiers have provided numerous risk factors for us to address

The purpose of research is to tell us how it is. Well, we have three great studies that have found a list of risk factors that increase certain Soldiers’ risk of experiencing an injury.

As a leader, you should care about this! Want to improve your medical readiness? Want to minimize how many and how often Soldiers are at medical appointments? Take care of them and they’ll make you look good.

Here are the studies:

This study, by a few of my PT professors (great job!), was done on Army Rangers. This is an elite group of Soldiers, nevertheless, maybe you’ll be surprised that many of the risk factors for Rangers are the same as those ordinary Soldiers!

The more risk factors you (your Soldiers) have the greater the risk of sustaining an injury in the future.

This study evaluated injury risk in the conventional Army. Same approach as able.

This third study merely looked at general injury risk across a single brigade combat team.

This study was unique in that they also assessed the impact of unit PRT training, such as how many days per week Soldiers ran and the risk of injury, etc.

They found that if a unit ran > 3 times per week or ran > 16 miles in a week that the injury rate increased. This is applicable to most units in the Army!

Risk Factors that increase your odds of experiencing an injury

As you read through this list, make a checklist of the ones that you have.

• smoking
• being overweight (even a BMI of between 25-29.9 increases injury risk)
• having a prior injury
• previous history of surgery
• not feeling as if you’ve recovered fully from a previous injury
• having been on profile in the past year
• unequal ankle dorsiflexion range of motion (as if when you lift your foot off the gas pedal)
• poor or unequal performance on each extremity on the Lower and Upper Quarter Y-Balance tests
• pain during one of the Functional Movement Screen (FMS) clearing tests (your local PT can show you these if you’re interested)
• slower 2-mile run times
• older age
• female sex

Assessing your Soldiers (and you!) for increased risk of injury

How many risk factors did you have?

We all have some. The problem arises when we have too many.

Two of the studies above calculated the odds ratios however I simply combined the risk factors from the studies. In general, I will suggest that if you or your Soldier has > 4 of these risk factors that they are likely at least TWICE as likely to sustain an injury in the future.

So, what do we do?

Some of the injury risk factors listed above are modifiable, in that we can do something to change them such as helping a Soldier lose weight, while others are non-modifiable, in that we cannot change them (e.g. female sex or older age).

However, we can still greatly influence ALL of the risk factors.

Examples of addressing & influencing injury risk factors

Example #1 – a 27-year-old active-duty male with the following risk factors:

• overweight (BMI is 28)
• struggles to pass the 2-mile run
• has chronic lower back pain
• smokes

What should we do?

To address his weight I would:

• Enroll him in the Army Body Composition Program (ABCP)
• Ensure that he visits the closest Army Wellness Center (AWC) to get a BodPod assessment and some good education
• Encourage him to schedule an appointment with a dietician, preferably one that specializes is sports nutrition

To address his weight and fitness, I would simply ensure that my overall PRT program is appropriate. He should be able to participate in normal PRT without needing “extra help” if you have a good program established. In fact, that extra PRT just might be what causes him to sustain an overuse injury! So be careful. Be purposeful. Hold your Soldiers accountable.

To address his chronic low back pain I would:

• Encourage him to begin PT (or re-initiate PT if it’s been awhile)
• Allow him to participate in PRT and work with him as long as he’s steadily improving his fitness and is participating as he should

To address his smoking I would:

• Encourage him to schedule an appointment with his PCM to discuss medicine and request a Behavioral Health referral
• Encourage him to attend Behavioral Health or other smoking cessation courses
• Reward him for quitting!

Doing all of this requires effort and time by leadership. But it’s worth it. That’s why you’re a leader. You should be making those under you better, to help them do what they cannot do on their own and may need your encouragement to do.

So counsel your Soldiers on what your expectations of them are and how you will help them achieve the mutual goals that you set together. Stick to a realistic timeline.

If you do these things right you’ll likely gain a loyal Soldier who’s grateful for having had the chance to be under your leadership and mentorship.

Example #1 – a 30-year-old active-duty female with the following risk factors:

• prior knee injury (ACL reconstruction in high school)
• chronic knee pain
• slow 2-mile run time
• unable to complete a Leg Tuck but is working really hard

To address her slow running time likely due to chronic knee pain from the prior surgery I would:

• Encourage her to re-engage with physical therapy to see if there are any deficiencies in her strength (usually quads, hips, glutes)
• Have her work on single leg balance and functional exercise (mini-single-leg squats, etc.) at the end of PRT sessions for a few minutes
• Have her work with you MFT or PT to ensure her squatting, deadlifting, and running form are all good
• Depending on her weight, encourage her to schedule an appointment at the Army Wellness Center to get a BodPod assessment

To address her struggle with leg tucks and to prevent developing shoulder pain I would:

• Have her workout with an MFT or PT to show her proper form
• Coach her on the most effective exercises for strengthening for the leg tuck so she’s not just doing high volume and going to develop pain somewhere

The risk factor that I didn’t list…

Her sex – female.

If you’re reading this and think it sounds controversial, it’s not. So before you call up the EO officer know that it’s statistically true that females are at greater risk of injury. The potential EO issue becomes how we leaders handle this fact.

My goal is to empower leaders, even female leaders(!), with information that they likely don’t know to help them better lead and take care of their female Soldiers.

According to the most recent Health of the Force Report, females are injured significantly more likely than males. Females are also more likely to report having multiple injuries at once. And being female tends to fall out of the research as a risk factor. Why?

It’s likely due to the difference in natural muscle mass and less dense bone structure.

The reason we can say that is because there’s good research showing that when females undergo strength training they perform at levels equal to untrained males. Basically, build strength and many of these injury risks decrease back to baseline levels equal to that of males.

This is one of those non-modifiable risk factors that we can still influence quite a bit.

How?

Ensure that they are progressively strengthening and progressively, slowly, increasing their road march load. Try to keep it at < 25% of body weight unless you’re training up for something.

I’ll write more on this in greater detail, but know that strength training over a 6-month period is extremely beneficial for females.

The best study on this found that when inactive women were tested, only 24% of them could meet the requirements for a “heavy” or “very heavy” MOS. However, after 6 months of training 78% of the females met the benchmarks for those MOSs.

They also found that over those 6 months they were able to increase their road marching speed by over 1 mph!

So, be patient. Have a solid training program and ensure your female Soldiers are participating in the strengthening. Over time, you’ll have a stronger, more confident, ready group of female Soldiers that have less to worry about. That’s a big deal! Take care of your female Soldiers.

Additional considerations for female Soldiers

I’m putting my PT and husband hats on for this one.

Females who are postpartum truly need more time to recover and train up for the ACFT. Don’t rush them back.

To my knowledge, there’s currently no plan for extending the amount of time a postpartum Soldier has to take a record ACFT from the old standard of 6 months for the APFT. But we all know that the ACFT is way more demanding, especially on the core and abdominal muscles.

Be realistic. Be a leader. Protect your postpartum Soldiers and take care of them. There are very few females in the Army who will be ready to take and pass an ACFT at 6 months postpartum. I’ve known many super-fit women who struggled after pregnancy to get back to their pre-pregnancy condition, and I’m not even talking about weight!

Reasons why postpartum females need more time

• Stretched out, weak abdominal muscles – this just takes time to return to “normal”

• Diastasis recti (click the link) – this also takes time to reduce and may not ever go away. This doesn’t mean they’ll never do a leg tuck or have a weak core forever but it does mean it’s going to be significantly more challenging for quite a while.

• Hormonal imbalances mean that there may still be lingering lower back, SI Joint, pubic symphysis, and hip pain for months after surgery. Pushing them to do “more” won’t help, some things just take time.

• Engorged breasts – postpartum Soldiers who are breastfeeding will likely have fuller breasts and may have more breast or upper back pain, leakage, difficulty, etc. doing pushups, especially the hand release pushups on the ACFT(!), and greater difficulty running.

• Loss of muscle mass – unless women maintain some level of appropriate strength training while pregnant, it’s likely that they’ve lost muscle mass. Understand that it will take time to build that back up following delivery.

• Pregnancy weight – some women lose it quickly, others don’t. Part of the weight is directly related to pregnancy and that’s why many women quickly lose weight after delivering. But other women will struggle to lose weight. And with the loss of muscle mass, this is a double whammy! Help them engage with a dietician and the AWC to address this in healthy ways. Ensure you’re not adding to their stress causing them to stress-eat… Obviously, a higher body weight adds significant risk of injury.

• Being extra tired – we all know babies wake you up at night. But when you’re a postpartum Soldier waking up early to get to PRT you have to wake up even earlier if you need to pump or breastfeed before you leave. A sleep-deprived postpartum female with all the risk factors I’ve just mentioned is a lot of potential injuries waiting to happen.

For me, this just comes down to being a reasonable leader and using common sense, regardless of what the AR says. I’m a firm believer that if you take care of Soldiers they’ll take care of you.

Work with your postpartum females, encourage them, help them progress, and I’m willing to bet they’ll do their best for you.

Heck, maybe even go ahead and see if there’s anything that you could do for them that might make their transition to motherhood a little easier. I think a happier, more positive, more efficient, less distracted, and less depressed Soldier is worth going above and beyond.

Conclusions on Injury Prevention

I hope you have learned that injuries are an inherent risk of being a Soldier. But I also hope you now appreciate how much control you actually have over this issue.

To the leaders reading this: be a good leader and take care of your Soldiers. Educate yourself, lead from the front, set a good example, and NEVER break one of your Soldiers.

To you Soldiers reading this: take care of yourself. It’s ultimately on you to eat healthily, work out appropriately, maintain healthy body weight, and avoid those other bad habits that increase your risk of injury. Trust me, as you age the 40 and 50-year-old future you will appreciate you took care of your knees and back today!

If you’re not in charge but feel your unit should make some useful changes, subtly share this website with them. Offer to lead PRT. Do well at it and see if they’ll send you to the Master Fitness Trainer Course. Then come back and blow them away!

My bottom line in everything I do is to add value.

So if you find yourself complaining about your PRT, add some value… 😉

There are numerous approaches that we can take at both the leadership and individual level to reduce our risk of injury. But it doesn’t stop there. Because we know that injuries will still happen, you must be prepared to rehab them back in as expeditious of a manner as possible.

What to do when it doesn’t work?

Rehab!

Oh yeah, every PT’s chance to be a hero. More on that on another page!

If there’s any way I can be of service let me know!

Cheers,

Max