Most Aren’t Related to Combat

BETHESDA, MD—Three-quarters of medically nondeployable servicemembers are out of commission as a result of musculoskeletal injuries, and the vast majority of those injuries come from training and sports activities, according to a recent study.

TAXONOMY OF INJURIES: Click to enlarge

While combat-related musculoskeletal injuries are typically more severe, non-combat-related musculoskeletal injuries occur six times more often and put 68,000 servicemembers in nondeployable status every year, according to researchers at the Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center in Bethesda, MD.1

In their report published in Sports Medicine and Arthroscopic Review,  the researchers determined that, in all, noncombat MSKIs cause 25 million days of limited duty and drive more than two million clinic visits per year. Total costs for these injuries exceed $3.7 billion annually.

The high cost related to these injuries in recent years is not an anomaly but part of a consistent pattern going back many years. “The primary health threat to troops for more than two decades has been common muscle, joint, tendon/ligament and bone injuries like knee or back pain that are caused by running, sports and exercise-related activities such as basketball and weightlifting,” explained Veronique Hauschild, MPH, of the Injury Prevention Program, Army Public Health Center, Aberdeen Proving Ground, MD.

No matter how you slice the data, musculoskeletal injuries have huge immediate impact and significant long-term sequelae. “There are, in the realm of orthopedics, two areas you can divide injuries into: orthopedic trauma and casualty care and military-related musculoskeletal conditions,” said Marvin Helgeson, MD, chief of orthopedics at Walter Reed. “Both types primarily affect the lower extremities and spine.”

Acute traumatic musculoskeletal injuries such as those resulting from accidents, falls, improper lifts or explosions account for 14% of injuries in the Army. Traumatic musculoskeletal injuries include fractures, dislocations, sprains and strains. Cumulative microtrauma from military-related training and overuse leads to nearly 70% of musculoskeletal injuries, such as stress fractures, shin splints, patellofemoral syndrome, tendinitis, bursitis, plantar fasciitis and back pain.2

These nonbattle injuries require medical evacuation more often than any other condition, with lower extremity injuries alone responsible for 40% of medevacs from combat theaters. “Spine pain is a very large reason for having to medically evacuate patients,” as well, Helgeson told U.S. Medicine.

MSKIs dominate as the primary reason for medical visits and hospitalizations in the nondeployed environment, too. They also are the leading cause of disability discharges.

Lingering Impact

Many patients continue to experience the consequences of musculoskeletal injuries for years. A variety of factors can cause MSKIs to recur, become chronic or even disabling. Osteoarthritis is a common long-term effect of these injuries which can “continue to degrade the physical and mental health status of Army soldiers and contribute to some of the highest military medical costs,” according to the APHC. Osteoarthritis develops in about one-third of servicemembers and veterans, compared to about 20% of the civilian population, the Sports Medicine and Arthroscopic Review authors found.

For many servicemembers, musculoskeletal injuries while on active duty translate into ongoing issues as veterans. While VA data “does not allow us to separate trauma and other injuries from degenerative conditions resulting in musculoskeletal pain,” said Friedhelm Sandbrink, MD, neurologist at the Washington, DC, VAMC, “the most common pain conditions in veterans are musculoskeletal conditions.”

Joint pain affects 43.6% of veterans, Sandbrink told U.S. Medicine, while 32.8% are plagued by back pain, and 15.9% have neck pain.

That’s consistent with findings by Hauschild and her colleagues that knee and lower back injuries each accounted for 16% of all injuries in active duty soldiers in 2017, with most caused by cumulative microtrauma.3 Notably, acute anterior cruciate ligament injuries occur 10 times more often in servicemembers than in the general population. As ACL injuries entail a recovery period of more than six months, the impact on readiness is significant.

Primary Causes

The high rate of overuse or cumulative microtrauma injuries in the lower limbs and lower back “are attributed primarily to running and foot marching long distances with heavy loads” and routinely lifting heavy objects, according to the APHC.

Running, marching with heavy loads and lifting heavy objects comprise common activities during military training, but the training is not designed to injure servicemembers but to strengthen them. Ideally, the body repairs microtears in the tissues of the lower body caused by running, foot marching, jumping and other training activities, making them stronger. When the body does not have time to heal the tears, however, an overuse injury can occur.

The APHC notes that rates of injury are highest among less fit recruits and servicemembers, with risk rising with the initiation or resumption of a new strenuous training activity. For individuals new to intense physical training, like many recruits, the sudden demands on their bodies and limited time allotted for rebuilding translates into high rates of injury. More than 45% of Army recruits sustain at least one MSKI, about half of which affect the lower extremities or back, the Sports Medicine and Arthroscopic Review authors found.

Completion of basic training does not eliminate the risk of injury, however. Nondeployed soldiers have musculoskeletal injury rates as high as 1.42 per infantryman, according to those authors. Female servicemembers have higher rates of musculoskeletal injury than their male counterparts, with rates twice that of male servicemembers in some cases, they noted.

A number of other factors increase the risk of MSKI, including smoking, high or very low body mass index, extreme or limited flexibility, inadequate sleep and prior injury. Women with the female athlete triad—inadequate consumption of calories or nutrition, decreased bone mineral density (generally associated with very low body fat), and amenorrhea—face additional risk.

  1. Grimm PD, Mauntel TC, Potter BK. Combat and Noncombat Musculoskeletal Injuries in the US Military. Sports Med Arthrosc Rev. 2019 Sep;27(3):84-91. doi: 10.1097/JSA.0000000000000246.
  2. Hauschild V, Hauret K, Richardson M, Jones BH, Lee T. A Taxonomy of Injuries for Public Health Monitoring and Reporting—Public Health Information paper (PHIP) No. 12-01-0717. 25 July 2017.
  3. Hauschild VD, Schuh-Renner A, Lee T, Richardson MD, Hauret K, Jones BH. Using causal energy categories to report the distribution of injuries in an active population: An approach used by the U.S. Army. J Sci Med Sport. 2019 Sep;22(9):997-1003.