Non-battle injuries result in more medical evacuations than combat

By Veronique Hauschild, Injury Prevention Program, U.S. Army Public Health CommandJanuary 29, 2015

Non-battle injuries result in more medical evacuations than combat
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Non-battle injuries result in more medical evacuations than combat
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ABERDEEN PROVING GROUND, Md. (Jan. 28, 2015) -- If you ask Soldiers what the biggest physical health threat they face while in the Army, only a portion are aware that it has nothing to do with warfighting.

In fact, 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.

These activities are not just a primary cause of injuries in stateside locations, but also in deployed locations.

"Non-battle injuries resulted in more medical air evacuations from Afghanistan and Iraq than battle injuries," said Keith Hauret, an epidemiologist at the U.S. Army Public Health Command, or USAPHC. "The leading causes of these non-battle injuries were physical training and sports."

One health provider responding to a recent USAPHC anonymous survey about injuries noted, "we spend time and money training a Soldier to become 'physically fit' -- but because we don't do this right -- we over-train them to the point of injury -- so they are given restricted duties or medically discharged before they can ever fight our wars."

These injuries continue to cause temporary or even permanent disability and limit the physical capability of thousands of active-duty Service members each year. The impacts include millions of clinic visits annually, millions of lost or restricted duty days, as well as millions of dollars in medical costs.

Leaders need to be better educated on taking care of Soldiers.

The Army places a great deal of emphasis on training Soldiers so they are fit and capable of successfully performing their physically demanding jobs. But physical training can stress the body and cause various muscle, skeletal, tendon or ligament injuries. Soldiers can also get caught up in the competitive nature of sports programs and overdo it, resulting in sprains, strains or more severe injuries.

"While participating in physical activities such as running or sports puts you at risk for an injury, the risk of injury should certainly not be interpreted as an excuse to not exercise," said Dr. Bruce Jones, injury prevention program manager at USAPHC. "Instead, high or increasing injury rates should be a wake-up call to leaders, indicating a need to adjust the physical training program to prevent over-training. This will reduce injuries and ultimately enhance fitness and physical performance."

Army medical experts say training should be conducted in a way that avoids preventable injuries.

"Fit, healthy and uninjured Soldiers are what make an exceptional Army," said Maj. Tanja Roy, an epidemiologist at the USAPHC. "Unit leaders should follow proper physical training guidance and be careful to avoid over-training Soldiers with too much running or improperly instructed exercises."

It's not just the lack of leadership awareness that prevents the Army from avoiding first-time injuries. To some health care providers it is sadly ironic that remedial physical fitness, or PT, programs often force less fit individuals to work out twice a day -- which ultimately can result in injury making it more difficult to meet the standards.

In the USAPHC anonymous survey, one Army medical provider noted, "I am currently seeing a patient for an ankle fracture. He is in a cast and on crutches, yet was forced to walk for his (physical training)."

Injury prevention experts say the lack of proper procedures increases risk of re-injuries and costly chronic conditions especially as these Soldiers age. They report that some Soldiers are forced to run every day and are plagued with lower back pain and knee pain.

So what can a Soldier do to prevent injuries?

Simply put: train smarter. There is scientifically supported guidance and doctrine that describes injury prevention to be a priority in the Army.

All Soldiers, but especially leaders, should be aware of behaviors or conditions that put individuals at increased risk of exercise-related injuries as well as training principles that can prevent them. Examples include:

• Excessive running is the most common cause of overuse injuries especially in feet, ankles or lower legs. These can be avoided by using a training regimen that incorporates alternative days of low-impact aerobic workouts (e.g. swimming, biking or rowing) and days of strength training. Running distances and durations should be slowly increased over time, and Soldiers should not be forced to run if injured. Cadence runs are not recommended as a fitness method (for esprit de corps only), and group runs should be organized by pace and distance abilities.

• Balanced physical fitness programs should include a mix of aerobic, strength and agility drills and conditioning exercises. Studies that have evaluated the effectiveness of the Army's standardized Physical Readiness Training, or PRT, program described in Army field manual 7-22 have shown that units following the PRT program had significantly lower injury rates than those following a run-centric PT regimen.

• Basketball injuries predominantly involve the foot or ankle. Scientific studies have shown that the use of semi-rigid ankle braces during basketball significantly reduces the risk of recurring ankle injury. Likewise, science has shown that wearing mouth guards during basketball reduces the number of people with broken teeth and other mouth-related injuries.

• Weight-lifting and high-intensity extreme conditioning programs most often involve the shoulders and back. These injuries are often linked to improper form and using too much weight too quickly. These injuries are not likely to be prevented with equipment. While some Soldiers choose to wear back braces during weight-lifting, substantial evaluation of this equipment has not shown them to reduce injury--in fact they may actually increase risk. Though the best physical training routine will include strength training, as with running, the physical training principles of moderation, slow progressive increases and form are important to avoid injuries.

• Military training activities other than exercise, such as parachuting and combatives have also been associated with high rates of certain types of injuries. Though not always used, some equipment has been proven to prevent these injuries. For example, mouth guards are now required during combatives, as they are proven effective at reducing painful and costly teeth and mouth injuries. Ankle braces, though not required, have also been proven as an effective tool to reduce parachuting ankle injuries.

Balancing exercise regimens and gradually building up performance levels.

Through its performance triad campaign, the Army's medical community continues to encourage incorporating exercise into every Soldier's routine.

"The duration, frequency, level and type of exercise activity, however, should be balanced against known injury risks," Jones said. "Remember that regardless of how fit and how strong you are, an injured back, a sprained ankle, a stress fracture or a torn shoulder ligament can put you out of commission for days, weeks or longer. If not prevented or properly treated, an overuse injury can become a chronic debilitating condition."

By carefully following proper training techniques, avoiding over-training, and adhering to scientifically proven exercise regimens, Soldiers can help to prevent injuries and improve fitness.

NOTE: The Army's Institute of Public Health has studied Army injury trends and risk factors for years and published numerous articles and reports on these topics. Technical references can be provided by contacting the program at The program is also currently developing educational products to help increase awareness of common physical training related injuries and prevention tactics.

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U.S. Army Public Health Command Health News