ABERDEEN PROVING GROUND, Md. -- Over the past year, a selected set of Army units have been piloting the new six-test Army Combat Fitness Test as the first phase of replacing the three-test Army Physical Fitness Test.Used since 1980, the APFT includes the 2-mile run, push-up test, and sit-up test. The ACFT is an almost hour-long series of the six tests described in Table 1: the dead lift, the standing power throw, the hand-release push up, the sprint-drag-and-carry, the leg tuck hold, and the 2-mile run.The ACFT is designed to better assess Soldiers' abilities to perform common tasks that reflect combat readiness. "It's much more rigorous, but a better test," agreed several members of the units testing the ACFT. Some studies are still underway, but transition to the ACFT is imminent:The ACFT will be conducted by all Soldiers Army-wide starting October 1, 2019. Soldiers will also conduct the APFT as the official test of record during a one-year transition until October 1, 2020. While some aspects of standards, training, and administration are being finalized, procedures and techniques are documented in Field Manual (FM) 7-22, Army Physical Readiness Training (PRT), 2012.The ACFT and associated training requires Soldiers to use several parts of the body not previously addressed by the APFT. This supports a more holistic, balanced approach to Army physical readiness. While ACFT is intended to improve Soldiers' physical performance while reducing injuries long term, as with any new physical activity it comes with new injury risks.Observations by Army experts suggest certain injuries that may be anticipated (see Table 1). While the Army is sending out ACFT trainers to every unit to help train Soldiers, everyone should be aware of potential new problems and how to avoid them.WHY AND HOW WERE NEW ACFT TESTS SELECTED?Leaders and Soldiers alike have long expressed concerns that the APFT doesn't adequately measure Soldiers' abilities to perform common required tasks important during deployment.Not all aspects of the APFT are bad, however. Studies have demonstrated that the 2-mile run is an excellent way to test Soldiers' cardiorespiratory endurance, also known as aerobic fitness. Aerobic capacity is linked to performance of more military tasks than any other aspect of fitness."Aerobic capacity is the most important measure of a Soldier's fitness," says Dr. Bruce Jones, a retired Army colonel and medical doctor with the U.S. Army Public Health Center. "And weight-bearing physical activities such as running or marching are inescapable routine military aerobic activities." Jones also explains that "Poor run times are not only associated with poor performance, they are associated with higher risk of injury." So the 2-mile run time is a reliable way to monitor both aerobic fitness and injury risk.The push-up test is also linked to key military tasks, and is a good measure of upper body muscle endurance. However, evidence did not support the value of using the sit-up test to measure military task performance.An in-depth review of key fitness elements and their association with military tasks found that muscle strength and power are critical to military task performance. Agility and speed are also very important. The APFT does not measure these key fitness elements. The ACFT will now ensure Soldiers' combat readiness determinations include these additional fitness components.WHAT INJURY RISKS ARE ASSOCIATED WITH THE ACFT?:Historically, the majority of Soldiers' injuries have occurred in the lower body, which includes the knee, lower leg, ankle, and foot and the lower back. Excessive physical training emphasis on distance running and long foot marches have been to blame."While lower body injuries may be reduced with more cross-training, they are expected to remain a primary concern," explained Tyson Grier, an APHC kinesiologist. "Soldiers spend the majority of their time on their feet. Their lower body is constantly absorbing forces from carrying their body weight in addition to other loads."The Army updated its training doctrine to the physical readiness training program in 2012 to reduce lower body injuries. The PRT deemphasizes distance running and encourages a mix of training activities to promote strength, agility, balance, and power.The PRT has been associated with a reduction of injuries in initial entry training. Army operational units have not shown comparable trends in injury reduction, however. Since the APFT has continued to be the test of record these units may not have fully embraced the PRT.With the implementation of the ACFT, the Army will still monitor Soldiers' aerobic fitness with the 2-mile run, but training time will need to be devoted to a variety of other activities too. The new tests are not risk-free, but the goal is to slowly build up the body's ability to perform activities than might cause Soldiers injuries on the job. While this is to enhance physical performance, Army experts recognize that the training for and conduct of the ACFT could also increase risk of injuries to the upper body such as the back and spine, shoulder, and elbows.Some items used for the ACFT, such as the trap/hex bar for the deadlift, have been specifically selected to reduce injury risk. To avoid injuries caused by excessive weight lifts, the maximum weight for the deadlift was limited to 340 pounds, considered a moderate weight by serious lifter. Procedures are designed to avoid injury. For example, the grader must spot the Soldier during leg tuck to reduce falling injury. A required warm up before the ACFT and a specific deadlift warm up period will reduce injuries. Despite these efforts, there will be a learning curve."A primary reason for injury resulting from the new test and training activities will be due to improper form and technique," says Grier. "These are new activities to learn. It is very important that Soldiers learn proper technique from the start, and avoid developing bad habits.""We also worry that "too much too soon" will cause injuries," notes Maj. Timothy Benedict., Army physical therapist. "Some Soldiers will start this training by lifting too much weight, conducting too many repetitions, or not allowing days of rest between sessions that stress specific muscles."While only future surveillance of Soldiers' injuries will be able to identify actual changes to the Army's injury trends, a review of existing evidence suggests potential injury risks associated with the new tests and associated training. Table 1 highlights key injury concerns.Some injuries associated with the ACFT will be sudden acute injuries. Acute injuries are usually associated with sudden sharp pain and typically require immediate medical attention. These include strains or tears in arm, shoulder, chest, or back muscles, torn knee ligaments, dislocated shoulders, herniated discs in the back, pinched nerves, or fractured bones (such as from falling during the leg tuck).While these acute injuries can occur when soldiers are conducting military tasks or other personal activities, specific training activities may raise the risk. For example, studies of both professional and amateur and weightlifters and power lifters have indicated that use of extremely heavy weights during the dead-left is associated with lower back disc herniation and knee injuries. On the other hand, some rehabilitation studies have suggested that using lighter weights during the dead-lift may be useful to strengthen the back and knees.An acute tear of fatigued muscles and tendons in the chest, arm, or shoulder during bench-pressing of heavy weights, such as a pectoralis major rupture, is another highly studied injury. This injury is almost uniquely associated with the bench press activity -- only a couple past military cases were other causes (parachuting and push-up training). Though the bench press is not part of the ACFT, there is concern that soldiers may use this activity to train for the ACFT.Injuries that develop gradually over time from over training are known as cumulative or overuse injuries. Overuse injuries occur when a repeatedly used set of body tissues haven't had adequate time to heal and rebuild. "Continuing to stress tissues already injured from improper or excessive use or weight will only make the condition worse," warns Benedict.While delayed muscle soreness can be a normal sign that muscles are rebuilding stronger, pain in a joint or bone is not normal. Pain associated with overuse injuries may dull during the activity, but can become more serious if use continues.Overuse injuries to the lower body are the most common type of Soldier injury. Overuse to joints in shoulders, elbows, as well as knees and spinal joints are concerns because of the new ACFT tests. A common shoulder overuse injury is a torn rotator cuff - though it can occur suddenly, tissues have often already been worn from excessive use. Other common overuse injuries include tendonitis, bursitis, and pain syndromes in the knee and the lower back. These injuries may lead to long term chronic or permanent tissue damage.WHY IT MATTERS:Though injuries will continue to be experienced by Soldiers -- most are preventable.Injury can mean out of commission for some time -- and can notably increase your chances of getting injured again. Or develop chronic life-long conditions as you get older.Injuries critically impact individual, units, and Army performance. Injuries cost the Army billions of dollars annually for medical treatment, rehabilitation and re-training, medical disability, and reduced productivity from restricted duties, and attrition. Training-related musculoskeletal injuries are the leading reason for temporary medical non-deployment status.WHAT YOU CAN DO:In order to optimize U.S. military performance, Soldiers and Leaders must do their part to train smarter which includes avoiding injury."An ounce of prevention is worth a pound of cure." So do what you can to avoid getting injured in the first place. Table 2 provides some general guidance. Using proper technique, slowly building up intensity and weight levels to acclimate your body, and allowing rest days between similar activities are the primary keys to minimizing your risk.To minimize risk follow procedures as taught by Army ACFT trainers. Seek guidance from Army Fitness Centers, doctrine in FM 7-22, a certified trainer, such as a Master Fitness Trainer, and use a buddy system during training to be warned of poor form and for hands on help as a 'spotter' to ensure proper balance and range of motion.And if you are injured? Stop activities at early signs of pain and seek medical advice. Taking a break from activities temporarily to let the tissues heal can minimize the likelihood of a more serious injury. An injured knee can require weeks or months of rehabilitation. A worn rotator cuff tear can mean surgery. Lower back pain can result in a long term health condition.To learn more about safely conducting and training for the ACFT visit www.army.mil/acft/.The Army Public Health Center focuses on promoting healthy people, communities, animals and workplaces through the prevention of disease, injury and disability of Soldiers, military retirees, their Families, veterans, Army civilian employees, and animals through population-based monitoring, investigations, and technical consultations.