Sports Medicine Injuries: A Challenge to Military Readiness

1
Sports Medicine Injuries A Challenge to
Military Readiness

• Francis G. OConnor, MD, MPH
• Medical Director, USUHS Consortium for Health
• and Military Performance (CHAMP)
• Uniformed Services University of the Health
  Sciences

2
Introduction

• Musculoskeletal Injuries in America
• 25 35 of all doctors visits for
  musculoskeletal complaints
• Leading cause of death (ages 1 - 44 yo.)

3
Introduction

• Musculoskeletal (MSK) Injuries in the Military
• Injuries from physical training are largest cause
  of morbidity mortality in peacetime military
• MSK Injuries cause significant morbidity during
  deployment

4
Introduction

• Musculoskeletal Injury vs Medical Illness
• Sick call visits?
• Illness Injury
• Lost Duty Time?
• Injury gtgt Illness
• Injury with highest number of lost duty days?
• ACL Ligament Tear

5
Introduction

• Musculoskeletal Injury and Force Morbidity
• Army Basic Training
• 23-27 males and 42-67 females injured during 8
  weeks
• Army Duty Statistics
• More limited duty days from injury than illness
• 51 male
• 221 female

6
Introduction

• Musculoskeletal Injury and Hospitalization
• Leading cause of Hospital Stay in US Armed Forces
• MSK System 14-28 of hospitalizations
• Other Injuries 2-10 of hospitalizations

7
Introduction

• Musculoskeletal Injury and Disability
• Leading cause of disability in US Armed Forces
• 22 63 of disabilities
• Mental Disabilities are 2nd (10-21)
• 34 of ALL V.A. Disability compensation

8
Injuries Impacting Force ReadinessMusculoskeletal
Injuries and Death

• Injuries are the leading cause of peacetime death
  in the Armed Services
• Accidental injuries
• 57 of all deaths in Army, Navy, Marines Air
  Force
• Violent injuries
• Suicides/Homicides/Casaualties
• 30 of deaths

9
Editorial Comment

• We Interrupt this Lecture for a Brief Editorial
  Comment
• How much Musculoskeletal Medicine will You See?
• 22-34 of outpt visits (civilian) for MSK
  complaints
• How much Musculoskeletal Medicine will You Learn?
• MSK 2 of Med School Curriculum (US Canada)

LOTS!!
Depends on You...
10
Objectives

• Sports Medicine Injuries Impacting Force
  Readiness
• Risk Factors that Predispose to Training-Related
  Injuries
• Intervention Studies Attempting to Prevent Injury
• The Future

11
Risk of Injury in Soldiers

• LTC J. Pitt Tomlinson et al
• Military Medicine, Vol. 152, 1987.

12
Injuries Impacting Force Readiness Risk of
Injury in Soldiers

• 15,295 soldiers of the 9th Infantry ID
• 81 injuries/100 soldiers/per year
• Unable to return to full duty 60
• Greatest number of disabled soldiers due to
• Musculoskeletal Injuries
• The majority of injuries occurred during
• - Physical Training

13
Injuries and Illnesses Incurred by an Army Ranger
Unit during Operation Just Cause

• Miser WF, Lillegard WA, Doukas WC.
• Military Medicine August 1995

14
Injuries Impacting Force Readiness Injury and
Illness During OPR Just Cause

• Retrospective interview of 471 members of a
  Ranger unit within 1 week of return
• Injury rate
• 35 of Rangers injured
• 90 of injuries during initial jump
• Morbidity Readiness
• 20 precluded Mission Completion
• 22 (additional) Limited Performance

15
Injuries Impacting Force Readiness Injury and
Illness During OPR Just Cause

• Ankle (19.6) most common site of injury 80
  sprains
• 67 of ankle injuries limited mission completion
• Closed fractures and ankle sprains resulted in 3X
  more Rangers out of duty than GSW and open
  fractures

16
Risk Factors and Incidence of Friction Blisters
in Marine Corps Officer Basic Training

• OConnor FG, Brannen SJ, et al
• 5th Annual Recruit and Trainee Healthcare
  Symposium,
• Parris Island, South Carolina
• Piantinada NA, Knapik JJ, Brannen SJ, OConnor
  FG Injuries during Marine Corps Officer Basic
  Training. Military Medicine 2000165(7) 515-520.

17
Injuries Impacting Force Readiness
Musculoskeletal Injuries in the Field

• 491 Officer candidates, six weeks of training at
  Quantico, VA
• 1,091 medical encounters
• Overuse injuries predominated 21
• Injury incidence (injuries/1000 training hours)
• blisters (1.16)
• sprains (0.68)
• stress reactions (0.49)
• knee ailments (0.42)

18
Factors Associated with Discharge during Marine
Corps Basic Training

• Reis JP, Trone DW, Macera CA, Rauh MJ Military
  Medicine 2007172(9)936-41.

19
Injuries Impacting Force Readiness Discharge
During Basic Training

• Prospective study assessed risk factors for
  discharge from Marine basic training
• 2,137 male marine recruits Feb thru April 2003
  Overall 10.3 were discharged
• Associated risk factors
• Stress fracture during BT
• Age over 23
• Poor incoming self-rated fitness
• No history of competitive exercise
• Incoming injury with incomplete recovery.
• Recommendations
• Strategies needed to allow proper healing, and
  improve physical fitness prior to starting basic
  training.

20
Injuries Impacting Force Readiness
Nontraumatic/Exertional Sudden Death

• Congenital cardiovascular disease is the leading
  cause of nontraumatic exertional sudden death in
  young athletes
• Civilian Population
• Hypertrophic cardiomyopathy
• Coronary anomalies
• Military Trainees
• Heat illness 1
• Coronary anomalies
• Myocarditis

21
Injuries Impacting Force Readiness Review
Important Facts

• Epidemiology
• Injuries cause MORE lost duty time, disability,
  hospitalization than illness in military
• Most Common Injuries sprains, closed fractures,
  stress fractures and blisters
• Sudden Death in Young Athletes
• - Civilian Congenital Cardiac Disease
• - Military Heat Illness, coronary anomalies
  Myocarditis
• Readiness Cost
• 50-60 of injured do Not Return to Full Duty

22
Objectives

• Sports Medicine Injuries Impacting Force
  Readiness
• Risk Factors that Predispose to Training-Related
  Injuries
• Intervention Studies Attempting to Prevent Injury
• The Future

23
Identify Causes and Risk FactorsCategorizing
Risk Factors for Injury

• Intrinsic
• Malalignment
• Muscle Imbalance
• Inflexibility
• Muscle Weakness
• Instability

• Extrinsic
• Training Errors
• Equipment
• Environment
• Technique
• Sports-acquired Deficiencies

24
Sickle-Cell Trait as a Risk Factor for Sudden
Death in Training

• Kark JA, Posey DM, et al.
• New England Journal of Medicine 1987.

25
Identify Causes and Risk FactorsSickle Cell and
Sudden Death

• Deaths in military basic training 1977 - 1981
• All sudden unexplained deaths related to physical
  exertion
• Caused by
• heat illness 1
• cardiac events
• exertional rhabdomyolysis
• The relative risk of a sudden death in African
  Americans with sickle-cell trait was 27x that of
  African Americans without sickle-cell
• - 40x that of other races

26
Epidemiology of Injuries Associated with Physical
Training among Men in the Army

• Bruce H. Jones et al Medicine and Science in
  Sports and Exercise 1993

27
Identify Causes and Risk FactorsInjuries and
Physical Training

• 303 men in Army Infantry Basic Training
• Cumulative incidence of training injuries 37
• Risk factors for injury included

28
Risk Factors for Lower Extremity Injuries
29
Risk Factors for Lower Extremity Injuries
30
Foot Morphologic Characteristics and Risk of
Exercise-Related Injury

• Cowan DN, Jones BH, et al.
• Archives of Family Medicine 2733-777, 1993

31
Identify Causes and Risk FactorsFoot Morphology
and Injury

• Prospective study in military basic trainees
• Radiographic imaging to classify foot type
• Highest arches had a risk ratio of 2.3 compared
  to the lowest arches for sustaining a lower
  extremity injury plt.05

32
Intrinsic Risk Factors for Exercise-Related
Injuries among Male and Female Army Trainees

• Jones BH, Bovee MW, et al.
• The American Journal of Sports Medicine 1993.

33
Identify Causes and Risk FactorsMale and Female
Trainees

• Prospective study involving 391 army trainees
  186 women and 124 men
• Time-loss injuries
• Women 44.6
• Men 29.0
• Soldiers with slower two-mile run times (men
  women) had significantly greater risk for injury

34
Comparison of InjuryDuring Cadet Basic Training
by Gender

• Bijur PE, Horodyski M, et al.
• Archives of Pediatric and Adolescent Medicine
  Vol. 151 1997

35
Identify Causes and Risk FactorsMale and Female
Trainees

• 558 West Point cadets 473 men and 85 women
• Women had 2.5 times the rate of injuries as men
• 3.9 times the rate of injuries requiring
  hospitalization
• Pre-training conditioning (entry 2 mile runtime)
  accounted for half the difference in injury rates
  
• Equal injury rates after cadet basic training by
  the end of the first semester

36
Identify Causes and Risk FactorsReview
Important Risk Factors

• Sickle Cell Trait a strong risk factor for
  Sudden Death in Heat Illness
• Age, Smoking, Baseline Fitness, Flexibility and
  Foot Type all proven risk factors for injury
• Is Gender a true risk factor or confounded by
  other variables?

37
Objectives

• Sports Medicine Injuries Impacting Force
  Readiness
• Risk Factors that Predispose to Training-Related
  Injuries
• Intervention Studies Attempting to Prevent Injury
• Future

38
Influence of Boot-Sock Systems on Frequency and
Severity of Foot Blisters

• Knapik JJ, Hamlet MP, Thompson KJ
• Military Medicine Vol 161, 1996.

39
Intervention Studies to Prevent InjuryBoot/Sock
Systems Blisters

• Participants were 357 male recruits undergoing
  Marine Corps basic training
• Recruits were divided into three different
  boot-sock systems
• Group 1 standard military sock
• Group 2 standard sock plus a polyester liner
• Group 3 polyester liner with a prototype sock
  made of a wool-polyester blend

40
Intervention Studies to Prevent InjuryBoot/Sock
Systems Blisters

• Influence of different boot-sock systems on
  incidence of blisters and cellulitis resulting in
  limited duty

41
Prevention of Lower Extremity Stress Fractures A
Controlled Trial of a Shock Absorbent Insole

• Gardner LI, Dziados JE, Jones BH, et al
• American Journal of Public Health Vol 78
  (12) 1988

42
Intervention Studies to Prevent InjuryShock
Absorbent Insole Stress Fx

• 3,025 Marine basic training recruits, 12 weeks at
  Parris Island
• Viscoelastic polymer (sorbothane) insole to
  prevent stress fractures stress reactions of
  feet/legs
• Prospective controlled trial
• Trainees selected their own running shoes

43
Intervention Studies to Prevent InjuryShock
Absorbent Insole Stress Fx
Results

• Elastic polymer insole did NOT prevent stress
  reactions/fractures
• Increasing stress injuries observed with
  increased age of running shoes
• Baseline physical activity level inversely
  related to stress injury rate
• 2.45 Relative Risk for Caucasians (compared to
  other racial groups) for stress injury

44
Impact of an Outside-the-Boot Ankle Brace on
Sprains Associated with Military Airborne
Training

• US Army Research Institute of Environmental
  Medicine, Natick, Massachusetts

45
Intervention Studies to Prevent InjuryAnkle
Braces to Prevent Jumping Injuries
46
Intervention Studies to Prevent InjuryAnkle
Braces to Prevent Jumping Injuries

• Ankle injuries account for 30 to 60 of parachute
  jump-related injuries
• 777 volunteers from four classes at the US Army
  Airborne School at Fort Benning, GA
• 389 braced soldiers 388 controls

47
Intervention Studies to Prevent InjuryAnkle
Braces to Prevent Jumping Injuries

• More Sprains in Non-Braced Group
• -1.9 non-braced vs 0.3 braced
• -RR 6.3 plt0.05
• No significant difference for any other category
  of injury

48
Stress Fractures in the Lower Extremities of
Soldiers in Basic Training

• Pester S, Smith C
• Orthopedic Review, March 1992.

49
Intervention Studies to Prevent InjuryReducing
Stress Fractures (Trial 1)

• 4-year study on lower extremity stress fractures
  in basic trainees at Fort Dix, NJ
• Incidence of 0.96 in 109,296 soldiers
• Modifications in the physical training program
• Eliminated continuous, high-impact activities
  during high risk weeks
• Resulted in 12.73 drop in stress fracture
  incidence
• New Incidence 0.84 (prevent 1 fx in 1,000
  trainees)

50
Effectiveness of Rest from Running on Stress
Injuries in Army Basic Training

• Popovich RM, Gardner JW, et al
• Department of Preventive Medicine and Biometrics,
  USUHS, Unpublished.

51
Intervention Studies to Prevent InjuryReducing
Stress Fractures (Trial 2)

• Modified training regimens at Fort Bliss, TX
• standard program progressive training with
  weekly marching and running
• cyclic training program avoidance of running
  during the second, third or fourth week
• Marine program increased running mileage

52
Intervention Studies to Prevent InjuryReducing
Stress Fractures (Trial 2)

• Resting from running during any predetermined
  week was NOT beneficial in reducing stress
  fracture or other injury incidence
• Consistent, scheduled progression of regular
  running and marching, alternating with days of
  rest (standard program), less injury-prone than
  other schedules

53
Increasing the Physical Fitness of Low-Fit
Recruits before Basic Combat training an
Evaluation of Fitness, Injuries and Training
Outcomes

• Knapik JJ, Darakjy S, Hauret KG, et al Military
  Medicine 2006171(1)45-54.

54
Intervention Studies to Prevent
InjuryRehabilitation Platoons

• Recruits between 1999 and 2004 at fort Jackson
  were given an entry level PT assessment.
• Three groups were established
• Failures who entered a fitness assessment program
  prior to entering BCT (Group 1)
• Failures who entered BCT directly (Group 2)
• Non-failures who entered BCT (Group 3).
• Army PT tests, injuries, and graduation outcomes
  were assessed.

55
Intervention Studies to Prevent
InjuryRehabilitation Platoons

• Proportion of graduates
• Group 1 59 men 52 women
• Group 2 83 men 69 women
• Group 3 87 men 78 women.
• Injury Rates
• Group 1 injury risk 1.5x greater than group 2
  (men)
• Group 1 injury risk 1.2x greater than group 2
  (women)
• Conclusion Fitness assessment Program
  demonstrated reduced attrition (plt0.01) and lower
  injury rates, compared with recruits of similar
  low fitness who did not precondition.

56
The Beneficial Relationship of the Colocation of
Orthopedics and Physical therapy in a Deployed
Setting Operation Iraqi Freedom

• Davis S, Machen MS, Chang L Military Medicine
  2006171(3)220-223.

57
Intervention Studies to Prevent InjuryReview

• Liners and Standard Socks Prevent Blisters Best
• Insoles, Breaks from Running, Marine Program
  have not been shown to reduce stress fractures
• Newer Running Shoes, Progressive Training, and
  avoiding other High Impact Activities minimally
  helpful for stress fractures
• Rehabilitation Platoons are helpful as Fit People
  get hurt Less

58
Objectives

• Sports Medicine Injuries Impacting Force
  Readiness
• Risk Factors that Predispose to Training-Related
  Injuries
• Intervention Studies Attempting to Prevent Injury
• Future

59
Human Performance Optimization An Evolving
Charge to the Department of Defense

• Deuster PA, OConnor FG, Henry KA, Martindale VE,
  Talbot L, Jonas W, Friedl K Military Medicine
  2007111133-1137.

60
USUHS Involvement in HPO

• Ms. Embry Report to OSD/HA
• DoD lacks a robust, comprehensive, fully
  integrated HPO program.
• A robust HPO program will
• Enhance mental and physical resilience of
  warfighters
• Reduce injury and illness or more rapid recovery
• Improve the human weapons systems ability to
  accomplish the mission and
• Allow the US to keep pace with other countries.

61
CHAMP A USUHS Initiative
Optimizing Human Performance the process of
applying knowledge, skills and emerging
technologies to improve and preserve the
capabilities of DoD personnel to execute
essential tasks. CHAMP, USUHS
62
Vision and Mission Statements

• To be the premier medical resource in military
  unique human performance optimization.

.. to promote basic, clinical and translational
research, education, and clinical expertise in
optimizing the functional capacity of the
warfighter, with the objective of maximizing
performance in the operational environment.
63
Goals/Specific Aims

• Lead in developing research, clinical services,
  and education agendas for HPO in DoD.
• Conduct, translate, and transfer research results
  into tools and educational materials for medical
  and operational communities, as well as
  commanders and warfighters.
• Develop a central clearinghouse for collecting
  and disseminating data on human performance in
  military settings around the world.
• Provide recommendations to DoD for HPO policy.

64
Basic, Translational and Clinical Research

• CHAMP will be a focal resource for facilitating
  USUHS/NCA HPO research
• Virtual communication network of CHAMP members
• Direct communication with HPO division of Joint
  Medical Research Command, COCOMs, Health Affairs
• Regular CHAMP meetings to facilitate group
  collaboration.

65
Educational and Evaluation Services

• Develop and direct a DoD HPO Clearinghouse
• Evidence-based information
• Knowledge Transfer, Education and Training
  Program (KTET)
• Communication system
• Mission customization
• Expert network.

66
Clinical Consultative Services

• CHAMP will be a resource to facilitate/coordinate
  medical care for warfighters with unique HPO
  needs
• Maintenance of expert network
• Human Performance Laboratory
• Environmental Chamber
• Electronic clinical consultation.

67
Conclusions

• Injuries are the leading cause of morbidity and
  mortality for soldiers in a peacetime military
• Research has elucidated some aspects (especially
  in epidemiology), tremendous work has yet to be
  accomplished in prevention
• Intervention studies have only scratched the
  surface

68
The Future of Military Sports Medicine

• Education of military providers to promote
  superior care to soldiers-athletes
• Closing the Gap
• - 34 of patient visits vs 2 of curriculum
• Designing Promoting Studies that focus on
  Intervention, not just Epidemiology
• Military Sports Medicine taking a significant
  leadership role in Operational Readiness