Journal of Science and Medicine in Sport 24 (2021) 963–969

Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Review

Musculoskeletal injuries in military personnel—Descriptive

epidemiology, risk factor identification, and prevention
Mita Lovalekar a,∗ , Keith Hauret b , Tanja Roy c , Kathryn Taylor c , Sam D. Blacker d ,
Phillip Newman e , Ran Yanovich f,g , Chen Fleischmann f,g , Bradley C. Nindl a , Bruce Jones b ,
Michelle Canham-Chervak b
a
Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, USA
b
U.S. Army Public Health Center, Aberdeen Proving Ground, USA
c
U.S. Army Research Institute of Environmental Medicine, USA
d
University of Chichester, UK
e
University of Canberra, Australia
f
Institute of Military Physiology, Israel Defense Forces Medical Corps, Israel
g
Department of Military Medicine, Hebrew University School of Medicine, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To provide an overall perspective on musculoskeletal injury (MSI) epidemiology, risk factors,
Received 4 July 2020 and preventive strategies in military personnel.
Received in revised form 15 March 2021 Design: Narrative review.
Accepted 24 March 2021
Methods: The thematic session on MSIs in military personnel at the 5th International Congress on Sol-
Available online 31 March 2021
diers’ Physical Performance (ICSPP) included eight presentations on the descriptive epidemiology, risk
factor identification, and prevention of MSIs in military personnel. Additional topics presented were bone
Keywords:
anabolism, machine learning analysis, and the effects of non-steroidal anti-inflammatory drugs (NSAIDs)
Military personnel
Machine learning
on MSIs. This narrative review focuses on the thematic session topics and includes identification of gaps
Public health in existing literature, as well as areas for future study.
Fractures, Stress Results: MSIs cause significant morbidity among military personnel. Physical training and occupational
tasks are leading causes of MSI limited duty days (LDDs) for the U.S. Army. Recent studies have shown
that MSIs are associated with the use of NSAIDs. Bone MSIs are very common in training; new imaging
technology such as high resolution peripheral quantitative computed tomography allows visualization of
bone microarchitecture and has been used to assess new bone formation during military training. Phys-
ical activity monitoring and machine learning have important applications in monitoring and informing
evidence-based solutions to prevent MSIs.
Conclusions: Despite many years of research, MSIs continue to have a high incidence among military
personnel. Areas for future research include quantifying exposure when determining MSI risk; under-
standing associations between health-related components of physical fitness and MSI occurrence; and
application of innovative imaging, physical activity monitoring and data analysis techniques for MSI
prevention and return to duty.
© 2021 Sports Medicine Australia. Published by Elsevier Ltd. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Practical implications as well as help focus prevention efforts on musculoskeletal

injuries that result in high limited duty days.
• The incidence of musculoskeletal injuries is high in military • Musculoskeletal injuries resulting in limited duty days reflect
personnel, and appropriate recording will allow leaders to best soldier readiness, whereas musculoskeletal injuries resulting in
position medical providers for prompt treatment of these injuries, medical encounters reflect health care utilization. Both measures
offer valuable insights.
• Road marching and obstacle courses have higher risks of injury
per unit of exposure, as compared with routine physical training.
∗ Corresponding author. Consider this when planning physical training schedules.
E-mail address: MitaL@pitt.edu (M. Lovalekar).

https://doi.org/10.1016/j.jsams.2021.03.016
1440-2440/© 2021 Sports Medicine Australia. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
M. Lovalekar et al. Journal of Science and Medicine in Sport 24 (2021) 963–969

• Aerobic capacity and body mass index have an interactive effect likely due to their high physical and operational demands.20 Para-
on the risk of musculoskeletal injuries. Higher aerobic capacity is doxically, the physical training (PT) that can result in MSIs is also
associated with the lowest injury risk. When the combined effects required to improve performance in military personnel.21 The same
of aerobic capacity and body mass index were evaluated, individ- parameters of exercise (intensity, duration, and frequency) that
uals with the lowest body mass index across all levels of aerobic determine the positive fitness and health effects of PT also appear
capacity had the highest injury risk. to influence MSI risk.22 Cutting-edge technologies including the
• New imaging technology, physical activity monitoring, and use of physical activity monitors, data linkage from various sources
machine learning could have important applications in monitor- (e.g., medical, physical fitness, activity), and machine learning algo-
ing and prevention of injuries. rithms can improve decision making in the management of overuse
MSIs.
The purpose of this manuscript was to provide an overall per-
1. Introduction spective on each of the eight unique topics that were presented
during the thematic session “Musculoskeletal injuries in military
Military personnel are exposed to intense physical demands personnel – descriptive epidemiology, risk factor identification, and
in their training and operational environments,1 which increases prevention” at the 5th International Congress on Soldiers’ Physical
their risk of musculoskeletal injuries (MSIs).2 MSIs cause Performance (ICSPP). The authors have summarized and evaluated
morbidity,3 disability,4 and attrition in military populations,5 and important aspects of the existing literature, identified significant
high financial cost to the military.6 Overuse MSIs caused by cumu- gaps, and outlined areas for future study. The focus of this narrative
lative microtrauma are an important component of MSIs in military review was on each specific topic in the thematic session, instead
personnel.7,8 of an extensive literature review. The narrative review of each of
MSIs among U.S. Army soldiers often lead to limited duty days the eight topics is presented in this manuscript in the same order as
(LDDs),9 which are defined as the number of days of restrictions they were presented during the thematic session at the 5th ICSPP.
to work or training issued to military members due to adverse
health conditions causing physical or mental limitations. Military
readiness depends on the ability to effectively perform military-
oriented tasks, whenever and wherever needed, while remaining 2. Causes of injury and associated days of limited duty
healthy and uninjured. This is achieved through training that devel- among soldiers in the U.S. Army
ops requisite levels of physical fitness and competencies to perform
required tasks, while also mitigating MSI risks.1,10 Documentation MSIs are a leading health problem for U.S. Army soldiers. In
of MSI-associated LDDs has been incomplete in the medical records, 2018, over 50% of U.S. Army soldiers sought medical care for any
while self-report surveys may be affected by recall bias.11,12 Until MSI, resulting in over two million medical encounters.9 MSI-related
2019, LDDs among U.S. Army soldiers were estimated using medi- LDDs represent significant costs to the Army due to lost training and
cal record reviews or self-report surveys as proxies. MSIs requiring work time.23 From January through June 2019, over seven million
LDDs are in some cases more severe than those solely requiring LDDs were prescribed to over 122,000 soldiers who were assigned
an office visit, without limitations to work or training, and have LDDs by Army medical providers, as recorded in the eProfile system
a greater effect on soldier readiness. The U.S. Army now uses an (Table 1). Over half (4.1 million days, 59%) were due to MSIs, fol-
electronic profile system (eProfile) that allows medical providers lowed by 724,000 days (10%) due to pregnancy-related conditions,
to record LDDs, mechanism of injury, and return to duty times and 709,000 days (9%) due to behavioral health disorders. Among
following MSIs, which provides more information than that con- MSIs, leading causes associated with LDDs were running (43%),
tained in medical records. To effectively focus prevention efforts, work-related tasks (11%), falls (10%), road marching (8%), and sports
information on mechanisms of MSIs is necessary. (7%) (Supplementary Table 1). Results were consistent with prior
One specific type of MSI, stress fractures, is a pervasive and investigations of activities associated with Army MSIs; running is
costly problem in military personnel, impacting up to 20% of commonly the leading activity associated with MSIs.21,24,25
women and 6% of men undergoing initial military training.13 In ani- The amount and type of PT represents an important risk factor
mal models, physical activity-induced bone formation was shown for MSIs. Civilian and military studies show that higher amounts of
to greatly increase the fatigue resistance of bone.14 It has been activity result in elevated MSI risk.26 A study of male Army recruits
hypothesized that in humans, individual variation in exercise- during basic training found that MSI risk increased as footsteps per
induced bone formation may contribute to differences in stress day increased. MSI risk for the highest activity group (17,948 ± 550
fracture risk during times of increased physical activity, such as steps/day) compared with the lowest activity group (14,722 ± 400
military training.15 A recent study in the U.S. Army identified a steps/day), was 1.9 times greater for men (95% confidence interval
2.9-fold increased risk of diagnosed stress fractures among soldiers (CI): 1.5–2.6) and 1.4 times greater for women (95% CI: 1.1–1.8).27
prescribed non-steroidal anti-inflammatory drugs (NSAIDs).16 This In addition to amount of activity, type of activity is also impor-
finding led to an exploration of whether NSAIDs usage similarly tant to consider when determining MSI risk, as certain military
increases MSI risk in other military personnel such as Israel Defense activities like road marching and obstacle courses have higher MSI
Force (IDF) soldiers. An overuse MSI, Medial Tibial Stress Syndrome risks per unit of exposure. For example, a 2017 study of an U.S.
(MTSS) has been identified as the most costly MSI in the British Army infantry unit demonstrated a 1.8 times greater risk of injury
Army.17 There is no reliable treatment for MTSS and reoccurrence per mile due to road marching (95% CI: 1.4–2.4), compared with
rates are high.18 Prevention of MTSS is critical to reducing its oper- running.25 However, since running is a more frequent activity, it
ational burden. Typically, MSI prediction is complex, has multiple contributes a greater number of LDDs (Supplementary Table 1). In
contributing causes, and has not been capable of discerning indi- a study conducted during U.S. Army basic training, risk of MSI per
vidual level risks.19 Machine learning approaches can combine best hour of activity was 4.8 times greater during road marching (95%
known risk factors into an individual risk profiling tool for MTSS. CI: 1.1–20.4), and 7.5 times greater during obstacle course events
Naval Special Warfare (NSW) Sea, Air, and Land (SEAL) and Spe- (95% CI: 1.8–30.6), compared with routine PT.28
cial Warfare Combatant-craft Crewman (SWCC) Operators are a Data presented by members of the U.S. Army Public Health
group of specialized military personnel trained to participate in Center (APHC) in this section are results from routine, systematic
unconventional warfare, and are especially susceptible to MSIs, injury surveillance and operational studies that were reviewed and

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Table 1
Leading medical conditions associated with limited duty days, active duty U.S. Army soldiers, January–June 2019.

Men # of days (%) Women # of days (%) Total # of days (%)

Musculoskeletal injury 3,298,697 (65.3) 857,717 (41.9) 4,156,414 (58.6)

Pregnancy/post-partum – 724,022 (35.4) 724,022 (10.2)
Behavioral health 551,236 (10.9) 157,886 (7.7) 709,122 (10.0)
Neurology 111,507 (2.2) 30,475 (1.5) 141,982 (2.0)
General surgery 81,689 (1.6) 23,716 (1.2) 105,405 (1.5)
All other 1,007,181 (19.9) 250,900 (12.3) 1,258,081 (17.7)
Total 5,050,310 (100) 2,044,716 (100) 7,095,026 (100)

Data source: eProfile from the U.S. Army Medical Operational Data System (MODS)
Notes: All soldiers with profiles = 122,671; soldiers can be counted in more than one condition type. Profiles had start date between 01 January and 30 June 2019 and expiration
date on or after 01 January 2019.

approved as public health practice by APHC’s Public Health Review body region was the knee (22%; mean of 53 LDDs per knee injury),
Board. and the most common activities associated with knee MSIs were
running, team sports, and fall/trip. The ankle/foot accounted for
3. Relationship of musculoskeletal injuries, physical 20% of LDDs with the same three main activities associated with
fitness, and military performance in the U.S. Army MSIs. The lumbar spine was the third most injured body region
(15%), and the activities associated with these MSIs were running,
The associations of health-related components of physical fit- occupational lifting, and PT, thus demonstrating that the activi-
ness (aerobic capacity, muscular strength, and endurance, body ties associated with lumbar spine MSIs were slightly different than
composition, and flexibility) with MSIs are well documented. Aer- those associated with lower extremity MSIs. Additionally, although
obic capacity has the strongest and most consistently reported MSIs involving the knee were most frequent, MSIs involving the
negative association with MSIs.29–31 Service members with lower shoulder had the highest average LDDs. These patterns of MSIs were
aerobic capacity (e.g., slower 2-mile run time, lower VO2 max) have very similar in 2018. Rates for all MSIs calculated by either using
between 1.4 and 2.4 times higher MSI risk compared with those medical encounters or surveys can be up to three times higher than
with higher aerobic capacity.29,30 For example, Knapik et al. found rates for MSIs that resulted in LDDs, as not all MSIs result in LDDs.
that men and women in the slowest quartile on a 3.2 km run at the Three studies reported incidence rates of all MSIs from 95 to 156
start of basic training (men: ≥19.2 min; women: ≥23.5 min) had a MSIs per 100 soldier-years, much higher than the 29 and 34 LDD
1.6 (95% CI: 1.0–2.4; p = 0.04) and 1.9 (95% CI: 1.2–2.8; p < 0.01) MSIs per 100 soldier-years for MSIs resulting in LDDs.34–36
times higher risk of injury during training, respectively, com-
pared with those in the fastest quartile (men: ≤15.4 min; women: 5. Sex differences in bone anabolism in U.S. Army soldiers
≤19.5 min).30 When the combined effects of aerobic capacity and is partially explained by baseline bone microarchitecture
body mass index (BMI) were evaluated, individuals with the highest during basic combat training
aerobic capacity and mid-to-high levels (quintiles) of BMI experi-
enced the lowest MSI risk while those with the lowest BMI across Bone MSIs, including stress fractures, occur frequently in mil-
all levels of aerobic capacity had the highest MSI risk.32 itary personnel.23 Advances in non-invasive imaging technology,
The requisite levels and combinations of health- and skill- in particular, high resolution peripheral quantitative computed
related (e.g., speed, agility, balance, coordination) physical fitness tomography (HRpQCT), has allowed in vivo, three-dimensional
vary by military task, but have not been defined for most tasks.33 capture of bone microarchitecture.37 The assessment of bone
Yet, studies have consistently shown that service members with microstructure can be used to evaluate indices of mechanical bone
lower physical fitness (e.g., lower aerobic capacity) have higher strength, which is not possible when evaluating bone mineral con-
risk of MSI compared to more fit individuals performing the tent or density with dual X-ray absorptiometry techniques. This
same military training.1,10,28 It is important that service members technology can be invaluable for increasing our understanding
engage in appropriate types and intensity of physical and military of the densitometric and structural underpinnings of stress frac-
training that will enable them to perform required tasks, while ture risk in susceptible individuals.38 In the laboratory at the U.S.
concomitantly minimizing injury risks. Future studies are needed Army Research Institute of Environmental Medicine (ARIEM), by
to quantify the volume of physical and task-related training that leveraging these improvements in technology, approximately 2%
units conduct and determine how MSI risks change at different increase in total volumetric bone mineral density, trabecular vol-
activity thresholds. Additionally, more information is needed on umetric bone density and in the trabecular bone volume fraction
the physical demand requirements of military tasks, and the fit- has been demonstrated to occur in female soldiers during eight
ness components necessary to train and perform military tasks in weeks of basic combat training (BCT), and starting bone density
operational settings. was inversely related to bone changes during BCT.39 Rat models
have demonstrated that an increase as small as 2% in volumetric
4. Musculoskeletal injuries receiving lost duty days in the bone mineral density, can result in greater than 100 fold increase
U.S. Army from 2017 to 2018 in the fatigue resistance of the loaded bone.14 Thus, it has been
postulated that the promotion of bone anabolism during times of
Data on MSI-associated LDDs are incomplete in medical charts, heightened physical activity may be protective against stress frac-
and self-report surveys suffer from issues with recall bias. The U.S. tures by increasing bone stiffness.15
Army’s eProfile system requires medical providers to record LDDs, Given the differing incidence of stress fracture by sex during
injured body region, and activities associated with injury, whereas BCT,23 research has focused on the sex differences in bone forma-
the medical records do not require this information to be docu- tion. In unpublished findings, while female trainees seem to gain
mented. In 2017 and 2018, 21% and 24%, respectively, of active more trabecular bone during training, this difference is only par-
duty soldiers suffered a duty limiting MSI (with rates of 29 and 34 tially explained by the fact that women on average have lower
MSIs per 100 soldier-years, respectively). In 2017, the most injured volumetric bone mineral density at the beginning of BCT. While

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Fig. 1. A model describing the relationship between physical activity, workload and moderators and their impact on outcomes in military settings.

lower bone density at baseline can partially explain the increased published research on the prevention of MSIs among NSW Oper-
risk of stress fracture in women, this observation suggests there ators. Many of these previous descriptive epidemiologic studies
are potentially other modifying factors of new bone formation dur- among NSW Operators utilized different methods of classifying MSI
ing BCT related to sex that may help to reduce the gap in injury causes and anatomic locations, making comparisons between stud-
risk between male and female recruits. As part of a large prospec- ies difficult. Also, MSI data are absent or incomplete if medical care
tive cohort study called the ARIEM Reduction in Musculoskeletal is not sought, which is a known issue among military personnel.44
Injury Study, the HRpQCT is being used to evaluate how a num-
ber of factors including demographics, life history, nutrition, sleep 7. Physical activity monitoring to quantify training load
habits, and body composition influence changes in different bone and inform injury prevention strategies
parameters and stress fracture risk during a trainee’s time in BCT.40
In athletic populations, relationships have been shown between
6. Descriptive epidemiology of musculoskeletal injuries physical activity exposure (described as training load) and MSI
among naval special warfare personnel incidence and it has been proposed that training load needs
to be balanced to minimize MSI risk whilst maintaining physi-
NSW Operators are especially susceptible to MSIs due to high cal performance.45,46 In the military setting, the micro-traumatic
physical training and operational demands.20,41 Peterson et al. forces and the MSIs they cause can result from a range of physical
described MSIs among NSW SEAL Operators and support person- activities including exercise, recreation, sports, and occupational
nel at a NSW Command location.41 The MSI rate was reported as a tasks.47 Monitoring this physical activity to quantify parameters
range (0.9–3.2 injuries/100 person-months). The back/neck was the such as energy expenditure, activity patterns, and ground reac-
leading anatomic site for MSIs treated at the medical clinic (26.5% of tion forces using wearable technologies could provide an effective
visits), followed by the knee (20.9%). The most common MSI diagno- approach to predict impending MSI, and inform interventions to
sis was shoulder bursitis/impingement (9.3%), followed by lumbar reduce MSI incidence.48 However, to our knowledge no research
strain/sprain (8.9%).41 The Naval Health Research Center conducted has demonstrated the effectiveness of prospective monitoring of
a self-reported injury survey among SWCC Operators from three these parameters to inform interventions to reduce MSI in military
Special Boat Units to determine the prevalence of injuries.42 A high settings. Training load can be quantified using a range of monitoring
percentage (64.9%) of SWCC Operators reported at least one MSI. tools such as accelerometers, heart rate monitors, questionnaires,
The time period covered by this self-reported survey was not listed and global positioning system.49 In the military setting, it is impor-
in the manuscript, and incidence was not calculated. The most tant to monitor all daily physical activity (not just pre-planned PT
prevalent MSI was strains/sprains (49.3%), and the most prevalent and exercise) and the selection of monitoring tools used needs to
anatomic location was the lower back (33.6%).42 A review of paper balance the participant burden, financial cost of devices, and the
medical charts at two NSW installations demonstrated that the fidelity of the data required. These data should also be collated and
one-year cumulative incidence of MSIs was slightly higher among presented in a format that is actionable by commanders, medical
SWCC Operators (22 injured/100 Operators/year) compared with practitioners, physical trainers, and/or researchers.
SEAL Operators (19 injured/100 Operators/year), though this differ- Fig. 1 presents a theoretical model that summarizes the rela-
ence was not statistically significant.43 The most common anatomic tionship between physical activity, workload and moderators, and
location varied by NSW group – shoulder (21.6% of MSIs) among their impact on outcomes in military settings. A soldier’s physical
SEAL, and lumbo-pelvic spine (21.7%) among SWCC Operators. Data activity (both occupational, driven by their role, and leisure time)
documenting cause of MSI were missing for a large proportion of can be quantified in terms of frequency, intensity, time, and type
MSIs in the medical charts. For MSIs with an identified cause of (FITT), and in military settings should include quantifying external
injury in the medical chart, the most frequent cause was lifting in loads carried. These parameters collectively describe the external
both Operator groups (SEAL: 13.5%, SWCC: 16.7%).43 There is no workload experienced by a soldier. For a group, the external work-

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Table 2
Prevalence (%) of musculoskeletal injuries (MSIs) among soldiers with and without prior use of non-steroidal anti-inflammatory drugs (NSAIDs).

NSAIDs treatment before MSI No NSAIDs treatment before MSI X2 (1) Odds ratio CI (95%)

Combat 35.2% 27.5% 90.03* 1.43 1.33−1.54

Males
Non-combat 30.2% 21.7% 82.18* 1.56 1.41−1.72
Combat 40.3% 26.9% 27.56* 1.84 1.45−2.33
Females
Non-combat 28.5% 19.4% 151.60* 1.65 1.52−1.79
*
p < 0.001.

load may be the same (e.g. soldiers walking at a fixed pace carrying related indications in medical encounters resulting in NSAIDs pre-
a load). However, the physiological response of each individual in scription. Non-pain related indications for prescriptions of NSAIDs
the group will be different depending on a series of moderators included in the analysis, were indications where NSAIDs were
which can either be modifiable (e.g. nutrition, hydration, fitness, prescribed for reasons other than musculoskeletal pain. Overuse
sleep) or non-modifiable (e.g. previous injury, job requirements, MSIs that occurred after NSAIDs prescription were identified;
environment, stature). The resultant outcome is described as the acute/accidental injuries were not included in the analysis. The
internal workload. results of the prevalence of MSIs after NSAIDs or other treatment
are presented in Table 2. There was an association between NSAID
8. A machine learning algorithm to enhance decision prescriptions and MSI as reflected in a significantly higher preva-
making in the management of Medial Tibial Stress lence of diagnosed MSIs among soldiers prescribed NSAIDs coupled
Syndrome with a higher risk (1.3–2.3-fold) of developing MSIs during military
service, independent of sex and/or service type. Future analyses of
Machine learning approaches have utility as individual risk this topic should focus on duration of NSAIDs use, the exact phase
profiling tools for overuse MSIs such as MTSS. An analysis of 10 in military training before MSI diagnosis, and the type and sever-
risk factors, the first eight of which were identified in two pre- ity of MSIs as an outcome of NSAIDs use. Other medications used
vious systematic reviews,50,51 identified – lower years of running concomitantly also need to be assessed. For soldiers, particularly in
experience, a previous MTSS diagnosis, increased BMI, increased combat training, maintenance of optimal health and performance,
Navicular Drop, prior orthotic use, female sex, increased ankle plan- and prevention of MSIs is crucial to mission readiness.
tarflexion range, increased hip external rotation range, increased
running distance per session, and more running sessions per 10. Conclusion
week as risk factors for prospective MTSS development. Modelling
including all these risk factors was used to determine the predictive Despite many years of research on MSIs, they continue to
accuracy of an ensemble of machine learners. Data was obtained occur frequently among military personnel. The purpose of this
from 123 recruits (28 females and 95 males) from a previous manuscript was to provide a narrative review on each of the eight
study.52 Follow-up was conducted at three months to determine subject areas or topics that were presented during the thematic
those in the group that had developed MTSS. Four ensemble learn- session on MSIs in military personnel at the 5th ICSPP.
ing algorithms- logistic regression (LR), k-nearest neighbors (kNN), While running is a leading cause of MSIs for U.S. Active Duty
Naïve Bayes (NB), and Decision Tree (Tree) were deployed and Army personnel, time spent conducting the activity must be consid-
trained five times on random stratified samples of 75% of the ered. Higher rates of MSIs per unit of exposure have been observed
dataset. The resultant algorithms were tested on the remaining for military training events such as road marching and obstacle
25% of the dataset and the models were compared for classifica- courses, but since running is a more frequent activity, it contributes
tion accuracy, precision and recall. Ranked classification accuracy a greater number of MSIs. Reporting MSIs with higher LDDs may
for the various machine learning algorithms was (Tree = 0.987, provide more accurate results related to the effect of MSIs on readi-
NB = 0.897, LR = 0.800, kNN = 0.755). Tree models improved pre- ness. Focusing prevention efforts on MSIs that result in the longest
dictive accuracy by 14.6% compared with a previously published LDDs (i.e., to the knee, ankle/foot, lumbar spine, and shoulder) is
multivariate model.52 recommended. While striving for medical and operational readi-
Accurate identification of individuals at risk of MTSS is an ness, leaders should be aware of the inter-relationships of physical
important advance in the management of this difficult and costly fitness, military task performance, and MSI risk. Among NSW Oper-
problem. The ability to mitigate occupational risk is increasingly a ators, MSI affecting the shoulder and lower back are most frequent.
responsibility of commanders and trainers. MSIs are often complex Future research should focus on further evaluating the etiology and
and multifactorial, making prediction and management arduous. prevention of MSIs among specific NSW Operator groups.
Machine learning methodologies can provide decision makers with Understanding the factors that modify how bone adapts to PT,
better tools for MSI control. may be key in providing recommendations for countermeasures to
reduce risk of stress fracture. Future analyses of MSIs should focus
9. Musculoskeletal injury rates among NSAID users in the on duration of NSAIDs use and the exact phase in military training
IDF: a decades perspective before MSI onset. Newer data analysis methods, including machine
learning, hold promise to further improve identification and under-
The effect of NSAIDs on bone remodeling has been observed standing of the cause of MSIs. Further research must determine the
in animal studies, but is not very clear in humans.53 NSAIDs act generalizability of these findings. The balance between the external
by inhibition of the cyclooxygenase enzymes, leading to suppres- and internal workload will impact an individual’s physical perfor-
sion of prostaglandin production.54,55 Prostaglandins of the E series mance and injury incidence. These combined individual outcomes
stimulate osteoblastic bone formation and inhibit the activity of all contribute to the organization’s operational effectiveness.
isolated osteoclasts, which might lead to increased occurrence of
MSIs among physically active individuals who use NSAIDs, such as Acknowledgements
athletes and military personnel.56,57
Data in medical registries from soldiers that served in the IDF The authors did not receive any external financial support with
between the years 2009–2018, were reviewed to analyze non-pain the manuscript. Disclaimer: The opinions or assertions contained

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herein are the private views of the author(s) and are not to be 24. Canham-Chervak M, Rappole C, Grier T, Jones BH. Injury mechanisms, activities,
construed as official or as reflecting the views of the Army or the and limited work days in US Army infantry units. US Army Med Dep J 2018;
2(18):6–13.
Department of Defense. The authors wish to thank the organizers 25. Schuh-Renner A, Grier TL, Canham-Chervak M, Hauschild VD, Roy TC, Fletcher
of the 5th International Congress on Soldiers’ Physical Perfor- J et al. Risk factors for injury associated with low, moderate, and high mileage
mance. road marching in a U.S. Army infantry brigade. J Sci Med Sport 2017; 20(Suppl
4):S28–S33.
26. Jones BH, Hauschild VD. Physical training, fitness, and injuries: lessons learned
from military studies. J Strength Cond Res 2015; 29(Suppl 11):S57–S64.
Appendix A. Supplementary data
27. Knapik JJ, Hauret KG, Canada S, Marin R, Jones B. Association between ambu-
latory physical activity and injuries during United States Army basic combat
Supplementary material related to this article can be found, in training. J Phys Act Health 2011; 8(4):496–502.
the online version, at doi:https://doi.org/10.1016/j.jsams.2021.03. 28. Knapik JJ, Graham BS, Rieger J, Steelman R, Pendergrass T. Activities associated
with injuries in initial entry training. Mil Med 2013; 178(5):500–506.
016. 29. Knapik JJ, Sharp MA, Canham-Chervak M, Hauret K, Patton JF, Jones BH. Risk
factors for training-related injuries among men and women in basic combat
training. Med Sci Sports Exerc 2001; 33(6):946–954.
References 30. Lisman PJ, de la Motte SJ, Gribbin TC, Jaffin DP, Murphy K, Deuster PA. A
systematic review of the association between physical fitness and muscu-
1. Nindl BC, Castellani JW, Warr BJ et al. Physiological employment standards III: loskeletal injury risk: part 1-cardiorespiratory endurance. J Strength Cond Res
physiological challenges and consequences encountered during international 2017; 31(6):1744–1757.
military deployments. Eur J Appl Physiol 2013; 113(11):2655–2672. 31. de la Motte SJ, Gribbin TC, Lisman P, Murphy K, Deuster PA. Systematic review
2. Hauret KG, Bedno S, Loringer K, Kao TC, Mallon T, Jones BH. Epidemiology of the association between physical fitness and musculoskeletal injury risk:
of exercise- and sports-related injuries in a population of young, physically part 2-muscular endurance and muscular strength. J Strength Cond Res 2017;
active adults: a survey of military servicemembers. Am J Sports Med 2015; 31(11):3218–3234.
43(11):2645–2653. 32. Jones BH, Hauret KG, Dye SK et al. Impact of physical fitness and body compo-
3. Jones BH, Canham-Chervak M, Canada S, Mitchener TA, Moore S. Medi- sition on injury risk among active young adults: a study of Army trainees. J Sci
cal surveillance of injuries in the U.S. Military descriptive epidemiology Med Sport 2017; 20(Suppl 4):S17–S22.
and recommendations for improvement. Am J Prev Med 2010; 38(1 Suppl): 33. Hauschild VD, DeGroot DW, Hall SM et al. Fitness tests and occupational tasks of
S42–60. military interest: a systematic review of correlations. Occup Environ Med 2017;
4. Songer TJ, LaPorte RE. Disabilities due to injury in the military. Am J Prev Med 74(2):144–153.
2000; 18(3 Suppl):33–40. 34. Knapik J, Ang P, Reynolds K, Jones B. Physical fitness, age, and injury incidence
5. Schwartz O, Levinson T, Astman N, Haim L. Attrition due to orthopedic rea- in infantry soldiers. J Occup Med 1993; 35(6):598–603.
sons during combat training: rates, types of injuries, and comparison between 35. Smith TA, Cashman TM. The incidence of injury in light infantry soldiers. Mil
infantry and noninfantry units. Mil Med 2014; 179(8):897–900. Med 2002; 167(2):104–108.
6. Cohen SP, Griffith S, Larkin TM, Villena F, Larkin R. Presentation, diagnoses, 36. Reynolds KL, Heckel HA, Witt CE et al. Cigarette smoking, physical fitness, and
mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Free- injuries in infantry soldiers. Am J Prev Med 1994; 10(3):145–150.
dom: an epidemiological study conducted at two military pain management 37. Manske SL, Davison EM, Burt LA, Raymond DA, Boyd SK. The estimation of
centers. Anesth Analg 2005; 101(4):1098–1103. second-generation HR-pQCT from first-generation HR-pQCT using in vivo cross-
7. Schwartz O, Malka I, Olsen CH, Dudkiewicz I, Bader T. Overuse injuries in the calibration. J Bone Miner Res 2017; 32(7):1514–1524.
IDF’s combat training units: rates, types, and mechanisms of injury. Mil Med 38. Unnikrishnan G, Xu C, Popp KL et al. Regional variation of bone density, microar-
2018; 183(3–4):e196–e200. chitectural parameters, and elastic moduli in the ultradistal tibia of young black
8. Reshef N, Guelich DR. Medial tibial stress syndrome. Clin Sports Med 2012; and white men and women. Bone 2018; 112:194–201.
31(2):273–290. 39. Hughes JM, Gaffney-Stomberg E, Guerriere KI et al. Changes in tibial bone
9. U.S. Army Public Health Center, Available at: https://phc.amedd.army.mil/ microarchitecture in female recruits in response to 8weeks of U.S. Army basic
topics/campaigns/hof. Accessed 24 June 2020 Health of the Force, 2019. combat training. Bone 2018; 113:9–16.
10. Epstein Y, Yanovich R, Moran DS, Heled Y. Physiological employment standards 40. Hughes JM, Foulis SA, Taylor KM et al. A prospective field study of U.S. Army
IV: integration of women in combat units physiological and medical considera- trainees to identify the physiological bases and key factors influencing mus-
tions. Eur J Appl Physiol 2013; 113(11):2673–2690. culoskeletal injuries: a study protocol. BMC Musculoskelet Disord 2019; 20(1):
11. Lovalekar M, Abt JP, Sell TC, Lephart SM, Pletcher E, Beals K. Accuracy of recall 282.
of musculoskeletal injuries in elite military personnel: a cross-sectional study. 41. Peterson SN, Call MH, Wood DE, Unger DV, Sekiya JK. Injuries in naval special
BMJ Open 2017; 7(12):e017434. warfare sea, air, and land personnel: epidemiology and surgical management.
12. Gabbe BJ, Finch CF, Bennell KL, Wajswelner H. How valid is a self reported 12 Oper Tech Sports Med 2005; 13:131–135.
month sports injury history? Br J Sports Med 2003; 37(6):545–547. 42. Ensign W, Hodgdon JA, Prusaczyk WK, Shapiro D, Lipton M. A survey of self-
13. Cosman F, Ruffing J, Zion M et al. Determinants of stress fracture risk in United reported injuries among special boat operators, San Diego, Naval Health Research
States Military Academy cadets. Bone 2013; 55(2):359–366. Center, 2000.
14. Warden SJ, Hurst JA, Sanders MS, Turner CH, Burr DB, Li J. Bone adaptation to a 43. Lovalekar M, Perlsweig KA, Keenan KA et al. Epidemiology of musculoskeletal
mechanical loading program significantly increases skeletal fatigue resistance. injuries sustained by Naval Special Forces Operators and students. J Sci Med Sport
J Bone Miner Res 2005; 20(5):809–816. 2017; 20(Suppl 4):S51–S60.
15. Hughes JM, Popp KL, Yanovich R, Bouxsein ML, Matheny Jr RW. The role of adap- 44. Lynch JH, Pallis MP. Clinical diagnoses in a Special Forces Group: the muscu-
tive bone formation in the etiology of stress fracture. Exp Biol Med (Maywood) loskeletal burden. J Special Oper Med 2008; 8(2):76–80.
2017; 242(9):897–906. 45. Gabbett TJ. The development and application of an injury prediction model for
16. Hughes JM, McKinnon CJ, Taylor KM et al. Nonsteroidal anti-inflammatory drug noncontact, soft-tissue injuries in elite collision sport athletes. J Strength Cond
prescriptions are associated with increased stress fracture diagnosis in the US Res 2010; 24(10):2593–2603.
Army population. J Bone Miner Res 2019; 34(3):429–436. 46. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely?
17. Sharma J, Greeves JP, Byers M, Bennett AN, Spears IR. Musculoskeletal injuries The acute:chronic workload ratio permits clinicians to quantify a player’s risk
in British Army recruits: a prospective study of diagnosis-specific incidence and of subsequent injury. Br J Sports Med 2016; 50(8):471–475.
rehabilitation times. BMC Musculoskelet Disord 2015; 16:106. 47. Hauret KG, Jones BH, Bullock SH, Canham-Chervak M, Canada S. Musculoskele-
18. Winters M, Eskes M, Weir A, Moen MH, Backx FJ, Bakker EW. Treatment tal injuries description of an under-recognized injury problem among military
of medial tibial stress syndrome: a systematic review. Sports Med 2013; personnel. Am J Prev Med 2010; 38(1 Suppl):S61–S70.
43(12):1315–1333. 48. Friedl KE. Military applications of soldier physiological monitoring. J Sci Med
19. Bittencourt NFN, Meeuwisse WH, Mendonca LD, Nettel-Aguirre A, Ocarino JM, Sport 2018; 21(11):1147–1153.
Fonseca ST. Complex systems approach for sports injuries: moving from risk 49. Halson SL. Monitoring training load to understand fatigue in athletes. Sports Med
factor identification to injury pattern recognition-narrative review and new 2014; 44(Suppl 2):S139–S147.
concept. Br J Sports Med 2016; 50(21):1309–1314. 50. Newman P, Witchalls J, Waddington G, Adams R. Risk factors associated with
20. Prusaczyk WK, Stuster JW, Goforth H, Smith TS, Meyer LT. Physical demands medial tibial stress syndrome in runners: a systematic review and meta-analysis.
of U.S. Navy Sea-Air-Land (SEAL) operations, San Diego, Naval Health Research Open Access J Sports Med 2013; 4:229–241.
Center, 1995. 51. Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress
21. Jones BH, Hauschild VD, Canham-Chervak M. Musculoskeletal training injury syndrome in physically active individuals such as runners and military per-
prevention in the U.S. Army: evolution of the science and the public health sonnel: a systematic review and meta-analysis. Br J Sports Med 2015; 49(6):
approach. J Sci Med Sport 2018; 21(11):1139–1146. 362–369.
22. Jones BH, Cowan DN, Knapik JJ. Exercise, training and injuries. Sports Med 1994; 52. Garnock C, Witchalls J, Newman P. Predicting individual risk for medial tibial
18(3):202–214. stress syndrome in navy recruits. J Sci Med Sport 2018; 21(6):586–590.
23. Molloy JM, Pendergrass TL, Lee IE, Chervak MC, Hauret KG, Rhon DI. Muscu- 53. Wheatley BM, Nappo KE, Christensen DL, Holman AM, Brooks DI, Potter BK.
loskeletal injuries and United States Army readiness part I: overview of injuries Effect of NSAIDs on bone healing rates: a meta-analysis. J Am Acad Orthop Surg
and their strategic impact. Mil Med 2020; 185(9–10):e1461–e1471. 2019; 27(7):e330–e336.

968
M. Lovalekar et al. Journal of Science and Medicine in Sport 24 (2021) 963–969

54. Ishiguro H, Kawahara T. Nonsteroidal anti-inflammatory drugs and prostatic 57. Cornu C, Grange C, Regalin A et al. Effect of non-steroidal anti-inflammatory
diseases. Biomed Res Int 2014; 2014(436123). drugs on sport performance indices in healthy people: a meta-analysis of ran-
55. Cottrell J, O’Connor JP. Effect of non-steroidal anti-inflammatory drugs on bone domized controlled trials. Sports Med Open 2020; 6(1):20.
healing. Pharmaceuticals (Basel) 2010; 3(5):1668–1693.
56. Walker LA, Zambraski EJ, Williams RF. widespread use of prescription nons-
teroidal anti-inflammatory drugs among U.S. Army active duty soldiers. Mil Med
2017; 182(3):e1709–e1712.

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