Musculoskeletal Injuries in the Military

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1 Musculoskeletal Injuries in the Military

2 Kenneth L. Cameron Brett D. Owens Editors Musculoskeletal Injuries in the Military 1 3

3 Editors Kenneth L. Cameron Keller Army Hospital West Point New York USA Brett D. Owens Keller Army Hospital West Point New York USA ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer New York Heidelberg Dordrecht London Springer Science+Business Media New York 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer Science+Business Media LLC New York is part of Springer Science+Business Media (

4 I would like to thank my family and colleagues who inspired and supported this project. This book is dedicated to them. This book is also dedicated to our military service members and their families who sacrifice so much in service to our nation. They deserve nothing less than the very best evidence-based injury prevention strategies and cutting edge health care for the musculoskeletal injuries and conditions that are commonly seen in this high-risk population. K.L.C. I am grateful for the support of my family, who made this work possible. I thank my mother who taught me kindness and inspired me to lead a life of caring for others. I thank the soldiers for whom I have been fortunate to be able to care and from whom I have learned much. B.D.O.

5 Foreword the soldier, above all other people, prays for peace, for he must suffer and bear the deepest wounds and scars of war. General Douglas MacArthur More than 2 million soldiers, sailors, airmen, and marines were engaged in the longest continuous conflict in America s history. We were at war for more than 13 years, with an astonishingly high survival rate and relatively low amputation rate. I had the honor to serve as the orthopedic advisor (consultant) to the US Army surgeon general for 8 years of this war and to serve three surgeon generals. It was during the performance of this responsibility that I came to know Dr. Brett Owens and Dr. Kenneth Cameron. Brett completed his sports medicine fellowship during my early tenure and was finishing his study at the Institute for Surgical Research on the epidemiology of combat injuries. His subsequent seminal publications have garnered more than 500 citations the most in all combat surgery literature and are directly responsible for bringing public and medical attention to the vast burden of musculoskeletal disability currently facing our warriors. Ken has served as the Director of Orthopaedic Research for the John A. Feagin Jr. Sports Medicine Fellowship at the United States Military Academy at West Point and is a fervent scientist investigating ways to optimize human performance. Dr. Owens and Dr. Cameron have produced a body of independent research directed at better understanding the nature of these injuries and how to prevent them. Together, they have examined battle, non-battle, and training-related injuries, and in this new text, they present the cumulative American military expertise acquired during the past 15 years in the treatment and prevention of disability. I am humbled and honored to introduce these scholars, who are respected and skilled clinicians, committed to best practices and prevention, and who are also world-renowned scientists in the field of sports- and combat-related trauma. In this text, they address the factors leading to high rates of morbidity and consider all aspects of the musculoskeletal system. They lead the students of military-related injuries on a tour of the body by system and region and then outline a systematic approach to prevention and mitigation of the impairments these patriots experience. I believe this text will inspire further investigation into the causes of and solutions to what represents the largest and longest-term burden facing the patriots who have served in contemporary volunteer military service. vii

6 viii Foreword The text is thoughtfully written by clinician-scientists with diverse perspectives surgeons, rehabilitation specialists, and operationally oriented clinicians. Although amputations have been perhaps, the most visible reminder of the human cost of recent conflicts, non-battle injuries, as well as the high-performance sports like joint injuries of the tactical athlete constitute even larger losses to the fighting forces. Additionally, and perhaps, a product of today s more sedentary youth, injuries during initial entry training are more common and may be completely preventable. The discussion regarding stress fractures and overuse syndromes highlights this epidemic and is directly relevant to civilian sports medicine providers. This fascinating text also tours the body, discussing gaps in treatment, prevention strategies, and types of impairments leading to losses of the fighting force. All contributing authors are specialty fellowship-trained practicing surgeons who have served in clinical practice, combat conditions, and academic centers, and who have broad expertise in their respective areas. Finally, with contributions that promise to be practical, as well as influential, in both policy development and data-driven research funding, the final section assimilates these combat subtractors into several strategies for prevention, mitigation, and management. National health policy is increasingly focused on the critical examination of population-based health and what appears to be the indefinite future of the all-volunteer fighting force. The concepts and observations presented herein are leading from the front to direct thoughts on military medicine. This text is a must read for anyone committed to understanding the significance of musculoskeletal injuries experienced by our military and for the thought leaders who will be responsible for preventing and mitigating the sacrifices made by our warriors in the defense of our nation. James R. Ficke, MD Colonel (retired) US Army Robert A. Robinson Professor and Director Department of Orthopaedic Surgery The Johns Hopkins Hospital

7 Preface Musculoskeletal injuries and conditions are endemic in US military populations. Former US Army Surgeon General, James Peake, referred to the burden of musculoskeletal injuries in the military as a hidden epidemic in 2000 [4]. Today, as the US military is transitioning from more than a decade of war on two fronts in the Middle East, new data suggest that this epidemic is emerging from the shadows [1 3]. Significant combat wounds, as well as non-battle injuries during deployment, have contributed to long-term disability and decreased quality of life in our veterans. This is, in addition, to the already high rates of training and sports-related injuries commonly observed in the young and active military population. In this text, we have assembled a comprehensive panel of military and civilian clinicians and researchers with the primary objective of shedding some additional light on this hidden epidemic. Our goal was to produce an authoritative text on the epidemiology of musculoskeletal injuries and conditions typically seen in service members, utilizing the best data available to date. Clearly, some areas are still lacking in quality studies and supporting data and we have solicited expert opinion in these cases. We have provided some general chapters on combat, noncombat, and sports and physical training-related injuries, as well as an anatomic breakdown of injury patterns commonly observed in military populations. In the final section, we have provided an overview of how the public health model has been applied to study and address the injury epidemic in the military and we have provided a framework for developing and implementing effective injury prevention strategies within this unique high-risk population. Our ultimate hope is to generate dialogue, research, and effective interventions that can be implemented in real-world settings to help mitigate the impact of musculoskeletal injuries and conditions among those who have committed to selflessly serve our nation. ix

8 x Preface References 1. Belmont PJ Jr., Goodman GP, Waterman B, DeZee K, Burks R, Owens BD. Disease and nonbattle injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom. Mil Med. Jul 2010;175(7): Goodman GP, Schoenfeld AJ, Owens BD, Dutton JR, Burks R, Belmont PJ. Non-emergent orthopaedic injuries sustained by soldiers in Operation Iraqi Freedom. J Bone Joint Surg Am. Apr ;94(8): Owens BD, Kragh JF, Jr., Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. Feb 2008;64(2): Peake JB. Reflections on injuries in the military: the hidden epidemic. Am J Prev Med. Apr 2000;18(3 Suppl):4 5.

9 Contents Part I The Spectrum of Musculoskeletal Injuries in the Military 1 The Burden of Musculoskeletal Injuries in the Military... 3 Brett D. Owens and Kenneth L. Cameron 2 Traumatic Combat Injuries Andrew J. Schoenfeld and Philip J. Belmont 3 The Burden of Deployment-Related Non-battle Injuries (NBIs) and Their Impact on the Musculoskeletal System Kenneth L. Cameron 4 Sports and Exercise-Related Injuries in the Military Michael Garrison, Scott Dembowski, and Nathan Shepard 5 Musculoskeletal Injuries During Military Initial Entry Training Scott D. Carow and Jennifer L. Gaddy 6 Disability Associated with Musculoskeletal Injuries Chad A. Krueger and James R. Ficke Part II The Epidemiology of Musculoskeletal Injuries by Anatomic Region 7 Shoulder Injuries Christopher J. Tucker and Brett D. Owens 8 Elbow, Wrist, and Hand Injuries Danielle L. Scher, Emily H. Shin, Jennifer M. Wolf, and Leon J. Nesti 9 Hip Injuries Joseph T. Lanzi and Steven J. Svoboda xi

10 xii Contents 10 Knee Injuries Jeremy McCallum and John M. Tokish 11 Lower Leg, Ankle, and Foot Injuries Brian R. Waterman, John Dunn, and Justin D. Orr 12 Thoracic and Lumbar Spine Injuries Jeffrey B. Knox and Joseph Orchowski 13 Cervical Spine and Neck Injuries Scott C. Wagner and Ronald A. Lehman Part III Public Health Strategies for Injury Prevention and Treatment in the Military 14 Application of the Public Health Model for Musculoskeletal Injury Prevention Within the Military Kenneth L. Cameron 15 Successful Injury Prevention Interventions Sarah J. de la Motte and Robert Oh 16 Overcoming Barriers to Injury Prevention in the Military Deydre S. Teyhen, Stephen L. Goffar, Timothy L. Pendergrass, Scott W. Shaffer, and Nikki Butler Index

11 Contributors Philip J. Belmont Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX, USA Nikki Butler Army Human Resources Command, 1600 Spearhead Division Avenue, Fort Knox, KY, USA Kenneth L. Cameron John A. Feagin, Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, West Point, NY, USA Scott D. Carow Department of Physical Therapy, William Beaumont Army Medical Center, El Paso, TX, USA Sarah J. de la Motte Injury Prevention Research Laboratory, Consortium for Health and Military Performance, Uniformed Services University, Bethesda, MD, USA Scott Dembowski Moncrief Army Community Hospital, Ft Jackson, SC, USA John Dunn Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA James R. Ficke Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA Jennifer L. Gaddy Multisport Athletics, Columbus, GA, USA Michael Garrison Evans Army Community Hospital, Ft Carson, Colorado Springs, CO, USA Stephen L. Goffar School of Physical Therapy, University of the Incarnate Word, San Antonio, TX, USA Jeffrey B. Knox Orthopedic Surgery Service, Tripler Army Medical Center, Honolulu, HI, USA Chad A. Krueger Department of Orthopaedic Surgery and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX, USA Joseph T. Lanzi Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA xiii

12 xiv Contributors Ronald A. Lehman Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA Jeremy McCallum Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA Leon J. Nesti Walter Reed National Military Medical Center, Bethesda, MD, USA Robert Oh National Capital Consortium, Uniformed Services University, Bethesda, MD, USA Joseph Orchowski Orthopedic Surgery Service, Tripler Army Medical Center, Honolulu, HI, USA Justin D. Orr Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA Brett D. Owens John A. Feagin, Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, NY, USA Timothy L. Pendergrass Department of Physical Medicine and Rehabilitation, Madigan Army Medical Center, US Army Medical Command, Tacoma, WA, USA Danielle L. Scher Department of Orthopaedics, Brian Allgood Army Community Hospital, APO, AP, USA Andrew J. Schoenfeld Department of Orthopaedic Surgery, Brigham and Women s Hospital, Harvard Medical School, Boston, MA, USA Scott W. Shaffer US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX, USA Nathan Shepard Joint Base Elmendorf-Richardson, Anchorage, AK, USA Emily H. Shin Walter Reed National Military Medical Center, Bethesda, MD, USA Steven J. Svoboda COL John A. Feagin, Jr. West Point Sports Medicine Fellowship, Keller Army Hospital, West Point, NY, USA Deydre S. Teyhen System for Health and Performance Triad, G-3/5/7, HQDA, Office of the Surgeon General, Falls Church, VA, USA John M. Tokish Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA Christopher J. Tucker Fort Belvoir Community Hospital, Fort Belvoir, VA, USA Scott C. Wagner Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA Brian R. Waterman William Beaumont Army Medical Center, El Paso, TX, USA Jennifer M. Wolf University of Connecticut, Hartford, CT, USA

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