msmr MEDICAL SURVEILLANCE MONTHLY REPORT MUSCULOSKELETAL ISSUE: A publication of the Armed Forces Health Surveillance Center

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1 VOL. 17 NO. 7 JULY 21 msmr A publiction of the Armed Forces Helth Surveillnce Center MEDICAL SURVEILLANCE MONTHLY REPORT MUSCULOSKELETAL ISSUE: Low bck pin, ctive component, U.S. Armed Forces, Thorcolumbr spine frctures, ctive nd reserve components, Tendon ruptures, ctive component, U.S. Armed Forces, Surveillnce snpshot: Plntr fsciitis 2 Surveillnce snpshot: Abnorml glucose tolernce test 21 Summry tbles nd figures Updte: Deployment helth ssessments, U.S. Armed Forces, July Sentinel reportble medicl events, service members nd beneficiries, U.S. Armed Forces, cumultive numbers through June of 29 nd Deployment-relted conditions of specil surveillnce interest 29 Red the MSMR online t:

2 2 VOL. 17 / NO. 7 Low Bck Pin, Active Component, U.S. Armed Forces, 2-29 In the United Sttes, low bck pin is dignosed during pproximtely one of every 35 (2.8%) physicin visits by dults. 1 The vst mjority of low bck pin episodes resolve within two to four weeks of onset. However, 25% of ptients hve recurrent episodes within one yer, nd the prevlence of chronic bck pin (7-1%) my be incresing. 2,3,4 In the U.S. Armed Forces, low bck pin is mong the most frequent cuses of medicl visits nd lost-duty time. In 29, intervertebrl disc disorders nd other disorders of the bck (including lumbgo nd unspecified bckche) were the primry (first-listed) dignoses during 66,332 outptient medicl encounters (6.4% of ll outptient visits for ny illness or injury mong ctive component members). 5 Bck problems re lso leding cuses of medicl evcutions from Irq nd Afghnistn. Since the beginning of militry opertions in those countries, more thn 3,1 U.S. service members hve been mediclly evcuted from theter for disc disorders nd other disorders of the bck. In 1992, Cherkin nd collegues described n lgorithm for using dignostic nd procedure codes from medicl dministrtive dtbses to identify ptients with mechnicl low bck problems which were defined s locl or rdiculr pin ssocited with conditions of the scrum or lumbr spine unrelted to mjor trum, neoplsms, pregnncy, or infectious or inflmmtory cuses. 6 This report pplies the Cherkin lgorithm to estimte the ntures nd incidence of low bck pin (LBP) dignosed during medicl encounters of U.S. militry members while in ctive service. Methods: The surveillnce period ws 1 Jnury 2 to 31 December 29. A medicl visit for mechnicl low bck pin (LBP) ws defined s n inptient or outptient encounter tht ws documented with dignosis (in ny dignostic position) of ICD-9-CM codes indictive of low bck problems. 6 Encounters tht were ssocited with Tble 1. Numbers of medicl encounters for mechnicl low bck pin, by clinicl ctegory, ctive component, U.S. Armed Forces, 2-29 Clinicl ctegory Ambultory visits Hospitliztions Nonspecifi c bck pin 4,552,42 9,26 Miscellneous bck problems 1,395,74 2,475 Degenertive chnges 464,81 6,271 Hernited disc 433,265 11,75 Possible instbility 11,777 1,573 Spinl stenosis 41,171 1,98 Sequele of previous bck surgery 2, Totl 7,8,557 31,675 mjor trum (e.g. trffic ccidents, vertebrl frctures or disloctions), pregnncy, neoplsms, infections, or other inflmmtory cuses of bck pin were excluded. The incident episode of mechnicl LBP ws defined s ech individul s first low bck pin-relted medicl encounter. Incidence rtes of LBP overll were clculted by dividing the totl of first (incident) episodes of LBP during the period by the totl yers (person-time) of ctive militry service during the sme period. Also, incidence rtes of ech of seven clinicl ctegories of mechnicl LBP were clculted seprtely. For these nlyses, individuls could be counted s incident cses once in ech ctegory during the 1-yer period; medicl encounters with multiple LBP indictor dignoses were clssified using the LBP dignosis tht ws reported in the highest position. Finlly, the ge distribution t ech ffected service member s first encounter nd the number of individuls with more thn one LBP episode were ssessed. Results: Numbers nd ntures of medicl encounters: During the 1-yer surveillnce period, ctive component members hd more thn seven million mechnicl low bck problem-relted medicl encounters. Approximtely 7.2% nd 2.% of ll LBP-ssocited hospitliztions nd outptient encounters, respectively, were ssocited with mjor trum, pregnncy, neoplsm, infection, or other inflmmtory cuse of bck pin. These episodes were excluded from further nlyses. After excluding medicl encounters for conditions tht my cuse bck pin, there were 7,8,557 mbultory visits (mong 1,2,71 individuls) nd 31,675 hospitliztions (mong 26,575 individuls) with mechnicl low bck pinrelted dignoses (Tble 1). Nonspecific bck pin ws the clinicl ctegory of nerly two-thirds of ll mbultory visits for low bck problems (n=4,552,42, 64.9%); one-fifth of ll LBP-relted mbultory visits were reported s miscellneous bck problems (n=1,395,74, 19.9%). Degenertive chnges nd hernited disc ech represented pproximtely six percent of ll outptient dignoses; the remining clinicl ctegories combined ccounted for only two percent of ll visits. The mjority (63%) of ll hospitliztions for mechnicl low bck problems were documented with hernited disc (n=11,75, 35.%) or nonspecific bck pin (n=9,26, 28.5%) dignoses (Tble 1). Lumbgo ws by fr the most frequent dignosis during mbultory visits for LBP. During the 1-yer

3 JULY 21 3 Figure 1. Most frequent mechnicl low bck pin dignoses during mbultory visits, ctive component, U.S. Armed Forces, ,, Ambultory visits 6. Individuls ffected No. of visits/individuls ffected 2,5, 2,, 1,5, 1,, Averge visits per individul , 1.. Lumbgo Bckche, unspecified Nonllopthic lesions, lumbr region Sprins nd strins, lumbr Displcement of lumbr intervertebrl disc Degenertion of lumbr or lumboscrl intervertebrl disc Thorcic or lumboscrl neuritis or rdiculitis, unspecified Nonllopthic lesions, scrl region Sprins nd strins of scroilic region Sciti Averge visits per individul period, 667,378 service members hd pproximtely three million mbultory visits for lumbgo (verge per person: 4.5) (Figure 1). The nonspecific dignoses of bckche, unspecified (95,447 visits; 411,767 individuls; verge per person: 2.) nd sprins nd strins, lumbr (324,548 visits; 163,825 individuls; verge per person 2.2) were the second nd fourth most frequent dignoses reported during LBPrelted visits. Nonllopthic lesions, lumbr region (often indictive of chiroprctic cre) 7 ws the third most frequent dignosis during LBP-relted mbultory visits (57,686 visits; 11,673 individuls); the verge number of visits per individul who received the dignosis ws 5. (Figure 1). During hospitliztions, the most frequent dignoses were displcement of lumbr intervertebrl disc, lumbgo, degenertion of lumbr or lumboscrl intervertebrl disc nd bckche, unspecified (Figure 2). These four conditions ccounted for 71% of ll LBP-relted hospitliztions. Surgery ws performed during more thn 7% of hospitliztions for lumbr disc problems, rdiculitis, stenosis nd spondylolisthesis. LBP-relted hospitliztions documented with nonspecific bck pin dignoses rrely involved surgery: lumbgo nd bckche, unspecified were treted with surgery in just 8% nd 3% of cses, respectively (Figure 2). Incidence rtes nd trends During the 1-yer period, 86,524 service members hd their first (incident) LBP-relted medicl encounter. The overll incidence rte ws 74.1 visits per 1, personyers (p-yrs) (Tble 2). The number of service members with t lest one LBP-relted visit during ech clendr yer shrply declined from 2 (n=14,645) to 23 (n=82,187), then remined reltively stble through 29 (rnge of number ffected per yer, 24-9: 77,749 [26] to 87,35 [24]) (Figure 3). Incidence rtes in ech of the Services were lso reltively stble during the period (Figure 3). Undjusted incidence rtes were highest in the Army (29: 12.6 per 1, p-yrs), intermedite in the Air Force (29: 74.4 per 1, p-yrs),

4 4 VOL. 17 / NO. 7 Figure 2. Most frequent mechnicl low bck pin dignoses during hospitliztions, ctive component, U.S. Armed Forces, 2-29 No. of hospitliztions 12, 1, 8, 6, 4, without surgery with surgery 2, Displcement of lumbr intervertebrl disc Lumbgo Degenertion of lumbr or lumboscrl intervertebrl disc Bckche, unspecified Lumboscrl spondylosis without myelopthy Thorcic or lumboscrl neuritis or rdiculitis, unspecified Spinl stenosis, lumbr region Acquired spondylolisthesis Displcement of intervertebrl disc, site unspecified Tble 2. Incidence rtes (per 1, person-yers) of mechnicl low bck pin, by dignostic ctegory, ctive component, U.S. Armed Forces, 2-29 Totl (ll ctegories) Nonspecifi c bck pin Misc bck problems Degenertive chnges Hernited disc Possible instbility Spinl stenosis Sequele of bck surgery No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte Totl individuls 86, , , , , , , ,182.4 Age (yers) <2 11, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,441.8 >=4 78, , , , , , , ,43 1. Gender Femle 171, , , , , , , Mle 689, , , , , , , ,518.4 Service Army 381, , , , , , , ,985.4 Nvy 164, , , , , , , ,127.3 Air Force 2, , , , , , , ,453.4 Mrine Corps 93, , , , , , , Cost Gurd 2, , , , , Rce/ethnicity Blck, non-hispnic 162, , , , , , , White, non-hispnic 542, , , , , , , ,841.4 Other 155, , , , , , , Militry occuption Combt 157, , , , , , , Helth Cre 76, , , , , , , Admin/supply 217, , , , , , , ,36.4 Other 41, , , , , , , ,429.4

5 JULY 21 5 Figure 3. Numbers nd incidence rtes of ny mechnicl low bck pin dignosis, by Service, ctive component, U.S. Armed Forces, , Army 14. No. of service members with ny low bck pin dignosis (brs) 1, 8, 6, 4, 2, Nvy Air Force Mrine Corps Rte per 1, p-yrs (lines) Yer Figure 4. Incidence rtes of mechnicl low bck pin, by clinicl ctegory nd ge, ctive component, U.S. Armed Forces, Nonspecific bck pin Miscellneous bck problems Degenertive chnges Rte per 1, p-yrs < >=4 Age

6 6 VOL. 17 / NO. 7 Figure 5. Age t fi rst mechnicl low bck pin (LBP) dignosis (during militry service), ctive component, U.S. Armed Forces, Mles Femles Figure 6. Among service members with n incident low bck pin, proportion who hve t lest one encounter during ech yer of followup, ctive component, U.S. Armed Forces, Percent of service members with LPB dignosis Percent of service members with n dditionl low bck pin dignosis < >=4 Age t first LBP dignosis No. of yers following the first low bck pin encounter nd lowest in the Nvy nd Mrine Corps (29: 55.7 nd 63.4 per 1, p-yrs, respectively) (Figure 3). Among the vrious clinicl ctegories of mechnicl low bck pin, the highest rtes by fr were for nonspecific bck pin (Tble 2). Of service members with ny LBP dignoses during the period, 93% were dignosed t lest once with nonspecific bck pin (rte: 68.2 per 1, p-yrs), pproximtely one-third were dignosed with miscellneous bck problems (rte: 22.1 per 1, p-yrs), one-eighth with degenertive chnges (rte: 8. per 1, p-yrs), nd onetenth with hernited disc (rte: 6.7 per 1, p-yrs) (Tble 2). For ll clinicl ctegories except nonspecific bck pin, incidence rtes were lowest mong the youngest service members nd incresed monotoniclly with ge (Tble 2). In contrst, incidence rtes of nonspecific bck pin were highest mong the youngest service members (<2 yers: 99.5 per 1, p-yrs) nd declined with ge until the mid- 3s (3-34 yers: 58.1 per 1, p-yrs) (Figure 4). The clinicl ctegories of LBP ffected demogrphicllydefined subgroups differently. For exmple, the incidence rte of LBP overll ws higher mong femles thn mles (femle to mle, incidence rte rtio [f:m, IRR: 1.59]). Incidence rtes of possible instbility (f:m, IRR: 1.83), miscellneous bck problems (f:m, RR: 1.75), nd non-specific bck pin (f:m, RR: 1.57) were higher mong femle thn mle service members, but rtes of sequele of bck surgery (f:m, RR:.86) nd spinl stenosis (f:m, IRR:.95) were higher mong mles thn femles (Tble 2). Also, there were no striking differences or consistent reltionships of rtes of LBP with rcil/ethnic identity. For exmple, rtes of ny LBP nd nonspecific bck pin were higher mong blck non-hispnic, nd rtes of degenertive chnges, hernited disc, nd possible instbility were higher mong white non- Hispnic, service members thn their respective counterprts (Tble 2). In generl, femles experienced their first medicl visits for low bck pin t older ges thn mles (Figure 5). Recurrence One-hlf (5.1%) of ll service members with t lest one LBP dignosis during the period hd t lest one recurrence (LBP dignosis >3 dys fter the initil episode) (dt not shown). Of 86,524 service members who received their first (incident) dignoses of LBP (while in militry service) during the surveillnce period, pproximtely one-fourth (23%) hd t lest one medicl encounter for LBP within one yer fter the incident episode. During ech of the first nine yers following the incident episode, 22-24% of those still in militry service hd t lest one dditionl LBP-relted medicl encounter (Figure 6).

7 JULY 21 7 Editoril comment: This report documents tht, during the pst 1 yers, 7.4% of ll ctive component members hd t lest one dignosis of mechnicl low bck pin; one-hlf of ll service members with ny LBP-relted medicl encounter hd more thn one documented episode of LBP (while in militry service). From the time of their initil medicl encounters for LBP, pproximtely one-fourth of those still in militry service hd t lest one LBP-relted encounter during ech of the next nine yers. During the pst 1 yers, the vst mjority of ll medicl encounters for mechnicl low bck pin were documented with nonspecific bck pin dignoses, prticulrly lumbgo, bckche, unspecified, nd sprins nd strins. Incidence rtes of nonspecific bck pin were highest mong the youngest service members (18-24 yers old), while rtes of ll other clinicl ctegories of low bck pin were lowest mong the youngest nd incresed with ge. Specific LBP-relted dignoses (e.g., intervertebrl disc disorders, spinl stenosis) were reported infrequently during mbultory visits; when such dignoses were mde, they my hve indicted provisionl or rule out dignoses. Studies in civilin popultions hve found tht very few ptients presenting with low bck pin hve detectble spinl pthology; 8 lso, findings from rdiogrphic nd mgnetic resonnce imging studies do not strongly correlte with the presence or severity of low bck pin symptoms or relibly indicte the cuses of low bck pin. 9,1,11 In prospective study of symptomtic veterns, self-indicted depression ws stronger predictor of low bck pin thn ny imging bnormlities (e.g. disc bulges, protrusions, degenertion). 11 This summry included medicl encounters reported from fixed medicl fcilities outside of combt theters. However, lumboscrl strin is the second most prevlent disbility mong veterns of the first Gulf Wr; 12 nd lengthy deployments (or recurrent deployments) to Irq/ Afghnistn my increse low bck pin risk. Among both mle nd femle deployers to OIF/OEF, low bck pin is much more prevlent fter thn before they deployed. 13 In modern times, U.S. militry members in combt settings crry hevier lods thn those who served in such settings in the pst. 14 A recent survey of U.S. soldiers in Irq reveled substntil increse in self-reported bck nd neck pin during deployment; mny respondents ttributed the symptoms to lengthy periods of wering body rmor. 15 The LBP surveillnce report bove does not document incresed numbers or rtes of LBP-relted dignoses in the ctive component overll since the beginning of lrge scle deployments to Afghnistn nd Irq. However, even significnt increse in risk in reltionship to deployment would be difficult to detect ginst the bckground of LBP tht ffects militry members in generl. The ntures nd strengths of reltionships between service in combt settings nd risk of LBP re relevnt force helth protection concerns; s such, they wrrnt further study. The medicl helth cre nd militry opertionl costs of LBP re enormous. Interventions tht could reduce the prevlence nd recurrence of LBP could be extremely cost-effective nd should be high priority for militry reserch. A three-yer clinicl tril to determine the effectiveness of core stbiliztion exercise progrms nd other interventions in preventing nd reducing the severity of LBP in service members is nerly complete, with finl results expected in References: 1. Hrt LG, Deyo RA, Cherkin DC. Physicin offi ce visits for low bck pin. Frequency, clinicl evlution, nd tretment ptterns from U.S. ntionl survey. Spine Jn 1;2(1): Stnton TR, Henschke N, Mher CG, et l. After n episode of cute low bck pin, recurrence is unpredictble nd not s common s previously thought. Spine. 28;33: Speed C. Low bck pin. BMJ. 24; 328: Freburger J, Holmes G, Agns R, et l. The rising prevlence of chronic low bck pin. Arch Intern Med. 29;169(3): Armed Forces Helth Surveillnce Center. Ambultory visits mong members of the ctive component, U.S. Armed Forces, 29. MSMR. 21 Apr;17(4): Cherkin D, Deyo R, Volinn E, et l. Use of the Interntionl Clssifiction of Diseses (ICD-9-CM) to identify hospitliztions for mechnicl low bck problems in dministrtive dtbses. Spine. 1992; 17(17): Armed Forces Helth Surveillnce Center. Ambultory visits mong members of the ctive component, U.S. Armed Forces. Uses of complementry nd lterntive medicine (CAM) procedures, U.S. Armed Forces, MSMR. 29 Sep; 15(7):6. 8. Chou R, Qseem A, Snow V, Csey D, Cross JT Jr, Shekelle P, Owens DK; Dignosis nd tretment of low bck pin: joint clinicl prctice guideline from the Americn College of Physicins nd the Americn Pin Society. Ann Intern Med. 27 Oct 2;147(7): vn Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinl rdiogrphic findings nd nonspecifi c low bck pin. A systemtic review of observtionl studies. Spine. 1997;22: Boden SD, Dvis DO, Din TS, et l. Abnorml mgneticresonnce scns of the lumbr spine in symptomtic subjects. A prospective investigtion. J Bone Joint Surg Am. 199;72: Jrvik JG, Hollingworth W, Hegerty PJ, Hynor DR, Boyko EJ, Deyo RA.Three-yer incidence of low bck pin in n initilly symptomtic cohort: clinicl nd imging risk fctors. Spine. 25 Jul 1;3(13):1541-8; discussion Deprtment of Veterns Affirs. Veterns Benefi ts Administrtion. Annul Benefi ts Report FY29. br/29_br.pdf. Accessed 6 July Brundge, JF. Medicl Conditions with Higher thn Expected Incidence Within Two Yers fter Returning from OEF/OIF: Deployment-relted Helth Effects Differ Between Mle nd Femle OEF/OIF Veterns. Presented t the Force Helth Protection Conference, Phoenix, AZ. 12 Aug Knpik JJ, Reynolds KL, Hrmn E. Soldier lod crrige: historicl, physiologicl, biomechnicl, nd medicl spects. Mil Med. 24 Jn;169(1): Konitzer, et l. Assocition between bck, neck, nd upper extremity musculoskeletl pin nd the individul body rmor. J Hnd Ther. 28 Apr-Jun;21(2): George SZ, Childs JD, Teyhen DS, Wu SS, Wright AC, Dugn JL, Robinson ME.Rtionle, design, nd protocol for the prevention of low bck pin in the militry (POLM) tril. (NCT3739). Musculoskelet Disord. 27 Sep 14;8:92.

8 8 VOL. 17 / NO. 7 Thorcolumbr Spine Frctures, Active nd Reserve Components, 2-29 The spine consists of serilly connected bones (vertebre) in column; it provides stbility nd flexibility to the body nd protects the spinl cord. While the thorcolumbr spine (mid-to-lower bck) is reltively well protected nd strongly reinforced, highenergy trum cn seriously injure the thorcolumbr spine nd spinl cord. 1 In the generl U.S. popultion, most thorcolumbr spine frctures result from motor-vehicle collisions (MVCs), flls, violence, nd ccidents during recretionl ctivities. 2 To gret extent, the cute nd long-term clinicl effects of spine frctures depend on the nture nd severity of complicting injuries. For exmple, in generl, spine frctures produce significnt pin nd disbility; in turn, most ffected individuls require hospitliztion for cute cre nd posthospitl rehbilittive cre. 3 However, epidemiologic studies hve estimted tht 1-35% of thorcolumbr spine frctures re complicted by spinl cord injuries; the short nd longterm consequences of such injuries re enormous (e.g., prlysis, lengthy hospitliztions nd rehbilittion, high cute nd lifetime helth cre costs). 1,2,4 Militry members encounter risks of severe trumtic injuries (including spine frctures) during combt, trining, nd trnsporttion-relted ctivities. Common militry ctivities tht cn be hzrdous include flying (plnes/ helicopters), prchute jumping, climbing (e.g., ropes, rocky terrin), nd combt trining. 5,6 During combt opertions in Irq nd Afghnistn, spine frctures hve resulted from explosions (e.g., improvised explosive devices [IEDs]), gunshots, nd MVCs. 7,8 This report documents the numbers, rtes, trends, nd demogrphic nd militry chrcteristics of U.S. militry members who were hospitlized for thorcolumbr spine frctures from Methods: The surveillnce period ws 1 Jnury 2 to 31 December 29. The surveillnce popultion included ll individuls in the ctive or reserve components (including Ntionl Gurd) of the U.S. Army, Nvy, Air Force, Mrine Corps, or Cost Gurd who served on ctive duty ny time during the surveillnce period. Dt were derived from records routinely mintined in the Defense Medicl Surveillnce System (DMSS). An incident cse of thorcolumbr spine frcture ws defined s the first hospitliztion of ech individul tht included dischrge dignosis of thorcolumbr spine frcture. For this nlysis, the thorcolumbr spine ws defined s the thorcic (T1-T12) nd lumbr (L1- L5) vertebre. Cse-defining dignoses were scertined from records of hospitliztions tht included ICD-9-CM dignosis codes indictive of thorcolumbr spine frcture in ny dignostic position. Cse-defining dignosis codes were lso used to document the presence or bsence of concurrent spinl cord injuries (Tble 1). For this nlysis, summry mesures were numbers of thorcolumbr spine frctures in the surveillnce popultion overll (i.e., ctive nd reserve component members on ctive duty) nd frcture rtes (clculted s frctures per 1, person-yers of ctive militry service) mong members of the ctive component only. Reserve component members were not included in rte clcultions becuse the strt nd end dtes of their ctive duty service periods were not vilble. Deths of ctive duty service members were scertined from records produced by service-specific csulty offices nd mintined by the Armed Forces Medicl Exminer in the DoD Medicl Mortlity Registry; the mortlity registry clssifies deths by mnner nd underlying cuse. Cuses of thorcolumbr spine frctures mong ctive component members were ssessed bsed on STANAG codes (per NATO Stndrd Agreement No. 25) reported on the record of ech cse-defining hospitliztion in U.S. militry medicl fcility. Records of medicl evcutions (medevcs) conducted by the U.S. Trnsporttion Commnd (TRANSCOM) re routinely provided for helth surveillnce purposes to the Armed Forces Helth Surveillnce Center (AFHSC) vi the Office of the Assistnt Secretry of Defense for Helth Affirs. For this report, cuses of injuries tht resulted in medevcs were ssessed bsed on descriptions (recorded in text) on medevc records. Results: In the ten-yer surveillnce period, there were 4,655 incident thorcolumbr spine frcture-relted hospitliztions mong ctive nd reserve component U.S. militry members. More thn four-fifths of ll thorcolumbr Tble 1. Cse-defining dignosis codes (per ICD-9-CM): thorcolumbr spine frcture Frcture of vertebrl column without mention of spinl cord injury Frcture of vertebrl column with spinl cord injury 85.2 Dorsl [thorcic], closed 86.2(x) Dorsl [thorcic], closed 85.3 Dorsl [thorcic], open 86.3(x) Dorsl [thorcic], open 85.4 Lumbr, closed 86.4 Lumbr, closed 85.5 Lumbr, open 86.5 Lumbr, open 85.8 Unspecifi ed, closed 86.8 Unspecifi ed, closed 85.9 Unspecifi ed, open 86.9 Unspecifi ed, open

9 JULY 21 9 Tble 2. Hospitliztions relted to thorcolumbr spine frctures, ctive nd reserve components, U.S. Armed Forces, 2-29 Active component Rte per 1, person-yers of service Reserve component Overll No. Rte No. No. Totl 3, ,655 Service Army 1, ,344 Nvy Air Force Mrine Corps Cost Gurd Sex Mle 3, ,243 Femle Rce ethnicity White, non-hispnic 2, ,436 Blck, non-hispnic Other Age < , , Militry occuption Helth Combt 1, ,66 Other 2, ,827 spine frcture-relted hospitliztions (n=3,853; 83%) ffected ctive component members; the incidence rte in the ctive component ws 2.7 per 1, person-yers (p-yrs) (Tble 2). During the 1-yer period, in the ctive component, incidence rtes were reltively high mong members of the Mrine Corps (3.7 per 1, p-yrs) nd Army (3.5 per 1, p-yrs), 2-24 yer olds (3.6 per 1, p-yrs), white non-hispnic members (3.1 per 1, p-yrs), nd mles (2.9 per 1, p-yrs) (Tble 2). Incidence rtes were more thn twice s high mong service members with combt specific militry occuptions (4.6 per 1, p-yrs) compred to non-combt (Tble 2). In the ctive components, nnul incidence rtes incresed in the Army ech yer from 23 through 27, plteued t reltively high rte in the Mrine Corps between 24 nd 26, nd were reltively low nd stble in the other Services throughout the period (Figure 1). Incidence rtes nd trends mrkedly vried cross militry occuptionl ctegories. For exmple, beginning in 23, incidence rtes shrply incresed mong service members with combt-specific occuptions; in contrst, mong those in helth cre nd other non-combt specific occuptions, rtes remined reltively low nd stble fter 23 (Figure 2). In both the ctive nd reserve components, most thorcolumbr spine frctures were not complicted by spinl cord injuries (Figure 3). In the ctive component, the highest number (n=66) nd percentge (19.1%) of thorcolumbr spine frctures tht were complicted by spinl cord injuries occurred in 26. In the reserve component, the highest number (n=15) nd percentge (15.2%) of thorcolumbr spine frctures complicted by spinl cord injuries occurred in 25. During the 1-yer period, there were more thn twice s mny thorcolumbr spine frcture-relted hospitliztions of U.S. militry members t Lndstuhl Regionl Medicl Center, Germny (n=66) thn t ny other U.S. militry medicl fcility. In the United Sttes, U.S. militry medicl fcilities t 18 loctions hd 5 or more thorcolumbr spinl frcture-relted hospitliztions ech during the period (dt not shown). Seventy-three U.S. militry members died while on ctive duty (per records in the DoD Mortlity Registry) during or fter hospitliztions with thorcolumbr spine frctures. Accidents involving motorcycles (n=28) or other motor vehicles (n=3) were considered the underlying cuses of the deths of pproximtely two-thirds (68%) of these individuls (Tble 4). Of 2,617 U.S. militry members who were treted for thorcolumbr spine frctures in U.S. militry medicl fcilities, lnd trnsport (n=946, 36%), flls nd miscellneous (n=6, 23%), nd ir trnsport (n=365, 14%) were consistently the leding cuses of their injuries (per STANAG No. 25 cuse of injury codes). Guns nd explosives (including ccidents during wr) nd bttle csulties ccounted for reltively lrge numbers of thorcolumbr spine frcture-relted hospitliztions beginning in 23 (n=26) nd peking in 27 (n=12) (Figure 4). During the surveillnce period, there were 73 medicl evcutions of militry members with thorcolumbr spine frctures to the Lndstuhl Regionl Medicl Center from the U.S. Centrl Commnd re of opertions. Explosions (including improvised explosive devices [IEDs]) (n=381), motor vehicle collisions (n=91), gunshot wounds (n=66), flls (n=59), nd helicopter ccidents (n=5) ccounted for more thn 9% of ll spine frcture-relted medevcs during the period (Figure 5). Editoril comment: This report documents tht, during the pst ten yers, n verge of pproximtely 465 U.S. militry members per yer were hospitlized with thorcolumbr spine frctures.

10 1 VOL. 17 / NO. 7 Figure 1. Annul incidence rtes of hospitliztions relted to thorcolumbr spine frcture by service, ctive component, U.S. Armed Forces, 2-29 Hospitliztions per 1, p-yrs Army Mrine Corps Nvy Cost Gurd Air Force Yer Figure 2. Annul incidence rtes of hospitliztions relted to thorcolumbr spine frcture by occuptionl ctegory, ctive component, U.S. Armed Forces, Combt Other Helth 5. Hospitliztions per 1, p-yrs Yer

11 JULY Figure 3. Hospitliztions relted to thorcolumbr spinl frctures, by type, number per yer by component, nd nnul rtes in ctive component, U.S. Armed Forces, 2-29 No. of thorcolumbr spine frctures With spinl cord injury (Reserve) Without spinl cord injury (Reserve) With spinl cord injury (Active) Without spinl cord injury (Active) Rte (Active) Hospitliztions per 1, p-yrs Yer Figure 4. Hospitliztions relted to thorcolumbr spinl frctures in U.S. militry medicl fcilities by externl cuses of injuries (n=2,539), ctive component, U.S. Armed Forces, Bttle csulty Guns, explosives (includes ccidents during wr) Other b Air trnsport Flls nd miscellneous Lnd trnsport 25 No. of hospitliztions Cuses determined by codes specifi ed in NATO Stndriztion Agreement (STANAG) No. 25. b Other includes: Athletics, complictions of medicl surgery, mchinery, tools, wter trnsport, environmentl poisons nd fi re, self-infl icted, non-bttle (ssult), missing/ invlid code Yer

12 12 VOL. 17 / NO. 7 Tble 3. Underlying cuses of deth of U.S. service members during/fter hospitliztions relted to thorcolumbr spine frctures, ctive nd Reserve components, Description Underlying cuse of deth code Number % Motorcycle ccidents All other motor vehicle ccidents 31, 32, 34, 35, Opertions of wr nd their sequele Air nd spce trnsport ccidents Fll from one level to nother Intentionl self-hrm (suicide) 334, Pedestrin vs. motor vehicle Rilwy ccidents Assult (homicide) 34, Other nd unspecifi ed trnsport ccidents nd their sequele Pedl cyclist involved in collision with motor vehicle Totl 85 1% Throughout the 1-yer period (including severl yers of intensive combt opertions in Irq nd Afghnistn), most thorcolumbr spine frctures of U.S. militry members were cused by lnd nd ir trnsporttion ccidents or flls nd miscellneous. The findings reiterte the importnce of motorcycle, utomobile, militry vehicle, nd militry vition sfety progrms. There re limittions to the report tht should be considered when interpreting the results. For exmple, the nlysis only considered thorcolumbr spine frcture cses tht were hospitlized; thus, individuls who sustined severe injuries to vitl orgns in ddition to thorcolumbr spine frctures my hve died before they could be hospitlized. To the extent tht this occurred, the numbers nd rtes of trumtic events tht cused thorcolumbr spine frctures mong U.S. militry members were underestimted, nd the cuses nd consequences of thorcolumbr spine frctures were only prtilly ssessed. Also, the nlysis did not ccount for the ntures or severities of injuries nd medicl conditions tht were concurrent with or complicted the clinicl courses Figure 5. Number nd percent by cuse, eromedicl evcutions relted to thorcolumbr spinl frctures (n=73) from the U.S. Centrl Commnd re of opertions, ctive nd Reserve components, U.S. Armed Forces, % 35 No. of medicl evcutions % 9.4% Explosions b MVCs c GSWs Flls Helicopter Unknown Crush/blunt trum IEDs, mortrs, rocket-propelled grendes b MVCs=Motor vehicle collisions c GSWs=Gunshot wounds 8.4% 7.1% 3.3% 2.6% 1.4% Misc.7% Shrpnel

13 JULY of thorcolumbr spine frctures. Undoubtedly, such fctors re importnt determinnts of epidemiologic nd clinicl chrcteristics of thorcolumbr spine frctures. In spite of such limittions, the findings of this report re informtive nd potentilly useful. Thorcolumbr spine frcture-relted hospitliztions of U.S. militry members shrply incresed beginning in 23, the first yer of Opertion Irqi Freedom; frctures cused by bttle injuries nd explosions stedily incresed from 23 through 27 nd slightly declined therefter. Still, during ech yer of the surveillnce period, lnd nd ir trnsporttion ccidents nd flls nd miscellneous were the most frequent cuses by fr of thorcolumbr spine frctures mong U.S. militry members; numbers of hospitlized cses relted to these cuses remined firly stble throughout the period. During the surveillnce period, pproximtely oneeighth of ll U.S. militry members who were hospitlized with thorcolumbr spine frctures hd concurrent spinl cord injuries. The proportion is similr to tht reported in epidemiologic studies in non-militry popultions. 1,4 The finding suggests tht most non-lethl high impct trums tht cuse thorcolumbr spine frctures re not complicted by spinl cord injuries. Of note, however, high impct trums tht frcture the thorcolumbr spine nd significntly dmge the spinl cord re often life thretening; mny individuls ffected with such ctstrophic injuries my not survive to be hospitlized (nd would not be included s cses for this report). References: 1. Sboe L, Reid DC, Dvis LA, Wrren, SA, et l. Spine trum nd ssocited injuries. J Trum. 1991; 31: Ntionl Spinl Cord Injury Sttisticl Center 21. Spinl Cord Injury Fcts nd Figures t glnce. University of Albm t Birminghm. 3. Ross PD. Clinicl consequences of vertebrl frctures. Am J Medicine. 1997;13(2):S3-S Hu R, Mustrd CA, Burns C. Epidemiology of Incident Spinl Frcture in Complete Popultion. Spine. 1996;21(4): Belmont PJB, Tylor KF, Mson KT, Shwen SBS, et l. Incidence, epidemiology, nd occuptionl outcomes of thorcolumbr frctures mong U.S. Army Avitors. J Trum. 21;5: Armed Forces Helth Surveillnce Center. Accidentl injuries from hnd-to-hnd combt trining nd combt sports, U.S. Armed Forces, Medicl Surveillnce Monthly Report (MSMR). 21 Februry;17(2): Belmont PJ Jr, Goodmn GP, Zcchilli M, et l. Incidence nd epidemiology of combt injuries sustined during the surge portion of Opertion Irqi Freedom by U.S. Army Brigde Combt Tem. J Trum. 21;68: Owens BD, Krgh JF Jr, Wenke JC, Mcitis JBS, et l. Combt wounds in Opertion Irqi Freedom nd Opertion Enduring Freedom. J Trum. 28;64(2):

14 14 VOL. 17 / NO. 7 Tendon Ruptures, Active Component, U.S. Armed Forces, 2-29 Injuries nd musculoskeletl disorders ccount for significnt morbidity, lost duty time, nd helth cre burdens in the U.S. Armed Forces. In 29, more service members received medicl cre for injuries thn ny other ctegory of medicl conditions. 1 Tendon ruptures re ters in the fibrous tissue tht ttches muscle to bone; ruptures of tendons without significnt trum ( spontneous ruptures ) occsionlly occur in physiclly ctive, young dults such s U.S. militry members. Tendon ruptures cn be chroniclly pinful nd/ or disbling depending on the nture nd loction of the ffected tendon. 2 Most ruptured tendons cn be repired surgiclly or with immobiliztion; however, regrdless of the therpeutic pproch, there re often long periods of rehbilittion, inbility to perform physiclly demnding duties, nd unvilbility for overses deployments. In militry popultions, primry prevention of spontneous tendon ruptures is prticulrly desirble becuse of their disproportiontely lrge impcts on militry opertionl effectiveness nd the militry helth system. 3,4,5 Sudden, strenuous ctivities re the usul proximte cuses of spontneous tendon ruptures (e.g., running, sudden stops nd strts, nd jumping re often ssocited with Achilles tendon ters); however, there re other risk fctors. For exmple, incresing ge, mle gender, use of certin medictions (e.g., fluroquinolone ntibiotics, nbolic steroids), nd degenertive chnges in tendon tissue hve been ssocited with incresed risk; 6,7,8 in ddition, there my be genetic predispositions (e.g., tendon width nd vsculture, ABO blood group). 9,1,11 This report summrizes the numbers, incidence rtes, trends, nd demogrphic nd militry chrcteristics of U.S. militry members ffected by spontneous tendon ruptures from 2 to 29. Methods: The surveillnce period ws 1 Jnury 2 to 31 December 29. The surveillnce popultion included ll individuls who served in the ctive component of the U.S. Armed Forces ny time during the surveillnce period. Cses were defined by inptient or outptient medicl encounters with primry (first-listed) dignoses of tendon rupture (ICD-9 codes: ). The dte of the first csedefining medicl encounter for ech ffected tendon of ech ffected individul ws considered the incident dte. Incidence rtes were clculted s incident tendon rupture cses, overll nd by specific tendon or ntomic loction (Tble 1) per 1, person-yers (p-yrs) t risk. Ech Tble 1. ICD-9-Codes for tendon ruptures by body loction Body loction ICD-9 -CM code Shoulder/rm , Hnd , Leg , Foot/nkle , Unspecifi ed/other tendon rupture 727.6, Achilles tendon rupture Rottor cuff rupture Anterior crucite ligment ter Ankle sprin 845 Biceps tendon rupture individul could be included s n incident cse once for nlysis of ny tendon rupture nd once per nlysis by specific tendon type/loction. As secondry nlyses, incident episodes of Achilles tendon (ICD-9: ) nd rottor cuff (ICD-9: ) ruptures during clendr yer 29 were ssessed in more detil. Achilles tendon ruptures were exmined becuse of their reltively high incidence (second only to rottor cuff ruptures), ssocited morbidity, nd prolonged incpcittion. Rottor cuff ters were exmined becuse they re the most frequent type of tendon rupture nd the incidence hs been incresing. Results: During the 1-yer surveillnce period, there were 3,955 incident tendon ruptures mong ctive component members (Tble 2). During the period, nnul incidence rtes of ny tendon rupture incresed by more thn 4% (2: 17.3 per 1, p-yrs; 29: 24.7 per 1, p-yrs). Incidence rtes of ny tendon rupture monotoniclly incresed with ge. More thn one-hlf of ll incident tendon ruptures ffected service members older thn 3 yers; the highest tendon rupture incidence rte by fr (61.5 per 1, p-yrs) ffected service members older thn 4 (Tble 2). Over the entire period, the incidence rte of ny tendon rupture ws nerly twice s high mong mles thn femles nd more thn two-thirds higher mong blck non-hispnic thn white non- Hispnic or other rcil/ethnic group members (Tble 2). Incidence rtes of ruptures of shoulder nd rm tendons stedily incresed nd pproximtely doubled over the 1-yer surveillnce period (Figure 1); during ech yer nd overll, the rottor cuff ws the specific tendon type/group most frequently ruptured (dt not shown). Incidence rtes of ruptures of tendons in other ntomic loctions slightly incresed (e.g., foot/nkle) or were stble during the period (Figure 1).

15 JULY Tble 2. Numbers nd rtes of incident tendon ruptures, ctive component, U.S. Armed Forces, 2-29 Totl No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte Totl 3, , , , , , , , , , , Service Army 11, , , , , , , Cost Gurd Air Force 7, Mrine Corps 3, Nvy 7, Sex Femle 2, Mle 28, , , , , , , , , , , Rce/ethnicity Blck non-hispnic 8, White non-hispnic17, , , , , , , , , , , Other 4, Age < , , , , , , , , Rte per 1, person-yers of service Figure 1. Annul incidence rtes of tendon ruptures, by ntomic loction, ctive component, U.S. Armed Forces, 2-29 Shoulder or rm (727.61, ) Foot/nkle (727.67, ) Hnd (727.63, ) Leg (727.65, ) Unspecified/other tendon rupture (727.6, ) Incidence per 1, p-yrs Yer.

16 16 VOL. 17 / NO. 7 Figure 2. Incidence rtes of ruptures of chilles tendon nd rottor cuff, by demogrphic chrcteristics, ctive component, U.S. Armed Forces, 29. Achilles tendon, by sex nd ge group b. Achilles tendon, by rce nd ge group Femle Mle 25 Blck White Other 12 Incidence per 1, p-yrs Incidence per 1, p-yrs < Age Error brs indicte 95% confi dence intervls for rtes. < Age Error brs indicte 95% confi dence intervls for rtes. c. Rottor cuff, by sex nd ge group d. Rottor cuff, by rce nd ge group 6 8 Femle Mle Blck White Other Incidence per 1, p-yrs Incidence per 1, p-yrs < Age Error brs indicte 95% confi dence intervls for rtes. < Age Error brs indicte 95% confi dence intervls for rtes.

17 JULY Figure 3. Crude overll incidence rtes of chilles tendon nd rottor cuff rupture, by service, ctive component, U.S. Armed Forces, Achilles tendon rupture Rottor cuff rupture 16 Incidence per 1, p-yrs Army Cost Gurd Air Force Mrine Corps Nvy Brnch of service Error brs indicte 95% confi dence intervls for rtes. Figure 2 (pnels -d) summrizes incidence rtes of Achilles tendon nd rottor cuff ruptures in 29 in vrious demogrphic subgroups. Rtes of both Achilles tendon nd rottor cuff ruptures shrply incresed with ge; nd in ll ge groups, rtes of Achilles tendon ruptures were much higher mong mle nd blck non-hispnic service members thn their respective counterprts. Also, in most ge groups, mle nd blck non-hispnic members hd higher rtes of rottor cuff ters thn their respective counterprts; however, the differences in rtes relted to these fctors were much smller for rottor cuff thn Achilles tendon ruptures (Figure 2, -d). Blck non-hispnic service members lso experienced reltively high rtes of ptellr tendon ruptures but not biceps tendon ruptures, nterior crucite ligment (ACL) ters, or nkle sprins (dt not shown). In 29, the Cost Gurd nd Mrine Corps hd reltively high nd low overll rtes, respectively, of both rottor cuff nd Achilles tendon ruptures (Figure 3); the differences in rtes cross the Services were miniml when ge effects were controlled (Figure 4,,b). Editoril comment: Over the lst ten yers, dignoses of rottor cuff ruptures hve mrkedly incresed mong members of the ctive component of the U.S. militry; the increse in rottor cuff ruptures ccounts for much of the overll increse in tendon rupture dignoses. The finding must be interpreted cutiously becuse, unlike ruptures of other mjor tendons (e.g., Achilles, ptellr), rottor cuff ruptures re not necessrily cute injuries tht re immeditely disbling. It is possible tht the recent increse in rtes of dignoses of rottor cuff ruptures reflects, t lest in prt, more complete scertinment of previously undetected cses. In the U.S. militry, s in other popultions, ge is strongly correlted with tendon rupture risk. In the U.S. militry, incresing ge is lso correlted with higher rnk nd greter responsibilities. As such, tendon ruptures tht entil prolonged periods of disbility nd nondeploybility hve disproportiontely lrge militry opertionl impcts. New insights regrding modifible risk fctors nd primry prevention prctices would be very vluble dditions to militry force helth protection prctices. Even fter ge djustment, the rte of Achilles tendon rupture but not rottor cuff rupture ws much higher mong blck non-hispnic thn other service members. Bsed on their review of experience t Fort Brgg, NC, White nd collegues estimted tht the rte of mjor tendon ruptures ws more thn 13-times higher mong blck thn white soldiers. 5 In this report, blck non-hispnic service members lso hd reltively high rtes of ptellr tendon ruptures but not ACL ters or nkle sprins; the finding suggests tht differences in ctivities such s recretionl ctivities tht involve sudden ccelertion, decelertion, twisting, or jumping were not key determinnts of the rce-ethnicityrelted differences in rtes of ruptures of lower extremity

18 18 VOL. 17 / NO. 7 Figure 4. Incidence rtes of chilles tendon nd rottor cuff ruptures, by service nd ge group, ctive component, U.S. Armed Forces, 29. Achilles tendon 35 < Incidence per 1, p-yrs Army Cost Gurd Air Force Mrine Corps Nvy Service brnch Error brs indicte 95% confi dence intervls for rtes. b. Rottor cuff 12 1 < Incidence per 1, p-yrs Army Cost Gurd Air Force Mrine Corps Nvy Service brnch Error brs indicte 95% confi dence intervls for rtes.

19 JULY tendons. The pprently strong ssocition between risk of lower extremity tendon rupture nd rce-ethnicity deserves further investigtion. Finlly, mechnisms of injury were not ssessed in this nlysis; however, other studies hve consistently documented tht lrge proportions of mjor tendon ruptures re sustined during thletic nd other recretionl ctivities. A recently published study of injuries of U.S. Air Force members during ten-yer period reveled tht bsketbll ws one of the leding cuses of lost workdys overll; injuries to the Achilles tendon (including rupture) cused more lost work dys, on verge, thn ny other bsketbll-relted injury. 12 The development nd implementtion of policies, prctices, nd perhps equipment tht cn reduce sports-relted injuries mong young nd middle-ged (i.e., militry-ged) dults re indicted. References: 1. Armed Forces Helth Surveillnce Center. Absolute nd reltive morbidity ttributble to vrious illnesses nd injuries, U.S. Armed Forces, 29. MSMR. 21 Apr;17(4): Myerson MS, Mcgrvey W. Disorders of the insertion of the chilles tendon nd chilles tendinitis. J Bone Joint Surg Am.1998; 8: Nyyssönen T, Lüthje P, Kröger H. The incresing incidence nd difference in sex distribution of Achilles tendon rupture in Finlnd in Scnd J Surg. 28;97(3): Jrvinen TAH, Knnus P, Mffulli N, Khn KH. Achilles tendon disorders: etiology nd epidemiology. Foot Ankle Clin N Amer. 25; 1: White DW, Wenke JC, Mosely DS, Mountcstle SB, Bsmni CJ. Incidence of mjor tendon ruptures nd nterior crucite ligment ters in US Army soldiers. Am J Sports Med. 27 Aug;35(8): Mikolyzk DK, Wei AS, Tonino P, et l. Effect of corticosteroids on the biomechnicl strength of rt rottor cuff tendon. J Bone Joint Surg Am. 29 My; 91(5): Sode J, Obel N, Hlls J, Lssen A. Use of fl uoroquinolone nd risk of Achilles tendon rupture: popultion-bsed cohort study. Eur J Clin Phrmcol. 27 My;63(5): Childs SG. Pthogenesis of tendon rupture secondry to fl uoroquinolone therpy. Orthop Nurs. 27 My-Jun;26(3): Knnus P, Jozs L. Histopthologicl chnges preceding spontneous rupture of tendon: controlled study of 891 ptients. J Bone Joint Surg Am Dec;73(1): Courville XF, Coe MP, Hecht PJ. Current concepts review: noninsertionl chilles tendinopthy. Foot Ankle Int. 29 Nov;3(11): Jozs L, Blint JB, Knnus P, Reffy A, Brzo M. Distribution of blood groups in ptients with tendon rupture: n nlysis of 832 cses. J Bone Joint Surg Br Mr;71(2): Burnhm BR, Copley B, Shim MJ, Kemp PA. Mechnisms of bsketbll injuries reported to the HQ Air Force Sfety Center: A 1-yer descriptive study, Am J Prev Med. 21; 38(1S);S134-S14.

20 2 VOL. 17 / NO. 7 Surveillnce Snpshot: Plntr Fsciitis Plntr fsciitis is inflmmtion of the thick bnd of tissue tht connects the heel to the toes. The hllmrk symptoms re heel pin tht is worst with the first steps of the dy nd pin tht worsens with weight-bering. In the civilin popultion, plntr fsciitis ccounts for pproximtely one million ptient visits per yer; it is estimted tht pproximtely 1% of ll individuls will hve plntr fsciitis in their lifetimes. 1 There re severl tretment options; however, in pproximtely 8% of ptients, the condition is self-limiting, nd symptoms resolve within twelve months. 2 Fctors ssocited with the development of plntr fsciitis include incresing ge, femle gender, running or other ctivities tht plce stress on the heel nd ttched tissue, obesity, inpproprite footwer, nd vrious mechnicl cuses (e.g., excessive prontion, limited nkle dorsiflexion). 3 In the U.S. militry, service in the Army nd Mrine Corps hs been ssocited with incresed risk. 4 Among ctive component militry members, the overll incidence rte of plntr fsciitis incresed slightly during the pst 1 yers. Throughout the period, the highest rtes mong mle service members were mong the oldest (> 4 yers); mong them, the rtes stedily incresed from 23 through 29. In contrst, from 2 to 27, the highest rtes mong femle service members were mong the youngest (< 2 yers); however, mong them, rtes shrply declined beginning in 28. Since 28, the highest rtes mong femles hve been mong the oldest (>4 yers). 1. Riddle DL, Schpper SM. Volume of mbultory visits nd ptterns of cre for ptients dignosed with plntr fsciitis: ntionl study of medicl doctors. Foot Ankle Int. 24 My;25(5): Buchbinder R. Clinicl prctice. Plntr fsciitis. N Engl J Med. 24 My 2;35(21): Neufeld SK, Cerrto R. Plntr fsciitis: evlution nd tretment. J Am Acd Orthop Surg. 28 Jun;16(6): Scher DL, Belmont PJ Jr, Ber R, et l. The incidence of plntr fsciitis in the United Sttes militry. J Bone Joint Surg Am. 29 Dec;91(12): Incident dignoses of plntr fsciitis mong femles, by ge group nd yer, ctive component, U.S. Armed Forces, Rte per 1, p-yrs >= < Yer Incident dignoses of plntr fsciitis mong mles, by ge group nd yer, ctive component, U.S. Armed Forces, Rte per 1, p-yrs >= < Yer

21 JULY Surveillnce Snpshot: Abnorml Glucose Tolernce Test An bnorml glucose tolernce test ws defi ned s n individul s fi rst outptient record with ICD-9-CM: 79.2 in ny dignostic position. Acknowledgement: MAJ Pul Ciminer, MD, MPH (USA) Incident outptient dignoses, counts nd rtes of bnorml glucose tolernce test in mles, by ge group, ctive component, U.S. Armed Forces, 2-29 Incident bnorml glucose tolernce tests No. of bnorml tests < Incident bnorml glucose tolernce tests per 1, p-yrs Yer. Incident outptient dignoses, counts nd rtes of bnorml glucose tolernce test in femles, by ge group, ctive component, U.S. Armed Forces, 2-29 Incident bnorml glucose tolernce tests No. of bnorml tests < Incident bnorml glucose tolernce tests per 1, p-yrs Yer

22 22 VOL. 17 / NO. 7 Updte: Deployment Helth Assessments, U.S. Armed Forces, July 21 In July 21, there were lower numbers of pre-deployment helth ssessment forms trnsmitted to the Armed Forcces Helth Surveillnce Center thn t ny time in the pst 12 months (Tble 1, Figure 1). Since Jnury 23, peks nd troughs in the numbers of pre- nd postdeployment helth ssessment forms trnsmitted generlly corresponded to times of deprture nd return of lrge numbers of deployers. The numbers of post-deployment helth ressessments (PDHRA) trnsmitted in July 21 were the lowest since November 29. Between April 26 nd Mrch 21, the number of forms per month rnged from 17, to 43, (Tble 1, Figure 1). During the pst 12 months, the proportions of returned deployers who rted their helth s fir or poor were 8-11% on post-deployment helth ssessment questionnires nd 1-14% on PDHRA questionnires (Figure 2). In generl, on post-deployment ssessments nd ressessments, deployers in the Army nd in reserve components were more likely thn their respective counterprts to report helth nd exposure-relted concerns (Tble 2, Figure 2). Both ctive nd reserve component members were more likely to report exposure concerns three to six months fter, compred to the time of return from deployment (Figure 3). At the time of return from deployment, soldiers serving in the ctive component were the most likely of ll deployers to receive mentl helth referrls; however, three to six months fter returning, ctive component soldiers were less likely thn Army Reservists to receive mentl helth referrls (Tble 2). Finlly, during the pst three yers, reserve component members hve been more likely thn ctive to report exposure concerns on postdeployment ssessments nd ressessments (Figure 3). Tble 1. Deployment-relted helth ssessment forms, by month, U.S. Armed Forces, August 29-July 21 Pre-deployment ssessment DD2795 Post-deployment ssessment DD2796 Post-deployment ressessment DD29 No. % No. % No. % Totl 417, , , August 39, , , September 3, , , October 36, , ,87 8. November 32, , , December 31, , , Jnury 55, , , Februry 31, , , Mrch 32, , , April 32, , , My 37, , , June 29, , ,66 8. July 28, , , Figure 2. Proportion of deployment helth ssessment forms with self-ssessed helth sttus s fir or poor, U.S. Armed Forces, August 29-July Figure 1. Totl deployment helth ssessment nd ressessment forms, by month, U.S. Armed Forces, Jnury 23-July 21 Number of completed forms 12, 11, 1, 9, 8, 7, 6, 5, 4, 3, 2, 1, Post-deployment ressessment (DD 29) Post-deployment ssessment (DD 2796) Pre-deployment ssessment (DD 2795) Percent August September October Post-deployment ressessment (DD 29) Post-deployment ssessment (DD 2796) Pre-deployment ssessment (DD 2795) November December Jnury Februry Mrch April My June July Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July

23 JULY Tble 2. Percentge of service members who endorsed selected questions/received referrls on helth ssessment forms, U.S. Armed Forces, August 29-July 21 Helth concerns, not wound or injury Helth worse now thn before deployed n n n n n Exposure concerns n n n n n PTSD symptoms (2 or more) n n n n n Depression symptoms (ny) n n n n n Referrl indicted by provider (ny) Mentl helth referrl indicted Medicl visit following referrl b Army Nvy Air Force Mrine Corps All service members n= 63,126 n= 86,911 Includes behviorl helth, combt stress nd substnce buse referrls. b Record of inptient or outptient visit within 6 months fter referrl. Army Nvy Air Force Mrine Corps All service members Predeplodeplodeplodeplodeplodeplodeplodeplodeplodeploy Post- Pre- Post- Pre- Post- Pre- Post- Pre- Post- Ressess Ressess Ressess Ressess Ressess DD29 DD29 DD29 DD29 DD29 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 n= n= n= n= n= n= n= n= n= n= n= n= n= n= n= Active component 154, , ,182 19,25 14,968 12,66 59,274 54,321 5,822 32,86 28,711 32, ,65 252,274 28,852 % % % % % % % % % % % % % % % Generl helth "fir" or "poor" Predeploy DD2795 Postdeploy DD2796 Predeplodeplodeplodeplodeplodeplodeplodeploy Post- Pre- Post- Pre- Post- Pre- Post- Ressess Ressess Ressess Ressess DD29 DD29 DD29 DD29 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 n= 6,78 n= 5,176 n= 4,27 n= 5,474 n= 16,14 n= 15,196 n= 16,337 n= 3,346 n= 4,299 n= 7,385 n= 87,788 n= 11,433 Reserve component % % % % % % % % % % % % % % % Generl helth "fir" or "poor" Helth concerns, not wound or injury Helth worse now thn before deployed n n n n n Exposure concerns n n n n n PTSD symptoms (2 or more) n n n n n Depression symptoms (ny) n n n n n Referrl indicted by provider (ny) Mentl helth referrl indicted Medicl visit following referrl b Ressess DD29 n= 89,94 Figure 3. Proportion of service members who endorsed exposure concerns on post-deployment helth ssessments, U.S. Armed Forces, Jnury 24-July 21 Percent Reserve, post-deployment ressessment (DD29) Reserve, post-deployment ssessment (DD2796) Active, post-deployment ressessment (DD29) Active, post-deployment ssessment (DD2796) Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July

24 24 VOL. 17 / NO. 7 Sentinel reportble events mong service members nd beneficiries t U.S. Army medicl fcilities, cumultive numbers for clendr yers through 3 June 29 nd 3 June 21 Number of Food-borne Vccine preventble Reporting loctions reports ll Cmpylobcter events b Slmonell Shigell Heptitis A Heptitis B Vricell c NORTHERN Aberdeen Proving Ground, MD Fort Belvoir, VA Fort Brgg, NC Fort Dix, NJ Fort Drum, NY Fort Eustis, VA Fort George G Mede, MD Fort Knox, KY Fort Lee, VA Fort Monmouth, NJ Wlter Reed AMC, DC West Point Militry Reservtion, NY SOUTHERN Fort Benning, GA Fort Cmpbell, KY Fort Gordon, GA Fort Hood, TX 976 1, Fort Jckson, SC Fort Polk, LA Fort Rucker, AL Fort Sm Houston, TX Fort Sill, OK Fort Stewrt, GA WESTERN Fort Bliss, TX Fort Crson, CO Fort Huchuc, AZ Fort Levenworth, KS Fort Leonrd Wood, MO Fort Lewis, WA Fort Riley, KS Fort Winwright, AK NTC nd Fort Irwin, CA PACIFIC Hwii Jpn Kore EUROPEAN Heidelberg Lndstuhl Bvri CENTCOM LOCATIONS CENTCOM Totl 8,278 8, Army Events reported by July 8, 29 nd 21 b Sixty-seven medicl events/conditions specifi ed by Tri-Service Reportble Events Guidelines nd Cse Defi nitions, June 29. c Service member cses only. Note: Completeness nd timeliness of reporting vry by fcility.

25 JULY Sentinel reportble events mong service members nd beneficiries t U.S. Army medicl fcilities, cumultive numbers for clendr yers through 3 June 29 nd 3 June 21 Arthropod-borne Sexully trnsmitted Environmentl Trvel ssocited Reporting loction Lyme disese Mlri Chlmydi Gonorrhe Syphilis Cold c Het c Q Fever Tuberculosis NORTHERN Aberdeen Proving Ground, MD Fort Belvoir, VA Fort Brgg, NC Fort Dix, NJ Fort Drum, NY Fort Eustis, VA Fort George G Mede, MD Fort Knox, KY Fort Lee, VA Fort Monmouth, NJ Wlter Reed AMC, DC West Point Militry Reservtion, NY SOUTHERN Fort Benning, GA Fort Cmpbell, KY Fort Gordon, GA Fort Hood, TX Fort Jckson, SC Fort Polk, LA Fort Rucker, AL Fort Sm Houston, TX Fort Sill, OK Fort Stewrt, GA WESTERN Fort Bliss, TX Fort Crson, CO Fort Huchuc, AZ Fort Levenworth, KS Fort Leonrd Wood, MO Fort Lewis, WA Fort Riley, KS Fort Winwright, AK NTC nd Fort Irwin, CA PACIFIC Hwii Jpn Kore EUROPEAN Heidelberg Lndstuhl Bvri CENTCOM LOCATIONS CENTCOM Totl ,765 6, Army

26 26 VOL. 17 / NO. 7 Sentinel reportble events mong service members nd beneficiries t U.S. Nvy medicl fcilities, cumultive numbers for clendr yers through 3 June 29 nd 3 June 21 Reporting loctions Number of Food-borne Vccine preventble reports ll Cmpylobcter events b Slmonell Shigell Heptitis A Heptitis B Vricell c NATIONAL CAPITOL AREA NNMC Bethesd, MD NHC Annpolis, MD NHC Ptuxent River, MD NHC Quntico, VA NAVY MEDICINE EAST NH Beufort, SC NH Cmp Lejeune, NC NH Chrleston, SC NH Cherry Point, NC NH Corpus Christi, TX NHC Gret Lkes, IL NH Guntnmo By, Cub NH Jcksonville, FL NH Nples, Itly NHC New Englnd, RI NH Penscol, FL NMC Portsmouth, VA NH Rot, Spin NH Sigonell, Itly NAVY MEDICINE WEST NH Bremerton, WA NH Cmp Pendleton, CA NH Gum-Agn, Gum NHC Hwii, HI NH Lemoore, CA NH Ok Hrbor, WA NH Okinw, Jpn NMC Sn Diego, CA NH Twentynine Plms, CA NH Yokosuk, Jpn NAVAL SHIPS COMNAVAIRLANT/CINCLANTFLEET COMNAVSURFPAC/CINCPACFLEET OTHER LOCATIONS Other 2,18 1, Totl 4,128 3, Nvy Events reported by July 8, 21 b Sixty-seven medicl events/conditions specifi ed by Tri-Service Reportble Events Guidelines nd Cse Defi nitions, June 29. c Service member cses only. Note: Completeness nd timeliness of reporting vry by fcility.

27 JULY Sentinel reportble events mong service members nd beneficiries t U.S. Nvy medicl fcilities, cumultive numbers for clendr yers through 3 June 29 nd 3 June 21 Reporting loction Arthropod-borne Sexully trnsmitted Environmentl Trvel ssocited Lyme Mlri Chlmydi Gonorrhe Syphilis Cold disese c Het c Q Fever Tuberculosis NATIONAL CAPITOL AREA NNMC Bethesd, MD NHC Annpolis, MD NHC Ptuxent River, MD NHC Quntico, VA NAVY MEDICINE EAST NH Beufort, SC NH Cmp Lejeune, NC NH Chrleston, SC NH Cherry Point, NC NH Corpus Christi, TX NHC Gret Lkes, IL NH Guntnmo By, Cub NH Jcksonville, FL NH Nples, Itly NHC New Englnd, RI NH Penscol, FL NMC Portsmouth, VA NH Rot, Spin NH Sigonell, Itly NAVY MEDICINE WEST NH Bremerton, WA NH Cmp Pendleton, CA NH Gum-Agn, Gum NHC Hwii, HI NH Lemoore, CA NH Ok Hrbor, WA NH Okinw, Jpn NMC Sn Diego, CA NH Twentynine Plms, CA NH Yokosuk, Jpn NAVAL SHIPS COMNAVAIRLANT/CINCLANTFLEET COMNAVSURFPAC/CINCPACFLEET OTHER LOCATIONS Other ,857 1, Totl ,454 3, Nvy

28 28 VOL. 17 / NO. 7 Sentinel reportble events mong service members nd beneficiries t U.S. Air Force medicl fcilities, cumultive numbers for clendr yers through 3 June 29 nd 3 June 21 Reporting loctions Air Force Number of Food-borne Vccine preventble reports ll Cmpylobcter c events b Slmonell Shigell Heptitis A Heptitis B Vricell Air Combt Cmd Air Eduction & Trining Cmd Air Force Dist. of Wshington Air Force Mteriel Cmd Air Force Specil Ops Cmd Air Force Spce Cmd Air Mobility Cmd Pcifi c Air Forces U.S. Air Forces in Europe U.S. Air Force Acdemy Other Totl 3,341 3, Arthropod-borne Sexully trnsmitted Environmentl Trvel ssocited Reporting loction Lyme disese Mlri Chlmydi Gonorrhe Syphilis Cold c Het c Q Fever Tuberculosis Air Combt Cmd Air Eduction & Trining Cmd Air Force Dist. of Wshington Air Force Mteriel Cmd Air Force Specil Ops Cmd Air Force Spce Cmd Air Mobility Cmd Pcifi c Air Forces U.S. Air Forces in Europe U.S. Air Force Acdemy Other Totl ,863 2, Events reported by July 8, 21 b Sixty-seven medicl events/conditions specifi ed by Tri-Service Reportble Events Guidelines nd Cse Defi nitions, June 29. c Service member cses only. Note: Completeness nd timeliness of reporting vry by fcility.