Injury Prevention Training: Back in Business

Musculoskeletal Injuries (MSKI) are accountable for up to 25 million limited working days annually (Heagerty et al. 2018), with a global financial cost in excess of $3 billion (Sharma et al. 2018). With renewed interest in this issue together with recent injury prevention articles as seen in The Cove, it has been well documented that the strain on the medical chain, lost training days due to temporary downgrade and risk of subsequent medical discharge presents an on-going challenge to organisational efficiency, operational capability and represents a back-breaking financial burden.

MSKI’s have been pin-pointed as the leading cause (61% or 1200 per year) of medical discharge from the Armed Forces and represent an estimated annual cost of £86 million to the British Army and predicted £1.02 billion over fifteen years (Heagerty et al. 2018). Like an ongoing back pain, these global findings can be viewed as some fairly ‘painful’ statistics, therefore the heavy burden of MSKI’s within the Armed Forces underscores the importance of injury prevention.

Injury

In medical diagnosis, pain is regarded as a symptom of an underlying condition. As potentially career and life changing events in the physical domain and from a psychological perspective, the moral responsibility to identify mechanisms of mitigation and reduce injuries is iron-strong. In order to address this underlying issue, the intent of this training article is to better educate and arm soldier athletes with knowledge about correct and current training techniques, preventative practices and early injury management. As a female GCC soldier and PTI, by improving our health education and by task oriented conditioning, the articles aim is to better protect and improve soldier athletes’ physical conditioning in preparation for future events and deployments, and to improve longevity of service within the Armed Forces.

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The aim of Project THOR is to increase readiness and deployability across the Army by reducing the incidence and effects of MSKI. Therefore in support of the British Army’s new physical training programme, this training article specifically concerns injury education and prevention and has been written to stimulate awareness and healthy discussion on this topic.

Having recently recovered from a hard-hitting injury myself, throughout my rehabilitation process, I sought to better understand my own physiology and investigate the risk factors, the leading injury causations and effective injury prevention measures in order to arm myself and other soldier athletes with stronger physiological defences - the literature I uncovered on the topic in question was profound.

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PTI Thompson: "We cannot choose our external circumstances, but we as soldier athletes can always choose how we respond to them."

Physical Demands of the Soldier Athlete

The occupational physical demands imposed on soldier athletes require abilities across the entire spectrum of physical fitness. Dependent upon the role, specific training, mission and operational demands, the degree of reliance on either aerobic, strength and power fitness elements varies. The demands differ profoundly from civilian athletes, where physical exertion is defined, planned and conducted in well-controlled environments with predictable recovery periods.

Nidl et al., (2017) found that 'external loads carried by soldiers during combat operations have increased linearly over time.’ Proficiency at heavy load carriage is considered one of the major physical abilities that GCC (Ground Close Combat) soldiers must successfully develop to demonstrate competency as a dismounted GCC soldier. In addition to this, muscular strength, endurance and conditioning along with good cardio-vascular fitness are considered vital armour of the physical robustness required for a career as a professional infantry soldier. The external load a dismounted soldier is required to carry, tolerate, and be mobile under is a standard dictated by mission requirements and is correctly not scaled with respect to sex, body size, muscle mass, strength, or fitness level.

Using GCC reservists as example, we’re aware that not all physical jobs require physically demanding activity on a daily basis, therefore if physical training falls down to a ‘low priority’ this will result in deconditioning leading to poor job performance and a higher risk of injury. To prevent this, soldier athletes must follow an effective physical training programme in their own time. This enables the individual to maintain their fitness level such as they can continue to perform critical job tasks in a safe and efficient manner over time. Train like a soldier athlete by reading this training article.

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PTI Thompson: “It does not matter what injury you bare but how you bear it. Three months from now you’ll be in a completely different space physically and mentally.”

MSKI’s

Musculoskeletal injuries are classed as stress fractures, osteoarthritis, sprains and strains in specific anatomic structures such as within the groin, knee or ankle. Many recent studies on MSKI’s have been conducted within the Armed Forces, with the majority taking place in the controlled environment of basic training; held at ATR’s and the British Infantry Training Centre Catterick (ITC). The transition from civilian to combat-ready infanteer requires soldier athletes to complete a minimum of 26 weeks of military training at ITC. ITC delivers the Combat Infantryman’s course (CIC), a combined phase 1 & 2 programme up to 4,000 recruits per year during which soldier athletes are susceptible to sustaining an MSKI (Sharma et al. 2018). In response to the analysis of MSKI collated over 4 consecutive training years, an integrated injury prevention strategy – Project OMEGA was commissioned by ITC. ITC proactively undertook initiatives aimed at identifying injury risk factors which provided the rationale for the introduction of subsequent injury prevention strategies.

Project OMEGA

Three recent trials with RSME Gp, 2 Mercian and ITC Catterick have highlighted the benefits of the new Army Physical Training System (APTS) and support the embedded ERI approach.  A survey of training injuries to recruits between 2012 and 2016 revealed a third of those on the Combat Infantryman’s course had suffered musculoskeletal problems.

Project OMEGA involved a trial 12-month intervention at ITC Catterick, in which 1,450 recruits took part and the medical discharge rate was nearly half of that experienced between 2012 and 2016. The increase of musculoskeletal injuries dropped from 35 to 21% of trainees. The intervention resulted in a 70% reduction in MSKI and commensurate improvements to downgrades, retention and physical attainment. At the RSME Gp, a version of the APTS resulted in an 84% decrease in injuries (Heagerty et al. 2018). The 2 MERCIAN study cut MSKI and increased the combat readiness of the battalion. The OMEGA programme included leadership support, integrated culture, planning of training, education and health literacy and injury surveillance.

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Injury Causations

The majority of studies found that the incidence of injury in recruits and Service Personnel was higher for women compared to men, with 45% to 57% of women and 27% to 46% of men, respectfully sustaining an MSKI during initial military training (Almeida et al. 1999; Bell et al. 2008). It was found that Service women continue to experience more injuries than men both in simulated military operations (10% of men and 23% of women) (Darakjy et al. 2003) and during active deployment (22% of men and 39% of women (Roy et al. 2015). Physical training, mechanical work, and airborne activity were ranked as the leading causes of injury for both sexes, whilst tabbing and marching drills produced the most injuries in women (Knapik et al. 2007).

 

Common Injuries Sustained

Studies found that women reported more lower extremity injuries and men reporting more back injuries (Billings 2004; Roy et al. 2015). In addition to this, in a study investigating lower extremity injuries, women were found to experience predominantly patellofemoral pain syndrome (known as runners knee), whereas men suffered mostly iliotibial band syndrome (Almeida et al. 1999). Research with soldiers and athletes have shown that specific movement patterns commonly seen in women can place them at greater risk for patellofemoral pain (Myer et at. 2014). Sex differences in injury risk include muscle strength, Q angle in the knee, smaller notch size in the femur, movement patterns, joint laxity, and ligament size (Hewett et al. 2006). Atomical differences in bone structure (narrower long bones with thinner cortices) between men and women may also lead to higher incidence of stress fractures seen in female Army and Marine recruits (Gam et al. 2005).

Knapik et al. (2005) found that interventions that reduced the running mileage in training decreased the number of injuries in female soldiers by over 10% and stress fractures by 54% with no reduction in running speed. In addition to this, Lappe et al. (2008) found that the provision of calcium and vitamin D supplements was also shown to be effective in reducing the number of stress fractures in women Naval recruits by 20%.

PTI Thompson: “Do not let circumstances control you, you change your circumstances. A strong, healthy and resilient body gives us a sense of achievement and has a wide-reaching effects on our life.”

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Injury Risk Factors

Investigation of the risk factors is a vital component of injury prevention in which may be subdivided as either intrinsic or extrinsic.

Aerobic Fitness Level

Although the then physical training programme was reportedly structured and progressive, Gemmell (2002) found that females going through Basic Training at an ATR were at greater risk of injury because of differences in muscle physiology, bone architecture, and body composition. It’s important to highlight that analysis of injury risk factors showed that when the effect of aerobic fitness is at the same level, gender ceases to be to be a risk factor; the risk of injury is similar among men and women of the same absolute level of aerobic fitness (as defined by maximal rate of oxygen consumption per unit body mass) (Jones et al. 1999; Bell et al. 2000).

Individuals with a lower level of aerobic fitness regardless of gender work at a higher % HRR than the fitter individuals with a high level of aerobic fitness in the same platoon. Individuals operating at a high % of HRR compared to individuals operating at a low % HRR experienced a greater cardiovascular strain which resulted in more rapid fatigue. Knapik et al. (2002) suggested fatigue reduces the ability of the muscles to absorb eccentric force and may cause prolonged eccentric lengthening of the muscle which may result in more exercise induced muscle damage, increases in muscle strain injury, or transfer of forces to other body structures (e.g, ligaments, bones) and subsequent overuse or traumatic injury in these structures. Greater cardiovascular strain and fatigue therefore partially explains the higher injury rates experienced by recruits with low aerobic fitness, irrespective of gender.

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Equipment

Many Service Personnel are routinely required to lift or carry loads in the 40kg range (Sharp et al. 1994; Gebhardt et al. 2011) reflected in the old PES physical employment standards (PES) 40kg bag lift, and personal protective equipment can double this weight (Roy et al. 2015). Poorly fitting equipment can significantly contribute to the mental and physical demands of a task and may increase the risk of injury (Murphy et al. 2001; Knapik et al. 2004). The US Army have redesigned body armour to better fit women by accommodating narrower shoulders, shorter torsos and breast tissue. These modifications have resulted in an increased range of movement in the arms and an improved ability to seat a weapon while firing (Leipold 2012).

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Age

The decline in physical capabilities seen with aging has implications for strenuous job performance. Studies have shown that VO2 Max decreases at a rate of approximately 1% per year in healthy men and women, beginning at around 30 years of age (Pimentel et al. 2003). Lindle et al (1997) examined age and sex differences in muscle strength and found both men and women lose strength at a similar rate (8 – 10% per decade), starting at around 40 years. This normal age-related decline in physical capacities may be more problematic for women than men as the average woman will have to perform at a higher level of submaximal fitness to sustain such a load. Interestingly, the paradox is that this higher workload can itself provide the training stimulus to maintain a woman’s fitness level.

Physical training to maintain age fitness can reduce age-related declines in aerobic power by 40% in both men and women as well as prevent the loss of muscle mass and strength with aging in both men and women (Leenders et al. 2013). Is therefore necessary that careful selection procedures exist and specific physical training for demanding tasks is needed to help both men and women perform safely and efficiently.

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Higher Body Fat Percentage & Low Levels of Physical Fitness

A reduced body fat percentage was associated with an increase in cardiorespiratory fitness as opposed to increased body fat which was associated with increased risk of prolonged sick leave. Extra weight on joints combined with low levels of overall physical fitness are also a significant risk factor for the subsequent development of overuse musculoskeletal injuries (Lappe et al. 2001).

PTI Thompson: “We must also eat a nutrient rich healthy diet to have a good performance in training and help the body recover after physical exertion. Food is fundamental for every training session, physical tasking and exercise enabling us to perform to the best of our abilities."

Biomechanical Profile

Foot pressure distribution through walking gait has also been shown to have a significant impact on developing an MSKI. A study revealed 232 recruits out of 562 sustained at least one MSKI during CIC, equating to an injury rate of 41.28% (Sharma et al. 2018). The MSKI group had significantly higher peak heel pressure with greater pronator movements (increased speed of heel rotation), which was indicative of a more rigorous heel-strike during walking. The velocity of these movements which occurred significantly faster than in the injury free group suggests uncontrolled/ reduced control of movement patterning. Poor control and/or inappropriate timing of pronation is associated with compromised muscle activity whilst altered ankle-foot mechanics may in turn further compromise the capacity and efficiency of the kinetic chain to absorb and dissipate ground forces and therefore the capacity to sustain loads. Compromised load acceptance and transference can result in the overloading of joints, muscles, tendons and ligaments which in turn limits tissues tolerance ultimately influencing MSK health.

In relation to Medial Tibial Stress Syndrome (MTSS), biomechanical, physiological and lifestyle factors have all been recognised as key contributing factors to the development of MTSS in British military recruits as well as the active population (Sharma et al. 2018). Higher medial pressure, central heel strike and general over pronation during walking and running are all potential risk factors for developing MTSS.

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Smoking

Smoking has been firmly associated with delaying and impairing tissue repair (Sharma et al. 2018). Teyhen et al (2015) reported that a history of previous injury, smoking and lower physical output tests results were associated with an increased risk of future injury in US Army Rangers. These intrinsic risks combined with established external factors such as abrupt increases in high impact physical activity significantly contributes to the development of training injuries. Smoking has been regularly associated with both musculoskeletal pain and impaired healing times as it affects microcirculatory function, rate of hypoperfusion and can impair microcirculation in tissues affected by both acute trauma or progressive overload (Sharma, 2013; Siafaka, 2007). Smoking causes the release of reactive oxygenated species and oxygen free radicals which delay tissue healing and impair the capacity to tolerate and respond to the stresses of physical loading (Sharma et al. 2018)

Risk Factors of a MSK Injury

Physiological Risk Factors Biomechanical Risk Factors Socio-demographic Risk Factors Anthropometric Risk Factors
Muscular endurance and strength/control Previous injury Deprive area Body composition
Run time Bone geometry/ architecture Smoking Age
Cardiovascular fitness Flexibility/muscle balance/altered neuromuscular control Contraceptive use Body fat percentage
Military fitness test Gait pattern profile Dietary intake/ nutrition Ethnicity
Prior exercise level Alcohol consumption Gender

 

Injury Prevention Strategies

The 2016 Interim Health Reports states that single sex physical training, particularly during initial training, can reduce the rate of severe overuse injuries. Effective leadership and awareness of training errors are essential elements of all injury prevention strategies. Appropriately trained personnel are required to deliver injury prevention strategies to promote adherence, effect change and maximise benefits to injury prevention. The introduction of health surveillance, particularly during training, is expected to contribute to reducing medical discharges.

The prevention of musculoskeletal injuries (MSKI’s) is central to efforts to improve the readiness, performance and long-term health of soldier athletes. Existing intervention strategies relate to additional or modified physical activity (volume), conditioning, educational programmes and footwear modifications, bracing and leadership/supervision/awareness (Flanagan et al. 2018). Knapik et al (2005) showed that by following a physical readiness training programme which de-emphasizes running and provides a greater variety of exercises compared to traditional training programmes, recruits had a higher success rate on the Army physical fitness test and a decreased injury rate.

Knapik et al. (2006) found that prior training for less fit recruits before they commenced basic training (in order to raise their aerobic fitness levels) was very successful. In addition to this, Blacker et al. (2009) proposed moderating the cardiovascular strain experienced by recruits in basic training; benefits would involve improved fitness and reduced prevalence of injury. Finally, Blacker et al. (2009) also suggests separating recruits into platoons by their aerobic fitness level upon beginning basic training.

Hewett et al. (2006) have shown that simple proprioceptive exercises to improve lumbar and hip control by women athletes are extremely effective as part of an injury prevention programme. Roberta (2013) also suggested that correcting poor movement patterns can provide some protection against injuries in physically demanding occupations. Pre-employment functional movement assessments may hold promise for reducing injuries in the workplace.

Several researchers have concluded that sex is an independent factor in predicting injury rates (George et al. 2012; Strowbridge 2005), but when corrected for fitness this relationship no longer holds true (Bell et al. 2000; Blacker et al. 2008; Knapik et al. 2011). Many studies have shown that women’s physical performance capability can be significantly bolstered by optimised physical training programmes (Nindl et al. 2015; Jones et al. 2016). With regards to fitness level, female soldiers, on average, have previously demonstrated less absolute strength, higher fatigability during repetitive tasks and less aerobic capacity than male soldiers. However after participating in resistance programmes, women have demonstrated proportional improvements in strength equal to that of men (Cureton et al. 1988; Hunter et al. 1985; Gettman et al. 1981).

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Injury Prevention Exercises

Flexibility and Mobility Exercises

The following is an example of flexibility and mobility exercises that can be used to aid post-exercise recovery. Each exercise should be held for 30-40 seconds at a mild to moderate stretch pain free.

Rotation stretch in lying (lower back, glutes): Lie on your back. Using your hand, take your opposite leg across your body, keeping your other arm straight on the ground as demonstrated. Perform on each side.

Fig four stretch (glutes): Lie on your back. Bend knees with feet on the floor. Cross one leg over the thigh of the other leg. Grasp the back of the thigh of the lower leg with both hands. Pull leg towards torso until you feel a stretch in the buttock. Repeat with opposite leg.

Lower back extension mobility: Lie on your stomach. Gently prop yourself up onto your forearms, keeping your back relaxed. Hold for 2 seconds, then slowly lower yourself down flat. Repeat 10 times pain-free.

Lower back extension mobility – advanced: Lie on your stomach with your hands in the press up position as demonstrated. Gently straighten your elbows, letting your back fall into an arch. Keep your back relaxed. Straighten your elbows as far as possible pain-free. Hold for 2 seconds, repeat 10 times.

Lower back flexion and extension mobility: Start on the floor on your hands and knees. Arch your back up towards the ceiling until you feel a stretch in your lower back. Lower your back down, moving your stomach towards the floor. Continue arching up and lowering down for 10 repetitions.

Cat stretch (shoulders, arms and lattisimus dorsi): Start on the floor on your hands and knees. Sit back onto your heels stretching your arms out in front. To increase the stretch down the side of the body, move your hands to the opposite side to where you want to stretch.

Hip flexor stretch: Begin in the lunge position, with the leg to be stretched behind you. Keeping your back straight and buttock muscles contracted, gently lunge forward until you feel a stretch in the front of your hip. Repeat on the other side.

Groin stretch: In a seated position hold the soles of your feet together by the hand with the elbows resting against the knees. Lean forward bending from the hips and gently press the knees down with the elbows until a stretch is felt in the groin area.

Quadriceps stretch: Use an object for balance. Take your heel towards your bottom, keeping your knees together and your back straight until you feel a stretch in the front of your thigh. Repeat on the other side.

Hamstring Stretch: Place your foot flat on a raised surface. Keep your back straight and your leg straight. Lean forward at your hips until you feel a stretch in the back of your thigh. Repeat on the other side.

Calf stretch (gastrocnemius): Begin this calf stretch with your hands against the wall and your leg to be stretched behind you. Keep your heel down, knee straight and feet pointing forwards. Gently lunge forwards until you feel a stretch in the back of your calf or knee. Repeat on the other side.

Calf stretch (soleus): Begin this calf stretch with your hands against the wall and your leg to be stretched behind you. Keeping the feel on the floor, bend your back knee and transfer the weight onto your back foot. Keep bending the back knee until you feel a stretch in the lower half of the back leg. Make sure that the back heel does not lift off the floor. Repeat on the other side.

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Self-Management of Minor Injuries

The vital strong points of effective self management are:

  • Preventative stretching
  • Use a foam roller
  • Preventative and protective taping
  • Early us of POLICE (Protection, Optimum Loading, Ice, Compression, Elevation) post injury
  • Maintaining proper hydration
  • Maintaining proper diet and nutrition

Common Injuries that can occur when training

  • “Runners Knee” – Iliotibial Band Syndrome
  • “Bergen Hip” – Hip Flexor tightness/ overuse
  • Anterior Shin Pain/ Stress Reaction or Fracture
  • Ankle Inversion
  • Patella Tendinopathy
  • Achilles Tendinopathy
  • Shoulder Pain
  • Back pain – Both Lumbar and Thoracic

Iliotibial Band Syndrome

  • Pain on the outside of the knee or hip that gets worse daily/ gradually increases.
  • Associated with repeated mid range movement.
  • Hip flexor/ quadriceps dominance.
  • Weak gluteus medius/ hip adductors.
  • Treatment: glute strength, stretching & foam roller use.

Bergen Hip

  • Caused by bent forward posture associated with load carrying and hill climbing.
  • Leads to over-use and pain in the hip flexors.
  • Weak gluteus maximus/ hip adductors.
  • Preventative measures: stretching/ strengthening.
  • Treatment: stretching/ foam roller use.

Anterior Shin Pain/ Stress reaction or stress fracture

  • Repeated load/ impact.
  • Over-use injury.
  • Tender to the touch.
  • Preventative measures: strengthening and stretching.
  • Treatment: ice it, rest it (if able), strap it up, stretching.

Ankle Sprain

  • Associated with undulating terrain.
  • Prevention taping/ bracing.
  • Shaved from the mid-calf downwards to aid taping.
  • Boot choice – some boots cater to certain feet better.
  • Preventative measures: proprioception/ balance training.
  • Treatment: POLICE, strapping, bracing.

Patella Tendinopathy

  • Gradual onset
  • Preventative measures: eccentric training and stretching.
  • POLICE, eccentric loading plan – speak to your MO/rehab team for advice.

Achilles Tendinopathy

  • Overuse injury.
  • Generally progressive onset.
  • Preventative measures: strength work, preventative taping.
  • POLICE, offload taping, eccentric loading – speak to your MO/ rehab team for advice.

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Foam Roller Stretching

Foam rolling is a self-myofascial release technique that is used by athletes and physical therapists to inhibit overactive muscles. This form of stretching utilises the concept of autogenic inhibition to improve soft tissue extensibility, thus relaxing the muscle and allowing the activation of the antagonist muscle.

In layman’s terms it relaxes tight muscles. The equipment that is used for foam rolling usually consists of a foam cylinder of various sizes. Foam rollers up to 36 inches in length are produced for rolling over certain muscles in the back.

Soldier athletes who are new to foam rolling, or those who have particularly tight muscles or severe trigger points should start with a softer foam roller. Often the colour can help to distinguish the density. White rolls are typically softer, while blue and black rolls tend to be harder.

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When is it best to use a foam roller?

Foam rolling before you stretch, workout, run or your CrossFit WOD is recommended. Taking a few minutes and foam rolling to help loosen the muscles and break up the adhesions before you perform can actually help prevent injury.

Post workout is another recommended time to foam roll. This will help with blood flow to the muscles and speed up the recovery time.

Foam Roller Exercises

Foam rolling the glutes

When foam rolling the glutes shift your body over so the pressure is put through the bulk of the muscle. Have the foot of the side you are rolling up onto the thigh of the opposite leg. Start from the ‘sitting bone’ area of the glute and roll up to the lower back. Repeat for 30 seconds and change sides.

Foam rolling the hamstrings

Start by rolling on both hamstrings, when ready to cross the legs and focus all the weight through one of the legs. Roll from the back of the knee up your ‘sitting bone’. Repeat for 30 seconds and change legs.

Foam rolling the calf

Start by rolling on both calves for 30 seconds to get yourself comfortable in the position. Then cross your lower legs so the pressure is put through one calf. Continue the rolling for a further 30 seconds.

Summary

To conclude, Project THOR (Training for Human Optimisation for Readiness) led by the RAPTC, will significantly change the way the Armed Forces conduct physical training. The THOR programme aims to reduce the incidents and impact of MSKI across the Army thereby optimising deployability, swiftly returning to duty those suffering MSKI, reducing costs and sustaining the Army’s reputation for, and delivery of, duty of care (Soldier Magazine, May 2018).

PTI Thompson: "Our training teaches us that we all start from zero, and it is through the accumulation of small, seemingly insignificant steps (and sometimes back and side steps), that we progress towards our goals and inch away from our starting point of zero. My individual training has taught me to work hard, not give up, and dream bigger than what I would dare to dream. After a rough few months of injury, it feels good to back in business - time to work."

You can find more training advice and soldier athlete workouts on Twitter and Instagram.

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(Note: All information within this training article is publically available.)

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