Where We Stand on Injury Prevention
MOPs and MOEs is pleased to announce the addition of John Romanello to the coaching team. A Physical Therapist by trade, John has spent the entirety of his career working as an embedded human performance PT within special operations and conventional military units. He has vast experience in assessing and treating sports-based injuries with a focus on return to military demands. To see some of our initial Injury Prevention offerings, click here.
Is injury prevention truly possible or just a myth that briefs well? For me, I have mixed feelings. I hope that the treatments I prescribe make an athlete more resilient for the future, but I never think they’re a surefire way of preventing injuries. Now, I’ve only been treating athletes for three years, so this article is not a cynical diatribe. Rather, it’s a conversation combining research, my lessons learned, and what I hope to impart to the young athlete. More specifically, I believe a well-balanced lifestyle, proper load management, and proper training are the key elements in POTENTIALLY reducing injury risk.
Well-Balanced Lifestyle
With the Army’s push for holistic health, you’ve probably heard this time and time again, but these truly are the foundation.
Nutrition and Weight Management
In 2023, a group of researchers investigated tactical populations to find the relationship between BMI and musculoskeletal injury occurrences (Sergi, et al., 2022). From the systematic review, several interesting findings include:
Firefighters with a BMI >30 kg/m were 5.2x more likely to sustain a musculoskeletal injury over a 9-month period compared to those with a BMI between 18.5-24.9 kg/m. However, there were no increases in the odds of injury for those who were overweight.
Compared to Soldiers with a normal BMI (18.5-24.9 kg/m 2 ), Soldiers who were underweight, overweight, or obese had 7%, 11%, and 33% increased risks of injury.
Another study found no significant differences in injury incidence between male and female Army Soldiers who just completed basic training and advanced individual training based on BMI.
The systematic review found nine studies to show increasing BMI was associated with injury, three studies showing no differences between injury differences and BMI, and one study indicating that being overweight or obese may even protect against certain injuries!
What’s the consensus? Despite the research wavering, I would recommend getting on a proper nutrition plan. More importantly, a well-balanced diet rich in vitamins and minerals can be key to ensuring you can recover and rebuild post-workouts. One can focus solely on body composition but neglecting to refuel may pose a risk.
Sleep
Oddly enough, the support for a relationship between sleep and injury is small predominantly due to poor quality studies. Nonetheless, a systematic review from Lisman, et al. (2022) investigated tactical populations and found some interesting notes:
US Special Operations Forces Soldiers who slept <5 hours a night were twice as likely to report an injury than those who slept 8 or more hours.
Soldiers with a diagnosed sleep disorder at the time of encounter for low back pain were 50% more likely to develop chronic low back pain.
Soldiers who reported poor quality sleep (≥ 7 on the Pittsburgh Sleep Quality Index) were more than twice as likely to suffer from injury compared to those who reported good quality sleep (<7 on PSQI).
More research is needed to determine whether sleep quantity or quality influences injury rates in military personnel. However, I have rarely, if ever, seen someone avoid injuries and crush it in the gym with <5 hours of sleep per night.
My take: get your 8 hours.
Load Management
One of the main contributors to overuse injuries in my clinic is poor load management. Below are some guidelines from the research (Dijksma, et al., 2021) on proper load management:
Find a sustainable moderate training load. Lower monthly training loads have been associated with an increased risk of injury than consistent moderate loading. This is especially pertinent during periods of block leave or prolonged mission lulls.
Understand the workload demands of the job and coordinate training appropriately: weeks in the field may just look like a couple of runs and some plyometric training due to the accumulated stress. More on this to come in a future article!
Routine monitoring of athletes: some injuries take up to 28 days to manifest after the initial biological onset. Leader touchpoints are critical to ensure athletes don’t continue to train at the same intensity with an injury.
Optimal load carriage (rucking) occurs once every 10-14 days when combined with progressive resistance and aerobic training (Orr, et al., 2021).
The overarching theme with load management is autoregulation, or the individual ability to account for fitness, fatigue, and stressors. Whether it’s RPE or HRV, use something that allows you to incorporate your daily stressors into your workouts to identify changes in patterns. Additionally, stay consistent with a program and keep changes small but progressive. Fitness is never built in a day, but the mindset that it is can certainly pull you off the right track of progression.
Proper Training
As a PT, I am all about finding new things to help reduce injury risk. However, what does the research have to say about specific programs to reduce injury risk? A systematic review (Dijksma, et al, 2020) looked deeper into the issue:
There were no associations between programs and the reduction of injuries for core stability training and movement enhancement warm-ups
There was a decreased risk of injury for anterior knee pain prevention programs and gait retraining programs; however, both studies had a high risk of bias.
Weight training compared to calisthenics resulted in a reduced injury risk and fewer training days lost.
Again, unclear research on the absolute best answer. Is there a perfect injury prevention program out there? No. However, there are certainly many good programs that allow you to become more resilient in the face of injury. In my experience, proper training comes down to three things:
Follow a prescribed program and stay consistent.
Identify issues when they arise and incorporate rehab into your programming.
Proper training is never a single focus: combine cardiorespiratory fitness with resistance training and address specific weaknesses for the best results.
Concluding Thoughts
I firmly believe that you can reduce the risk of injuries. A well-balanced lifestyle, load management, and proper progressive training can put you on the right track. However, don’t treat a program as the final answer. Injuries are rarely just a physical manifestation but instead a combination of individual psychosocial factors with the biological damage. Understanding the person first is the foundation to proper programming and treatment. However, a good program is a great way to start your journey. To incorporate all three tenets at potentially reducing injury risk, I created the Masterplan and Blueprint Pain Programs. Check them out!
Works Cited
Dijksma, I., Arslan, I. G., Etten-Jamauldin, F. S., Elbers. R. G., Lucas, C., & Stuiver, M. (2020). Exercise Programs to Reduce the Risk of Musculoskeletal Injuries in Military Personnel: A Systematic Review and Meta-Analysis. American Academy of Physical Medicine and Rehabilitation, 12. https://dx.doi.org/10.1002/pmrj.12360
Dijksma, I., Sharma, J., & Gabbett, T. (2021). Training Load Monitoring and Injury Prevention in Military Recruits: Considerations for Preparing Soldiers to Fight Sustainably. Strength and Conditioning Journal, 43 (2). https://doi.org/10.1519/SSC.0000000000000632
Lisman, P., Ritland, B. M., Burke, T. M., Sweeney, L., & Dobrosielski, D. A. (2022). The Association Between Sleep and Musculoskeletal Injuries in Military Personnel: A Systematic Review. Military Medicine, 187 (11-12). https://doi.org/10.1093/milmed/usac118
Orr, R., Pope, R., Lopes, T. J., Leyk, D., Blacker, S., Bustillo-Aguirre, B. S., & Knapik, J. (2021). Soldier Load Carriage, Injuries, Rehabilitation and Physical Conditioning: An International Approach. International Journal of Environmental Research and Public Health, 18 (8). https://doi.org/10.3390/ijerph18084010
Sergi, T. E., Bode, K. B, Hildebrand, D. A., Dawes, J. J., & Joyce, J. M. (2022). Relationships between Body Mass Index and Health and Occupational Performance among Law Enforcement Officers, Firefighters, and Military Personnel: A Systematic Review. Current Developments in Nutrition, 7 (1). https:// 10.1016/j.cdnut.2022.100020