Expanding the injury definition: evidence for the need to include musculoskeletal conditions

Musculoskeletal injuries in US Air Force Tactical Air Control Party trainees: an 11-year longitudinal retrospective cohort study and presentation of a musculoskeletal injury classification matrix

INTRODUCTION

Little is known of the epidemiology of musculoskeletal injuries (MSKIs) in US Air Force Special Warfare (AFSPECWAR) Tactical Air Control Party trainees. The purpose of this longitudinal retrospective cohort study was to (1) report the incidence and type of MSKI sustained by AFSPECWAR trainees during and up to 1 year following training, (2) identify factors associated with MSKI, and (3) develop and present the MSKI classification matrix used to identify and categorise injuries in this study.

METHODS

Trainees in the Tactical Air Control Party Apprentice Course between fiscal years 2010-2020 were included. Diagnosis codes were classified as MSKI or non-MSKI using a classification matrix. Incidence rates and incidence proportion for injury types and regions were calculated. Measures were compared for differences between those who did and did not sustain an MSKI during training. A Cox proportional hazards model was used to identify factors associated with MSKI.

RESULTS

Of the 3242 trainees, 1588 (49%) sustained an MSKI during training and the cohort sustained MSKIs at a rate of 16 MSKI per 100 person-months. Overuse/non-specific lower extremity injuries predominated. Differences were seen in some baseline measures between those who did and did not sustain an MSKI. Factors retained in the final Cox regression model were age, 1.5-mile run times and prior MSKI.

CONCLUSION

Slower run times and higher age were associated with an increased likelihood of MSKI. Prior MSKI was the strongest predictor of MSKI during training. Trainees sustained MSKIs at a higher rate than graduates in their first year in the career field. The MSKI matrix was effective in identifying and categorising MSKI over a prolonged (12-year) surveillance period and could be useful for future injury surveillance efforts in the military or civilian settings. Findings from this study could inform future injury mitigation efforts in military training environments.

Capturing and Categorizing the Burden of Musculoskeletal Injuries in U.S. Active Duty Service Members: A Comprehensive Methodology

BACKGROUND

Musculoskeletal injuries (MSKIs) represent the most common, costly, and impactful medical conditions affecting active duty service members (ADSMs) of the United States Armed Forces. Inconsistent, variable MSKI surveillance methods and often incompletely described criteria for cohort selection, injuries, incidence, and prevalence have limited efforts to observe longitudinal trends, identify gaps in care, or highlight specific military branches or sites that could benefit from enhanced MSKI intervention protocols. The purpose of this manuscript is to present a comprehensive, well-documented, and reproducible framework for capturing and categorizing MSKI burden, healthcare utilization, and private sector costs for ADSMs across a 12-year period spanning the International Classification of Diseases, 10th Revision, Clinical Modification transition.

METHODS

This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Upper Extremity, Lower Extremity, Spine, and Head/Neck MSKIs, associated health care utilization, and private sector costs were obtained by querying electronic health records from military treatment facilities, private sector care (PC) claims, and theater medical data from October 1, 2010 to September 30, 2021 (Fiscal Years 10-21), using the Military Health System Data Repository. Utilization associated with MSKIs per body region in the direct care and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs were captured per year and categorized by service, body region, and setting.

CONCLUSIONS

MSKI surveillance research in ADSMs has been impacted by variable, often incompletely described methods. While our approach is not without limitations, our aim was to present a well-documented, reproducible methodology for MSKI investigation in military personnel. By presenting a comprehensive blueprint for capturing and categorizing MSKI care in U.S. service members, our goal is for this methodology to enhance the efforts of researchers, public health officials, and Military Health System leaders to combat MSKIs, the primary medical threat to military readiness.

Musculoskeletal Complaint Epidemiology in Australian Special Operation Forces Trainees

INTRODUCTION

Elite military trainees are burdened by high numbers of musculoskeletal (MSK) injuries and are a priority military population for injury prevention. This research aims to describe the MSK complaint epidemiology of trainees undertaking special forces (SF) training in the Australian Defence Force (ADF). One barrier to accurate injury surveillance in military populations is that traditional surveillance methods rely on personnel engaging with the military healthcare system to collect injury data. This approach is likely to underestimate the injury burden as it is known that many military personnel, particularly trainees, avoid reporting their injuries because of various motives. Subsequently, the insights from surveillance systems may underestimate the injury burden and limit the ability to inform prevention requirements. This research aims to actively seek MSK complaint information directly from trainees in a sensitive manner to mediate injury-reporting behaviors.

MATERIALS AND METHODS

This descriptive epidemiology study included two consecutive cohorts of ADF SF trainees from 2019 to 2021. Musculoskeletal data items and their respective recording methods were based on international sports injury surveillance guidelines and adapted to a military context. Our case definition encompassed all injuries or physical discomforts as recordable cases. A unit-embedded physiotherapist retrospectively collected MSK complaint data from selection courses and collected prospective data over the training continuum. Data collection processes were external to the military health care system to mediate reporting avoidance and encourage injury reporting. Injury proportions, complaint incidence rates, and incidence rate ratios were calculated and compared between training courses and cohorts.

RESULTS

In total, 334 MSK complaints were reported by 103 trainees (90.4%), with a complaint incidence rate of 58.9 per 1,000 training weeks (95% CI, 53.0-65.5). Of these MSK complaints, 6.4% (n = 22) resulted in time loss from work. The lumbar spine (20.6%, n = 71) and the knee (18.9%, n = 65) were the most frequently affected body parts. Most of the MSK complaints were reported during selection courses (41.9%), followed by field survival and team tactics (23.0%) and urban operations courses (21.9%). Physical training accounted for 16.5% of complaints. Fast-roping training was associated with more severe MSK complaints.

CONCLUSIONS

Musculoskeletal complaints are highly prevalent in ADF SF trainees. Complaints are more frequently reported in selection and qualification training courses than in physical training. These activities are priorities for focused research to understand injury circumstances in ADF elite training programs to inform injury prevention strategies. A strength of our study is the data collection methods which have provided greater MSK complaint information than past research; however, much work remains in conducting consistent and accurate surveillance. Another strength is the use of an embedded physiotherapist to overcome injury-reporting avoidance. Embedded health professionals are recommended as continued practice for ongoing surveillance and early intervention.

The Neuromusculoskeletal Epidemiological Outcome (NEO) matrix: An innovative injury classification based on anatomical location and primary tissue type

INTRODUCTION

The purpose of this paper is to propose the Neuromusculoskeletal Epidemiological Outcome (NEO) Matrix, an injury classification based on anatomical location and primary tissue type to classify NMSKI of the trunk and extremities in orthopaedic and sports medicine epidemiological research.

MATERIALS AND METHODS

In the proposed NEO matrix, NMSKI diagnosis (International Classification of Disease) codes are classified by the anatomical complex affected. These regional anatomical complexes are frequently employed in orthopaedic and sports medicine disciplines in biomechanical and clinical research. The complexes are arranged from distal to proximal in the lower extremity, inferior to superior in the trunk and head, and proximal to distal in the upper extremity. Injuries are characterized by the primary tissue type affected (Osseous; Articular; Musculotendinous; Neural; Non-specific) based on classified using International Classification of Disease codes.

DISCUSSION

The expected patterns of impairment and healing rates of bone, cartilage, ligaments, muscles, tendons, and neural structures vary considerably by the tissue type based on the differences in function, perfusion, and metabolic physiology. Using knowledge of the function of the tissues, expected minimum healing times, and expected sequelae of residual body system impairments, an estimation of morbidity and expected recovery times can be made. While heterogeneity is certainly expected due to varying pathomechanics involved and intrinsic and environmental factors, the NEO matrix classifies the ICD diagnosis codes in framework that qualifies the expected patterns of impairment based on the body system type.

CONCLUSION

The NEO matrix provides an alternative approach for characterizing NMSKI in epidemiological research.

Improving musculoskeletal injury surveillance methods in Special Operation Forces: A Delphi consensus study

Musculoskeletal injury mitigation is a priority in military organisations to protect personnel health and sustain a capable workforce. Despite efforts to prevent injury, inconsistencies exist in the evidence used to support these activities. There are many known limitations in the injury surveillance data reported in previous Special Operation Forces (SOF) research. Such studies often lack accurate, reliable, and complete data to inform and evaluate injury prevention activities. This research aimed to achieve expert consensus on injury surveillance methods in SOF to enhance the quality of data that could be used to inform injury prevention in this population. A Delphi study was conducted with various military injury surveillance stakeholders to seek agreement on improving surveillance methods in SOF. Iterative questionnaires using close and open-ended questions were used to collect views about surveillance methods related to injury case definitions and identifying essential and optional data requirements. Consensus was predefined as 75% group agreement on an item. Sixteen participants completed two rounds of questionnaires required. Consensus was achieved for 17.9% (n = 7) of questions in the first-round and 77.5% (n = 38) of round two questions. Several challenges for surveillance were identified, including recording injury causation, SOF personnel's injury reporting behaviours influencing accurate data collection, and surveillance system infrastructure limitations. Key military injury surveillance stakeholders support the need for improved data collection to enhance the evidence that underpins injury prevention efforts. The consensus process has resulted in preliminary recommendations to support future SOF injury surveillance.

The Impacts of ICD-10-CM on U.S. Army Injury Surveillance

INTRODUCTION

Injuries are the leading cause of medical encounters and lost work days in the U.S. Army, affecting more than half of active-duty soldiers annually. Historically, Army injury surveillance has captured both acute traumatic and cumulative microtraumatic overuse injuries. This article describes how the transition from the ICD-9-CM to ICD-10-CM impacted U.S. military injury surveillance by comparing injury rates and distributions under both systems.

METHODS

Mapping ICD-9-CM codes to the expanded ICD-10-CM codes is not a straightforward endeavor; therefore, the Army Public Health Center incorporated ICD-10-CM codes into a comprehensive, systematic approach to taxonomically categorize injuries. This taxonomic methodology was applied to Army injuries under ICD-10-CM (2016-2019) and compared with the ICD-9-CM Army injury surveillance definitions (2012-2015).

RESULTS

Soldier injury rates appeared to increase when surveillance with ICD-10-CM began. Soldiers experienced 1,276 incident injury medical encounters per 1,000 person-years in 2015 (ICD-9-CM), compared with 1,804 injuries per 1,000 in 2016 (ICD-10-CM), a 41% increase. Importantly, the distribution of injuries also shifted, such that the average cumulative microtraumatic injury rate increased by 42% during 2016-2019 (ICD-10-CM) compared with the 2012-2015 average (ICD-9-CM), whereas acute traumatic injuries only increased by 17%.

CONCLUSIONS

The enhanced descriptions provided by ICD-10-CM codes and the applied taxonomic categorizations have improved precision in Army injury surveillance. Data unequivocally show that most injuries in this physically active population are cumulative microtraumatic injuries. The taxonomic methodology can be extended to injury surveillance in other populations and may allow a more efficient transition to ICD-11-CM.

Musculoskeletal injury in military Special Operations Forces: a systematic review

INTRODUCTION

Special Operations Forces conduct military activities using specialised and unconventional techniques that offer a unique and complementary capability to conventional forces. These activities expose Special Operations Forces personnel to different injury risks in comparison with personnel in the conventional forces. Consequently, different injury patterns are expected in this population. The purpose of this research is to establish high-level evidence informing what is known about musculoskeletal injury epidemiology in Special Operations Forces.

METHODS

A systematic review was conducted using three online databases to identify original studies reporting musculoskeletal injury data in Special Operations Forces. A critical appraisal tool was applied to all included studies. Descriptive data were extracted for demographics, study design details and injuries (eg, injury frequency, injury type, body part injured, activity, mechanism, severity). Results were narratively synthesised.

RESULTS

Twenty-one studies were included. Trainees conducting qualification training had the highest injury frequency, up to 68% injured in a training period. The ankle, knee and lumbar spine were the most common body parts affected. Parachuting caused the most severe injuries. Physical training was the most common activity causing injury, accounting for up to 80% of injuries. Running and lifting were common injury mechanisms. Injury causation information was frequently not reported. Partially validated surveillance methods limited many studies.

CONCLUSIONS

Injuries are prevalent in Special Operation Forces. Future research should prioritise identifying injury causation information that supports prevention. Focus on improving surveillance methods to enhance the accuracy and comparison of results across cohorts is also recommended.

Worldwide epidemiology of foot and ankle injuries during military training: a systematic review

INTRODUCTION

Musculoskeletal foot and ankle injuries are commonly experienced by soldiers during military training. We performed a systematic review to assess epidemiological patterns of foot and ankle injuries occurring during military training.

METHODS

A review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search, done on 14 February 2019, resulted in 1603 reports on PubMed, 565 on Embase and 3 on the Cochrane Library. After reading the remaining full-text articles, we included 91 studies.

RESULTS

Among a population of 8 092 281 soldiers from 15 countries, 788 469 (9.74%) foot and ankle injuries were recorded. Among the 49 studies that reported on length of training, there were 36 770/295 040 (18.17%) injuries recorded among women and 248 660/1 501 672 (16.56%) injuries recorded among men over a pooled mean (±SD) training period of 4.51±2.34 months. Ankle injuries were roughly 7 times more common than foot injuries, and acute injuries were roughly 24 times more common than non-acute injuries. Our findings indicated that, during a 3-month training period, soldiers have a 3.14% chance of sustaining a foot and ankle injury. The incidence of foot or ankle injury during military parachutist training was 3.1 injuries per thousand jumps.

CONCLUSIONS

Our findings provide an overview of epidemiological patterns of foot and ankle injuries during military training. These data can be used to compare incidence rates of foot and ankle injuries due to acute or non-acute mechanisms during training. Cost-effective methods of preventing acute ankle injuries and non-acute foot injuries are needed to address this problem.