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Use of Physical Therapists to Identify and Treat
Musculoskeletal Injuries at “The Tip of the Trident”

Jesse Shaw, DO *; Laura Brown, DPT ; Brittany Jansen, DPT 3
2
1

ABSTRACT
Musculoskeletal injuries continue to be the most common cause approximately three to six times the rate of battle injuries. 7–10
of decreased readiness and loss of productivity in all military Therefore, DNBIs and associated morbidities have a signifi-
environments. In commands with smaller footprints, such as cant impact on the readiness status of military commands,
Naval Special Warfare (NSW), every asset is critical for mission especially those that are forward deployed with limited field
success. Studies have shown that early intervention by a medical medical resources.
provider can enhance healing and maintain unit readiness by
preventing medical evacuations. Reports are limited with regard Multiple studies have shown that early evaluation and treat-
to Special Forces commands, especially during deployment. ment by physical therapists (PTs) enhance healing, decrease
This article describes the injury characteristics and treatment of down time, and are crucial in decreasing medical evacuations
injuries seen by a physical therapist while deployed at forward from down range. 5–7,11–13 The historical success of PTs at Level
operation commands embedded with NSW Group 2 Team 4. III–V commands 11,14 (Table 1) demonstrate expertise with mus-
Over 4 months, 282 patients were evaluated and treated in culoskeletal injury identification, diagnosis, and treatment.
southeast Afghanistan. In descending order, the three most com- Restricting PTs to these larger medical commands limits their
mon injured body regions were the lumbar/sacral spine (n = 82), direct access and requires PTs further down range to be re-
shoulder (n = 59), and knee (n = 28). Therapy exercises (n = moved from their mission and transferred to distant locations.
461) were the most frequently performed treatment modality,
followed by mobilization/manipulation (n = 394) and dry nee- Table 1 Explanations of Each Level of the Integrated Military
dling (n = 176). No patient evaluated was medically evacuated Trauma Care System
from the area or sent to an advanced medical site. Our data Level Characteristics
are similar to other published data reported on deployed units I Battlefield, first responders
in terms of mechanisms and locations of injuries; thus, Special Mobile units, surgical resuscitation capabilities, small but
Forces commands do not appear to have unique injury patterns. II complete team
These results support continued use of physical therapists in for- Highest level of care in combat zone, complete
ward operations because of their ability to evaluate injuries and III radiological and laboratory capabilities
provide treatment modalities that help maintain the integrity of IV First zone outside combat zone, Landstuhl Regional
small commands at the site of injury. Medical Center
V Military treatment facilities in continental United States
Keywords: physical therapist; Naval Special Warfare; inju-
ries, musculoskeletal NSW Command differs from other commands by its small
teams, constant troop movement, high operational tempo,
and heavy combat environments, which shape its missions. A
concern for NSW Command is that its units are exposed to
Introduction
especially austere environments, which increases the external
During the past decade, we have seen an increase in the opera- forces on the units’ assets and makes unanticipated transport
tional tempo of US Military Forces to meet the requirements to large-scale medical commands complicated. Because of this,
of the 21st century. Standard military commands have de- NSW Command has transformed its paradigm and is now
creased their footprint “in country” and have transitioned to testing physical therapists closer to the “tip of the trident” at
smaller units, which are more mobile and can rapidly respond Level I/II commands. 11,14 This forward deployed configuration
to global threats. Specialized military commands, such as Na- allows access to a multitude of treatment techniques to assets
val Special Warfare (NSW) Command, exemplify this; these before, after, and between missions, keeping operators and
commands are structured to use fewer people to accomplish support staff operational.
mission objectives, making individual Sailor readiness more
pivotal to mission success. As the needs and requests for PTs change during war, it has
become apparent that utilizing them down range is beneficial
Musculoskeletal injuries are the most prevalent reason for to commands and missions. 5-7,11-13 We hope to further solidify
loss of productivity, medical visits, and medical evacuation the forward application and use of PTs at the tip of the trident
from theater. It has been reported that the prevalence of and clarify their roles as extensions of physicians during future
1–6
disease and nonbattle injuries (DNBIs) while in country is operations and during sustained deployments. This report de-
87% of all injuries seen by medical providers; DNBIs occur at scribes the experience of a forward deployed PT down range
*Address correspondence to jdshawdo@yahoo.com
2
1 LT Shaw, MC USN, is at Naval Health Branch Clinic Bangor, Silverdale, WA. LT Brown, MSC USN, is at Naval Health Clinic Charleston,
Goose Creek, SC. LT Jansen, MSC USN, is at Naval Medical Center Portsmouth, Portsmouth, VA.
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