Page 110 - JSOM Spring 2025

Some studies further analyzed the mechanisms of injury and muscular asymmetries and imbalances. Previous studies 78–80
reported that running and lifting were the most common phys- have reported that prescreening assessments aimed at identify-
ical training activities causing MSK injuries. This is not unex- ing MSK injury risk factors are important to guide the devel-
pected given that running has been associated with military opment of injury prevention programs.
MSK injuries across multiple studies and reports, 48,51,67,68 and
reductions in running mileage have been shown to reduce in- In recent years, testing using force plates (e.g., countermove-
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jury risk. Furthermore, replacing some running sessions with ment jump, isometric mid-thigh pull [IMTP]), and comput-
specific loaded walking sessions has been shown to simultane- erized systems to enhance injury mitigation strategies have
ously improve aerobic fitness as well as overall load carriage become increasingly popular in elite sport athletes and mili-
capacity and performance. 70 tary populations. 81–85 These types of assessments have demon-
strated more reliability in a military context than traditional
23
These findings emphasize the suggestion by Lendal and Kjaer testing methods for performance evaluation and injury risk
on the need for education on injury mitigation strategies identification. 86,87 In a study of Australian Special Forces se-
88
that could be applied during physical training. For example, lection candidates, Doyle et al. observed that 26% of can-
based on an analysis of the United States Army Special Op- didates incurred a preventable lower extremity injury, with
erations Command (USASOC) Tactical Human Optimization 65% involving the knee. The uninjured candidates had higher
Rapid Rehabilitation and Reconditioning (THOR ) program, values of absolute strength measured through the IMTP peak
3
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Pearce demonstrated that educating Operators on the devel- absolute force and a lower eccentric utilization ratio (EUR)
opment of a strong foundational movement base provides a compared with the injured. Furthermore, the preventable
long-term investment in injuries reduction as the complexity knee injuries were significantly correlated to those values. The
of the exercises performed and the skills required increases. findings by Doyle et al. suggest that individuals with higher
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Proper education on lifting technique, utilization of evi- strength levels may have a reduced risk of sustaining an MSK
dence-based strength training programs, proper training loads injury when compared with their relatively weaker colleagues.
41
(volume and intensity), and a periodization model might like- Furthermore, given the findings of Teyhen et al., who re-
wise mitigate MSK injury risk and optimize military manual ported that a history of previous injuries was a significant risk
handling (i.e., load carriage, equipment lift and carry, etc.) task factor for MSK injury in SOF, force plate testing may help in-
performance. 72 form rehabilitation programs. Nevertheless, considering these
findings, while force plate assessments can be used to exam-
Risk Factors for Injury ine performance (e.g., jump height) and movement strategies
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Only two studies in this systematic review examined risk factors (e.g., asymmetries) they do not directly predict injury. How-
for injury. Teyhen et al. reported that a multifactorial approach ever, the data can be used by suitably qualified professionals
41
that investigated history of injury and smoking, pain provoca- (e.g., physical training instructors, strength and conditioning
tion, movement, and performance measures could help to iden- coaches, physical therapists) to create individualized training
tify U.S. Army Rangers with higher injury risk. These results are programs aimed at increasing strength and reducing imbal-
akin to those found in U.S. Army Pre-Ranger candidates, where ances and asymmetries to reduce the risk of MSK injury.
poorer fitness, cigarette and tobacco use, and movement qual-
73
ity were associated with increased injury risk. In a qualitative Cigarette smoking has been highlighted as a risk factor for MSK
systematic review conducted in military populations, Sammito even if not reviewed for this population and variables. 41,73,89
74
et al. also identified cigarette smoking as a risk factor. In their Based on this, the implementation of smoking cessation pro-
74
review, smoking was associated with a 27%–71% increase in grams to reduce smoking among military personnel should be
the risk of MSK injuries in a military context. considered. 90
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In a study of U.S. Army SOF Operators, Heebneer et al. found Limitations
that a deficit in knee-extensor strength, as well as shoulder- This systematic review has some limitations that warrant con-
retraction and shoulder internal-rotation deficits, contributed sideration. Apart from the notable lack of consensus in injury
to a higher probability of injury occurrence. These findings, definitions, five studies (25% of identified studies) examined
36
paired with those of Teyhen et al., suggest the importance of injuries in SOF Operators resulting from a specific training
individual assessments based not only on examining perfor- activity, as opposed to service requirements. Furthermore,
mance but also comprehensive movement strategies and mus- some studies were conducted more than 20–25 years ago and
cular asymmetries and imbalances—a supposition supported as such may be less generalizable to the modern SOF Opera-
by the previously mentioned findings of Davis et al. 73 tor owing to changes in equipment, roles and duties, opera-
tional theaters, etc. Finally, the research was limited to only
In the past, the physical performance of military personnel has four countries, and, although SOF have similar characteristics
been typically assessed using a series of physical tests based and injury patterns all around the world, there could be differ-
on bodyweight exercises (e.g., push-ups, sit-ups, pull-ups) and ences between countries, units, and even teams, again limiting
75
running (e.g., 1.6-mile or 2.4-km run, shuttle runs). These transferability, but highlighting the importance of a tailored
assessments are being replaced with physical performance human performance program approach that is country, unit,
tests, which are considered to be more occupationally rele- and team specific.
vant (e.g., pack march over a distance for a time, lifting, and
carrying military equipment), and are aimed at evaluating Conclusion
load carriage and manual handling. 76,77 Although this could
be considered a positive change toward assessing the ability The leading nature and sites of reported injury rates in SOF
of personnel to execute occupational tasks, these tests are of- personnel were sprains and strains to the lower extremities, and
ten limited in the evaluation of movement characteristics, and the most common mechanism of injury was physical training.

108 | JSOM Volume 25, Edition 1 / Spring 2025