Tactical athletes: maximizing their ability to protect and serve

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// July 2017
Tactical athletes: Maximizing their ability to protect and
serve
Increasingly, clinicians and researchers are focusing on tactical athletes—
including warfighters, firefighters, law enforcement officers, and other
professionals—as a unique population with regard to lower extremity
injuries.
By Hank Black
Almost 15 years ago, the US secretary of defense called for rates of accidents and
injuries in the armed services to be driven down significantly to enhance readiness
for battle, and save money and training time. Thus began a long march toward
recognition of service personnel as a special type of athlete.
Tactical athletes, as they are now known, also include firefighters, law enforcement
personnel, emergency medical technicians, and others whose protect-and-defend
professions require high-level physical abilities—and, in turn, high-level medical
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care.
Experts in this field say tactical athletes, like those competing at collegiate or

Olympic levels, should be given every chance to be at the top of their game.
“We need to start treating our warfighters and first responders as the athletes they
are—their sport is protecting the public,” according to Kenneth Games, PhD, LAT,
ATC, who directs a research center at Indiana State University in Terre Haute that
focuses on firefighters and other civilian tactical athletes.
Growing interest
Interest in working with tactical athletes is growing. Sports medicine and athletic
trainer organizations are heavily engaged in the field, the American Physical
Therapy Association is launching a related special interest section, and strength
and conditioning specialists have created a certification program for the area. A
wave of tactical-fitness exercises has gained popularity in the commercial fitness
world, supplanting “boot camp” for many who seek high-intensity workouts.
In November 2016, the National Athletic Trainer’s Association (NATA) devoted a
whole issue of its journal (the Journal of Athletic Training [JAT]) to the subject of
tactical athletes.
“These are people who dedicate their lives to serving us, and who depend on
functioning at their highest possible level of athleticism to carry out the many
challenges they face, often under life-threatening circumstances,” said guest
coeditor JoEllen M. Sefton, PhD, ATC, who directs the Warrior Research Center at
Auburn University in Alabama. “As such, they deserve the best we can give in
terms of research and clinical care.”
Sefton works with all levels of warfighters, from cadets to special operations
forces, many of them at Fort Benning, GA, just a few miles east of Auburn.
Warfighters
Much of the research focused on reducing musculoskeletal injuries in tactical
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athletes involves the lower extremities, where the majority of noncontact injuries
occur. In Army trainees, for example, chronic knee injuries account for up to 44%
of all injuries.
The potential payoff is high. In the special JAT issue, Nathaniel S. Nye, MD, and
colleagues found that 12.5% of Air Force trainees who sustained at least one
musculoskeletal injury were more than three times more likely to be discharged
from the service than their uninjured counterparts, and the cost of such injuries
totaled more than $21.8 million in medical and nonmedical expenses.
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The sports medicine model of injury prevention and management is most fully
realized by embedded teams of training specialists in deployed units of the armed
services, according to an editorial Nye coauthored that accompanied the study in
JAT. Nye, a primary care sports medicine physician attached to the 559th Trainee
Health Squadron at Joint Base San Antonio-Lackland, TX, pointed out that the
usual medical care model in the armed services still resembles the model used for
many civilians, including primary care referrals, 15-minute appointments, and long
waits for specialty consultations.
“We have top-notch sports medicine programs for our intercollegiate athletes, but
only meager facilities and services are available to the tactical athletes of our
special operations training units,” Nye said. “Even a small reduction in trainee
attrition would bring large cost savings.”
The first discussions about embedded sports medicine teams began in the 1990s,
with the Marine Corps and Navy recognizing the need for dedicated sports
medicine professionals to provide on-site rapid assessment and care. Teams
might include athletic trainers, physical therapists, strength and conditioning
specialists, sports medicine physicians, and surgeons, backed up by a full bench
of researchers in biomechanics, epidemiology, and other fields.
Many trainees hide their injuries for fear that a healthcare provider will remove
them from their duty status and their team, Nye said.
“Embedding healthcare providers into operational organizations, to ensure that
they understand the mission and know the people, will significantly bridge this
gap,” he said.
Prediction and prevention
Predicting and preventing injury in trainees is the focus of much current research.
Scott D. Carow, DSc, PT, OCS, SCS, led a study of new cadets at the US Military
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Academy in West Point, NY, that showed a reduction in risk of acute knee-joint
injury in a cohort whose trainers (upper-class cadets who had been through a two-
week supervisory course) were supervised by professional staff, either a physical
therapist or athletic trainer, compared with another group performing the same
exercise program whose trainers had no supervision.
Although the findings seem to support increasing the direct involvement of medical
professionals during training, Carow noted that isn’t necessarily a realistic option.
“That model of putting a PT or AT behind every platoon to make sure movement
was executed correctly would be impractical,” Carow said. “There’s one PT per
brigade [3500 soldiers] now, so we have to come up with better instruction of
training leaders or exercises unit-level leaders can correctly supervise.”
Carow, now stationed at William Beaumont Army Medical Center in El Paso, TX,
noted the Army has developed a Master Fitness Trainers Course with a goal of
including one such trainer in every company secondary to their main military
occupation specialty, such as truck driver.
“That may be the right way to try integrating this training at the unit level,” he said.
A complex problem
A coauthor on the West Point study, Anthony I. Beutler, MD, program director for
the Military Sports Medicine Fellowship at the Uniformed Services University in
Bethesda, MD, said, “Injury reduction is a very complex problem, and it is difficult
to think of a single strategy that would dramatically work across the board.”
As an example, he said, the Army tasked his group with conducting a
comprehensive literature review (not for publication) of running shoe styles—in
particular, minimalist versus traditional cushioned running shoes—and asked if one
type of shoe would be appropriate for every military trainee.

“Our recommendation was, ‘No,’” Beutler said. “We know that transitioning
someone from traditional heel strike running to midfoot running is a time when
injuries are very likely to happen. So we wouldn’t want to just have one type of
shoe for basic trainees to choose from, since shoe type might force them to alter
their biomechanics in unpredictable and nonbeneficial ways. The individuality of
the trainee—the athlete—is really quite striking.”
Games developed the Tactical Athlete Research and Education Center at Indiana
State, where he is assistant professor in the Department of Applied Medicine and
Rehabilitation and director of the Neuromechanics, Interventions, and Continuing
Education Research Laboratory.
He agrees with Nye that tactical athletes are typically reluctant to leave duty for
treatment of nagging musculoskeletal issues—persistent knee pain, for example.
Like warfighters, he said, firefighters are part of a team whose members depend
on each other. But firefighters, and other first responders, also fear the possibility
of losing time and pay.
“If they go to clinic and get a prescription for nine physical therapy sessions, at
three a week, they may be on half-pay all that time,” Games said.
Games targets lower extremity injury prevention through a program of functional
training that has firefighters carrying up to 100 lbs of personal protective
equipment, as they might be required to use while on the job, which alters the
parameters of neuromuscular control and muscular systems, he said.
“Fatigue makes an athlete perform more poorly on dynamic balance, for example,
so we have them do a five-minute activity protocol in their equipment before
putting them through balance exercises. It’s the combination of exercises and
equipment restrictions that make you work harder and fatigue faster and therefore
risk missing a jump and spraining an ankle, for example,” he said.
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The functional training strategy—now in press but described in several
presentations at the NATA annual meeting in June —calls for a collaborative
team to address muscular strength, balance and neuromuscular control, mobility,
and cardiovascular fitness, he said.
Additional findings
The JAT special issue included several other studies involving the lower
extremities.
Sefton et al identified cut-off scores for events in one common fitness screen,
the Army 1-1-1 Fitness Assessment. The analysis will help clinicians assess
the risk of musculoskeletal injuries for various military specialty units and
identify recruits most likely to successfully complete their basic training.
Kollock et al conducted a meta-analysis that found individuals with knee
overuse symptoms—which account for up to 44% of injuries in military trainees
and are also a significant concern in active-duty and reserve warfighters—have
lower absolute and normalized hip muscle strength compared with
asymptomatic controls, and might benefit from training to strengthen specific
muscles.
Cameron et al systematically reviewed the literature on osteoarthritis (OA) and
the tactical athlete whose occupation requires repetitive bending, squatting,
kneeling, and lifting. In 12 retrospective cohort studies meeting their criteria,
the group found a significantly higher incidence of OA—including knee OA and
hip OA specifically—compared with controls who were not tactical athletes. The
disparities persisted regardless of age or sex, and increased with age.
In a cohort study involving 2479 Chinese military cadets over two years, Ma et
al found the incidence of meniscal injury was 10.08 per 1000 person-years,
with overweight or obese cadets (8% of the study population) at greatest risk of
such injury. In addition, the researchers found medial meniscal injuries were
twice as frequent as lateral ones. The incidence of meniscal injury was higher
8-10
11
3
12
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than in a 2012 study of active-duty US military service members, which also
found a similar distribution of medial and lateral injuries.
Although the US study on meniscal injuries did not look at body mass index (BMI),
US Army researchers reported in 2016 that higher BMI was associated with
increased risk of musculoskeletal injury in new soldiers followed for two years.
Hruby et al suggested focusing recruitment on individuals with BMI of 21 to 23
kg/m —the range associated with the lowest risk of incidence.
Footwear factors
Footwear has always been a concern for the armed services. Combat boots were
required for training and duty prior to 1980, when, on the intuitive assumption that
fewer injuries would occur, running shoes were allowed for training.
Surprisingly, no reduction in injury rate was evident in a recent systematic review
of studies in basic training that examined injury rates before and after the historic
change to running shoes. However, anecdotally reported methodological issues
related to how often the running shoes were actually worn during training may
have affected the findings.
The recent popularity of minimalist running shoes also doesn’t seem to have
affected injury rates in military personnel. In more than 1300 male soldiers in a
single brigade, Tyson Grier, MS, a kinesiologist with the Army Public Health Center
(Provisional) in Aberdeen Proving Ground, MD, and colleagues found no
differences in overuse injury rates for a traditional running-shoe group (motion
control, stability, or cushioning shoe) and a minimalist running-shoe group
(“barefoot,” minimalist, or transitional shoe).
Wendi H. Weimar, PhD, director of Auburn University’s Sport Biomechanics
Laboratory, analyzes gait and other characteristics of military basic trainees to help
them attain running patterns associated with a reduced risk of lower extremity
14
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2 15
16,17
18
19
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injury. She is an assistant professor in the university’s Department of Kinesiology.
“We might encourage them to take a shorter stride, and land on their midfoot
rather than their heel, particularly if running on sand with or without a heavy
rucksack,” Weimar said.
She teaches trainees to tie their boots with a runner’s loop to allow the foot to fit
better in the heel cup and have a truer gait. More shoe design and materials
options are available to match individual job requirements, including different cleat
configurations and sole thicknesses.
“And orthotics, while not prescribed on a global basis, are available as needed, to
promote performance and avoid injury,” Weimar said.
She also takes note of how soldiers—and other tactical athletes—fill the side
pockets of their cargo pants.
“A lot of paramedics and police officers carry weight on their side pockets, which
can alter the weight distribution and affect the way they swing their weight
forward,” she said.
Positive outcomes
In 2010, Timothy Sell, PhD, PT, FACSM, and colleagues at the University of
Pittsburgh helped develop and implement the Eagle Tactical Training Program
in Fort Campbell, KY, specifically for an Army airborne unit after determining its
injury profile, which was high in lower extremity injuries.
Among other aspects, the program featured a different type of workout daily
(speed/agility/balance one day, muscular strength the next, then interval running,
power, and endurance training). The training was associated with improvements in
soldiers’ strength, flexibility, balance, anaerobic power, agility, and annual fitness
scores.
21,22
21,22

Last year Sell et al published a related study that found program graduates had
significantly lower numbers of preventable musculoskeletal injuries and stress
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REFERENCES - Hide
fractures compared with controls.
“It shows the importance of a scientifically designed training program tailored to a
target population,” said Sell, who is now associate professor and director of the
Michael W. Krzyzewski Human Performance Laboratory in the Department of
Orthopedic Surgery at Duke University in Durham, NC.
Sell was one of the several researchers and clinicians interviewed who expressed
their respect for and appreciation of the tactical athletes they worked with.
“While I am not in the service, it’s a great privilege to support and work with men
and women who are dedicated to our safety and well-being,” he said.
Hank Black is a freelance writer in Birmingham, AL.
1. Rumsfeld DH. Reducing preventable accidents. Memorandum. Offıce of the
US Secretary of Defense. Published May 19, 2003.
2. Sefton J, Burkhardt T, eds. J Athl Train 2016;51(11).
3. Kollock RO, Andrews C, Johnston A, et al. A meta-analysis to determine if
lower extremity muscle strengthening should be included in military knee
overuse injury-prevention programs. J Athl Train 2016;51(11):919-926.
4. Nye NS, Pawlak MT, Webber BJ, et al. Description and rate of
musculoskeletal injuries in Air Force basic military trainees, 2012-2014. J
Athl Train 2016;51(11):858-865.
5. Nye NS, de la Motte SJ. Editorial: Rationale for embedded musculoskeletal
care in Air Force training and operational units. J Athl Train
2016;51(11):846-848.
6. Carow SD, Haniuk EM, Cameron KL, et al. Risk of lower extremity injury in

a military cadet population after a supervised injury-prevention program. J
Athl Train 2016;51(11):905-918.
7. Salzler MJ, Kirwan HJ, Scarborough DM, et al. Injuries observed in a
prospective transition from traditional to minimalist footwear: correlation of
high impact transient forces and lower injury severity. Physician Sportsmed
2016;44(4):373-379.
8. Games KE, Csiernik AJ, Winkelmann ZK, et al. Fatigue diminishes static
and dynamic balance in firefighters. J Athl Train 2017;52(6):S151.
9. Csiernik AJ, Winkelmann ZK, Eberman LE, et al. Personal protective
equipment diminishes static and dynamic balance in firefighters. J Athl Train
2017;52(6):S38.
10. Rogers SM, Winkelmann ZK, Eberman LE, Games KE. Examination of the
triple hop for distance as a predictor of lower extremity performance in
firefighter equipment. J Athl Train 2017;52(6):S39.
11. Sefton JM, Lohse KR, McAdam JS. Prediction of injuries and injury types in
Army basic training, infantry, armor, and cavalry trainees using a common
fitness screen. J Athl Train 2016;51(11):849-57.
12. Cameron KL, Driban JB, Svoboda SJ. Osteoarthritis and the tactical athlete:
a systematic review. J Athl Train 2016;51(11):952-961.
13. Ma JZ, Cui SF, Hu F, et al. Incidence and characteristics of meniscal injuries
in cadets at a military school, 2013-2015. J Athl Train 2016;51(11):876-879.
14. Jones JC, Burks R, Owens BD, et al. Incidence and risk factors associated
with meniscal injuries among active-duty US military service members. J
Athl Train 2012;47(1):67-73.
15. Hruby A, Bulathsinhala L, McKinnon CCJ, et al. BMI and lower extremity
injury in US Army soldiers, 2001-11. Am J Prev Med 2016;50(6):e163-e171.

16. Fort Benning testing athletic shoes. Sneakers may get foothold in Army.
Stars and Stripes website. http://www.stripes.com/customer-
service/archives. Published May 21, 9183. Accessed February 25, 2017.
17. US Department of the Army. Physical Readiness Training, Field Manual 21-
20. Washington, DC: Department of the Army; October 31, 1980.
18. Knapik JJ, Jones BH, Steelman RA. Physical training in boots and running
shoes: a historical comparison of injury incidence in basic combat training.
Mil Med 2015;180(3):321-328.
19. Ingraham P. Boot blooper. Painscience.com.
https://www.painscience.com/microblog/boot-blooper.html. Published
December 22, 2014. Accessed July 11, 2017.
20. Grier T, Canham-Chervak M, Bushman T, et al. Minimalist running shoes
and injury risk among United States Army Soldiers. Am J Sports Med
2016;44(8):1439-1446.
21. Sell TC, Abt JP, Crawford K, et al. Warrior model for human performance
and injury prevention: Eagle Tactical Athlete Program (ETAP) Part I. J Spec
Oper Med 2010;10(4):2-21.
22. Abt JP, Sell TC, Crawford K, et al. Warrior model for human performance
and injury prevention. Eagle Tactical Athlete Program (ETAP) Part II. J Spec
Oper Med 2010;10(4):22-33.
23. Sell TC, Abt JP, Nagai T, et al. The Eagle Tactical Athlete Program reduces
musculoskeletal injuries in the 101st airborne division (air assault). Mil Med
2016;181(3):250-257.

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