Abstract
Musculoskeletal injuries, especially resulting from physical training, are a significant threat to military readiness. Due to costs related to treating injuries and the high probability of chronic, recurrent injuries, prevention should be a primary focus to maximize human performance and military success. However, in the US Army, many personnel are uninformed on injury prevention topics, and no research has identified injury prevention knowledge gaps in military leaders. This study examined the current knowledge of US Army ROTC cadets on injury prevention topics. This cross-sectional study was conducted at two university ROTC programs in the US. Cadets completed a questionnaire to identify participants’ knowledge of injury risk factors and effective prevention strategies. Participants’ perceptions of their leadership and their desires for future injury prevention education were also assessed. The survey was completed by 114 cadets. Except for dehydration and prior injury, participants had a greater than 10% incorrect response rate for questions regarding the impact of various factors on injury risk. Overall, participants displayed a positive view of their leadership’s interest in injury prevention. The majority (74%) of participants reported a preference to receive injury prevention educational materials via electronic delivery. To develop implementation strategies and educational materials for injury prevention, identifying current injury prevention knowledge of military personnel should be a priority for researchers and military leaders. The initial military training of future officers is a critical time for further research and education efforts to improve the effectiveness and adoption of injury prevention strategies.
Keywords: Military, physical training, injury prevention
INTRODUCTION
Physical training-related injuries remain one of the most significant threats to military readiness (6, 10, 15, 18), the organization’s ability to meet operational demands (17). Military readiness depends not only on capabilities and technology, but on the knowledge, skills, and physical performance of military members (17). In the US Army alone, musculoskeletal injuries (MSKI) accounted for more than eight million limited duty days in 2018 (15). Additionally, a history of previous MSKI increases the risk of attrition and experiencing another injury in the future (1).
Thus, preventing primary, and even secondary, MSKI is paramount for the health and success of the military. A number of risk factors for MSKI have been identified (2), and prevention strategies’ efficacy has been evaluated with varying degrees of success (5). While the need for investigations into MSKI risk factors and interventions remains, if a majority of military members are unaware of these risk factors and how to appropriately incorporate prevention strategies, the threat of physical training-related injuries will persist.
To characterize US Army military and civilian personnel’s knowledge of MSKI risk factors and prevention strategies, the US Army Public Health Center (USAPHC) conducted a survey-based investigation in 2014 (9). The authors theorized that confusion and a lack of awareness of effective prevention strategies may be one of the causes for the persistence of physical training-related MSKI (9). The study found that while most respondents were aware of the magnitude of the MSKI problem, they were less likely to identify correct responses to questions pertaining to injury risk factors and interventions (9). These findings highlight a knowledge gap in an active duty population made up of both military and civilian personnel (9). However, no attempts have been made to identify knowledge of these topics specifically in military leaders despite leadership support being considered a mandatory component of injury prevention programs (5).
The Reserve Officers’ Training Corps (ROTC) is the largest ascension source for commissioned officers joining the US Army (26). Despite cadets’ importance to the US Army as future military leaders, minimal research has been conducted regarding risk factors and injury etiology in ROTC cadets compared to the active component of the US Army. Previous investigations indicate that ROTC cadets experience MSKI of similar types and at similar rates as service members in initial entry training environments (20). In the authors’ experience working with numerous US ROTC programs, injury prevention is not a mandatory element of the ROTC curriculum. In addition, ROTC cadets’ awareness of the impact of MSKI on the military and knowledge of injury risk factors is unknown. Therefore, the purpose of this study was to assess the current knowledge of injury prevention topics in US Army ROTC cadets. In addition, we aimed to identify information needs and areas of cadets’ interest in further education.
METHODS
Participants
A total of 125 cadets agreed to participate and complete the survey: 68 from a university in the southwestern United States and 57 from a university in the midwestern United States. Inclusion criteria were any cadets actively enrolled in the US Army ROTC programs and courses at the participating universities. There were no specific exclusion criteria so long as participants met the inclusion criteria. The study protocol was approved by the Institutional Review Boards of both participating universities. This research was carried out fully in accordance to the ethical standards of the International Journal of Exercise Science (16).
Protocol
The current study used an observational, cross-sectional survey design to assess cadet knowledge of injury prevention topics. A modified version of the injury prevention knowledge survey developed by the USAPHC (9), with permission from the original author, was utilized. The original survey instrument was designed to assess knowledge of unintentional musculoskeletal, heat, and cold-related injuries (9). Survey sections involve questions on topics including injury history, injury risk factors, interventions, leadership perspectives, and injury prevention interests (9). For the current study, questions pertaining to heat and cold injuries were removed to focus on MSKI knowledge. To better represent ROTC as the target demographic, some questions were altered (e.g., phrases such as “service member” or “soldier” changed to “cadet”) or removed (e.g., questions about military occupation due to cadets not having a defined military occupation specialty). Outside of demographic and leadership perspective questions, no other questions within the survey were changed. The final questionnaire used included 45 questions. The survey included questions regarding self-rated fitness [2 questions], injuries in the previous twelve months [3], the impact of injuries on the US military [5], injury risk factors and prevention strategies [25], perceptions of cadre’s injury prevention behaviors [4], and preferences for receiving future injury prevention educational materials [6]. The questions concerned with injury risk factors and interventions are categorized into those that increase injury risk [8 questions], those that do not decrease or may increase risk [4], those that reduce risk [4], those that neither increase nor decrease risk [2], and those for which scientific evidence is not conclusive [7]. The survey included a written informed consent document detailing the aims, procedures, survey content, and potential risks of completing the survey. Those cadets who signed and voluntarily agreed to the informed consent document initiated the survey. Beyond distributing the survey, military science instructors had no direct involvement with the study, and information regarding cadets’ responses and study results were not shared with instructors.
Cadets from the two ROTC programs completed the survey at different time points. Participants from the midwestern university completed paper copies of the survey. Cadets anonymously filled out the questionnaire in August 2018 in a classroom setting. For cadets participating at the southwestern university, the survey was disseminated by military science instructors via university email using an anonymous web address link. The web-based survey was hosted online and delivered using Qualtrics XM software (Qualtrics, Provo, UT, USA) from January to March 2020.
Statistical Analysis
Data from cadets who completed all questions on the survey were included in the final analysis. Data analyses were conducted using Office Excel 365 (Microsoft, Redmond, WA, USA). Quantified results were presented as frequencies and percentiles.
RESULTS
Of the 125 cadets who agreed to participate, 114 (91%) completed the survey in its entirety; 7 cadets from the midwestern university and 4 cadets from the southwestern university began but did not complete the survey. Of those who completed the survey, the average time to completion was 7 minutes online (60/114) and under 10 minutes for the paper version (54/114).
In the current population of participating cadets, slightly more than one third (43/114, 38%) reported having been injured in the previous year. Figure 1 shows the distribution of self-reported causes of injury, with nearly three-quarters (31/43, 72%) reporting a type of physical training (e.g., running or exercise) as the cause of injury. Of those with an injury, the mechanism of injury was self-identified as resulting from a single incident (12/43, 28%), overuse (28/43, 65%), or unsure (3/43, 7%).
Figure 1.
Percentage distribution of self-reported injury causes among respondents who reported an injury (n = 43). Cadets most frequently self-reported running as the primary mechanism for injuries sustained during the 12 months prior to completing the survey.
Findings for questions pertaining to MSKI risk factors and interventions are presented in Tables 1–5. Of those topics that have been previously defined as contributing to increased risk of injury, only high flexibility was incorrectly associated with decreased risk. Regarding topics categorized as not decreasing, but potentially increasing risk, the majority of participants incorrectly identified back brace/lifting belts and stretching prior to exercise as interventions that would decrease injury risk. Participants correctly identified all interventions that reduce MSKI risk except for agility training. The majority of cadets could not identify any items that neither increase nor decrease injury risk or the items for which scientific consensus does not exist for ascribing risk.
Table 1.
Percentage distribution of respondents’ knowledge of factors that increase MSKI risks†.
| Decreases Risk (%) | Neither (%) | Increases Risk (%) | Not Sure (%) | |
|---|---|---|---|---|
| Increase running mileageⱡ | 12% | 18% | 56% | 13% |
| Dehydration | 3% | 0% | 96% | 2% |
| Prior injury | 3% | 2% | 93% | 3% |
| Tobacco useⱡ | 5% | 6% | 82% | 7% |
| High flexibilityⱡ | 75% | 9% | 7% | 10% |
| Very thin body typeⱡ | 4% | 19% | 66% | 11% |
| Low physical fitness levelⱡ | 4% | 13% | 77% | 6% |
| Low calorie intakeⱡ | 4% | 8% | 80% | 8% |
Table 2.
Percentage distribution of respondents’ knowledge of factors that do not decrease or may increase MSKI risks†.
Table 3.
Percentage distribution of respondents’ knowledge of factors that reduce MSKI risks†.
Table 4.
Percentage distribution of respondents’ knowledge of factors that do not decrease nor increase MSKI risks†.
Table 5.
| Decreases Risk (%) | Neither (%) | Increases Risk (%) | Not Sure (%) | |
|---|---|---|---|---|
| Fatigue | 3% | 3% | 92% | 3% |
| High body mass index | 6% | 10% | 75% | 9% |
| Proper exercise technique | 94% | 0% | 3% | 4% |
| Older age (>40 years) | 1% | 5% | 82% | 12% |
| Dietary supplements | 25% | 31% | 29% | 16% |
| Older running shoes | 6% | 5% | 82% | 6% |
| Male sex | 21% | 45% | 17% | 18% |
Cadets’ opinions regarding their ROTC program cadre’s interest in injury prevention are shown in Figure 2. The majority of cadets reported agreement in three of the four questions evaluating program cadre’s injury prevention behaviors; however, only 43% of cadets agreed that they are being provided information to reduce injuries. Negative views regarding cadre’s emphasis of injury prevention were reported by 7–16% across the four questions.
Figure 2.
Percentage distribution of respondents’ perceptions of leadership interest in injury prevention. A: 80% of cadets agree that their leadership makes injury prevention a priority. B: 46% of cadets agree that they are provided information to help reduce injuries. C: 61% of cadets agree that they are informed about injuries within their ROTC program. D: 66% of cadets agree that their leadership models injury prevention efforts.
Cadets’ areas of interest in receiving future injury prevention information, in relation to specific activities, are reported in Figure 3. Cadets were allowed to choose all topics that applied to their interests. Due to low responses, the following items were combined into a single “Sports” category: football, basketball, racket sports (e.g., racquetball, tennis, badminton, etc.), softball/baseball, and snow sports (e.g., skiing, snowboarding, etc.). A majority of responses (234/364, 64%) showed a desire for further injury prevention information on physical training-related subjects such as running, resistance training, and agility training.
Figure 3.
Respondents’ choices of activities for which they were interested in receiving further injury prevention information. Running, weight-lifting, agility training, ruck marching, and extreme conditioning training were the most frequently chosen activities of interest for cadets. Note: Total number of responses to this question exceed the total number of responses to the survey as respondents were allowed to select all activities for which they had interest in learning more.
Injury-specific areas of interest in receiving further injury prevention information are reported in Figure 4. Regarding preferred modality for future injury prevention educational materials, 43% (58/135) preferred computer-based delivery, 31% (42/135) mobile (phone or tablet) delivery, and 21% (28/135) printed materials. While a small number (7/135, 5%) of respondents provided a free-text response to the question about preferred delivery method, all free-text responses described a desire to receive classroom instruction on injury prevention.
Figure 4.
The types of injuries for which respondents would like further information. Strains were the injury type most frequently chosen followed by fractures, sprains, and tendinopathies. Note: Total number of responses to this question exceed the total number of responses to the survey as respondents were allowed to select all injury types for which they would like further information.
DISCUSSION
The current study evaluated US Army ROTC cadets’ injury prevention knowledge utilizing a survey originally produced by the USAPHC (9). Similar to the USAPHC’s study (9), present findings indicate that ROTC cadets hold many common beliefs about injury prevention which are not scientifically supported. These results show that respondents hold many common beliefs about injury prevention which are not scientifically supported. In accordance with the USAPHC’s delineation of topics needing further education, as indicated by a greater than 10% incorrect response rate (9), only dehydration and previous injury do not show need for educational intervention in an ROTC population. Current findings provide preliminary insight into the knowledge base of future, commissioned US Army officers. In addition, data on self-reported injuries, views on leadership’s support, and desired areas of future education provide a holistic perspective of injury prevention within an Army ROTC population.
While overall response distributions of injury prevention topic areas (Table 1) were comparable to US Army personnel, key differences did exist (9). Based on the frequency of responses, cadets were more likely to select the “Not Sure” response than US Army personnel when evaluating interventions on the survey (9). Multiple factors could have potentially influenced this discrepancy between populations such as differences in intellectual humility, openness, and belief superiority; however, no research has investigated these constructs in either population. At this time, data do not exist to statistically compare these two population demographics; however, both the similarities and differences in survey responses between US Army ROTC cadets and US Army employees warrants further investigation.
When contrasting the populations, ROTC cadets were more likely to identify the increased injury risk associated with being clinically underweight (ROTC: 66%, US Army personnel: 25%) and were less likely than US Army personnel to identify increased running mileage (ROTC: 56%, US Army personnel: 80%) as a factor that escalates injury risk (9). Failure of almost half of ROTC cadets to identify running mileage as elevating injury risk is of particular concern. A profound body of evidence exists linking running loads to MSKI, especially of the lower extremity (8). Decreasing the frequency, duration, and mileage of sustained running while replacing it with other aerobic modalities, such as interval running, lowers injury incidence without any meaningful decrease in performance on military physical fitness assessments (12). Likewise, the addition of neuromuscular-based proprioception and agility exercises decreases injury risk (7); however, only 46% of cadets identified the injury-reducing benefits of such training and 33% marked agility training as increasing injury risk.
Responses suggest that cadets attributed protective qualities to many concepts that do not lower injury risk. Compared to US Army personnel (9), ROTC cadets more frequently reported stretching prior to exercise as lowering injury risk (ROTC: 86%, US Army personnel: 58%). This belief tends to be common amongst a running population (22), despite most research-based evidence finding no connection between stretching and lower injury risk (13). In addition, the majority of cadets (75%) reported that maintaining a high degree of flexibility lowers injury risk. In actuality, flexibility shows a U-shaped curve regarding injury risk, where both high and low flexibility increases risk compared to individuals who display a normal range (11). A number of cadets (42%) expressed the belief that using nonsteroidal anti-inflammatory drugs (NSAIDs) after exercise would decrease injury risks. This response is of great concern because NSAID use (both prescribed and self-administered) in the US Army is high (23,24) despite the risk of gastrointestinal adverse events from NSAIDs, especially with prolonged use (19). Scientific literature has not shown a reduction in MSKI rates as a result of peri-exercise use of NSAIDs (5). Seventy-six percent of cadets responded that back braces/lifting belts lower injury risk. Lifting belts have shown obvious performance benefits with no strong arguments against their use for strength and conditioning (21). However, the overall scientific consensus regarding back braces and lifting belt use on injury rates suggests no effect on risk with the majority of literature finding no observable benefit (21). Cadets’ responses on these topics indicate that they may be learning MSKI prevention information from sources that are not evidence-based.
In questions regarding perceptions of leadership, ROTC cadets in this study were far more likely to agree that their leadership showed interest in injury prevention (Figure 4) than US Army personnel in USAPHC’s study (9), possibly due to the nature of leader-subordinate relationships in a training environment such as the ROTC. Similar responses were seen between the ROTC cadets and US Army personnel (9) regarding agreement with the statement: I am provided information to help reduce injuries (my own and/or others). Forty-six percent of ROTC cadets agreed with the statement while 43% of US Army personnel agreed (9). As MSKI prevention is not a standard component of the ROTC program curriculum, cadets may only receive military-related injury prevention material from military instructors based on the instructor’s personal experiences, beliefs, and willingness to share such information. Oftentimes, cadets rely on each other to spread injury prevention and treatment strategies amongst themselves rather than obtaining information from a valid and reliable source.
ROTC cadets expressed interest in further injury prevention information regarding running, weight training, agility exercises, strains, fractures, and sprains. The majority of respondents showed a preference for educational materials to be delivered electronically. However, classroom instruction on injury prevention and physical training maybe highly desirable for some, as all seven free-text responses expressed a desire for this education modality. At this time, US Army Cadet Command does not mandate injury prevention as a component of the ROTC curriculum. The Defense Oversight Council’s Joint Services Physical Training Injury Prevention Working Group concluded that education of military commanders and leadership support are necessary components of successful prevention programs (5). The ROTC program is the largest accession source for commissioned officers across all branches of the military (26). Thus, ensuring that the future military officers trained through the ROTC are well-educated on physical training and injury prevention, may improve leader support and empower force-wide support for the adoption of, and adherence to, prevention programs. The US Army has been progressively moving towards a holistic health model, which focuses on injury prevention and health in all forms. The recently introduced Holistic Health and Fitness (H2F) program is a multi-faceted human performance framework designed with the goal of optimizing military readiness, reducing injury rates, and improving rehabilitation after injuries (4). Due to the universal impact of injuries on all branches of the military and countries around the world, future research should be performed to identify the potential for universal knowledge gaps as well as those that are branch and nationality specific. Once knowledge gaps have been identified, specific educational interventions can be developed to improve targeted areas.
While this study provides valuable observations on the current injury prevention knowledge of US Army ROTC cadets, some limitations should be noted. This study used a multi-mode survey method where one group completed the survey online and the other group completed a paper copy of the survey. The literature comparing validity, reliability, and psychometric quality between web-based and paper surveys has been inconsistent, with some research showing no psychometric difference between modes (3) and other research finding that respondents to web-based surveys are more likely to disclose information on sensitive topics (14). However, exploratory binary logistic regression comparisons of responses between our two groups suggested minimal difference in answers between paper and web-based responses to the survey, as only five of the twenty-five total questions were found to be significant covariates (stretching after exercise: p = 0.021, mouthguard use: p = 0.017, tobacco use: p = 0.001, low physical fitness: p = 0.045, and fatigue: p = 0.033), indicating differences between ROTC battalion responses. Another limitation of this study is that demographic information was not collected for survey respondents. While this did not impact the ability to observe cadets’ knowledge of injury prevention topics based on survey responses, the lack of demographic information prevented statistical comparison of response differences based on descriptive categories such as age, sex, and how many years cadets have participated in the ROTC.
In order to develop implementation strategies and educational materials on injury prevention, identifying the current injury prevention knowledge of military personnel is essential. Based on the results of this study, there is demonstrated need to improve the injury prevention knowledge of ROTC cadets, particularly in the areas of running, flexibility, and agility training. Cadets self-identified areas of desired additional information and education included running, weight training, agility training, and injuries such as strains, sprains, fractures, and tendinopathies, primarily through electronic media. The current study provides vital information into the future knowledge base of military officers, as ROTC is the largest commissioning source of US military officers (26). ROTC cadets and officer recruits during their initial military training should be a critical target population for injury prevention education, as a lack of leader support and awareness may inhibit the effectiveness of injury prevention programs. Future research should not only continue to identify MSKI knowledge gaps but also determine how best to address behavioral and cultural barriers that prevent appropriate adoption of injury prevention strategies.
ACKNOWLEDGEMENTS
The authors wish to thank the ROTC cadets from Illinois State University Redbird Battalion and University of Nevada, Las Vegas Rebel Battalion for participating in this study. We would also like to thank the School of Kinesiology and Recreation, Illinois State University for collecting and sharing data used for this article.
The authors have no funding sources or competing interests to declare.
REFERENCES
- 1.Andersen KA, Grimshaw PN, Kelso RM, Bentley DJ. Musculoskeletal lower limb injury risk in army populations. Sports Med Open. 2016;2:22. doi: 10.1186/s40798-016-0046-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Anderson MK, Grier T, Canham-Chervak M, Bushman TT, Jones BH. Occupation and other risk factors for injury among enlisted U.S. Army soldiers. Public Health. 2015;129(5):531–8. doi: 10.1016/j.puhe.2015.02.003. [DOI] [PubMed] [Google Scholar]
- 3.Börkan B. The mode effect in mixed-mode surveys: Mail and web surveys. Soc Sci Comput Rev. 2010;28(3):371–80. [Google Scholar]
- 4.Brading T. Holistic health added to Army fitness doctrine. 2020. Available at: https://www.army.mil/article/239475/holistic_health_added_to_army_fitness_doctrine.
- 5.Bullock SH, Jones BH, Gilchrist J, Marshall SW. Prevention of physical training-related injuries recommendations for the military and other active populations based on expedited systematic reviews. Am J Prev Med. 2010;38(1 Suppl):S156–181. doi: 10.1016/j.amepre.2009.10.023. [DOI] [PubMed] [Google Scholar]
- 6.Dijksma CI, Bekkers M, Spek B, Lucas C, Stuiver M. Epidemiology and financial burden of musculoskeletal injuries as the leading health problem in the military. Mil Med. 2020;185(3–4):e480–6. doi: 10.1093/milmed/usz328. [DOI] [PubMed] [Google Scholar]
- 7.Dijksma I, Arslan IG, Etten-Jamaludin FS, Elbers RG, Lucas C, Stuiver MM. Exercise programs to reduce the risk of musculoskeletal injuries in military personnel: A systematic review and meta-analysis. PM R. 2020;12(10):1028–1037. doi: 10.1002/pmrj.12360. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Gabbett TJ, Ullah S. Relationship between running loads and soft-tissue injury in elite team sport athletes. J Strength Cond Res. 2012;26(4):953–60. doi: 10.1519/JSC.0b013e3182302023. [DOI] [PubMed] [Google Scholar]
- 9.Hauschild VD, Schuh A, Jones BH. What soldiers know and want to know about preventing injuries: A needs survey regarding a key threat to readiness. US Army Med Dep J. 2016 January–March;10-9 [PubMed] [Google Scholar]
- 10.Heagerty R, Sharma J, Clayton J. A retrospective analysis of five years musculoskeletal injury data in British infantry recruits. Ann Musculoskelet Med. 2017;1(2):32–8. [Google Scholar]
- 11.Ingraham SJ. The role of flexibility in injury prevention and athletic performance: Have we stretched the truth? Minn Med. 2003;86(5):58–61. [PubMed] [Google Scholar]
- 12.Knapik JJ. Influence of an injury reduction program on injury and fitness outcomes among soldiers. Inj Prev. 2004;10(1):37–42. doi: 10.1136/ip.2003.002808. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med. 2014;48(11):871–7. doi: 10.1136/bjsports-2013-092538. [DOI] [PubMed] [Google Scholar]
- 14.Link MW, Mokdad AH. Effects of survey mode on self-reports of adult alcohol consumption: A comparison of mail, web, and telephone approaches. J Stud Alcohol. 2005;66(2):239–45. doi: 10.15288/jsa.2005.66.239. [DOI] [PubMed] [Google Scholar]
- 15.Molloy JM, Pendergrass TL, Lee IE, Chervak MC, Hauret KG, Rhon DI. Musculoskeletal injuries and United States Army readiness part I: Overview of injuries and their strategic impact. Mil Med. 2020;185(9–10):e1461–e1471. doi: 10.1093/milmed/usaa027. [DOI] [PubMed] [Google Scholar]
- 16.Navalta JW, Stone WJ, Lyons TS. Ethical issues relating to scientific discovery in exercise science. Int J Exerc Sci. 2019;12(1):1–8. doi: 10.70252/EYCD6235. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Nindl BC, Jaffin DP, Dretsch MN, Cheuvront SN, Wesenstein NJ, Kent ML, et al. Human performance optimization metrics: Consensus findings, gaps, and recommendations for future research. J Strength Cond Res. 2015;29(11S):S221–45. doi: 10.1519/JSC.0000000000001114. [DOI] [PubMed] [Google Scholar]
- 18.Orr R, Schram B, Pope R. Sports injuries in the Australian Regular Army. Safety. 2020;6(2):23. [Google Scholar]
- 19.Qaseem A, McLean RM, O’Gurek D, Batur P, Lin K, Kansagara DL. Nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults: A clinical guideline from the American College of Physicians and American Academy of Family Physicians. Ann Intern Med. 2020;173(9):739–748. doi: 10.7326/M19-3602. [DOI] [PubMed] [Google Scholar]
- 20.Radzak KN, Sefton JM, Timmons MK, Lopp R, Stickley CD, Lam KC. Musculoskeletal injury in Reserve Officers’ Training Corps: A report from the Athletic Training Practice-Based Research Network. Orthop J Sports Med. 2020;8(9) doi: 10.1177/2325967120948951. 2325967120948951. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Renfro GJ, Ebben WP. A review of the use of lifting belts. Strength Cond J. 2006;28(1):68–74. [Google Scholar]
- 22.Saragiotto BT, Yamato TP, Lopes AD. What do recreational runners think about risk factors for running injuries? A descriptive study of their beliefs and opinions. J Orthop Sports Phys Ther. 2014;44(10):733–8. doi: 10.2519/jospt.2014.5710. [DOI] [PubMed] [Google Scholar]
- 23.Sauers SE, Smith LB, Scofield DE, Cooper A, Warr BJ. Self-management of unreported musculoskeletal injuries in a U.S. Army brigade. Mil Med. 2016;181(9):1075–80. doi: 10.7205/MILMED-D-15-00233. [DOI] [PubMed] [Google Scholar]
- 24.Walker LA, Zambraski EJ, Williams RF. Widespread use of prescription nonsteroidal anti-inflammatory drugs among U.S. Army active duty soldiers. Mil Med. 2017;182(3):e1709–12. doi: 10.7205/MILMED-D-16-00183. [DOI] [PubMed] [Google Scholar]
- 25.Wardle SL, Greeves JP. Mitigating the risk of musculoskeletal injury: A systematic review of the most effective injury prevention strategies for military personnel. J Sci Med Sport. 2017;20:S3–10. doi: 10.1016/j.jsams.2017.09.014. [DOI] [PubMed] [Google Scholar]
- 26.Population representation in the military services: Fiscal year 2018 summary report. Arlington, VA: CNA Military Advisory Board; 2018. [Google Scholar]