prevention of physical training–related injuries resource library/prevention of physical...

FtMItpR

D2

S

Prevention of PhysicalTraining–Related Injuries

Recommendations for the Military and Other ActivePopulations Based on Expedited Systematic Reviews

Steven H. Bullock, DPT, MA, ATC, Bruce H. Jones, MD, MPH, Julie Gilchrist, MD,Stephen W. Marshall, PhD

Background: The Military Training Task Force of the Defense Safety Oversight Council chartered aJoint Services Physical Training Injury PreventionWorking Group to: (1) establish the evidence base formaking recommendations to prevent injuries; (2) prioritize the recommendations for prevention pro-grams andpolicies; and (3) substantiate theneed for further research and evaluationon interventions andprograms likely to reduce physical training–related injuries.

Evidence acquisition: Awork groupwas formed to identify, evaluate, and assess the level of scientifıcevidence for various physical training–related injury prevention strategies through an expedited system-atic review process. Of 40 physical training–related injury prevention strategies identifıed, education,leader support, andsurveillanceweredetermined tobeessential elementsof a successful injurypreventionprogram and not independent interventions. As a result of the expedited systematic reviews, one moreessential element (research)was added for a total of four. Six strategieswere not reviewed. The remaining31 interventions were categorized into three levels representing the strength of recommendation:(1) recommended; (2) not recommended; and (3) insuffıcient evidence to recommendornot recommend.

Evidence synthesis: Education, leadership support, injury surveillance, and research were deter-mined to be critical components of any successful injury prevention program. Six interventions (i.e.,prevent overtraining, agility-like training, mouthguards, semirigid ankle braces, nutrient replace-ment, and synthetic socks) had strong enough evidence to becomeworking group recommendationsfor implementation in the military services. Two interventions (i.e., back braces and pre-exerciseadministration of anti-inflammatory medication) were not recommended due to evidence of inef-fectiveness or harm, 23 lacked suffıcient scientifıc evidence to support recommendations for allmilitary services at this time, and six were not evaluated.

Conclusions: Six interventions should be implemented in all fourmilitary services immediately to reducephysical training–related injuries. Two strategies shouldbediscouragedby all leaders at all levels.Of particularnote, 23 popular physical training–related injury prevention strategies need further scientifıc investigation,review, and group consensus before they can be recommended to the military services or similar civilianpopulations. The expedited systematic process of evaluating interventions enabled theworking group tobuildconsensus around those injury prevention strategies that had enough scientifıc evidence to support arecommendation.(AmJPrevMed2010;38(1S):S156–S181)PublishedbyElsevier Inc.onbehalfofAmerican JournalofPreventiveMedicine

I

Itf(ma

rom thePublicHealthAssessment Program (Bullock) and the Injury Preven-ion Program (Jones), U.S. ArmyCenter forHealth Promotion andPreventiveedicine, Aberdeen Proving Ground, Maryland; Division of Unintentional

njury Prevention (Gilchrist), National Center for Injury Prevention andCon-rol, Centers for Disease Control and Prevention, Atlanta, Georgia; and De-artment of Epidemiology Biostatistics Core (Marshall), Injury Preventionesearch Center, University of North Carolina, Chapel Hill, North CarolinaAddress correspondence and reprint requests to: Steven H. Bullock,

PT, MA, ATC, 5158 Blackhawk Road, Aberdeen Proving Ground MD1010. E-mail: [email protected].

f0749-3797/00/$17.00doi: 10.1016/j.amepre.2009.10.023

156 Am J Prev Med 2010;38(1S):S156–S181 Published by El

ntroduction

n 2003 the Secretary of Defense (SECDEF) directedthat rates of accidents and injuries must be markedlyreduced.1 In response to the SECDEF’s instruction,

he Defense Safety Oversight Council (DSOC) wasormed to provide governance onDepartment ofDefenseDoD)-wide efforts to reduce preventable injuries andishaps. The Under Secretary of Defense for Personnelnd Readiness chairs the DSOC, who chartered nine task
orces to develop recommendations for policies, pro-
sevier Inc. on behalf of American Journal of Preventive Medicine

mailto:[email protected]

gr(at

nctaDbhdMstseesPisw

Wwtegrivdg

1

2

3

EAanreit

vtassr

iicmwittaiboAtbrT(vSmrGCifMap

eteEisgpr

fTfwi

Bullock et al / Am J Prev Med 2010;38(1S):S156–S181 S157

J

rams, and other investments to reduce preventable inju-ies and accidents. The Military Training Task ForceMTTF) was chartered to support the SECDEF’s accidentnd injury prevention directive with a focus on interven-ions that relate to all aspects of military training.Injury is undisputedly the leading health and readi-ess threat to the armed forces. Injuries are the leadingause of service member hospitalizations and outpa-ient visits, many resulting in preventable discharges,nd account for over 25 million limited duty daysoD-wide annually.2–4 Training-related injuries haveeen identifıed as the leading cause of clinic visits andave a substantial impact on the readiness of the forceue to the amount of limited duty time they cause.5,6

ost of the preventable acute and traumatic injuriesustained by military personnel are due to the cumula-ive effect of weight bearing physical training activitiesuch as running, particularly for military basic train-es.7–16 A working group of civilian andmilitary injuryxperts from the Johns Hopkins Center for Injury Re-earch and Policy and the U.S. Army Center for Healthromotion and Preventive Medicine (USACHPPM)dentifıed physical training as the largest and mostevere health problem for the U.S. Army and the oneith the greatest possibility for prevention success.17,18

The Joint Services Physical Training Injury Preventionorking Group (JSPTIPWG, hereafter referred to asorking group, except in the tables) was created underhe Military Training Task Force in September 2004 tovaluatemilitary physical training injury prevention pro-rams, policies, and research for recommendations toeduce physical training–related injuries during and afternitial military training within the four U.S. military ser-ices (army, navy, air force, andMarine Corps). An expe-ited systematic review process used by the workingroup served three primary purposes:

. Establish the evidence base for making recommenda-tions to prevent physical training–related injuries;. Prioritize the recommendations for prevention pro-grams and policies; and. Substantiate the need for further research and evalua-tion of interventions and programs likely to reducephysical training–related injuries.

vidence Acquisitionworking group was formed which included 29 militarynd civilian researchers, public health practitioners, cli-icians, training offıcers, epidemiologists, and analystsepresenting the four U.S. military services and injuryxperts from the CDC as well as professors at academicnstitutions. The working group initially met twice by
eleconference and discussed a strategy for accessing pre- t
anuary 2010

ious subject matter expert panel recommendations, de-ermined how to systematically review the scientifıc liter-ture, developed inclusion and exclusion criteria fortudies identifıed in the search process, and divided re-ponsibility for each of the intervention topics to beeviewed.In order to formulate a list of interventions, the work-

ng group looked to the past work of six expert panels todentify commonalities among the services. This in-luded a 1994 panel of injury prevention experts andilitary leaders from the U.S. Navy and Marine Corpsho met to evaluate and discuss improvements to phys-cal training. As a result of this meeting, recommenda-ions were published by the Naval Health Research Cen-er.19 Later, guidelines for preventing injuries in sailors inccession training were published.20,21 A panel of armynjury and fıtness expertsmet in 1999 at the army’s largestasic training post, Fort Jackson SC, under the directionf the Army Surgeon General and the Commander of thermy Training and Doctrine Command, and prioritizedheir fındings and recommendations.22 In 2000, theMor-idity and Mortality Weekly Report (MMWR) summa-ized recommendations to reduce injury risk inwomen.23

he Army Musculoskeletal Injury Prevention PlanMIPP) represented a collection of evidence-based inter-entions compiled by the USACHPPM for the Armyurgeon General in 2003. This compilation of recom-endations for the prevention of musculoskeletal inju-ies in basic training was endorsed by the Army Surgeoneneral andprovided to theArmyTraining andDoctrineommand as medical recommendations to reduce phys-cal training–related injuries.24 In addition, scientistsrom the U.S. Army Research Institute of Environmentaledicine summarized the literature on the preventionnd control of musculoskeletal injuries associated withhysical training.25

Working from the interventions identifıed by thesexpert panels, an initial list of topics included 27 preven-ion strategies, divided into the following categories: Ex-rcise/Training Programs; Equipment and Environment;ducation; Nutrition, Supplements andHydration;Med-cation and Medical Care; Leadership/Accountability Is-ues; and Surveillance and Evaluation. The workingroup expanded this list to a total of 40 strategies withotential to reduce the incidence of physical training–elated injuries.An expedited literature review process was defıned in

ıve steps to be completed before a face-to-face meeting.he fırst step was to conduct an online literature searchor the specifıc prevention strategies assigned. The focusas on the primary prevention of injuries related to phys-cal training. Working group members were encouraged
o use a variety of online search engines, but a minimum

oTIwwtdt

rawatowmnsonipscrsibfairat

oterccttgOdl(e

it

psitcetceea

toeaTmfptwactfaid

icSqiaitnftooliieohsl

S158 Bullock et al / Am J Prev Med 2010;38(1S):S156–S181

f the following three were required:MEDLINE, Defenseechnical Information Center Scientifıc and Technicalnformation Network, and Cochrane databases. Searchesere limited to human studies published after 1970 andritten in English. Working group members were askedo record the total number of hits per search as well as toocument the scientifıc reference of the studies meetinghe inclusion criteria.Studies that met the review inclusion criteria were

esearch studies that presented the methods, results,nd conclusions of an original scientifıc investigationhich included injury as a measured outcome. System-tic reviews that described the results of original scien-ifıc investigations and included injury as a measuredutcome represented the highest level of evidence andere also included. However, public health decisionsust often consider all available scientifıc evidence,ot just randomized controlled trials.18,26 Interventiontudies, risk factor/cause studies, descriptive epidemi-logy studies, and case series (as defıned in A Dictio-ary of Epidemiology27) were listed and categorized ifnjury was a measured outcome. Although not therimary focus of the search, other original researchtudies (e.g., fıeld, epidemiologic, lab, or biomechani-al) related to topics that did not measure injury, butather measured intermediate outcomes (e.g., atretching study measuring flexibility, a physical train-ng program measuring improvements in fıtness, oriomechanical studies examining shock absorbency ofootwear) were listed but were not considered to haven influence on the recommendations for preventingnjury. Original scientifıc investigations not directlyelevant to the topic or nonresearch publications suchs editorials, letters, expert opinion papers, and educa-ional articles were excluded from further assessment.The next step was to classify the literature on injuryutcomes by the study type (i.e., systematic reviews, in-ervention studies, risk factor/cause studies, descriptivepidemiology, case series, and other non-injury outcomeesearch) within a classifıcation matrix and assess theonsistency of the studies. Table 1 is an example of aompleted classifıcation matrix for the Prevent Over-raining strategy. Injury outcomes were of prime impor-ance as they most clearly demonstrated the effect of aiven strategy on the ultimate goal of reducing injuries.ther outcomes that represented markers of muscleamage or were related to performance were consideredess conclusive. The strength and quality of the evidenceincluding markers of muscle damage in one instance)ventually factored into the decision-making process.Asa thirdstep, theworkinggroupmemberswereasked to

ndicate whether or not the study included other interven-
ions in addition to the intervention in question. For exam- m
le, a study was considered to be a multi-interventionaltudy if more than one strategy may have influenced thenjury outcome. If the study included multiple interven-ions, it was annotated as such in the multiple-interventionolumn. Additionally, if the study had an overall positiveffect on injuries or injury rates (i.e., a reduction in injuries),he investigators would annotate a plus sign in the directionolumn. Conversely, if the study had an overall negativeffect (i.e., increase in injuriesor injury rates)or therewasnoffectmeasuredon injuries, anegative sign (�)oran“x”wasnnotated respectively.The fourth step in the process was to assess the quality of

he individual intervention and risk factor/cause studies inrder to gain some appreciation for the strength of the sci-nce. Each intervention study was qualitatively rated usingn adaptation of a ten-point scoring system developed byhacker and colleagues, which included sample, design,ethodology, and statistical analysis using a quality scoring

orm (Table 2).28 Each individual working group membererformed their own scoring and in the cases where morehan onemember scored the study, the average of all scoresere reported. A similar quality scoring form (Table 3) wasdapted for risk factor/cause studies. Once a score had beenalculated it was transferred to the appropriate column onhe classifıcationmatrix. Quality scores were not computedor descriptive epidemiology, clinical case series, or reviews,s these study types were not expected to contribute mean-ngfully to the evidence supporting the fınal recommen-ations.The fıfth and fınal step of the literature review process

nvolved a preliminary interpretation of prevention effı-acy using a format adapted from the U.S. Preventiveervices Task Force (USPSTF).29 The USPSTF grades theuality of the overall evidence for a strategy, service, orntervention on a three-point grading scale (good, fair,nd poor) and categorizes its recommendations accord-ng to one of fıve classifıcations reflecting the strength ofhe evidence and magnitude of net benefıt (benefıts mi-us harms). Good evidence includes consistent resultsrom well-designed, well-conducted studies in represen-ative populations that directly assess effects on healthutcomes. Fair evidence is suffıcient to determine effectsn health outcomes, but the strength of the evidence isimited by the number, quality, or consistency of thendividual studies, generalizability to routine practice, orndirect nature of the evidence on health outcomes. Poorvidence is insuffıcient to assess the effects on healthutcomes because of limited number of studies, lack ofomogeneity, low statistical power, important flaws intudy design or conduct, gaps in the chain of evidence, orack of information on important health outcomes.In keeping with military classifıcation schema, recom-
endations were color coded on a three-color scale (red,
www.ajpm-online.net

aimowdomoiewmmi

mht

scwaocitet

T

M es); �i


J

mber, and green) plus one additional color (gray). Greenncluded strategies with fair to good evidence to recom-end or strongly recommend, where the benefıts clearlyutweigh the harms; amber included those strategieshere no recommendation for or against could be made,ue to fair evidence supporting the strategy but a balancef benefıts and harms too close to justify a general recom-endation; and red indicated suffıcient evidence to rec-mmend against the strategy either due to evidence ofneffectiveness and/or where harms outweighed the ben-fıts. Gray was added to indicate those strategies forhich there was insuffıcient evidence in the literature toake a recommendation for or against. Working groupemberswere asked to classify each intervention strategy

able 1. Example classification matrix of literature search

Reviews Interventions Risk fac

Study Study M �/� Score Study

x

Almeida19

(1997)Knapik7,9 (2004) M � 8 Koplan39

Gillespie82

(2000)Knapik10,80 (2003) M � 8 Koplan38

Jones83 (2002) Rudzki16 (1999) M � 5 Marti41 (

Kellett84 (1986) Pope12 (1999) M � 5 Macera4

Renstrom85

(1985)Pollock66 (1977) M � 4 Sullivan3

VanMechelen86

(1992)Rudzki14 (1997) � 8 Jacobs37

Yeung204

(2001)Rudzki15 (1997) � 8 Brunet35

Pester11 (1992) M � 1 Bennell3

Yeung87 (2001) Deuster3

Rice13 (2002) � Not scored Reynolds

Buist328 (2008) x Not scored

, multiple intervention study; �, positive effect (reduces injuries or injury ratnjury rates

nto one of the four colors based on the combined assess- e

anuary 2010

ent of the strength of the evidence by the amount,omogeneity, and quality of the evidence according tohe adapted USPSTF format (Table 4).All intervention strategies thatwere considered to have

uffıcient scientifıc evidence by the reviewers were dis-ussed among all members of the working group. Eachorking group member had an opportunity to reviewnd comment on the quality scores and preliminary rec-mmendations from each review. Some of the factorsonsidered in the discussion were: (1) the number ofntervention studies demonstrating effectiveness (sys-ematic reviews, randomized controlled trials, and otherpidemiologic studies; (2) the homogeneity or consis-ency of the evidence (the number of studies showing

ults: prevent overtraining

useDescriptiveepidemiology

Caseseries

Non-injuryresearch

�/� Score Study Study Study

x

5) � 7.3 Beck44 (1985) Johnston326

2003

2) � 5.3 Browning45 (2000)

) � 7.3 Fredericson46 (1996)

9) � 9.3 Haverstock47 (2001)

84) � 1.3 Hreljac48 (2004)

6) � 6.0 Jones49 (1994)

0) � 2.0 Jones3 (1999)

9) � Not scored Kaeding51 (2001)

97) � Not scored Karlsson52 (2004)

990) � Not scored Kaufman5 (2000)

Kennedy53 (2005)

Macera54 (1992)

McCully55 (1986)

McKeag56 (1992)

Paty57 (1988)

Paty58 (1994)

Pell59 (2004)

Reeder60 (1996)

Sherrard61 (2004)

Watson62 (1998)

Wexler63 (1995)

, negative effect (increases injuries or injury rates); x, no effect on injuries or

res

tor/ca

(199

(198

1988

0 (198

27 (19

(198

(199

4 (199

6 (19

42 (1

ffıcacy versus no effıcacy, or harm); (3) the quality of the

elm�aotevdiosciasssjtdtlrdswcdtovme

svgtURtott(aettei

citaiatp5tdptm

ETtwip(Tttg

ainin


vidence (scores �3�ow quality, 4–6�oderate quality,7�high quality);nd (4) the numberf other interven-ions included inach study (multipleersus single). Afteriscussing all of thentervention topicsn which literatureearches had beenompleted, the work-ng group membersgreed that to be con-idered effective,trategies had to behown to reduce in-ury rates by at leastwo prospective, ran-omized or observa-ional studies or ateast one systematiceview showing a re-uction across multiple studies, and the quality of at leastome of the studies had to be high. Intervention strategiesith these characteristics were considered to have suffı-ient strength of scientifıc evidence to make recommen-ations for immediate implementation among all mili-ary services. However, in the absence of direct injuryutcomes, if there was an overwhelming reduction ofalidated markers for injury (e.g., biomarkers indicatinguscle damage) it was accepted as having suffıcientvidence.For those strategies that were found to have suffıcient

cientifıc evidence tomake recommendations for the pre-ention of injury among all military services, the workingroup prioritized them using a refıned set of criteria ini-ially developed through a joint effort between theSACHPPM and the Johns Hopkins Center for Injuryesearch andPolicy.17,18Criteriawereadapted forusewithhe working group, which provided a quantitativemeans ofbjectively rating and ranking injury prevention interven-ions to arrive at a prioritized list of recommended interven-ions to reduce military physical training–related injuriesTable 5). Three of the seven criteria assessedwereweightedsmore important factors than theothers: (1) strengthof thevidence (including the quality of the science); (2) magni-ude of the effect (e.g., size of health benefıt and the popula-ion affected); and (3) practicality of implementation (e.g.,xisting infrastructure to support the intervention, feasibil-

Table 2. JSPTIPWG Interventio

Author/year/title of interventi

Date of Review:

Problem and sample

1. Is there a clear statement

2. Is there a source of subjeyes, score 1.

3. Is there a clear description

Study design and methodology

4. Is it a randomized controll

5. Is it an observational stud

6. Is there collected data on

Data presentation and statistica

7. Are statistical methods cle

8. Are confidence intervals or

9. Are multivariate methods i

10. TOTAL SCORE—MaximumMatrix)

JSPTIPWG, Joint Services Physical Tr

ty, acceptability, and start-up cost). Other less important q

riteria included; (1) timeliness of reduction (e.g., time tomplement and see reduction); (2) sustainability (e.g., efforto keep going, maintenance cost, and training); (3) measur-bleoutcomes (measurable reductionsare lessnoteworthy ifmplementinga strategy thathasalreadybeendemonstrateds effective); and (4) collateral benefıt (e.g., increased mili-ary readiness, decreased attrition, or decreased other healthroblem). Each recommended intervention was rated on a-point scale, with 1 being low and 5 being high, for each ofhese seven criteria. The points given by raters were thenivided by 5 and multiplied by the maximum number ofoints for specifıed criteria, and the products added to gethe total points for a particular intervention (100 pointsaximum) (Table 5).

vidence Synthesishere were 40 physical training–related injury preven-ion strategies identifıed by the working group. Threeere determined to be critical components of a successfulnjury prevention program and not independent injuryrevention strategies: (1) education of military leaders;2) leadership support; and (3) unit injury surveillance.he working group agreed to categorize them as “essen-ial elements” of an injury prevention program. Duringhe process of the face-to-face meeting, the workingroup added a fourth essential element to the list: ade-

udies Quality Scoring Form

tudy:

Score

search question or hypothesis? If yes, score 1.

r sample described (e.g., inclusion criteria listed)? If

ntervention? If yes, score 1.

ial? If yes, score 2.

h data on relevant confounders? If yes, score 1.

rtant covariates used in the analysis? If yes, score 1.

lysis

described? If yes, score 1.

lues used? If yes, score 1.

alysis (e.g., regression) used? If yes, score 1.

re possible is 10 (transfer total to the Classification

g Injury Prevention Working Group

n St

on s

of re

cts o

of i

ed tr

y wit

impo

l ana

arly

p-va

n an

sco

uate resources for injury research and program evalua-

www.ajpm-online.net

te

aktsas

sct

irboeiaiic

TS

�

PJ Grou


J

ion (generally limited to service-level injury preventionfforts).Six intervention strategies were not reviewed (pre-

ssessment fıtness programs, individualized training,nee braces, forearm and elbow straps, early interven-ion, and psychosocial issues related to injury). Thesetrategies still require a literature review, objective qualityssessment, and working group discussion and consen-us (Table 6).Six interventions (20%) of the 31 injury prevention

trategies evaluated had strong enough evidence to be-ome working group recommendations for implementa-

able 3. JSPTIPWG Risk Factor/Cause of Injury Studies (coring Form

Author/year/title of risk factor/cause study:

Date of Review:Name of Reviewer:

Problem and sample

1. Is there a clear statement of research question or hypo

2. Is it stated that a power or sample size calculation was

3. Is the source of subjects or sample described (e.g., inclisted)? If yes, score 1.

4. Is the measurement of exposures/risk factors and outccriterion fully met, score 2; if partially met, score 1.

Study design and methodology

5. Is this a prospective cohort study? If yes, score 2.

or

Is it a retrospective cohort or case control study or othescore 1.

6. Is data on relevant confounders provided and controlledfully met, score 2; if partially met, score 1.

7. Is there data collected on important covariates used in

Data presentation and statistical analysis

8. Are statistical methods clearly described and appropriat

9. Are incidences (rates), risks (percentages), or odds of inIf yes, score 1.

10. Are confidence intervals or p-values used appropriately?

11. Are multivariate methods in analysis (e.g., regression) uscore 1.

12. Are demographic variables and associated risks/rates dyes, score 1.

13. TOTAL SCORE—Maximum score possible is 15.

14. TOTAL SCORE CORRECTED to 10-point scale�points ftotal to the Classification Matrix)

Significant contributions to content and design of this form made byrevention Working Group members: LtCol Vincent Fonseca, Dr. JuliSPTIPWG, Joint Services Physical Training Injury Prevention Working

ion in all four military services (prevent overtraining, g

anuary 2010

agility-like training,mouthguards, semi-rigid ankle braces,nutrient replacement,and synthetic socks).The recommended in-jury prevention strate-giesareprovided inTa-ble 7 in order of thestrength of the evi-dence, magnitude ofthe effect, practicality,timelinessof reduction,sustainability, measur-ableoutcomes,andcol-lateral benefıt as mea-sured by the scoringinstrument. Includedwithin this table are theaverage quality scores,the number of stud-ies with a positive ef-fect (a reduction ininjuries or injuryrates), negative effect(an increase in inju-ries or injury rates),and the number ofthose studies that dem-onstrated no effect oninjuries or injury rate.Two interventions

(6%) were not recom-mended (i.e., backbraces andpre-exerciseadministration of anti-inflammatory medica-tion) due to at leastfair evidence of inef-fectiveness or harm,respectively.

Twenty-three (74%) interventions (stretching, restart-ng exercise at lower levels, muscle strengthening, newunning shoes, warm-up and cool-down, group runningy body height, change in stride length, graduated hikingr marching, graduated loading, avoiding hazardous ex-rcise, separating body weight and fıtness assessments,nsoles, prescribing running shoes based on foot shape,nkle tape, improved running surfaces, improved land-ng surfaces, seasonal adjustments in training, smok-ng cessation programs, safe lifting education, ice, oralontraceptives for women, unit reconditioning pro-

ytic Epidemiology) Quality

Score

s? If yes, score 1.

? If yes, score 1.

and exclusion criteria

clearly described? If

propriate design? If yes,

ppropriately? If criterion

nalysis? If yes, score 1.

yes, score 1.

reported appropriately?

s, score 1.

appropriately? If yes,

ibed appropriately? If

line 13 �.667 (transfer

llowing Joint Physical Training Injuryhrist, and Dr. Stephen Marshall.p

Anal

thesi

done

lusion

omes

r ap

for a

the a

e? If

jury

If ye

sed

escr

rom

the foe Gilc

ram, and predictive modeling using an injury risk

ibsg

DAgsanm

EP

Ediogdeptpdoivs

wt

LiwaWiosp

Sdiigtoassttt(rphb

T

a

J Grou


ndex) reviewed from the scientifıc literature could note recommended due to lack of evidence, poor qualitytudies, or a balance of conflicting evidence (no homo-eneity) (Table 8).

iscussions the essential elements of an injury prevention pro-ramwere not considered independent injury preventiontrategies, they were not reviewed with the same scrutinys the other strategies. The following discusses the ratio-ale for selecting these four components as essential ele-ents of an injury prevention program.

ssential Elements of an Injury Preventionrogram

ducation. There are only three randomized trials thatemonstrate the effect of education on musculoskeletalnjury risks or rates, but those are in conjunction withther interventions as part of community-based pro-rams.7,30,31 One such program demonstrated a 75% re-uction in soccer injuries when coaches and players wereducated and supervised by physicians and physiothera-ists.30 Injuries were reduced 30% in Army initial entryrainees when education was included as a primary com-onent of an injury prevention program.7 While it isiffıcult to preciselymeasure the effect of education alonen injury rates, the dissemination of information regard-ng the proven strategies for the prevention of injury isital to the support of military commanders in their re-

able 4. Format for JSPTIPWG recommendationsa

Color code Recommendation template

Green

The JSPTIPWG strongly recommends [preventiongood evidence that [prevention strategy] reducesharms.orThe JSPTIPWG recommends [prevention strategy]fair evidence that [prevention strategy] reduces in

Amber

The JSPTIPWG makes no recommendation for orworking group found at least fair evidence that [pbut concludes that the balance of benefits and hServices and/or[but] may be appropriate for individual Services o

RedThe JSPTIPWG recommends against [prevention sleast fair evidence that [prevention strategy] is in

Gray

The JSPTIPWG concludes that the evidence is insprevention of injuries. The working group found evstrategy is lacking, of poor quality, or conflicting,Therefore, the working group recommends further

Adapted from United States Preventive Services Task Force (USPSTSPTIPWG, Joint Services Physical Training Injury Prevention Working

ponsibility to protect service members.31 Therefore, the h

orking group determined that education was an essen-ial element of any successful injury prevention program.

eadership support. The value of leader responsibil-ty and accountability cannot be overemphasized. It isell understood that when those who are responsiblere held accountable, the rate of progress improves.hile the literature does not specifıcally address the

mpact of leadership responsibility and accountabilityn injury rates, the working group deemed leadershipupport as an essential element of any successful injuryrevention program.

urveillance. Surveillanceprovides thedatanecessary foretermining current status of a problem, setting goals formprovement, and targeting interventions, and serves as annstrument to evaluate intervention success. The workingroup agreed that military commanders could influenceheir injury ratesbysimplyunderstanding their current statef injuries,what causes the injuries, settinggoals to improve,nd monitoring their success. This is not possible unlessurveillance of injuries and fıtness are routine and easilyummarized. Unit injury rates should be used as a barome-er of physical training program success or failure just as israditionally done with fıtness test scores. As the physicalraining program is a major cause of injuries in the militaryparticularly in the new recruit environment), high injuryates indicate a need to modify that program. Regular re-orting of injury data through the chain of command mayave the effect of encouraging greater command responsi-ility for unit physical performance and musculoskeletal

gy] for the prevention of injuries. The working group foundies and concludes that benefits substantially outweigh

he prevention of injuries. The working group found at leasts and concludes that benefits outweigh harms.

st [prevention strategy] for the prevention of injuries. Thetion strategy] can reduce injuriesis too close to justify a general recommendation for all

risk individuals.

gy] for the prevention of injuries. The working group found attive or that harms outweigh benefits.

ent to recommend for or against [prevention strategy] for thece that [prevention strategy] is an effective preventionthe balance of benefits and harms cannot be determined.arch on the [prevention strategy].

p

strateinjur

for tjurie

againrevenarms

r high

trateeffec

ufficiidenandrese

F)29

ealth. The working group agreed that surveillance and re-

www.ajpm-online.net

pgRgamstcn

“ofpamttt

TIPoHpp

DJ


J

orting of standardized injury metrics32 is an essential pro-ram element of any successful injury prevention program.esearch and program evaluation. The workingroup discovered a lack of scientifıc evidence in the liter-ture fromwhich tomake broad recommendations to theilitary services. In many cases, there simply were nocientifıc studies to indicatewhether strategieswere effec-ive. In other cases the evidence was of poor quality or wasonflicting, or the balance of the benefıts and harms could

able 5. JSPTIPWG criteria for ranking recommended injuntervention Name:urpose: This score sheet is a tool that provides a systebjectively comparing total scores of competing interventow to use this score sheet: Complete a score sheet foreliminary rating (1�low, 5�high) for each criterion. Theresented. Adding the final scores will provide a total sco

Criterion Totalpossib

1. Strength of the evidence (quality of science) 20

2. Magnitude of Net Effect 20

� Size of health benefit

� Size of population affected

3. Practicality 20

� Feasible

� Start-up cost

� Acceptable

� Existing infrastructure

4. Timeliness of reduction 10

� Implementation time

� Result time

5. Sustainability 10

� Effort to keep going

� Maintenance cost

� Training

6. Measurable outcomes 10

� Measurable reductions

7. Collateral benefit (e.g.: 10

� Increase readiness

� Decrease attrition

� Decrease in other health problem, etc.

TOTAL SCORE 100

ate of review:_____ Name of reviewer:_________________________SPTIPWG, Joint Services Physical Training Injury Prevention Working

ot be determined. As a result, the working group added p

anuary 2010

Adequate Resources for Research andProgramEvaluationf Training-Related Injury Prevention Interventions” as aourth essential element of a successful injury preventionrogram.Withoutmilitary branch or Service-level researchnd program evaluation of injury prevention strategies inilitary populations (and in comparable civilian popula-

ions), the rate of physical training–related injurieswill con-inue to be a burden on the military services and a healthhreat to force readiness. This paper identifıes 23 injury

evention strategies

c means of rating an injury prevention intervention and.h intervention under consideration. First, decide on asign a final score for each criterion using the formulahe maximum total score is 100.

s Preliminaryscore

Final score (preliminary score/5 � total points possible)

1 2 3 4 5 —/5 � 20 �

Low High

1 2 3 4 5 —/5 � 20 �

Low High

1 2 3 4 5 —/5 � 20 �

Low High

1 2 3 4 5 —/5 � 10 �

Low High

1 2 3 4 5 —/5 � 10 �

Low High

1 2 3 4 5 —/5 � 10 �

Low High

1 2 3 4 5 —/5 � 10 �

Low High

_______________________________________p

ry pr

matiionsr eacn asre. T

pointle

_____Grou

revention strategies which do not yet have suffıcient evi-

dseivp

wdweesvpro

PS

Ft

ioscpws

Tr

a

T

a

b

Te


ence to support as broad recommendations to themilitaryervices and six prevention strategies that have not yet beenvaluated. This total of 29 strategies represents a good start-ng point for researchers interested in studying the pre-ention of injuries in the military and similar civilianopulations.The literature related to six injury prevention strategiesas not searched for and, therefore, was not reviewed, oriscussed by the working group. There are currently noorking group recommendations for these interventionsxcept that they be reviewed and discussed by a group ofxperts in a systematic manner. The following discussesome key points from the supporting literature and pro-ides some rationale behind the classifıcation of the sixrevention strategies found to have suffıcient evidence toecommend immediate implementation to all branchesf the military Services.

revention Strategies with Sufficientcientific Evidence to Recommend

inding only six prevention strategies with enough scien-ifıc evidence to make recommendations to the four mil-

able 6. Intervention strategies without a completedeviewa

1. Provide pre-basic training fitness assessment andfitness programs for the least fit

2. Individualize physical training versus training as a groupor unit

3. Wear knee braces4. Wear forearm or elbow straps5. Utilize allied health professionals in a Pre-Military

Treatment Facility (MTF) care setting6. Accommodate for psychosocial issues related to injury

Interventions that require a systematic literature review, workinggroup discussion, and objective assessment

able 7. Recommended injury prevention strategies in or

Order Strategy

1 Prevent overtraining

2 Perform multiaxial, neuromuscular, proprioceptive, andagility training

3 Wear mouthguards during high-risk activities

4 Wear semirigid ankle braces for high-risk activities

5 Consume nutrients to restore energy balance within 1hour following high-intensity activity

6 Wear synthetic-blend socks to prevent blisters

Two of the most recent studies on this topic were of high quality.
Low-quality studies
tary services (Table 9). was surprising, given that manythers have been proposed by expert opinion or profes-ional organizations or promoted in laymagazines, or areommon traditional practices. Each of the following sixrevention strategies (presented in order of priority)ere deemed by the working group to have suffıcientcientifıc evidence for immediate implementation in all

f priority

iorityore

SD Qualityscore (M)

# positiveeffect

# negativeeffect

# noeffect

.3 8.5 5.9 8 0 0

.7 7.8 5.9 12 0 3b

.2 11.6 2.9a 16 0 3b

.1 10.3 6.4 11 0 0

.0 11.6 5.5 13 0 2b

score:ded afteroup scoring

7.3 5 0 0

able 8. Intervention strategies without sufficientvidence to recommend at this time

1. Stretch muscles before or after exercise2. Reinitiate exercise at lower intensity levels for

detrained individuals3. Target specific muscles to strengthen4. Replace running shoes at standard intervals5. Warm-up and cool-down before and after activity6. Place shorter service members in front of formations to

set running pace and cadence7. Manipulate stride length8. Participate in a standardized, graduated marching

(a.k.a hiking) program9. Gradually increase load-bearing during marching

10. Avoid hazardous exercises or exercise machines (e.g.,sit-ups, flutter kicks, etc.)

11. Separate body weight assessment and maximal effortphysical fitness tests

12. Wear shock-absorbing insoles13. Prescribe running shoes based on individual foot shape14. Wrap ankle with athletic tape prior to high-risk activity15. Run on improved surfaces that minimize injury risk16. Improve obstacle course landing surfaces17. Adjust training loads by seasonal variations18. Encourage smoking cessation programs to prevent

musculoskeletal injuries19. Educate service members on safe lifting techniques20. Apply ice to injuries early to prevent re-injury21. Take oral contraceptives to decrease injury if female22. Standardize unit reconditioning program after

rehabilitation from injury23. Predict injury risk by injury risk index modeling

der o

Prsc

86

77

74

70

67

Noadgr

www.ajpm-online.net

fsosrh

TwoibptehTsotto6aprn

ntsCrrcnsem1

rtanimm

otj2

tMfw

bbsawpbbdtms

(Bg22p

ptnsrrdmcntwrtdNdmepivteao


J

our military branches. In each case there were ampleystematic reviews or randomized controlled trials dem-nstrating effectiveness; the evidence across multipletudies consistently demonstrated a reduction of injuryates; and at least some of the evidencewas ofmoderate toigh quality.

he prevention of overtraining. Overtraining is a termithwhich the literature collectively refers to thephysiologyfmusculoskeletal overuse due to exercise or physical train-ng.Physical training isnecessary to condition servicemem-ers for their occupational andmilitary tasks and to providerotection against cardiovascular and bone healthhreats.20,33 In classic military tradition however, efforts toxceed the standards and/or execution of training errorsave contributed to the injury epidemic present today.here is a preponderance of military and civilian re-earch34–43 anddescriptive epidemiology3,5,44–63 that dem-nstrates that high running volume substantially increaseshe risk for lower-extremity injury. During initial militaryraining about 25% of men and about 50% of women incurne or more physical training–related injuries. Roughly0%–80% of these injuries occurs to the lower extremitiesnd are of the overuse type—a condition brought about byhysical training–volume overload (presumably excessiveunning relative to initial fıtness level and individual run-ing capability).Given the very strong evidence showing higher run-ingmileage as an injury risk factor, an obvious interven-ion is to reduce the amount of running performed byervice members. A study of recruits in U.S. Marineorps boot camp demonstrated that a 40% (22 mile)eduction in running distance was associated with a 54%eduction in stress fracture incidence with an insignifı-ant increase (3%) in run times.64 Thus, reducing run-ing mileage reduced stress fracture incidence with es-entially no effect on aerobic fıtness. In 1995 dollars it wasstimated that this intervention saved $4.5 million inedical care costs and nearly 15,000 training days in justyear.In a study of U.S. Army soldiers49 showed those who

an 74 fewer miles during 12 weeks of basic combatraining (BCT) decreased their injury incidence by 24%,nd maintained their aerobic fıtness. It is interesting toote that while they decreased the running mileage, theyncreased the miles marched (high-mileage run grouparched 68 miles; low-mileage run group marched 117iles).In a more recent study during 9 weeks of army BCT,ne battalion that ran a total of 17 miles (plus an unde-ermined amount of interval training) lowered their in-ury rates by one thirdwith similar improvements in their
-mile run times, as compared to a battalion that ran a t
anuary 2010

otal distance of 38 miles during the same time frame.10

ost of the miles run in the 17-mile group were per-ormed toward the end of BCT and very few in the earlyeeks.AU.S. Navy study comparingmale recruits assigned toasic training divisions reduced the amount of runningy 20 miles during naval recruit training and demon-trated a reduction of injuries by 20% without negativelyffecting physical fıtness.65 Similar results were obtainedith Australian Army recruits when running was re-laced with a graduated program of foot marches withackpack loads,14,15 which reduced all lower limb injuriesy 43% and knee injuries by 53%. The Australians alsoemonstrated that multi-interventional injury preven-ion programs that include the reduction of runningileage as the primary prevention strategy can reduceerious lower extremity stress fractures by 91%.12

The U.S. Army Training and Doctrine CommandTRADOC) Standardized Physical Training Program forCT, which incorporates less running mileage and areater variety of exercises, was implemented in April004. Since that time, injuries have been reduced by1% compared to a traditional BCT physical trainingrogram.9

While running is an excellent way to build aerobicower or cardiovascular fıtness, there are physiologicalhresholds of overtraining above which increases in run-ing duration and frequency do not result in a commen-urate increase in fıtness, but do result in higher injuryates. Among previously sedentary young male adults,unning above thresholds for duration and frequencyramatically increases risk of injury with little improve-ent on VO2max (the single best measure of cardiovas-ular fıtness). A classic study66 demonstrated that a run-ing duration of 45 minutes versus 30 minutes threeimes a week increases the injury incidence by 125%ithout a signifıcant change in VO2 max. Similarly aunning frequency of fıve times per week versus threeimes per week for 30 minutes increases the injury inci-ence by 225% without a signifıcant change in VO2max.ot only can the amount of running be dramatically re-uced to prevent injuries without adverse affects on serviceember cardiorespiratory endurance, but injuries can bexpected to increase disproportionately with fıtness im-rovements when thresholds are exceeded.67–70 Overtrain-ng thresholds are not necessarily absolutes, and they mayary between services and between units.71 Findings fromhe American College of Sports Medicine72 and oth-rs69,73–76 are consistentwith this idea of the disproportion-lity of fıtness and injury when exceeding thresholds ofvertraining.Theminimum threshold for physical training required

o achieve desired training effects has been less well char-

atiobipnndisr

ptrn(pocdt

tiltwntwdipj(tl

gamtmgmsFfsa

nsFpaw

meTtlartlituo

vlistIaorgroorg

nieolsjadFaeads


cterized for servicemembers. However, if cardiorespira-ory fıtness improvements require aerobic exercise at anntensity that produces heart rates between 55% and 90%f a person’s maximum heart rate, the lower end of thisroad range would be appropriate for initially low-fıtndividuals. Those who have been training for longereriods can work at higher levels. Cardiorespiratory fıt-ess can be improved by many activities other than run-ing. Aerobic activities that provide alternatives to linearistance running include: graduated walking or march-ng, stair climbing, swimming, bicycling, cross-countrykiing, rope-skipping, exercising to music, nonlinearunning, and sprinting.Combining strenuousmilitary training and traditionalhysical exercise may cause units to exceed physiologichresholds of overtraining, which results in higher injuryates without the expected improvements in physical fıt-ess.77 Commanders can monitor limited duty excusalalso known as the physical profıle) rates and fıtness testass rates and run times to determine if their units arevertraining. Signs that a unit is overtraining might in-lude high or increasing lower body injury profıle rates,ecreased fıtness test pass rates, and slower average runimes.77–79

Research in military populations has demonstratedhat the gradual introduction of runningmileage reducesnjury incidence.7,9–16,80 A program that starts with veryowmileage and progressively increases running mileageo a maintenance point keeps total running mileage low,hich reduces injury rates while improving physical fıt-ess. Several reviews of the literature repeat the commonheme that standardized running programs that beginith low mileage and intensity, and gradually progressistance and speed, allow the body to gradually adapt toncreasing stressors.19,81–87 These types of programs arearticularly important for lower fıt individuals who areust starting or restarting a physical training programe.g., new recruits, those changing units, and those re-urning to physical training after time off for an injury oreave).Physical training injury prevention programs that tar-

et service members at the highest risk of injury (those ofverage or below average fıtness) ensure that the runningileage for the least fıt servicemembers is appropriate for

heir fıtness level. The use of initial fıtness test perfor-ance (run times) to place service members in abilityroups of similar fıtness levels provides each serviceember with a more appropriate level of physiologicaltimulus to enhance fıtness and minimize injury risk.88

or example, asking a unit to run for a fıxed time, not aıxed distance, allows the slower (less fıt) groups to runhorter distances than the faster (more fıt) groups, thus
ccommodating low and high fıtness groups simulta- i
eously. This strategy can be ideal for military trainingchedules as groups can start and end at the same time.ormation running (large group running at the sameace) not onlymay overtrain the least fıt but may providen inadequate training effect for the fıttest individuals,ho need a greater cardiovascular stimulus.The least fıt service members are two to three timesore likely to be injured as their more fıt counterparts,specially in the recruit training environment.7,9,10,89

herefore, giving the least fıt trainees extra sessions ofraining only increases injury risk in this population withittle or no fıtness improvement. To reduce injuries andttrition rates while maximizing physical performanceequires that the core of the physical training program beargeted at individuals of average and below average fıtnessevels. Furthermore, the commonmilitary practice of utiliz-ng physical exercise as a punitive, corrective, or motiva-ional tool has the potential to lead to overtraining due to itsnpredictable frequency and volume—particularly whenverstressing the lower extremities.Interval training is an excellent way to train the cardio-

ascular systemwhile minimizing repetitive strain on theower extremities.90 Military studies that have includednterval training with reduced total runningmileage havehown fıtness improvements as great as or greater thanhose with long, slow sustained running.7,9,10,19–21,33,80,81

nterval running is performed with multiple bouts ofll-out (high intensity) running interspersedwith periodsf recovery (e.g., intervals, shuttle runs, and hill/stairunning). Intervals are performed by adhering to a pro-ressive work to recovery ratio. For example, a work-to-ecovery ratio of 1:3 would be an intense run of 10 sec-nds followed by a relative relief period (walk or slow jog)f 30 seconds (progressively 15:45 and 20:60). Intervalunning can be conducted individually aswell as in abilityroups.88

Soft tissue, such as muscles, tendons, and cartilage,eeds time between exercise bouts to recover and build. Its during this recovery time that structures are strength-ned. If recovery is not allowed, the rate of breakdownutpaces the body’s ability to build up and injuries are theikely result. Periodization training is a performancetrategy used to optimize performance and minimize in-ury in athletics. This type of training is characterized asn on-again, off-again type of training, and the literatureiscusses this as a soundway to prevent overtraining.77–79

urthermore, delayed onset muscle soreness peaksround 48 hours after an intense exercise bout andmakesxercise diffıcult.91 Military physical training that bal-nces the body’s need for a physiologic overload with theemand for recovery and rebuilding may provide theervice member with the greatest protection against
njury.
www.ajpm-online.net

Misatvresadalpbtpsetpddcseantnr(bwb

pmitmitrsbdlabma

oi

eewSoi

MtmafAAmitflbiSihlstt

arMittr

SfAftnva5cwhw


J

ulti-axial, neuromuscular, proprioceptive, and agil-ty training. Rehabilitation of soccer players with ankleprains using a wobble board for balance, coordination,nd proprioceptive training has been shown to be effec-ive in improving postural sway, reaction times, and pre-enting subsequent ankle sprains.28,92–107 Evidence fromesearch with handball players106–111 and soccer play-rs30,112 suggest that this training may also prevent ankleprains and anterior cruciate ligament injuries in healthythletes. These and other studies utilize exercises that areesigned to improve awareness and control of knees andnkles during standing, running, cutting, jumping, andanding. Some programs consist of exercises and partner-erturbation with an inflatable ball, wobble board, andalance mat. A prospective cluster randomized con-rolled trial demonstrated that some neuromuscular androprioceptive activities specifıcally designed for a single-port (team handball) signifıcantly reducedmusculoskel-tal injuries in youth aged 15–17 years.113 Recent effec-iveness of a neuromuscular and proprioceptive trainingrogram in competitive female youth soccer players inecreasing anterior cruciate ligament injuries has beenemonstrated over a 2-year period. The program, whichonsisted of a number of activities in addition to sport-pecifıc agility drills (such as strengthening, stretching,ducation, and plyometrics), resulted in a 74% reduction innterior cruciate ligament tears.114 A 6-week, preseasoneuromuscular training intervention program, performedhree times a week for one to 1 1⁄2 hours reduced the rate ofoncontact ACL injuries in women by 72%.115,116 Militaryesearch on exercises that develop core body stabilizationtrunk control), agility, and multi-axial movement skills inasic trainees without the aid of balls, balance mats, andobble boardshavedemonstrated reductionsof injury ratesy 20%–30%.7,9,10,19–21,80,81

Aside from the neurophysiological learning that takeslace to assist athletes and military service members inoving their bodies in smoother,more coordinated fash-

on, including neuromuscular, multi-axial, propriocep-ive, and agility conditioning in physical training sessionsay reduce injury risk for other reasons: (1) incorporat-

ng these activities into a fınite training period reduces therainees’ excessive exposure to running activities, therebyeducing lower-body injury risk; (2) musculoskeletaltresses of training are more evenly distributed across theody (and in different axes of motion) by these types ofrills (unlike linear running, which focuses stress in theower body in one plane), thereby reducing injury risk;nd (3) strength and stabilization exercises directed at theody core (trunk) represent many of the same move-ents required during more complex combat activities
nd thismay increase the likelihood of improvedmilitary o
anuary 2010

ccupational task performance and possibly reducenjuries.The majority of these exercise programs involve sev-

ral neuromuscular, multi-axial, and proprioceptive ex-rcises; however, as all exercises have the same goal, noneould be considered multi-interventional.5,50,117–201

everal systematic reviews are supportive of this typef training for the reduction of musculoskeletalnjuries.28,105,202–205

outhguards. Orofacial injuries are often caused byhe same vigorous activities and exercises that can lead tousculoskeletal injuries.206 Mouthguards are mandateds essential protective equipment in such sports such asootball, ice hockey, men’s lacrosse, and boxing. Themerican Dental Association and the Internationalcademy of Sports Dentistry currently recommend thatouthguards be used in 29 sport or exercise activities

ncluding acrobatics, basketball, bicycling, boxing, eques-rian events, extreme sports, fıeld events, fıeld hockey,ootball, gymnastics, handball, ice hockey, inline skating,acrosse, martial arts, racquetball, rugby, shot put, skate-oarding, skiing, skydiving, soccer, softball, squash, surf-ng, volleyball, water polo, weight lifting, and wrestling.tudies have compared mouthguard users and nonusersn many sports including football, rugby, basketball, andockey. Despite the fact that there are study design prob-ems in virtually all the investigations, most interventiontudies support the concept that mouthguards reduce orend to reduce the incidence of orofacial injuries in sportshat involve contact to the face.207–225

The military, not surprisingly, engages in a number ofctivities that pose considerable risks of oral facial inju-ies. A pilot study was initiated at Fort Leonard WoodO in 1999 that targeted injuries during pugil stick train-

ng, M16 with bayonet training, and confıdence courseraining. Providing army trainees with mouthguards forhese activities decreased the total number of dental inju-ies by 74%.226,227

emirigid ankle braces. The epidemiology and riskactors for ankle injuries are well described.104,228–237

nkle braces have been consistently demonstrated as ef-ective in reducing ankle injuries during high-risk activi-ies such as basketball, soccer, and parachute landings in aumber of intervention trials.43,238–247 Systematic re-iews employingmeta-analysis methods estimate the rel-tive risk of ankle injury while wearing an ankle brace is3% of the injury risk without bracing.28,248,249 Amongivilian athletes, the protection is greatest among thoseith previous ankle injuries but remains signifıcantlyigh as a prophylactic measure for uninjured athletes asell. During U.S. Army Airborne operations, 30%–60%
f injuries involve the ankle.238 Studies have demon-

T


able 9. Recommended injury prevention strategies (based on sufficient scientific evidence)

1. Prevent overtraining (strongly recommended)

The Joint Physical Training Injury Prevention Working Group recommends a standardized physical training program that controlsthe amount of total body overload performed; particularly for the lower extremities. Lower extremity overtraining (caused largelyby excessive distance running) results in higher injury rates, lowered physical performance, decreased motivation, andincreased attrition. Good evidence was found that physical training programs, especially in initial military training, that reducedistance running miles prevent overtraining and reduce injury rates while maintaining or improving physical fitness. Theelements described below should be incorporated to assist in reducing running mileage.

● Commanders at all levels should actively avoid combinations of physical and military training that exceed physiologicthresholds of training, as exceeding these thresholds result in higher injury rates with minimal or no improvement in fitness.Commanders can monitor profile (limited duty excusals) rates and fitness test pass rates and run times to determine if theirunits are overtraining. Signs that a unit is overtraining include high or increasing lower body injury profile rates, decreasedfitness test pass rates, and slower average run times.

● Other ways to achieve this objective include the following recommendations:

Œ Follow a gradual, systematic progression of running distance and speed beginning with lower mileage and intensity,especially for those just starting a physical training program (e.g., new recruits, changing units, or returning to physical trainingafter time off for an injury or leave). This practice provides for less total running over a finite period of time.

Œ Structure physical training injury prevention programs to target those Service members at the highest risk of injury (thoseof average or below average fitness) by ensuring that the running mileage for the least fit Service members is appropriate fortheir fitness level.

a. Group Service members according to physical ability. For example, fitness test performance (run times) can be usedto place Service members in groups of their peers with similar fitness levels. This provides each Service member with a moreappropriate level of physiological stimulus to enhance fitness and minimize injury risk.

b. Run for specified time periods, not distance. Running for specified time periods, not distance, allows the least fit torun shorter distances than the most fit, thus accommodating low and high fitness groups simultaneously.

c. Limit running in formation. Placing limits on unit formation running allows a greater chance that Service members areprovided an adequate training effect for maximum improvement through ability group running.

d. Avoid the practice of giving extra physical training sessions to the least fit Service members, especially recruits, sincethis will increase the risk of overtraining and injury with little or no fitness improvement. (Gradual, progressive ability grouptraining programs improve fitness with less risk of overtraining and injury.)

e. Refrain from or modify use of physical training as a punitive, corrective, or motivational tool as it has the potential to causeexcessive training overload that can lead to overtraining. Other methods to discipline new recruits should be sought or the amountand type of physical demands placed on a new recruit should be limited and standardized (e.g., a maximum number of push-upsallowed per day). An activity that we want Service members to embody for a career and a lifetime should not be used for punishment.

Œ Replace some distance runs with interval running (multiple bouts of short distance, high intensity running interspersed withperiods of recovery) that increase speed and stamina more rapidly than distance running while limiting total running miles.

Œ Balance the body’s need for a physiologic training overload to improve fitness with the need for recovery and rebuildingby coordinating military and physical training to:

a. Avoid exhaustive military or physical training (e.g., obstacle courses, long road marches with heavy loads, longer runs,maximal-effort physical fitness testing, etc.) on the same or successive days

b. Allow adequate recovery time between administrations of maximal effort physical fitness tests to prevent overtrainingand increase the likelihood of improved physical performance. (Since muscle soreness peaks at 48 hours the minimumrecovery time would be 3-5 days.)

c. Alternate training days that emphasize lower body–weight bearing physical activity with training days focused on upperbody conditioning.

d. Minimize the accumulated weight-bearing stress on the lower body from marching/hiking, movements to training sites, drilland ceremony, obstacle courses, running, etc., by not overscheduling such activities on the same or successive days.

2. Perform multiaxial, neuromuscular, proprioceptive, and agility training (recommended)

The Joint Physical Training Injury Prevention Working Group recommends that multiaxial (many planes of motion), neuromuscular(coordinated muscular movement), proprioceptive (body position sense), and agility (nonlinear movement) exercises be includedas a regular component of military physical training programs. The working group found good evidence that injuries are reducedby increasing the proportion of physical training time devoted to exercises that vary musculoskeletal stress in multiple plainsand improve body coordination, position sense, and agility.

(continued on next page)

www.ajpm-online.net

siifribaicDparlaah

Redmifdf

chaasdo

vbatttvamDrctelr

T

feet


J

trated that during airborne jumpoperations; thosewear-ng an outside-the-boot brace had 0.6 ankle inversionnjuries/1000 jumps compared to 3.8 injuries/1000 jumpsor those who did not wear the brace. In an operationalesearch study of Rangers over a 3-year period, anklenjuries were three times higher among those notwearingraces.245 In spite of the demonstrated effectiveness ofnkle braces in reducing ankle injuries among parachut-sts, this intervention was discontinued over concerns ofost and anecdotal reports of parachute entanglements.uring the period after the brace was discontinued, hos-italizations for severe ankle injuries rose by 70%. Thenkle brace was reinstituted for airborne training in Feb-uary 2005, and a central funding mechanism was estab-ished to pay for and replace the braces.244 Ankle bracesre particularly appropriate for high-risk sports activitiesnd military parachuting, especially in individuals with aistory of a previous ankle sprain.

estoration of energy balance and injury biomark-rs. Research shows a link between muscle glycogenepletion and markers of muscle damage, fatigue andusculoskeletal pain.250–254 Studies of activewomen also

ndicate a negative energy balance is a risk factor for stressractures of the bone.255–258 These same risk factors andescriptive epidemiologic studies indicate that stress

able 9. (continued)

3. Wear mouthguards during high-risk activities (recommend

The Joint Physical Training Injury Prevention Working Group recmembers participating in activities with a high risk for orofaciamouthguards reduce orofacial injuries when worn during activitactivities listed by the working group include combatives, obstcontact sports such as basketball, football, etc. The evidencemeans of preventing concussion injuries.

4. Wear semirigid ankle braces for high-risk activities (recom

The Joint Physical Training Injury Prevention Working Group strparticipation in high-risk physical activity. The working group foinjuries when participating in high-risk physical activity such asmay prevent ankle injuries in other similar high-risk activities.ankle braces reduce re-injury among individuals with previous

5. Consume nutrients to restore energy balance within 1 hou

The Joint Physical Training Injury Prevention Working Group reccarbohydrate and a fluid replacement beverage within 1 hour amarching/hiking lasting longer than 1 hour) to minimize musclsufficient evidence that consuming this balance of nutrients wrecovery from musculoskeletal breakdown caused by the activand enhanced physical performance can be expected.

6. Wear synthetic blend socks to prevent blisters (recommen

The Joint Physical Training Injury Prevention Working Group recacrylic, and nylon versus cotton socks) to prevent blisters to thfair evidence that synthetic blend socks prevent blisters to the

ractures may well be related to nutritional defıcien- m

anuary 2010

ies.255–258 Sustained physical activity and intermittent,igh-intensity activity deplete the body’s glycogen storesnd fatiguemuscles, which then reduce their strength andbility to protect joints. On balance, most original re-earch251–253,259–270 and systematic reviews250,271–274 in-icate that restoring muscle glycogen decreases markersf muscle damage due to physical activity.While both civilian and military research have pro-

ided evidence that consuming foods that restore energyalance overcomes fatigue, minimizes muscle damage,nd protects against heat injury, the timing of the nutri-ional intervention appears to matter. Research indicateshat consuming a combination of carbohydrates and pro-ein within a 60-minute window immediately followingery strenuous exercise initiates repair of muscles dam-ged during the activity and begins the replenishment ofuscle glycogen stores.250,251,253–258,260–262,267,268,270

uring this time,metabolic environment is optimized forebuilding what was metabolized during the exer-ise.250,251,253,254,260–262,268 It appears that when the nu-rients are consumed more than 60 minutes after thend of the exercise bout, the metabolic environment isess able to absorb the nutrients; thus diminishingecovery.250,254,261,262

The ideal balance of nutrients needed to allow for the

ends all Services provide mouthguards for all Serviceries. The working group found good evidence thatith high orofacial injury risk. Examples of potential high-risk

and confidence courses, rifle/bayonet training, etc., andsufficient to recommend for or against mouthguards as a

ded)

recommends that semirigid ankle braces be utilized duringgood evidence that semirigid ankle braces reduce ankleorne operations (parachuting), basketball, and soccer; andionally, the working group found good evidence that semirigidrate or severe ankle sprains.

owing high-intensity activity (recommended)

ends consuming 12–18 g of protein and 50–75 g ofvery strenuous, continuous physical activity (e.g., road

age and optimize recovery. The working group founda 1-hour time frame restores energy balance and optimizesollateral benefits such as reduced risk of heat-related illness

ends the use of synthetic blend socks (e.g., polyester,et during physical training. The working group found at least, especially during long-distance marching.

ed)

omml injuies wacleis in

men

onglyundairb

Additmode

r foll

ommftere damithinity. C

ded)

omme fe

ost rapid replenishment of muscle glycogen to opti-

mtdc

Satsaamtsdptitwwwi

I

Tmmsosthrt

BhaabtsstIfoNuGbiO

Sbrts(bebrtptfosiowci

AcfitmN

T(


ize and accelerate the recovery process is roughly 12o 18 grams of protein and 50 to 75 grams of carbohy-rate (a ratio of 1 gram of protein for every 4 grams ofarbohydrate).250,253,254,261

ynthetic-blend socks for blister prevention. Blistersppear to be caused by friction between the skin and sock;hat friction is exacerbated by moisture produced byweating.275–281 Special hydrophobic (having little or noffınity for water) socks designed to reduce foot moistureppear to reduce the likelihood of foot blisters.282–286 Inarine recruits undergoing 12 weeks of training, 39% of

hose wearing the standard U.S. military wool/cottonock experienced blisters or cellulitis resulting in limiteduty. Among those wearing a liner sock composed ofolyester (thought to “wick” or draw awaymoisture fromhe skin) worn with the standard sock, the foot frictionnjury rate was 16% (a 56% decrease in blister injuries). Ahird group of recruits had a comparable 17% injury ratehile wearing the same polyester liner with a very thickool/polyester blended sock designed to assist with theicking action while reducing friction. Thus, both exper-mental sock systems were successful in reducing blisters.

nterventions Not Recommended

wo common intervention strategies that have been pro-oted as practices to reduce low-back injuries and otherusculoskeletal injuries in general are back braces (orimilar devices) and pre-physical training administrationf nonsteroidal anti-inflammatory drugs (NSAIDs) re-pectively. There is suffıcient evidence not to recommendhese strategies. The following discusses the rationale be-ind these strategies and how they may have physiologicisks that do not justify prophylactic use. Recommenda-ions against their use are presented in Table 10.

ack braces, harnesses, or support belts. Back beltsave been aggressively promoted as a preventivemeasuregainst back injuries in healthy individuals during liftingctivities for a couple of reasons: it is theorized that backelts increase the intra-abdominal pressure, which ishought to decrease compressive forces on the lumbarpine, and also minimize movement of some lumbaregments. These theories have not been substantiated inhe literature. In fact, in 1992, theDirector of theNationalnstitute for Occupational Safety and Health (NIOSH)ormed a working group to review the scientifıc literaturen back belt usage in healthy individuals. The CDC/IOSH report concluded that back belt effectiveness wasnproven.287 That same year, the Offıce of the Surgeoneneral (OTSG) issued a memorandum stating, “Thelanket use of back belts to prevent or minimize backnjuries resulting from lifting is not supported by the
ffıce of the Surgeon General” because the Occupational r
afety and Health Administration did not accept backelts as personal protective equipment.288 A systematiceview on the prevention of back injuries concluded thathere was no evidence for the effectiveness of lumbarupports.289 In 1998, Department of Defense InstructionDoDI) 6055.1 directed that “DoD does not recognizeack support belts or wrist splints as personal protectivequipment, or the use of these devices in the prevention ofack or wrist injuries.”290 Two independent systematiceviews published in 2001 came to the same conclusion;here is moderate to strong evidence that lumbar sup-orts or back belts are not effective in primary preven-ion, and there is no evidence that back belts are effectiveor secondary prevention of low-back injury.291,292 An-ther literature review in 2003 came to the same conclu-ion.293 Based on the amount of scientifıc evidence show-ng the ineffectiveness of back belts, as well as the numberf government agencies that do not support their use, itas the consensus of the working group that back beltsould not be endorsed as a low back–injury preventionntervention in healthy individuals.

nti-inflammatory medication prior to exer-ise. Contraction-induced muscle damage, especiallyrom eccentric muscle contractions, is known to cause annflammatory response. This response itself can causeissue damage beyond that originally sustained by theuscle. It is hypothesized that administration of anSAIDprior to exercisewould control that inflammatory

able 10. Intervention strategies not recommendeddue to evidence of ineffectiveness or harm)

1. Wear back braces, harnesses, or support belts (notrecommended)

The Joint Physical Training Injury Prevention Working Groupdoes not recommend the use of back braces, harnesses, orsupport belts for the prevention of low back injuries. Theworking group found at least moderate to strong evidencethat back belts/supports are ineffective or that thepotential harms outweigh the benefits. These findingssupport the Department of Defense position that backsupport belts are not personal protective equipment, anduse of these devices for the prevention of back injuries isnot endorsed (see DoDI 6055.1, DoD Safety andOccupational Health Program, para E6.1.3).

2. Take anti-inflammatory medication prior to exercise(not recommended)

The Joint Physical Training Injury Prevention Working Groupdoes not recommend taking anti-inflammatory medicationprior to exercise for the prevention of injuries. The workinggroup found insufficient evidence for the efficacy of pre-administration of anti-inflammatory medication for theprevention of injuries. The potential harms outweigh anypotential benefits.

esponse, thus diminishing tissue damage. However,

www.ajpm-online.net

Ntodeiifesp

tobctvmKmKpdsoctt

IR

Wtibtinqsinsfsmst

Eca

maaeeiaonatafiep

sssd(itswifdil

Ti


J

SAIDs have been the cause of more than 76,000 hospi-alizations and 7600 deaths in the U.S. annually.294Whilene study demonstrated that the pre-administration oficlofenac sodium signifıcantly reduces measures of ex-rcise-induced skeletal muscle damage,295 the results arenconsistent with regard to NSAID use prior to activ-ty.296–299 Intervention studies have demonstrated no ef-ect on delayed onset muscle soreness or observed mark-rs formuscle damage as a surrogate for injury.300–302Notudy has demonstrated a reduction in injury rates fromre-exercise NSAIDs.Furthermore, there are harmful risks to takingNSAIDs

hatmust be considered. Some of themost common risksf NSAID use are stomach discomfort, gastrointestinalleeding, and ulceration.303–305 One way to counter theseommon side effects is to ingest food with the medica-ion. The consumption of food immediately prior to aigorous activity to buffer the effects of the medicationay, itself, cause considerable discomfort during activity.idney, heart, liver, and skin problems can also occur,ost related to the inhibition of prostaglandin synthesis.idney failure has been reported during marathons, inart due to these substances in the body combined withehydration and the strenuous effort that takes place overeveral hours. Themajority of gastrointestinal side effectsf NSAIDs are symptomatic responses, such as bloating,ramping, pain, acid reflux, and diarrhea or constipa-ion.306 These are not symptoms that would be favorableo experience while participating in physical activity.

nterventions Without Sufficient Evidence toecommend

hat stands out as a singularly important outcome ofhis working group effort is the majority (74%) of thenjury prevention strategies that had some theoreticalasis for effıcacy was found to have insuffıcient evidenceo recommend as injury prevention strategies to the mil-tary services at this time (Table 8). Either the science hasot been done; what has been done is of poor to fairuality research and evaluation; or there are too manytudies showing either a negative effect or no effect onnjuries which cast too much doubt on their effıcacy. It isot recommended that military leaders implement thesetrategies; they should, at least, carefully weigh the bene-ıts and costs of implementing any of these 23 unproventrategies in their units in order to conserve resources andaximize training time. An example of one such strategy,tretching, is discussed below and concise recommenda-ions are given in Table 11.

xample: stretching muscles before or after exer-ise. Formany years sportsmedicine professionals have
dvocated stretching prior to physical activity as a p
anuary 2010

ethod for reducing the risk of injury.67 One of theuthors of this paper (JG) co-authored a recent system-tic review307 on the topic and provided extensive refer-nces and insight into stretching effıcacy. This reviewxceeded the level of reviewperformed for other potentialnterventions addressed by the working group. This liter-ture review and others89,203,308–310 examined hundredsf citations only to come to the same conclusion; thateither stretching prior to exercise nor stretching prior tond after exercise, reduces the risk of injury. Other sys-ematic reviews54,86,311–323 address injury or soreness butre focused on non-injury outcomes (such as increasedlexibility). There is not suffıcient evidence to endorsendiscriminate and routine stretching before or after ex-rcise to prevent injury among servicemembers (or com-etitive or recreational athletes alike).The few risk-factor and intervention studies that did

how an effect of stretching on injuries suffered fromerious design flaws, such as including pre-exercisetretching with warm-up in the intervention. Since epi-emiologic data indicate that both extremes of flexibilitytoo much or too little) are associated with increasednjury rates,50,324 studies to date have not specifıcallyargeted individuals with limited flexibility. Thus, futuretretching studies should selectively target individualsith low flexibility to determine whether stretching tim-ng can increase flexibility and reduce injuries for the leastlexible individuals. Furthermore, it would not seem pru-ent to invest limited military training time in perform-ng indiscriminate group stretching exercises when theiterature demonstrates this strategy has no proven injury

able 11. Example recommendation when there isnsufficient evidence to support

Stretching muscles before or after exercise has noscientific basis for recommendation (insufficient evidenceto support)

The Joint Physical Training Injury Prevention Working Groupcannot recommend organized stretching as a means forpreventing physical training–related injuries. The workinggroup found good evidence that stretching is ineffective asan injury prevention strategy in a generally young, healthypopulation. While the working group does not endorsestretching as a method to prevent musculoskeletal injury,there is insufficient evidence that it may cause harm inthose who perceive a benefit. Additionally, studies to datehave not specifically targeted individuals with limited rangeof motion. Because epidemiological data suggest that bothextremes of flexibility (too much or too little) are risk factorsassociated with increased injury rates, the working grouprecommends research selectively targeting individuals withlimited range of motion only to determine the effect ofstretching in this select population.

revention effıcacy when performed in this manner.

tfsr

L

Ltosoti

rTsip

itspawAdwts

seHvtaowe

iaiaiwcr

CAsvietldtawrttimtstitsutciista

TbPefatfa

o

R


Adiscussionof rationale anda list of references regardinghe remaining 22 prevention strategies found to have insuf-ıcient evidence to make recommendations to the militaryervices is available by reviewing theUSACHPPMtechnicaleport.325

imitations

iterature searches were limited to published articles inhe English language only. Reviewers had varying degreesf epidemiologic and online medical literature searchingkills and expertise.While defınitions of various epidemi-logic studies and how to classify them were provided tohe reviewers, some had more experience than others indentifying and classifying the literature appropriately.This paper was not designed to be a critical systematic

eview ormeta-analysis for any one intervention strategy.he expedited nature of the literature review was neces-ary for the purpose of working group–consensus build-ng and prioritization of evidence-based strategies thatrevent military physical training–related injuries.The expedited review process of assessing the qual-

ty of the scientifıc studies may not have been consis-ently applied. Abstracts were considered an adequateource if they provided suffıcient information to com-lete the quality scoring instrument. In cases where thebstract was limited, it is unknown how thoroughlyorking group members reviewed the full text article.dditionally, reviewers were asked to report if confı-ence intervals or p-values were used in the study butere not asked tomake a judgment as to the strength ofhe intervals or values when completing the qualitycoring instrument.Working group members provided other research

tudies with non-injury outcomes in varying degrees,specially in the absence of systematic reviews and RCTs.owever, as the principal focus was on the primary pre-ention of physical training–related injuries utilizing sys-ematic reviews, randomized controlled trials (RCTs),nd risk-factor/cause studies with injury as the primaryutcome, the completeness of the classifıcation matrixith other studies of less power or signifıcance had littleffect on the fınal recommendation.In the years following the face-to-face meeting, an ed-

tor provided additional reviews of some topics when itppeared that critical data weremissing.When the editorncluded new research in the classifıcation matrices thatppeared to affect the recommendation content, the orig-nal reviewer and all othermembers of theworking groupere contacted by electronic mail for their input to thehanges. Consensus was achieved only among those who
esponded.
onclusionn expedited systematic process of evaluating commontrategies enabled the Joint Physical Training Injury Pre-entionWorkingGroup to build consensus around thosenjury prevention interventions that had good scientifıcvidence to recommend to all military services. The sys-ematic, criteria-based process and adaptation of guide-ines that required a standardized level of scientifıc evi-ence beforemaking any recommendationwas central tohe formulation of evidence-based recommendationsnd their prioritization. While the initial effort of theorking group sought to elucidate “proven” strategies toeduce physical training–related injuries in the basicraining environment, we believe the principles behindhe six recommended interventions can be broadly andnexpensively applied to operational training environ-ents within the military services and to similar popula-

ions who have high activity demands. Military leadershould discourage the use of back braces, advise theirroops against the prophylactic use of nonsteroidal anti-nflammatory drugs before activity, and carefully weighhe costs and benefıts of implementing any of the 23trategies with insuffıcient scientifıc evidence in theirnits (such as indiscriminate stretching before physicalraining). The unproven strategies identifıed in this arti-le provide a starting point for further investigation intonterventions that may prevent physical training–relatednjuries in servicemembers of themilitary and in those ofimilar populations who may have frequent physicalraining requirements (e.g., fırefıghters, police offıcers,nd athletes).

his review was completed as a result of collaborationetween the U.S. ArmyCenter for Health Promotion andreventive Medicine and injury prevention and fıtnessxperts for the Military Training Task Force of the De-ense Safety Oversight Council. Individual contributorsnd their organizations are listed in the USACHPPMechnical report.325 A special thanks to BarbaraWeyandtor facilitating the working group, and Judith B. Schmittnd Val Buchanan for their editing.No fınancial disclosures were reported by the authorsf this paper.

eferences1. Rumsfeld DH. Memorandum. Offıce of the Secretary of De-

fense. Reducing Preventable Accidents. 19 May 2003.2. Atlas of injuries in the United States Armed Forces. Mil Med

1999;164(8S):633 pages.

www.ajpm-online.net


J

3. Jones BH, Knapik JJ. Physical training and exercise-relatedinjuries. Surveillance, research and injury prevention in mil-itary populations. Sports Med 1999;27(2):111–25.

4. Jones BH, Perrotta DM, Canham-Chervak ML, Nee MA,Brundage JF. Injuries in the military: a review and commen-tary focused on prevention. Am J Prev Med 2000;18(3S):S71–84.

5. Kaufman KR, Brodine S, Shaffer R. Military training-relatedinjuries: surveillance, research, and prevention. Am J PrevMed 2000;18(3S):S54–63.

6. Ruscio B, Smith J, Amoroso P, et al. DoD Military Injury Pre-vention PrioritiesWorkingGroup: leading injuries, causes, andmitigation recommendations.Washington: Offıce of the Assis-tant Secretary of Defense for Health Affairs, 2006. http://www.stormingmedia.us/75/7528/A752854.html.

7. Knapik JJ, Bullock SH, Canada S, et al. Influence of an injuryreduction program on injury and fıtness outcomes amongsoldiers. Inj Prev 2004;10(1):37–42.

8. Knapik JJ, Craig SC, Hauret KG, Jones BH. Risk factors forinjuries during military parachuting. Aviat Space EnvironMed 2003;74(7):768–74.

9. Knapik JJ, Darakjy S, Scott S, Hauret KG, Canada S. Evalua-tion of two Army fıtness programs: the TRADOC standard-ized physical training program for basic combat training andthe fıtness assessment program. Aberdeen Proving GroundMD: U.S. Center for Health Promotion and PreventiveMed-icine, 2004.

10. Knapik JJ, Hauret KG, Arnold S, et al. Injury and fıtnessoutcomes during implementation of physical readiness train-ing. Int J Sports Med 2003;24(5):372–81.

11. Pester S, Smith PC. Stress fractures in the lower extremities ofsoldiers in basic training. Orthop Rev 1992;21(3):297–303.

12. Pope RP. Prevention of pelvic stress fractures in female armyrecruits. Mil Med 1999;164(5):370–3.

13. RiceV,ConnollyV, BergeronA,MaysM, Evans-ChristopherG. Evaluation of a progressive unit-based running programduringadvanced individual training:ArmyResearch InstituteofEnvironmental Medicine; 2002 Feb. http://oai.dtic.mil/oai/oai?verb�getRecord&metadataPrefıx�html&identifıer�ADA402890.

14. Rudzki SJ. Injuries in Australian Army recruits. Part II: loca-tion and cause of injuries seen in recruits. Mil Med 1997;162(7):477–80.

15. Rudzki SJ. Injuries in Australian Army recruits. Part I: de-creased incidence and severity of injury seen with reducedrunning distance. Mil Med 1997;162(7):472–6.

16. Rudzki SJ, CunninghamMJ. The effect of amodifıed physicaltraining program in reducing injury and medical dischargerates in Australian Army recruits. Mil Med 1999;164(9):648–52.

17. Canham-ChervakM, Jones B, Lee R, Baker S. Focusing injuryprevention efforts: using criteria to set objective priorities.American Public Health Association Annual Meeting. Phila-delphia PA; 2005.

18. Jones BH, Bullock SH,Canham-ChervakM.Amodel processfor setting military injury prevention priorities and makingevidence-based recommendations for interventions: a whitepaper for the Defense Safety Oversight Council, Military Train-ing Task Force. Aberdeen Proving Ground MD: U.S. Army
Center for Health Promotion and Preventive Medicine,
anuary 2010

2005. http://oai.dtic.mil/oai/oai?verb�getRecord&metadataPrefıx�html&identifıer�ADA493445.

19. Almeida S,WilliamsK, Shaffer R, Luz J, Badong E. A physicaltraining program to reduce musculoskeletal injuries in U.S.Marine Corps recruits. SanDiegoCA:NavalHealth ResearchCenter, 1997.

20. Trone DW, Hagan RD, Shaffer RA. Physical training pro-gram guidelines for U.S. Navy recruits: preparing recruits forbattle stations. San Diego CA: Naval Health Research Center,1999.

21. U.S. Navy Injury Prevention Work Group. Prevention ofinjuries of sailors during accession training. Pensacola FL:Naval Aviation Schools Command and Navy EnvironmentalHealth Center, 2000.

22. Injury Prevention Work Group. Prevention of injuries tosoldiers during initial entry training. In: A users’ conferenceto prioritize injury prevention efforts. 1999 Oct 19–20; FortJackson SC; 1999.

23. Gilchrist J, Jones BH, Sleet DA, Kimsey CD. Exercise-relatedinjuries among women: strategies for prevention from civilianand military studies. MMWR Recomm Rep 2000;49(RR–2):15–33.

24. Memorandum. Offıce of the Surgeon General, U.S. Army.Army Musculoskeletal Injury Prevention Program (MIPP)for Initial Entry Training (IET). 24 March 2003.

25. Technical Bulletin. Medical (TB MED) 592, Prevention andControl of Musculoskeletal Injuries Associated with PhysicalTraining (Draft).

26. Institute of Medicine, Committee for the Study of the Futureof PublicHealth, Division ofHealthCare Services. The futureof public health.Washington:National AcademyPress, 1988.

27. Last JM. A dictionary of epidemiology. 3rd ed. New York:Oxford University; 1995.

28. Thacker SB, Stroup DF, Branche CM, Gilchrist J, GoodmanRA, Weitman EA. The prevention of ankle sprains in sports.A systematic review of the literature. Am J Sports Med1999;27(6):753–60.

29. U.S. Preventative Services Task Force. U.S. Preventative Ser-vices Task Force Ratings: strength of recommendations andquality of evidence. Guide to Clinical Preventive Services,third edition: periodic updates 2000–2003. Rockville MD:Agency for Healthcare Research and Quality. www.ahrq.gov/clinic/3rduspstf/ratings.htm.

30. Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccerinjuries. Supervision by doctor and physiotherapist. Am JSports Med 1983;11(3):116–20.

31. Walters TJ. Injury prevention in the U.S. Army, a key com-ponent of transformation. Carlisle Barracks PA; Army WarCollege, 2002 Apr 09;XA/USAWC.

32. Lopez M. DoD Military Injury Metrics Working Group whitepaper. Washington DC; U.S. Department of Defense; 2002.www.ergoworkinggroup.org/ewgweb/SubPages/ProgramTools/Metrics/MilitaryInjuryMetricsWhitepaperNov02rev.pdf.

33. U.S. Army. Field Manual 21–20. Physical training. Washing-ton: U.S. Government Printing Offıce, 1946.

34. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk fac-tors for stress fractures. Sports Med 1999;28(2):91–122.

35. BrunetME, Cook SD, BrinkerMR,Dickinson JA. A survey ofrunning injuries in 1505 competitive and recreational run-
ners. J Sports Med Phys Fitness 1990;30(3):307–15.
http://www.stormingmedia.us/75/7528/A752854.html

http://www.stormingmedia.us/75/7528/A752854.html

http://oai.dtic.mil/oai/oai?verb=getRecord%26metadataPrefix=html%26identifier=ADA402890





http://www.ahrq.gov/clinic/3rduspstf/ratings.htm

http://www.ahrq.gov/clinic/3rduspstf/ratings.htm

http://www.ergoworkinggroup.org/ewgweb/SubPages/ProgramTools/Metrics/MilitaryInjuryMetricsWhitepaperNov02rev.pdf

http://www.ergoworkinggroup.org/ewgweb/SubPages/ProgramTools/Metrics/MilitaryInjuryMetricsWhitepaperNov02rev.pdf


36. Deuster PA, Jones BH, Moore J. Patterns and risk factors forexercise-related injuries in women: a military perspective.Mil Med 1997;162(10):649–55.

37. Jacobs SJ, Berson BL. Injuries to runners: a study of entrantsto a 10,000 meter race. Am J Sports Med 1986;14(2):151–5.

38. Koplan JP, Powell KE, Sikes RK, Shirley RW, Campbell CC.An epidemiologic study of the benefıts and risks of running.JAMA 1982;248(23):3118–21.

39. Koplan JP, Rothenberg RB, Jones EL. The natural history ofexercise: a 10-yr follow-up of a cohort of runners. Med SciSports Exerc 1995;27(8):1180–4.

40. Macera CA, Pate RR, Powell KE, Jackson KL, Kendrick JS,CravenTE. Predicting lower-extremity injuries among habit-ual runners. Arch Intern Med 1989;149(11):2565–8.

41. Marti B, Vader JP, Minder CE, Abelin T. On the epidemiol-ogy of running injuries. The 1984 Bern Grand-Prix study.Am J Sports Med 1988;16(3):285–94.

42. Reynolds K, Pollard J, Cunero J, Knapik J, Jones B. Frequencyof training, and past injuries as risk factors for injuries ininfantry soldiers. Natick MA: Army Research Institute ofEnvironmental Medicine, 1990.

43. Surve I, Schwellnus MP, Noakes T, Lombard C. A fıvefoldreduction in the incidence of recurrent ankle sprains in soc-cer players using the Sport-Stirrup orthosis. Am J SportsMed1994;22(5):601–6.

44. Beck JL, Day RW. Overuse injuries. Clin Sports Med1985;4(3):553–73.

45. Browning KH, Donley BG. Evaluation and management ofcommon running injuries. Cleve Clin J Med 2000;67(7):511–20.

46. Fredericson M. Common injuries in runners. Diagnosis, re-habilitation and prevention. Sports Med 1996;21(1):49–72.

47. Haverstock BD. Stress fractures of the foot and ankle. ClinPodiatr Med Surg 2001;18(2):273–84.

48. Hreljac A. Impact and overuse injuries in runners. Med SciSports Exerc 2004;36(5):845–9.

49. Jones BH, Cowan DN, Knapik JJ. Exercise, training and inju-ries. Sports Med 1994;18(3):202–14.

50. Jones BH, Cowan DN, Tomlinson JP, Robinson JR, PollyDW, Frykman PN. Epidemiology of injuries associated withphysical training among young men in the army. Med SciSports Exerc 1993;25(2):197–203.

51. Kaeding C, Tomczak RL. Running injuries about the knee.Clin Podiatr Med Surg 2001;18(2):307–18.

52. Karlsson MK. Physical activity, skeletal health and fracturesin a long-term perspective. J Musculoskelet Neuronal Inter-act 2004;4(1):12–21.

53. Kennedy JG, Knowles B, Dolan M, Bohne W. Foot and ankleinjuries in the adolescent runner. Curr Opin Pediatr 2005;17(1):34–42.

54. MaceraCA. Lower extremity injuries in runners. Advances inprediction. Sports Med 1992;13(1):50–7.

55. McCully KK. Exercise-induced injury to skeletal muscle. FedProc 1986;45(13):2933–6.

56. McKeag DB. Overuse injuries. The concept in 1992. PrimCare 1991;18(4):851–65.

57. Paty JG Jr. Diagnosis and treatment of musculoskeletal run-ning injuries. Semin Arthritis Rheum 1988;18(1):48–60.

58. Paty JG Jr. Running injuries. Curr Opin Rheumatol 1994;
6(2):203–9.
59. Pell RF, Khanuja HS, Cooley GR. Leg pain in the runningathlete. J Am Acad Orthop Surg 2004;12(6):396–404.

60. Reeder MT, Dick BH, Atkins JK, Pribis AB, Martinez JM.Stress fractures. Current concepts of diagnosis and treatment.Sports Med 1996;22(3):198–212.

61. Sherrard J, Lenne M, Cassell E, Stokes M, Ozanne-Smith J.Injury prevention during physical activity in the AustralianDefence Force. J Sci Med Sport 2004;7(1):106–17.

62. Watson AS. Running injuries—knees to toes. Aust Fam Phy-sician 1988;17(2):99–103.

63. Wexler RK. Lower extremity injuries in runners. Helpingathletic patients return to form. Postgrad Med 1995;98(4):185–7, 191–3.

64. Shaffer RA. Musculoskeletal Injury Project. In: 43rd AnnualMeeting of theAmericanCollege of SportsMedicine. Cincin-nati OH; 1996.

65. Trank TV, Ryman DH, Minagawa RY, Trone DW, ShafferRA. Runningmileage,movementmileage, and fıtness inmaleU.S. Navy recruits. Med Sci Sports Exerc 2001;33(6):1033–8.

66. PollockM,GettmanL,Milesis C, BahM,Durstine L, JohnsonR. Effects of frequency and duration of training on attritionand incidence of injury. Med Sci Sports 1977;9(1):31–6.

67. American College of Sports Medicine Position Stand. Therecommended quantity and quality of exercise for developingand maintaining cardiorespiratory and muscular fıtness, andflexibility in healthy adults. Med Sci Sports Exerc 1998;30(6):975–91.

68. Gettman LR, Pollock ML, Durstine JL, Ward A, Ayres J,Linnerud AC. Physiological responses of men to 1, 3, and 5day per week training programs. Res Q 1976;47(4):638–46.

69. Pollock ML. The quantifıcation of endurance training pro-grams. Exerc Sport Sci Rev 1973;1:155–88.

70. Wenger HA, Bell GJ. The interactions of intensity, frequencyandduration of exercise training in altering cardiorespiratoryfıtness. Sports Med 1986;3(5):346–56.

71. Hootman JM, Macera CA, Ainsworth BE, Addy CL, MartinM, Blair SN. Epidemiology of musculoskeletal injuriesamong sedentary and physically active adults. Med Sci SportsExerc 2002;34(5):838–44.

72. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity andpublic health in older adults: recommendation from theAmerican College of Sports Medicine and the AmericanHeart Association. Med Sci Sports Exerc 2007;39(8):1435–45.

73. Hickson RC, Foster C, Pollock ML, Galassi TM, Rich S.Reduced training intensities and loss of aerobic power, en-durance, and cardiac growth. J Appl Physiol 1985;58(2):492–9.

74. Hickson RC, Kanakis C, Jr., Davis JR, Moore AM, Rich S.Reduced training duration effects on aerobic power, endur-ance, and cardiac growth. J Appl Physiol 1982;53(1):225–9.

75. Hickson RC, Rosenkoetter MA. Reduced training frequen-cies and maintenance of increased aerobic power. Med SciSports Exerc 1981;13(1):13–6.

76. MartinWH3rd,Montgomery J, Snell PG, et al. Cardiovascu-lar adaptations to intense swim training in sedentarymiddle-aged men and women. Circulation 1987;75(2):323–30.

77. Fry RW,MortonAR,Garcia-Webb P, CrawfordGP, Keast D.Biological responses to overload training in endurance
sports. Eur J Appl Physiol Occup Physiol 1992;64(4):335–44.
www.ajpm-online.net

1

1

1

1

1

1

1

1

1

1

1

1

1


J

78. Mellion MB, Ketner JB. Medical syndromes unique to ath-letes. In: Offıce Sports Medicine. 2nd ed. Philadelphia PA:Mosby; 1996.

79. Wilmore JH, Costill DL. Quantifying sports training. In:Physiology of sport and exercise. Champaign IL: HumanKinetics; 2004.

80. Knapik JJ, Bullock SH, Canada S, Toney E, Wells JD. TheAberdeen Proving Ground Injury Control Project: influenceof a multiple intervention program on injuries and fıtnessamong ordnance school soldiers in advanced individualtraining. Aberdeen Proving Ground MD: U.S. Army Centerfor Health Promotion and Preventive Medicine, 2003.

81. Almeida S, Williams K, Moinagawa R, Benas D, Shaffer R.Guidelines for developing a physical training program forU.S. Navy recruits. San Diego CA: Naval Health ResearchCenter, 1997.

82. GillespieWJ, Grant I. Interventions for preventing and treat-ing stress fractures and stress reactions of bone of the lowerlimbs in young adults. Cochrane Database Syst Rev 2000(2):CD000450.

83. Jones BH, Thacker SB, Gilchrist J, Kimsey CD Jr, Sosin DM.Prevention of lower extremity stress fractures in athletes andsoldiers: a systematic review. Epidemiol Rev 2002;24(2):228–47.

84. Kellett J. Acute soft tissue injuries—a review of the literature.Med Sci Sports Exerc 1986;18(5):489–500.

85. RenstromP, JohnsonRJ.Overuse injuries in sports. A review.Sports Med 1985;2(5):316–33.

86. vanMechelenW. Running injuries. A review of the epidemi-ological literature. Sports Med 1992;14(5):320–35.

87. Yeung EW, Yeung SS. Interventions for preventing lowerlimb soft-tissue injuries in runners. Cochrane Database SystRev 2001(3):CD001256.

88. Knapik J, Scott S, Sharp M, et al. Guidance for ability grouprun speeds and distances in basic combat training. Fort Ben-ning GA: U.S. Army Center for Health Promotion and Pre-ventive Medicine, U.S. Army Physical Fitness School, 2003.

89. Knapik JJ, Jones BH, Bauman CL, Harris JM. Strength, flexi-bility and athletic injuries. Sports Med 1992;14(5):277–88.

90. McArdle WD, Katch FL, Katch VL. Training for anaerobicand aerobic power. In: Essentials of exercise physiology.Philadelphia; Williams and Wilkins, 1994.

91. Szymanski DJ. Recommendations for the avoidance ofdelayed-onset muscle soreness. Strength and Condition-ing Journal 2001;23(4):7–13.

92. Bernier JN, Perrin DH. Effect of coordination training onproprioception of the functionally unstable ankle. J OrthopSports Phys Ther 1998;27(4):264–75.

93. Eils E, RosenbaumD.Amulti-station proprioceptive exerciseprogram in patients with ankle instability. Med Sci SportsExerc 2001;33(12):1991–8.

94. Hoiness P, Glott T, Ingjer F. High-intensity training with abi-directional bicycle pedal improves performance inmechani-cally unstable ankles—a prospective randomized study of 19subjects. Scand JMed Sci Sports 2003;13(4):266–71.

95. Kaminski TW, Buckley BD, Powers ME, Hubbard TJ, OrtizC. Effect of strength and proprioception training on eversionto inversion strength ratios in subjects with unilateral func-tional ankle instability. Br J Sports Med 2003;37(5):410–5;
discussion 415.
anuary 2010

96. OsborneMD,Chou LS, Laskowski ER, Smith J, KaufmanKR.The effect of ankle disk training on muscle reaction time insubjects with a history of ankle sprain. Am J Sports Med2001;29(5):627–32.

97. PintsaarA, Brynhildsen J, TroppH. Postural corrections afterstandardised perturbations of single limb stance: effect oftraining and orthotic devices in patients with ankle instabil-ity. Br J Sports Med 1996;30(2):151–5.

98. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance train-ing for persons with functionally unstable ankles. J OrthopSports Phys Ther 1999;29(8):478–86.

99. Sheth P, Yu B, Laskowski ER, An KN. Ankle disk traininginfluences reaction times of selected muscles in a simulatedankle sprain. Am J Sports Med 1997;25(4):538–43.

00. StasinopoulosD. Comparison of three preventivemethods inorder to reduce the incidence of ankle inversion sprainsamong female volleyball players. Br J Sports Med 2004;38(2):182–5.

01. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains.Am J Sports Med 1985;13(4):259–62.

02. Tropp H, Odenrick P. Postural control in single-limb stance.J Orthop Res 1988;6(6):833–9.

03. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, vanMechelen W. The effect of a proprioceptive balance boardtraining program for the prevention of ankle sprains: a pro-spective controlled trial. Am J Sports Med 2004;32(6):1385–93.

04. Verhagen EA, Van der Beek AJ, Bouter LM, Bahr RM, VanMechelen W. A one season prospective cohort study of vol-leyball injuries. Br J Sports Med 2004;38(4):477–81.

05. Verhagen EA, van Mechelen W, de Vente W. The effect ofpreventive measures on the incidence of ankle sprains. ClinJ Sport Med 2000;10(4):291–6.

06. Wedderkopp N, Kaltoft M, Holm R, Froberg K. Comparisonof two intervention programmes in young female players inEuropean handball—with and without ankle disc. ScandJ Med Sci Sports 2003;13(6):371–5.

07. Wedderkopp N, Kaltoft M, Lundgaard B, Rosendahl M,Froberg K. Prevention of injuries in young female players inEuropean team handball. A prospective intervention study.Scand J Med Sci Sports 1999;9(1):41–7.

08. Holm I, Fosdahl MA, Friis A, Risberg MA, Myklebust G,Steen H. Effect of neuromuscular training on propriocep-tion, balance, muscle strength, and lower limb function infemale team handball players. Clin J Sport Med2004;14(2):88–94.

09. Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, OlsenOE, Bahr R. Prevention of anterior cruciate ligament injuries infemale team handball players: a prospective intervention studyover three seasons. Clin J SportMed 2003;13(2):71–8.

10. Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Ol-sen OE, Bahr R. Prevention of noncontact anterior cruciateligament injuries in elite and adolescent female teamhandballathletes. Instr Course Lect 2007;56:407–18.

11. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mecha-nisms for anterior cruciate ligament injuries in teamhandball: asystematic video analysis. Am J Sports Med 2004;32(4):1002–12.

12. Ekstrand J, Gillquist J. The frequency of muscle tightness and
injuries in soccer players. Am J Sports Med 1982;10(2):75–8.

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1


13. Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R.Exercises to prevent lower limb injuries in youth sports: clus-ter randomised controlled trial. BMJ 2005;330(7489):449.

14. MandelbaumBR,SilversHJ,WatanabeDS, et al.Effectivenessofa neuromuscular and proprioceptive training program in pre-venting anterior cruciate ligament injuries in female athletes:2-year follow-up. Am J SportsMed 2005;33(7):1003–10.

15. Hewett TE, Myer GD, Ford KR. Reducing knee and anteriorcruciate ligament injuries among female athletes: a systematicreview of neuromuscular training interventions. J Knee Surg2005;18(1):82–8.

16. Hewett TE, Myer GD, Ford KR, et al. Biomechanical mea-sures of neuromuscular control and valgus loading of theknee predict anterior cruciate ligament injury risk in femaleathletes: a prospective study. Am J Sports Med 2005;33(4):492–501.

17. Ageberg E, Zatterstrom R, Moritz U, Friden T. Influence ofsupervised and nonsupervised training on postural controlafter an acute anterior cruciate ligament rupture: a three-yearlongitudinal prospective study. J Orthop Sports Phys Ther2001;31(11):632–44.

18. Andersen TE, Floerenes TW, Arnason A, Bahr R. Videoanalysis of themechanisms for ankle injuries in football. Am JSports Med 2004;32(1S):S69–79.

19. Bandettini MP, Innocenti G, Contini M, Paternostro F, LovaRM. Postural control in order to prevent chronic locomotorinjuries in top level athletes. Ital J Anat Embryol 2003;108(4):189–94.

20. Barclay-Goddard R, Stevenson T, Poluha W, Moffatt ME,Taback SP. Force platform feedback for standing balancetraining after stroke. Cochrane Database Syst Rev 2004(4):CD004129.

21. Bartlett MJ,Warren PJ. Effect of warming up on knee propri-oception before sporting activity. Br J SportsMed 2002;36(2):132–4.

22. Benesch S, Putz W, Rosenbaum D, Becker H. Reliability ofperoneal reaction timemeasurements. Clin Biomech (Bristol,Avon) 2000;15(1):21–8.

23. Blackburn JT, RiemannBL,Myers JB, Lephart SM.Kinematicanalysis of the hip and trunk during bilateral stance on fırm,foam, andmultiaxial support surfaces. Clin Biomech (Bristol,Avon) 2003;18(7):655–61.

24. Blackburn JT GK, PetschauerMA, PrenticeWE. Balance andjoint stability: the relative contributions of proprioceptionand muscular strength. J Sport Rehabil 2000(9):315–328.

25. Cahill BR, Griffıth EH. Effect of preseason conditioning onthe incidence and severity of high school football knee inju-ries. Am J Sports Med 1978;6(4):180–4.

26. Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Preventionof anterior cruciate ligament injuries in soccer. A prospectivecontrolled study of proprioceptive training. Knee Surg SportsTraumatol Arthrosc 1996;4(1):19–21.

27. Carter ND, Khan KM, Petit MA, et al. Results of a 10 weekcommunity based strength and balance training programmeto reduce fall risk factors: a randomised controlled trial in65–75 year old women with osteoporosis. Br J Sports Med2001;35(5):348–51.

28. Cerulli G, Benoit DL, Caraffa A, Ponteggia F. Proprioceptivetraining and prevention of anterior cruciate ligament injuriesin soccer. J Orthop Sports Phys Ther 2001;31(11):655–60;
discussion 661.
29. Chappell JD, Yu B, Kirkendall DT, Garrett WE. A compari-son of knee kinetics between male and female recreationalathletes in stop-jump tasks. Am J Sports Med 2002;30(2):261–7.

30. CookG, Burton L, Fields K. Reactive neuromuscular trainingfor the anterior cruciate ligament-defıcient knee: a case re-port. J Athl Train 1999;34(2):194–201.

31. Cowling EJ, Steele JR. Is lower limbmuscle synchrony duringlanding affected by gender? Implications for variations inACL injury rates. J Electromyogr Kinesiol 2001;11(4):263–8.

32. CowlingEJ, Steele JR.Theeffectofupper-limbmotionon lower-limb muscle synchrony. Implications for anterior cruciate liga-ment injury. J Bone Joint Surg Am 2001;83-A(1):35–41.

33. Cowling EJ, Steele JR,McNair PJ. Effect of verbal instructionson muscle activity and risk of injury to the anterior cruciateligament during landing. Br J SportsMed 2003;37(2):126–30.

34. Crossley K, Bennell KL, Wrigley T, Oakes BW. Groundreaction forces, bone characteristics, and tibial stress frac-ture in male runners. Med Sci Sports Exerc 1999;31(8):1088–93.

35. Delfıco AJ, Garrett WE, Jr.Mechanisms of injury of the ante-rior cruciate ligament in soccer players. Clin Sports Med1998;17(4):779–85, vii.

36. DeMont RG, Lephart SM. Effect of sex on preactivation of thegastrocnemius and hamstring muscles. Br J Sports Med2004;38(2):120–4.

37. Ekdahl C, Jarnlo GB, Andersson SI. Standing balance inhealthy subjects. Evaluation of a quantitative test battery on aforce platform. Scand J Rehabil Med 1989;21(4):187–95.

38. Emery CA. Is there a clinical standing balance measurementappropriate for use in sports medicine? A review of the liter-ature. J Sci Med Sport 2003;6(4):492–504.

39. Emery CA, Cassidy JD, Klassen TP, Rosychuk RJ, Rowe BH.Effectiveness of a home-based balance-training program in re-ducing sports-related injuries amonghealthyadolescents: a clus-ter randomized controlled trial. CMAJ 2005;172(6):749–54.

40. Ettlinger CF, Johnson RJ, Shealy JE. Amethod to help reducethe risk of serious knee sprains incurred in alpine skiing. Am JSports Med 1995;23(5):531–7.

41. Fagenbaum R, Darling WG. Jump landing strategies in maleand female college athletes and the implications of such strat-egies for anterior cruciate ligament injury. Am J Sports Med2003;31(2):233–40.

42. Fitzgerald GK, Axe MJ, Snyder-Mackler L. The effıcacy ofperturbation training in nonoperative anterior cruciate liga-ment rehabilitation programs for physical active individuals.Phys Ther 2000;80(2):128–40.

43. Ford KR, Myer GD, Hewett TE. Valgus knee motion duringlanding in high school female and male basketball players.Med Sci Sports Exerc 2003;35(10):1745–50.

44. Frank JS, Earl M. Coordination of posture and movement.Phys Ther 1990;70(12):855–63.

45. Gervais P. Movement changes in landings from a jump as aresult of instruction in children. Coaching Sport Sci J1997;3:11–16.

46. Grabiner MD, Koh TJ, Miller GF. Further evidence against adirect automatic neuromotor link between the ACL andhamstrings. Med Sci Sports Exerc 1992;24(10):1075–9.

47. Gribble PA,Hertel J, Denegar CR, BuckleyWE. The effects offatigue and chronic ankle instability on dynamic postural
control. J Athl Train 2004;39(4):321–9.
www.ajpm-online.net

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1


J

48. Gwinn DE,Wilckens JH, McDevitt ER, Ross G, Kao TC. Therelative incidence of anterior cruciate ligament injury in menandwomen at the United States Naval Academy. Am J SportsMed 2000;28(1):98–102.

49. Hardin JA, Voight ML, Blackburn TA, Canner GC, Soffer SR.The effects of “decelerated” rehabilitation following anteriorcruciate ligament reconstruction on a hyperelastic female ado-lescent: a case study. J Orthop Sports Phys Ther 1997;26(1):29–34.

50. Harmon KG, Dick R. The relationship of skill level toanterior cruciate ligament injury. Clin J Sport Med 1998;8(4):260–5.

51. Heidt RS Jr, SweetermanLM,CarlonasRL, Traub JA,TekulveFX. Avoidance of soccer injuries with preseason condition-ing. Am J Sports Med 2000;28(5):659–62.

52. Henderson NE, Knapik JJ, Shaffer SW, McKenzie TH,Schneider GM. Injuries and injury risk factors among menand women in U.S. Army Combat Medic Advanced individ-ual training. Mil Med 2000;165(9):647–52.

53. Hewett TE. Neuromuscular and hormonal factors associatedwith knee injuries in female athletes. Strategies for interven-tion. Sports Med 2000;29(5):313–27.

54. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. Theeffect of neuromuscular training on the incidence of kneeinjury in female athletes. A prospective study. Am J SportsMed 1999;27(6):699–706.

55. Hewett TE,Myer GD, Ford KR. Prevention of anterior cruciateligament injuries. CurrWomens Health Rep 2001;1(3):218–24.

56. Hiemstra LA, Lo IK, Fowler PJ. Effect of fatigue on kneeproprioception: implications for dynamic stabilization. J Or-thop Sports Phys Ther 2001;31(10):598–605.

57. Hoffman M, Payne VG. The effects of proprioceptive ankledisk training on healthy subjects. J Orthop Sports Phys Ther1995;21(2):90–3.

58. Hoffman M, Schrader J, Koceja D. An investigation of pos-tural control in postoperative anterior cruciate ligament re-construction patients. J Athl Train 1999;34(2):130–6.

59. Hurley CL, Kozey JW, Stanish WD. The effects of staticstretching exercises and stationary cycling on range of mo-tion at the hip joint. J Orthop Sports Phys Ther 1984;8:104–9.

60. Ihara H, Nakayama A. Dynamic joint control training forknee ligament injuries. Am J Sports Med 1986;14(4):309–15.

61. Irmischer BS, Harris C, Pfeiffer RP, DeBelisoMA, Adams KJ,Shea KG. Effects of a knee ligament injury prevention exer-cise program on impact forces in women. J Strength CondRes 2004;18(4):703–7.

62. Irrgang J, Whitney S, Cox E. Balance and proprioceptivetraining for rehabilitation of the lower extremity. J SportRehabil 1994 February;14(3):68–83.

63. Kaminski TW,WabbersenCV,MurphyRM.Concentric ver-sus enhanced eccentric hamstring strength training: clinicalimplications. J Athl Train 1998;33(3):216–21.

64. Kingma I, Aalbersberg S, van Dieen JH. Are hamstrings acti-vated to counteract shear forces during isometric knee exten-sion efforts in healthy subjects? J Electromyogr Kinesiol2004;14(3):307–15.

65. Knapik JJ, McCollam R, Canham-Chervak M, et al. Injuriesand injury prevention among senior military offıcers at theArmyWar College. Mil Med 2002;167(7):593–9.

66. Kollmitzer J, Ebenbichler GR, Sabo A, Kerschan K, Bochdan-
sky T. Effects of back extensor strength training versus bal-
anuary 2010

ance training on postural control. Med Sci Sports Exerc2000;32(10):1770–6.

67. Kovacs EJ, BirminghamTB, Forwell L, Litchfıeld RB. Effect oftraining on postural control in fıgure skaters: a randomizedcontrolled trial of neuromuscular versus basic off-ice trainingprograms. Clin J Sport Med 2004;14(4):215–24.

68. Krivickas LS. Anatomical factors associated with overusesports injuries. Sports Med 1997;24(2):132–46.

69. Leanderson J, Wykman A, Eriksson E. Ankle sprain andpostural sway in basketball players. Knee Surg Sports Trau-matol Arthrosc 1993;1(3–4):203–5.

70. Lepers R, BigardAX,Diard JP, Gouteyron JF, Guezennec CY.Posture control after prolonged exercise. Eur J Appl PhysiolOccup Physiol 1997;76(1):55–61.

71. Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role ofproprioception in the management and rehabilitation of ath-letic injuries. Am J Sports Med 1997;25(1):130–7.

72. Liu-Ambrose T, Taunton JE, MacIntyre D, McConkey P,Khan KM. The effects of proprioceptive or strength trainingon the neuromuscular function of the ACL reconstructedknee: a randomized clinical trial. Scand J Med Sci Sports2003;13(2):115–23.

73. LloydDG. Rationale for training programs to reduce anteriorcruciate ligament injuries in Australian football. J OrthopSports Phys Ther 2001;31(11):645–54; discussion 661.

74. Loudon JK, JenkinsW, LoudonKL. The relationship betweenstatic posture and ACL injury in female athletes. J OrthopSports Phys Ther 1996;24(2):91–7.

75. Malliou P, Amoutzas K, Theodosiou A, et al. Proprioceptivetraining for learning downhill skiing. Percept Mot Skills2004;99(1):149–54.

76. Matavulj D, KukoljM,UgarkovicD, Tihanyi J, Jaric S. Effects ofplyometric training on jumping performance in junior basket-ball players. J SportsMed Phys Fitness 2001;41(2):159–64.

77. Mattacola CG, Lloyd JW. Effects of a 6-week strength and pro-prioception training program onmeasures of dynamic balance:a single-case design. J Athl Train 1997;32(2):127–135.

78. McLean SG, Huang X, Su A, Van Den Bogert AJ. Sagittalplane biomechanics cannot injure the ACL during sidestepcutting. Clin Biomech (Bristol, Avon) 2004;19(8):828–38.

79. McNair PJ, Marshall RN, Matheson JA. Important featuresassociated with acute anterior cruciate ligament injury. N ZMed J 1990;103(901):537–9.

80. Myer GD, Ford KR, Hewett TE. Rationale and clinical tech-niques for anterior cruciate ligament injury preventionamong female athletes. J Athl Train 2004;39(4):352–64.

81. Myer GD, Ford KR, Hewett TE. Methodological approachesand rationale for training to prevent anterior cruciate liga-ment injuries in female athletes. Scand J Med Sci Sports2004;14(5):275–85.

82. Myer GD, Ford KR, McLean SG, Brent JL, Hewett TE. Theeffects of plyometric vs. dynamic stabilization and balancetraining on power, balance, and landing force in female ath-letes. J Strength Cond Res 2006;20(2):345–53.

83. Newton RU, Kraemer WJ, Hakkinen K. Effects of ballistictraining on preseason preparation of elite volleyball players.Med Sci Sports Exerc 1999;31(2):323–30.

84. Onate JA, Guskiewicz KM, Sullivan RJ. Augmented feedbackreduces jump landing forces. J Orthop Sports Phys Ther
2001;31(9):511–7.

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2


85. PaternoMV,MyerGD, FordKR,Hewett TE.Neuromusculartraining improves single-limb stability in young female ath-letes. J Orthop Sports Phys Ther 2004;34(6):305–16.

86. Pettit RW, Bryson ER. Training for women’s basketball: abiomechanical emphasis for preventing anterior cruciate lig-ament injury. J Strength Cond Res 2002;24(5):20–9.

87. Piantanida NA, Knapik JJ, Brannen S, O’Connor F. Injuriesduring Marine Corps offıcer basic training. Mil Med 2000;165(7):515–20.

88. Potter RN, Gardner JW, Deuster PA, Jenkins P, McKee K Jr,Jones BH.Musculoskeletal injuries in anArmy airborne pop-ulation. Mil Med 2002;167(12):1033–40.

89. Riemann BL, Myers JB, Lephart SM. Comparison of the an-kle, knee, hip, and trunk corrective action shown duringsingle-leg stance on fırm, foam, andmultiaxial surfaces. ArchPhys Med Rehabil 2003;84(1):90–5.

90. Riemann BL, Myers JB, Stone DA, Lephart SM. Effect oflateral ankle ligament anesthesia on single-leg stance stability.Med Sci Sports Exerc 2004;36(3):388–96.

91. Risberg MA, Lewek M, Snyder-Mackler L. A systematic re-view of evidence for anterior cruciate ligament rehabilitation:how much and what type? Physical Therapy in Sport 2004;3:125–45.

92. Risberg MA, Mork M, Jenssen HK, Holm I. Design andimplementation of a neuromuscular training program fol-lowing anterior cruciate ligament reconstruction. J OrthopSports Phys Ther 2001;31(11):620–31.

93. Shelbourne KD, Davis TJ. Evaluation of knee stability beforeand after participation in a functional sports agility programduring rehabilitation after anterior cruciate ligament recon-struction. Am J Sports Med 1999;27(2):156–61.

94. Simonsen EB, Magnusson SP, Bencke J, Naesborg H, Havk-rog M, Sorensen H. Can the hamstrings protect the anteriorcruciate ligament during a side-cutting maneuver? ScanJ Med Sci Sports 2000;10:78–84.

95. Smith J, Szczerba JE, Arnold BL, Perrin DH,Martin DE. Roleof hyperpronation as a possible risk factor for anterior cruci-ate ligament injuries. J Athl Train 1997;32(1):25–28.

96. Snedecor MR, Boudreau CF, Ellis BE, Schulman J, Hite M,Chambers B. U.S. Air Force recruit injury and health study.Am J Prev Med 2000;18(3S):S129–40.

97. Soderman K, Werner S, Pietila T, Engstrom B, Alfredson H.Balance board training: prevention of traumatic injuries ofthe lower extremities in female soccer players? A prospectiverandomized intervention study. Knee Surg Sports TraumatolArthrosc 2000;8(6):356–63.

98. Swanik CB, Lephart SM, Giraldo JL, Demont RG, Fu FH. Reac-tive muscle fıring of anterior cruciate ligament-injured femalesduring functional activities. J Athl Train 1999;34(2):121–129.

99. Tsang WW, Hui-Chan CW. Effect of 4- and 8-wk intensivetai chi training on balance control in the elderly. Med SciSports Exerc 2004;36(4):648–57.

00. Vengust R, Strojnik V, Pavlovcic V, Antolic V, Zupanc O. Theeffect of proprioceptive training in patientswith recurrent dislo-cation of the patella. Cell Mol Biol Lett 2002;7(2):379–80.

01. Wilson GJ, Newton RU, Murphy AJ, Humphries BJ. The opti-mal training load for the development of dynamic athletic per-formance. Med Sci Sports Exerc 1993;25(11):1279–86.

02. Griffın LY, AlbohmMJ, Arendt EA, et al. Understanding and
preventing noncontact anterior cruciate ligament injuries: a
review of the Hunt Valley II meeting, January 2005. Am JSports Med 2006;34(9):1512–32.

03. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD. The preven-tion of shin splints in sports: a systematic review of literature.Med Sci Sports Exerc 2002;34(1):32–40.

04. Yeung EW, Yeung SS. A systematic review of interventions toprevent lower limb soft tissue running injuries. Br J SportsMed 2001;35(6):383–9.

05. Thacker SB, Stroup DF, Branche CM, Gilchrist J, GoodmanRA, Porter Kelling E. Prevention of knee injuries in sports. Asystematic review of the literature. J Sports Med Phys Fitness2003;43(2):165–79.

06. Kumamoto DP, Maeda Y. A literature review of sports-related orofacial trauma. Gen Dent 2004;52(3):270–80; quiz281.

07. Alexander D, Walker J, Floyd K, Jakobsen J. A survey on theuse of mouthguards and associated oral injuries in athletics.Iowa Dent J 1995;81(2):41, 43–4.

08. Blignaut JB, Carstens IL, Lombard CJ. Injuries sustained inrugby by wearers and non-wearers of mouthguards. Br JSports Med 1987;21(2):5–7.

09. Board of Dental Education. Evaluation of mouth protectorsused by high school football players. JADA 1964;68:430–42.

10. Caglar E, Kargul B, Tanboga I. Dental trauma and mouth-guard usage among ice hockey players in Turkey premierleague. Dent Traumatol 2005;21(1):29–31.

11. Chapman PJ. Orofacial injuries and mouthguards: a study ofthe 1984 Wallabies. Br J Sports Med 1985;19(2):93–5.

12. Chapman PJ. Orofacial injuries and the use of mouthguardsby the 1984 Great Britain Rugby League touring team. Br JSports Med 1985;19(1):34–6.

13. Cohen A. A fıve year comparative study of various mouthprotectors. J Sch Health 1963;33:83–5.

14. Cohen A, Borish AL. Mouth protector project for footballplayers in Philadelphia high schools. J Am Dent Assoc1958;56(6):863–4.

15. Cohen A, Borish AL. A four year comparative study of vari-ous mouth protectors. Bul Nat Assoc Secondary School Prin-cipals 1961;45:145–8.

16. Davies RM, Bradley D, Hale RW, Laird WRE, Thomas PD.The prevalence of dental injuries in rugby players and theirattitude to mouthguards. Br J Sports Med 1997;11:72–4.

17. de Wet FA, Badenhorst M, Rossouw LM. Mouthguards forrugby players at primary school level. J Dent Assoc S Afr1981;36(4):249–53.

18. Dunbar D. Report on reduction in mouth injuries. J Massa-chusetts Dental Society 1962;11.

19. Heintz WD. Mouth protectors: a progress report. Bureau ofDental Health Education. J AmDent Assoc 1968;77(3):632–6.

20. Labella CR, Smith BW, Sigurdsson A. Effect of mouthguardson dental injuries and concussions in college basketball. MedSci Sports Exerc 2002;34(1):41–4.

21. Maestrello-deMoyaMG, Primosch RE. Orofacial trauma andmouth-protector wear among high school varsity basketballplayers. ASDC J Dent Child 1989;56(1):36–9.

22. Marshall SW, Loomis DP, Waller AE, et al. Evaluation ofprotective equipment for prevention of injuries in rugbyunion. Int J Epidemiol 2005;34(1):113–8.

23. McNutt T, Shannon SW Jr, Wright JT, Feinstein RA. Oraltrauma in adolescent athletes: a study of mouth protectors.
Pediatr Dent 1989;11(3):209–13.
www.ajpm-online.net

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2


J

24. Moon DG, Mitchell DF. An evaluation of a commercial pro-tective mouthpiece for football players. J Am Dent Assoc1961;62:568–72.

25. Morton JG, Burton JF. An evaluation of the effectiveness ofmouthguards in high-school rugby players. N Z Dent J1979;75(341):151–3.

26. dela Cruz GG, Knapik JJ, BirkMG. Evaluation of mouthguardsfor the prevention of orofacial injuries during United StatesArmy basic military training. Dent Traumatol 2008;24(1):86–90.

27. Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sportactivities: history, physical properties and injury preventioneffectiveness. Sports Med 2007;37(2):117–44.

28. Baumhauer JF, AlosaDM, RenstromAF, Trevino S, BeynnonB. A prospective study of ankle injury risk factors. Am JSports Med 1995;23(5):564–70.

29. Beynnon BD, Renstrom PA, Alosa DM, Baumhauer JF,Vacek PM. Ankle ligament injury risk factors: a prospectivestudy of college athletes. J Orthop Res 2001;19(2):213–20.

30. Giza E, Fuller C, Junge A, Dvorak J. Mechanisms of footand ankle injuries in soccer. Am J Sports Med2003;31(4):550–4.

31. Hosea TM, Carey CC, Harrer MF. The gender issue: epide-miology of ankle injuries in athletes who participate in bas-ketball. Clin Orthop Relat Res 2000(372):45–9.

32. Jensen SL, Andresen BK, Mencke S, Nielsen PT. Epidemiologyof ankle fractures. A prospective population-based study of 212cases in Aalborg, Denmark. Acta Orthop Scand 1998;69(1):48–50.

33. Leanderson J, Nemeth G, Eriksson E. Ankle injuries in basket-ball players. Knee Surg Sports Traumatol Arthrosc 1993;1(3–4):200–2.

34. McGuine TA, Greene JJ, Best T, Leverson G. Balance as apredictor of ankle injuries in high school basketball players.Clin J Sport Med 2000;10(4):239–44.

35. Mei-Dan O, Kahn G, Zeev A, et al. The medial longitudinalarch as a possible risk factor for ankle sprains: a prospectivestudy in 83 female infantry recruits. Foot Ankle Int 2005;26(2):180–3.

36. Milgrom C, Shlamkovitch N, Finestone A, et al. Risk factorsfor lateral ankle sprain: a prospective study among militaryrecruits. Foot Ankle 1991;12(1):26–30.

37. Willems TM, Witvrouw E, Delbaere K, Mahieu N, DeBourdeaudhuij I, DeClercqD. Intrinsic risk factors for inver-sion ankle sprains in male subjects: a prospective study. Am JSports Med 2005;33(3):415–23.

38. Amoroso PJ, Ryan JB, Bickley B, Leitschuh P, Taylor DC,Jones BH. Braced for impact: reducingmilitary paratroopers’ankle sprains using outside-the-boot braces. J Trauma1998;45(3):575–80.

39. Barrett JR, Tanji JL, Drake C, Fuller D, Kawasaki RI, FentonRM. High- versus low-top shoes for the prevention of anklesprains in basketball players. A prospective randomizedstudy. Am J Sports Med 1993;21(4):582–5.

40. Garrick JG, RequaRK. Role of external support in the preven-tion of ankle sprains. Med Sci Sports 1973;5(3):200–3.

41. Mann G, Kahn G, Suderer M, Zeev A, Constaintini N, NyskaM. Preventive effects of an on-shoe brace on ankle sprains ininfantry. In: The Unstable Ankle. Champaign IL: Human
Kinetics, 2002.
anuary 2010

42. Milford PI, Dunleavy PJ. A pilot trial of treatment of acuteinversion sprains to the ankle by ankle supports. J RNavMedServ 1990;76(2):97–100.

43. Rovere GD, Clarke TJ, Yates CS, Burley K. Retrospectivecomparison of taping and ankle stabilizers in preventing an-kle injuries. Am J Sports Med 1988;16(3):228–33.

44. Schmidt MD, Sulsky SI, Amoroso PJ. Effectiveness of anoutside-the-boot ankle brace in reducing parachuting relatedankle injuries. Inj Prev 2005;11(3):163–8.

45. Schumacher JT, Jr., Creedon JF, Pope RW. The effectivenessof the parachutist ankle brace in reducing ankle injuries in anairborne ranger battalion. Mil Med 2000;165(12):944–8.

46. Sharpe SR, Knapik J, Jones B. Ankle braces effectively reducerecurrence of ankle sprains in female soccer players. J AthlTrain 1997;32(1):21–24.

47. Sitler M, Ryan J, Wheeler B, McBride J, Arciero R, AndersonJ, et al. The effıcacy of a semirigid ankle stabilizer to reduceacute ankle injuries in basketball. A randomized clinicalstudy at West Point. Am J Sports Med 1994;22(4):454–61.

48. Beynnon BD, Murphy DF, Alosa DM. Predictive factors forlateral ankle sprains: a literature review. J Athl Train 2002;37(4):376–80.

49. Nigg BM, Segesser B. The influence of playing surfaces on theload on the locomotor system and on football and tennisinjuries. Sports Med 1988;5(6):375–85.

50. Hawley JA, Tipton KD, Millard-Stafford ML. Promotingtraining adaptations through nutritional interventions.J Sports Sci 2006;24(7):709–21.

51. SaundersMJ, KaneMD, ToddMK. Effects of a carbohydrate-protein beverage on cycling endurance and muscle damage.Med Sci Sports Exerc 2004;36(7):1233–8.

52. Umeda T, Nakaji S, Shimoyama T, Yamamoto Y, TotsukaM,Sugawara K. Adverse effects of energy restriction on myo-genic enzymes in judoists. J Sports Sci 2004;22(4):329–38.

53. Zawadzki KM, Yaspelkis BB 3rd, Ivy JL. Carbohydrate-protein complex increases the rate ofmuscle glycogen storageafter exercise. J Appl Physiol 1992;72(5):1854–9.

54. Kerksick C, Harvey T, Stout J, et al. International Society ofSports Nutrition position stand: nutrient timing. J Int SocSports Nutr 2008;5:17.

55. Armstrong DW 3rd, Rue JP, Wilckens JH, Frassica FJ. Stressfracture injury in young military men and women. Bone2004;35(3):806–16.

56. Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors forstress fractures in female track-and-fıeld athletes: a retrospec-tive analysis. Clin J Sport Med 1995;5(4):229–35.

57. Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors forstress fractures in track and fıeld athletes. A twelve-monthprospective study. Am J Sports Med 1996;24(6):810–8.

58. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Riskfactors for recurrent stress fractures in athletes. Am J SportsMed 2001;29(3):304–10.

59. Bloomer RJ, Goldfarb AH, McKenzie MJ, You T, Nguyen L.Effects of antioxidant therapy in women exposed to eccentricexercise. Int J Sport Nutr Exerc Metab 2004;14(4):377–88.

60. Flakoll PJ, Judy T, Flinn K, Carr C, Flinn S. Postexerciseprotein supplementation improves health and muscle sore-ness during basic military training in Marine recruits. J ApplPhysiol 2004;96(3):951–6.

61. Ivy JL, Goforth HW Jr, Damon BM, McCauley TR, Parsons
EC, Price TB. Early postexercise muscle glycogen recovery is

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2


enhanced with a carbohydrate-protein supplement. J ApplPhysiol 2002;93(4):1337–44.

62. Ivy JL, Res PT, Sprague RC, Widzer MO. Effect of acarbohydrate-protein supplement on endurance perfor-mance during exercise of varying intensity. Int J SportNutr Exerc Metab 2003;13(3):382–95.

63. Knitter AE, Panton L, Rathmacher JA, et al. Effects ofbeta-hydroxy-beta-methylbutyrate on muscle damage af-ter a prolonged run. J Appl Physiol 2000;89(4):1340–4.

64. Kreider RB, Ferreira M, Wilson M, Almada AL. Effects ofcalcium beta-hydroxy-beta-methylbutyrate (HMB) supple-mentation during resistance-training on markers of catabo-lism, body composition and strength. Int J Sports Med1999;20(8):503–9.

65. Paddon-Jones D, Keech A, Jenkins D. Short-term beta-hydroxy-beta-methylbutyrate supplementation does not re-duce symptoms of eccentric muscle damage. Int J Sport NutrExerc Metab 2001;11(4):442–50.

66. Panton LB, Rathmacher JA, Baier S, Nissen S. Nutritionalsupplementation of the leucine metabolite beta-hydroxy-beta-methylbutyrate (hmb) during resistance training.Nutri-tion 2000;16(9):734–9.

67. Rasmussen BB, TiptonKD,Miller SL,Wolf SE,Wolfe RR. Anoral essential amino acid-carbohydrate supplement enhancesmuscle protein anabolism after resistance exercise. J ApplPhysiol 2000;88(2):386–92.

68. RowlandsDS, ThorpRM,RosslerK,GrahamDF, RockellMJ.Effect of protein-rich feeding on recovery after intense exer-cise. Int J Sport Nutr Exerc Metab 2007;17(6):521–43.

69. Shafat A, Butler P, Jensen RL, Donnelly AE. Effects of dietarysupplementation with vitamins C and E on muscle functionduring and after eccentric contractions in humans. Eur JApplPhysiol 2004;93(1-2):196–202.

70. Tarnopolsky MA, BosmanM,Macdonald JR, Vandeputte D,Martin J, Roy BD. Postexercise protein-carbohydrate andcarbohydrate supplements increase muscle glycogen in menand women. J Appl Physiol 1997;83(6):1877–83.

71. Alon T, Bagchi D, Preuss HG. Supplementing with beta-hydroxy-beta-methylbutyrate (HMB) to build and maintainmuscle mass: a review. Res Commun Mol Pathol Pharmacol2002;111(1-4):139–51.

72. Peake JM, Suzuki K, Coombes JS. The influence of antioxi-dant supplementation on markers of inflammation and therelationship to oxidative stress after exercise. J Nutr Biochem2007;18(6):357–71.

73. Shirreffs SM, Armstrong LE, Cheuvront SN. Fluid and elec-trolyte needs for preparation and recovery from training andcompetition. J Sports Sci 2004;22(1):57–63.

74. Slater GJ, Jenkins D. Beta-hydroxy-beta-methylbutyrate(HMB) supplementation and the promotion of musclegrowth and strength. Sports Med 2000;30(2):105–16.

75. Akers WA, Sulzberger MB. The friction blister. Mil Med1972;137(1):1–7.

76. Bush RA, Brodine SK, Shaffer RA. The association of blisterswith musculoskeletal injuries in male marine recruits. J AmPodiatr Med Assoc 2000;90(4):194–8.

77. Hoeffler DF. Friction blisters and cellulitis in a navy recruitpopulation. Mil Med 1975;140(5):333–7.

78. Knapik JJ, Reynolds K, Barson J. Risk factors for foot blistersduring road marching: tobacco use, ethnicity, foot type, pre-
vious illness, and other factors. Mil Med 1999;164(2):92–7.
79. Naylor PF. Experimental friction blisters. Br J Dermatol1955;67(10):327–42.

80. Patterson HS, Woolley TW, Lednar WM. Foot blister riskfactors in an ROTC summer camp population. Mil Med1994;159(2):130–5.

81. Reynolds K,Williams J,Miller C,Mathis A, Dettori J. Injuriesand risk factors in an 18-day Marine winter mountain train-ing exercise. Mil Med 2000;165(12):905–10.

82. Herring KM, Richie DH Jr. Friction blisters and sock fıbercomposition. A double-blind study. J Am Podiatr Med Assoc1990;80(2):63–71.

83. Herring KM, Richie DH Jr. Comparison of cotton and acrylicsocks using a generic cushion sole design for runners. J AmPodiatr Med Assoc 1993;83(9):515–22.

84. Jagoda A,MaddenH, Hinson C. A friction blister preventionstudy in a population of marines. MilMed 1981;146(1):42–4.

85. Knapik JJ, HamletMP, Thompson KJ, Jones BH. Influence ofboot-sock systems on frequency and severity of foot blisters.Mil Med 1996;161(10):594–8.

86. Knapik JJ, Reynolds KL, Duplantis KL, Jones BH. Frictionblisters. Pathophysiology, prevention and treatment. SportsMed 1995;20(3):136–47.

87. Centers for Disease Control and Prevention, National Insti-tute for Occupational Safety and Health. Workplace use ofback belts: review and recommendations. Cincinnati OH:USDHHS, 1994.

88. Memorandum. Offıce of the Surgeon General, U.S. Army.Use of back support belts. 24 June 1994.

89. VanPoppelM,KoesB, SmidT,Bouter L.A systematic reviewofcontrolled clinical trials on the prevention of back injury inindustry. Occupational & Environmental Medicine 1997;54(12):841–7.

90. Department of Defense Instruction 6055.1. DoD Safety andOccupational Health (SOH) Program. 1998. http://www.dtic.mil/whs/directives/corres/pdf/605501p.pdf.

91. Jellema P, van Tulder MW, van Poppel MN, Nachemson AL,Bouter LM. Lumbar supports for prevention and treatment oflow back pain: a systematic review within the framework ofthe Cochrane Back Review Group. Spine 2001;26(4):377–86.

92. Linton S, VanTulder M. Preventive interventions for backand neck pain problems: what is the evidence? Spine2001;26(7):778–7.

93. Gatty CM, Turner M, Buitendorp DJ, Batman H. The effec-tiveness of back pain and injury prevention programs in theworkplace. Work 2003;20(3):257–66.

94. Tamblyn R, Berkson L, Dauphinee WD, et al. Unnecessaryprescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med1997;127(6):429–38.

95. O’Grady M, Hackney AC, Schneider K, Bossen E, SteinbergK, Douglas JM Jr, et al. Diclofenac sodium (Voltaren) re-duced exercise-induced injury in human skeletal muscle.Med Sci Sports Exerc 2000;32(7):1191–6.

96. Bauer DC, Orwoll ES, Fox KM, et al. Aspirin and NSAID usein older women: effect on bone mineral density and fracturerisk. Study of Osteoporotic Fractures ResearchGroup. J BoneMiner Res 1996;11(1):29–35.

97. Pizza FX, Cavender D, Stockard A, Baylies H, Beighle A. Anti-inflammatory doses of ibuprofen: effect on neutrophils and ex-ercise-induced muscle injury. Int J Sports Med 1999;20(2):
98–102.
www.ajpm-online.net

http://www.dtic.mil/whs/directives/corres/pdf/605501p.pdf

http://www.dtic.mil/whs/directives/corres/pdf/605501p.pdf

2

2

3

3

3

3

3

3

3

3

3

3

3

3

3

33

3

3

3

3

3

3

3

3

3

3

3

3

3

3


J

98. Sheikh RA, Romano PS, Prindiville TP, Yasmeen S, TrudeauW. Endoscopic evidence of mucosal injury in patients takingticlopidine compared with patients taking aspirin/nonsteroi-dal antiinflammatory drugs and controls. J Clin Gastroen-terol 2002;34(5):529–32.

99. van Staa TP, Leufkens HG, Cooper C. Use of nonsteroidal anti-inflammatory drugs and risk of fractures. Bone 2000;27(4):563–8.

00. Bourgeois J, MacDougall D, MacDonald J, Tarnopolsky M.Naproxen does not alter indices of muscle damage in resis-tance-exercise trained men. Med Sci Sports Exerc1999;31(1):4–9.

01. LoramLC,Mitchell D, Fuller A. Rofecoxib and tramadol do notattenuate delayed-onset muscle soreness or ischaemic pain inhuman volunteers. Can J Physiol Pharmacol 2005;83(12):1137–45.

02. Tokmakidis SP, Kokkinidis EA, Smilios I, Douda H. Theeffects of ibuprofen on delayedmuscle soreness andmuscularperformance after eccentric exercise. J Strength Cond Res2003;17(1):53–9.

03. Baker J, Cotter JD, GerrardDF, BellML,Walker RJ. Effects ofindomethacin and celecoxib on renal function in athletes.Med Sci Sports Exerc 2005;37(5):712–7.

04. Olsen NV, Jensen NG, Hansen JM, Christensen NJ, Fogh-Andersen N, Kanstrup IL. Non-steroidal anti-inflammatorydrugsandrenal response toexercise: a comparisonof indometh-acin and nabumetone. Clin Sci (Lond) 1999;97(4):457–65.

05. WalkerRJ,Fawcett JP,FlanneryEM,GerrardDF. Indomethacinpotentiates exercise-induced reduction in renal hemodynamicsin athletes. Med Sci Sports Exerc 1994;26(11):1302–6.

06. Hungin AP, Kean WF. Nonsteroidal anti-inflammatorydrugs: overused or underused in osteoarthritis? Am J Med2001;110(1):S8–11.

07. Thacker SB,Gilchrist J, StroupDF,KimseyCD Jr. The impactof stretching on sports injury risk: a systematic review of theliterature. Med Sci Sports Exerc 2004;36(3):371–8.

08. Herbert RD, Gabriel M. Effects of stretching before and afterexercising on muscle soreness and risk of injury: systematicreview. BMJ 2002;325(7362):468.

09. Shrier I. Stretching before exercise does not reduce the risk oflocal muscle injury: a critical review of the clinical and basicscience literature. Clin J Sport Med 1999;9(4):221–7.

10. Weldon SM, Hill RH. The effıcacy of stretching for preven-tion of exercise-related injury: a systematic review of theliterature. Man Ther 2003;8(3):141–50.

11. Anderson B, Burke ER. Scientifıc, medical, and practical as-
pects of stretching. Clin Sports Med 1991;10(1):63–86.
anuary 2010

12. Beaulieu JE. Stretching for all sports. Pasadena CA; AthleticPress, 1980.

13. Corbin CB. Flexibility. Clin Sports Med 1984;3(1):101–17.14. Entyre BR, Lee EJ. Comments on proprioceptive neuromuscular

facilitation stretching techniques. Res Q Exerc Sport 1987;58:184–8.

15. Garrett WE Jr. Muscle strain injuries. Am J Sports Med1996;24(6S):S2–8.

16. Holland GJ. The physiology of flexibility: a review of theliterature. Kinesthesiol Rev 1968;1:49–62.

17. Holt J, Holt LE, Pelhan TW. Flexibility redefıned. In: BauerST, ed. XIIIth International Symposium for Biomechanics inSport, July 1996. Lakehead University, Ontario 1996: 170–4.

18. Hubley-Kozey CL, Stanish WD. Can stretching prevent ath-letic injuries. J Musculoskeletal Med 1990;7:21–31.

19. Knudson DV, Magnusson P, Mchugh M. Current issues inflexibility fıtness. Pres Council Phys Fit Sports 2000;3:1–6.

20. Lopez R, Dausman D.Warm-up: a psychophysiological phe-nomenon. Physical Educator 1981;38:138–43.

21. Neuberger T.What the ResearchQuarterly says about warm-up. JOPERD 1969;40:75–77.

22. SafranMR, Seaber AV, GarrettWE Jr.Warm-up andmuscularinjury prevention. An update. SportsMed 1989;8(4):239–49.

23. Worrell TW, Perrin DH. Hamstring muscle injury: the influ-ence of strength, flexibility, warm-up fatigue. J Orthop SportsPhys Ther 1992;16:12–8.

24. Knapik JJ, Bauman CL, Jones BH, Harris JM, Vaughan L.Preseason strength and flexibility imbalances associated withathletic injuries in female collegiate athletes. Am J SportsMed1991;19(1):76–81.

25. Bullock SH, Jones BH. Recommedations for prevention ofphysical training (PT)–related injuries: results of a systematicevidence-based review by the Joint Services Physical TrainingInjury Prevention Work Group (JSPTIPWG). AberdeenProving GroundMD: U.S. Center for Health Promotion andPreventive Medicine, 2008. Report No. 21-KK-08QR-08.

26. Johnston CA, Taunton JE, Lloyd-Smith DR, McKenzie DC.Preventing running injuries. Practical approach for familydoctors. Can Fam Physician 2003;49:1101–9.

27. Sullivan D,Warren RF, Pavlov H, Kelman G. Stress fracturesin 51 runners. Clin Orthop Relat Res 1984(187):188–92.

28. Buist I, BredewegSW, vanMechelenW,LemminkKA,PeppingGJ, Diercks RL. No effect of a graded training program on thenumber of running-related injuries in novice runners: a ran-
domized controlled trial. Am J SportsMed 2008;36(1):33–9.

prevention of physical training–related injuries resource library/prevention of physical...

Documents