You are here

  • Home
  • Online First
  • MSKI reduction strategies: evidence-based interventions to reduce musculoskeletal injuries in military service members

Article Text

Article menu

Download PDFPDF

Invited review
MSKI reduction strategies: evidence-based interventions to reduce musculoskeletal injuries in military service members
  1. Hans Christian Tingelstad1,
  2. E Robitaille2,3,
  3. TJ O'Leary4,5,6,
  4. M-A Laroche1,
  5. P Larsen7,8 and
  6. T Reilly1
  1. 1Personnel Support Programs, Directorate of Programs, Human Performance Research and Development, Canadian Forces Morale and Welfare Services, Ottawa, Ontario, Canada
  2. 231 Canadian Forces Health Services Centre Detachment Meaford, Canadian Armed Forces Health Services Group, Ottawa, Ontario, Canada
  3. 3Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
  4. 4Army Health and Performance Research, Andover, UK
  5. 5Army Headquarters, Andover, UK
  6. 6Division of Surgery and Interventional Science, UCL, London, UK
  7. 7Centre for Medical and Exercise Physiology, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
  8. 8School of Allied Health, Exercise and Sport Science, Charles Sturt University, Albury, New South Wales, Australia
  1. Correspondence to Dr T Reilly; reilly.tara{at}cfmws.com

Abstract

Musculoskeletal injuries (MSKI) are one of the biggest challenges for military services globally, contributing to substantial financial burdens and lost training and working days. Effective evidence-based intervention strategies are essential to reduce MSKI incidence, and research has shown the positive effect of both nutritional interventions and physical training (PT) interventions on reducing MSKI incidence. Levels of vitamin D metabolites have been associated with MSKI and bone stress fracture risk, while calcium and vitamin D supplementation has been shown to reduce the incidence of stress fractures during military training. Protein and carbohydrate supplementation during arduous military training (high volume, high intensity) has also been shown to reduce MSKI risk and the number of limited/missed duty days. PT has played a key role in soldier development to meet the occupational demands of serving in the armed forces. Paradoxically, while PT is fundamental to enhancing soldier readiness, PT can also be a major contributor to MSKI; emerging evidence suggests that the nature of the PT being performed is a risk factor for MSKI. However, strategies like reducing training load and implementing PT programmes using evidence-based training principles can reduce MSKI incidence among military service members by 33–62%, and reduce the financial burdens for military services. This review provides a summary of effective MSKI reduction interventions and provides strategies to enhance the success and adoption of such interventions.

  • SPORTS MEDICINE
  • REHABILITATION MEDICINE
  • PREVENTIVE MEDICINE
  • OCCUPATIONAL & INDUSTRIAL MEDICINE
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/military-2024-002747

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Musculoskeletal injury (MSKI) is a major challenge for military services globally, with significant financial and operational costs.

    WHAT THIS STUDY ADDS

    • Vitamin D and calcium, protein and carbohydrate supplementation can have a beneficial effect on reducing MSKI incidence.

    • Using evidence-based training principles in the development of physical training programmes can reduce MSKI incidence.

    • Reducing training load is not detrimental to improvements in military physical performance and reduces self-reported musculoskeletal pain/discomfort.

    • Encouraging a collaborative environment between researchers, military stakeholders and subject matter experts will increase the successful implementation of MSKI mitigation programmes.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Implementation of evidence-based strategies, as highlighted in this review, can substantially reduce MSKI incidence among military services globally, as well as reduce the financial burden caused by MSKI.

    Introduction

    Musculoskeletal injuries (MSKI) are an ongoing challenge for military services that negatively impact military readiness, recruitment, retention and career progression, as well as imposing economic and administrative burdens; MSKI contributes to a high proportion of missed training/duty days and discharges.1 2 Globally, military services report high rates of MSKI, ranging from 40% to 76% across Canadian, British and US Armed Forces.1 3 The most common MSKIs are lower body, repetitive strain injuries, and although considered preventable,1 3 MSKIs cost military services hundreds of millions of dollars annually.1 2

    Previous research has sought to better understand the mechanisms of commonly sustained MSKI in military settings to identify groups most at risk.4–6 However, the impact of these studies has been somewhat limited, as risk factors often vary depending on the population and the nature of the physical activity performed.4 Many recognised risk factors, such as sex and age, are non-modifiable5 7; however, there is an increasing amount of evidence in support of the association between low physical fitness and MSKI risk.4 6 8 Recognising risk factors alone does not reduce MSKI risk. Intervention studies are required to confirm if strategies designed to modify injury risk factors will result in the anticipated reduction in MSKI incidence, and randomised controlled trials serve as the gold standard to accomplish this. Effective evidence-based interventions are essential to reduce MSKI, and several recent publications have shown positive results for both nutritional and physical training (PT) interventions to reduce MSKI incidence.2 3 9–17 This invited review will offer a summary of some of the most effective interventions to date for reducing MSKI incidence, strategies to enhance success and adoption, and actionable recommendations for military decision-makers aiming to mitigate MSKI incidence.

    Nutritional interventions

    Over the past two decades, nutritional supplementation has emerged as a prominent area of research for reducing MSKI incidence in military service members. Military training is commonly characterised by high training loads,18 limited time for recovery17 and often a caloric deficit.19 The combination of these factors can lead to reductions in lean body mass,11 endocrine disturbances18 and disrupted bone metabolism.18 Nutrition also plays an important role in supporting musculoskeletal tissues’ adaptation to military training.11 19 These factors collectively elevate the risk of MSKI, particularly bone-related injuries like stress fractures.9 19 Consequently, various forms of nutritional supplementation have been explored as potential interventions to mitigate MSKI risk.

    Calcium and vitamin D

    Calcium and vitamin D are essential for bone health,2 and in an attempt to mitigate bone stress injuries over a 9-week training course, Schwellnus and Jordaan20 administered 500 mg of calcium daily to recruits. However, results revealed no discernible difference in bone stress MSKI incidence between the calcium supplementation and control group. It was hypothesised that this lack of distinction could be attributed to both groups meeting the baseline requirement for calcium intake (>800 mg/day), indicating that they were not calcium deficient. Stress fracture incidence is higher in female service members compared with males,19 so Lappe and colleagues2 supplemented a group of female naval basic trainees with 2000 mg of calcium and 800 IU of vitamin D daily for 8 weeks. Results showed that compared with placebo controls, the group receiving calcium and vitamin D supplementation experienced a 21% lower incidence of stress fractures (6.8% vs 8.6%). These results could indicate a dose–response relationship for supplementation with calcium and vitamin D. This was further supported by a series of studies conducted by Gaffney-Stomberg and colleagues.21 22 Their research showed that providing US Marine Corps recruits with an additional 2000 mg calcium and 1000 IU vitamin D during basic training led to a reduction in markers of bone resorption compared with placebo. Serum vitamin D levels decreased in both groups, however, participants with high vitamin D levels at the start of training were able to maintain these levels in the supplementation group, but not in the placebo group. There was also an effect of season, where bone strength index improved in the supplementation group compared with placebo in the summer serials, but not in the winter. In contrast, providing US Army recruits with an additional 1000 mg calcium and 1000 IU vitamin D during basic training had no effect on bone strength.22 However, calcium and vitamin D supplementation did prevent an increase in bone resorption markers, compared with placebo. These results seem to suggest a larger dose is required to see the beneficial effects of calcium and vitamin D supplementation on bone health during a short-duration military training course. This has been supported by research suggesting the required dose can be affected by individual factors like health status, age and body weight.23

    The association between lower circulating vitamin D levels and MSKI incidence has also been reported in other studies,18 and was further reinforced by Carswell and colleagues,24 who conducted a prospective cohort study and found that during British Army recruit training, vitamin D metabolites were associated with MSKI risk; recruits with low levels of 1,25(OH)2D:24,25(OH)2D and higher serum 24,25(OH)2D at the onset of physically demanding military training were less likely to sustain overuse MSKI and bone stress injuries. These results imply potential protective effects of serum 24,25(OH)2D against overuse MSKI among younger service members.

    Protein and carbohydrates

    The combination of high training volume, inadequate sleep and caloric deficit commonly observed during military training can result in widespread endocrine and musculoskeletal disturbances19 and blunted postexercise recovery.25 Lack of nutrients like protein and carbohydrates can also reduce muscle repair and growth,11 increase muscle soreness,11 impair bone metabolism18 and increase the risk of MSKI (especially bone stress injuries).19 To assess the impact of postexercise protein supplementation on muscle soreness and MSKI rate, Flakoll and colleagues11 provided Marine Corps recruits with either a placebo, carbohydrate (8 g carbohydrate and 3 g fat) or protein (10 g protein, 8 g carbohydrate and 3 g fat) tablet daily during a 54-day basic training course. Results showed that recruits taking the protein supplement had 49% and 17% fewer visits to the medical clinic for muscle and joint pain, respectively, compared with placebo and carbohydrate supplementation. The protein supplementation group also reported reduced muscle soreness compared with the other groups. Similar results were found by McAdam and colleagues,26 who showed that US Army Initial Entry Training soldiers who consumed a protein supplement two times per day (38.6 g protein, 19.0 g carbohydrates, 7.5 g fat) or carbohydrate supplement two times per day (0.5 g protein, 63.4 g carbohydrates, 3.9 g fat) were 3.9 times less likely to sustain an MSKI compared with soldiers not taking any supplements. Soldiers who consumed only one serving of either protein or carbohydrate were three times more likely to sustain an injury compared with those who consumed two servings. Soldiers consuming two servings of either protein or carbohydrate also exhibited a decrease in limited/missed duty days compared with non-supplemented soldiers. In summary, the evidence presented here points to the benefit of calcium, vitamin D, protein and carbohydrate supplementation in military training with high physical demands to reduce the risk of sustaining an MSKI. However, more studies are required to confirm these results and potential dose–response relationships.

    PT interventions

    PT is an integral part of military service and essential for meeting the rigorous physical demands of serving in the armed forces.27 While improving soldier readiness is achieved through PT, it paradoxically remains a major cause of MSKI in the armed forces.1 However, emerging evidence suggests replacing traditional military PT routines (ie, callisthenic-type bodyweight strength training and continuous unit-paced runs) with PT plans developed using evidence-based fitness principles has shown promise in reducing MSKI rates, particularly overuse MSKI, across various military training courses.

    In the athletic literature, principles such as standardisation (using standardised rest periods between sessions), progressive overload (gradually increasing training stimuli) and individualisation (tailoring training to individual requirements) are fundamental components of training programme development.28 Most athletic strength and conditioning programmes are founded on the use of external loads during strength training and high-intensity interval training to improve aerobic capacity,29 and studies have shown that low absolute strength and aerobic capacity are risk factors for MSKI.4 8 However, most military PT has historically relied heavily on equipment-free bodyweight exercises and group runs, where participants run at a pace set by course staff.29 In many instances, there appears to have been a misalignment between the content of PT programmes and military physical demands, which can result in improvements in physical performance that may not translate to improvements in military performance.

    Although efforts have been made to develop interventions aimed at reducing PT-related MSKI in the armed forces, not all interventions have yielded successful outcomes, potentially due to the nature of the intervention. For instance, Goodall et al30 found an increased risk of MSKI when balance and agility training were introduced into military basic training, suggesting that increasing training volume may not be the optimal strategy for MSKI mitigation. Similarly, Brushøj 31and colleagues found no significant effect of implementing a short MSKI prevention PT programme (squats, lunges, hip abduction/extension/rotation, forefoot lift, coordination, quad stretch) compared with a placebo programme (abdominal curls, back extensions, biceps and triceps towel curls, pectoral stretch) on MSKI rates. The lack of effectiveness of the intervention programme might be attributed to its short duration (only 15 min, five days/week).

    One of the first successful PT interventions happened as early as 1987 when Marcinik and colleagues13 showed in a randomised controlled study that replacing callisthenic strength training with an external load strength circuit reduced both the number of lower body injuries (59%) and the number of training days lost to injury (62%). Despite this early discovery, there has been persistent resistance to moving away from callisthenic-type strength training and low-intensity to moderate-intensity platoon runs in military training programmes. However, with the substantial burden MSKI has on military services, both in terms of reducing readiness and increasing financial cost,1 5 16 several studies have been conducted to better understand the potential of PT interventions for reducing MSKI. The US Army introduced the Physical Readiness Training (PRT) programme in 2004, which aligns with common fitness principles such as progressive overload, regularity/standardisation and specificity. The implementation of the PRT has led to a notable decrease in trainee MSKI rates (33–45%), while also maintaining or improving fitness levels.14 In 2016, Sell and colleagues15 assessed the efficacy of the Eagle Tactical Athlete Program (ETAP) in reducing MSKI rates. Previously shown to increase physical performance in members of the 101st Airborne Division, the ETAP programme follows a standardised plan, with each day of the week dedicated to a specific objective (eg, speed, agility, balance, strength training, power development, interval training, endurance training), allowing for adequate rest between sessions. During a 5-month course, MSKI rates among Soldiers (n=1136) following the ETAP programme were compared with Soldiers (n=584) following regular course PT (alternating cardiorespiratory activities and muscular endurance/strength activities). Results showed that the proportion of soldiers with preventable MSKI was reduced from pre-course to post-course in the group following the ETAP programme (3% reduction), while there was no significant change in preventable injuries observed in the group following regular course PT.

    Reducing training load

    Modifying PT programmes and reducing training load have been proposed as a strategy to mitigate MSKI risk.9 However, some military leaders have shown reluctance to such modifications due to concerns about their effect on physical performance.32 Burley and colleagues10 showed that a training programme with reduced training volume (lower volume of loaded marching and continuous runs), and a primary focus on strength training and interval runs led to larger improvements in both muscular strength, aerobic capacity and load carriage performance, with fewer MSKIs, compared with usual military PT practice. Similar results were seen in the OMEGA Injury Prevention and Physical Performance concept, implemented at the British Infantry Training Centre Catterick.16 The intervention consisted of progressive incremental loading (volume, frequency, intensity), reduced running mileage and standardised load carriage protocols with incremental progression of loaded activity, aimed at enhancing physical performance while reducing MSKI.16 An integral aspect of the OMEGA programme was the development of an integrated culture between the chain of command, course staff and healthcare providers to generate buy-in from all stakeholders. The OMEGA programme increased the number of recruits graduating, and reduced MSKI incidence from a 34% and 38% average over the previous 4 years to 22% and 21%, in Line and Guard soldiers, respectively. Additionally, there was a combined reduction in medical discharges from 7.7% to 4.3%, potentially saving £8.9 million in preventable medical discharges.16 Larsen and colleagues12 employed a similar approach with Australian Army Infantry trainees. In their intervention, loaded marching was conducted with a progressive increase in load, with the starting load reduced by 39%. Additionally, maximal aerobic speed runs were replaced with 3 min running intervals, and continuous moderate-intensity cardio sessions were substituted with 30 s sprint intensity intervals during the first 7 weeks of training. The results from the intervention were compared with a control group, performing regular PT. Irrespective of the training regime, trainees made significant improvements in the incremental fire and move assessment (~24%). However, differences were observed for self-reported musculoskeletal pain/discomfort which were approximately twofold higher for the control group compared with the experimental group, suggesting a possible association with a reduction in load carriage mass in the first four weeks of training and musculoskeletal complaints, without sacrificing potential physical performance gains.

    A persistent challenge with PT interventions has been sustaining the implementation over the long term. After noticing a high number of MSKIs sustained by recruits undergoing basic training at the Canadian Forces Leadership Recruit School, Chassé and colleagues8 were able to show a significant association between physical performance and MSKI risk, with higher fitness being associated with lower MSKI risk. Using these findings as a foundation, the training plan for the Basic Military Qualification course was changed, and mandatory PT was written into the training plan. Fitness experts collaborated in revising the training plan to prioritise fitness training and adjusting the training load to enhance physical performance and reduce MSKI. The new curriculum features a standardised PT plan and supervised strength sessions led by fitness experts, the addition of a fitness test to screen for MSKI risk, modified progressions in loaded marching and a more balanced training load.17 This has led to a 50% reduction in time lost to injury compared with numbers seen prior to making the changes to the training plan and is estimated to save the Canadian Forces Leadership and Recruit School between $C930 000 and $C1 400 000 annually.

    Challenges associated with evidence-based interventions and how they can be overcome

    Sustained commitment to successful MSKI interventions has been a challenge, and a lack of stakeholder engagement to apply research evidence to context-appropriate interventions has been reported as a common barrier to implementation.33 Researchers typically develop theoretical interventions using comparable participants in controlled, low-risk settings and presume that demonstrating effectiveness under these conditions validates wide-scale implementation. In contrast, military training typically includes disparate participants, in adverse, high-risk settings, which demand practical interventions feasible for implementation without compromising operations or military-specific training demands. Such contextual discrepancies between stakeholders may have impeded the wide-scale implementation of modified PT to minimise MSKI in military populations. The importance of stakeholder engagement has recently been validated in a systematic review citing low stakeholder engagement as a key barrier and strong stakeholder engagement as the main facilitator to implementing MSKI mitigation programmes in military populations.34

    The Knowledge Transfer Scheme (KTS) is a five-step framework developed specifically to bridge the gap between research and practice by engaging in collaboration between stakeholders to adopt effective interventions to cocreate an evidence-based, context-appropriate product suitable for implementation.33 The five steps of the KTS include: developing a problem statement, describing the relevant evidence, forming a knowledge transfer group, developing the product and evaluating its effectiveness. The Generating Resilience to Injuries through Training (GRIT) research project strategically adapted the KTS framework to engage Canadian Armed Forces (CAF) Defence Team Stakeholders (fitness, health services, military leadership, military training and research staff) to collaboratively cocreate, implement and measure the effectiveness of an evidence-based modified PT programme to minimise MSKI during basic infantry training.3 Defence Team Stakeholders reported that the evidence-based modified PT programme was feasible, posing a manageable demand on resources without compromising operations, and effective, with GRIT participants reporting 68% fewer MSKIs, 296 fewer medical employment limitation days and 11 fewer attritions than control participants.3 Stakeholder engagement was crucial to the successful development and implementation of a modified PT programme to minimise MSKI during CAF basic infantry training, and a similar approach was adopted during the implementation of the OMEGA programme for British Line and Guard soldiers.16 Given the results and the current research evidence, it is strongly recommended that researchers collaborate with military stakeholders to ensure that research evidence is adapted for the context of military training, as only feasible interventions will potentially minimise MSKI and their measures of burden in military populations.

    Conclusions

    Scientific research has demonstrated several effective intervention strategies that can minimise MSKI incidence during military training. However, there is a need for strategic implementation on an institutional scale, and discrepancies between the priorities of various stakeholders may be a barrier to the successful implementation and/or sustainability of effective MSKI reduction interventions. It is, therefore, crucial to foster an environment of collaboration between researchers, military stakeholders and subject matter experts to increase the understanding of how PT and supplementation interventions can have a substantial positive impact on improving physical performance and reducing MSKI incidence among military service members. A collaborative effort is also required to improve the understanding of the implementation process, thereby increasing the chance of successful implementation, and sustained adherence to the implementation long term. In addition, involving PT and nutritional experts in the development of these interventions is crucial for optimising their effectiveness and ensuring they are tailored to the unique needs and demands of military personnel.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    References

    1. ↵
      1. Nindl BC,
      2. Williams TJ,
      3. Deuster PA, et al
      . Strategies for optimizing military physical readiness and preventing musculoskeletal injuries in the 21st century. US Army Med Dep J 2013;5–23.
    2. ↵
      1. Lappe J,
      2. Cullen D,
      3. Haynatzki G, et al
      . Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res 2008;23:741–9. doi:10.1359/jbmr.080102
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      1. Robitaille E,
      2. Larter V,
      3. Heipel S, et al
      . The feasibility of implementing an evidence-based physical training program during a Canadian Armed Forces basic infantry course. J Sci Med Sport 2021;24:886–93. doi:10.1016/j.jsams.2021.03.012
      OpenUrlPubMed
    4. ↵
      1. Robitaille E,
      2. Reilly T,
      3. Heipel S, et al
      . The value of strength as a predictor of musculoskeletal injury in Canadian Armed Forces basic infantry candidates. Mil Med 2024;189:e1675–82. doi:10.1093/milmed/usae015
      OpenUrlPubMed
    5. ↵
      1. Sammito S,
      2. Hadzic V,
      3. Karakolis T, et al
      . Risk factors for musculoskeletal injuries in the military: a qualitative systematic review of the literature from the past two decades and a new prioritizing injury model. Mil Med Res 2021;8:66. doi:10.1186/s40779-021-00357-w
    6. ↵
      1. Rhon DI,
      2. Molloy JM,
      3. Monnier A, et al
      . Much work remains to reach consensus on musculoskeletal injury risk in military service members: a systematic review with meta-analysis. Eur J Sport Sci 2022;22:16–34. doi:10.1080/17461391.2021.1931464
      OpenUrlPubMed
    7. ↵
      1. Molloy JM,
      2. Pendergrass TL,
      3. Lee IE, et al
      . Musculoskeletal injuries and United States Army readiness part I: overview of injuries and their strategic impact. Mil Med 2020;185:e1461–71. doi:10.1093/milmed/usaa027
      OpenUrlCrossRefPubMed
    8. ↵
      1. Chassé E,
      2. Laroche MA,
      3. Dufour CA, et al
      . Association between musculoskeletal injuries and the Canadian Armed Forces physical employment standard proxy in Canadian military recruits. Mil Med 2020;185:e1140–6. doi:10.1093/milmed/usaa011
      OpenUrlPubMed
    9. ↵
      1. Wardle SL,
      2. Greeves JP
      . Mitigating the risk of musculoskeletal injury: a systematic review of the most effective injury prevention strategies for military personnel. J Sci Med Sport 2017;20 Suppl 4:S3–10. doi:10.1016/j.jsams.2017.09.014
      OpenUrl
    10. ↵
      1. Burley SD,
      2. Drain JR,
      3. Sampson JA, et al
      . Effect of a novel low volume, high intensity concurrent training regimen on recruit fitness and resilience. J Sci Med Sport 2020;23:979–84. doi:10.1016/j.jsams.2020.03.005
      OpenUrlPubMed
    11. ↵
      1. Flakoll PJ,
      2. Judy T,
      3. Flinn K, et al
      . Postexercise protein supplementation improves health and muscle soreness during basic military training in marine recruits. J Appl Physiol (1985) 2004;96:951–6. doi:10.1152/japplphysiol.00811.2003
      OpenUrlCrossRefPubMed
    12. ↵
      1. Larsen P,
      2. Alfiero L,
      3. Gibson N, et al
      . The influence of a reduced external load and sprint intensity intervals on infantry trainees. London, UK, 2023.
    13. ↵
      1. Marcinik EJ,
      2. Hodgdon JA,
      3. O’Brien JJ
      . A comparison of sprain and strain injury rates during aerobic/calisthenic and aerobic/circuit weight training programs. Mil Med 1987;152:252–4. doi:10.1093/milmed/152.5.252
      OpenUrlPubMed
    14. ↵
      1. Molloy JM,
      2. Pendergrass TL,
      3. Lee IE, et al
      . Musculoskeletal injuries and United States Army readiness. Part II: management challenges and risk mitigation initiatives. Mil Med 2020;185:e1472–80. doi:10.1093/milmed/usaa028
      OpenUrlPubMed
    15. ↵
      1. Sell TC,
      2. Abt JP,
      3. Nagai T, et al
      . The eagle tactical athlete program reduces musculoskeletal injuries in the 101st airborne division (air assault). Mil Med 2016;181:250–7. doi:10.7205/MILMED-D-14-00674
      OpenUrlPubMed
    16. ↵
      1. Heagerty R,
      2. Sharma J
      . Musculoskeletal training injury in military recruit populations: an integrated prevention strategy-project OMEGA-(part 1). Int J Phys Med Rehabil 2018;6:1–11.
      OpenUrl
    17. ↵
      1. Laroche MA,
      2. Chassé É,
      3. Théoret D, et al
      . Assessment of training load, sleep, injuries, and operational physical performance during basic military qualification. Mil Med 2023;188:e2018–25. doi:10.1093/milmed/usac334
      OpenUrlPubMed
    18. ↵
      1. O’Leary TJ,
      2. Walsh NP,
      3. Casey A, et al
      . Supplementary energy increases bone formation during arduous military training. Med Sci Sports Exerc 2021;53:394–403. doi:10.1249/MSS.0000000000002473
      OpenUrl
    19. ↵
      1. O’Leary TJ,
      2. Wardle SL,
      3. Greeves JP
      . Energy deficiency in soldiers: the risk of the athlete triad and relative energy deficiency in sport syndromes in the military. Front Nutr 2020;7:142. doi:10.3389/fnut.2020.00142
    20. ↵
      1. Schwellnus MP,
      2. Jordaan G
      . Does calcium supplementation prevent bone stress injuries? A clinical trial. Int J Sport Nutr Exerc Metab 1992;2:165–74. doi:10.1123/ijsn.2.2.165
      OpenUrl
    21. ↵
      1. Gaffney-Stomberg E,
      2. Nakayama AT,
      3. Guerriere KI, et al
      . Calcium and vitamin D supplementation and bone health in Marine recruits: effect of season. Bone 2019;123:224–33. doi:10.1016/j.bone.2019.03.021
      OpenUrlPubMed
    22. ↵
      1. Gaffney-Stomberg E,
      2. Hughes JM,
      3. Guerriere KI, et al
      . Once daily calcium (1000mg) and vitamin D (1000iU) supplementation during military training prevents increases in biochemical markers of bone resorption but does not affect tibial microarchitecture in army recruits. Bone 2022;155:116269. doi:10.1016/j.bone.2021.116269
    23. ↵
      1. Erdmann J,
      2. Wiciński M,
      3. Szyperski P, et al
      . Vitamin D supplementation and its impact on different types of bone fractures. Nutrients 2022;15:103. doi:10.3390/nu15010103
    24. ↵
      1. Carswell AT,
      2. O’Leary TJ,
      3. Swinton P, et al
      . Vitamin D metabolites are associated with musculoskeletal injury in young adults: a prospective cohort study. J Bone Miner Res 2023;38:1453–64. doi:10.1002/jbmr.4890
      OpenUrlPubMed
    25. ↵
      1. Granlund J,
      2. Kyröläinen H,
      3. Santtila M, et al
      . Time-course of recovery for biomarkers and physical performance after strenuous military training: a systematic review. Physiol 2023;3:627–41. doi:10.3390/physiologia3040046
      OpenUrl
    26. ↵
      1. McAdam JS,
      2. McGinnis KD,
      3. Beck DT, et al
      . Effect of whey protein supplementation on physical performance and body composition in army initial entry training soldiers. Nutrients 2018;10:1248. doi:10.3390/nu10091248
    27. ↵
      1. Richmond VL,
      2. Horner FE,
      3. Wilkinson DM, et al
      . Energy balance and physical demands during an 8-week arduous military training course. Mil Med 2014;179:421–7. doi:10.7205/MILMED-D-13-00313
      OpenUrlPubMed
    28. ↵
      1. Schwellnus MP
      , ed. Olympic textbook of medicine in sport. 1st edn. Wiley, 2008. Available: https://onlinelibrary.wiley.com/doi/book/10.1002/9781444300635
    29. ↵
      1. Kraemer WJ,
      2. Szivak TK
      . Strength training for the warfighter. J Strength Cond Res 2012;26 Suppl 2:S107–18. doi:10.1519/JSC.0b013e31825d8263
      OpenUrl
    30. ↵
      1. Goodall RL,
      2. Pope RP,
      3. Coyle JA, et al
      . Balance and agility training does not always decrease lower limb injury risks: a cluster-randomised controlled trial. Int J Inj Contr Saf Promot 2013;20:271–81. doi:10.1080/17457300.2012.717085
      OpenUrlPubMed
    31. ↵
      1. Brushøj C,
      2. Larsen K,
      3. Albrecht-Beste E, et al
      . Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med 2008;36:663–70. doi:10.1177/0363546508315469
      OpenUrlCrossRefPubMedWeb of Science
    32. ↵
      1. Payne JM
      . Leading the change to holistic health and fitness. Mil Rev 2020;6:66.
      OpenUrl
    33. ↵
      1. Verhagen E,
      2. Voogt N,
      3. Bruinsma A, et al
      . A knowledge transfer scheme to bridge the gap between science and practice: an integration of existing research frameworks into a tool for practice. Br J Sports Med 2014;48:698–701. doi:10.1136/bjsports-2013-092241
      OpenUrlAbstract/FREE Full Text
    34. ↵
      1. Bullock GS,
      2. Dartt CE,
      3. Ricker EA, et al
      . Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review. Inj Prev 2023;29:461–73. doi:10.1136/ip-2023-044905
      OpenUrlAbstract/FREE Full Text

    Footnotes

    • Contributors This paper is a collaboration of authors from a conference panel. All authors submitted their content as it relates to their presentation for inclusion. HCT conducted the literature review and compiled the author contents to write the manuscript. HCT, TR, ER, M-AL, PL and TJO'L reviewed and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Commissioned; externally peer reviewed.