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The limbs of soldiers are in as much danger from the ardor of young surgeons as from the missiles of the enemy.

Confederate surgeon Julian John Chisholm’s observations on the limitations of medical care for military personnel in the American Civil War (1861–1865)

In the United States (US) Army, injuries and injury-related musculoskeletal conditions are responsible for more than 660 000 visits annually.1 Injuries are the biggest cause of disability in the US Army.1

In this chapter, we discuss the principles of sport and exercise medicine that will help you provide services to a military population.

We introduce:

  • the special culture of the military environment

  • epidemiology of military injuries

  • common military injuries with a sport and exercise medicine focus (i.e. not major trauma).


Clinicians who provide medical and physiotherapy care in a military setting have a challenging task. An important difference between civilian and military practice is the compulsory nature of physical training. All military recruits undergo exercise regimes that are designed not only to improve their fitness, but also to prepare them physically and psychologically for extreme environments, discomfort and pain (Fig. 45.1). Military trainees have not always had a background of physical training. Increasingly, young adults come into the military with little experience of contact sports or regular physical activity. It is challenging to bring them to a required level of strength and aerobic fitness without causing injury.

Figure 45.1

Physical training in the military takes place within a distinct culture and environment


The traditional military culture generally encouraged personnel to continue exercising despite early warning signs of pain that would cause civilian athletes to stop or slow down. Many recruits conceal injuries until graduation for fear of medical ‘back squadding’ (recruits held back in training) and derision from fellow recruits and their superiors. A soldier who finishes a forced march by walking on a broken ankle for 20 km with a fully weighted rucksack receives accolades and respect from peers and superiors.

Further to the drive towards pushing through pain, soldiers with a history of previous injury demonstrate an increased pain threshold—they feel less pain for a given stimulus compared to controls.2, 3 Pain thresholds may also be related to environmental and psychological factors (e.g. the common experience of World War II soldiers reporting no pain during the heat of battle despite severe injuries).4

As a consequence of these changes in experiencing or reporting of pain, military members often present to clinics with musculoskeletal injuries that are severe and debilitating, requiring longer periods of rehabilitation. Patients may present stoically, making it challenging to determine the true severity of pain or injury.

Because ...

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