The Effect of a Neuromuscular Training Program on Reducing the Incidence of Lower Extremity Stress Fracture in Military Service Members

Stress fractures are a bone-related disease that directly impact military service members, and stress fractures are a leading cause of musculoskeletal injury in the U.S. military. Stress fractures place a significant burden on the Military Health System, and they notably impact combat readiness. Specifically, the costs associated with medical care, lost duty time, and the increased likelihood of attrition due to stress fracture during initial entry training are tremendous. Reducing physical training-related injuries such as stress fractures was recently identified as the top priority for injury prevention within the military by the U.S. Army Public Health Command due to their cost and impact on combat readiness.

Despite our growing understanding of the risk factors associated with the incidence of stress fracture injuries, implementing effective injury prevention programs within the context of the military has been challenging. A major challenge to effective injury prevention practice is translating research outcomes into actions and programs that can be effectively implemented in real-world training settings. One of the primary steps in this translation process is prospectively identifying modifiable risk factors for injury and evaluating barriers that affect the successful implementation of injury prevention programs.

Though a significant amount of research has focused on identifying risk factors associated with stress fracture injuries in military personnel, no study to date has prospectively identified modifiable biomechanical and neuromuscular risk factors associated with injury in a large military training population. The proposed study population will focus on military recruits going through basic combat training, as they have been shown to be at the greatest risk for stress fracture. The proposed study is innovative because it will utilize baseline biomechanical assessments from the 5,686 military recruits in an established prospective cohort study to identify specific modifiable risk factors that predispose individuals to stress fracture injury. Identifying modifiable risk factors is critical because they can be changed through intervention efforts to reduce the risk of injury. Using a cluster randomized controlled trial design, the proposed study will also evaluate the impact of a targeted neuromuscular training program on reducing high-risk movement patterns associated with stress fracture (first order outcome) and reducing stress fracture injury risk (second order outcome) in a military training population, both of which are novel approaches.

The proposed study specifically addresses stress fracture injuries and injury prevention, which is directly aligned with the 'Osteoporosis and Bone Related Disease' topic area for the Peer Reviewed Medical Research Program. As noted above, stress fractures are a bone-related disease that has direct relevance to U.S service members and the Department of Defense. The proposed research complements studies affiliated with the Bone Health and Military Medical Readiness program and recommendations for injury prevention program development proposed by the U.S. Army Public Health Command. Therefore, the results of the proposed study align with clearly stated research and injury prevention objectives within the Department of Defense.

The proposed study builds on previous collaborative research efforts between military clinicians and civilian researchers (Partnering Principal Investigator [PI]: Dr. Cameron) at Keller Army Hospital at the United States Military Academy at West Point, and researchers (Partnering PI: Dr. Marshall) at the University of North Carolina at Chapel Hill, to address important research questions related to musculoskeletal injuries that impact active military populations. Drs. Cameron and Marshall have collaborated previously on other projects funded by the National Institutes of Health and the Congressionally Directed Medical Research Programs, and this prior experience will be leveraged to successfully accomplish the research objectives and specific aims of the proposed study.