- Identify injuries specific to the tactical athlete and their operational status (e.g. trainee, general duties or pre-deployment/operations).
- Describe the sites of injuries common to tactical athletes, the common types of injuries and their potential causes.
- Outline considerations for reconditioning the tactical athlete in preparation for return to work and full duties.
- List challenges associated with reconditioning the tactical athlete following injury.
The physical job requirements of tactical personnel are diverse and varied, both within different tactical populations and within the same given population. Urban firefighters can perform tasks that include stair climbing and dragging or carrying other people (Louhevaara, Smolander, Tuomi, Korhonen, & Jaakkola, 1985; Park, Hur, Rosengren, Horn, & Hsiao-Wecksler., 2008; Richmond, Rayson, Wilkinson, Carter, & Blacker, 2008; von Heimburg, Rasmussen, & Medbo, 2006) while rural firefighters must negotiate wilderness tracks (Ruby, Leadbetter III, Armstrong, & Gaskill, 2003) racing against firestorms that can move at over 50 kilometres (31 miles) per hour (Orr, 2013b). Military personnel can be required to patrol various distances over various terrains, negotiate obstacles, perform short explosive tasks and ultimately engage the enemy in an unpredictable environment (Kraft, 2002; Orr, Pope, Johnston, & Coyle, 2012). Police officers are required to move in and out of vehicles, walk, run and even chasing criminals over obstacles at a maximum pace (Jacobsen, 2009; Pritchard, 2010). As an example, an Australian police officer was recently required to chase an offender over a kilometre through fields before being engaged in a struggle whereby the perpetrator repeatedly tried to acquire the officer’s firearm (Calligeros, 2014). These demanding physical requirements expose the tactical athlete to a high risk of musculoskeletal injuries (Jones & Knapik, 1999; Orr, Pope, Johnston, & Coyle, 2013; Reichard & Jackson, 2010; Reynolds, 2000).
Within the tactical population, recruits are typically at a higher risk of injury when compared to the trained counterparts. Research suggests that recruits / trainees in particular have a high potential for injury due to the sudden increase in physical conditioning requirements, the complexity of new physical tasks, reduced recovery potential and increased risk of overtraining (Booth, Probert, Forbes-Ewan, & Coad, 2006; Kaufman, Brodine, & Shaffer, 2000; Knapik et al., 2011; Orr, 2014). Studies by O’Connor (2000) and Havenetidis et al. (2011), found that new military recruits were particularly susceptible to injuries in their early weeks of training. In contrast, Ross et al. (2002) found that the incidence of overuse injuries peaked at the point of maximum training load, being the final weeks of training in the cohort they studied. On this basis, while being at a greater risk of injury, where in their training program their potential for injury is highest varies.
Considering these task requirements and this injury potential, physical training and sport have been found to be a leading cause of injuries in military populations (Defence Health Services Branch, 2000) (Knapik, Hauret, & Jones, 2006), as has load carriage (Knapik, Reynolds, & Harman, 2004; Orr, Pope, et al., 2013). Even on combat operations, musculoskeletal injuries often account for more injuries that actual combat (Cohen, Griffith, Larkin, Villena, & Larkin, 2005). For firefighters, musculoskeletal injuries has been attributed to being a leading cause of compensation and injury reporting, even overshadowing actual burns (Karter, Molis, & Association, 2011; Walton, Conrad, Furner, & Samo, 2003). In police, apart from direct physical assault from offenders, injuries are commonly caused by the handling of non-cooperative offenders to more mundane factors like the interaction between hip holster and police car seats with the officer required to rotate to either exit the vehicle (sometimes at speed) or read from their mobile data terminal (Orr, 2013a).
Tactical Athlete Injuries
The lower limbs in particular have been found to be the leading site of injury to military and police populations not on combat operations (Havenetidis, et al., 2011; Jones et al., 1993; Kaufman, et al., 2000; Knapik, et al., 2011; Knapik et al., 2001; O'Connor, 2000; Orr & Stierli, 2013). In some instances injuries to the lower limbs has been associated with attributing to over 80% of reported injuries in a tactical population (Knapik, et al., 2001).
When serving in a combat theatre or firefighting structural fires, the lower back typically presents as the leading site of injury (Cohen, et al., 2005; Roy, Knapik, Ritland, Murphy, & Sharp, 2012; Walton, et al., 2003). Potential reasons for this change in injury site may be attributed to the wearing of body armour and load carriage. Wearing body armour has been found to increase the physical demands of performing a given task (Ricciardi, Deuster, & Talbot, 2008) and as such it is not unexpected that it is associated with causing lower back injuries in both police and military populations (Burton, Tillotson, Symonds, Burke, & Mathewson, 1996; Roy & Lopez, 2013). Likewise, load carriage has been found to increase the risk of the carrier tripping (Park, Hur, Rosengren, Horn, & Hsiao-Wecksler, 2010), with tripping a known cause of injury in firefighters (Sy, Horn, Kesler, Petrucci, & Park; Walton, et al., 2003).
The leading reported types of injuries to tactical athletes range from strains and sprains to blisters and fractures (Havenetidis, et al., 2011; Jones, Cowan, et al., 1993; Reichard & Jackson, 2010; Walton, et al., 2003) with fractures associated with the highest amount of limited work duties (Kaufman, et al., 2000). Considering this, some activities do present with very specific injuries, brachial plexus palsy or ‘backpack’ palsy, caused by load carriage as an example (Attard, 1985; Wilson, 1987). Of interest, one study by Roy et al., (2012) identified lifting and carrying, dismounted patrolling and physical training as the leading causes of reported injuries for soldiers on operational deployments. Considering this, physical conditioning to improve lifting and carrying resilience (strength and technique), dismounted patrolling fatigue resistance (musculoskeletal and metabolic endurance) and physical training capability (general physical fitness) would be of benefit to these populations. The importance of such physical conditioning cannot be understated given the potential of these injuries to impact of the military to complete operational tasks (Orr, Pope, Johnston, & Coyle, 2011).
Reconditioning the tactical athlete
The importance of reconditioning the injured tactical athlete cannot be understated as research has identified previous injury as a leading risk of future injury in this population (Jones, Bovee, Harris, & Cowan, 1993; Kaufman, et al., 2000; Knapik, et al., 2011). Considering this, evidence suggests that work hardening physical conditioning has a positive impact on the return to work prospects of injured workers (Burke, Harms-Constas, & Aden, 1994; Cheng & Hung, 2007; Lechner, 1994). While muscle strength / endurance / power or metabolic fitness may impact on a given task, the specifics of the task will have different synergistic movement and force transfer patterns to a generic conditioning exercise (concepts like segmentation force velocity, force transfer, current and counter-current shifts, Lombard’s paradox, etc. all come into play). As such, the nature of this reconditioning must be task focussed.
Any reconditioning program needs to progress to not only meet occupational requirements, but to do so in the clothing required while performing these tasks. For example, a police officer may be required to restrain an offender while wearing chest rigging or an accoutrements belt. A firefighter may be required to roll out and ‘charge’ a hose wearing full protective turn-out gear and a self-contained breathing apparatus. A soldier may be required to carry stores, whilst wearing body armour. These clothing requirements may alter the movement mechanics of the tactical athlete or impact on their thermal regulation, and as such should form part of their reconditioning as opposed to performing these tasks in shorts and a singlet. Furthermore, performing these tasks in a work context may impact on the injured member’s confidence, especially when the reconditioning takes place in their workplace (Orr, Stierli, Amabile, & Wilkes, 2013).
Research suggests that conditioning conducted within the workplace may be more effective at returning personnel to work than clinically based work hardening (Cheng & Hung, 2007; Goss, Christopher, Faulk, & Moore, 2009). The benefits of conducting a return to work conditioning program within the workplace has been found to not only improve the functional performance of the tactical athlete but to improve their mental health in this regard as well (Orr, Stierli, et al., 2013). It is important to note that this does not suggest that the tactical athlete is returned to full duties but rather that they remain connected to their work environment.
To optimise the impact of any return to work conditioning program, continual, reliable and valid outcome measures of physical capability are needed. These measures can be movement based (e.g. Functional Movement Screen), performance based (progressive shuttle run test), or measures of health outcomes (Short Form 36 Questionnaire). Initial, progressive and final assessments will provide for continual evaluation of program effectiveness and provide a means of evaluating the value of the reconditioning program and its impact. As an example, a pilot study by Orr, Stierli, et al. (2013) found that a structured reconditioning program conducted by a Police Physical Trainer over 8 weeks not only improved their movement skills (as measured by the FMS) but more importantly, and to a greater extent, improved their general attitude and measures of mental health (as measured by the SF-36), a significant benefit given the greater costs associated with mental health claims in tactical populations.
Challenges with Return to Work Conditioning
Time is often a leading challenge with returning the tactical athlete to work and operations. Often there may be no replacement for tactical personnel who are injured and as such the workplace, be it a fire station, police station or military unit, must operate with fewer personnel. As such, workplace pressures may be placed on both the tactical athlete and their rehabilitation personnel to return them to work prematurely. Continual ongoing consultation and education of the injured athlete and valid outcome measures are vital if trust is to be gained in long term effectiveness of the rehabilitation/reconditioning process.
A second limitation could be that of conditioning progression, especially in tactical workplaces with a dedicated conditioning program. Recruit training presents as a prime example. While a tactical athlete is injured and undergoing recovery, the rest of that athlete’s cohort is receiving progressive conditioning. As such, when returning the rehabilitated tactical athlete to their cohort, they must be fitter than when they were injured and at least at the standard of their cohort if the potential for re-injury is to be minimised.
Encapsulation and Application
The above discussion highlights that tactical athletes are prone to a variety of musculoskeletal injuries with recruits and those who have sustained a previous injury more likely to be injured. The nature of these injuries can be varied however sprains and strains to the lower limbs and back are common.
Considering this, when designing a rehabilitation or reconditioning program for a tactical athlete, the following needs to be considered:
The tactical athlete’s status and requirements, for example whether they are a recruit/trainee, general duties, pre-deployment or operational.
Given the nature of their common duties, physical conditioning musculoskeletal resilience, load carriage capability and general physical fitness would be of benefit to these populations.
Outcome measures of physical capability are important to provide ongoing review of the effectiveness of the conditioning program, the athlete’s recovery trajectory and to provide feedback to both the individual tactical athlete and their organization.
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