There is much discussion about the physical challenges facing our veterans and career soldiers. Soldiers today are returning home with long-term, disabling effects from their time in service. The injuries receiving the most—and certainly warranted— attention are posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) resulting from combat incidents. These injuries alone present extraordinary physical, psychological, and emotional challenges for both the active soldier and the veteran. 

What might be surprising to hear, however, is the fact that the military has one of the highest incident rates of musculoskeletal disorders (MSDs) of all workforce populations. These soldiers endure ongoing pain and impaired physical function, as many of these injuries go untreated or treated insufficiently. 

When you add constant pain and physical dysfunction to PTSD and TBI, you have a nasty combination. Besides impairing soldiers’ abilities to accomplish their duties, these conditions can end or shorten their careers, hurt their personal lives and families, and even lead to suicide. 

These issues are recognized, and there are attempts being made by the military to address prevention and treatment (called “warrior resilience training”). Notably, massage therapy is being used with these veterans to some degree, or at least being experimented with. As most massage therapists know, massage has enormous potential as a therapeutic solution for these men and women and their conditions. 

There are numerous articles available on PTSD treatment and alternative care (see “PTSD is Not Just Everyday Stress” on page 70). Anyone working with someone with PTSD must research how to adequately address the unique needs of these individuals, as there are many special concerns and skills that need to be considered. 

In this article, let’s focus on three MSDs that challenge both active-duty soldiers and veterans. Addressing MSDs can significantly improve a soldier’s life experience and career options, and massage in particular presents many options to prevent and ease these debilitating conditions.

Musculoskeletal Injury in Soldiers

An extremely large number of MSDs are noncombat related. These injuries begin showing up in basic training and extend throughout a soldier’s military career. A US military report states the injury rate for Army personnel is 2,500 reported injuries for every 1,000 soldiers, with “2.1 million injury-related medical visits, affecting 900,000 service members … [adding] up to an estimated 25 million limited-duty days per year.”¹ 

The report notes that musculoskeletal injuries are the cause of 68 percent of all limited-duty orders (doctors’ orders to limit or change a soldier’s tasks). What is perhaps most surprising is that the report only cites statistics from noncombat garrisons and does not include the Iraq or Afghanistan operations. 

In the Iraq and Afghanistan military conflicts, 34 percent of deployed troops sustained a noncombat musculoskeletal injury, making it the most common reason for medical air evacuation, surpassing combat injuries.² In addition, 25 percent of musculoskeletal injuries result in medical discharges. 

Lower-extremity injuries are particularly prevalent in the military because of the nature of many military activities. In training and active duty, heavy loads are often carried while running, jumping, marching, or performing other physical activity. According to the Army Times, an Army Science Board study recommended that soldiers carry no more than 50 pounds, yet soldiers on extended foot patrols routinely carry an average load ranging from 87 to 127 pounds.³ These heavy loads put tremendous stress on numerous structures of the body and lead to the high occurrence of MSDs. In addition, routine occupational tasks often require carrying and transferring heavy loads. 

Of the numerous MSDs which plague military personnel, injuries to the low back and lower extremities account for more than 80 percent of the injuries, with that percentage split roughly in half between the two areas.⁴ Three of the most commonly occurring lower-extremity injuries are tibial stress, iliotibial band friction syndrome, and anterior cruciate ligament sprains. 

Medial Tibial Stress Syndrome

During running, the lower extremity can absorb three to four times an individual’s body weight on each foot strike. If an individual is carrying very heavy equipment, this cumulative load puts even greater stress on the shock-absorbing tissues of the body. The key responsibility for shock absorption is then spread among several tissues, with the primary responsibility being taken over by bones, ligaments, muscles, and tendons.

The tibialis posterior muscle is a primary contributor to shock absorption in the lower extremity. One of its key functions is to resist excessive pronation of the foot during gait. As this muscle works eccentrically to resist excessive pronation, it is also absorbing a great deal of the impact load from repeated foot strikes. However, repeated overload on the tibialis posterior often leads to muscle fatigue.

Excessive tensile force on the muscle’s attachment sites can cause nearby inflammation resulting in significant pain, commonly known as shin splints. If constant overload and fatigue of the tibialis posterior muscle progresses, the muscle can no longer accomplish its primary shock-absorbing role and a greater stress load is transferred to the bone. In time, this higher stress load overwhelms the bone’s capability to respond to the stress and small stress fractures develop. 

Stress fractures are a serious problem in the military because they take a long time to heal and require significant time away from activities. One important way to reduce the frequency of stress fractures is to decrease the stress transferred to the bone by keeping the muscles and other soft tissues in their optimum functioning capacity. Massage treatment of the tibialis posterior and other deep compartment muscles is highly valuable in achieving this goal.

One of the most effective methods for addressing the tibialis posterior and other deep compartment muscles is through active engagement. These techniques are especially helpful because the tibialis posterior is difficult to access with other treatment methods, and consequently the muscle is often ignored. This technique is, of course, highly valuable for many individuals doing repetitive lower-extremity activities, like running, that put significant repeated loads on the lower extremity. 

Iliotibial Band Friction Syndrome

Any repetitive movement of a lower extremity is likely to involve frequent flexion and extension of the knee. The weight of the equipment or packs carried by military personnel puts greater load on the tissues performing these motions. Lateral knee pain routinely occurs for individuals doing repetitive lower-extremity motions. Historically, this condition has been referred to as iliotibial band friction syndrome because the primary pathology was suspected to be the iliotibial band rubbing back and forth across the lateral condyle of the femur (Image 1, page 107).

Several years ago, a study published in the Journal of Anatomy seriously challenged the traditional understanding of this condition, as well as our common treatment approach.⁵ The study notes that the iliotibial band is actually fibrously connected to the femur, and is not truly capable of rubbing back and forth across the lateral femoral condyle. Instead, the apparent friction is most likely due to changes in tension between the anterior and posterior aspects of the band as the knee moves in flexion and extension.

The pain of this condition is most likely due to compression of a fat pad lying under the iliotibial band. Traditionally, massage treatments for this condition have encouraged friction of the fibers in the distal iliotibial band directly over the lateral condyle with the idea of encouraging fibroblast proliferation and reducing fibrous adhesions that result from fraying and friction of the iliotibial band. However, based on our new understanding of anatomical relationships in this region, that treatment may not be very helpful. 

Instead, as the study notes, ideal treatment for iliotibial band friction syndrome should focus on reducing excessive tensile forces within the band. The gluteus maximus and tensor fasciae latae are the primary muscles that pull on the iliotibial band. When they become hypertonic, they pull even more. Consequently, our key goal is to reduce tightness in these muscles. The gluteus maximus is broad and thick, and is effectively treated with simple, deep, stripping techniques directly along the length of its fibers. It is also valuable to address the gluteus medius and gluteus minimus muscles to make sure tightness is reduced in all of the primary gluteal muscles.

The tensor fasciae latae is significantly smaller and more challenging to treat (Image 2). Due to the position and size of the tensor fasciae latae, there is not a great deal of room or muscle length for stripping methods. However, active engagement methods allow longitudinal stripping techniques and are highly effective on this muscle.

Anterior Cruciate Ligament Sprain

The anterior cruciate ligament (ACL) is one of the most frequently injured ligaments of the knee. A closer look at the biomechanical function of the ACL illustrates why injury here occurs so frequently in the military and with other physically active individuals.

The ACL attaches to the posterior aspect of the femur and the anterior surface of the tibial plateau (Image 3). Its primary biomechanical function is to prevent forward translation of the tibia in relation to the femur. It is also involved in preventing excessive rotational movements between the tibia and femur.

When an individual lands from a jump or attempts to decelerate the body, such as when going down a hill, the quadriceps muscles, which attach on the anterior tibia, contract strongly to decelerate forward motion. When they contract to decelerate motion, they pull the tibia in an anterior direction. Their direction of pull is the direction of force the ACL is attempting to resist. A strong and forceful contraction of the quadriceps in decelerating forward motion can be enough to overstretch or tear the ACL. 

The greater the velocity or distance traveled prior to deceleration, the greater is the quadriceps contraction. When you add the excessive weight many soldiers carry, the forces the ACL must resist are great, which leads to many ACL injuries.

Massage can play an important role in ACL rehabilitation. While the ACL is deep within the knee joint and not accessible to palpation, one of the key factors that stresses the ACL is quadriceps pulling, and massage can be very helpful in reducing excess hypertonicity and tensile loads in the quadriceps muscle group during ACL rehabilitation. 

Hamstring strengthening is also important during rehabilitation as the hamstrings provide additional stability for the ACL while it is in a weakened state. The hamstring muscles have an angle of pull that aids the ACL in producing knee stability. 

For those Who give so much

Clearly, there are far more soldier injuries than these three lower-extremity conditions. And in many of those other conditions, such as low-back complaints, massage could prove very useful for injury prevention and rehabilitation. While there are some facilities that include massage as a treatment modality for soldiers, for the most part it is left out. 

One of the arguments against massage is that soldiers might find that it feels good, and therefore would want to use it more. No doubt! Feeling good can be one of the best things there is for improved function. But massage is more than a feel-good therapy. It produces (sometimes extensive) tissue changes and is proven to be so effective that professional sports teams use it regularly. If a modality is accepted and provided to our professional athletes, isn’t it only fair that those who are voluntarily contributing to our country are also given these benefits? 

Note

1. US Army, “Injuries: The Modern Military Epidemic,” accessed February 2013, www.army.mil/article/25626/Injuries_the_modern_military_epidemic.

2. US Medicine, “Human Performance Optimization Used to Prevent Common Injuries in Troops,” accessed February 2013, www.usmedicine.com/articles/human-performance-optimization-used-to-prevent-common-injuries-in-troops.html#.UN44fW9TySp. 

3. Army Times, “Report: Combat Soldiers Carry Too Much Weight,” accessed February 2013, www.armytimes.com/news/2011/02/ap-report-soldiers-carry-too-much-weight-021411. 

4. K.G. Hauret et al., “Musculoskeletal Injuries Description of an Under-Recognized Injury Problem Among Military Personnel,” American Journal of Preventive Medicine 38, no. S1 (2010): S61–70. 

5. J. Fairclough et al., “The Functional Anatomy of the Iliotibial Band During Flexion and Extension of the Knee: Implications for Understanding Iliotibial Band Syndrome,” Journal of Anatomy 208, no. 3 (2006): 309–316.