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E X E R C IS E -R E L A T E D IN JU R IES
THE PREVENTION OF EXERCISE-RELATED
INJURIES AMONG SOUTH AFRICAN
ARMY RECRUITS: A REVIEW
HJ va n Heerden
IN T R O D U C T IO N
The high in cid ence o f ex ercise-related
injuries, p r i m a r i l y in the f o r m o f o v e r ­
use s y n d r o m e s to the l o w e r extrem ities,
is a un iversal p r o b l e m a m o n g recruits
being sub je cte d to an inten sive p h ysical
c o n d itio n in g p r o g r a m m e (basic tra in ­
ing) o n e n te rin g the m ilita ry s e r v ic e .1'3
In this respect a v a r y in g incid ence has
been r e p o rte d , w ith A m e r i c a n a r m y 1
and m a rin e 2 rec ruits s u ffe rin g a 2 6 %
and 3 7 % rate o f i n j u r y respectively, and
the N e w Z e a la n d 3 a rm ed fo rces d o c u ­
m entin g an e x tre m e 6 5 , 4 % in cid ence o f
“w o r k - r e l a t e d ” injuries. T h e p o ss ib ility
that a sim ila r s itu a tio n m a y exist in the
S o u th A f r i c a n D efen c e F o rc e ( S A D F )
was first suspected b y C illiers and G o r ­
d o n , 4 w h o suggested that the effic acy o f
the S A D F basic tra in in g centres m a y be
limited d u e to the p a r tic u la rly injurious,
n ature o f the p h y sic a l tra in in g e m ­
p lo y e d .
Su b se q u e n tly , G o r d o n 5 critically
evaluated the S o u th A f r i c a n A r m y
p h ysical tra in in g p r o g r a m m e in term s
o f fitness attained and injuries sus­
tained. R esu lts pu b lish ed fr o m this re ­
search revealed u n s a tis fa c to r y gains in
e n d u r a n c e fitn ess ,6 and c o n firm e d the
a fo re m e n tio n e d h y p o th e s e is b y n o tin g
a 3 7 , 9 % incid ence o f e x e rtio n -re la te d
R e n s tr o m and J o h n s o n , 13 these factors
can be classified into the f o ll o w in g in­
trin sic and extrinsic categories:
injuries to rec ruits d u rin g basic tr a in ­
i n g .7
In trin sic factors
H ] van Heerden M A (Biokinetics)
Department o f H um an M ovement
Science
University o f Zululand
Private Bag X I 001
Kwadlangezwa 3886
THE A ETIO LO G Y A N D
PR E V E N T IO N OF O V E R U SE
IN JU R IE S
In re v ie w o f the p ossible causes o f o v e r ­
use injuries to the l o w e r extrem ities,
n u m e r o u s research ers 812 have i d e n ­
tified certain c o m m o n factors that
s h o u ld be c o n sid e re d w h e n devisin g a
p re v e n ta tiv e strategy. A c c o r d i n g the
E xtrinsic factors
P o o r p h ysical
fitness
Training surfaces
P re v io u s in j u r y
Training m e th o d s
Excessive b o d y
mass
F ootw ear
P h ysical
a b n o rm a lities
-----------------------------------
SPORTSGENEESKUNDE VOL. 6 NR. I
17
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A n y of the above m entioned intrinsic
risk factors m ay be observed in the new
m ilitary recruit. As a result, strict com ­
p ulso ry m edical exam ination and sub­
sequent graded health classification of
recruits prior to the start of basic train­
ing, should p lay a m ajor role in identi­
fyin g and protecting those w ith an in ­
herent or acquired predisposition to
in ju ry.2
Training surface is another varied
and com plex factor affecting in ju ries,14
and one that is difficult to standardize
in and around basic training centres.
The association of the rem aining ident­
ified extrinsic factors ie. training methods8,9,14 and footw ear10,12 w ith overuse
injury, has received prom inent focus in
the lite ratu re.1517 The reason for this
being their frequent im plication and
perhaps m ore im portantly, p articularly
from a m ilita ry perspective, their am e­
n ab ility to m anipulation for the p u r­
pose of preventing in ju ries.18
A ccordingly, since G ordons’ initial
exposition of the problem atic high inci­
dence of overuse injuries in the
SA D F ,5’7 two m ajor intervention strate­
gies have been considered, nam ely a re­
vision of the South A frican A rm y
physical training program m e and the
m anipulation of m ilitary footwear.
W hile the possible corresponding salu­
tary effects on the p hysical fitness of re­
cruits are currently under investi­
g atio n ,19 the im plem entation of these
preventative measures and their influ­
ence on the incidence of injury, m erits
further discussion.
T R A IN IN G M E TH O D S
largely based on the pioneering research
of Scully and Besterm an24 in the United
States A rm y, concerning the successful
m anipulation of basic training pro­
gramm es as prophylactic measure
against the risk of overuse injuries, and
stress fractures in particular, among re­
cruits.
F O O T W E A R R E G U LA T IO N S
The extrinsic aetiological relationship
between m ilitary footw ear and the risk
of exertion-related injuries to the low er
extrem ities am ong recruits25"27 has been
highlighted. A s a result, global attem pts
to m anipulate footw ear have been con­
ducted in three spheres. F irstly the type
of com bat boot worn has been changed,
albeit unsuccessfully.2 A lternative ap­
proaches which have however, proved
to be successful in reducing injuries,
are:
•
the alteration of w ear regulation of
boots;3 and
•
the placing of the shock-absorbing
innersoles inside boots.29'31
A ll three of these approaches have been
considered and experim ented w ith by
the South A frican A rm y,21'22 and cur­
rently all running activities during o r­
ganised physical training periods is car­
ried out in running shoes w ith adequate
shock-absorbing properties, and not in
boots or “takkies” as was the case in the
p ast.21
Furtherm ore, van H eerden et a l,n
and Schw ellnus33 have recently re­
ported the significant reduction of
overuse injuries am ong South African
arm y recruits by the incorporation of
shock-absorbing innersoles w ithin
com bat boots, thus m otivating the
possible m andatory application of this
preventive measure in the near future.
P rior to 1986, South A frican A rm y re­
cruits underw ent a basic 10-week
period of progressive physical con­
ditioning consisting of four phases of
increasing inten sity.20 Follow ing the re­
alisation of the injurious nature of this
program m e however, a revised cyclicprogressive physical training pro­ A P P R A ISA L O F PREVEN TATIVE
gram m e21"23 was im plem ented, which M E A SU R E S
stipulated that activities such as run­
ning, jum ping, route-m arches and In a retrospective attem pt to appraise
drill-train in g be lim ited to the absolute the possible prophylactic effect of these
m inim um during every third w eek of intervention strategies em ployed b y the
training. This new program m e was SAD F, the incidence of exertion-re­
18
---------------------------------------------------------------------------------
SPORTS MEDICINE VOL. 6 NO. I
lated injuries am ong recruits as re­
ported by the study o f G ordon et aF
carried out in 1982, can be compared
w ith another recent investigation28'32
conducted five years later, after the in ­
troduction of the previously discussed
preventative measures. In these studies,
a uniform research protocol was used
concerning the definition and classifica­
tion of injury, as w ell as the method of
data collection, thus allow ing for a fa­
vourable com parison. As reflected in
Table 1, both traum atic and overuse in­
juries, interpreted as being sustained in
the presence or absence of a sudden
precipitating
event
respectively,
showed a substantial reduction from
1982 as opposed to 1987, in contribut­
ing to a total recruit in ju ry incidence of
37,9% (pre-intervention) versus 17,1%
(post-intervention). The incidence of
overuse injuries, as distrubted over
various anatom ical sites of the low er ex­
trem ities (Figure 1), has how ever not
altered much.
T able 1: R ecruit in ju ry incidence and
type/year
1982+
%
1987*
%
7,5
1,1
O veruse
Stress fractures
32,4
(4,1)
16,0
(0,4)
T o tal
37,9
17,1
In ju ry typ e
Traumatic
* G o rd o n 7 *van H eerden e t a l . 32
% Injury incidence expressed as a percentage o f i
the total num ber o f recruits observed in study '
() Denotes a subset o f in jury type
C O N C L U S IO N
It has been suggested17 that the m ilitary
is an ideal m ilieu in w hich to conduct
epidem iological research due to its con­
trolled nature. A practical problem is,
how ever, encountered w ith recruits
who serve as subjects leaving the service
on com pletion of their period of cons­
cription. A s a result, longitudinal data
reporting in ju ry rates from indepen­
dent studies, as in this case, precludes
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)
FIGURE 1:
‘TILC0TIL’ ROCHE
IN C ID EN C E O F O V E R U S E IN JU R Y (% )
Components:
Tenoxicam
Indications:
Symptomatic treatment of the
following painful inflammatory and
degenerative disorders of the
musculoskeletal system:
rheumatoid arthritis; osteoarthritis;
ankylosing spondylitis; extraarticular disorders, e.g. tendinitis,
bursitis, periarthritis, gouty
arthritis (for tablets).
Dosage:
Thigh
Foot
Heel
Ankle
Achilles Lower Leg
20 mg once daily at the same time
each day. The parenteral form is
used for one or two days. For
treatment initiation in acute gouty
arthritis 40 mg (2 tablets) once daily
for two days followed by 20 mg
once daily for a further five days is
recommended.
Knee
ANATOMICAL SITE
■
1982
U S 1987
Contra-indications:
an absolute com parative interpre­
tation.34 N otw ithstanding this lim i­
tation, the observed data leads one to
deduce that the introduction of the re­
vised South A frican A rm y physical
training program m e and accom panying
adapted footw ear regulations, has
brought about a viable decrease in the
risk of exertion-related injuries. As a
consequence, the efficacy of the SADF
basic training centres should be en­
hanced by the dim inished loss of train ­
ing tim e and corresponding cost of
m edical care, w hile recruits m ay derive
the optim um conditioning benefits
presented during basic m ilitary train­
ing.
RE F E R E N C E S
1.
2.
3.
4.
K ow al D. N ature and causes o f injuries in
w om en resulting from an endurance training
program m e. A m ] Sports M e d 1980; 8:
2 64-269.
Bensel C K . The effects o f tropical leather
combat boots on lo w er extrem ity disorders
among M arine C o rp s recruits. C lothing,
Equipment and M aterials Engineering L ab­
oratory, Natick A rm y Labs. Technical R e­
p o rt N o. 76-49-C E M E L , 1976.
Stacy R J, H ungerford R L. A method to re ­
duce w o rk -related injuries during basic
training in the N ew Zealand A rm y. M ilit
M e d 19 8 4 ; 14 9 :3 1 8 -3 2 0 .
C illiers JF , G o rd o n N F. Effect o f the South
A frican A rm y physical training instructor
5.
6.
7.
8.
9.
10.
11 .
12.
course on physical w o rk capacity. SA J R e ­
search Sport, Physical Education and R ecre­
ation 19 8 3 ; 6 (i); 35-42.
G o rd o n NF. Evaluation o f the South A fr i­
can A rm y physical trainingprogram m e: F it­
ness attained and injuries sustained. U n p u b ­
lished PhD (Med) thesis. U n iversity o f the
W itw atersrand, 1985.
G o rd o n N F, van Rensburg JP , M oolm an J ,
K rug er PE, Russell H M S, G ro b ler H C ,
C illiers JF . The South A frican Defence
Force physical training program m e: Part 1.
Effect o f one years m ilitary training on en­
durance fitness. S A fr M e d ] 19 8 6 ; 6 9; 477482.
G o rd o n N F, H ugo EP, C illiers J F . The
South A frican Defence Force physical train­
ing program m e: Part 1 1 1 . Exertion-related
injuries sustained at an S A D F basic training
centre. S A fr M e d ] 19 8 6; 6 9 :4 9 1 -4 9 4 .
Jam es SL, Bates BT, O sternig LR . Injuries
to runners. A m J Sports M e d 19 7 8; 6 :4 0 -5 0 .
M cK enzie D C , C lem ent DB, Taunton JE .
Running shoes, orthotics and injures. Sports
M ed 19 8 5 ; 2 :3 3 4 -3 4 7 .
N oakes Td. L ore o f Running. Cape Town:
O xford U n iversity Press, 1985.
Sp erryn PN. Sp ort and Medicine. London:
B utterw orth s, 1985.
Nigg BM. Biomechanics, load analysis and
sports injuries in the lo w er exremities.
Sports M ed 19 8 5 ; 2 :3 6 7 -3 7 9 .
The views and opinions expressed
and the findings contained in this
paper are those o f the author and
should not be construed as an of­
ficial South African Defence Force
position, policy or decision, unless
so designated by other official
documentation.
Known hypersensitivity to the drug.
Patients in whom salicylates or
other nonsteroidal anti­
inflammatory drugs (NSAIDs)
induce symptoms of asthma,
rhinitis or urticaria. Patients who
are suffering or have suffered from
severe diseases of the upper
gastrointestinal tract, including
gastritis, gastric and duodenal
ulcer. Before anaesthesia or
surgery, ‘TIL C 0T IL ’ should not be
given to patients at risk of kidney
failure, or to patients with increased
risk of bleeding.
Concurrent treatment with
salicylates or other NSAIDs should
be avoided.
Pregnancy and lactation.
Precautions:
Simultaneous treatment with
anticoagulants and/or oral
antidiabetics should be avoided
unless the patient can be closely
monitored.
Renal function (BUN, creatinine,
development of oedema, weight
gain, etc.) should be monitored,
when giving a NSAID to the elderly
or to patients with conditions that
could increase their risk of
developing renal failure.
Packs:
Tablets 20 mg: 1 0 ’s, 3 0 ’s.
Vial pack containing 1 vial active
substance and 1 ampoule water for
injection.
SPORTSGENEESKUNDE VOL. 6 NR. 1