Identification of Risk Factors Prospectively Associated with Musculoskeletal Injury in a Warrior Athlete Population

Teyhen DS, Shaffer SW, Goffar SL, Kiesel K, Butler RJ, Rhon DI, Plisky PJ. Sports Health. doi: 10.1177/1941738120902991.

Take-Home Message

Pre-existing health factors (prior injury, age, sex) and functional movement findings (lower and upper Y- Balance Test performance and pain during their movements) may help identify Army service members at risk for musculoskeletal injury.


Musculoskeletal injuries among military service members burden the individual and healthcare system and are a common reason for discharge. If we knew which factors identify military service members with greater injury risk, then we could develop risk mitigation programs and personalized prevention programs. Therefore, the authors aimed to identify risk factors that help identify Army service members at high risk for injury. They collected pre-injury data and tracked full duty United States Army service members in combat, combat service, and combat support units over one year. As part of another study, service members completed pre-injury demographic and medical history surveys. Service members also completed functional movement screenings such as the Functional Movement Screen (FMS), the lower- and upper-quarter Y-Balance Tests (YBT), 2 hop tests, and an ankle dorsiflexion mobility assessment. Over the following year, the service members completed a monthly survey to track injuries, and the authors reviewed medical records to identify musculoskeletal injuries. Service members without a self-reported or medical visit for a musculoskeletal injury were classified as noninjured. The authors excluded anyone with an injury but no associated time loss.

A total of 922 individual service members (94% male) completed the study and met the eligibility criteria. Of the 922 service members, 358 (39%) suffered a musculoskeletal injury. The authors found 11 influential factors to identify someone at risk for musculoskeletal injury:
1) prior injury,
2) prior work restrictions,
3) lower perceived injury recovery,
4) asymmetrical ankle dorsiflexion,
5-7) 3 measures of decreased lower- or upper-quarter YBT performance,
8) pain during functional movement tests,
9) slower 2-mile run time,
10) older age, and
11) female sex.
A service member with only 2 of the 11 risk factors was at ~10% greater risk for musculoskeletal injury than someone with no risk factors. This threshold offered a high sensitivity at 0.89. In contrast, a service member with 7 of the 11 risk factors was at 2 times greater risk for a musculoskeletal injury than someone with no risk factors. This threshold offered a high specificity at 0.94.


The authors identified risk factors for musculoskeletal injury risk among Army service members. Unfortunately, some risk factors such as prior injury, female sex, and age are not modifiable. However, clinicians could intervene to modify several risk factors. For example, balance, ankle dorsiflexion range of motion, and 2-mile run times can often be improved and may reduce the injury risk. Interestingly, someone with pain during functional movement screenings was at a 60% greater risk of injury (sensitivity = 0.80). Hence, clinicians should ask about and address dysfunction causing pain. However, clinicians should be cautious when directly applying these findings because of potential differences between military service members and their patients. Furthermore, it will be helpfulto know if these findings hold up when tested again among different Army service members. Ultimately, these risk factors when examined individually or together displayed a tradeoff between specificity and sensitivity and indicates musculoskeletal injury prediction is far from perfect. Lastly, clinicians may not have enough time, personnel, or finances to conduct pre-injury screenings such as functional movement assessments. An argument could be made that many injury prevention programs designed for specific or general populations are highly effective and should be implemented regardless of risk profiles. Clinicians should critically evaluate the time and resources available for conducting pre-injury movement assessments to determine whether the relative cost is beneficial for their practice.

Questions for Discussion

What standardized functional movement assessments are you familiar with? What are some of the positives and negatives you have seen in your practice from implementing these assessments? In your opinion, do you believe these assessments have ultimately improved or changed your practice?

Written by: Landon B. Lempke, MEd, LAT, ATC
Reviewed by: Jeffrey Driban

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