Never have I seen so many young adults with musculoskeletal injuries until I joined the United States Army.  And I'm not referring to basic training where some injuries are expected; I'm speaking of the active Army. Specifically, the airborne infantry is my point of reference, the part of the Army most of my experience is in. Many of these injuries are preventable.

Some of the blame can be placed on the individual solider from this new "inside" generation; however, much of the blame must be placed on the Army. I was even more surprised at the amount of injuries I saw in basic training considering the moderate (dare I say low) intensity of the training regimen, but that was not so much the fault of the Army. 

Spc. Kevin Withrow is an infantryman and former fitness trainer who suggests ways the Army can improve fitness training and minimize the number of soldiers who are injured as a result of training.

I enlisted in the Army with a bachelor of science degree, having been a certified personal trainer and martial arts instructor prior to joining. In basic training, I was taught PRT (Physical Readiness Training), the Army's exercise program. It had many great exercises that are usually only seen from exercise professionals (surprise, it was designed by them).  Most soldiers do not think very highly of PRT because it will not take one to a high level of fitness. What it is designed to do is to create proper movement and muscle balance in a soldier's body.

Many people, whether they work in an office or play a professional sport, have movement deficiencies and muscle imbalances. Certain muscles tend to become tight and overused, while others become weak and lengthened. They lose their natural balance between each other. If a muscle is not doing its part in a particular movement, then the body will compensate with other muscles that are not meant to support that movement in that way. This leads to improper body mechanics, which leads to injury, as the human body is designed to move a very specific way. These imbalances can be caused by a repetitive activity, such as sitting with poor posture at a desk; they can also be caused by an improper exercise routine that overworks some muscles and neglects others. They can be corrected with proper strength and flexibility training (known as corrective exercise), and that is usually the first goal for a new client of any good trainer.

The PRT manual is decent. It has great drills for exercise preparation, recovery, mobility and endurance (aerobic and muscle); it even touches on postural deficiencies. However, the manual is lacking in certain areas. PRT drills consist primarily of calisthenics and running, meaning weighted resistance is not used. Strength is one of the foundations of fitness, and it is obtained by lifting somewhat heavy weights. Calisthenics will build muscle in a detrained person; for a fit individual, calisthenics are more of a muscle endurance activity. PRT has a good circuit done with kettlebells ("Strength Training Circuit"), but a circuit is not the best method of building muscle, as it is more of a muscle endurance activity. The manual does have the "Strength Training Machine Drill," which utilizes weight machines. Unfortunately, it is a very basic and limited routine that is categorized under "Special Conditioning Programs" used for injury rehabilitation.

Muscle endurance and strength differ from each other, and each is trained for in a different way.  Muscle strength refers to the maximal force that a muscle can exert (usually measured in one repetition), while muscle endurance refers to a muscle's ability to exert a submaximal force over time. Muscle strength can be thought of as bench pressing a heavy weight for two to three repetitions, and muscle endurance can be thought of as doing a hundred push-ups without stopping. Muscle strength is beneficial to both aerobic and muscle endurance, but endurance does not help strength.  Both are needed in athleticism.

The Army needs to conduct strength training because it keeps the body in balance and prevents injury. Also, studies show that strength training dramatically improves performance in endurance activities. I was less fit when I graduated basic training than when I began because the training intensity is not very difficult, and basic trainees are not allowed to work out in the gym. PRT is strictly adhered to, so I lost a lot of muscle. Toward the end, I even developed hip and shoulder pain from the repetitive unbalanced physical training, which I immediately corrected with a proper routine upon graduating.

In the Regular Army, physical training is done every morning as a group with a soldier's unit. Usually it is done at either the platoon or squad level. Therefore, the training regimen is most often left up to the platoon sergeant or squad leaders. It is safe to say that most of these guys are not exercise professionals and have no sort of exercise science background. Their intentions are good, but all they know about exercise is what they have learned from the Army (not much). PRT is considered to be a joke by many, at least in the infantry. Many do not know the entire program. Many leaders pick certain parts of PRT to follow, such as the preparation and recovery drills, while others do not utilize any of PRT. At my unit, we are told that we are not allowed to use the gym for morning training, as if it is somehow less important.

Even if leaders did solely utilize PRT, it would not work because it is not flexible enough for the dynamic environment of an active unit.  PRT is designed for the adherence to a schedule of increasing exercise intensity.  However, in a unit, most soldiers are at different levels of fitness because new soldiers are constantly joining while others are leaving.  No matter what exercise intensity is chosen, it will not be the right one for many.  Also, the breadth of PRT is not great; the same exercises will inevitably end up being recycled over and over.  A good exercise program must be individualized, varied, and goal-specific.  PRT does not qualify someone to lead an exercise program; the manual contains only a fraction of the information in any civilian trainer certification.

One might argue that an exercise science background is not necessary for leading military physical fitness. One might believe that there are those who have been working out for years on their own who have acquired much knowledge in doing so. I worked out on my own for many years, and I used to think I knew a lot about physical fitness, as I was very fit; I also thought personal training was kind of a joke. Once I got certified and became a trainer, I realized that I hardly knew anything at all. Trainers are educated in anatomy, physiology, biomechanics, bioenergetics, exercise technique and programming, nutrition and more. And after training clients for a while, I realized that even a certification does not mean much, as I learned that much more from the experience of training many different types of people. (I did encounter some people with no exercise science background who knew what they were talking about, but they were rare). No gym will hire a non-certified trainer, and many gyms will hire only certified trainers who have experience. Gyms know that it is dangerous to let an unqualified person lead others in physical training, and they do not want to be sued. So, why is it acceptable for our soldiers to be led in a (forced) fitness program by unqualified people?

The Army ensures that its leaders are qualified in their particular job by putting them through specific schooling, which it takes very seriously. The Army also claims to take physical fitness very seriously, but this is hard to believe because the Army does so many things wrong in how it conducts physical training. Physical training at the unit level is not well-rounded, and it causes soldiers to get injured.  There is too much endurance training (aerobic and muscle) and not enough other types of training:  muscle strength and power, agility, flexibility, balance, coordination, corrective exercise/injury prevention and rehabilitation. Also, there are specific exercises predominately done that are causing muscle imbalances in soldiers and leading to injury. These particular exercises that are overdone are directly related to the Army Physical Fitness Test (APFT), which consists of push-ups, sit-ups, and a two mile run.

The first area of injury I have seen a lot is that of the lower-limbs: hips, knees, shins, ankles and feet. Soldiers get iliotibial band syndrome, patella tendonitis (knee cap pain), medial tibial stress syndrome (shin splints), Achilles tendonitis, and plantar fasciitis (pain on the bottom of the foot). These injuries are inflammation of tendons and are most often caused by overuse. In the Army, that overuse is due to excessive running. My unit once did a five-mile run on pavement for morning training five days in a row, causing numerous guys to develop overuse injuries. Running is hard on the joints of the lower limbs, and it is even worse when done on pavement. Unless one is an advanced runner, running should not be done every day. 

The second area of injury I often see is the shoulders. Soldiers get shoulder impingement syndrome, rotator cuff tears, dislocation, subluxation (partial dislocation) and shoulder instability. These injuries are mostly due to dysfunction of the muscles responsible for the function and stabilization of the glenohumeral joint (shoulder). These muscles include the rotator cuff (small muscles deep in the shoulder that hold it together) and scapular muscles (shoulder blade/upper back). The Army does a lot of exercises that put much torque on the shoulder joint, such as push-ups and pull-ups. These create strong pectoralis (chest) and latissimus dorsi (pull-up) muscles, but the most important parts of the shoulder are left untrained. This creates an imbalance, which can prime the shoulder for injury, as those untrained muscles serve to stabilize (counter the torque on) the shoulder joint during movement.  I have yet to see a platoon doing rotator exercises for morning training; yet, they are included in the training routine of nearly every professional sports team for a reason.

The third area of injury I often see is the lumbar region (lower back). Lower back pain can be caused by many things. But in the young adult soldiers I have seen, I attribute it to an imbalance of the core muscles and overuse. The core is the muscles of the trunk (torso). Core muscles are key to proper movement of the body, and they are responsible for the stabilization of the spine during movement. Because the APFT has a sit-ups event, most of the core training in the Army focuses on the two main muscles responsible for the sit-up:  rectus abdominis and hip flexors. The more important muscles of the core, such as the transversus abdominis, are left untrained, creating an imbalance. This imbalance can cause excessive stress to be put on the lower back muscles like the erector spinae. It can also contribute to a condition called excessive lordosis, also known as anterior pelvic tilt, which puts one at increased risk for injury to the lower back. I have seen many soldiers with this condition, as it is easy to spot when they are in the push-up position. The sit-up is a terrible exercise that puts harmful pressure on the spinal discs, and it is not even a good indicator of true core strength.

One frequent activity that the Army does contributes to all three areas of injury I have discussed: ruck marching. The rucksack places a harmful load across the shoulders, spine and hips that is carried over a long distance and time. The human body is not built for this. It is made even worse when soldiers run ("ruck run") during a ruck march. I am not advocating that the Army abandon rucking, as I realize it is an essential skill for light infantry. However, it is overdone, especially when combined with excessive running. There are smarter, less harmful ways to train for it.

Most of the injuries that I have observed in soldiers would normally be only temporary setbacks, but they are made worse because the culture of the Army infantry does not value rehabilitation and injury prevention. Simply stated, the Army is not good at rehabilitation. I have witnessed plenty of injured solders who are not given adequate time to recover. These soldiers will get a "profile" from medical that exempts them from certain exercises, but the profile typically does not last long enough. They are usually told to exercise on their own until the profile expires. Once the profile expires, soldiers are thrown back into group training, often with the injury unresolved. Many soldiers will not get another profile because medical will not approve one, or they fear being considered as "weak" by leaders and peers.  Also, while soldiers are on profile, they are not fixing the underlying cause of the injury. Many need physical therapy, but few get it. I have seen soldiers in a constant cycle of being on and off profile for what started as an easily correctable injury (such as tendonitis).

Often, if soldiers are not on a profile, they must do whatever physical training their squad or platoon is doing, even if they know it is going exacerbate an injury. Unfortunately, this is because leaders do not trust their soldiers, as the Army has a huge problem with malingerers (injury fakers). To make things worse, sometimes soldiers do not even have immediate access to a doctor. A guy in my platoon dislocated his shoulder, but he was not able to see a doctor until over a week later because of the way the medical system is organized.  My battalion's physician assistant was with the rest of the battalion on a training rotation in another country, while my company was back at home. There is a medical clinic with doctors at our garrison, but this guy was told that he is not allowed to see them because he must go through our battalion medical staff. He was made to do morning physical training until he saw a doctor and was given a profile.  Even after he saw a doctor, he was given a physical therapy appointment for over a month later. That is downright negligence and a failure of the Army medical system and leadership; it is an outrage! When I dislocated my shoulder as a civilian, I was immediately put under the care of an orthopedic surgeon (shoulder specialist), and I started physical therapy the next week. That is the standard of care the Army should have, as proper treatment immediately after a dislocation is crucial to successful rehabilitation.

The Army's readiness is harmed by all of these preventable musculoskeletal injuries. The Army already knows this! The PRT manual states:

"In the Army alone, musculoskeletal conditions account for over half of all disabilities creating compensation of about $125 million per year. Knee and back injuries constitute a significant proportion of disability and limited duty. Training injuries treated on an outpatient basis and sports injuries may have the biggest impact on readiness."

Clearly, the Army has failed to stop preventable injuries with PRT.

I have some suggestions.

The Army should abandon PRT and group physical training. It makes no sense to utilize a one-size-fits-all approach. Everyone's body is unique; what works for one person might not be the best for another, especially with people of different fitness levels. The Army conducts group training because it fears its soldiers will not exercise on their own. Judging by the many unfit soldiers I observe in the infantry alone, it is obvious that group training does not work. Fit soldiers already exercise on their own in addition to the morning group training, and that is why they are fit.  If soldiers cannot keep a high level of fitness on their own, then the Army should get rid of them.

The Army needs to take a sports team-style approach to physical training.  Civilian exercise professionals should be hired to work at units. These professionals could create programs tailored to individuals and the unit mission. They could also teach and motivate soldiers to exercise on their own with a proper program. Injury prevention and rehabilitation would naturally be a huge focus. These civilians would need to have complete authority over anything exercise related at a unit. When they actually see results, soldiers will learn to love exercising instead of dreading it, just as I taught many people to when I was a trainer. I realize this program would be costly, but I believe the benefit of preventing injury and increasing readiness will outweigh the cost.

Soldiers with education and experience in exercise science should also be utilized. There are a handful of junior enlisted guys in my company alone with college degrees in exercise science-related fields. Considering only six percent of enlisted personnel across all the armed services have a bachelor's degree (even less with exercise science), why would leaders not want to take advantage of this valuable knowledge and experience? Civilians paid a lot of money for my time when I was a trainer, but I gladly offered it for free to my unit.

The Army should train all leaders in exercise science. Currently, some are trained at the Master Fitness Trainer Course. From what I can tell, this course is underutilized, as I have not met or heard of anyone at my unit who has been to it. And if there are some who have, they are either not doing a good job, or leaders are not utilizing them. This course should be expanded (and PRT removed from it) and made a high priority by all units. However, it hardly qualifies someone to lead an exercise program. It takes a lot of time, experience and continual education to become a proficient trainer. Graduates of the course should work under the guidance of civilian exercise professionals at their unit. The Army should even consider making it a primary MOS (job) like the Marine Corps is currently doing.

Better nutrition for soldiers is needed. The Army makes it challenging to have a healthy diet. The dining facilities (DFAC) are not exactly a shining example of nutrition. Some are better than others. I once went to a tank unit's DFAC for lunch where the only choices were cheeseburgers, hot dogs, corn dogs and fries. The DFAC at my unit is the worst I have seen; it is almost impossible to have a nutritious diet. The Army forces unmarried junior enlisted soldiers to eat at the DFAC. The additional money that is paid to soldiers each month for food is taken out of our paycheck because we are forced to take a "meal card" to eat at the DFAC for free. Some spend their own money to buy and cook food in their barracks instead of eating at the DFAC. However, many barracks (like mine) do not even have a kitchen or any means to cook food. The restaurants on posts are not any better.  With choices like Burger King, Popeye's, Taco Bell, Dunkin' Donuts and Domino's Pizza, it is no wonder why there are so many fat soldiers. The Army fails miserably at nutrition; it is ridiculous.

A great example of how the Army should conduct fitness training is the THOR3 (Tactical Human Optimization Rapid Rehabilitation and Reconditioning) program of Special Forces. The program brings together strength and conditioning coaches, physical therapists, dieticians and sports psychologists to train special operations soldiers. The DFACs of Special Forces units are outstanding because they have input from dieticians.  As usual, Special Forces leads the way in doing what makes sense. The Regular Army could learn a lot from them.

My (limited) experience of the Army is not necessarily representative of the entire Army. I am sure there are some units that have a good exercise program. However, I am in a great unit with high quality leadership, but we still have this problem. I am sick and tired of seeing soldiers not reach their fitness potential because of poor fitness training. It is a problem that starts at the very top. There is absolutely no reason why the Army of the most powerful country in the world, with all of its vast resources, should not be able to fix this. Doing so will create a stronger, more prepared Army. The right people in the right places just need to get their priorities right.  

Spc. Kevin Withrow is an infantryman assigned to D Company, 1st Battalion, 503rd Infantry Regiment, 173rd Airborne Brigade. He enlisted 2015.