GENERAL MEDICAL CONDITIONS

Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCyw

Optimizing Health, Wellness, and Performance of

CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 09/25/2023

the Tactical Athlete

Sean R. Wise, MD, RMSK, FAAFP1 and Steven D. Trigg, MD2

specific duty within that profession. For

Abstract example, the United States Army has phys-
Tactical athletes are individuals in service occupations with significant ical standards that all service members
physical fitness and performance requirements such as law enforcement, must meet. However, different occupa-
firefighters, emergency responders, and military service members. Tactical tions within the Army have individualized
athletes also may have specific administrative requirements related to daily requirements. The daily physical re-
documenting physical injuries. Musculoskeletal injuries are a large burden quirements of a personnel clerk are vastly
on the tactical athlete population, with incident rates varying based on different from those of an infantryman.
the specific profession. Chronic exertional compartment syndrome (CECS) Similarly, within the United States Air
is difficult to manage in the tactical athlete population due to their limited Force, a fighter pilot and an aircraft me-
ability to reduce impact activities and poor surgical outcomes. Botulinum chanic have vastly different physical re-
neurotoxin-A and gait retraining show promise as alternative treatments quirements and occupational exposures.
for CECS. Heat injuries are frequent in the tactical athlete populations, In law enforcement, a special weapons
and a graduated return to play process helps to prevent morbidity. Manage- and tactics officer and a traffic officer
ment of musculoskeletal injuries in tactical athletes requires consideration would have significantly different de-
of operational schedules and adequate reconditioning, in addition to tradi- mands. As sports medicine professionals
tional injury evaluation. evaluating a tactical athlete, it is essen-
tial to identify the individual tactical
athlete's occupational requirements, because there may be tac-
Introduction tical athletes with widely different daily physical requirements
Tactical athletes are individuals performing in service occu- even in the same unit or team.
pations that have significant physical fitness and performance In addition to the physical requirements of tactical athletes,
requirements with the potential for exposure to life-threatening many of their professions, particularly within the military,
situations every day. The term is most commonly used to refer- have administrative requirements to document physical and
ence military service members, law enforcement, firefighters, cognitive limitations. In most military services, there is a base-
and emergency responders (1). The physical requirements of line assumption that all service members are healthy and capa-
these occupations can often involve direct physical trauma, ble of doing all physical tasks required for the job unless there
long movements under load, and the need to suddenly sprint is written medical documentation otherwise. When a tactical
or bypass obstacles. Because of the unique physical require- athlete is injured and unable to perform these tasks, they re-
ments of tactical athletes, sports medicine providers need to quire specific documentation of their limitations to allow re-
ensure that clinical evaluations of this population consider habilitation and recovery from their injuries while informing
their tactical and administrative requirements. their leadership of their readiness status. In addition to the ba-
The physical requirements of individual tactical athletes can sic documentation of physical limitations, some tactical ath-
vary widely based on their specific profession and even their letes may be on a special duty status that creates additional
administrative requirements, such as aviation, dive, or parachut-
1
National Capital Consortium Military Primary Care Sports Medicine ing duties. Physicians outside of military systems are generally
Fellowship, Uniformed Services University of Health Sciences, Bethesda, not expected to be familiar with the details of these adminis-
MD; and 2National Capital Consortium Military Primary Care Sports Medicine
trative requirements. However, it is essential that the patient's
Fellowship, Uniformed Services University of Health Sciences, Bethesda, MD
physical restrictions or limitations are communicated back to
Address for correspondence: Sean R. Wise MD, RMSK, FAAFP, NCC either their military command or the military medical system.
Military Primary Care Sports Medicine Fellowship, 4301 Jones Bridge Rd, Law enforcement and rescue personnel may require similar
Bethesda, MD 20814; E-mail: [email protected]. reporting regarding mental health issues that affect safe weapon
1537-890X/1902/70–75
handling in law enforcement or respiratory conditions that af-
Current Sports Medicine Reports fect equipment use for fire fighters. Clear communication en-
Copyright © 2020 by the American College of Sports Medicine sures that appropriate physical limitations are followed and

70 Volume 19  Number 2  February 2020 Optimizing Health of the Tactical Athlete

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 prevents the patient from further injuring themselves or plac- from 250 to 2500 injuries per 1000 police officers per annum.
ing their coworkers at risk by being unable to assist in emer- The most common injuries were sprains and strains (42% to
gencies. The restrictions of the Health Insurance Portability 95%) with the most common causes being assaults from non-
and Accessibility Act (HIPAA) still apply to tactical athletes. compliant offenders and operational training (11). Chronic
However, at least in the case of military service members, if injuries also are a concern, with 50% of respondents reporting
nonmilitary health care providers communicate directly with back pain in a survey of Minnesota police officers (12). In fire-
the patient's military health care team or provide written doc- fighters and emergency medical services personnel, Poplin
Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCyw

umentation to the service member that focuses exclusively on et al. (13) reported an annual injury rate of 17% with the most
current limitations, rather than diagnosis or injury history, common injuries being sprains and strains and the most com-
HIPAA compliance can be maintained. mon causes being patient transport, exercise, and training.
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 09/25/2023

Epidemiology Exertional Compartment Syndrome

Musculoskeletal injuries cause a significant burden for tacti- Chronic exertional compartment syndrome (CECS) is not a
cal athletes. Within the United States military, more than 40% problem unique to tactical athletes. However, the inability of
of all medical encounters can be attributed to acute and chronic most tactical athletes to adjust their level of physical exertion
musculoskeletal conditions (2). In 2017, more military service has direct implications for the medical management of this
members received care for musculoskeletal conditions than condition for these populations. CECS has two diagnostic
for any other category of diagnoses (3). components: pain in the involved compartment exacerbated
The incidence of specific injuries varies depending on the by a specific exercise and relieved upon cessation of this exer-
tactical athlete. Military trainees have very high injury rates, cise, and the elevation of the intramuscular compartment pres-
ranging from 12.5% in U.S. Air Force trainees (4) to 61% in sure (IMCP) in those compartments after exercise (14,15).
Army initial entry trainees (5). Female trainees, in particular, Conservative treatment measures include prolonged rest, mod-
have extremely high injury rates with 82% of female Army ification of physical activity, anti-inflammatory agents, orthot-
initial entry trainees having at least one injury during basic ics, ultrasound, massage, stretching, and electrical stimulation
training (5). A majority of trainee injuries involve the lower (16) with surgical fasciotomy or fasciectomy reserved for those
extremities, and most are attributed to overuse or cumulative who do not improve with the above mentioned interventions.
microtrauma, rather than acute traumatic events (5). The cost Tactical athletes are unique due to their inability to modify
for these injuries is significant. It includes not only medical ex- certain required physical activities beyond the demands of
penses but also lost training time for trainees and the cost of their occupation, which often leads to limited success of con-
the training provided when service members' injuries are sig- servative treatments and a more rapid progression to surgical
nificant enough to require removal from military service. It is intervention. A recent systematic review included more than
estimated that the annual direct and indirect costs of injuries 1500 patients and demonstrated a failure rate of 94% for con-
in U.S. Army Initial Entry Training alone exceed US $200 mil- servative treatment (17).
lion per year (5). The threshold for determining elevated IMCP is a topic of
In other military settings, the incidence and distribution of some debate. The majority of research on CECS uses the diag-
injuries vary with the physical requirements of the setting. In nostic threshold established by Pedowitz et al. (18) in 1990,
army infantry brigades, 30% of the soldiers reported injuries with diagnostic thresholds of 30 mm·Hg at 1-min postexercise
over a 6-month period. The most common injury locations or 20 mm·Hg at 5 min postexercise. This threshold has dem-
were the knee (19%), ankle (15%), back (13%), foot (8%), onstrated high sensitivity (97%) but not specificity (10%).
and shoulder (7%). The most common activities associated with Roscoe et al. (19) proposed an alternative diagnostic criteria
injuries were running (32%), lifting heavy objects (13%), and utilizing continuous monitoring of the IMCP. Using a diag-
walking or marching under load (11%) (6). Among airmen in nostic threshold of 105 mm·Hg during exercise at the point
Air Force Special Operations, a similar distribution was noted of maximum tolerable pain demonstrated a sensitivity of
with the lower extremities being the most common injury site, 63% and specificity of 95% in a small study of 40 individuals.
followed by the lower back and the upper extremities. The most Based on this small study, the specificity of their results would
common activities associated with injuries were weight lifting, limit false positive and potentially unnecessary interventions
followed by tactical training (7). In Navy Sea, Air, and Land in patients that would not have been excluded by the Pedowitz
Teams, whose mission profile requires more work in water, et al. criteria. Further research is required to determine more
upper-extremity injuries were more common (38%), followed specific IMCP testing techniques and thresholds.
by lower extremity injuries (35%) and the back (24%) (8). In Despite being the gold standard for the management of
military and nonmilitary helicopter pilots, on the other hand, CECS, surgical fasciotomy or fasciectomy fails to provide
back and neck pain predominate with 57% to 67% reporting sustained relief in 10% to 40% of cases in the civilian popula-
neck pain while flying and up to 82% reporting back pain tion (17,20,21). The effectiveness of surgical interventions for
while flying (9,10). Much of this pain has been attributed to a military population appears to be significantly worse. In a
the load placed on the neck by night vision goggles and er- case series of 41 military patients who underwent fasciotomy,
gonomic issues related to back support while flying (10). only 46% experienced clinical improvement, and only 22%
Less literature has been published on injury patterns in non- improved enough to return to an unrestricted medically deploy-
military tactical athletes. However, as with military tactical able status (22). These findings are in stark contrast to the civil-
athletes, the available evidence suggests that injury patterns re- ian community, where 75% of patients report returning to their
flect the common physical loads encountered. In law enforce- previous level of activity after fasciotomy (17). In a second case
ment personnel, injury incidence has been reported to vary series published by McCallum et al. in 2014, 70 extremities in

www.acsm-csmr.org Current Sports Medicine Reports 71

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 46 patients were treated with surgical fasciotomy for CECS. higher among recruit trainees when compared with other service
With an average follow-up of 26 months, only 19 (41.3%) members (26). Organizations of tactical athletes are unique in
were able to return to full active military service, while 17 (37%) that they must juggle the need to protect tactical athletes from
stayed in the military with physical and duty limitations, and heat-related illness with the requirement to perform realistic
10 (21.7%) had to leave the military altogether. These case series training and actual operations that may occur in extreme
demonstrate the poor outcomes of surgical interventions in the heat conditions.
military compared with civilian athletes, which is likely due to Previous reviews of heat illnesses in military trainee popula-
Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCyw

military patients' inability to modify their physical activities tions have demonstrated that BMI extremes (both high and
postoperatively (15). low), and medication use (specifically NSAIDs, opioids, and
Given these relatively poor outcomes after surgical inter- stimulants) were key modifiable risk factors that increased
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 09/25/2023

vention in CECS, alternative treatment options are needed. the risk for heat illness. In addition, prior heat illness, younger
In 2012, Diebal et al. presented a case series of 10 patients age groups, female sex, black race, having never married or
with CECS treated with a 6-wk training program consisting being divorced, and lower or missing cognitive aptitude
of 45-min sessions thrice weekly designed to eliminate the scores and lower or missing physical fitness test scores were
hindfoot strike, increase step rate to 180 steps per minute, nonmodifiable risk factors associated with a higher risk of
and use the hamstring group to pull the foot from the ground heat illnesses. As might be expected, the incidence of heat
instead of using the gastrocnemius and soleus muscles to push illnesses increased at training locations with lower altitudes
off. At 1 year, 8 of 10 were running at least 5 km two to three and warmer climates (27,28). One proposed method to miti-
times per week with the other two being limited by unre- gate the risk of heat injury is to expose tactical athletes to
lated acute injuries (23). A similar intervention performed graduated strenuous activity in each new geographic location.
on Norwegian service members was reported by Helmhout Tactical athletes, particularly military recruits, are at risk per-
et al. (16) in 2015. These service members showed improve- forming new activities in new locations with unique climates.
ment in pain, distance running, self-reported function, and Gradually exposing the tactical athletes to higher levels of ex-
measured IMCP. ertion should help to develop heat tolerance (27).
A newer promising intervention is an intracompartmental While a full discussion of the management of heat injuries is
injection of botulinum toxin (BoNT-A). BoNT-A inhibits the beyond the scope of this article, the most important concept in
release of acetylcholine at the motor endplate. The effects of management is the immediate treatment of the heat stroke
a BoNT-A injection are expected to last 2 to 3 months. How- with rapid cooling. The goal time is less than 30 min for cooling
ever, BoNT-A injections have shown effectiveness beyond this to a normalized temperature (29). Casa et al. (30,31) have previ-
timeframe via mechanisms that are not entirely understood. It ously described the relative efficacy of various cooling methods.
is hypothesized that some degree of muscle atrophy and loss of In the ideal, resource-rich environment, ice-water or cold-water
contractile tissue results in prolonged improvement but has immersion is the treatment of choice. However, in more austere
not resulted in decreased athletic performance (24). locations, other more portable methods may be required.
A retrospective case series assessing 42 compartments in In the authors' experience, the ice burrito method, which
16 patients reported by Isner-Horobeti et al. (14) in 2013 dem- cools the patient utilizing sheets and towels that are
onstrated clinical improvement in 10 of 16 patients 1 month af- soaked in an ice slurry in a water cooler is particularly ef-
ter BoNT-A injection guided by electrical stimulation. Post hoc fective in remote or more austere environments because it
evaluation 3 to 9 months later (average 4.4 months) demon- is portable, and the ice cooler can be strapped to the exterior
strated decreased average compartment pressures and resolu- of a vehicle (Fig. 1).
tion of pain in 15 of 16 patients. Within the military setting, Because prior heat injury is a significant risk factor for de-
Hutto et al. (25) reported a case in 2018, where a military ser- veloping future heat injury and future training may place tac-
vice member with anterior and lateral CECS was treated with tical athletes in situations where they are again exposed to
BoNT-A and demonstrated symptom resolution through extremes of exertion and heat, a common conundrum encoun-
10 months of follow-up. BoNT-A is not without side effects, tered when assessing tactical athletes after heat injury involves
and both foot drop and soreness in the injected muscle groups determining when to return them to full duty. Return to activ-
have been reported, but some of this may be due to the fact ity policies can be designed to ensure the safety of a tactical
that the ideal dose has not yet been determined. athlete as they reacclimate to activity during the period of de-
Because of the relatively poor functional outcomes after creased heat tolerance immediately following a heat injury.
fasciotomy in military patients with CECS, we recommend While research suggests that the norm is for individuals to re-
initial treatment of tactical athletes with noninvasive modali- cover within a few weeks with appropriate treatment, some do
ties, particularly running form modification and BoNT-A in- experience long-term complications with reduced exercise ca-
jection, prior to consideration of surgical treatment. pacity and heat tolerance potentially increasing the risk of sub-
sequent heat injury (27,33). ACSM has published clinical
Heat Injury guidelines for return to play after exertional heat stroke, that
Heat injuries, which include heat cramps, heat exhaustion, require the resolution of symptoms, normalization of laboratory
and heat stroke, are a prominent concern in many athletic pop- values, and graded heat acclimatization to improve tolerance
ulations, but especially so among tactical athletes. In 2018, (Table) (34).
there were a total of 578 heat stroke and 2214 heat exhaustion Laboratory-based exercise-heat tolerance testing may not
diagnoses among active duty service members in the United be routinely available in clinical settings. However, should
States for a rate of 0.45 and 1.71 cases per 1000 person- such testing be warranted, regional experts can be engaged
years, respectively. The incidence rate was more than three times to help guide further assessment.

72 Volume 19  Number 2  February 2020 Optimizing Health of the Tactical Athlete

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 If treatment is delayed, it is extremely important, as discussed
above, to relay information regarding the service member's
functional status to their unit or military medical provider to
ensure that physical limitations do not place the service mem-
ber or their teammates at risk.
Tactical athletes may require additional rehabilitation and
reconditioning compared with injured nonathletic patients.
Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCyw

When released from care and cleared to return to work, tacti-

cal athletes may immediately find themselves in situations
where their lives or the lives of those around them depend
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 09/25/2023

on their ability to perform arduous physical tasks. In addition,

their employing organizations will generally assume that they
have no physical or functional limitations unless there is ex-
plicit communication from medical professionals stating oth-
erwise. In some cost-conscious health systems, it is common
for injured patients to be released at a point where they are
clinically pain-free but have not fully regained their prior en-
durance and agility. Ardern et al. (35) have described a model
Figure 1: Demonstration of the “ice burrito” method of external of return to sport that progresses from returning to participa-
cooling. After exposing patient's skin, the patient's body is wrapped
in a sheet and their head is wrapped in a towel soaked in an ice slurry.
tion through returning to sport to return to performance. This
After 30 s to 60 s, an additional soaked sheet and towel are laid over model can be adapted to tactical athletes with a progression
the first. Each subsequent 30 s to 60 s, the top towel and sheet are from return to participation to return to duty, and ultimately
exchanged for fresh soaked towels and sheets (32). return to tactical performance (Fig. 2) (36). Return to partici-
pation is similar to the initial model in that it describes when
Rehabilitation and Treatment Plan Considerations the tactical athlete is capable of physical activity, but not ready
In general, the treatment of most injuries will be the same in to return to duty. Return to duty describes when the tactical
tactical athletes as it is in other athletes. However, there are ex- athlete has returned to performing occupational tasks, but
ternal considerations that may alter treatment plans and must has not reached prior levels of tactical performance. Return
be considered. to tactical performance describes when the tactical athlete
While tactical athletes do not have traditional athletic seasons has returned to their prior level of physical and psychological
and competitions, military service members may have scheduled performance within a tactical or occupational context. Be-
missions, field training exercises, or overseas deployments. The cause of the potential for tactical athletes to experience unpre-
presence of an injury may not automatically disqualify a tacti- dictable life-threatening situations at almost any time, it is the
cal athlete from participating in these events, particularly when authors' opinion that tactical athletes are better served with a
the athlete may be a member of a smaller unit where the loss of more conservative rehabilitative course that ensures return to
one team member could lead to mission failure. When devel- tactical performance, with a focus on the restoration of endur-
oping a treatment plan, it is important to work with tactical ance and agility, prior to being released from treatment. In ci-
athletes to determine how a planned treatment, particularly vilian occupations, such as law enforcement, firefighters, and
if it may lead to prolonged downtime, would impact other oc- EMS, this may take the form of a formal work-hardening pro-
cupational requirements. As with other athletes, it is common gram. In military occupations, this will often involve a longer
that a treatment plan may be altered or delayed to allow a tac- reconditioning phase with a focus on specific functional or tac-
tical athlete to complete a mission or important training event. tical tasks associated with the service member's potential duties.

Table. Traumatic Brain Injury and Posttraumatic Stress Disorder

ACSM guidelines for return to play after heat stroke (34). as Comorbid Conditions
A full discussion of the management of traumatic brain inju-
1. Refrain from exercise for at least 7 d after release from
medical care. ries (TBI) and Posttraumatic stress disorder (PTSD) is outside
2. Follow up about 1 wk postincident for a physical examination
and laboratory testing or diagnostic imaging (biomarkers) of the
affected organs. This will address the clinical course of the heat
stroke incident.
3. When the individual has been cleared for return to activity, he
or she should begin exercise in a cool environment and gradually
increase the duration, intensity, and heat exposure over 2 wk to
demonstrate heat tolerance and initiate acclimatization.
4. If return to vigorous activity is not accomplished within 4 wk,
a laboratory exercise-heat tolerance test should be considered.
5. If the athlete proves heat tolerant, he/she may be cleared
for full competition between 2 and 4 wk after the return to
Figure 2: Modification of the return to sport model for tactical athletes.
full training.
Adapted from Adern et. al. and Lazicki and Deccarreu (35,36).

www.acsm-csmr.org Current Sports Medicine Reports 73

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 the scope of this article as both are complex diagnoses that re- providers need to ensure that they are considering the occupa-
quire multidisciplinary management. However, both condi- tional and administrative requirements of the tactical athlete
tions are important to consider when treating tactical athletes when evaluating these patients.
because of their prevalence and because their presence may
complicate the management of other more routine diagnoses.
The United States Defense and Veterans Brain Injury Center The authors declare no conflict of interest and do not have
reports 383,947 TBI in the U.S. military from 2000 through any financial disclosures.
Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCyw

the first quarter of 2018 (37). Approximately 19% of the ser-

vice members from the current wars sustained at least one The views expressed herein are those of the authors and
mild TBI (38). With more than 2 million veterans of the wars do not reflect the official policy or position of the Defense
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 09/25/2023

in Iraq and Afghanistan, this has resulted in substantial disease Health Agency, Department of the Air Force, Department of
burden. In a similar manner, between 5% and 15% of U.S. ser- the Army, Department of Defense, or the U.S. Government.
vice members have symptoms of PTSD (38). This is likely an
underestimate as the military experiences similar issues with
underreporting symptoms as athletic populations do. Previ- References
ous studies have demonstrated a link between the diagnosis 1. Sefton JM, Burkhardt TA. Introduction to the tactical athlete special issue. J.
Athl. Train. 2016; 51:845.
of TBI or PTSD and a higher prevalence of chronic pain in
2. Absolute and relative morbidity burdens attributable to various illnesses and in-
both military and nonmilitary tactical athletes (39,40). Thus, juries, active component, U.S. Armed Forces, 2017. MSMR. 2018; 25:2–9.
when evaluating tactical athletes in a sports medicine setting, 3. Ambulatory visits, active component, U.S. Armed Forces, 2017. MSMR. 2018;
particularly for chronic conditions that have not responded 25:17–23.
to initial treatment, there may be some benefit to assessing 4. Nye NS, Pawlak MT, Webber BJ, et al. Description and rate of musculoskeletal
whether comorbid TBI or PTSD is present. injuries in Air Force Basic Military Trainees, 2012−2014. J. Athl. Train. 2016;
51:858–65.
5. Hauschild VD, Lee T, Barnes S, et al. The etiology of injuries in U.S. Army initial
Recent Developments entry training. U.S. Army Med. Dep. J. 2018; 22–9.
The paradigm for how tactical athletes train and receive ini- 6. Canham-Chervak M, Rappole C, Grier T, Jones BH. Injury mechanisms, activ-
tial care for their musculoskeletal concerns is undergoing a ities, and limited work days in U.S. Army Infantry Units. U.S. Army Med. Dep. J.
2018; 6–13.
massive paradigm shift. A number of militaries and law en-
7. Lovalekar M, Johnson CD, Eagle S, et al. Epidemiology of musculoskeletal inju-
forcement agencies across the globe are moving away from a ries among U.S. Air Force Special Tactics Operators: an economic cost perspec-
traditional model where physical training is entirely separate tive. BMJ Open Sport Exerc. Med. 2018; 4:e000471.
from medical care toward the development of integrated organi- 8. Lovalekar M, Abt JP, Sell TC, et al. Descriptive epidemiology of musculoskeletal
zations focused on human performance optimization (41). Early injuries in naval special warfare sea, air, and land operators. Mil. Med. 2016;
181:64–9.
work toward this end included developing dedicated sports
9. Posch M, Schranz A, Lener M, et al. Prevalence and potential risk factors of
medicine teams, such as the U.S. Navy SMART clinics and flight-related neck, shoulder and low back pain among helicopter pilots
the embedding of athletic trainers with military training units and crewmembers: a questionnaire-based study. BMC Musculoskelet. Disord.
(42). These concepts have now progressed to multiple organi- 2019; 20:44.
zations developing integrated facilities similar to college train- 10. Walters PL, Cox JM, Clayborne K, Hathaway AJ. Prevalence of neck and back
pain amongst aircrew at extremes of anthropometric measurements. [Internet].
ing rooms where tactical athletes have access to professional Fort Rucker, AL: United States Army Aeromedical Research Laboratory; 2012
strength and conditioning coaches, sports dietitians, athletic Sep [cited 2019 Jun 11]. (USAARL Report). Report No.: 2012–12. Available
from: https://apps.dtic.mil/dtic/tr/fulltext/u2/a564323.pdf.
trainers, physical therapists, and mental performance special-
11. Lyons K, Radburn C, Orr R, Pope R. A profile of injuries sustained by law enforce-
ists working in an integrated team focused on training and re- ment officers: a critical review. Int. J. Environ. Res. Public Health. 2017; 14.
habilitating tactical athletes for their specific mission requirements 12. Nabeel I, Baker BA, McGrail MP Jr., Flottemesch TJ. Correlation between phys-
(43). Some special operations units have extended this concept ical activity, fitness, and musculoskeletal injuries in police officers. Minn. Med.
even further, integrating behavioral health and spiritual sup- 2007; 90:40–3.
port assets, such as chaplains into the team in an attempt to 13. Poplin GS, Harris RB, Pollack KM, et al. Beyond the fireground: injuries in the
fire service. Inj. Prev. J. Int. Soc. Child Adolesc. Inj. Prev. 2012; 18:228–33.
optimize the “whole human.”
14. Isner-Horobeti M-E, Dufour SP, Blaes C, Lecocq J. Intramuscular pressure be-
This new model has implications for sports medicine pro- fore and after botulinum toxin in chronic exertional compartment syndrome
viders. First, it may affect how tactical athletes present for of the leg: a preliminary study. Am. J. Sports Med. 2013; 41:2558–66.
care. As many of these organizations have open access for tac- 15. McCallum JR, Cook JB, Hines AC, et al. Return to duty after elective fasciotomy
tical athletes, the athletes may often have received significant for chronic exertional compartment syndrome. Foot Ankle Int. 2014; 35:871–5.
care from their unit athletic trainers and physical therapists be- 16. Helmhout PH, Diebal AR, van der Kaaden L, et al. The effectiveness of a 6-week
intervention program aimed at modifying running style in patients with chronic
fore ever seeing a sports medicine provider in a clinical setting. exertional compartment syndrome: results from a series of case studies. Orthop.
Second, it may provide an alternative source for the rehabilita- J. Sports Med. 2015; 3:2325967115575691.
tion of an injured tactical athlete. In one author's experience, 17. Campano D, Robaina JA, Kusnezov N, et al. Surgical management for chronic
exertional compartment syndrome of the leg: A systematic review of the litera-
the integrated team capable of smoothly transitioning a patient ture. Art Ther. 2016; 32:1478–86.
from physical therapy to reconditioning to standard physical 18. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the
training leads to improved long-term outcomes for tactical ath- objective diagnosis of chronic compartment syndrome of the leg. Am. J. Sports
letes as they return to duty fully prepared to perform their duties. Med. 1990; 18:35–40.
19. Roscoe D, Roberts AJ, Hulse D. Intramuscular compartment pressure measure-
ment in chronic exertional compartment syndrome: new and improved diagnos-
Conclusions tic criteria. Am. J. Sports Med. 2015; 43:392–8.
In conclusion, tactical athletes are a unique population with 20. Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome:
significant rates of musculoskeletal injuries. Sports medicine diagnosis, management, and outcomes. Am. J. Sports Med. 1985; 13:162–70.

74 Volume 19  Number 2  February 2020 Optimizing Health of the Tactical Athlete

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 21. Slimmon D, Bennell K, Brukner P, et al. Long-term outcome of fasciotomy with 33. Epstein Y. Heat intolerance: predisposing factor or residual injury? Med. Sci.
partial fasciectomy for chronic exertional compartment syndrome of the lower Sports Exerc. 1990; 22:29–35.
leg. Am. J. Sports Med. 2002; 30:581–8. 34. Armstrong LE, Casa DJ, Millard-Stafford M, et al. American College of Sports
22. Simpson C, Roscoe D, Hughes S, et al. Surgical outcomes for chronic exertional Medicine position stand. Exertional heat illness during training and competition.
compartment syndrome following improved diagnostic criteria. J. R. Army Med. Med. Sci. Sports Exerc. 2007; 39:556–72.
Corps. 2019.
35. Ardern CL, Glasgow P, Schneiders A, et al. 2016 consensus statement on return
23. Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and to sport from the first world congress in sports physical therapy, Bern. Br. J.
disability associated with chronic exertional compartment syndrome. Am. J. Sports Med. 2016; 50:853.
Sports Med. 2012; 40:1060–7.
Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCyw

36. Lazicki RL, Deccarreu RM. Bridging injury and performance training in the mil-
24. Fortuna R, Vaz MA, Youssef AR, et al. Changes in contractile properties of mus- itary tactical athlete. American Physical Therapy Association NEXT Confer-
cles receiving repeat injections of botulinum toxin (Botox). J. Biomech. 2011; 44: ence. 2018; Orlando, FL.
39–44.
37. DoD worldwide numbers for TBI [internet]. DVBIC. 2016 [cited 2019 Jun 20].
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 09/25/2023

25. Hutto WM, Schroeder PB, Leggit JC. Botulinum toxin as a novel treatment for Available from: https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi.
chronic exertional compartment syndrome in the U.S. Military. Mil. Med.
38. Tanielian T, Jaycox LH, editors. Invisible Wounds of War: Psychological and
2019; 184:e458–61.
Cognitive Injuries, Their Consequences, and Services to Assist Recovery [Internet].
26. Update: heat illness, active component, U.S. Armed Forces, 2018. MSMR. 2019; Santa Monica, CA: RAND Corporation; 2008. [cited 2019 Jun 20]. Available
26:15–20. from: https://www.rand.org/pubs/monographs/MG720.html.
27. Nelson DA, Deuster PA, O’Connor FG, Kurina LM. Timing and predictors of 39. McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated
mild and severe heat illness among new military enlistees. Med. Sci. Sports Exerc. with chronic pain: an examination in a nationally representative sample. Pain.
2018; 50:1603–12. 2003; 106:127–33.
28. Barnes SR, Ambrose JF, Maule AL, et al. Incidence, timing, and seasonal pat- 40. Nampiaparampil DE. Prevalence of chronic pain after traumatic brain injury: a
terns of heat illnesses during U.S. Army basic combat training, 2014–2018. systematic review. JAMA. 2008; 300:711–9.
MSMR. 2019; 26:7–14.
41. Park GH, Messina LA, Deuster PA. A shift from resilience to human perfor-
29. Heled Y, Rav-Acha M, Shani Y, et al. The “golden hour” for heatstroke treat- mance optimization in special operations training: advancements in theory and
ment. Mil. Med. 2004; 169:184–6. practice. J. Spec. Oper. Med. 2017; 17:109–13.
30. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional heat stroke in com- 42. Masters D. Sports Medicine and Rehabilitation Team Clinic. Falls Church, VA:
petitive athletes. Curr. Sports Med. Rep. 2005; 4:309–17. Comparative Model Analysis of Navy and Marine Corps Options [Internet];
31. Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard 2003. [cited 2019 Jun 19]. Available from: https://apps.dtic.mil/dtic/tr/fulltext/
for exertional heatstroke treatment. Exerc. Sport Sci. Rev. 2007; 35:141–9. u2/a420814.pdf.
32. Human Performance Resource Center. Cooling in the Field [Internet]. Bethesda, MD; 43. Grier T, Anderson MK, Depenbrock P, et al. Evaluation of the US Army special
2018. [cited 2019 Jun 20]. Available from: https://www.youtube.com/watch?v= forces tactical human optimization, rapid rehabilitation, and reconditioning pro-
XQga2aWERXs&list=PLhh_lxc4bmz9mjEjkIz9_YKMFxMca8986&index=6&t=0s. gram. J. Spec. Oper. Med. 2018; 18:42–8.

www.acsm-csmr.org Current Sports Medicine Reports 75

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.