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No More Suck It Up and Press on -- Preventing Injury is Hard Science

Image of Military personnel working on a crane. Sailors attach high-performance cargo slings to a crane during operator training in Saipan Harbor aboard a Military Sealift Command maritime prepositioning force container, roll-on/roll-off and mobile landing platform (Petty Officer 1st Class John Wagner).

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Occupational injuries for service members are common in every branch of the military and in practically every job, from wrenching one's back while lifting a missile to wiping out on a freshly mopped office corridor.

"One ankle fracture can take somebody out of their job for six months, just as stress or strain can take somebody out on limited duty for 90 days," said Catherine Hall, chief of occupational safety for the Defense Health Agency in San Antonio, Texas.

"They're a cost to the mission any time you take somebody out of the fight."

All jobs are unique. While a mechanic is going to have more hand injuries than an office worker, all occupations have an "injury trend," Hall said. Repetitive stress injuries, for instance, Hall described as "cumulative traumas." A dentist does very different work than a wrench-turning mechanic but is just as likely, if not more so, to develop repetitive motion wrist and hand injuries. For a mechanic, working in cold weather makes things even worse, she said, because blood flows away from hands, resulting in more force being applied.

But for mechanics, medical professionals, or many other jobs, "working in a small, finite area and doing it all day long" is going to result in stress to the fingers, hands, and arms, said Hall, who is a retired Air Force jet mechanic turned safety specialist.

"With the term 'ergonomics,' people automatically think [of a desk and] computer work station setting, but there's so much more work-related musculoskeletal risk in a lot of other settings," said Kelsey McCoskey, an ergonomist from the U.S. Army Public Health Center (APHC) at the Aberdeen Proving Ground in Maryland.

And even with corrective surgery, very often one's injured back or knee might not ever be the same, said John Pentikis, a colleague of McCoskey and the manager of the ergonomics and engineering branch at APHC. With carpal tunnel surgery, for example, surgery usually "only brings back about 70% of [one's] original capability to exert force, even without symptoms," he said.

Engineering controls

Hand injuries that result from doing difficult-to-reach repairs are never going to go away. But there are many tools to ease a workload, under the rubric of "engineering controls." These are the best way to minimize and eliminate exposure to work-related musculoskeletal disorder risk factors, but often they come down to simply using basic tools - dollies, carts, lifts, power tools, and other task-appropriate equipment.

"That's our gold standard," said McCoskey. "There are also administrative controls like training, or adding more people, or rotating more people through positions. But really, it's engineering controls that are what we try to do as much as possible - reduce the work related musculoskeletal risk that someone is exposed to. There are some things we simply can't design out. But if we can minimize overall risk by having controls where we can, that's going to reduce the risk."

Pentikis spoke of the "hierarchy of controls," or how to mitigate the workplace hazards by eliminating or substituting those hazards. They are, in order of effectiveness:

Military health personnel measuring the hand of a carpal tunnel patient
Lt. Cmdr. Philip Sherrick, an occupational therapist at Naval Hospital Jacksonville, measures Aretha Figueroa’s hand after carpal tunnel surgery (Photo by: Petty Officer 1st Class Jacob Sippel, Naval Hospital Jacksonville).
  1. Elimination: Physically remove the hazard
  2. Substitution: Replace the hazard
  3. Engineering controls: Isolate people from the hazard
  4. Administrative controls: Change the way people work
  5. Personal protective equipment: Protect the worker with PPE

"The closer you can get to the top, the closer you can reach that ideal and make people healthier and safer," Pentikis said, acknowledging that very often it is impossible to eliminate or substitute a particular hazard.

"When we talk about engineering controls, even though it is third on the level of the hierarchy, it is the most effective means that ergonomists or anyone has to improve or eliminate risk factors that exist at the job."

Still, active-duty troops are usually able-bodied young people, usually able to pick up heavy loads from the ground, repeatedly, with not much concern about their backs 20 years from now. But strains and sprains and stress fractures can happen to anyone from cumulative exposures, Hall said.

"Even if you're really young, really strong, and really healthy, absolutely," she said. "[Commanders] will tell you: 'Make sure your loads are disbursed evenly,' those kinds of things. But for women it causes a lot of hip injuries over time. The woman's body frame isn't necessary built to carry a load the same way a man does."

'Get it done'

Hall said a typical soldier or Marine in the field is carrying more than 100 pounds of gear, causing cumulative trauma on the shoulders, back, hips, joints, knees, and everything from the knee down.

The positive to all this, of course, is overall strength and resiliency. The downside is the repetitive stress. This is why it's smart to exercise different parts of your body on different days when going to the gym. The cumulative buildup is where stress factors come in with the lower legs, Hall said.

New, high-tech equipment is often made smaller and lighter, but its effectiveness in preventing strain exposure is perhaps exaggerated, Pentikis said.

"Not even close," he said. "Technology at best is only going to take away a few pounds, here and there, from a soldier's load. ... The solution is going to be more of a better understanding of the work environment to meet the needs of a soldier's ability to stay safe and to minimize what they're carrying for more maneuverability and a greater chance of survival."

"While there is certainly strength in youth and physical training, there are limits to that," said McCoskey. "Even though the services do different things, from a musculoskeletal risk factor standpoint, the body is exposed to those risk factors in many of the jobs that they're doing."

Military personnel working together
U.S. Air Force Staff Sgt. Demetrious Moutos, left, and Senior Airman Josef Thompson, of the 77th Aircraft Maintenance Unit (AMU), work together to finish loading munitions on an F-16CM Viper during the quarterly load crew competition at Shaw Air Force Base, South Carolina in October 2019. The load crew competition emphasized team work and their abilities to work together to complete the task efficiently ( Photo by: Airman 1st Class Jacob Gutierrez).

That's where leadership and education come into play.

"Training is only effective if the message gets through," Pentikis said, adding that having engineering controls within easy reach is a better means of long-term injury prevention.

Hall said the leadership of today's military is much more aware than it used to be.

"Now we have formalized processes for managing and accessing and identifying risk," she said. "Before, it was just, 'suck it up, buttercup -- get it done.' Things change."

Posture is an important risk factor as well, said Pentikis, who holds a doctorate in industrial engineering.

"Being able to maintain a neutral posture within the entire realm of a lift, from the second the fingers touch the object to the second you let go of that item, keeping your back straight and not twisted will increase your probability of being able to do that lift without suffering an injury."

"One often hears the phrase "lift with your legs." Both McCoskey and Pentikis are in agreement on this one, too: use equipment instead.

"A warehouse or distribution center setting is notoriously hard on the body, based on the amount of weight of the boxes being lifted, the size of the boxes, and often the boxes are starting at ground level," said Pentikis.

For more information, check out the PHC's "Ask an Ergonomist."

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