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Introduction

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Pain is weakness leaving the body.

US Marine Corps

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The principles of sport and exercise medicine apply to a large extent when caring for military personnel. However, there are also important differences between military and athletic populations (Fig. 45.1). In this chapter, we discuss additional issues that are relevant when taking care of military personnel. For those inexperienced in working in this setting we introduce:

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  • the special culture of the military environment

  • the epidemiology of military injuries

  • common military injuries.

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Figure 45.1

Physical training in the military takes place within a unique culture and environment

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Special military culture

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Providing primary care in a military setting offers unique challenges to the clinician. With regards to sports medicine, there are many special features which influence the type and severity of injuries seen, and multiple factors which have an impact on the rehabilitation process. The clinician must become well versed in these unique factors in order to ensure appropriate diagnosis, treatment, and, ultimately, timely and effective return to full duties.

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One of the most important differences between civilian and military practice is the compulsory nature of physical training. To prepare a recruit for the ultimate goal of being fit for deployment, all military recruits undergo exercise regimens that are designed not only to improve their fitness, but also to prepare them physically and psychologically for extreme environments, discomfort, and pain. Furthermore, trainees have not always had a background of physical training, unlike an elite sportsperson who has come up through the junior ranks. With training in the military, it is the same goal whether a soldier is training to become a paratrooper, a weapons technician, or an administrator.

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It follows that most militaries encourage personnel to continue exercising despite early warning signs of pain that would normally cause civilian sportspeople to stop or slow down. Many recruits conceal the nature and extent of their injuries until graduation, for fear of medical “back squadding” (recruits held back in training), and a degree of derision from fellow recruits and their superiors. A soldier who finishes a forced march by walking on a broken ankle for 12 miles with a fully weighted rucksack receives accolades and respect from peers and superiors.

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Further to the drive toward pushing through pain, soldiers with a history of previous injury or who are diagnosed with post-traumatic stress demonstrate an increased threshold of pain—meaning they feel less pain for a given stimulus compared with controls.1, 2 Pain thresholds may be related to environmental and psychological factors (for example, the common experience of WWII soldiers reporting no pain during the heat of battle despite severe injuries).3

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As a consequence of these changes in experiencing or reporting of pain, ...

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