Prevention of Lower Extremity Musculoskeletal Injuries in Tactical and First Responder Populations: A Systematic Review and Meta-Analysis of Randomized Trials From 1955 to 2020

This article was published in The Journal of Strength and Conditioning Research in January 2023 (DOI: 10.1519/JSC.0000000000004293).

Note: This article was not submitted to ExultX Spotlight by the authors. However, due to its relevance, we have decided to share it with our community. This text is a commentary on the original article, attempting to highlight the key points. For a more thorough and complete understanding of the content, we strongly recommend everyone to read the original article.

All rights to the findings belong to the authors of the article. Responsibility for the commentary lies with ExultX.

As we published in our article "Tactical Fitness: Navigating Injury Challenges," tactical populations face a higher risk of musculoskeletal injuries, especially in the lower limbs, compared to the majority of other jobs. The authors of the article analyzed present data that align with this dialectic and noted that most injuries occur during physical training.

We know there are many opinions on the topic and a lot of "my method will keep you free of injuries" talk and publicity. However, we understand that injuries result from a combination of multifactorial mechanisms. Every year, millions of operators around the world get injured, and billions are spent on injury recovery processes, jeopardizing the health and longevity of the operators and the performance of the unit.

Some might argue otherwise, but experts in the field understand that maintaining high readiness levels is crucial for these professionals, and that's only achievable through rigorous training. Naturally, this represents an injury risk, but that doesn't mean we should accept high rates of injuries, especially high rates of long-term injuries, as normal.

While there is considerable evidence on this topic, most of it pertains to sports athlete populations. Like all processes or methods, injury prevention strategies need to be contextualized. To determine if this contextualization has been done, the authors of this article proposed evaluating the effectiveness of Lower Extremity Musculoskeletal Injury (LEMSI) prevention strategies compared to standard activities in tactical and first responder populations as the main objective of their investigation.

The systematic review search was conducted across databases such as MEDLINE, EMBASE, Cochrane, CINAHL, ProQuest, and DTIC. Meanwhile, the meta-analysis involved statistical analysis of the pooled data from these studies to determine the effectiveness of various LEMSI prevention strategies. The study followed PRISMA 2020 guidelines and used the Cochrane Risk of Bias tool 2.0 and GRADE approach to assess the certainty of evidence.

The review included 18 randomised controlled trials with over 11,000 subjects from military, police, firefighter, and paramedic populations. Below we present the interventions examined, with the highlights of each one:

Physical Training: No significant reduction in LEMSI occurrence. Specific interventions like core stabilization and lower extremity strengthening or stretching did not show significant benefits.

Footwear Modifications: No significant reduction in LEMSI or stress fractures. Orthotic insoles showed mixed results.

Nutritional Supplementation: No significant impact on LEMSI occurrence.

Training Modifications: Substituting running with weight-loaded walking showed potential in reducing LEMSI.

Key Takeaways:

Weak evidence for current prevention strategies: The analysis revealed weak evidence supporting the effectiveness of current LEMSI prevention strategies, indicating that existing methods that are being applied that may not significantly reduce injury rates.

Need for improved research: Future research should involve longer surveillance periods, include diverse populations beyond the military, and focus on improving methodological rigour.

Interdisciplinary approach: The author highlight the significance of an interdisciplinary approach in tactical settings.

Specific recommendations: From the studies analysed, many had moderate to high risk of bias. The overall certainty of evidence was low to very low, indicating a need for more rigorous research. The study suggests focusing on training modifications such as weight-loaded walking, which showed some promise in reducing LEMSI.

Learn more about the article here.