April – June 2014 

Perspectives 1

MG Steve Jones; COL Mustapha Debboun; Richard Burton 

History of United States Army Physical Fitness and 5

Physical Readiness Testing 

Joseph J. Knapik, ScD; Whitfield B. East, PhD 

Relationships of Physical Performance Tests to 20

Military-relevant Tasks in Women 

Tunde K. Szivak; William J. Kraemer, PhD; Bradley C. Nindl, PhD; et al 

Screening Initial Entry Training Trainees for Postural Faults and 27

Low Back or Hip Pain 

MAJ John R. Lane 

Diagnosing Another Great Imposter 31

LTC Mark D. Thelen; Michael D. Ross, DHSc, PT; Lt Col Michael A. Tall, USAF 

Angioedema as a Prodrome of Rheumatoid Arthritis Exacerbation 39

Ketan Desai, MD, PhD 

Radiofrequency Denervation of the Hip Joint for Pain Management: 41

Case Report and Literature Review 

Gaurav Gupta, MD; Mohan Radhakrishna, MD; Paul Etheridge, MD; et al 

A Bier Block Implementation Protocol 53

CPT Stewart A. Stancil 

Central Odontogenic Fibroma: Case Report and Review 57

MAJ John P. Batson; Frank Strickland, DDS, MPH 

Focal Epithelial Hyperplasia (Heck’s Disease): 61

A Case Report and Review 

MAJ Zachary H. Highberger; MAJ Joseph W. Ivory; et al 

Median and Ulnar Neuropathies in US Army Dental Personnel at 65

Fort Sam Houston, Texas 

COL Scott W. Shaffer; 1LT Kaitland Alexander; 1LT Daniel Huffman; et al 

Risk Factors Associated with Higher Body Fat in 75

US Army Female Soldiers

Morgan K. Anderson, MPH, CPH; Tyson Grier, MS; Michelle Canham-Chervak, PhD; et al 

Act Resilient 83

Genie Joseph, MFA; Wynona Bice-Stephens, EdD, RN
April – June 2014 The Army Medical Department Center & School PB 8-14-4/5/6 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx 

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LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG Steve Jones 

Commanding General 

US Army Medical Department Center & School 

Administrative Assistant to the 

Secretary of the Army 

GERALD B. O’KEEFE 

1405005 

By Order of the Secretary of the Army: 

Official: 

Raymond T. Odierno 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 
 April – June 2014 1

Perspectives

An Army and an AMEDD in Transition

MG Steve Jones

With the end of combat operations in Iraq and the drawdown of forces in Afghanistan, we are transitioning from 

an Army at war to one preparing for the next fi ght—an 

Army of Preparation. The Army Medical Department 

(AMEDD) must now shift from a singular focus on caring for the casualties of Operating Enduring Freedom 

to a broader view that also looks to the future. As we 

continue to provide the same high level of care to the 

casualties of this confl ict, we will transform to provide 

even more effective care in the next. As noted by General Robert W. Cone, commander of the Army’s Training and Doctrine Command, we must fi nd the right balance so we shortchange neither the Soldiers fi ghting in 

today’s war nor those who will fi ght in future confl icts. 

We must balance investments in training, equipment 

and maintenance that keep us ready for today’s confl icts, with investments in science and technology that 

will make us more capable in the future. This task is far 

more diffi cult in an environment of fi scal uncertainty.

To provide effective support to an Army of Preparation, 

the AMEDD must understand the Army Chief of Staff’s 

vision, strategic priorities, and the objectives of Army 

transformation. The Army is transforming through a 

strategy that addresses near, mid, and long-term requirements. It will change from an Army focused on winning 

the current fi ght to an expeditionary Army that does 

many things well. In the near term, the Army will create 

more capable brigade combat teams by adding a third 

maneuver battalion, fi res, and engineer assets. It will 

develop units that are more expeditionary, scalable, and 

can be tailored according to the mission. Forces will be 

regionally aligned so they are able to study the cultures, 

geography, languages, and militaries of the countries 

where they are most likely to be employed. They will 

be trained to conduct operational missions, bilateral and 

multilateral military exercises, and theater security cooperation activities. Army 2020 will be a more globally 

responsive force, able to deploy more rapidly, and prepared for the full spectrum of threats the nation is likely 

to confront. It will be more responsive to the combatant 

commander and a critical element of Joint Force 2020.

Several initiatives serve as the foundation of Army 

2020: The Army Profession, Mission Command, Leader 

Development, The Squad, and The Army in the Joint 

Fight. The Army Profession will instill 5 characteristics 

into Soldiers and Army Civilians: trust, military expertise, esprit de corps, honorable service, and stewardship. 

Mission Command is a leadership style defi ned as “the 

exercise of authority and direction by the commander 

using mission orders to enable disciplined initiative 

within the commander’s intent.” Mission Command 

was developed because ground combat is complex and 

unpredictable. It recognizes the requirement for greater 

decentralization in operational decision making, and 

the central role of the commander in building adaptive 

teams. Leader Development is key to preparing offi cers 

and noncommissioned offi cers to succeed in the more 

dangerous and complex security environment, and lead 

Army, joint, and multinational teams. The Squad Initiative extends technology, leader development, and 

training to the squad, the fundamental building block of 

Army 2020. It will provide the squad the lethality and 

mobility to achieve and retain overmatch. The Army in 

the Joint Fight recognizes that we will continue to fi ght 

as part of a joint team, with interagency, coalition, and 

host nation partners.

In the midterm the Army will transition to Force 2025, 

a leaner, more capable, and more expeditionary force 

than today. Smaller but equally capable units will deploy to remote and austere environments. They must be 

prepared to defeat adversaries who attempt to exclude or 

limit United States access to forward areas and staging 

bases. These adversaries will avoid our strengths, cause 

us to fi ght in ways we do not want to fi ght, and prolong 

confl ict to undermine our national will. Forces in 2025 

will operate differently. Deployment and employment of 

units will be unpredictable, nonlinear, and much faster, 

taking hours or days rather than weeks or months. Deploying units will integrate their operations with unifi ed 

action partners and regionally aligned forces already in 

theater conducting exercises or engagement activities. 

They will be delegated the authority required to respond 

more quickly to changing circumstances. They will be 

distributed across the area of operations to reduce mass, 

hide their intent, cover more terrain, and be better prepared to react to opposing forces’ capabilities.

It will take a very different AMEDD to support future 

operations. The fi rst step in our transformation is to 

capture and build on the lessons of the past 12 years of 

war. What we learned on the battlefi eld, in our medical 
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

EDITOR’S PERSPECTIVES

From the earliest days of formal, structured military organizations, the requirement for the Warfi ghters to possess a high level of physical fi tness, both strength and 

endurance, was recognized and addressed in one form 

or another. Historically, the various approaches in training to achieve fi tness were based mostly on guesswork, 

personal opinions, and tradition. Indeed, prior to the 19th 

century, usually physical fi tness was achieved through 

rigorous combat skills training and the sheer hard work 

demanded within military service. As Dr Joseph Knapik 

and Dr “Chip” East explain in their excellent article, the 

fi rst effort to establish a physical training doctrine in 

the US military was an 1851 initiative at the US Military Academy. Their article then tracks the evolution 

of US military physical fi tness and readiness standards 

from that point to the present, as refl ected by the work 

to establish objective tests measuring an individual’s 

physical capability to perform the necessary tasks of 

military service. Their extensive research resulted in a 

historical record of the increasing level of sophistication 

in the methodology employed in evaluating the physical 

demands of military service, and the types of tests which 

are most indicative of an individual’s capabilities. This is 

a detailed, revealing chronology which demonstrates the 

commitment to establishing the safest and most effective 

physical readiness training possible, and the willingness 

to quickly make changes based on research and results.

The study described in the next article is an excellent 

example of research directed at determining tests that 

demonstrate an accurate, direct relationship to specifi c 

military physical tasks. Ms Tunde Szivak, a doctoral fellow in the Department of Kinesiology at the University 

of Connecticut, and her team of coauthors report the 

results of their research examining such relationships 

for women in the military. As the roles of women in the 

military have greatly expanded, so have their challenges 

in situations and job categories which historically require body strength and physical endurance. The study 

concentrated on perhaps the most basic of those requirements, lifting and carrying heavy loads over long distances in combat situations. The proven statistical relationship between the test results and task performance 

allow physiologists and training specialists to design 

training regimen which provide physical requirements 

similar to those involved in the actual tasks, and objectively evaluate the results. This research presented in 

this article is representative of the increasingly refi ned 

science now used to optimize effi ciency, safety, and results in military physical fi tness and readiness training.

MAJ John Lane’s article is another look at the Army’s 

emphasis on maintaining a healthy force rather than 

treating injuries and sickness. He reports on a study performed by the Injury Protection Program at Fort Lee, 

Virginia, to investigate any relationship between a newly 

AN ARMY AND AN AMEDD IN TRANSITION

treatment facilities, and in Warrior Transition Units 

must be incorporated into doctrine and standard operating procedures. The second step is to redesign medical 

units to make them more expeditionary and capable. As 

the brigade combat team becomes smaller, the brigade 

support battalion medical company will get smaller as 

well. We will be fl exible and responsive when supporting combatant commanders. They tell us the capabilities they need and we provide them quickly. If the commander only needs 10 beds, that is all we will send, not 

an entire combat support hospital. We will work with 

Special Operations Forces, and we will support the Army’s regionally aligned forces. We will train designated 

medical units and individuals on the health aspects of 

their region. They will learn the unique diseases, environmental, cultural, and political considerations affecting health care that will make them more effective. We 

will review emerging technologies and push forward 

with the development of those that can increase our capabilities by 2025.

As the Army develops smaller but more capable units, 

it will seek to improve human performance and develop new technologies. The Human Dimension concept 

addresses the moral, physical and cognitive components 

of individual and team performance. The Performance 

Triad and Comprehensive Soldier and Family Fitness 

programs are key components. Improvements in accessions, leader development, assignments, training, education, and resilience will lead to more capable Soldiers 

and units. Army Medicine is moving forward in support 

of this concept with the AMEDD 2020 Campaign Plan 

and transition to a System for Health. The AMEDD is 

reinvigorating leader development and will soon publish a leader development strategy. It is implementing 

the philosophy of mission command using the operating 

company model as a tool. Combat Medics and Soldiers 

will learn more advanced techniques to maintain their 

health and fi tness, and treat casualties on the battlefi eld.

Throughout its transformation, the Army will maintain 

a continuity of vision and requirements. It will fi eld 

Army 2020 while focusing on Force 2025 and rebalancing investments in science and technology. By 2025 the 

Army will have leaner, more expeditionary formations 

with equal or greater capabilities, and strategic leaders 

working to create a fundamentally different Army for 

2030 and beyond.
 April – June 2014 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

accessed Soldier’s posture and his or her experience 

with back and/or hip pain during Basic Combat Training. In addition, the study provided data on the individual’s awareness of his or her personal posture, whether 

proper or faulty, to examine whether those without pain 

were aware of postural faults. The investigators were interested in determining whether bad posture could be a 

reliable indicator (or predictor) of hip and/or back pain. 

If so, perhaps such pain could be prevented with posture 

correction, application of exercises, or physical therapy. 

This is an interesting look at another effort to identify 

potential problems and apply corrective measures to 

prevent problems later, before they can adversely affect 

readiness or combat effectiveness.

Despite the best efforts to build and maintain a healthy 

force, injuries occur and debilitating conditions do develop, and Army Medicine is prepared to address them 

and return the Soldier to full duty status as quickly as 

possible. Of course, that is possible only if the correct 

diagnosis is developed for prompt, appropriate treatment and/or therapy. LTC Mark Thelen and his coauthors have contributed an article about a condition that 

is diffi cult to diagnose because it can manifest as neurologic and musculoskeletal symptoms anywhere in 

the body. For this reason, they have added cervical myelopathy (spinal cord disease) to the list of conditions 

known as “great imposters.” Further, the potential for 

misdiagnosis is especially present within the military 

population, because the condition is most prevalent in 

those aged 55 years or more, well above the age range of 

most active duty military personnel. However, cervical 

myelopathy is also found among those who participate 

in contact sports and military activities involving repetitive trauma and the general wear and tear of those occupations. The article discusses a number of diagnostic 

tests and techniques that can be performed effi ciently 

and inexpensively to assess the possibility of myelopathy producing the observed symptoms. LTC Thelen et 

al have presented important, detailed information which 

should be understood by all those charged with providing healthcare to our nation’s Warriors of all ages.

Dr Ketan Desai of the Veterans Administration has contributed a case report about a diagnostic presentation 

that is not normally associated with the underlying condition. In his article, he describes how a patient successfully being treated for rheumatoid arthritis presented 

with angioedema which did not respond to the normal 

treatments for the swelling in the subcutaneous tissues of 

the tongue, lips, etc. However, eventually a relationship 

between the occurrence of the angioedema and fl ares of 

rheumatoid arthritis in this patient was determined, an 

observation that was not refl ected in a literature search. 

This is an interesting and unique case report which 

should be of interest for both rheumatologists and immunologists who may be involved in treatment of the same 

patient for conditions usually considered unrelated.

Dr Gaurav Gupta and his coauthors work with Canadian 

Forces Health Services and pain management clinics in 

Canada. They have provided an excellent article describing a successful, nonpharmaceutical treatment which relieved osteoarthritic hip joint pain in a patient awaiting 

hip replacement surgery. After extensive research of the 

literature, they employed a different approach to a procedure using thermal radiofrequency probes to denervate 

the nerves in the joint, thus reducing the pain level by 

90% in the initial treatment. Previously, the patient had 

little success and some adverse reactions to conventional 

treatments employing medications, physical therapy, and 

injections. He was facing a number of months of severe 

pain and limited mobility until the hip replacement could 

be performed. The procedure developed and performed 

by Dr Gupta and his team provided crucial pain relief 

during that period. The signifi cant pain reduction afforded by the initial procedure was temporary (6 months), but 

a subsequent second treatment and medication provided 

additional relief until the surgery. This is a meticulously 

written, very professional presentation of the case study 

and supporting scientifi c literature which should be 

must-reading for caregivers treating chronic joint pain.

Pain is also the focus of CPT Stewart Stancil’s article, but 

from the perspective of the emergency department where 

patient load and is often high and staff resources can be 

severely taxed. He proposes a protocol for use of a regional anesthetic technique, the Bier block, fi rst introduced in 

1908 for procedures on the body’s extremities, such as 

treatment of broken bones, wounds, removal of foreign 

bodies, burns, etc. Normally, treatment of such injuries 

involves sedation or general anesthesia, relatively complex procedures which require more material, caregivers, 

and time than application of the Bier block. CPT Stancil 

presents a carefully researched, clearly explained protocol which can be administered by a single caregiver both 

before and after the treatment procedure. In addition to 

emergency room use, the potential advantages of such a 

protocol in a battlefi eld environment are very obvious. 

This article deserves the attention of those charged with 

establishing standards and doctrine for military medical 

care, both in garrison and in deployed conditions.

Of necessity, standards and screening mean that people 

accepted for military service are healthier than the general population in almost every way. Further, the nature of 

the military organization establishes that the vast majority of active duty military personnel are young, therefore 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

not normally developing health problems and conditions 

associated with aging. Military healthcare professionals 

must be vigilant and professionally sound to recognize, 

diagnose, and treat conditions that may have never been 

seen by even the most experienced among them. This 

issue contains 2 articles from Army Dental Corps professionals who had just such encounters. MAJ John Batson and former MAJ Frank Strickland provided a case 

report about an 18 year-old-patient who presented with 

central odontogenic fi broma, an extremely rare type of 

tumor, in his left mandible. The article clearly describes 

the diagnostic and corrective procedures that were followed, as well as the information regarding the rarity 

of this occurrence. This is another example of the high 

level of knowledge and skill that is the norm among the 

Army’s military healthcare professionals.

MAJ Zachary Highberger and his colleagues contributed a case study concerning another extremely unusual and rare oral condition that was presented with 

a 32-year-old Soldier. Focal epithelial hyperplasia, also 

known as Heck’s disease, is a virus-induced disease that 

causes lesions to grow in the mouth; in this case they 

manifested on the patient’s tongue. Their research revealed that Heck’s disease is primarily found in western hemisphere Indian populations, including Eskimos, 

which is the patient’s racial heritage. Their research also 

revealed that the Heck’s disease virus has been found 

in HIV patients, possibly owing to immunosuppression 

of their antibodies. Obviously this should be considered 

whenever Heck’s disease is diagnosed. This article is a 

very interesting, clearly presented description of their 

research, diagnosis, and treatment of a condition that the 

majority of dental professionals will probably never encounter. Again, another example of the caliber of knowledge, skill level, and professionalism of the members of 

the US Army Dental Corps.

COL Scott Shaffer and his colleagues return the ArmyBaylor University Doctoral Program in Physical Therapy 

to the pages of the AMEDD Journal with a report on their 

study investigating the presence of electrodiagnostic abnormalities in the median and ulnar nerves among active duty military dental personnel assigned to Fort Sam 

Houston, Texas. A high prevalence of upper-extremity 

musculoskeletal disorders among dental care providers 

relative to the general population has been recognized 

for a number of years. Although many studies have explored these disorders, COL Shaffer et al found a lack of 

published research involving patient history, physical examination, and nerve conduction studies. Their article is 

the fi rst published dental study to report electrodiagnostic fi ndings of ulnar mononeuropathy at or distal to the 

wrist. This well-designed and executed research project 

is another example of level of professional expertise that 

military medicine directs towards providing only the 

best “care for the caregivers” across all of our specialties.

Although there are exceptions, for the vast majority of 

people, physical fi tness and body fat have a direct inverse 

relationship. Unfortunately, it is obvious to even the casual observer that the modern lifestyle of the population 

of the United States is conducive to increased body fat, 

with a majority proportion of the general population now 

considered to be overweight or obese according to the 

classifi cations of the Centers for Disease Control and Prevention. The US military is not immune to this phenomenon, but the adverse ramifi cations of the trend towards 

increasing body fat among the military population can be 

signifi cant, not only to the individuals, but also to the security of the United States. Over the last several decades, 

the military services have been required to increasingly 

focus on this trend in their forces. Now, as the numbers 

of women in the armed forces have continued to grow, 

both in real numbers and in proportion of the total force, 

attention is being directed to understanding the risk factors associated with excess body fat in women who are 

assigned to deployable combat units. Morgan Anderson 

and her coauthors have contributed the results of their 

study examining those factors—personal characteristics, physical training, physical fi tness, injury history—

among women Soldiers in a light infantry brigade. The 

results of their study are concerning, but this is an initial 

effort to capture data which can be used to identify and 

address the factors peculiar to women, and design/refi ne 

programs to specifi cally address those requirements.

The challenges faced by our Warriors attempting to return to normal life while suffering from traumatic brain 

injury and/or posttraumatic stress disorder are daunting. 

Fortunately, there are many concerned, dedicated professionals throughout military medicine who work tirelessly to assist them, often devising unique and innovative 

techniques based on their research and personal experience in other areas. Genie Joseph and Dr Wynona BiceStephens close this issue of the AMEDD Journal with 

a description of one such program that Ms Joseph conceived while volunteering at the Tripler Army Medical 

Center in Hawaii. The program is called Act Resilient, 

a 4 to 8 week educational program which uses coping 

skills, improvisation, expressive arts, emotional fl exibility, and laughter to teach stress management. Family 

members are encouraged to participate, learning to recognize subtle changes in body language and nonverbal 

cues. All indications are that the program has been very 

successful in lowering stress and raising morale, not only 

for the Soldier, but for those closest to him or her. Act 

Resilient is providing a new start for those in diffi culty.

PERSPECTIVES
 April – June 2014 5

The physical fi tness of individual Soldiers is a critical 

element in military operations. Military historians have 

repeatedly emphasized the importance of a high level 

of physical capability for the occupational tasks that 

Soldiers are required to perform.1-3 Early in US history, 

physical training was disorganized and decentralized 

involving primarily drill and ceremony combined with 

demanding physical labor. The Prussian “Turnverein” 

movement initiated by Ludwig Jahn in 1806 which emphasized mass calisthenic-type exercises and gymnastics, was brought to the United States by immigrants 

in the mid-1800s. During this period of Army history, 

the US Military Academy (USMA) was the center of 

training doctrine. The fi rst attempt to establish a physical training doctrine was initiated by First Lieutenant 

John Kelton in 1851. At the behest of USMA Superintendent Richard Delafi eld, Kelton traveled to Europe just 

prior to the Civil War to learn the European system of 

Turnverein “gymnastics.” Kelton conducted a thorough, 

professional review and recommended comprehensive 

changes in the USMA physical education program. He 

proposed a curriculum that included instruction in gymnastics, calisthenics, swimming, and fencing.

After a long hiatus caused by the US Civil War, the 

USMA hired Herman John Koehler as its fi rst professional physical educator in 1885. Koehler was a graduate 

of the Normal School of the Turnerbund (North American Gymnastic Union) of Milwaukee and served as Master of the Sword at the USMA from 1885 to 1923. Under 

his wide-ranging infl uence, systematic physical training 

was initiated throughout the US Army.4

 Koehler’s physical training manual, A Manual of Calisthenic Exercises,

5

was published in 1892 and became the fi rst Army-wide 

publication providing leaders with guidance to methodically improve the physical fi tness of individual Soldiers.

While the value of physical training for improving Soldier operational performance has long been understood 

and appreciated,4

 the testing of Soldier physical capability in the Army has a shorter history. This article reviews 

the history of Army fi tness evaluations and examines 

the development and rationale for these evaluations. Recently, there has been an effort by the Initial Military 

Training Center of Excellence of the US Army Training and Doctrine Command to revise the current Army 

Physical Fitness Test that has been in place since 1980. 

Knowledge of the past Army fi tness assessments may 

assist in placing the current efforts into a broader historical context.

EARLY TESTS AND INFLUENCES

First Lieutenant John Kelton proposed the fi rst physical assessment and standards for USMA Cadets in 1858. 

Kelton’s test involved climbing a 15-foot wall, vaulting 

a horse 15 hands high (5 feet), leaping a 10-foot ditch, 

running a mile in 8 minutes or 2 miles in 18 minutes, 

walking 4.5 miles in one hour, and walking 3 miles in 

one hour with a 20-pound knapsack, arms, and equipment. Kelton also recommended that each USMA Cadet 

History of United States Army Physical

 Fitness and Physical Readiness Testing

Joseph J. Knapik, ScD

Whitfi eld B. East, PhD

ABSTRACT

This article traces the history of US Army physical fi tness assessments from the fi rst test developed for Cadets 

at the US Military Academy in 1858 through efforts to revise the current Army Physical Fitness Test (APFT). 

The fi rst “Individual Effi ciency Test” (1920) for all Soldiers consisted of a 100-yard run, running broad jump, 

wall climb, hand grenade throw, and obstacle course. The fi rst scientifi c efforts involved testing of 400 Soldiers 

and a factor analysis of 25 individual test items. In 1944, this resulted in a 7-item test (pull-up, burpee, squat 

jump, push-up, man-carry, sit-up and 300-yard run) with a 100-point scoring system. In 1943, women were 

encouraged to take a “self-assessment” consisting of push-ups, bent knee sit-ups, wing lifts, squat thrusts, running, and a stork stand. In 1946, age-adjusted standards were introduced and in 1965 semiannual fi tness assessments were mandated. The number of tests proliferated in the 1969-1973 period with 7 separate assessments. 

The current APFT consisting of push-ups, sit-ups, and a 2-mile run was introduced in 1980 and alternative tests 

for those with physical limitations in 1982. Current efforts to revise the assessment involve systematic literature reviews and validating the relationship between test items and common Soldiering tasks.
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

should be able to swim a mile, dive and remain 45 

seconds swimming underwater, dive head fi rst from a 

height of 8 feet, and leap into the water from a height of 

20 feet. Kelton’s recommendations were adopted along 

with other physical training proposals. However, the 

program and testing was discontinued in 1861 with the 

onset of the Civil War.6,7

In the late 1800s and early 1900s, the concept of objective measurements of physical capacity was rapidly 

developing in American colleges, universities, and elsewhere. Initially, pioneers like Dudley Sargent, John Kellogg, and EG Martin promulgated objective methods of 

measuring strength using dynamometers.8-11 Sargent later thought that strength tests were somewhat limited because they did not “...try the heart and lungs suffi ciently 

to afford a good test of endurance....” He developed a 

test involving 6 items that was required to be performed 

continuously and completed in 30 minutes.12,13 Others 

agreed that strength tests were limited14 and various 

tests to evaluate “athletic achievement” and “physical 

effi ciency” emerged. One of the earliest of these was 

that of Luther Gulick, developed for the Athletic League 

of the YMCA. It consisted of a 100-yard dash, high 

jump, triple jump, shot put, and rope climb.15 Later, college athletic tests were proposed at Columbia University (New York),14,16 the University of California,17 and 

The Ohio State University.18 Physical effi ciency tests 

were also proposed for elementary school students.19,20

In 1913 and 1916, the American Playground Association 

developed the Athletic Badge Test for boys and girls, respectively. The exact test items and standards to achieve 

the badge depended on age.21,22 The application of statistical methods for the development of normative scoring 

tables for athletic achievement tests was discussed by 

Charles McCloy in 1921.23

The fi rst systematic program of unit physical training 

for the entire US Army was published in 1906 in General Order Number 44.24 This order required infantry 

troops to conduct weekly marches of 12 miles and horsemounted artillery and cavalry troops 18 miles. A 3-day, 

90-mile riding test (on horseback) for artillery/cavalry 

and 45-mile marching test for infantry was initiated to assess the 

benefi ts of the new physical training program. General Franklin 

Bell was the driving force behind 

implementation of the order. He 

was widely noted for addressing 

fi tness issues and had studied under 

Dudley Sargent in 1887. There was 

much opposition to Bell’s strong 

desire to physically transform the 

Army, likely due to the poor physical condition of many 

senior Army leaders.4

 However, Bell’s efforts were reinforced by Theodore Roosevelt, US President from 1901-

1909. Partly as a result of his combat service with the 

Rough Riders (2nd Brigade, 1st US Volunteer Cavalry) 

in the 1898 Spanish-American War. Roosevelt was a 

strong proponent of rigorous physical training. He was 

also the honorary president of the Playground Association of American that had developed the Athletic Badge 

Tests.25 Like Bell, Roosevelt was concerned with the 

ability of Army offi cers to ride long distances on horses 

and believed that such “physical fi tness” could only be 

demonstrated by “actual physical tests.” As President, 

he directed that all offi cers considered for promotion 

be tested for skill and endurance in riding.26 Roosevelt 

later prescribed that all fi eld offi cers would perform 

daily horseback marches of not less than 30 miles/day 

over a period of 3 days (90 miles total) in the fall of the 

year. He also required that “appropriate action should 

be taken in the case of all offi cers found not qualifi ed 

physically for active service.”27

INFLUENCES OF WORLD WAR I

It was not surprising that the advances in the testing 

and measurement of physical capacities in universities 

were soon applied to the military where a high level of 

physical ability was an occupational necessity. From 

1917 to 1919, Dr Joseph Raycroft served as chairman of 

the Athletic Division of the Commission on Training 

Camp Activities. The Commission directed sport and 

recreational activities at military camps during World 

War I.4,25,28 Prior to Raycroft’s selection for the chairmanship, he had been the Chairman/Professor of Hygiene and Physical Education at Princeton University 

since 1911. In 1920, through a consortial effort of active duty offi cers and civilian fi tness experts, Raycroft 

published Mass Physical Training for Use in the Army 

and Reserve Offi cers’ Training Corps with approval of 

the War Department, War Plans Division of the General 

Staff.29 In this book, Raycroft proposed an Individual 

Effi ciency Test consisting of the 6 items and passing 

standards shown in Table 1. Included in the test battery 

was the fi rst obstacle course test, a 100-yard linear route 

consisting of 6 obstacles: (1) vaulting a 3-foot hurdle; (2) negotiating 

a 10-foot wire entanglement (arms 

folded); (3) climbing a 5-foot ramp; 

(4) jumping from the top of the 

5-foot ramp over a 10-foot trench; 

(5) negotiating a 1-foot wide, 20-

foot long plank; and (6) climbing 

an 8-foot, smooth-faced wall. Soldiers sprinted 10 to 15 yards between each obstacle and at the start 

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Table 1. Test Items and Passing Standards 

for the Individual Effi ciency Test (1920).

Event Passing

Standard

Run, 100 yd 14 seconds

Running broad jump 12 ft

Wall climb (8 ft high, unassisted) Climb over

Hand grenade throw

(distance 30 yd; 10 ft square)

Hit inside 

Square

Obstacle course (6 obstacles) 30 seconds
 April – June 2014 7

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

and fi nish of the course. Based on testing at Camp Gordon, Georgia, suggestions and considerations for other 

test items were made by Dr Thomas Browne from the 

University of North Carolina.30

Although the Army published a basic fi eld manual in 

1927 and again in 1936 that incorporated various aspects of physical training, it was not until March 1941 

that the Army published the fi rst fi eld manual dedicated 

exclusively to physical training, Field Manual (FM) 21-

20.

31 The Standards and Testing section of this manual 

stated that “...the physical training program should be 

based upon the condition and aptitude of the men to be 

trained. The best method of determining this condition 

and aptitude of the group is by comparison with known 

standards.” Table 2 shows the test items with the qualitative, 4-level, graded, performance scale which was included in the manual. In addition to the 4-item test, there 

were 14 other potential test items described in Table 3. 

Instructors were encouraged to conduct tests at regular 

intervals to measure fi tness improvements among Soldiers and to determine the effectiveness of the training 

program. It was also stated that Soldiers would be able 

to compare their ability with that of other men.

Field Manual 21-2031 also described a 100-yard obstacle course 

modeled after Raycroft’s course. 

The rationale provided for the obstacle course was that running, 

jumping, vaulting, climbing, and 

crawling were basic activities that 

all Soldiers would be required to 

perform and the obstacle course 

could enhance these skills, in addition to developing endurance, agility, and self-confi dence. A fi gure 

from FM 21-2031 describing the 

course is shown as Figure 1. The 

Soldier was required to sprint between the obstacles, spaced at the 

distances shown. Field Manual 21-

2031 described a progressive training program for the course. No criterion standard was described, but 

it did state that “...when the Soldier 

has shown that he can overcome each obstacle in the 

course, he should be required to run the course against 

time. However, the time allowed should be determined 

by the condition and ability of the Soldier. As his condition and ability improve, the time should be reduced.”

THE WORLD WAR II PERIOD

In the 1930s, the selection of test events to measure 

physical ability was aided by the development of a statistical technique called factor analysis. As it applied to 

the development of a physical fi tness test battery, factor analysis involved evaluating the performance of individuals on a broad array of physical tasks for which 

quantitative measures could be obtained. The tests were 

mathematically assembled into groupings (called factors) that were assumed to have a hypothetical common 

physical performance attribute/requirement. A “factor 

loading” described the degree of relationship between 

a single test item and a hypothetical factor; some tests 

would have high factor loadings and others less so.32,33

Generally, the test event with the highest factor loading 

would provide an optimal simulation of the factor, and 

therefore be selected for the test battery. In some cases, 

test selection depended upon other requirements such 

as cost, simplicity of the test, availability of equipment, 

and rater training.

The fi rst scientifi c efforts directed at military physical readiness assessment was spearheaded by Colonel 

Theodore Bank working with Dr Charles McCloy and 

Dr Arthur Esslinger who were physical educators at the 

University of Iowa and Stanford University, respectively.4

 They conducted studies in which 25 tests were administered to 400 men. The 10 tests 

that “best discriminated between 

fi t and unfi t individuals” were 

pull-ups, the 20-second burpee, 3 

broad jumps, the shotput, pushups, 75-yard pick-a-back (man carry), dodging run, 6-second run, situps, and 300-yard run.34 Charles 

McCloy published a portion of 

these results and, through a factor 

analysis of 12 items, demonstrated 

the existence of 4 physical fi tness 

factors, which he titled (1) circulorespiratory endurance, (2) velocity 

or muscular contraction speed, (3) 

muscular endurance, and (4) mesomorphic build.35

Before Bank, McCloy, and Esslinger could complete their investigations, the Army conducted a 

Table 2. Tests and Standards (1941).

Event Minimum

Standard

Average Above

Average

Superior

Dash, 100 yd 14 sec 13 sec 12.6 sec 12.2 sec

Running high jump 3 ft, 9 in 4 ft 4 ft, 3 in 4 ft, 6 in

Running broad jump 12 ft 13 ft, 6 in 15 ft 16 ft, 6 in

Push-up from ground 20 reps 25 reps 30 reps 35 reps

Note: reps indicates repetitions; sec indicates seconds.

Table 3. Additional Test Items and Standards 

for “Average Men” (1941).

Event Minimum

Standards for 

Average Men

Baseball throw 125 ft

Basketball throw 60 ft

Bar or fence vault 4 ft

Run, 1⁄4 mile 87 sec

Run, 1⁄2 mile 3 min, 15 sec

Walk, 2 miles 23 min, 30 sec

Vertical jump 13 in

Pull-up 6 reps

Rope climb, 20 ft 20 sec

Standing hop, step, and jump 18 ft

Running hop, step, and jump 22 ft

Standing broad jump 6 ft

Standing backward jump 2 ft, 8 in

Running long dive 5 ft, 6 in

Note: reps indicates repetitions;

sec indicates seconds.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

major reorganization in preparation for war in which the 

Army Ground Forces was created. The Army Ground 

Forces was tasked with proponency for physical readiness training and assessment, and in 1942 published the 

Army Ground Forces Test.36,37 That test consisted of the 

6 events shown in Table 4, and was administered in the 

order shown. The 70-yard zigzag run was a complex set 

of movements involving creeping, crawling, jumping, 

and running in 7 legs of 10-yards each. On the 4-mile 

march, “straggling” was defi ned as 1 minute late at any 

mile marker. The score the Soldier achieved on each 

event was multiplied by a weighting factor (Table 4), 

added together, and divided by the sum of the weighting 

factors (10). The resulting score was given a qualitative 

rating such that less than 70 was unsatisfactory, 70-77 

was satisfactory, 78-87 was very satisfactory, 88-94 was 

excellent, and greater than 94 was superior.36,37

The Women’s Auxiliary Corps, later renamed the Women’s Army Corps (WAC), 

was established in 1942,38 and in 1943, FM 

35-20 was published.39 It provided guidance 

for physical training for the WAC and included a chapter entitled “Self Testing Activities.” The self-test items included pushups, bent knee sit-ups, wing lifts, squat 

thrusts, running, and the stork stand. Pushups were executed with knees on the ground. 

Wing lifts involved prone trunk extensions 

with the fi ngers interlocked behind the head. 

Running could be in place (stationary) or for 

an unspecifi ed distance, with the goal of progressively 

increasing time or distance. The stork stand involved 

balancing on one leg with the unsupported leg on the 

supported knee, eyes closed, and arms crossed in front 

of the body. While there were no published standards, 

women were encouraged to use the test to gauge their 

improvement over time and instructors were encouraged to use the tests to evaluate the “physical quality” 

of the group.

War Department Pamphlet 21-940 was published in May 

1944. It contained an entire chapter devoted to “Physical 

Effi ciency Testing” and provided the criteria used for 

selection of the test items. These criteria included minimal use of equipment, quick and easy administration, 

safety, and the facts that the test items measured individual fi tness components, were not dependent on skill 

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Figure 1. The obstacle course as depicted in the 1941 Field Manual 21-20.

31

Table 4. Events and Scoring of the Army Ground Forces Test (1942).

Event Scoring Maximum

Score

(100%)

Weighting

Factor

Push-up 3% added for each repetition 34 1

Run, 150 yd out,

150 yd back 4% deducted for each sec >45 sec 45 sec 2

Burpee, 20 sec 9% added for each repetition 12 1

Pick-a-back, 75 yd 4% deducted for each sec >20 sec 20 sec 2

Zigzag run, 70 yd 4% deducted for each sec >30 sec 30 sec 1

March, 4 miles 8% deducted for straggling 1st mile,

6% deducted for straggling 2nd mile,

4% deducted for straggling 3rd mile,

2% deducted for straggling 4th mile.

50 min 3

Note: sec indicates seconds.
 April – June 2014 9

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

acquisition, could separate fi t and unfi t men, and could 

be scored with a point system. The pamphlet states 

that “this test battery was developed after a tremendous 

amount of testing experience in the Army. It represents 

the 7 best tests out of an original group of 25.” Thus, it 

was likely that the events were selected directly from the 

work of Bank, McCloy, and Esslinger. No specifi c test 

order was prescribed, but it was noted that all men should 

take the test in the same order and recommended retesting no more than every 8 to 12 weeks. Table 5 shows the 

7 events in the “Physical Effi ciency Test Battery” and a 

sample of the point system. The points were established 

on a normative scale using data from “an average infantry division.” Fifty points represented the mean, a 

score of 100 represented 3 standard deviations above 

the mean, and zero represented 3 standard deviations below the mean. 

The points achieved on 

each event were added 

together and a qualitative 

scale provided such that 

“excellent” was more 

than 600, “good” was 

445-600, “average” was 

247-444, “poor” was 114 

to 246, and “very poor” 

was less than 114. The 

point scale was to provide commanders with a 

quantitative assessment 

of the physical readiness 

of an individual Soldier or unit.

THE POST WORLD WAR II AND KOREAN WAR PERIOD

In January 1946, FM 21-20 was revised41 and superseded War Department Pamphlet 21-9 (1944)40 and the earlier FM 21-20 (1941).31 The test items and a sample of the 

scoring system of the new Physical Effi ciency Test Battery are shown in Table 6. Field Manual 21-20 (1946)41

provided both an indoor test and an outdoor test. The 

burpee and pick-a-back events of the 1941 test were no 

longer included as part of the outdoor test. The scoring 

system differed from that of 194440 for the remaining 

outdoor items. A higher performance level was necessary to achieve maximal or average scores on squat 

jumps and push-ups; the 300-yard run standards were 

lower. The sit-up was now limited to 2 minutes, whereas 

in 1941 there was no time limit. For the fi rst time there 

was an adjustment for age such that scores dropped one 

point for each year a Soldier was 30 or more years of age. 

Thus, a score of 50 achieved by a 40-year-old Soldier 

was equivalent to a score of 60 achieved by a Soldier 

aged 30 or less years. 

The 1950 FM 21-20 42 retained the same test items and 

the scoring system of the 1946 FM 21-20.

41 In 1957, FM 

21-20 43 was signifi cantly revised and a complimentary 

Technical Manual 21-200 44 was introduced. There were 

several changes in the scoring system Physical Effi ciency Test Battery as shown in Table 6. The shuttle run 

was eliminated from the outdoor test. The 1957 FM 21-

20 43 stated that “...10,000 men...were tested to establish 

the scoring tables.” Both the outdoor and indoor tests 

were now called “Physical Fitness Tests” and the test 

items were to be administered in the order shown in 

Table 6. In an unprecedented move, the Army also introduced a functional “combat readiness” test in 1957. The 

“Physical Achievement Test” was for administration to 

“combat type units” only and included the events and 

scoring shown in Table 

7. For the fi rst time, in 

keeping with the birth of 

the aerobics movement 

in the United States,4

 a 

longer-distance run (1-

mile) was included as a 

test item and the pick-aback test returned in the 

form of a 150-yard man 

carry. Technical Manual 

21-200 44 specifi ed that 

the fi rst 4 items should 

be administered on one 

day and the 1-mile run 

administered within 4 

days of the fi rst 4 items.

THE COLD WAR PERIOD AND BEYOND

In July 1961, the Army published Change 2 to Technical Manual 21-200,

45 within which the lessons learned 

in Korea were refl ected in training doctrine. Change 2 

marked a return to “combat readiness” as the primary 

focus of Army fi tness testing (as was the case in 1920 

and again in 1946). As described in Change 2 to the 

manual,45 the major purpose of Army physical fi tness 

testing was to assess those components of fi tness and 

functional skills that were deemed necessary in combat. Essential military skills were defi ned as running, 

jumping, dodging, climbing and traversing, vaulting, 

carrying, balancing, falling, and swimming. Both the 

Physical Fitness Test and the Physical Achievement Test 

(1957) were discarded in favor of the Physical Combat Profi ciency Test. The test events and scoring are 

shown in Table 8. Each event had a maximal score of 

100 points with a maximum total score of 500 points. 

A minimum of 300 points was considered passing, and 

a Soldier had to achieve a minimum of 60 points/event 

to be considered “combat qualifi ed.” The grenade throw 

Table 5. Events and Scoring for the Physical Effi ciency Test Battery 

(1944).

Event Maximum

Score

(100 points)

Average

Score

(50 points)

Parachute

Trooper

Average Score

Pull-up (reps) 18 8 11

Burpee, 20 sec (reps) 13.75 10.5 12

Squat jump (reps) 72 32 40

Push-up (reps) 44 24a 33

Pick-a-back, 100 yd (sec) 18 26 23

Sit-up (reps) 82 32 70

Shuttle run, 300 yd (sec)b 35 45c 43

Note: reps indicates repetitions; sec indicates seconds.

a

Fifty points for the push-up event is 23 reps in another table in War Department Pamphlet 21-9.

40

bFive repeats of 60 yd each.

c

Fifty points for the 300-yd run is 46 seconds in another table in War Department Pamphlet 21-9.

40
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

involved throwing 5 grenades at a series of 4 concentric 

circles (Figure 2), the center of which was 90 feet away 

from the throw line. Figure 3 depicts the layout, setup, 

and running directions for the run, dodge, and jump, 

and Figure 4 shows Soldiers performing the horizontal 

ladder event. The Physical Combat Profi ciency Test was 

mandatory for Basic Combat Training (BCT) and generally used to assess combat readiness of most Soldiers.

Department of the Army Pamphlet (DA Pam) 21-146 was 

published in 1963. In an attempt to reduce the training 

requirements for some Soldiers, the pamphlet introduced 

a “Minimum Physical Fitness Test-Male” for male Soldiers who were “... instructors at service schools, staff 

offi cers, technicians, specialists, and other personnel assigned to T/D type organizations who perform duty only 

in an administrative or sedentary capacity.” The test 

items and “minimal acceptable standards” are shown in 

Table 9. Before starting a physical training program, individuals 40 years of age or older were directed to obtain a 

physical exam including a “cardiograph check.” Change 

2 to DA Pam 21-147 emphasized that the test was mandatory for Soldiers less than 

40 years of age. Department 

of the Army Pamphlet 21-2,

48

published in 1963, contained 

an “Army Minimum Physical 

Fitness Test-Female.” The test 

items and “minimal acceptable standards” are shown 

in Table 9. Change 1 to DA 

Pam 21-249 emphasized that 

the test was also mandatory 

for female military personnel less than 40 years of age. 

The second edition of DA Pam 21-250 noted that the test 

could be taken in shorts and provided only standards for 

women aged 17 to 29 years and 30 to 39 years.

In January 1965, Army Regulation 600-951 specifi ed for 

the fi rst time that all male and female personnel less than 

40 years of age would be tested periodically for physical 

fi tness. Twice yearly testing was mandated for all active Army units and minimum passing standards were 

specifi ed. Testing was also required for BCT, Advanced 

Individual Training (AIT), leadership-type schools that 

were 8 weeks or more in length, and specialist courses 

which required 20 or more weeks. Personnel who failed 

to pass the applicable tests were allowed retesting and 

personnel action was to be considered for Soldiers who 

could not meet the test standards.

In January 1969, the fi fth revision of FM 21-20 was published,52 and it contained 4 assessments that commanders could use. These were the Physical Combat Profi -

ciency Test, the Minimum Fitness Test-Male, Airborne 

Physical Fitness Test, and the 

Inclement Weather Test. The 

 Physical Combat Profi ciency 

Test was considered the standard test and the test items. 

The slightly revised scoring 

(compared to 1961) is shown 

in Table 8. Retained was 

the 1961 minimum “combat 

ready” criteria of 300 total 

points with at least 60 points 

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Table 6. Events and Scoring for the Physical Effi ciency Test Battery (1946, 1950) and Physical Fitness Test (1957).

Test Location Event 1946/1950 Scores 1957 Scores

Maximum

Score

(100 points)

Average

Score

(≈50 pointsa

)

Maximum 

Score

(100 points)

Average 

Score

(≈50 pointsa

)

Outdoor Test

Pull-up (reps) 20 8 18 6

Squat jump (reps) 75 34 95 52

Push-up (reps) 54 28 60 27

Sit-up, 2 min (reps) 79 46 85 47

Shuttle run,

300 yd (sec)b 44.0 51.5 44.0 58.5

Indoor Test (same events 

as above but substituted shuttle run or squat 

thrust for 300-yd run)

Shuttle run,

250 yd (reps)c 41 47 NAd NAd

Squat thrust,

1 min (reps) 41 29 41 29

Note: reps indicates repetitions; sec indicates seconds.

a

Some events do not have exact values at 50 points but rather at 51 or 52 points. The values shown are as close to 

50 points as possible.

b

Shuttle run was 5 laps of 60 yd each.

c

Shuttle run was 10 laps of 25 yd each.

d

Shuttle run was not included in the 1957 Field Manual 21-2043 or Technical Manual 21-200.

44

Figure 2. Grenade throw event target layout and scoring table.
 April – June 2014 11

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

on each test event. “Combat support” personnel had to 

achieve a minimum of 45 points on each event and a 

300-point total score. In BCT, AIT, and Combat Support 

Training (CST), a 150-yard man carry was substituted 

for the grenade throw, with 100 points awarded for a 

34-second performance and 60 points for 52 seconds. 

The Minimum Fitness Test-Male was to be used for “... 

active duty personnel who are assigned to duties that 

preclude their participation in a physical fi tness program 

that prepare them for the Physical Combat Profi ciency 

Test.” The test could also be used when facilities were 

lacking for conducting the Physical Combat Profi ciency Test. The Minimum Fitness Test-Male had 6 events, 

and each event had an alternative. The Soldier could 

choose which primary or alternative testing event he 

desired. The test had the age-adjusted pass or fail standards shown in Table 10. The Airborne Trainee Physical 

Fitness Test was also a pass or fail evaluation in which 

passing required at least 6 chin-ups, 80 knee benders 

(2 minutes), 22 push-ups, 20 sit-ups, and completing a 

1-mile run in 8.5 minutes. The airborne test was actually fi rst published in Change 3 to Technical Manual 

21-200 in 1962.53 The Inclement Weather Test was not 

described in the 1969 FM 21-20.

52

The 1973 FM 21-2054 produced 

further test proliferation and identifi ed 7 separate assessments that 

were part of the “Army Physical 

Fitness Evaluation.” The 2 tests 

designed for operational units 

were the Advanced Physical Fitness Test (for combat and combat 

support units) and the Staff and 

Specialist Fitness Test (for combat 

support units; Table of Distribution 

and Allowances units; and 

staff, faculty, and students 

assigned to Army schools). 

There was also an Inclement Weather/Limited 

Facility Fitness Test administered in inclement 

weather or when units did 

not have the facilities for 

the other 2 tests. Table 11 

shows the events and scoring for the 3 tests. To pass 

the Advanced Physical Fitness Test, 300 points were 

required with at least 60 

points in each event; the 

Staff and Specialist Fitness Test required only 

300 total points (no minimum on each event). The point 

scale was age-adjusted and Soldiers aged 40 years or 

more were not required to take either test. 

Four special purpose tests were also identifi ed in the 

1973 FM 21-20.

54 Events and scoring for 3 of these tests 

are shown in Table 12. A total score of 300 points with 

60 points or more on each event was required to pass, 

and there was no age adjustment. The Basic Physical 

Fitness Test (Table 12)was used to measure the physical 

fi tness of new Soldiers (BCT and Modifi ed BCT). To 

graduate from AIT or CST, new Soldiers were required 

to pass the Advanced Physical Fitness Test (Table 11) 

with 300 or more total points and 60 or more points on 

each event for the 17-25 year age group. The Minimum 

Physical Fitness Test (Table 12) was administered to 

personnel aged 40 years or more who volunteered to be 

tested. Two special tests were administered to individuals attempting to qualify for Ranger or Special Forces 

training (Table 12) and for Airborne training. The Airborne Trainee Physical Fitness Qualifi cation Test had 

only passing standards as follows: 6 chin-ups, 20 bentknee sit-ups, 22 push-ups, 80 half knee bends (2 minute 

period), and 8.5 minutes or less on a 1-mile run.

Change 1 to the 1973 FM 21-2054

was published in January 1974.55

The test items on the 7 tests remained the same, but the point 

system on several tests were revised as shown in Table 13. On 

the Advanced Physical Fitness 

Test, higher performance levels 

were required for both maximal 

and passing scores on the inverted crawl, sit-up, and 2-mile run. 

Table 7. Events and Scoring for the Physical Achievement Test (1957)

Event Maximum

Score

(100 points)

Average

Score

(50 points)

Dash, 75-Yd (sec) 8.0 10.0

Triple jump (ft) 26.5 20.0

Rope climb, 5-Sec (ft) 20.0 12.5

Man carry, 150 Yd (sec) 30.0 47.0

Run, 1 mile (min) 5.1 7.5

Note: sec indicates seconds.

Figure 3. Setup and running route of the run, dodge, and jump event.
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

On the run, dodge, and jump, maximum performance 

standards also became faster. Only minor changes were 

made on the Staff and Specialist Physical Fitness Test. 

Performance required for the maximum score and for 

passing the Basic Physical Fitness Test was more diffi cult on 4 of the 5 events. Passing standards for those in 

AIT or CST were also more diffi cult on 3 of the 5 events, 

with graduation still requiring new Soldiers to pass the 

Advanced Physical Fitness Test with 60 or more points 

on each event at the 17-25 year age group. 

Editions of FM 35-20 were published in 1956 and 1965, 

both of which were entitled Physical Training, Women’s 

Army Corps. The 1965 edition mentions fi tness evaluations but provides no test and does not refer to the test 

in the 1963 or 1965 DA Pam 21-2.

48,50 The fourth edition 

of FM 35-2056 was published in 1975 with the new title 

Physical Fitness Training for Women, and contained 

5 physical fi tness tests. The events and standards for 

3 of these tests are shown in Table 14. The Advanced 

Physical Fitness Test for Women was for those 

in combat and combat support units as well as 

trainees in AIT and Advanced Reserve Offi cer 

Training Corps. The minimum passing score 

was 300 or more points with 60 or more points 

on each event. The push-up and sit-up events 

were not timed and women were instructed to 

complete as many as possible. The Staff and 

Specialist Physical Fitness Test for Women was 

administered to women assigned to combat 

service support units and military school faculty, staff, and students. The passing score was 

3 00 or more points with no passing standard 

for individual events. The Basic Physical Fitness Test was administered in BCT. Passing 

the test required 300 or more total points with 

50 or more points on each event. The Airborne 

Trainee Physical Fitness Qualifi cation Test for 

women was for those who were training to become parachute riggers. Each test event had a minimum passing 

standard (no point system) requiring 7 incline chin-ups, 

50 knee benders (2 minutes), 22 modifi ed push-ups, 20 

bent-knee sit-ups, and completing a 1-mile run in 10.0 

minutes or less. The incline chin-up used a foot rest 

with a bar adjusted to the woman’s height. An Inclement 

Weather Physical Fitness Test for BCT and AIT involved 

the same test items as the Basic Physical Fitness Test for 

Women except that a stationary run was substituted for 

the half-mile run with 100 points for 596 steps and 50 

points for 346 steps.

The WAC was disestablished by the US Congress 

in 1978 and women were integrated into the regular 

Army.57 General Donn Starry directed an Army Physical Readiness Study Group to revise and combine the 

physical training and testing doctrine in FM 21-20 (for 

men) and FM 35-20 (for women). The guidance General Starry provided the study group was to develop an 

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Table 8. Events and Scoring for the Physical Combat Profi ciency Test (1961 and 1969).

Publication Event Maximum

Score

(100 points)

Combat

Ready Score

(60 points)

Combat Support 

Passing Score

(45 points)

Technical Manual 21-200,

Change 2 (1961)45

Low crawl, 40 yds (sec) 25 36

Not

Considered

Horizontal ladder (rungs) 76 36

Run, dodge, and jump (sec) 22.0 26.5

Grenade throw (points) 36 15

Run, 1 mile (min) 6.0 8.5

Field Manual 21-20 (1969)52

Low crawl, 40 yds (sec) 23 36 45

Horizontal ladder (rungs) 76 36 21

Run, dodge, and jump (sec) 21.0 25.0 27.0

Grenade throw (points) 36 15 8

Run, 1 mile (min) 6.0 8.6 9.6

Note: sec indicates seconds.

Figure 4. Soldiers performing the horizontal ladder event, circa 1969.
 April – June 2014 13

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

assessment that was gender integrated, easy to administer at any location, and required no or minimal equipment.4

 According to Dr James Vogel (oral communication), the scientifi c advisors in the study group settled on 

the push-up to measure upper body muscular endurance 

and the 2-mile run to measure cardiorespiratory endurance. There was discussion that the pull-up might be a 

more appropriate test of upper body muscular strength/

endurance but at the time studies had shown that few 

women could perform a single pull-up.58,59 Since trunk 

muscular endurance appeared to be an independent fi tness factor,33,60-62 a sit-up test was also recommended.

The work of the Army Physical Readiness Study Group 

was codifi ed into Army doctrine in the 1980 edition 

of FM 21-20.

63 The events and age-adjusted scoring for 

the new Army Physical Readiness Test is shown in Tables 15 and 16. Push-up and sit-up standards for those 

aged 40 or more years were not provided until 1982 in 

Change 1 to FM 21-20.

64 Testing was mandated twice a 

year for all Soldiers aged 60 or less years. Soldiers aged 

40 or more years were required to go through medical 

screening for cardiovascular disease prior to testing. 

Only passing standards were provided for those aged 40 

or more years. Alternative tests were provided for those 

aged 40 or more years with limiting medical conditions 

(profi les). These alternative tests included an 800-yard 

swim, 6-mile cycle test, and a 2.5-mile walking test, all 

of which had age-adjusted standards. Soldiers in Initial 

Entry Training (IET) were required to achieve 50 or 

more points on each event by the sixth week of IET and 

60 or more points on each event by graduation.

In publications after 1980, the test scoring standards 

were revised based on the testing of large groups of 

Soldiers performed by the US Army Physical Fitness 

Table 9. Events and “Minimal Acceptable Standards” for the Army Minimum Physical Fitness Tests (1963).

Men

Test Event

Numbera Event Age Group for Men (years)

17-29 30-39 40-44 45-49 50-59 ≥60

Army Minimum 

Physical Fitness 

Test–Male

1 Bend and reach (reps)b 15 12 10 8 6 5

Squat stretch (reps)b 15 12 10 8 6 5

2 Rower (reps)b 15 12 10 8 6 5

Sit-ups (rep)b 15 12 10 8 6 5

3 Trunk twister (reps)b 12 10 8 6 4 3

Body twist (rep)b 10 9 8 6 4 2

4 8-count push-up (reps)c 5 4 4 3 21

Push-up (reps)b 10 8 8 6 4 2

5

1⁄2-mile run (min)d 4.0 4.0 – – – –

1-mile walk (min)d – – 15.0 15.0 15.0 15.0

Stationary run,

2 min (reps)d,e 175 150 125 115 100 90

Women

Test Event

Numbera Event Age Group for Women (years)

17-29 30-39 40-44 45-50 >50

Army Minimum 

Physical Fitness 

Test–Female

1 Jumping jack (reps)f 16 12 10 8 6

Bouncing (reps)b 16 12 10 8 6

2 Double arm circle (reps)g 18 12 12 6 6

Double arm swing (reps)b 18 12 12 6 6

3 Twister (reps)b 15 12 10 8 6

Cross and fly (reps)b 15 12 10 8 6

4 Sit-up (reps)f 15 12 10 8 6

Circle-O (reps)h 15 12 10 8 6

5 Bent-over airplane (reps)f 15 12 10 8 6

Trunk twist & arm fling (reps)f 15 12 10 8 6

Note: reps indicates repetitions.

a The Soldier selected one test from among the 2 listed under each Event Number.

b 4-count is one rep.

c8-count is one rep.

dThe 1⁄2-mile run was for Soldiers aged 17-39 years; the 1-mile walk or stationary run was for all age groups. 

eCount each time left foot hits ground.

f 2-count is one rep.

g 6-count is one rep.

h 3-count is one rep.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

School. Although there were changes to the standards, 

the 3 test items (push-ups, sit-ups, and 2-mile run) have 

remained until this writing. The 1985 edition of FM 21-

20 65 contained the identical scoring system as that of the 

1980 edition,63 but the test was called the Army Physical Fitness Test. Male Soldiers were directed to take the 

test in “...attire that is appropriate for physical training 

(shorts, T-shirt, socks, running shoes)...” Prior to this, 

male Soldiers took the tests in their uniforms (without 

blouse) and boots. Alternative test events with pass/fail 

standards were provided for Soldiers of all ages who 

had temporary or permanent profi les. Alternative test events included an 800-yard 

swim, 6.2-mile cycle (stationary and track), 

and a 3-mile walk. Change 1 to the 1985 FM 

21-20 was published in June 1986.66 This 

change revised the age groups and provided a 100 point system for those 40 or more 

years of age (Tables 15 and 16), instead of 

just the earlier (1982) pass or fail standard 

(Table 15). Examination of Tables 15 and 16 

shows that the performance levels required 

to achieve points in 1986 were considerably 

higher as compared to 1982.66

The ninth and fi nal full-form edition of FM 

21-2067 was published in 1992. It retained 

the 1986 standards66 except for a revised 

2-mile run point system for women aged 27-

31 years. For these Soldiers, 100 points were 

awarded for 17 minutes or less, reducing to 60 points at 

21 minutes. Change 1 to the 1992 FM 21-20 was published in 199868 containing the fi nal revision of the point 

system to date. The new point system expanded the age 

gradations for those aged 52 years or more. The sit-up 

point system was identical for men and women. Points 

were established such that 100 points represented the 

90th percentile and the 60 points represented the 8th 

percentile, based on testing of large groups of Soldiers 

(Louis Tomasi, oral communication). The 800-yard 

swim and 6.2-mile alternative tests and their standards 

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Table 11. Events and Scoring for the Advanced Physical Fitness Test, Staff and Specialist Physical Fitness Test, and Inclement 

Weather/Limited Facility Fitness Test (1973).

Test Event 100 points (Maximum Score) 60 Points (Passing Score)

Age Group (years) Age Group (years)

17-25 26-30 31-35 36-39 17-25 26-30 31-35 36-39

Advanced Physical 

Fitness Test

Inverted crawl, 40 yd (sec) a 16.0 17.0 18.0 19.0 29.0 30.0 31.0 32.0

Run, dodge & jump (sec) 20.5 21.0 21.5 22.0 24.5 25.0 25.5 26.0

Horizontal ladder, 1 min (rungs) 84 80 75 69 39 32 27 21

Sit-up, bent knee, 1 min (reps) 50 49 48 47 30 29 28 27

Run, 2 miles (min) 14.7 14.8 14.9 15.0 20.6 20.7 20.9 21.1

Staff and Specialist 

Physical Fitness 

Test

Push-up, 1 min (reps) 51 49 47 44 26 24 22 19

Run, dodge & jump (sec) 20.5 21.0 21.5 22.5 24.5 25.0 25.5 26.5

Horizontal ladder (rungs) 80 75 74 73 33 28 27 25

Sit-up, bent knee, 1 min (reps) 48 47 45 43 28 27 25 23

Run, 1 mile (min) 6.0 6.1 6.2 6.3 8.3 8.5 8.6 8.7

Inclement Weather/

Limited Facility

Fitness Test

Push-up, 1 min (reps) 50 48 46 44 25 23 21 19

Bend and reach, 2 min (reps) 114 109 104 99 83 78 73 68

Squat thrusts, 2 min (reps) 57 54 51 48 34 31 28 25

Sit-up, bent knee, 1 min (reps) 50 47 45 43 27 24 22 20

Shuttle run, 80 m (sec) b 21.0 21.5 22.0 22.5 25.0 25.5 26.0 26.5

Note: reps indicates repetitions; sec indicates seconds.

a20 yd out and 20 yd back.

bEight laps of 10 m each shuttling 4 by 4 by 2 inch wooden blocks back and forth.

Table 10. Events and Scoring for the Minimum Physical Fitness Test-Male 

(1969).

Event

Number a Event MinimumPassing Score,

Aged 17 to 29 Years 

Minimum

Passing Score,

Aged 30 to 39 Years

1 Squat bender (reps) 10 9

Squat stretch (reps) 10 9

2 Push-up (reps) 19 17

Push-up, 8 count (reps) 7 6

3 Sit-up (reps) 19 17

Body twist (reps) 10 9

4 Legs-over (reps) 16 14

Leg spreader (reps) 21 20

5 Squat thrust (reps) 10 9

Mountain climber (reps) 21 20

6 Run, stationary (reps) b 350 275

Run, 1⁄2 mile (min) 4.0 4.0

Note: reps indicates repetitions.

aThe Soldier selected one test from among the 2 listed under each Event Number.

bCount each time left foot hits ground.
 April – June 2014 15

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

were identical to that of 1986, but the walk test 

distance was reduced to a 2.5-miles with new 

passing standards. Two other physical training 

manuals have been published since 199869,70 but 

these publications have the identical test items 

and standards as that of 1998 (Tables 15 and 16).

Since 1998, there have been 2 attempts by the 

US Army Physical Fitness School to revise the 

Army Physical Fitness Test items. The 2003 

proposed test items included a standing long 

jump (2 trials), a 1-minute power squat, a 1-minute heel hook, a shuttle run (12 repeats of 25 

yards each), a 1-minute push-up, and a 1-mile 

run. The 2003 proposal was not implemented 

due partly to concerns of the safety and administration of some test items.71 The 2010 proposal included a test of physical capacity (Army 

Physical Readiness Test (APRT)) and a test of 

functional capacity (Army Combat Readiness 

Test(ACRT)). The APRT consisted of a standing 

long jump, a 1-minute rower, a shuttle run (60 

yards), a 1-minute push-up, and a 1.5-mile run. 

The ACRT (Figure 5) was designed to assess 

Soldier mobility and was similar to the obstacle 

courses of the 1920s and 1940s. It was proposed 

that both the APRT and ACRT be performed 

once per year. After Army leaders expressed 

concerns about the scientifi c basis about the effectiveness of the fi tness test and the feasibility of the ACRT, the US Army Training and 

Table 12. Events and Scoring for the Basic Physical Fitness Test, Minimum Physical Fitness Test, and Ranger/Special Force Qualifi cation Test 

(1973).

Test Event 100 Points

(Maximum Score)

60 Point

Criteria

Basic Physical 

Fitness Test

Inverted crawl,

40 yd (sec)a 16.0 29.0

Run, dodge & jump (sec) 20.5 24.5

Horizontal ladder (rungs) 84 36

Sit up, bent knee,

1-min (reps) 50 28

Run, 1 mile (min) 5.9 8.0

Minimum

Physical 

Fitness Test 

(Voluntary)

Run, dodge & jump (sec) 23.0 30.0

Push-up, 1 min (reps) 34 15

Sit-up, bent knee,

1 min (reps) 34 22

Squat thrust,

1 min (reps) 27 15

Run, 1⁄2 mile (min) 3.2 5.6

Ranger and

Special Forces 

Qualification 

Test 

Inverted crawl,

40 yd (sec)a 15.0 25.0

Sit-up, bent knee,

1 min (reps) 55 37

Push-up, 1 min (reps) 54 33

Run, dodge & jump (sec) 20.0 24.0

Run, 2 mile (min) 12.8 16.5

Swim, 15 m or 50 m Pass/Fail b Pass/Fail b

Note: reps indicates repetitions; sec indicates seconds.

a20 yd out and 20 yd back.

bRanger qualification: the trainee was required to complete a 15-m swim with 

clothing, boots, equipment (pistol belt, first aid pouch, 2 full canteens, 2 

ammunition pouches, and harness), and rifle. Special Forces qualification: the 

trainee was required to complete a 50-m swim with clothing and boots..

Table 13. Events and Scoring for the Advanced Physical Fitness Test, Staff and Specialist Physical Fitness Test, and 

Basic Physical Fitness Test (1974).

Test Event 100 points (Maximum Score) 60 Points (Passing Score)

Age Group (years) Age Group (years)

17-25 26-30 31-35 36-39 17-25 26-30 31-35 36-39

Advanced Physical 

Fitness Test

Inverted crawl, 40 yd (sec)a 14.0 15.0 16.0 17.0 25.0 27.0 28.0 29.0

Run, dodge & jump (sec) 19.5 20.0 20.5 21.0 24.5 25.0 25.5 26.0

Horizontal ladder, 1 min (rungs) 83 80 75 69 36 32 27 21

Sit-up, bent knee, 1 min (reps) 54 53 52 51 32 31 30 29

Run, 2 miles (min) 14.1 14.4 14.6 14.7 19.1 19.3 19.5 19.6

Staff & Specialist 

Physical Fitness 

Test

Push-up, 1 min (reps) 51 49 47 44 26 24 22 19

Run, dodge & jump (sec) 20.5 21.0 21.5 22.5 25.0 25.5 26.0 27.0

Horizontal ladder (rungs) 80 75 71 67 34 30 25 19

Sit-up, bent knee, 1 min (reps) 48 47 45 43 28 27 25 23

Run, 1 mile (min) 6.1 6.2 6.3 6.4 8.4 8.5 8.7 8.8

Basic Physical 

Fitness Testb

Inverted crawl, 40 yd (sec)a 15.0 27.0

Run, dodge & jump (sec) 20.0 25.5

Horizontal ladder, 1 min (rungs) 82 34

Sit-up, bent knee, 1 min (reps) 52 30

Run, 1 mile (min) 6.0 8.3

Note: reps indicates repetitions; sec indicates seconds.

a20 yd out and 20 yd back.

bThere were no age-adjusted standards for this test.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

Doctrine Command ordered a feasibility study in 2011. 

After reviewing input from several sources, Army leaders postponed implementation of the APRT and ACRT 

and ordered a comprehensive study of Army physical 

readiness testing. That study, began in May 2012, involves a number of organizations and has a 3-pronged 

approach. Organizations include the US Military Academy, the Initial Military Training Center of Excellence, 

the US Army Research Institute of Environmental 

Medicine, and the US Army Public Health Command. 

The approach involves (1) systematic literature reviews, (2) linking both capacity and functional fi tness assessments to 

common soldering tasks, and (3) validating the fi nal test items against Soldiering 

tasks.4

 It is anticipated that the primary 

study will be completed in late 2014 or 

early 2015.

SUMMARY AND CONCLUSIONS

Physical readiness and fi tness testing 

within the US Army has evolved in concert with the evolution of concepts of 

physical fi tness and military readiness. 

Combat experience in both World Wars, 

the Korean War, and the Cold War added 

combat-specifi c events (such as grenade 

throw, rope climb, wall climb, obstacle 

course) and developments in physical 

education and the exercise sciences provided more general performance events 

to assess physical fi tness. The current 

Army Physical Fitness Test was based 

primarily on the scientifi c literature and 

the expert opinion of scientists 

and Army leaders. The currently evolving approach to 

the development of a new test 

will involve the most comprehensive review and evaluation 

performed in the history of 

Army fi tness testing, and hopefully will provide a more solid 

scientifi c foundation based on 

our current knowledge of the 

physical fi tness and physical 

requirements of Army operations. It will likely incorporate 

lessons learned in the Iraq and 

Afghanistan confl icts. 

While the individual test items 

in US Army physical fi tness 

and physical readiness assessments have changed over time, the basic reasons for 

using these assessments have remained the same since 

they were outlined by Raycroft 29 in his description of 

the Physical Effi ciency Test in 1920: motivate physical 

training, provide commanders with an evaluation of 

the physical capacity of his/her Soldiers, and examine 

the effectiveness of physical training programs. These 

goals will likely remain even as individual test items 

change and concepts of physical fi tness and the physical 

requirements of military operations evolve.

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Table 14. Events and Scoring for the 3 Physical Fitness Tests for Women (1975).

Test Event 100 Points

(Maximum Score)

60

Pointsa 50Pointsb

Advanced Physical 

Fitness Test for 

Women

Shuttle run, 80 m (sec) 21.0 26.5 28.0

Modified push-up (reps) c 42 18 15

Run, dodge & jump (sec) 21.0 27.5 28.5

Sit up, bent knee, (reps) 44 20 17

Run, 1 mile (min) 7.6 10.8 11.1

Staff & Specialist 

Physical Fitness 

Test for Women

Shuttle run, 80 m (sec) 22.5 28.0 29.0

Modified push-up (reps) c 36 16 14

Run, dodge & jump (sec) 22.0 29.0 30.0

Sit up, bent-knee (reps) 38 18 16

Run, stationary (steps)d 596 396 346

Basic Physical

Fitness Test

Shuttle run, 80 m (sec) 21.5 27.0 28.5

Modified push-up (reps) c 40 18 16

Run, dodge & jump (sec) 21.5 27.5 28.5

Sit up, bent-knee (reps) 40 20 17

Run, 1⁄2 mile (min) 3.3 4.4 4.8

Note: reps indicates repetitions; sec indicates seconds.

aCriteria was required on each event to pass the Advanced Physical Fitness Test for women.

bCriterion was required on each event to pass the Basic Physical Fitness Test for women. 

Criteria are approximate for all tests other than the Basic Physical Fitness Test since in some 

cases there are no values at the exact 50 point level, only at 52 or 53 point level.

cKnees on ground.

dSteps counted each time the left foot hit the ground.

Figure 5. The Combat Readiness Test proposed by the Army Physical Fitness School (2012).
 April – June 2014 17

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

ACKNOWLEDGEMENTS

Ms Susan Seifert and Mr Ryan Steelman performed editorial and technical reviews of this article. Mr Steelman 

and Ms Claudia Coleman assisted in obtaining supporting publications and documentation.

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Table 15. Events and Maximum Score Standards for the Army Physical Readiness/

Fitness Tests (1980-2012).

Publication Age 

Group 

(years)

Maximum Score (100 points)

Men Women

Push-up,

2 min 

(reps)

Sit-up,

2 min 

(reps) b

Run,

2 miles 

(min)

Push-up,

2 min 

(reps)

Sit-up,

2 min 

(reps) b

Run,

2 miles 

(min)

aField Manual 21-20

(1980) 63; aField Manual 21-20,

Change 1 (1982) 64; aField Manual 21-20

(1985) 65

17-25 68 69 13.1 40 61 17.2

26-30 66 67 13.7 38 51 17.4

31-35 61 65 14.3 34 41 19.0

36-39 60 63 15.1 30 31 20.5

40-45

Only passing standards for those aged 40 years or more

(Table 16).

46-50

51-55

56-60

aField Manual 21-20,

Change 1 (1986) 66

17-21 82 92 11.9 58 90 14.9

22-26 80 87 12.6 56 85 15.6

27-31 78 82 13.3 54 80 15.7

32-36 73 78 14.0 52 75 18.6

37-41 72 73 14.7 48 70 19.6

42-46 66 69 15.1 45 67 20.0

47-51 62 67 15.6 41 64 20.5

≥52 56 66 16.0 40 62 21.0

aField Manual 21-20,

Change 1 (1998) 68; aTraining Circular 

3-22.20 (2010) 69; 

Field Manual 7-22

Change 1 (2012)70

17-21 71 76 13.0 42 76 15.6

22-26 75 80 13.0 46 80 15.6

27-31 77 82 13.3 50 82 15.8

32-36 75 76 13.3 45 76 15.9

37-41 73 76 13.6 40 76 17.0

42-46 66 72 14.1 37 72 17.4

47-51 59 66 14.4 34 66 17.6

52-56 56 66 14.7 31 66 19.0

57-61 53 64 15.3 28 64 19.7

62+ 50 63 15.7 25 63 20.0

Note: reps indicates repetitions.

aObsolete.

bSit-ups are/were performed with bent knees.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

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July 15, 1943.

40. War Department Pamphlet 21-

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May 1, 1944.

HISTORY OF UNITED STATES ARMY PHYSICAL FITNESS AND PHYSICAL READINESS TESTING

Table 16. Events and Passing Score Standards for the Army Physical Readiness/

Fitness Tests (1980-2012).

Publication Age 

Group 

(years)

Passing Score (60 points)

Men Women

Push-up,

2 min 

(reps)

Sit-up,

2 min 

(reps) b

Run,

2 miles 

(min)

Push-up,

2 min 

(reps)

Sit-up,

2 min 

(reps) b

Run,

2 miles 

(min)

aField Manual 21-20

(1980) 63; aField Manual 21-20,

Change 1 (1982) 64; aField Manual 21-20

(1985) 65

17-25 40 40 17.9 16 27 22.2

26-30 38 38 18.5 15 25 22.5

31-35 33 36 19.2 14 23 24.1

36-39 32 34 19.6 13 21 25.6

40-45 20 25 20.0 10 15 26.0

46-50 20 25 21.0 10 15 27.0

51-55 15 20 22.0 8 10 28.0

56-60 15 20 23.0 8 10 29.0

aField Manual 21-20,

Change 1 (1986) 66

17-21 42 52 15.9 18 50 18.9

22-26 40 47 16.6 16 45 19.6

27-31 38 42 17.3 15 40 19.7

32-36 33 38 18.0 14 35 22.6

37-41 32 33 18.7 13 30 23.6

42-46 26 29 19.1 12 27 24.0

47-51 22 27 19.6 10 24 24.5

≥52 16 26 20.0 9 22 25.0

aField Manual 21-20,

Change 1 (1998) 68; aTraining Circular 

3-22.20 (2010) 69; 

Field Manual 7-22

Change 1 (2012)70

17-21 42 53 15.9 19 53 18.9

22-26 40 50 16.6 17 50 19.6

27-31 39 45 17.0 17 45 20.5

32-36 36 42 17.7 15 42 21.7

37-41 34 38 18.3 13 38 22.7

42-46 30 32 18.7 12 32 23.7

47-51 25 30 19.5 10 30 24.0

52-56 20 28 19.8 9 28 24.4

57-61 18 27 19.9 8 27 24.8

62+ 16 26 20.0 7 26 25.0

Note: reps indicates repetitions.

aObsolete.

bSit-ups are/were performed with bent knees.
 April – June 2014 19

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

41. War Department Field Manual 21-20: Physical 

Training. Washington, DC: US War Department; 

January 1, 1946.

42. Field Manual 21-20: Physical Training [obsolete]. 

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30, 1950.

43. Field Manual 21-20: Physical Training. Washington, DC: US Dept of the Army; October 8, 1957 

[obsolete].

44. Technical Manual 21-200: Physical Conditioning. 

Washington, DC: US Dept of the Army; December 

31, 1957 [obsolete].

45. Technical Manual 21-200: Physical Conditioning

[change 2]. Washington DC: US Dept of the Army; 

July 25, 1961 [obsolete]

46. Department of the Army Pamphlet 21-1: Physical 

Fitness Program for Specialists and Staff Personnel. Washington, DC: US Dept of the Army; January 7, 1963 [obsolete].

47. Department of the Army Pamphlet 21-1: Physical 

Fitness Program for Specialists and Staff Personnel [change 2]. Washington, DC: US Dept of the 

Army; July 26, 1963 [obsolete].

48. Department of the Army Pamphlet 21-2: Physical 

Fitness Program for Female Special Staff Personnel and TD Organizations. Washington, DC: US 

Dept of the Army; January 7, 1963 [obsolete].

49. Department of the Army Pamphlet 21-2: Physical 

Fitness Program for Female Special Staff Personnel and TD Organizations [change 1]. Washington, 

DC: US Dept of the Army; July 26, 1963 [obsolete].

50. Field Manual 35-20: Physical Training Women’s 

Army Corps. Washington, DC: US Dept of the 

Army; February 17, 1965 [obsolete].

51. Army Regulation 600-9: Army Physical Fitness 

Program. Washington, DC: US Dept of the Army; 

January 5, 1965 [obsolete].

52. Field Manual 21-20: Physical Readiness Training. 

Washington, DC: US Dept of the Army; January 

31,1969 [obsolete].

53. Technical Manual 21-200: Physical Conditioning

[change 3]. Washington DC: US Dept of the Army; 

July 11, 1962 [obsolete].

54. Field Manual 21-20: Physical Readiness Training. 

Washington, DC: US Dept of the Army; March 30, 

1973 [obsolete].

55. Field Manual 21-20: Physical Readiness Training

[change 1]. Washington, DC: US Dept of the Army; 

January 31, 1974 [obsolete].

56. Field Manual 35-20: Physical Fitness Training for 

Women. Washington, DC: US Dept of the Army; 

February, 1975 [obsolete].

57. Morden BJ. The Women’s Army Corps, 1945-1978. 

Washington, DC: US Government Printing Offi ce; 

1990.

58. Cotten DJ, Marwitz B. Relationship between 2 

fl exed-arm hangs and pull-ups for college women. 

Res Q. 1969;40:415-416.

59. Baumgartner TA. Modifi ed pull-up test. Res Q Exerc Sport. 1978;49:81-85.

60. Zuidema MA, Baumgartner TA. Second factor analysis study of physical fi tness tests. Res Q. 

1974;45(3):247-256.

61. Baumgartner TA, Zuidemia MA. Factor analysis of 

physical fi tness tests. Res Q. 1972;43:443-450.

62. Cousins GF. A factor analysis of selected wartime 

fi tness tests. Res Q. 1955;26:277-288.

63. Field Manual 21-20: Physical Readiness Training. 

Washington, DC: US Dept of the Army; October 

31, 1980 [obsolete].

64. Field Manual 21-20: Physical Readiness Training

[change 1]. Washington, DC: US Dept of the Army; 

February 4, 1982 [obsolete].

65. Field Manual 21-20: Physical Fitness Training. 

Washington, DC: US Dept of the Army; August 28, 

1985 [obsolete].

66. Field Manual 21-20: Physical Fitness Training

[change 1]. Washington, DC: US Dept of the Army; 

June 23 1986 [obsolete].

67. Field Manual 21-20: Physical Fitness Training. 

Washington, DC: US Dept of the Army; September 

30, 1992 [obsolete].

68. Field Manual 21-20: Physical Fitness Training

[change 1]. Washington, DC: US Dept of the Army; 

October 1, 1998 [obsolete].

69. Training Circular 3-22.20: Army Physical Readiness Training. Washington, DC: US Dept of the 

Army; 2010 [obsolete].

70. Field Manual 7-22: Army Physical Readiness 

Training [change 1]. Washington, DC: US Dept of 

the Army; October 26,2012.

71. Knapik JJ, Bullock S, Hauret K, et al. Administrative and Safety Evaluation of the Proposed Army 

Physical Readiness Test (2002). Aberdeen Proving 

Ground, MD: US Army Center for Health Promotion and Preventive Medicine; June 2002. Technical Report No. 12-HF-5738-02. Available at: http://

www.dtic.mil/dtic/tr/fulltext/u2/a403887.pdf. Accessed February 21, 2014.

AUTHORS

Dr Knapik, a retired US Army Medical Service Corps 

offi cer and research physiologist, is a contractor with the 

US Army Institute of Public Health, US Army Public 

Health Command, Aberdeen Proving Ground, Maryland.

Dr East is an instructor at the United States Military 

Academy, West Point, New York. He is temporarily at 

Fort Eustis, Virginia, working with the US Army Training and Doctrine Command on the development of the 

new Army Physical Fitness Test.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

Due to recent changes in Department of Defense policy, 

women in the military will have more opportunities to 

serve in combat arms military occupational specialties 

(MOS). These new opportunities will bring new challenges, including the ability to carry heavy loads over 

long distances in combat situations. Historically, the 

ability to lift and carry has been an important contributor to success in military combat operations.1,2 As modern warfare incorporates increasingly heavier external 

loads, load carriage capability has gained recognition as 

an essential physical attribute in warfare.3-5 Specifi cally, 

“fi ghting” loads average 29 kg, “approach” loads average 46 kg, and “emergency approach” loads average 60 

kg.1,2,6 These heavy loads often exceed the limits recommended by Army doctrine1,6 and may partially explain 

why musculoskeletal injuries now comprise the largest 

proportion of all injuries.7-10 Thus, as women enter new 

combat roles, it is necessary to determine which physical abilities are most closely related to performance on 

load carriage tasks. With this knowledge, load carriagespecifi c training interventions can be developed and 

implemented.7,11,12

The components of physical fi tness that contribute the 

most to successful load carriage performance in women 

have been previously examined and are a growing area 

of research.3,13-16 Load carriage is a frequent physical demand, particularly in deployed environments. Thus, a 

stronger Soldier could be expected to perform better on 

load carriage tasks and demonstrate greater resilience to 

the inherent injury risks these tasks present.7,17,18 To that 

end, Kraemer et al,16,19 Harman et al,20 and Hendrickson 

et al21 have shown that strength improvement, particularly in the upper body, has a profound impact on women’s 

physical performance in military-specifi c tasks (ie, load 

carriage). Nevertheless, since loads are often carried 

over great distances and with considerable speed, high 

aerobic capacity is a common trait in Soldiers who successfully perform long distance load carriages.2,3,12,21,22

The prevalence of acute and overuse injuries to the spine 

and lower body3,7,18,23-27 during military duties necessitates general physical preparedness and an emphasis on 

both strength and endurance capacity.16,21 A Soldier’s 

performance on military-relevant load carriage tasks 

 Relationships of Physical Performance Tests

 to Military-relevant Tasks in Women

Tunde K. Szivak Courtenay Dunn-Lewis

William J. Kraemer, PhD David P. Looney

Bradley C. Nindl, PhD Brett A. Comstock

Lincoln A. Gotshalk David R. Hooper

Jeff S. Volek Shawn D. Flanagan

Ana L. Gomez Carl M. Maresh, PhD

ABSTRACT

Purpose: This investigation sought to determine the most predictive measures of performance on a repetitive box 

lifting task (RBLT) and load bearing task (LBT) among 123 women (aged 23±4 years, height 165±7 cm, body mass 

64±10 kg).

Methods: To determine the relationship of various predictors to performance on the RBLT and LBT, multiple regression analysis was conducted on body mass, height, leg cross-sectional area, upper and lower body muscular strength, 

lower body explosive power, upper and lower body local muscular endurance, and aerobic capacity.

Results: The mean±SD (range) number of repetitions for the RBLT was 86±23 (20-159). The mean±SD (range) 

time to complete the LBT was 2,054±340 seconds (1,307-3,447). The following equations were generated: RBLT 

(number of repetitions)=57.4 + 0.2(peak jump power) + 0.4(number of pushups in 2 minutes) + 0.15(number of 

repetitions during the squat endurance test) + 1.39(one repetition maximal strength boxlift (kg)) – 0.04(2-mile run 

time (2MR) in seconds), R=0.81; standard error of the estimate (SEE)=14; LBT (in seconds)=1,831 – 4.28(number 

of repetitions during the squat endurance test) + 0.95(2MR in seconds) – 13.4(body mass), R=0.73; SEE=232.

Conclusions: We found that the 2MR and squat endurance test were signifi cant predictive factors for performance on 

both load carriage tasks. These data also imply that women’s performance in combat-related tasks can be improved 

with training that targets muscular strength, power, and local muscular endurance in addition to aerobic capacity.
 October – December 2013 21

may provide insight into his or her current state of physical preparation. Furthermore, due to the physically demanding nature of these tasks, directly addressing them 

in training programs may help resolve existing defi ciencies. This is of paramount importance when load carriage and repetitive lifting tasks are performed in theatre 

under less than ideal conditions (ie, extreme fatigue, dehydration, extended combat operations), which contribute to increased injury likelihood and incidence.10,28-30 A 

well-designed training program that emphasizes both 

resistance exercise and traditional cardiovascular training may not only improve Soldier performance, but also 

help prevent common overuse injuries that occur during 

load carriage tasks.

To better understand the physical demands of load carriage in women, we must evaluate the relationship of 

military-relevant tasks with various characteristics of 

physical fi tness. Such data would not only help to characterize the physical requirements of these tasks but 

would also provide valuable information on the physical 

training required to enable female Soldiers to successfully perform the duties of combat MOSs. The purpose 

of this investigation was to identify the physical fi tness components that most strongly predicted women’s 

performance in 2 military-relevant occupational tasks. 

These tasks utilized loads and conditions that refl ect limits prescribed by Army doctrine for approach marches,1,2

Soldier testing and training, and previous experimental 

work.12,19,20,31,32 These tasks included a repetitive box lifting task and an endurance-based, load bearing task. The 

knowledge obtained during this investigation could assist in the development of training strategies that, with 

time and further refi nement, would allow for improved 

Soldier productivity, resilience, and injury rates.

MATERIALS AND METHODS

The study participants were 123 untrained civilian 

women (mean±SD: aged 23±4 years; height 165±7 cm; 

body mass 64±10 kg). Each subject was briefed on the 

risks and benefi ts of the investigation, and each signed 

an institutionally approved, informed consent document 

prior to her participation. Each subject was medically 

screened by a physician to eliminate any medical concerns or pathologies that may have compromised the 

subject’s participation or confounded the results. This 

sample population of healthy women with no previous 

history of resistance training demonstrated a wide range 

of fi tness capabilities, such that might be representative 

of a typical cohort of women entering into military service.33,34 The factors used to predict task performance in 

this study were body mass, height, magnetic resonance 

imaging (MRI)-assessed thigh muscle cross-sectional 

area, one repetition maximal strength in the bench press, 

back squat, high pull and the box lift, pushup muscular 

endurance, explosive jump power, squat endurance, and 

2-mile run time. All predictors and load carriage tasks 

had been previously shown to possess test-retest reliability correlations R≥0.95.19

Performance Predictors

1. Thigh muscle cross-sectional area (TMCSA).

The TMCSA was assessed for the dominant leg using an 

MRI 0.5 Tesla super conduction magnet (Picker International Inc, Highland Heights, OH) with MR6B software. 

Tissue cross sectional area was obtained by displaying 

the images through a Maxitron displayer and Adobe 

program and using the MacIntosh version NIH 1.55.20A 

Image Analysis computer program (National Institutes 

of Health, Washington, DC).

2. One repetition maximal strength (1RM) measures.

These strength measures consisted of the squat, bench 

press, high pull, and box lift and were assessed with the 

use of the Plyometric Power System (PPS) (Power Systems Inc, Knoxville, TN). The PPS was specially designed to accurately collect strength and power data and 

to safeguard against injury by using a braking system to 

prevent falls. A National Strength and Conditioning Association Certifi ed Strength and Conditioning Specialist 

monitored all tests and ensured compliance with prescribed exercise techniques. For the 1RM squat, the subject was required to descend into a parallel squat position by fl exing the knees and hips until the trochanteric 

head of the femur reached the same plane as the superior 

border of the patella.35 For the 1RM bench press, the 

subject was required to lower the bar until it touched the 

chest, and lift the bar back to the straight-arm position.35

For the 1RM high pull, the subject stood upright with 

arms extended at the sides of the body and the feet positioned so that the instep of each foot was directly under the bar (resting position). The subject then fl exed her 

hips before performing a simultaneous “triple extension” 

(of the ankle, knee, and hips) with maximal power while 

pulling the bar, using trapezoid fl exion and shoulder abduction, to the height of the medial clavicles (the fi nish 

position).35 The 1RM box lift required the subject to lift 

a box from the fl oor to a height of 1.32 m (simulating the 

bed height of a military 5-ton cargo truck). Upon failing 

at an attempt on any of the 1RM tests, the subject was 

given a fi nal attempt with a weight less than that used 

in the failed attempt, but greater than that of the highest 

successful attempt (adapted from Maud and Foster35).

3. Muscular endurance and aerobic capacity. The 

maximum number of pushups that a subject could perform correctly in 2 minutes was used to assess upper 

body muscular endurance. The minimum amount of 
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

time in which a subject completed a 2-mile run was used 

to assess aerobic capacity. Both of these measures were 

tested according to guidelines and procedures provided 

in Field Manual 21-20 (now obsolete, superseded by 

Field Manual 7-2236)

4. Squat endurance test. The squat endurance test required the subjects to perform repetitive squatting with 

an absolute load of 45.36 kg placed on the PPS barbell 

system which was lifted over a specifi c distance of 0.36 

m per repetition at a rate of 37.5 repetitions per minute (0.625 repetitions per second).19 These specifi cations 

were employed to allow for an external power output of 

100 watts during the test. The total number of repetitions that the subject performed was used for analysis.

5. Lower body explosive power. To assess lower body 

explosive power, subjects performed an explosive squat 

jump lift using the PPS interfaced with a computer for 

data acquisition. Each subject’s previously determined 

1RM squat load was used to calculate her 30% of 1RM 

intensity for use in the squat jump test. The squat jump 

required the subject to perform a parallel squat and, 

upon reaching the bottom position of the lift, to explosively extend the hips and knees, thus accelerating the 

barbell mass upward with maximum power.19,37

Military-relevant Occupational Tasks

1. Repetitive box lift task (RBLT). The RBLT required 

the repetitive lifting of two 20.45 kg metal boxes placed 

on 2 platforms 1.32 m high (again, to simulate the height 

of a 5-ton military cargo truck) and 2.4 m apart. The 

subject moved at a volitional pace between one platform 

and the other to lift the box from its position adjacent to 

the platform to the top of that 

platform. The purpose of the 

test was to measure the subject’s ability to lift as many 

boxes as possible in 10 minutes; performance was measured by the total number of 

boxes lifted (adapted from 

Harman et al38 and Knapik39).

2. Load bearing task 

(LBT). The LBT required the 

subjects to carry a 34.1 kg 

backpack (termed rucksack) 

a distance of 2 miles on an 

all-weather 400 m track. The 

rucksack was constructed 

of an external frame with 

an attached backpack in 

which the load was properly 

positioned. Upon command, the subjects moved as fast 

as they could to cover the 2-mile distance. The performance was measured in seconds.19

Statistical Analyses

Values are reported as means±SD. Prior to all statistical 

runs, the data were confi rmed to have met the statistical 

assumptions for linear statistics. Simple and stepwise 

multiple regression analyses were used to determine 

relationships between and among variables and to determine the proportion of variance explained by specifi c 

variables of interest that entered into the respective regression equations for the RBLT and the LBT. In this 

study, signifi cance was defi ned as P≤.05.

RESULTS

Table 1 lists the descriptive data for the various tests 

and with the 25th, 50th, and 75th percentiles presented 

for all variables. These variables were selected because 

they represent a broad spectrum of physical fi tness 

components that infl uence military task performance. 

We attempted to select tests that assessed upper and 

lower body muscular strength, power, and endurance 

as well as aerobic capacity. Depending on the variable 

(as shown in Table 1), data was collected for 113 to 123 

study participants. For some variables (eg, pushups and 

squat endurance) some subjects failed to complete a successful repetition, thus demonstrating a high discriminating ability for these tests.

Table 2 displays the correlational matrix among all 

variables. All of the independent variables were signifi -

cantly correlated with the 2 dependent variables (RBLT 

and LBT). The 2-mile run time yielded the highest 

Table 1. Descriptive Data for the Various Tests. The variables were selected because they 

represent a broad spectrum of physical fi tness components that infl uence military task performance.

Variable n Mean±SD (range) 25th

Percentile

50th

Percentile

75th

Percentile

Height (cm) 122 166±7 (145-184) 162 166 169

Weight (kg) 123 64±10 (43-106) 57 62 70

TMCSA (cm2

) 122 122±17 (89-183) 111 120 132

Bench press (kg) 123 32±7 (17-58) 26 31 35

Squat (kg) 123 52±12 (17-88) 44 52 58

High pull (kg) 121 33±6 (15-54) 29 32 36

Maximal box lift (kg) 121 30±5 (21-48) 27 30 33

Pushups (no. reps) 120 20±13 (0-57) 10 17 28

Squat endurance (no. reps) 116 19±14 (0-95) 8 16 24

Jump power (watts) 116 1,623±323 (875-2,868) 1,390 1,587 1,797

Two mile run (seconds) 120 1,213±231 (830-2,040) 1,358 1,191 1,043

Rucksack run (seconds) 113 2,054±337 (1,307-3,447) 2,267 2,025 1,850

Repetitive box lift (reps) 113 86±23 (20-159) 69 85 104

Notes: n=number of participants from which data was collected; TMCSA indicates thigh muscle crosssectional area; reps indicates repetitions.

RELATIONSHIPS OF PHYSICAL PERFORMANCE TESTS TO MILITARY-RELEVANT TASKS IN WOMEN
 October – December 2013 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

correlation overall (r=-0.54 for the RBLT and 0.60 for 

the LBT). Other factors also contributed to these task 

performances, as only about 36% of the shared variance 

was explained. It is interesting to note that the test battery used was diverse and represented different physical 

requirements of the neuromuscular system as noted by 

the low to moderate relationships for multicollinearity 

of the tests performed.

Table 3 provides the regression equations for the RBLT 

and the LBT. For the RBLT; the explosive jump power, 

pushups, squat endurance test, 1RM box lift, and 2-mile 

run time entered into the equation. For the LBT; the 

squat endurance test, 2-mile run time, and body mass 

entered into the equation.

The fi nal regression equations explained approximately 65% of the variance for the RBLT and 53% of the 

variance for the LBT. The standard errors of estimates were 

14 repetitions for the RBLT 

and 232 seconds for the LBT. 

Interestingly, the squat endurance test and timed 2-mile run 

contributed signifi cantly to 

both regression equations. Our 

results show that, depending 

on the physical demands of the 

task, both aerobic capacity and local muscular endurance can contribute signifi cantly to task performance.

COMMENT

Research has consistently shown that increased strength 

contributes to signifi cant improvements in militaryspecifi c task performance.3,16,19,21 Previous studies have 

demonstrated that stronger, more muscular individuals 

perform load carriage and repetitive lifting tasks more 

effi ciently and with indications of lower stress to the 

musculoskeletal system.3,12,19,20 The results of the present 

investigation support the argument that upper and lower 

body strength, power, and local muscular endurance 

play important roles in load carriage task performance 

in women. Currently, military physical fi tness training 

prioritizes traditional cardiovascular training. Our fi ndings also support the importance of aerobic capacity, as 

higher aerobic capacity was associated with decreased 

Table 3. Regression equations for repetitive box lifting tasks (RBLT) and load bearing task 

(LBT).

Variable Regression Equation R R2 SEE

RBLT (reps) 57.4+0.2(JP)+0.4(PU)+0.15(SE)+1.39(BL)–0.04(2MR) 0.81 0.65 14

LBT (seconds) 1831–4.28(SE)+0.95(2MR)–13.4(BM) 0.73 0.53 232

Key

reps – repetitions BL – 1RM box lift

JP – jump power 2MR – 2 mile run time

PU – pushups BM – body mass (kg)

SE – squat endurance

Table 2. Matrix of Correlation Among the Variables.

BP BL TCSA HP HT JP PU SE SQ 2MR BM RBLT LBT

BP 1.00* 0.58* 0.50* 0.71* 0.09 0.50* 0.48* 0.48* 0.57* -0.28* 0.24* 0.56* -0.48*

BL 0.58* 1.00* 0.53* 0.62* 0.46* 0.66* 0.10 0.43* 0.58* -0.03 0.53* 0.54* -0.37*

TCSA 0.50* 0.53* 1.00* 0.60* 0.24* 0.74* -0.03 0.50* 0.61* 0.00 0.60* 0.41* -0.31*

HP 0.71* 0.62* 0.61* 1.00* 0.20* 0.66* 0.20* 0.52* 0.58* -0.18* 0.32* 0.52* -0.42*

HT 0.09 0.46* 0.29* 0.20* 1.00* 0.44* -0.35* 0.22* 0.04 0.01 0.54* 0.22* -0.27*

JP 0.50* 0.66* 0.74* 0.66* 0.44* 1.00* -0.10 0.59* 0.64* 0.00 0.67* 0.47* -0.35*

PU 0.48* 0.10 -0.03 0.20* -0.35* -0.01 1.00* 0.24* 0.28* -0.52* -0.39* 0.45* 0.26*

SE 0.48* 0.43* 0.50* 0.52* 0.22* 0.59* 0.24* 1.00* 0.59* -0.32* 0.17 0.55* -0.46*

SQ 0.57* 0.58* 0.61* 0.58* 0.04 0.69* 0.28* 0.59* 1.00* -0.16 0.26* 0.48* -0.27*

2MR -0.28* -0.03 0.00 -0.18* 0.01 0.00 -0.52* -0.32* -0.16* 1.00* 0.41* -0.54* 0.60*

BM 0.24* 0.53* 0.60* 0.32* 0.54* 0.67* -0.39* 0.17 0.26* 0.41* 1.00* 0.19* -0.19*

RBLT 0.56* 0.54* 0.41* 0.52* 0.20* 0.47* 0.45* 0.55* 0.48* -0.54* 0.19* 1.00* -0.61*

LBT -0.48* -0.37* -0.31* -0.42* -0.27* -0.35* -0.26* -0.46* -0.27* 0.60* -0.19* -0.61* 1.00*

*P≤.05

Key

BP – 1RM bench press (kg) SE – squat endurance

BL – 1RM box lift (kg) SQ – 1RM squat (kg)

TCSA – thigh cross-sectional area (cm2) 2MR – 2 mile run time

HP – 1RM high pull (kg) BM – body mass (kg)

HT – height (cm) RBL – repetitive box lift

JP – jump power (W) LBT – load bearing task (2-mile rucksack carry)

PU – pushups 
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

LBT time, while lower aerobic capacity was associated 

with decreased RBLT volume. It appears that training 

strategies for military populations must include both resistance and traditional cardiovascular training.

Our fi ndings also refl ect the importance of training 

specifi city. For example, the 1RM box lift factored 

strongly into performance on the RBLT. This is not surprising if we consider that individuals who are able to 

lift heavier loads (eg, 1RM box lift) will likely perform 

better on a related task such as the RBLT. Furthermore, 

lower body power (jump squat) and local muscular endurance (pushups and squat endurance) could be expected to contribute positively to a repetitive box-lifting 

task, which would appear to require these qualities. Performance on the LBT also appeared to refl ect the task’s 

specifi c physical attributes most strongly. For instance, 

lower aerobic capacity, refl ected in higher 2-mile run 

times, corresponded with higher LBT times, while increased body mass and lower body muscular endurance 

were associated with improved LBT times. Nevertheless, performance on both tasks benefi tted from higher 

aerobic capacity and local muscular endurance, thus illustrating the transferability of more nonspecifi c exercise adaptations.

The principle of specifi city dictates that training mirror the specifi c physical requirements of the activity.14,40

Therefore, to the extent possible, training programs for 

Soldiers should include physical tasks that are similar 

to those required by the MOS or duty assignment. Current training recommendations for load carriage include 

performing specifi c load carriage tasks with progressive 

loading and duration once per week, in addition to resistance training and aerobic conditioning.22 The selected 

occupational tasks (LBT and RBLT) were deemed highly relevant—they are either regularly performed or used 

in training.1,2,31,41 Our fi ndings also highlight the importance of upper body strength in women, as the 1RM box 

lift and pushup results were signifi cant predictors of 

RBLT performance.19,39

It is important to note that the 2 tasks evaluated in this 

study require many performance strategies, physiological systems, psychological demands, and biomechanical techniques. Therefore, it might be expected that 

the physical components measured in this study do not 

completely explain performance on these 2 tasks. Psychological factors such as motivation may also explain 

some of the results. In addition, the use of nonmilitary 

volunteers might have produced fi ndings that would differ from those of enlisted women although we specifi -

cally chose college-aged women of varying fi tness and 

anthropometrics in order to simulate a plausible enlistment cohort. Thus, other tests and/or factors (eg, psychological, inherent differences between enlisted and civilian volunteers) may need to be explored to better predict 

performance in untrained women. Finally, any laboratory test, however similar to those tasks carried out in 

combat, should not be expected to possess complete predictive accuracy as it relates to performance in theatre. 

A true evaluation of performance requires a multifactorial assessment encompassing both physical and psychological motivating factors in combat situations. 

RELEVANCE TO PERFORMANCE TRIAD

Muscular endurance, strength, power, aerobic capacity, and task-specifi c ability are all factors that infl uence an individual’s performance on military load carriage and repetitive lifting tasks such as those evaluated 

here. These data are important because it is necessary 

to know what components of physical fi tness contribute to military task performance so adequate training 

programs can be designed. The primary value of this 

study is that it reports the relationships of various physical fi tness components to military task performance in 

women. Prior research has demonstrated that load carriage can result in overuse injuries, particularly to the 

spine and lower extremities. Regardless of the injury 

risk, load carriage is an integral part of soldiering, and 

the external loads that Soldiers are required to carry has 

increased in recent years, despite improvements in load 

carriage equipment. 

As the military continues to place heavy demands on 

Soldiers and expands combat arms MOS opportunities 

to women, it is paramount that training programs include heavy periodized resistance training to improve 

lower and upper body power, strength, and local muscular endurance, in addition to traditional cardiovascular 

training. Moreover, the present investigation highlights 

the importance of training specifi city. To the extent possible, training should refl ect occupation-specifi c tasks 

such as load carriage.

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improves physical capacity and performance on 

tactical occupational tasks. Eur J Appl Physiol. 

2010;109(6):1197-1208.

22. Henning PC. Physical training to optimize load 

carriage in the tactical operator [internet]. National Strength and Conditioning Association; 

2013. Available at: http://www.nsca-lift.org/Education/Articles/Hot-Topic-Physical-Training-to-Opti

mize-Load-Carriage/. Accessed September 4, 2013.

23. Birrell SA, Hooper RH, Haslam RA. The effect of 

military load carriage on ground reaction forces. 

Gait Posture. 2007;26(4):611-614.

24. Knapik JJ, Darakjy S, Jones SB, et al. Epidemiological Report No. 12-HF-05SR-05: Injuries 

and Physical Fitness Before and After Deployment by the 10th Mountain Division to Afghanistan for Operation Enduring Freedom. Aberdeen Proving Ground, MD: US Army Center 

for Health Promotion and Preventive Medicine; 

2007. Available at: http://www.dtic.mil/cgi-bin/

GetTRDoc?AD=ADA496351. Accessed September 4, 2013.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

25. Knapik JJ, Rieger W, Palkoska F, Van Camp S, 

Darakjy S. United States Army physical readiness training: rationale and evaluation of the 

physical training doctrine. J Strength Cond Res.

2009;23(4):1353-1362.

26. Rodriguez-Soto AE, Jaworski R, Jensen A, et al. 

Effect of load carriage on lumbar spine kinematics. 

Spine (Phila Pa 1976). 2013;38(13):E783-E791.

27. Sell TC, Pederson JJ, Abt JP, et al. The addition of 

body armor diminishes dynamic postural stability 

in military soldiers. Mil Med. 2013;178(1):76-81.

28. Lester ME, Knapik JJ, Catrambone D, et al. Effect of a 13-month deployment to Iraq on physical fi tness and body composition. Mil Med. 

2010;175(6):417-423.

29. Nindl BC, Barnes BR, Alemany JA, Frykman PN, 

Shippee RL, Friedl KE. Physiological consequences of U.S. Army Ranger training. Med Sci Sports 

Exerc. 2007;39(8):1380-1387.

30. Reynolds K, Cosio-Lima L, Bovill M, Tharion W, 

Williams J, Hodges T. A comparison of injuries, 

limited-duty days, and injury risk factors in infantry, artillery, construction engineers, and special 

forces soldiers. Mil Med. 2009;174(7):702-708.

31. Kraemer WJ, Vogel JA, Patton JF, Dziados JE, 

Reynolds KL. Report 30-87: The Effects of Various Physical Training Programs on Short Duration, 

High Intensity Load Bearing Performance and the 

Army Physical Fitness Test. Technical. Natick, MA: 

US Army Research Institute of Environmental 

Medicine; 1987. Available at: http://www.dtic.mil/

cgi-bin/GetTRDoc?AD=ADA185473. Accessed 

September 4, 2013.

32. Pandorf CE, Nindl BC, Montain SJ, et al. Reliability assessment of two militarily relevant occupational physical performance tests. Can J Appl 

Physiol. 2003;28(1):27-37.

33. Sharp MA, Patton JF, Knapik JJ, et al. Comparison 

of the physical fi tness of men and women entering 

the U.S. Army: 1978-1998. Med Sci Sports Exerc. 

2002;34(2):356-363.

34. Knapik JJ, Sharp MA, Darakjy S, Jones SB, 

Hauret KG, Jones BH. Temporal changes in the 

physical fi tness of US Army recruits. Sports Med. 

2006;36(7):613-634.

35. Maud PJ, Foster C, eds. Physiological Assessment 

of Human Fitness. 2nd ed. Champaign, IL: Human 

Kinetics; 2006.

36. Field Manual 7-22: Army Physical Readiness 

Training. Washington, DC: US Dept of the Army; 

October 2012. Available at: http://armypubs.army.

mil/doctrine/DR_pubs/dr_a/pdf/fm7_22.pdf. Accessed September 4, 2013.

37. Wilson GJ, Newton RU, Murphy AJ, Humphries 

BJ. The optimal training load for the development 

of dynamic athletic performance. Med Sci Sports 

Exerc. 1993;25(11):1279-1286.

38. Harman EA, Frykman PN, Clagett ER, Kraemer 

WJ. Intra-abdominal and intra-thoracic pressures 

during lifting and jumping. Med Sci Sports Exerc. 

1988;20(2):195-201.

39. Knapik JJ. The infl uence of physical fi tness training on the manual material handling capability of 

women. Appl Ergon. 1997;28(5-6):339-345.

40. Spiering BA, Kraemer WJ, Anderson JM, et al. 

Resistance exercise biology: manipulation of resistance exercise program variables determines the 

responses of cellular and molecular signaling pathways. Sports Med. 2008;38(7):527-540.

41. Knapik J, Johnson R, Ang P, et al. Report No. T14-

93: Road March Performance of Special Operations Soldiers Carrying Various Loads and Load 

Distributions. Natick, MA: US Army Research Institute of Environmental Medicine; 1993.

AUTHORS

Ms Szivak is a doctoral fellow in the Department of Kinesiology at the University of Connecticut, Storrs, CT.

Dr Kraemer is a Professor in the Department of Kinesiology at the University of Connecticut, Storrs, CT.

Dr Nindl is a Scientifi c Advisor for the Army Institute of 

Public Health of the US Army Public Health Command, 

Aberdeen Proving Ground, MD.

Dr Gotshalk is an Associate Professor Department of 

Kinesiology and Exercise Sciences at the University of 

Hawaii at Hilo, Hilo, HI.

Dr Volek is a Professor in the Department of Kinesiology 

at the University of Connecticut, Storrs, CT.

Ms Gomez, Ms Dunn-Lewis, Mr Looney, Mr Comstock, 

Mr Hooper, and Mr Flanagan are doctoral fellows in the 

Department of Kinesiology at the University of Connecticut, Storrs, CT.

Dr Maresh is the Board of Trustees Distinguished Professor and Director, Human Performance Laboratory, 

Department of Kinesiology, University of Connecticut, 

Storrs, CT.

RELATIONSHIPS OF PHYSICAL PERFORMANCE TESTS TO MILITARY-RELEVANT TASKS IN WOMEN
 April – June 2014 27

BACKGROUND

Nonspecifi c lower back pain and lower extremity injuries without known event are reported frequently during Army Basic Combat Training (BCT) and Advanced 

Individual Training (AIT). Postural faults and related 

muscular endurance are common defi cits observed upon 

physical therapy examination for lower back pain.

Swayback posture is a simple postural fault to identify 

using gross landmarks of the lateral malleolus, greater 

trochanter of the femur, and the greater tubercle of the 

humerus. Exaggerated shifting of weight over one hip is 

also observable with short term assessment. Both postural faults may be considered a compensation for reduced 

postural muscle endurance or use and can shift stress to 

the hip joint or muscles and ligaments of the spine.

When assessed for posture using a plumb line, swayback 

posture is categorized by the hips and ankle bones being in front of the plumb line, and the upper back trying to counterbalance things by being further behind the 

line than usual. Kendall has referenced swayback as a 

primary postural fault.1

 Sahrmann has noted weakness 

in posterior hip muscles and anterior abdominal muscles to contribute to this postural fault.2

 Reeve et al has 

found that transverse abdominus thickness and activity 

is signifi cantly different in erect upright posture sitting 

or standing in comparison to slumped sitting or swayback posture.3

 Pezolato et al4 found that the multifi dus 

muscles demonstrated greater fatty infi ltrate in subjects 

with swayback posture, with or without symptoms, in 

comparison to a control group. Fatty infi ltrate in muscle 

tissue is associated with muscle atrophy.

No study measuring the frequency of postural faults 

in military trainees was identifi ed on literature review. 

Literature review did locate 2 studies on nonmilitary 

populations of similar age. Norris et al observed 26 university students ranging in age from 18 to 28 years in an 

exercise course. Fifteen of the 26 subjects (58%) demonstrated swayback posture but only six of those 15 had a 

complaint of low back pain.5

 Abdolvahabi et al observed 

70 female students ranging in age from 17 to 26 years 

without pain complaints to assess the effect of swayback 

on other joints, categorizing 35% of the subjects as having swayback posture.6

In clinical practice, the author has observed a high frequency of military patients with hip or back pain who 

present with swayback posture, most of whom were not 

aware of the postural fault. The frequency of subjects 

who have swayback posture without back or hip pain has 

not been established on a larger sample. 

This study was a cross-sectional survey of the incidence 

of swayback or exaggerated uneven weight distribution 

posture and the presence of hip or lower back pain. Male 

and female military trainees were recruited during inprocessing prior to initiating AIT. The primary research 

objective was to measure the frequency of subjects with 

upright, unilateral weight shift posture, or swayback 

posture and correlation with hip or lower back pain. The 

secondary research objective was to provide military 

training installation personnel feedback on the need for 

postural education and training as part of integration 

into military training.

Research hypotheses were that subjects with grossly 

identifi ed unilateral shift or swayback posture will have 

an increased frequency of low back pain or hip pain history, and that a signifi cant number of subjects without 

symptoms will be unaware of postural faults.

Screening Initial Entry Training Trainees for

 Postural Faults and Low Back or Hip Pain

MAJ John R. Lane, SP, USA

ABSTRACT

Background: The frequency of postural faults and postural awareness in military trainees has not been assessed.

Methods: Five hundred Soldiers entering Advanced Individual Training were screened for standing posture and 

completed an anonymous questionnaire during inprocessing.

Results: Postural faults were identifi ed in 202 subjects. Chi square analysis demonstrated a relationship between 

posture observed and posture reported: 87% of subjects with postural faults were unaware of postural faults; 12% 

with proper posture reported having poor posture. Subjects reported comparable frequencies of back pain and hip 

pain with postural faults (33.2%, 21.2%) and without faults (28.5%, 14.7%). Anonymous reporting was higher than 

formal reporting and requests for care during the same period (37% vs 3.4%).
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

METHODS

Over a 5-week period, inprocessing AIT trainees 

(N=1,904) at the installation inprocessing station were 

informed of the study’s process and intent after the subjects had completed administrative forms. The potential subjects were informed that the study would remain 

anonymous and that consent would be limited to verbal 

consent due to the limitation in time available for the 

subjects during inprocessing and prior to starting training. Inclusion and exclusion criteria were strictly based 

on the subject’s agreement to be observed for posture 

and to complete the questionnaire. The number of subjects verbally declining to participate in the study was 

not recorded.

Approximately 100 subjects per class were observed after individually providing verbal consent (5 groups totalling 500 subjects) while standing in line for administrative processing. Fourteen unanswered questionnaires 

were submitted. The fi nal group required measurement 

of 138 subjects to achieve the desired 500 participants.

Each subject was determined to have upright posture if 

observation from their side demonstrated a straight line 

from the ankle to the pelvis/femur and to the shoulder, 

and observation from the front or behind demonstrated a 

grossly vertical line with weight distributed between both 

feet. Subjects were determined to have a postural fault if 

the pelvis/head of the femur was observed to be forward 

of the line from shoulder to ankle or the subject’s weight 

was shifted over to a side. Subjects were given a stripsized questionnaire with bold face type if a swayback 

fault (bad) was identifi ed, or an underlined questionnaire 

(upright) if no gross fault was observed. Subjects were 

not informed of the different strip signifi cance or given 

any verbal feedback of the author’s conclusion.

No demographic data, including name, age, gender, 

height, or weight, were requested. Multiple subjects inquired about whether to submit their name and were instructed not to include it. This was intentional to avoid 

concerns for identifi cation and to provide the most honest feedback. Questionnaires were placed in a locked slot 

box and were not viewed by the author until all forms 

for that day were collected. Analysis was performed for 

correlation between postural fault presence and history 

of back pain, hip pain, and the percentage of subjects 

who are aware of the presence of a postural fault.

RESULTS

Five hundred total subjects were observed and also 

completed the questionnaire. Two hundred ninety-eight 

subjects demonstrated upright posture (59.6%) and 202 

(40.4%) demonstrated a postural fault. Three hundred 

fi fteen subjects had no history of hip or lower back pain 

(63% overall, 65.4% with upright posture, 59.4% with 

postural fault), 53 subjects reported having lower back 

and hip pain (10.6%), 99 subjects reported having only 

lower back pain (19.8%), and 33 subjects reported having only hip pain (6.6%). Total subjects with lower back 

pain were 152 (30.4%) and hip pain were 86 (17.2%). 

Thirty-two subjects had bilateral hip pain, 21 subjects 

had left hip pain, and 33 subjects had right hip pain.

Two hundred sixty of 298 subjects observed with proper 

posture believed they had proper posture (87.3%); 38 

subjects with observed proper posture believed that they 

had poor posture (12.7%).

One hundred seventy eight of 202 subjects observed 

with postural faults believed they had proper posture 

(88%); 24 subjects with observed postural faults believed that they had poor posture (12%).

Hip pain was reported by 44 subjects observed with 

upright posture (14.7%) and 42 subjects with postural 

faults (21.2%).

Lower back pain was reported by 85 subjects observed 

with upright posture (28.5%) and 67 subjects with postural faults (33.2%).

A comparison of frequencies for lower back pain based 

on observation and patient reports for posture found 

that lower back pain was present in 23.1% (60 of 260) 

subjects who demonstrated and reported proper posture, 

28.1% (50 of 178) subjects who demonstrated postural 

faults but reported proper posture, 62.5% (15 of 24) 

subjects who demonstrated postural faults and reported 

poor posture, and 71.1% (27 of 38) subjects who demonstrated proper posture but reported poor posture. The 

distributions are presented in Figures 1 through 4.

Analysis of frequency for hip pain based on observation and patient report for posture found that lower back 

pain was present in 10.8% (28 of 260) of subjects who 

demonstrated and reported proper posture, 18.5% (33 

of 178) of subjects who demonstrated postural faults but 

reported proper posture, 37.5% (9 of 24) of subjects who 

demonstrated postural faults and reported poor posture, 

and 42.1% (16 of 38) of subjects who demonstrated 

proper posture but reported poor posture. The data is 

presented in the Table.

DATA ANALYSIS

Chi-square measurements were completed for the ratios of the subjects with and without postural faults who 

present with hip pain history, subjects with postural 

SCREENING INITIAL ENTRY TRAINING TRAINEES FOR POSTURAL FAULTS AND LOW BACK OR HIP PAIN
 April – June 2014 29

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

faults who present with back pain history, and ratio of 

subjects matching perception of posture.

Values for Pearson χ2

 did not reach signifi cant levels 

for hip pain (3.071, minimum 34.74) or lower back pain 

(3.622, minimum 8.48), but did reach signifi cance for 

perception of posture (278.695, minimum 87.26). Likelihood ratios for poor posture and hip pain (3.03) and 

lower back pain (3.56) were not strong. Perception of 

posture had a likelihood ratio of 309.13.

COMMENT

Findings from this study suggest that there is no statistical correlation between observed posture quality and 

presence or absence of lower back pain or hip pain in 

this population. The only correlation supported by χ2

ratios relates to observed posture and perceived posture.

The percentage of subjects with postural faults was 

comparable to the fi nding of 35% by Abdolvahabi et al6

and below the fi nding of 58% by Norris et al.5

 The percentage reporting back pain was closer to the Norris et 

al fi nding (33.2% vs 40% of subjects with swayback).5

At the time of this study, the author was participating in 

an injury prevention program with the single objective 

of early injury identifi cation. All Soldiers arriving from 

BCT were given an intake form which included inquiries about any prior injury at BCT and present requests 

for medical care. More meaningful to military training 

and injury prevention is the observed discrepancy between prior injury or pain complaints in an anonymous 

survey and these intake screening questionnaires. This 

fi nding was not an initial objective and was not anticipated to the observed magnitude. Initial Entry Training 

Soldiers often delay reporting injury either during BCT 

or upon arrival at AIT due to concerns of having a delay in training while receiving medical treatment. During the 5 week study period, only 10 Soldiers reported 

hip pain and 7 Soldiers reported back pain when given 

the opportunity to seek care prior to starting advanced 

training. If all 17 of the Soldiers who requested care 

were included in the surveyed population, there would 

Distribution of observed and reported postures, 

with related reported pain symptoms.

Posture Category Total Low Back Pain Hip Pain

Upright observed, 

upright reported 260 60 28

Upright observed, 

fault reported 38 27 16

Fault observed, 

upright reported 178 50 33

Fault observed, 

fault reported 24 15 9

 No Symptoms

 Low back pain

 Hip pain only

 Hip and low

 back pain

8%

11%

17%

64%

Figure 2. Pain distribution reported by participants 

who incorrectly believed that they had proper posture (n=178).

 No Symptoms

 Low back pain

 Hip pain only

 Hip and low

 back pain

11%

6%

20%

63%

Figure 1. Pain symptom distribution reported by all 

participants in the study (N=500).

 No Symptoms

 Low back pain

 Hip pain only

 Hip and low

 back pain

5%

18%

70%

7%

Figure 3. Pain symptom distribution reported by 

participants who correctly believed that they had 

proper posture (n=260).

 No Symptoms

 Low back pain

 Hip pain only

 Hip and low

7% back pain

25%

34%

34%

Figure 4. Pain symptom distribution reported by 

participants who believed that they had poor posture (n=62), although 38 of them were observed to 

have proper posture.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

still be a discrepancy between the rate of direct reporting (3.4%) and the survey results (37%).

Due to the study’s anonymity and sample percentage, 

the investigator is not able to follow-up to determine the 

number of Soldiers who requested or required medical 

care during training or at BCT. The other recognized 

limitation in this fi nding is the potentially high percentage of reported lower back pain that has been resolved 

or reported when present for only a few days after more 

vigorous training.

Although the percentage of subjects who reported having poor posture was only 12.4%, the percentage within 

that subgroup that reported having a history of hip or 

back pain was 76% (47 of 62), which was higher than the 

percentage of subjects with hip or back pain observed 

with poor posture but reported proper posture (36%), 

or observed with good posture (24.5%). As a screening 

process, it suggests limiting future application for larger 

populations to a written survey. This conclusion will require validation through application on an intake survey 

that is not anonymous.

Limitations of the study include lack of clarifi cation 

as to whether the subjects had current back or hip pain 

and the duration of lower back or hip pain. There was 

uncertainty if subjects reported short duration soreness 

after vigorous work (wearing body armor or road 

march in BCT) as lower back pain, and there was a lack 

of demographic information including differentiation 

by gender. Most Soldiers completing initial training are 

aged 21 years or younger, but comparisons of groups 

cannot be provided and would require modifi cation of 

the study and the consent. 

The Soldiers participating in the study were typically 

standing in place for less than 2 to 3 minutes; therefore, 

postural faults that may develop after 15 to 20 minutes 

were not observed. Soldiers who have lower back and 

hip pain may also have concluded that they have poor 

posture based on symptoms history, but this could not 

be verifi ed. Due to the limitations in time available and 

level of consent, the author also consciously removed an 

axial compression test used in clinical practice to verify 

postural faults as functional or meaningful.

Follow-up studies should include a study of the rate of 

injury disclosure through inclusion of postural self-assessment on the intake survey and associated follow-up 

to assess for hip and lower back pain, and a study to 

validate the magnitude of swayback that is meaningful.

CONCLUSIONS

Observational screening of posture for Soldiers in Initial Entry Training does not effectively identify Soldiers 

with a history of lower back or hip pain. Written questionnaires including focus on posture may offer better 

feedback of a population but would require reevaluation 

without anonymity.

A signifi cant percentage (40%) of Soldiers in Initial Entry Training demonstrate postural faults, most of which 

are not recognized by the Soldiers.

ACKNOWLEDGEMENTS

This study was part of the Injury Prevention Program 

jointly sponsored by the Army Training and Doctrine 

Command and the Army Medical Command. It was conducted in compliance with a protocol approved by the 

Walter Reed National Military Medical Center Institutional Review Board.

REFERENCES

1. Kendall FP, McCreary EK. Muscles: Testing and 

Function. Baltimore, MD: Willaims & Wilkins; 

1983.

2. Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, MO: Mosby, Inc; 2002.

3. Reeve A, Dilley A. Effects of posture on the thickness of transversus abdominis in pain-free subjects. 

Man Ther. 2009;14(6):679-684.

4. Pezolato A, de Vasconcelos EE, Defi no HL, 

Nogueira-Barbosa MH. Fat infi ltration in the 

lumbar multifi dus and erector spinae muscles in 

subjects with sway-back posture. Eur Spine J. 

2012;21(11):2158-2164.

5. Norris CM, Berry S. Occurrence of common lumbar posture types in the student sporting population: an initial investigation. Sports Exerc Inj. 

1998;4:15-18.

6. Abdolvahabi Z, Naeini SS, Kallashi M, Shabani A, 

Rahmati H. The effect of sway back abnormality 

on body segments follow-up changes. Ann Biol Res. 

2012;3(1):140-148.

AUTHOR

When this study was conducted, MAJ Lane was working in the Injury Protection Program of the Musculoskeletal Action Team, Kenner Army Health Clinic, Fort Lee, 

Virginia. He is currently Chief, Physical Therapy, 168th 

Multifunctional Medical Battalion, in the Republic of 

Korea.

SCREENING INITIAL ENTRY TRAINING TRAINEES FOR POSTURAL FAULTS AND LOW BACK OR HIP PAIN
 April – June 2014 31

In every fi eld of clinical medicine there are a number of 

“cannot miss” diagnoses. These include pathologic conditions where diagnostic delay could contribute to signifi -

cant morbidity or mortality. For example, in orthopedic 

surgery this list would certainly include postoperative 

deep vein thrombosis, joint sepsis, and acute compartment syndrome. In military medicine, the list is substantially longer and occasionally not as obvious clinically. 

One such diagnosis is cervical myelopathy. Its clinical 

presentation is often ambiguous, making it diffi cult to detect, especially in the early stages. Further, it has the ability to produce neurologic and musculoskeletal symptoms 

anywhere in the body from head to toe. Consequently, it 

could be considered another “great impostor.” A classic 

medical example of a great impostor is syphilis due to its 

ability to mimic pathology in virtually any organ system 

in the body.1

 Other disease processes such as multiple 

sclerosis, systemic lupus erythematosus, and endocarditis have also been given the label “great masquerader” 

for similar reasons.2-5 The purpose of this clinical review 

is to provide an evidence-based update regarding the diagnostic utility of both common and novel clinical tools.

ETIOLOGY

Myelopathy generally refers to disease within the spinal 

cord. However, there is no universally agreed-upon defi -

nition or pathognomonic fi ndings to assist in the diagnosis. There are several etiologies of cervical myelopathy, 

including trauma, tumor, abscess, rheumatic disease, 

metabolic disorders, and syringomyelia, to name a few. 

The most common etiology is due to progressive degenerative changes within the cervical spine, commonly 

referred to as cervical spondylotic myelopathy (CSM). 

The exact prevalence remains unknown. However, it has 

been reported to be the most frequent cause of cord dysfunction in people older than 55 years.6

 Athletes are more 

likely to develop cervical spine pathology traumatically 

during participation in contact sports such as rugby, soccer, football, diving, and horse riding. In addition, some 

athletes and military occupations are more prone to develop early degenerative changes in the spine secondary 

to repetitive trauma and enduring the general rigors of 

their respective professions.7-9 Consequently, clinicians 

should not discount the possibility of myelopathy simply 

due to the age of the patient.

Cervical Myelopathy: Diagnosing Another

 Great Impostor

 LTC Mark D. Thelen, SP, USA

 Michael D. Ross, DHSc, PT

 Lt Col Michael A. Tall, MC, USAF

ABSTRACT

Context: Cervical myelopathy, especially during the early stages of the disorder, is very diffi cult to diagnose. It has the 

ability to mimic a number of other neurologic and musculoskeletal conditions, resulting in prolonged diagnostic delay in 

some cases. Excessive delay can result in permanent paralysis, gait, and genitourinary dysfunction. While most common 

in aging populations, it can present to military clinicians at any time. Consequently, there needs to be an increased index 

of clinical suspicion when evaluating Soldiers.

Objective: The purpose of this clinical review is to provide an evidence-based update regarding the diagnostic utility of 

both common and novel clinical tools.

Data Sources: English language articles published in peer reviewed journals were identifi ed by searching the PubMed, 

CINAHL, and SPORTDiscus databases.

Results: Historically, clinicians have performed tests such as the Hoffmann or Babinski signs in order to rule out the 

presence of cervical myelopathy or other upper motor neuron disease. While there is some evidence to suggest their clinical usefulness, several other clinical tools should be considered as well. Specifi cally, the Trömner and the Wazir hand 

myelopathy signs are very sensitive for detecting myelopathy at or above the C5-6 level. There is suffi cient evidence to 

suggest that any neurologic screen with the purpose of excluding cervical myelopathy needs to include the lower extremity tests such as the patellar tendon and Rossolimo refl exes. Analysis of the lateral cervical radiograph is an effi cient and 

inexpensive method of evaluating for the presence of congenital cervical spine stenosis, a known risk factor for cervical 

myelopathy. Magnetic resonance imaging fi ndings on T2, and especially the T1 weighted images, appear correlated with 

surgical outcomes.

Conclusion: Military clinicians should use the most valid clinical tools when evaluating for the presence of cervical 

myelopathy.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

EXAMINATION

Clinical Findings

Patients with cervical myelopathy present with a wide 

variety of symptoms ranging from mild sensory loss to 

obvious altered gait and concomitant genitourinary dysfunction. Typically, the onset is insidious in those older 

than 40 years and usually associated with CSM. The frequency of occurrence of CSM is higher in males by an 

approximately 3:2 ratio.10 The specifi c signs and symptoms of cervical myelopathy will be related to the affected level(s) of the cervical spine. In a severely degenerated spine, compression of the cord to varying degrees can 

occur at multiple levels, which can further complicate 

the clinical picture. The signs and symptoms of cervical 

myelopathy are summarized below. Although common, 

the presence of neck pain is not a reliable initial clinical indicator, as some will not complain of pain in this 

region. Stiffness, numbness, and weakness can be present in the upper and/or lower extremities. Further, the 

symptoms may present in a unilateral or bilateral fashion. Gait disturbance and genitourinary dysfunction is 

common in progressive stages of the disease. Urinary 

symptoms, such as increased urgency and frequency, 

appear to be more common than bowel-related symptoms.10 However, on some occasions, patients may present with solely lower extremity complaints.11

Given the wide diversity of symptoms associated with 

cervical myelopathy, it is essential to employ clinical 

tests and measures with the greatest diagnostic utility. 

Specifi cally, tests that demonstrate high levels of sensitivity will be of clinical value to sports medicine clinicians, as a negative fi nding will be helpful in ruling out 

the disorder. Historically, clinicians have used tests and 

measures such as ankle clonus, Babinski sign, hyperrefl exia, and the Hoffmann sign to screen for cervical 

myelopathy. However, diagnostic accuracy studies have 

shown that these clinical tests and measures for cervical myelopathy often display low sensitivity, indicating 

that a negative fi nding may falsely suggest the absence 

of a condition or disease that actually is present. Therefore, to counter the low levels of sensitivity, Cook et al12

proposed that a pragmatic approach looking at patient 

history and pertinent contributory tests and measures 

was the best course of action when evaluating patients 

for the presence of cervical myelopathy.

Subsequently, Cook et al6

 examined the reliability and 

sensitivity of 7 clinical tests: Babinski sign, clonus, 

Hoffmann sign, inverted supinator sign, hand withdrawal refl ex, suprapatellar quadriceps refl ex, and upper 

extremity deep tendon refl exes. Two highly experienced 

clinicians demonstrated substantial inter-rater agreement on 4 of the 7 tests. This potentially limits its applicability to novice clinicians. In contrast to a prior study 

by Cook et al,12 they found no single test or combination 

of tests proved to be an effective screening tool. Of note, 

the Babinski did alter the post-test probability greater 

than any combination of tests performed. A possible 

limitation for this study included the selection of highintensity signal changes, defi ned as myelomalacia, found 

on magnetic resonance imaging (MRI) being selected as 

the imaging reference standard. There is no defi nitively 

accepted diagnostic gold standard for diagnosing cervical myelopathy. Obviously, in order for cord compressive 

myelopathy to be present, there must be, at a minimum, 

physical indentation of the spinal cord. Although myelomalacia has commonly been used as a reference standard, this is a highly specifi c fi nding only addressing one 

possible MRI abnormality. Further, the high specifi city 

seen in both clonus and Babinski was possibly due to the 

fact the all of the subjects were referred to a spine surgeon for surgical evaluation. Therefore, the likelihood of 

diagnosing other causes of upper motor neuron pathologies was decreased. Lastly, an inconsistent time frame 

between imaging and examination was observed.

Since most clinical tests used to identify CSM are specifi c and no clusters of tests have proven more benefi cial 

DIAGNOSING ANOTHER GREAT IMPOSTOR

SIgns and Symptoms of Cervical Myelopathy

Common

Neck pain Neck stiffness

Parasthesias in upper extremities Unilateral or bilateral upper extremity pain

Urinary dysfunction; increased urgency and frequency Gait disturbance

Hyperrefl exia below the level(s) of the lesion Diminished deep tendon refl exes at the level of the lesion

Primitive refl ex(es) present Normal cranial nerve exam

Upper/lower extremity weakness not confi ned Lhermitte’s sign

to single root level

Less Common

Bowel dysfunction Isolated parasthesias in lower extremities

Isolated lower extremity pain Spasticity (usually in later stages)
 April – June 2014 33

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

than standalone tests in guiding treatment decision making, Cook et al13 developed a cluster of predictive clinical fi ndings for patients with cervical myelopathy. Data 

from 249 patients were analyzed using multivariate regression analyses and a defi nitive cluster was identifi ed. 

Thirteen clinical fi ndings were investigated for capacity 

to diagnosis cervical myelopathy. This study found that 

selected combinations of clinical fi ndings that consisted of (1) gait deviation, (2) positive Hoffmann sign, (3) 

inverted supinator sign, (4) positive Babinski sign, and 

(5) patients older than 45 years were effective in ruling 

out and ruling in cervical spine myelopathy. When clustered into one of 5 positive tests to rule out cervical myelopathy, the negative likelihood ratio was 0.18. When 

clustered into 3 of 5 positive fi ndings to rule in cervical 

myelopathy, the positive likelihood ratio was 30.9. This 

study found clustered combinations of clinical fi ndings 

that could rule in and rule out cervical myelopathy.

Rhee et al14 prospectively examined the prevalence of 

myelopathic fi ndings in patients with and without confi rmed CSM. Interestingly, they used postoperative clinical improvement determined by the modifi ed Nurick 

score as the gold standard for confi rming the diagnosis of CSM. At least one physical myelopathic sign was 

identifi ed in both the CSM group (79%) and the control 

group (57%). Subjects in the control group presented 

with neck and/or radicular symptoms, no myelopathic 

symptoms, no cord compression on imaging, and no 

history of cervical spine surgery. The primary result 

was that myelopathic clinical exam fi ndings are more 

common in those patients with myelopathy, however, it 

appeared to lack sensitivity for approximately 20% of 

subjects. No single test proved to be particularly sensitive and test clusters were not evaluated.

More recently, some studies have investigated the frequency of myelopathic clinical exam fi ndings. Chikuda 

et al15 performed a retrospective analysis of 120 patients 

who underwent surgery to address myelopathy due to 

cervical spondylosis or ossifi cation of the posterior longitudinal ligament. They further stipulated that patients 

included in the analysis also had high intensity signal 

changes on preoperative T2 weighted image MRIs. The 

purpose was to report the sensitivity of pyramidal or 

long tract signs in patients who underwent surgery for 

myelopathy. They reported the most sensitive test was 

an exaggerated patellar tendon refl ex (94%), followed 

by the Hoffmann sign (81%), Babinski sign (53%), and 

ankle clonus (35%).

Houten and Noce16 retrospectively reported the prevalence of the Hoffmann sign (68%), Babinski sign (33%) 

and hyperrefl exia (60%) in 225 patients who underwent 

surgery for CSM. Additionally, the severity of myelopathy as determined by modifi ed Japanese Orthopedic 

Association (m-JOA) scores showed selective diagnostic benefi t for the Hoffmann’s sign. Forty-six percent of 

individuals with mild m-JOA scores had a positive Hoffmann sign, compared to only 10% with Babinski sign 

present. In those with severe myelopathy, Hoffmann and 

Babinski signs were positive 81% and 83% respectively. 

This indicates that the Hoffmann sign is more likely to 

be present in milder cases and equally likely in severe 

cases. In addition, they also examined patients presenting exclusively with lumbar spine complaints for the 

presence of a positive Hoffmann sign. Of the 290 subjects in this group, 12% had a positive Hoffmann sign. 

Individuals with a bilateral sign had confi rmed cord 

compression on MRI 91% of the time and 50% of the 

time when the sign was present unilaterally. This fi nding is consistent with the concept of tandem spinal stenosis which has a reported prevalence of 5% to 25%.17

Despite the fact that those subjects were currently asymptomatic, the detection of occult cord compression is 

clinically valuable, especially when considering participation in contact sports or even consenting to surgical 

procedures that require intubation.

In contrast, Sung and Wang18 recommended no further 

evaluation with radiographs or MRI for asymptomatic 

patients that demonstrate a positive Hoffmann sign. 

They found 16 such patients, 15 of whom demonstrated 

signs of cord compression on imaging which ranged 

from mild to severe. Therefore, the presence of a positive Hoffmann sign in asymptomatic patients strongly 

suggests underlying cervical pathology. However, since 

the clinical course was not affected by the imaging results, they concluded that radiographs and MRI were 

unnecessary in this patient population. While this recommendation may be reasonable for the average patient, 

the same cannot be said for the Soldier that may be at 

higher risk for cervical spine injury.

While the Hoffmann sign appears to be very sensitive 

for detecting cord compression, Chang et al19 reported 

the Trömner sign to be a more effective method of detecting CSM. First, however, the difference between the 

two signs must be clarifi ed. The Hoffmann sign was fi rst 

reported in 1911 by a student of Johann Hoffmann and 

is described as fl icking or nipping the nail of the middle 

fi nger in a downward direction with a resultant fl exion of 

the index fi nger and/or thumb.16 The Trömner sign is defi ned as refl exive fl exion of the thumb and fi nger due to 

tapping or fl icking the volar aspect of the distal phalanx 

of the middle fi nger.19 Both the Trömner and Hoffmann 
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

signs are used as indicators for lesions at or above the 

C5-6 level. While not frequently reported in the literature, the Trömner sign demonstrated greater diagnostic 

sensitivity in this study than did the Hoffmann’s sign. 

The reported sensitivity was 93.5% and 89.1% respectively. They further designed a means of quantifying the 

Trömner sign electrophysiologically and found 100% 

sensitivity when CSM patients were assessed in that 

manner. The increased sensitivity of the Trömner sign 

can be reasoned anatomically, given the lack of nerve 

endings in the nail itself, and the robust cutaneous innervations on the volar aspect of the distal phalanx.

The same group of researchers20 also looked to quantify 

the sensitivity of the Rossolimo refl ex in a population 

with confi rmed cervical or thoracic spondylotic myelopathy. The Rossolimo refl ex is also underreported in the 

medical literature with regards to its sensitivity. It is classically described by fl icking or tapping the plantar aspect 

of the toes resulting in fl exion of the toes. Chang et al20

utilized a set-up where the patient is supine (with knees 

slightly fl exed) and a refl ex hammer was used to gently 

strike the skin of the plantar aspect of the 2nd metatarsophalangeal joint. A positive sign was confi rmed when 

there is resultant toe fl exion. In their population, the sensitivity of the test was 85.7% when performed manually, 

and 100% when done using an electrophysiological test.

Recently, Wazir and Kareem21 also reported a handbased myelopathy sign that appears to be sensitive for 

detecting the presence of CSM at or above the C5-6 

level. The Wazir hand myelopathy sign is described as 

the exaggerated fl exor response of the thumb, fi ngers, 

and wrist when the volar aspect of the relaxed extended 

wrist is tapped at the level of the palmaris longus tendon 

(Figure 1). This can be accomplished by lightly tapping 

with the examiner’s middle fi nger or using a refl ex hammer. Ninety-three percent of patients with documented 

CSM at or above the C5-6 level demonstrated a positive test, while no patients with CSM at or below C6-7 

demonstrated a positive sign. The rationale for this is 

anatomic distinction is clear given the disinhibition of 

the long fi nger fl exor refl ex arc when cord compression 

is present above the fi nger fl exor root levels.

Kobayashi et al22 developed a questionnaire that appears to be an effective patient screening tool. Twenty 

candidate questions were selected from the Japanese 

Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire. The reliability and validity for this 

instrument has already been documented.23 A series of 

8 questions were determined to be of the greatest value 

using multiple linear regression and receiver operating characteristic curve analysis. The range of possible 

scores for the questionnaire is 0 to 13. When the cutoff point for the total score was set at 6, the sensitivity 

was 93.5% and the negative likelihood ratio was 0.096. 

The authors concluded that these values are suffi ciently 

high for screening, and this questionnaire is useful to 

rule out cervical myelopathy when scores are less than 

6. The specifi city was 67.3% and the positive likelihood 

ratio was 2.96, suggesting that scores greater than 6 on 

the questionnaire are not useful for making a defi nitive 

diagnosis of cervical myelopathy.

Imaging

Imaging studies are clearly very important in establishing the diagnosis of cervical myelopathy. While MRI 

is the imaging study of choice, there is some valuable 

clinical information that can be obtained via plain radiographs. Particularly, the presence of congenital cervical 

stenosis can be assessed by applying the Torg-Pavlov ratio on a lateral radiograph. It is defi ned as the quotient 

of the development sagittal canal divided by the vertebral body diameter of the same level24 (Figure 2). Values 

lower than 0.80 are concerning for the presence of cervical spine stenosis. In one of only 2 published studies directly comparing the Torg-Pavlov ratio on myelopathic 

with nonmyelopathic individuals, Yue et al24 found the 

mean ratios were 0.73 and 0.95 respectively. Age served 

as a lesser predictive factor revealing that older subjects 

were more likely to have cervical myelopathy. Gender 

did not appear to be a predictive factor. Further, 50 years 

or older was the most common age range of those in the 

cervical myelopathy group who received surgery; when 

this subset was analyzed the mean ratios were 0.71 and 

0.91 respectively. While this method helps to address 

concerns over magnifi cation error, it has been shown by 

Herzog et al25 to have great sensitivity but low positive 

predictive value in athletes. False positives in their population of asymptomatic professional football players 

were largely due to increased diameter of the vertebral 

DIAGNOSING ANOTHER GREAT IMPOSTOR

Figure 1. Demonstration of the Wazir hand myelopathy sign.
 April – June 2014 35

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

body. Consequently, Tierney et al26 proposed a physical measure of the spinal cord using MRI described as 

space available for the cord (SAC). This measure is obtained from subtracting the sagittal diameter of the spinal cord from the sagittal diameter of the vertebral canal 

at that level. It is likely a more specifi c tool to diagnose 

cervical myelopathy given it directly measures the spinal cord and its surroundings. However, it requires the 

use of MRI, and critical SAC values consistent with stenosis have yet to be determined. Other canal measurements on the lateral radiograph have been proposed. For 

example, Herzog et al25 proposed the shortest distance 

between the most posteroinferior aspect (likely an osteophytic rim) of the superior vertebral body with the 

anterosuperior lamina of the inferior vertebral body 

(Figure 2). This can be assessed in the neutral position 

or extended. Extension is likely to show more clinically 

signifi cant diminishment of this diameter. It has been 

suggested that a distance of at least 11 mm to 13 mm is 

required to house the spinal cord, and anything less than 

11 mm is indicative of stenosis.10

Many, if not all, clinicians use MRI images to assist in 

diagnosing cervical myelopathy. There does not appear 

to be any true gold standard on MRI fi ndings other than 

the presence of an indentation of the spinal cord parenchyma.27 Spinal cord compression, indicated by physical 

indentation, can be present in asymptomatic individuals,18,28 but it will always be present with individuals diagnosed with cervical myelopathy. Cook et al6

 specifi -

cally used T2 weighted image high intensity signal (T2 

WI HI) as the diagnostic standard for their study (Figure 

3). The presence of T2 WI HI increases the likelihood 

of cervical myelopathy, but does not make the diagnosis. 

Harrop et al27 demonstrated that when cord compression 

was evident on MRI, the presence of T2 WI HI (odds 

ratio of 11.4) and sensory loss (odds ratio of 16.9) increased the likelihood of myelopathy. Kadanka et al29

prospectively examined a cohort of patients (N=243) to 

determine if a threshold of cord compression exists at 

which patients will develop clinical myelopathic signs. 

They reported that patients with a cross sectional area of 

between 50 mm2

 and 60 mm2 in conjunction with T2 WI 

HI at the same level are most likely to show clinically 

signifi cant symptoms of cervical myelopathy. Avadhani 

et al30 have proposed that both T1 weighted image low 

intensity signal (T1 WI LI) and T2 WI HI can be prognostically useful in determining those likely to obtain 

a poor surgical outcome. Their retrospective analysis 

demonstrated that T1 WI LI along the spinal cord was 

more predictive of a poor surgical outcome. Further, 

some patients with a poorer outcome developed T1 WI 

LI signal changes postoperatively, thereby supporting 

the value in obtaining postoperative MRI images.

Differential Diagnosis

Given the numerous etiologies of myelopathy, and the 

fact that cervical myelopathy presents either vaguely 

similar to or near indistinguishably from a multitude 

of pathologies, the differential diagnosis is very broad. 

Clearly, several other disease processes can produce 

long tract or pyramidal signs such as multiple sclerosis, 

myelitis, and stroke. Obvious muscular causes of upper 

extremity pain including rotator cuff disease are more 

likely and should be assessed. Additionally, there is a 

need to rule out the possibility of isolated or concomitant peripheral neuropathy. However, the list is not simply limited to musculoskeletal or neurologic complaints, 

but should include other organ systems. Clinicians must 

consider everything from infl ammatory causes of spinal 

cord dysfunction such as sarcoidosis to vascular abnormalities like arteriovenous malformation. The combination of clinical signs and imaging information discussed 

above will greatly assist in reducing the possibilities.

Figure 2. Lateral Radiograph Canal Measurements. The Torg–

Pavlov ratio is defi ned as the ratio of A/B and another method 

of evaluating canal diameter is through measuring the distance from the posteroinferior rim of the superior vertebral 

body to the anterosuperior lamina of the inferior vertebral 

body (C).
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

TREATMENT

The primary question with treatment concerns conservative or surgical management: which is more effective? Currently, the best course of treatment remains in 

question. Many clinicians believe that CSM is a result 

of fi xed degenerative deformity, and surgery is the only 

manner to address it. If a patient were to present with obvious and progressive neurologic decline that correlated 

with imaging results, it is clear that surgical intervention is necessary. However, a majority of patients presenting to sports medicine clinicians do not have severe 

cervical myelopathy requiring prompt surgical referral. 

They will likely fall into the category of asymptomatic, 

mild or moderately affected. Therefore, MRI fi ndings 

consistent with cord compression in an asymptomatic 

patient were found serendipitously. Bednarik et al28

prospectively evaluated a group of 199 patients with asymptomatic spondylotic cervical spinal cord encroachment with follow-ups ranging from 2 to 12 years in order to determine the clinical factors common in those 

who ultimately became symptomatic. Those likely to 

develop symptoms in less than a year had complaints of 

radiculopathy and abnormal somatosensory evoked potentials or motor evoked potentials during electrophysiological testing. T2 WI was a common predictor for 

those becoming symptomatic after a year. Ultimately, 

only 8% of the total group required surgery to address 

spondylotic cervical spinal cord encroachment during 

the study period. There are 2 key fi ndings that should 

be highlighted from this study: (a) implementation of 

preventive surgical decompression into routine clinical 

practice should be avoided until better-designed studies 

provide enough evidence for it to take precedence over 

a conservative approach; and (b) the presence of cervical radiculopathy, abnormal electrophysiological fi ndings, and T2 WI require close follow-up. Consequently, 

patients should closely followed and be restricted from 

high risk activities in order to decrease the likelihood of 

spinal cord injury.31

Cases of mild cervical myelopathy should also be closely followed and given a trial of conservative care. There 

is limited evidence to suggest the combination of intermittent cervical traction and thoracic spine manipulation is benefi cial for individuals with grade 1 cervical 

compressive myelopathy attributed to herniated disc.32

Otherwise, the evidence for conservative treatment approaches is scarce. Patients may also benefi t from education, activity modifi cation, and anti-infl ammatory or 

analgesic medications. Kadanka et al33 completed a prospective investigation comparing surgical to conservative management for mild to moderate nonprogressive 

CSM. The study, while underpowered, boasted a 10-year 

follow-up window. There was no difference between the 

2 groups regarding m-JOA scores, 10 m timed walk, and 

quality of daily activities. Therefore, it seems reasonable that a patient with mild to moderate CSM should be 

routinely followed at 6-month intervals to ensure there 

is no progression of the disease.

CONCLUSION

Cervical myelopathy represents one of the most challenging clinical conundrums military clinicians will 

face. The body of evidence regarding the diagnostic 

accuracy of both clinical tests and imaging modalities 

is improving, but lacks consistency. More high quality 

diagnostic cohort trials are needed. In the interim, tests 

that have demonstrated the greatest sensitivity should 

be employed. Hoffmann’s sign, Trömner sign, and the 

Wazir hand myelopathy sign offer the best sensitivity for lesions at or above the C5/6 level. Additionally, 

the Hoffmann sign appears to be especially sensitive in 

earlier stages of cervical myelopathy. Of the lower extremity tests, the Rossolimo refl ex and an exaggerated 

patellar tendon refl ex appear to be most useful. Clinicians that only use Babinski sign and ankle clonus in 

the lower extremities to evaluate for the possibility of 

DIAGNOSING ANOTHER GREAT IMPOSTOR

Figure 3. Sagittal T2 weighted image of the cervical spine 

demonstrating a protruded disc at C5-6 causing cord compression. Altered signal intensity of the cord is also seen (circle) (indicating localized myelomalacia).
 April – June 2014 37

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

upper motor neuron disease should consider expanding 

the scope of their neurologic evaluation. The Torg-Pavlov ratio is inexpensive and can indicate the presence 

of congenital cervical stenosis. Other lateral radiograph 

measurements can also indicate the presence of congenital or acquired stenosis. Findings on both T1 and T2 

weight MRI images should be correlated with clinical 

exam fi ndings. Ultimately, the clinical exam fi ndings 

must be correlated with the imaging results to arrive at 

the diagnosis. In the absence of other known neurologic conditions, the presence of at least one reproducible 

pyramidal sign and the presence of cord compression 

and T2 WI HI will signifi cantly increase the likelihood 

of myelopathy. Asymptomatic individuals and patients 

with mild signs and symptoms associated with nonprogressive cervical myeloplathy do not require preemptive 

surgical intervention, but recurrent neurologic follow-up 

and counseling to avoid high-risk activities are strongly 

recommended.

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secondary to neurosyphilis. Optom Vis Sci. 

2010;87(10):E790-E796.

2. Erneston AG. Multiple sclerosis, the great masquerader: an atypical ocular presentation. J Am 

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3. Hillman BC. Cystic fi brosis: a challenging masquerader. Clin Rev Allergy. 1983;1(1):57-72.

4. Lewis KS. Systemic lupus erythematosus: the great 

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5. Layland J, Jellis C, Doyle J, Fox P, Wilson A. Abiotrophia endocarditis: the great masquerader. Aust N 

Z J Psychiatry. 2008;42(11):991-993.

6. Cook CE, Roman M, Stewart KM, Leithe LG, Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for 

cervical dysfunction. J Orthop Sports Phys Ther. 

2009;39(3):172-178.

7. Aydog ST, Turbedar E, Demirel A, et al. Cervical 

and lumbar spinal changes diagnosed in four-view 

radiographs of 732 military pilots. Aviat Space Environ Med. 2004;75(2):154-157.

8. Berge J, Marque B, Vital JM, Sénégas J, Caillé 

JM. Age-related changes in the cervical spines 

of front-line rugby players. Am J Sports Med. 

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9. Tsirokos A, Papagelopoulos PJ, Giannakopoulos 

PN. Degenerative spondyloarthropathy of the cervical and lumbar spine in jockeys. Orthopedics. 

2001;24(6):561-564.

10. Tracy JA, Bartleson JD. Cervical spondylotic myelopathy. Neurologist. 2010;16(3):176-187.

11. Ross MD, Elliot R. Cervical cord compressive myelopathy in a man with a primary complaint of knee 

pain. J Spinal Cord Med. 2010;33(4):431-434.

12. Cook CE, Hegedus E, Pietrobon R, Goode A. A 

Pragmatic neurological screen for patients with 

suspected cord compressive myelopathy. Phys 

Ther. 2007;87(9):1233-1242.

13. Cook C, Brown C, Isaacs R, Roman M, Davis S, 

Richardson W. Clustered clinical fi ndings for diagnosis of cervical spine myelopathy. J Man Manip 

Ther. 2010;18(4):175-180.

14. Rhee JM, Hefl in JA, Hamasaki T, Freedman 

B. Prevalence of physical signs in cervical myelopathy a prospective, controlled study. Spine. 

2009;34(9):890-895.

15. Chikuda H, Seichi A, Takeshita K, et al. Correlation 

between pyramidal signs and the severity of cervical myelopathy. Eur Spine J. 2010;19:1684-1689.

16. Houten J, Noce L. Clinical correlations of cervical 

myelopathy and the Hoffmann sign. J Neurosurg 

Spine. 2008;9(3):237-242.

17. Laban MM, Green ML. Concurrent (tandem) cervical and lumbar spinal stenosis. A 10-yr review of 

54 hospitalized patients. Am J Phys Med Rehabil. 

2004:83(3):187-190.

18. Sung RD, Wang JC. Correlation between a positive Hoffmann’s refl ex and cervical pathology in 

asymptomatic individuals. Spine. 2001;26(1):67-70.

19. Chang CW, Chang KY, Lin SM. Quantifi cation of the Trömner signs: a sensitive marker for 

cervical spondylotic myelopathy. Eur Spine J. 

2011;20:923-927.

20. Chang CW, Chang KY, Lin SM. Quantifi cation of 

Rossolimo refl exes: A sensitive marker for spondylotic myelopathy. Spinal Cord. 2011;49:211-214.

21. Wazir NN, Kareem BA. New clinical sign of cervical myelopathy: Wazir hand myelopathy sign. Singapore Med J. 2011; 52(1) :47-49.

22. Kobayashi H, Kikuchi S, Otani K, Sekiguchi M, 

Sekiguchi Y, Konno S. Development of a self administered questionnaire to screen patients for 

cervical myelopathy. BMC Musculoskelet Disord. 

2010;11:268.

23. Nikaido T, Kikuchi S, Yabuki S, Otani K, Konno 

S. Surgical treatment assessment using the Japanese orthopedic association cervical myelopathy 

evaluation questionnaire in patients with cervical 

myelopathy. a new outcome measure for cervical 

myelopathy. Spine. 2009;34(23):2568-2572.
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24. Yue WM, Tan SB, Tan MH, Koh DC, Tan CT. The 

Torg–Pavlov ratio in cervical spondylotic myelopathy. a comparative study between patients 

with cervical spondylotic myelopathy and a nonspondylotic, nonmyelopathic population. Spine. 

2001;26(16):1760-1764.

25. Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ. 

Normal cervical spine morphometry and cervical 

spine stenosis in asymptomatic professional football players. Plain fi lm radiography, multiplanar 

computed tomography, and magnetic resonance 

imaging. Spine. 1991;16(suppl 6):S178-S186.

26. Tierney RT, Maldjian C, Mattacola CG, Straub SJ, 

Sitler MR. Cervical spine stenosis measures in normal subjects. J Athl Train. 2002; 37(2):190-193.

27. Harrop JS, Naroji S, Maltenfort M, et al. A clinical and radiographic evaluation and correlation to cervical spondylotic myelopathy. Spine. 

2010;35(6):620-624.

28. Bednarik J, Kadanka Z, Dusek L, et al. Presymptomatic spondylotic cervical myelopathy: an updated predictive model. Eur Spine J. 2008;17:421-431.

29. Kadanka Z, Kerkovsky M, Bednarik J, Jarkovsky 

J. Cross-sectional transverse area and hyperintensities on magnetic resonance imaging in relation to 

the clinical picture in cervical spondylotic myelopathy. Spine. 2007;32(23):2573-2577.

30. Avadhani A, Rajesekaran S, Shetty AP. Comparison of prognostic value of different MRI classifi cations of signal intensity change in cervical spondylotic myelopathy. Spine J. 2010;10:475-485.

31. Bednarik J, Sladkova D, Kadanka Z, et al. Are subjects with spondylotic cervical cord encroachment 

at increased risk of cervical spinal cord injury after minor trauma?. J Neurol Neurosurg Psychiatry. 

2011;82:779-781.

32. Browder DA, Erhard RE, Piva SR. Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy 

attributed to cervical herniated disc: a case series. 

J Orthop Sports Phys Ther. 2004;34(11):701-712.

33. Kadanka Z, Bednarik J, Novotny O, Urbanek I, 

Dusek L. Cervical spondylotic myelopathy: conservative versus surgical treatment after 10 years. 

Eur Spine J. 2011;20(9):1533-1538.

AUTHORS

LTC Thelen is an Assistant Professor, US Army-Baylor 

Doctoral Program in Physical Therapy, US Army Medical Department Center and School, Joint Base San Antonio–Fort Sam Houston, TX.

Dr Ross is an Assistant Professor, Department of Physical Therapy, University of Scranton, Scranton, PA.

Lt Col Tall is Chief, Musculoskeletal Imaging, Wilford 

Hall Ambulatory and Surgical Center, Joint Base San 

Antonio–Lackland, TX.

DIAGNOSING ANOTHER GREAT IMPOSTOR
 April – June 2014 39

SUMMARY

Angioedema has not been associated with rheumatoid 

arthritis. However, this case report demonstrates that 

it can be the leading presentation of an exacerbation of 

rheumatoid arthritis. This case report is important for 

both rheumatologists and immunologists who see patients with rheumatoid arthritis and angioedema, respectively, so they recognize this presentation.

BACKGROUND

Angioedema is a disorder characterized by swelling in 

the subcutaneous tissues resulting in a clinical presentation of swollen tongue, lips, throat, orbital tissues, and 

gastrointestinal tract distress. It can be hereditary or 

secondary to drugs or allergens. Rarely it can be associated with hypereosinophilic and Gleich’s syndrome. It 

has not been known to herald an acute exacerbation of 

rheumatoid arthritis. This case report identifi es one such 

possible example.

CASE PRESENTATION

A Caucasian male 62 years of age was diagnosed with 

rheumatoid arthritis in December 2010 after presenting 

to his physician with symmetrical pain and swelling in 

both shoulders and metatarsal phalangeal joints. He was 

started on methotrexate and titrated to 22.5 mg once a 

week. In addition, he was treated with prednisone 5 mg 

orally every day to control his disease. The patient remained on this treatment till December 2011 when the 

author became his care provider. At this time, he had no 

morning stiffness or joint swelling. He had mild pain in 

hands and left foot, rated 4/10. On exam, he had mild 

tenderness of metacarpal phalangeal and proximal interphalangeal joint pain bilaterally but no swelling or synovial thickening was appreciated. The shoulders were 

not tender, with normal range of motion. There was mild 

tenderness of his left metatarsal phalangeal joints but no 

synovial thickening or swelling was appreciated. Sedimentation rate was 0, rheumatoid factor 12, and antiCCP antibody greater than 250. At this time, hydroxychloroquine 200 mg bid was started and prednisone was 

tapered off to avoid steroid side effects. 

The patient did well on this regimen and was seen at 3 

monthly intervals with monitoring of hematology and 

chemistries.

Patient noted that he had a sore throat on October 28, 

2012, with swelling around eyes and mouth which was 

associated with pain but no itching. He went to the emergency room where he was noted to have no shortness of 

breath, but did have swelling of lips and tongue. He was 

treated with amoxicillin and discharged. He returned to 

the emergency room on November 2, 2012, with worsening swelling of tongue and lips. He had no skin rash, 

trouble breathing, diarrhea, abdominal pain, or swelling 

around the eyes. He was taken off amoxicillin and put on 

a Medrol dose pack. The lesions attenuated somewhat 

on Medrol, but recurred after the Medrol dose pack was 

fi nished. He once again returned to the emergency room 

on November 10 where the physician stopped methotrexate and hydroxychloroquine and placed an immunology consult. While waiting for the immunology consult, 

the patient had recurring episodes of swelling of his lips 

and periorbital tissues. There was no tongue swelling or 

trouble swallowing. There were days when he was completely asymptomatic with no symptoms. Despite being 

off antirheumatic drugs, the pain in joints stayed bearable, with no swelling or morning stiffness.

The immunologist saw the patient on December 18. At 

that time, the patient had no signs or symptoms of angioedema or urticarial lesions. He had no trouble breathing 

and had no gastrointestinal symptoms. A workup was 

ordered, which showed normal levels of C1 inhibitor, 

C4, hemolytic complement 50, erythrocyte sedimentation rate, comprehensive metabolic panel, urine analysis, 

and thyroid stimulating hormone. The immunologist advised the patient to restart the antirheumatic drugs and 

also started him on hydroxyzine and ranitidine. After 

initiation of hydroxyzine and ranitidine, the episodes 

of angioedema decreased in severity, with less swelling 

of lips and periorbital tissues. He continued to have no 

shortness of breath, abdominal pain, or tongue swelling.

Two months later (February 2013), the patient’s rheumatoid arthritis fl ared, with signifi cant bilateral hand tenderness, swelling, and synovitis in metacarpal phalangeal joints and proximal interphalangeal joints. Morning stiffness increased to 2 hours and sedimentation rate 

was above 50. His angioedema also became more severe, 

with greater involvement of lips and periorbital tissues 

and increased pain in lips. Since he was already on high 

Angioedema as a Prodrome of Rheumatoid

 Arthritis Exacerbation

Ketan Desai, MD, PhD
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

dosages of methotrexate and hydroxychloroquine, biologics were considered. After getting PPD and chest Xray, he was started on an anti-TNF biologic. 

Two weeks after starting the anti-TNF, the patient became asymptomatic, with no tenderness, swelling in 

any joint, and no morning stiffness. His ESR also normalized. The angioedema was completely absent. The 

hydroxyzine and ranitidine were discontinued after a 

month of anti-TNF therapy. There has been no recurrence of angioedema over the past 6 months.

COMMENT

Angioedema is the swelling of deep dermis, subcutaneous, or submucosal tissue due to vascular leakage. Histamine and bradykinin are the most recognized vasoactive mediators known to be critical in the pathogenesis 

of angioedema.1

 Histamine can be released by IgE or 

non-IgE mechnisms. Most commonly, the release of 

these mediators is a result of allergens or drugs. Rare 

causes include hypereosinophilic syndrome and Gleich’s Syndrome.2

 Angioedema has not been recognized 

as a complicating feature of rheumatoid arthritis. Certain medications have been implicated in the induction 

of angioedema. Among those are antirheumatic agents 

such as anti-TNF biologics3

 and methotrexate.4 There 

have also been rare case reports of rheumatoid arthritis developing in patients with hereditary angioneurotic 

edema.5

 However, there have been no reported cases of 

angioedema heralding a fl are of rheumatoid arthritis. 

This is possibly the fi rst such reported case. This is important since recognition of this manifestation can result 

in quick and appropriate management. It is possible that 

this could be a manifestation of methotrexate induced 

angioedema, but is unlikely since the patient had been 

on methotrexate for 2 years and the angioedema disappeared after the anti-TNF biologic was added, despite 

continuation of methotrexate.

CONCLUSIONS

 Rheumatologists should be aware that angioedema 

may herald a fl are in rheumatoid arthritis.

 Immunologists should also be aware that the angioedema may be a result of rheumatoid arthritis and 

can herald a fl are.

 The angioedema subsides if the rheumatoid arthritis is treated appropriately.

REFERENCES

1. Oschatz C, Maas C, Lecher B, et al. Mast cells 

increase vascular permeability by heparin-initiated bradykinin formation in vivo. Immunity. 

2011;34(2):258-268

2. Banerji A, Weller PF, Sheikh J. Cytokine-associated 

angioedema syndromes including episodic angioedema with eosinophilia (Gleich’s Syndrome). Immunol Allergy Clin North Am. 2006;26(4):769-781.

3. Benucci M, Manfredi M, Saviola G, Baiardi P, 

Campi P. Correlation between atopy and hypersensitivity reactions during therapy with three different TNF-alpha blocking agents in rheumatoid 

arthritis. Clin Exp Rheumatol. 2009;27(2):333-336.

4. Freeman AM, Dasgupta B. Angio-neurotic oedema associated with methotrexate treatment in 

rheumatoid arthritis. Rheumatology (Oxford). 

1999;38(9):908.

5. Duncan IJ, Tymms KE, Carney G. Rheumatoid 

arthritis and hereditary angioedema. J Rheumatol. 

1988;15(4):700-702.

AUTHOR

Dr Desai is a Clinical Immunologist practicing rheumatology and allergy/immunology at the Wilkes Barre VA 

Medical Center, Wilkes Barre, Pennsylvania. 

ANGIOEDEMA AS A PRODROME OF RHEUMATOID ARTHRITIS EXACERBATION
 April – June 2014 41

BACKGROUND

Osteoarthritis results in activity and functional limitations, high health care and economic costs, and increased mortality.1,2 Osteoarthritis (OA) of the hip and 

knee is the primary etiology of walking-related disability in the United States.3

 Depending on age, hip joint 

OA alone has an estimated prevalence of 28% to 43% 

radiologically, and 10% to 17% based on symptoms.4

The prevalence of this is rising, attributed in some studies to the advancing age of the population and increased 

incidence of obesity.5,6

While no reversible treatment for hip joint OA is available, total hip arthroplasty has been shown to provide 

excellent pain relief, return of function, and medication 

reduction.7

 With relatively low associated complication 

rates,7

 it is the standard of care for patients failing conservative treatment. However, barriers to arthroplasty 

treatment include patient factors such as comorbidities 

and active health issues, system factors (surgical wait 

times, lifespan of surgical implants, etc), and societal 

factors such as gender and race.1,7-9

Proposed conservative treatments for OA have varying levels of evidence and effi cacy and include lifestyle 

modifi cations (weight loss, exercise, nutriceuticals),10-14

physical therapy (modalities, bracing, gait aids, shoe 

modifi cations, acupuncture, aquatic therapy, strengthening),15-18 pharmaceuticals (topical medications, acetaminophen, nonsteroidal anti-infl ammatories, opioids, 

nitric oxide),19 and joint injections (steroids, hyaluronic 

acid, prolotherapy, autologous blood injections).20,21

Thermal radiofrequency (TRF) denervation of the sensory articular nerves to the hip joint is emerging as a 

possible adjunctive treatment for coxalgia. This has been 

validated for the management of zygapophyseal joint 

pain, having been shown to improve pain and function, 

and has good long term reproducibility.22,23 Exact mechanisms of action are not known, but coagulation likely 

Radiofrequency Denervation of the

 Hip Joint for Pain Management:

 Case Report and Literature Review

Gaurav Gupta, MD, FRCPC

 Mohan Radhakrishna, MD, FRCPC

 Paul Etheridge, MD

 L Col Markus Besemann, MD, FRCPC

 Roderick J Finlayson, MD, FRCPC

ABSTRACT

Background: A 55-year-old male presented with severe pain and functional limitations as a result of left hip osteoarthritis. He had failed multiple treatments while waiting for a hip arthroplasty, including physical therapy, medications, and various intra-articular injections. Thermal radiofrequency lesioning of the obturator and femoral articular 

branches to the hip joint was offered in the interim.

Objectives: To our knowledge, this is the fi rst report to describe an inferior-lateral approach for lesioning the obturator branch, the clinical application of successive lesions to increase denervation area, and outcomes in a patient 

receiving a second treatment with previously good results.

Methods: To discuss relevant and technical factors for this specifi c case, we reviewed previous literature on hip joint 

radiofrequency and critically evaluated previous anatomic studies in the context of radiofrequency.

Results: The fi rst treatment provided signifi cant benefi t for a period of 6 months. A second treatment was employed 

providing only mild to moderate benefi t until his joint replacement surgery 4 months later. Literature review revealed 

studies of low quality secondary to small sample sizes, patient selection methodology, inclusion of patients with heterogenous etiologies for pain, variable needle placement techniques, and lack of measurement of functional outcomes.

Limitations: Case report and low quality studies in existing literature.

Conclusions: Hip joint radiofrequency denervation is a promising avenue for adjunctive treatment of hip pain. Further cadaveric studies are required to clarify a multitude of technical parameters. Once these are well defi ned, future 

clinical studies should consider pain, functional, and economic outcomes in their design.
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

denatures peripheral nerves, preventing conduction in 

small myelinated and unmyelinated nerve fi bers until 

the nerve regenerates.24 This treatment is predicated 

on the need for limited anatomical variation, validated 

bony landmarks under fl uoroscopy, and careful patient 

selection.25

CASE REPORT BACKGROUND

Written permission for publication of this case report was 

obtained in concordance with current ethical guidelines.

A 55-year-old male presented with severe pain and functional limitations as a result of left groin pain attributed 

to osteoarthritis. Past medical history included hypertension, dyslipidemia, sleep apnea, type 2 diabetes mellitus, depression, and opioid addiction. Medications 

included atenolol, hydrochlorothiazide, amlodipine, 

trazodone, duloxetine, amitriptyline, quetiapine, and 

pregabalin. Physical examination revealed an antalgic 

gait, painful range of motion for the left hip, mild pain 

to palpation in the left groin, and a glove and stocking 

decrease for pinprick in the lower limbs. X-ray imaging 

revealed mild superior-lateral hip osteoarthritic changes. 

Magnetic resonance arthrogram revealed a small, undisplaced, anterior labral tear.

He failed multiple treatments including physical therapy, 

medications, and various injections. Arthroscopic debridement of the labral tear did not result in clinical improvement, but signifi cant osteoarthritic changes were 

noted superior-laterally. Because the waitlist for a hip 

arthroplasty was in excess of one year, thermal radiofrequency lesioning of the articular branches was offered 

in the interim. Given the patient had a concordant but 

time-limited response to intrarticular hip injection on 2 

separate occasions, diagnostic blocks of the femoral and 

obturator branches were not performed.

For the obturator articular component, a 10 cm radiofrequency cannula with a 10 mm active tip (Diros Technology Inc., Markham, Ontario, Canada) was advanced 

into position from an inferior-lateral position, directed 

towards the inferior-lateral margin of the “teardrop” 

using a combination of ultrasound (L14-5w linear array 

probe, Zonare Z.one Ultra sp, Zonare Medical Systems, 

Mountain View, CA) and fl uoroscopy (C-arm, Siemens, 

Burlington, Ontario, Canada) in an anterior-posterior 

(AP) projection. Two treatments were made with the 

cannula translated 1 cm from inferior to superior.

For the femoral branches, the cannula was positioned 

using the same imaging modalities from the lateral 

projection. The initial target was immediately inferior 

to the anterior inferior iliac spine in the upper third of 

the acetabulum. For the fi rst treatment, 2 lesions were 

made moving superiorly to inferiorly separated by 1 

cm, while the second treatment used 2 lesions along the 

same trajectory separated by 1 cm medially to laterally 

(Figure 1). Each radiofrequency lesion occurred at 80°C 

for 2 minutes.

The fi rst treatment provided almost 90% relief, a return 

to almost all baseline function except playing hockey, 

and discontinuation of pain medication for a period of 

6 months. The second treatment provided between 20% 

to 50% relief, with moderate ongoing functional limitations and the necessity for adjunctive pain medication 

until joint replacement 4 months later.

To our knowledge, this is the fi rst report to describe an inferior-lateral approach for lesioning the obturator branch, 

clinical application of successive lesions to increase denervation area, and outcomes in a patient receiving a second treatment with previously excellent results. Discussion includes relevant anatomic research, previous clinical studies, possible reasons for differences in outcomes 

for the second treatment, and future directions.

METHODS

Technical details of the procedure performed on our patient are described in the preceding section.

Literature searches were performed in PubMed, Embase, 

and Google Scholar. Search terms included hip joint, 

osteoarthritis, radiofrequency, femoral nerve, sciatic 

nerve, obturator nerve, hip joint anatomy, neurectomy, 

articular branch, joint denervation, coxalgia, pain, and 

hip joint anatomy. Citations were reviewed by authors 

Gupta and Finlayson, yielding 7 articles relevant to hip 

joint radiofrequency in a clinical setting, and 18 articles 

relevant to hip joint innervation or surgical neurectomy. 

Review of the bibliographies of these studies yielded 2 

more radiofrequency articles (for a total of 9), and 12 

more anatomy/surgery articles (for a total of 29). Only 

English language articles were reviewed by authors 

Gupta and Finlayson, except where a foreign language 

study was considered to provide unique information.

COMMENT

Clinical Studies-Treatment of Hip Pain

Without RF Denervation

There is considerable clinical precedent for denervation treatment for the hip joint for pain. Obturator neurectomy for osteoarthritis of the hip was introduced by 

Camitz26 in 1933 and Mol27 in 1935. Tavernier and Godinot reported successful outcomes in 38% of 57 patients 

undergoing surgical obturator neurectomy for hip OA.28

RADIOFREQUENCY DENERVATION OF THE HIP JOINT FOR PAIN MANAGEMENT:

CASE REPORT AND LITERATURE REVIEW
 April – June 2014 43

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

By combining neurectomy of the obturator and quadratus femoris component, 22 of 24 cases initially had 

satisfactory results,29 however, the long term outcomes 

between 3 and 18 month follow-ups showed excellent 

results in only 2 patients, and no improvement in 22.30

Results from another study showed 28 of 42 patients 

with hip pain of varying etiologies responded to surgical 

neurectomy of the obturator and quadratus femoris components, where failures were attributed to an extrapelvic 

surgical approach and variability in joint innervation. 

Hip fl exion weakness and sensory loss were commonly 

reported, but not as having any important functional 

signifi cance.31 Padovani performed surgical neurectomy 

including the femoral contribution to achieve complete 

sensory denervation.32 Subsequent studies have been reported over the years, but this technique eventually fell 

from favor owing to mixed results and residual symptoms 

attributed to iatrogenic nerve injury.33-35 Akatov and Dreval employed obturator main branch TRF in 15 patients 

with coxarthrosis, but the reported technical details and 

clinical outcomes were not clear. All but one patient had 

sensory disturbances postprocedure, and 3 other patients 

required additional treatment for myofascial pain.36

Heywang-Köbrunner and colleagues used CT guidance 

for diagnostic and therapeutic large volume, obturator 

nerve, local anesthetic blocks in 15 patients. Four patients reported excellent relief for between 3 to 11 months, 

and another 3 patients had good to excellent pain relief 

varying between one to 8 weeks. For the remaining 8 

patients there was either mild effect (4 patients), pain 

resolved for only one day (2 patients) or no effect.37

In contrast, Edmonds-Seal and colleagues compared 

outcomes for 18 patients with unilateral hip OA in a 

double blind trial comparing landmark guided, large 

volume, local anesthetic blocks to saline for the obturator and quadratus femoris branches. Five patients improved in pain and function and 8 patients in mobility, 

but there was no difference between local anesthetic and 

saline in treatment outcome, and effect was lost in all 

but one patient after 4 weeks. There were also a similar 

number of patients whose pain, function, and mobility 

worsened postinjection, and one patient seized postblock.38 Other studies have reported repeat block can be 

helpful in some patients.35

Clinical Studies-Treatment of Hip Pain

Using RF Denervation

Rivera and colleagues39 prospectively studied 17 patients with chronic hip pain who were nonoperative 

candidates (OA, prolonged postoperative pain). Eight 

patients reported a decrease in pain of at least 50% at 

the 6-month follow-up, associated with a statistically 

signifi cant improvement in WOMAC* and Harris Hip 

Scores. After noting transient hematoma in 3 cases from 

vessel puncture, they changed to the lateral needle approach described by Locher and colleagues40

partway through their study. However, they did 

not employ multiple lesions per nerve as suggested by Locher et al (ie, lesion stacking).40

Kawaguchi and colleagues showed 79% (11 patients) had effective treatment, while 3 patients 

had an ineffective response. They showed 12 

patients had 50% reduction in hip region pain 

lasting one to 11 months. One patient whose 

treatment was considered ineffective had close 

to a 50% reduction in groin pain, but not lateral hip pain. Patients were selected on this basis of response to either obturator blocks and/

or response to intra-articular injections. Nine 

patients had radiofrequency denervation of the 

obturator component only, and in addition, 5 

had denervation of the femoral component.41

Malik and colleagues showed denervation of 

the femoral and obturator components in 4 patients resulted in reduction in pain between 30% and 

70%, improvement in function in 3 of 4, and reduced 

medication usage in 2 patients.42

Wu and Groner looked at pulsed radiofrequency (PRF) 

as a potential treatment for hip pain in 2 patients, citing 

a small risk of neuroma and neuritis with TRF. When 

*Western Ontario and McMaster Universities Arthritis Index

Figure 1. Thermal monopolar radiofrequency denervation of the femoral 

and obturator branches of the left hip joint.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

compared to thermal radiofrequency, PRF applies heat 

at a lower temperature and therefore does not cause 

tissue coagulation, and ideal probe placement is perpendicular to the neural structure. Both patients had 

improved pain and relative function at short-term follow-up.43 The evidence for comparing PRF to TRF is 

limited, but there is suggestion they could be equivalent 

for cervical radicular pain, while TRF shows better effi -

cacy in idiopathic trigeminal neuralgia.44 We would not 

recommend PRF for this use, given that the required 

perpendicular needle placement is in close proximity to 

the neurovascular structures.40

 Chaiban and colleagues used ultrasound guidance for 

treatment of bilateral hip pain in a single patient with 

hip osteoarthritis, resulting in 80% reduction in pain at 

3-month follow-up.45 Fukui and Nosaka showed signifi -

cant decrease in pain, improved walking ability, and reduction in pain medication use for 6 months after femoral 

and obturator articular branch TRF in one patient. The 

needle was inserted from anterior-posterior for the obturator branch and directed from the superior pubic ramus 

to the obturator canal. They argued that motor weakness 

did not occur because only the obturator branch was 

only partially destroyed when using lesion of 90°C for 

180 seconds.46 In a Korean language case report, Shin 

and colleagues reported on a single case of thermal radiofrequency denervation of the femoral and obturator 

branches resulting in a 50% reduction in pain.47

Overall, studies for hip joint radiofrequency were of 

low quality secondary to small sample sizes, patient 

selection methodology, inclusion of patients with heterogeneous etiologies for pain (eg, OA, congenital, and 

metastasis), variable needle placement techniques, and 

lacking functional outcomes. However, no signifi cant 

adverse events were reported, with only one study reporting numbness developing in the thigh region in one 

patient, and another with transient hematoma formation 

in 3 cases.39,42

The relevant articles for hip joint radiofrequency are 

summarized in the Table.

Anatomical and Safety Considerations for Hip Joint 

Thermal Radiofrequency

For hip joint thermal radiofrequency denervation, the 

main anatomic and safety issues are:

 multiple contributions from various nerves,

 variable anatomy and course for each specifi c nerve,

 vascular injury,

 incomplete denervation secondary to closely associated vessels, and

 further joint injury through nerve or vascular 

destruction.

The following discussion of anatomy is meant to refl ect 

the perspective of the interventionalist, although most 

articles do not discuss nerve trajectory with respect to 

bony structures, which is imperative to designing a reliable and reproducible procedure. Also, for this discussion it is assumed branches that innervate a region of 

the capsule will supply the neighboring portion of the 

joint,48 however, this is not explicitly stated in all articles.

Some guiding principles can be applied to regional innervation of the hip joint, but signifi cant variation has 

been described.49 Generally, the anteriormedial portion of the capsule is innervated by the branches of the 

obturator nerve, anterolateral capsule branches of the 

femoral nerve, posteromedial joint from branches of the 

sciatic nerve, and/or nerve to quadratus femoris, superolateral (posterior and anterior) from branches of the superior gluteal nerve. Inferior capsule innervation is possibly from the obturator nerve or inferior gluteal nerve 

(Figure 2).40,48,50-65

The obturator nerve has a variable number of articular branches likely radiating from a common stem located lateral to the obturator foramen inferior to the 

acetabulum (Figure 3). The radiologic landmark is 

immediately below the teardrop silhouette seen on AP 

x-ray, corresponding to the junction of the pubis and ischium, where the lateral line is from the acetabular wall, 

the medial line formed by the lesser pelvis and the inferior wall from the acetabular notch.40,41 The branches 

usually course superior and laterally towards the anteromedial portion of the capsule, but can exit the obturator 

foramen as inferiorly as the junction between the proximal and middle third.40

The excellent anatomic description by Locher and colleagues for a superolateral approach for denervation of 

obturator components provides a good basis for discussion. The superior approach allows for parallel placement, and therefore the longest lesion along the branches.40 Our inferior approach may increase the likelihood 

of denervating multiple branches, but the lesion size will 

not be in parallel, resulting in a smaller lesion, equivalent to one or 2 electrode widths,25 and may require longer cannula length depending on the patient.

In our opinion, the initial placement of a 21 gauge spinal 

needle using the AP approach for guidance and local anesthetic purposes still poses a measurable risk to the neurovascular bundle.38 In our case, and where the cannula 

size was previously reported, no radiofrequency cannula 

RADIOFREQUENCY DENERVATION OF THE HIP JOINT FOR PAIN MANAGEMENT:

CASE REPORT AND LITERATURE REVIEW
 April – June 2014 45

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

larger than 22 gauge was employed.40,42,44 Rivera and colleagues started with an AP approach presumably using 

the 22 gauge cannula, but switched to the Locher approach after hematomas were noted.39,40 For this reason, 

we do not support use of this component of the approach.

Without the benefi t of the 21 gauge guiding needle,40 and 

given our limited experience, we found inserting the 

cannula from the superolateral projection too complex. 

This concern was not cited by Rivera and colleagues, 

who also did not report use of the guide needle.39 In our 

case, the simultaneous use of ultrasound allowed us to 

navigate around the neurovascular bundle and advance 

the needle from the lateral position (allowing us to account for depth), while using intermittent AP fl uoroscopy to confi rm trajectory. However, the need for both 

ultrasound and fl uoroscopy skills may be a barrier to 

adoption of this technique.

Studies Detailing Clinical Outcomes for Patients Undergoing Articular Radiofrequency for Treatment of Hip Joint Pain.

Study No. of Patients: 

Treatment Details

Pathology 

Types

Results Adverse 

Events

Notes

Chaibin et al45 1: TRF femoral and obturator 

bilateral, 80°C for 6 seconds. 

22 gauge 5 mm active tip.

OA P: 80% reduction 

at 3 months

F, M: N/A

None Ultrasound and fluoro guidance. 

Used sensory and motor stimulation. 

Selected based on time limited response to bursa and joint injections. 

Patient continued anticoagulation.

Rivera et al39 17: TRF femoral and obturator branches, 90°C for 90

seconds. 22 gauge 5 mm active tip.

OA, post 

THA, post 

girdlestone

P: 30% avg reduction at 6 months, 

8 patients >50% 

relief

F: improved Harris 

Hip and WOMAC 

scores

M: N/A

3 Transient 

hematomas

Diagnostic blocks (3 cc). Inserted 

needle medial or lateral to femoral 

artery for obturator. 5 mm active tip. 

Sensory and motor stimulation used. 

Switched to Locher40 method during 

course of study.

Wu and Groner43 2: PRF femoral and obturator branches, 45°C for 120

seconds. 22 gauge 10 mm 

active tip.

FHN, post 

THA

P: 50% to 60% 

reduction at 3-4 

months

F: improved 

ambulation

M: N/A

None Diagnostic blocks (0.5 cc to 1 cc). 

Sensory stimulation.

Shin et al47 1: Femoral and obturator 

branch TRF 

Metastasis P: 50% reduction None Korean Language.

Malik et al42 4: Femoral and obturator, 

TRF 75°C to 80°C for 90

seconds. Cannula size not 

reported.

OA, FHN, 

metastasis

P: 30% to 70% 

NRS at 3 months

F: improved 3⁄4 pt

M: reduced 1⁄2 pt

Thigh

numbness,

1 patient

AP approach. Diagnostic blocks

(1 cc LA).

Kawaguchi et al41 14: Obturator and/or femoral 

branch, TRF 75°C to 80°C

for 90 seconds. Cannula size 

not reported.

OA, metastasis, DL

P: 50% relief, 86% 

patients avg 4.2

months (1-11

months)

F,M: N/A

None Suggested pain location predicted 

articular nerve involved, no block for 

femoral component. Volume for IA or 

obturator diagnostic block.

Fukui et al46 1: Femoral and obturator 

branch, TRF 90°C for 180 

seconds. 22 gauge 4 mm active tip.

OA, infection P: 70% relief until 

4 months; pain 

increased at 6

months

F: improved walking with cane

M: stopped use 

until 6 months

None Diagnostic blocks with contrast (3 cc 

LA). Sensory stimulation. Obturator 

cannula walked to obturator cannal 

from superior pubic ramus. Introduced idea of cryoanalgesia for denervation of articular branches. Procedure not repeated because overall 

pain reduced.

Akatov and 

Dreval36

13 (15 hips): Obturator nerve 

proper, TRF 80°C for 120

seconds.

OA Increased range of 

motion in 9 patients, 

remainder of results 

not clear. Followed 

for up to 3 years.

Sensory loss 

in all but 

one patient.

Needle technique not well described. 

Unclear if live fluoro used. Additional treatment for myofascial pain 

in 3 patients. Unclear if diagnostic 

blocks used, but 2 cc to 3 cc of LA injected prior to lesion to ensure pain 

resolved.

Glossary:

AS – Ankylosing spondylitis LA – Local anesthetic post THA – Post total hip arthroplasty

DL – Dislocation (congenital or trauma) M – Medication reduction PRF – Pulsed radiofrequency

F – Functional improvement NRS – Numerical rating score RA – Rheumatoid arthritis

FHN – Head necrosis (AVN, trauma, Legg- Calve-Perthes) OA – Osteoarthritis TRF – Thermal radiofrequency

IA - Intra-articular P – Pain reduction
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

Another main advancement of the approach used by 

Locher and colleagues was the introduction of lesion 

stacking for this specifi c application to optimize denervation.40 This concept has previously been described 

in detail for thermal radiofrequency of other joints.25

Locher and colleagues advocated withdrawing and directing the cannula more caudally for those individuals 

where branches exit the obturator foramen more inferiorly.40 This trajectory was not specifi cally analyzed by 

MRI to confi rm safety, but the authors suggest staying 

lateral to the teardrop to avoid the obturator nerve.40 Presumably, the cannula would remain against the anterior 

portion of ischium and pubis, so perhaps the risk to the 

main obturator nerve, which passes anteriorly, may be 

overstated, but cadaveric validation would be essential 

to look at this further.

Our technique would not provide adequate coverage for 

these more inferior articular branches when compared 

with the Locher method. While not employed in this 

case, multipolar thermal radiofrequency could be considered in the future to improve coverage and potentially 

decrease procedure time. Cosman and Gonzalez showed 

in ex vivo studies that bipolar thermal radiofrequency 

could provide a longer and wider lesion than previously 

reported for monopolar or cooled radiofrequency technology. The depth of the lesion produced is similar in 

all 3 cases, while in the case of bipolar RF, varying the 

length of the probe’s tip could increase the length of the 

lesion and increasing spacing between probes could increase width. They concluded that an interprobe spacing 

of 10 mm, a 10 mm or 15 mm cannula active tip, and an 

18 gauge or 20 gauge cannula with radiofrequency for 

3 minutes at 90°C would provide a rectangular lesion 

relatively insensitive to small variations/inaccuracies 

in angles, offsets, and tip spacing.66 Burnham reported 

excellent clinical response in one patient with unilateral 

lumbosacral pseudoarticulation who partially responded to conventional z-joint radiofrequency denervation. 

Using bipolar radiofrequency, a strip lesion was created 

along the pseudoarticulation, which allowed the patient 

16 months of signifi cant functional improvements.67

There are numerous reported variations in the number of 

branches and branch points for the obturator nerve (for 

example, anterior vs posterior vs main trunk).40,47,48,56,57

In these situations, the currently described technical approaches would likely be adequate to denervate these 

varied articular branches, if these branches exit through 

the obturator foramen and course over the teardrop 

RADIOFREQUENCY DENERVATION OF THE HIP JOINT FOR PAIN MANAGEMENT:

CASE REPORT AND LITERATURE REVIEW

Figure 2. Anterior and posterior views of different types of distribution of nerves to the hip joint. The articular capsule is represented by stippling. Adapted from Gardner49 with permission.

To quad. fem

To quad. fem

To pecƟ neus

Superior gluteal

Muscular br. of femoral Femoral

Femoral

Posterior

Posterior

Anterior

Anterior Anterior

Femoral

Femoral

Accessory Obturator

Obturator

Obturator

Obturator

Obturator

Anterior
 April – June 2014 47

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

silhouette described above (the junction of 

the pubis and ischium on an anteroposterior 

x-ray). However, there are certain described 

anatomical variations where the current 

technical approaches would be inadequate 

for obturator articular branch denervation. 

These include cases where there are no obturator branches61; the articular branches 

arise before the obturator foramen; there is 

a dominant anterior obturator nerve (occurs 

in 10% to 30% of patients); or if the branches do not supply the portion of the joint that 

is affected clinically.48-50,52,54,55,58,59,64

There is considerably less ability to translate previous anatomic studies to develop 

a denervation protocol for other articular 

branches to the joints. According to Locher and colleagues,40 the variability of the 

femoral nerve course and branches would 

necessitate coagulation of several square 

centimeters (ie, greater than or equal to 50 

lesions), but no data was provided as to how this calculation was achieved.

Anatomic concerns also include branches from the femoral innervated muscles for whom trajectories are not 

clear, relative variability in innervation patterns to the 

anterior capsule in the presence of an accessory obturator nerve, accessory femoral nerve or superior gluteal 

nerve branches, the possibility of articular branches 

that start more inferiorly along the course of the femoral nerve and run with vessels, and a scenario where 

one common trunk supplies the joint, vessels, and muscles.47,48,53,55,57,61,62 Therefore, while signifi cant cadaveric 

work remains, with the preliminary results shown thus 

far in the literature, we remain hopeful that an acceptable percentage of patients will respond to treatment. 

Multipolar radiofrequency or a series of successive lesions approaching from the lateral margins (to avoid the 

femoral nerve) and moving caudally from the anterior 

inferior iliac spine would require further validation.

Translating current knowledge into a posterior innervation approach will also be challenging without the aid of 

further cadaveric study. It would appear the inferior to 

middle-medial to lateral portion of the hip joint are supplied by branches of the sciatic nerve directly, or through 

the trunk that is given off to the quadratus femoris muscle. Variations include multiple branches from the nerve 

to the quadratus femoris, different trajectories through 

the greater and/or lesser sciatic notch, branches from 

nerves to the obturator internus or superior gemellus, 

and direct innervation from the sacral branches or obturator nerve. Similarly, the posterior superior portion 

of the joint may be variably innervated by branches of 

sciatic nerve, or superior gluteal nerve.47,48,52-55,57,61-64

The vascular supply of the femoral neck and hip joint 

has been closely detailed and must be considered in a 

posterior approach. An extracapsular arterial ring is 

formed by branches of the medial and lateral circumfl ex 

arteries, contributing to the metaphyseal blood supply. 

The epiphyseal blood supply is mediated through the 

ligamentum teres and posterosuperior branches of the 

lateral epiphyseal vessels. Vascular supply to the joint is 

therefore predominantly from the posterior circulation 

of the epiphysis, away from the region of treatment.67

Given that the posterior blood supply runs lateral to 

medial for the hip joint, we propose a radiofrequency 

approach starting lateral and posterior to the greater 

trochanter and advancing towards the inferior portion 

of the acetabulum. Multipolar radiofrequency or successive lesions moving superiorly towards the middle third 

of the acetabulum may generate suffi cient coagulation 

for the sciatic and/or quadratus femoris nerve branches 

in this region without affecting any signifi cant neurovascular structures.

Other general reasons for failure of treatment of radiofrequency could arise from joints that have an important 

innervation from the sympathetic trunk,48 or posterior 

femoral cutaneous nerve.51 In addition, there could be a 

Figure 3. Articular branches of the obturator nerve and target region for radiofrequency denervation. Covering the right hip are tracings of the anteroposterior projections of the metal wires used to mark the location of the articular 

branches in cadavers. In each cadaver, articular branches were spread across 

band-like areas. The bold lines represent the upper boundary of each area, 

and the dotted lines represent the lower boundary. The stem of each band 

was located below the teardrop shape of the inferior end of the acetabulum. 

The matrix of lesions required to coagulate the articular branches is illustrated over the left hip. Its medial margin lies opposite and below the teardrop silhouette of the acetabulum. For reference, tracings of wires covering the obturator nerve have been depicted. Adapted from Locher et al40 with permission.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

long-term risk of developing a Charcot arthropathy, given that denervated nerves and coagulated vessels supply 

the anteromedial capsule of the hip joint and underlying 

bone .47 In some surgical neurectomy studies, femoral 

head deformity was a noted complication, but this may 

be attributable to complete denervation of all the sensory branches.32,47 Animal studies have shown erosion 

of articular cartilage and bone sclerosis resulting from 

lumbar sympathetic, 4th lumbar, and 3rd sacral root resection.34,68,69 The risk of Charcot joint has not been a 

factor in other similar joint denervation studies.70

We therefore propose close clinical follow-up to monitor 

signs, symptoms, and fall risk where proprioception is a 

concern. Where indicated, serial imaging could identify 

changes in patients consistent with a neuroarthropathy. 

The treatment in these cases would be nonweight-bearing on the affected side until the sensory innervation 

(ie, pain) returns.71 In the case of presurgical patients, 

further joint destruction may be less important if an arthroplasty will eventually be performed.

The fi nal consideration is the value of diagnostic blocks 

in this setting. Ideally, a low volume comparative diagnostic block could be performed that would have a high 

positive predictive value for response to radiofrequency 

treatment. The wider innervation area of the articular 

branches could lead to false negatives if the injection 

volume was too small, or false positives if a larger volume was used, or multiple branches were injected simultaneously. The other possibility is the use of intrarticular 

injections for diagnoses, but this would not direct treatment to a specifi c articular branch. Again, cadaveric and 

clinical studies are required to develop this further.

CASE REVIEW

The relative failure of the second treatment in this case 

was likely because stacked lesions in an inferior to superior manner were not performed for the femoral component. As in the fi rst treatment, this would have likely 

increased the lesion to up to 4 times the cannula’s width 

and increase the chance for denervation.25 Instead, we 

opted to attempt to increase lesion length for this component, which we had hoped would translate into longer 

clinical effi cacy.

Other potential reasons for failure include a placebo response to the fi rst treatment, which has been shown to 

be high in other controlled trials for some interventional 

procedures.72 Progression of the patient’s underlying osteoarthritis to other parts of the joints not innervated 

by the femoral or obturator components73 is another 

possibly complicating factor for this case. In cases of 

neurotmesis, the endoneural tubes are disrupted which 

can result in misdirected axonal regrowth (ie, synkinesis), which could potentially impact subsequent treatment where needle position is based on bony anatomic 

landmarks.74

Our results also dispute the notion that the articular regions subserved by the obturator component primarly 

cause groin region pain.41 In this case, it is more likely 

the failure of treatment is from the femoral component, 

not the obturator, where the same protocol was followed. 

Pain referral may be a helpful indicator of which nerve 

could be mediating pain, but, as shown in this case, is 

certainly not diagnostic.31,41 More study is required to 

delineate the positive predictive value of pain referral 

patterns in outcomes of patients undergoing articular 

branch radiofrequency denervation.

CONCLUSIONS

The current clinical literature concerning radiofrequency for treatment of hip joint pain is of low quality. 

Based on these studies, we propose the following general guidelines for the procedures:

1. Small volumes for diagnostic blocks, (especially 

if only a single lesion is to be used).

2. Use of omnipaque to rule out vascular spread, at 

least for the diagnostic blocks.

3. A lateral approach for the obturator branch to 

avoid the neurovascular structures, and/or supplementation with ultrasound.

4. At the least, motor stimulation to rule out somatic involvement.

5. At a minimum, 10 mm active tips to increase the 

length of lesion created and therefore the length 

of clinical response.

6. Consideration of stacked lesions or multipolar 

TRF to increase lesion size and thereby account 

for any anatomic variability.

7. Measurement of both pain and functional outcomes using standardized scales.

8. Close clinical monitoring after TRF in order to 

identify patients’ neurological defi cits or those 

at risk for progression to neuroathropathy.

The future research of this application should validate 

safe and effective parameters for diagnostic blocks and 

treatment in cadavers for all articular branches as well 

as any clinical information relevant to injection selection 

and/or outcomes, estimate the role of multipolar thermal 

radiofrequency in denervation of the hip joint,65,66,75-77

and delineate any associated economic benefi ts of hip 

joint thermal radiofrequency.

RADIOFREQUENCY DENERVATION OF THE HIP JOINT FOR PAIN MANAGEMENT:

CASE REPORT AND LITERATURE REVIEW
 April – June 2014 49

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

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CASE REPORT AND LITERATURE REVIEW
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AUTHORS

Dr Gupta, a physiatrist, works with the Canadian Forces 

Health Centre-Ottawa and the Alan Edwards Pain Management Unit of the Department of Anesthesia, Montreal 

General Hospital. He is also an adjunct professor at McGill University in Montreal, Quebec.

Dr Radhakrishna is a physiatrist in the McGill University 

Health Centre and the Alan Edwards Pain Management 

Unit of the Department of Anesthesia, Montreal General 

Hospital. He is also an assistant professor at McGill University in Montreal, Quebec.

Dr Etheridge is the medical director at the Okanagan 

Interventional Pain Clinic, Kwlowna, British Columbia. 

He is also a clinical instructor at the University of British 

Columbia.

L Col Besemann, a physiatrist, is head of the Canadian 

Forces physical rehabilitation program at the Canadian 

Forces Health Services Group Headquarters in Ottawa. 

He also works at the Canadian Forces Health Centre and 

is a lecturer at the University of Ottawa.

Dr Finlayson is an anesthesiologist with the Alan Edwards Pain Management Unit of the Department of Anesthesia, Montreal General Hospital. He is also an associate professor at McGill University in Montreal, Quebec.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

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.Z^_ZY9-nA?-n"ð#"-`R`^_#!"%
 April – June 2014 53

There is a demand for emergency procedures for extremity injuries that minimize time and expense, while 

still adequately providing treatment. One of these procedures is the Bier block. The advantages of the Bier block 

lie in the lack of sedating anesthesia, enabling a patient 

to be quickly treated and discharged with minimal allocation of resources, rather than that required for procedural sedation and certainly general anesthesia. Procedural sedation in the emergency department setting 

for most protocols requires 2 physicians and at least one 

nurse. This large provider requirement has the practical 

effect of almost shutting down one side of a busy emergency department. Completion of the presedation packet 

can take as long as 15 minutes before any part of patient 

care is even initiated. The recovery phase from procedural sedation can require an otherwise available bed for 

as long as an hour, thus presenting a risk of resource 

shortage for incoming serious emergencies. Lastly, in 

deployed environments, there is a need to use anesthetic 

methods that do not incapacitate a Soldier, and do not 

divert the attention of another Soldier-provider from 

the care of other patients for solely monitoring sedated 

patients.

CURRENT INDICATIONS

According to Roberts and Hedges,1

 the Bier block is indicated for procedures including reduction of fractures 

and dislocations, repair of major lacerations, removal 

of foreign bodies, debridement of burns, and drainage 

of infection. Other factors in the decision to use a Bier 

block are the desire for a bloodless operating fi eld as 

well as avoiding possible adverse effects of axillary 

blocks. Furthermore, the Bier block has the advantage 

of not requiring respiratory monitoring as does procedural sedation. The patient need not be NPO (nothing by 

mouth) for a Bier block, but, if possible, the procedure 

should be delayed if the patient has recently eaten a large 

meal.

CONTRAINDICATIONS

Contraindications include allergy to the anesthetic, uncontrolled hypertension, a preexisting ischemic limb 

from a crush injury, or disease states such as homozygous sickle cell disease, Reynaud’s disease, or Buerger’s 

disease. In addition, the Bier block should not be used 

in procedures which require monitoring of pulses in the 

distal extremity, such as a supracondylar fracture reduction. A pneumatic tourniquet is a required equipment 

item that must be used to administer a Bier block. The 

block is used for procedures lasting between 30 and 90 

minutes in duration. The block can be used in both upper 

and lower extremity blocks, with modifi cation as discussed further, although Wheeless recommends the Bier 

block only for the upper extremity.2

 Morbid obesity is 

also a relative contraindication, since it is diffi cult to apply effective tamponade pressure to the obese arm with 

the tourniquet to prevent systemic lidocaine toxicity.

SAFETY OF BIER BLOCKS

The question of safety is relevant in the case of the Bier 

block, especially with regard to use of the pneumatic 

pressure tourniquet, and the use of high dose lidocaine 

(1.5 mg/kg to 3 mg/kg). Several studies have been conducted to assess safety, the larger of which are listed 

below. There have been no reported cases of mortality 

resulting from the Bier block procedure.3

Whistler Health Care Center (2005-2006, Mohr4): a retrospective study involving 1,804 patients who received 

Bier block anesthesia for wrist, hand, and forearm injuries. Twelve of the patients received bilateral Bier 

blocks. There was no signifi cant mortality or morbidity, 

although there were 9 cases of adverse events (0.5%). 

These included one medication error (0.06%) and 3 cases of improper cuff infl ation (0.17%), resulting in tinnitus and dizziness from partial lidocaine entry into the 

circulation. These conditions resolved after a 30-minute 

monitoring period. There were 5 cases of inadequate analgesia. The procedure was successfully completed in all 

cases, as confi rmed by c-arm imaging.

Royal United Hospital/Bristol Medical School (2008-2010, 

Jakeman et al3

): another retrospective study of 416 patients receiving Bier blocks. There were 39 complications 

A Bier Block Implementation Protocol

CPT Stewart A. Stancil, MC, USA

ABSTRACT

The Bier block procedure has been in use for over 100 years, but only recently has received renewed attention. 

As emergency departments look for ways to maximize effi ciency, the use of the Bier block has been recognized 

as effective and fast with minimal adverse effects. This article summarizes a proposed protocol for the implementation of both pre- and posthospitalization Bier blocks by healthcare providers.
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

noted in this study. The complications included transient hypotension, vasovagal episodes, and transient 

mild bradycardia. No medical intervention was required 

for any of the episodes. There was no case of signifi cant 

morbidity or mortality.

Emergency Department Treatment of Childern’s Extremity Fractures: Blasier and White5

 detail a 1996 study 

of 470 children who underwent fracture reduction using the Bier block method from 1989 through 1994. All 

but 12 patients were successfully reduced. Nine of the 

12 required surgical fi xation in the operating room. In 

the other 3 cases, IV access could not be obtained for 

the Bier block. Two patients complained of signifi cant 

tourniquet pain. One had a transient metallic taste in 

his mouth. One patient complained of transient facial 

tingling without any changes in electrocardiogram 

readings. There were no cases of hypotension, tachycardia, seizures, or arrhythmia. There were no cases of 

decreased extremity sensation or neurological function.

EFFECTIVENESS

Handoll et al6

 compared anesthesia techniques and found 

5 trials which provided evidence that, when compared 

with hematoma block, intravenous regional anesthesia 

provided better analgesia during fracture manipulation 

and enabled better and easier reduction of the fracture, 

with additional fi ndings of reduced risk of later redislocation or need for re-reduction. In contrast, hematoma 

blocks can be performed more easily and quickly, and 

are less resource intensive.

BIER BLOCK PROTOCOL

The following are 8 steps to simplify Bier block 

administration:

1. Initiate painless sedation protocol.

2. Obtain IV access.

3. Elevate or apply Eschmarch bandage to the affected extremity.

4. Tourniquet is applied.

5. Lidocaine is injected.

6. Attempt the procedure.

7. Inspect for signs/symptoms of lidocaine toxicity.

8. Defl ate the tourniquet.

Details of Each Step in the Bier Block Protocol

1. Initiate painless sedation protocol 45 to 18 minutes 

before the procedure (T-45 to T-18 minutes).

Roberts and Hedges1

 recommend consideration 

of premedication with midazolam, diazepam, or 

fentanyl, but not necessary on a routine basis. Resusitation equipment and anticonvulsant drugs 

should be readily available. Ensure that suction is 

available. Consider delay if the patient has just eaten 

a large meal. The following is an effective prevascular access method for presedation:

(a) T-45 minutes – First apply EMLA® cream or 

LMX4® cream about 45 minutes prior at IV 

sites if time allows. Place the patient on the 

cardiac monitor.

(b) T-18 minutes – Give intranasal fentanyl at 2 

μg/kg and intranasal Versed® at 0.2 mg/kg.

2. Obtain IV access (T-15 minutes).

The fi rst IV line is place in the noninjured forearm for 

administration of sedation and fl uids. In the injured 

limb, a butterfl y needle is placed in a dorsal vein in 

the hand, distal to the fracture site.

3. Exsanguinate the extremity (T-14 to T-10 minutes).

This is done either by elevation of the extremity for 4 

minutes or use of an Eschmark bandage. Use elevation only in the case of extremity infections. Elevation for 4 minutes can easily be done by using fi nger 

traps.

4. Deploy the tourniquet (T-6 minutes).

Prior to performing the Bier block, be sure that the 

tourniquet is working properly. If the tourniquet malfunctions and defl ates during the case, the patient 

may have a seizure due to lidocaine toxicity. The 

tourniquet must specifi cally be a double pneumatic 

tourniquet to prevent failure and deliver the exact 

amount of pressure needed. This is because the lidocaine maximum dosage (3 mg/kg) used in a Bier 

block is twice the cardiac dose of lidocaine (1.5 mg/

kg). Pressure is 100 mm Hg above the systolic BP in 

the arm in adults, 150 mm Hg above systolic BP in 

the legs in adults and 50 mm Hg above systolic BP in 

children.7

 Marcaine® or any similar long acting anesthetic should never be used, since the medication 

will still be active when the tourniquet is defl ated at 

the end of the case (causing a seizure). Contraindications include excessive obesity (ie, a large fatty arm), 

causing excessive tissue damage from necessarily increased tourniquet pressures. For moderately obese 

patients, the double tourniquet may not provide adequate tamponade pressure to prevent leakage of the 

lidocaine into the systemic circulation. In this case, if 

it is determined to continue the Bier block procedure, 

it may be necessary to use a wide single tourniquet 

to apply the necessary tamponade force to the obese 

extremity.

A BIER BLOCK IMPLEMENTATION PROTOCOL
 April – June 2014 55

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

5. Lidocaine administration (T-5 minutes).

Dose using the “mini-Bier block dose,” 1.5 mg/kg 

of a 0.5% solution. For a 70 kg male, this is 105 mg, 

or 22 mL. The maximum “full dose Bier block” is 3 

mg/kg.8

 Start with the mini-Bier block dose. If more 

anesthetic is needed in 10 minutes, continue to the 

full dose Bier block.

6. Attempt procedure (T-zero).

There will reliably be between 35 to 45 minutes of 

anesthesia, before the lidocaine is eventually bound 

to the tissues. After 20 to 30 minutes, the patient will 

likely begin to experience pain from the tourniquet. 

To treat tourniquet pain, fi rst infl ate the distal cuff 

and then slowly defl ate the proximal cuff. The distal 

cuff is therefore now infl ated over anesthetized tissue. 

The infl ation must be done in the correct sequence to 

avoid systemic introduction of lidocaine.

7. Inspect for signs of lidocaine toxicity.

The fi rst sign of lidocaine toxicity is perioral tingling 

and tinnitus. The patient may also complain of a metallic taste sensation. The patient must be on a cardiac 

monitor. Look for increasing PR interval and QRS 

lengthening.

At 5 μg/mL, EKG fi ndings of cardiac toxicity begin.

At 10 μg/mL, seizures begin to occur.

At 30 μg/mL, cardiovascular depression begins to 

manifest.

If these things happen, give IV fl uids to treat hypotension. Use push-dose epinephrine to maintain 

blood pressure with the following method: 

Take 1 mL of 1:10,000 cardiac Epi (100 μg/mL 

concentration).

Add 9 mL to make 1:100,000 Epi (10 μg/mL 

concentration).

Give 0.5 mL (range of 0.5 mL to 2 mL) every 2 to 

5 minutes. This is about the same as an epinephrine 

drip at 1 to 10 μg/min.

Obtain TPN for lipid rescue.* First give an initial intravenous bolus of 20% lipid emulsion (approximately 1.5 ml/kg of lean body mass), followed immediately by a continuous infusion (approximately 0.25 

to 0.5 ml/kg/min) for roughly 10 minutes following 

recovery of vital signs. Repeat the bolus as needed 

every 5 minutes for cardiac instability.10

8. Defl ate the tourniquet.

The tourniquet cannot be defl ated until at least 25 

minutes have transpired since infl ation. For additional 

safety, a 30 minute minimum time to defl ation will be 

used for the protocol. It must then be defl ated in a 

cyclic manner. Defl ate over 5 seconds, and then reinfl ate for 1 to 2 minutes. Repeat this process 3 to 4 

times.7

Watch the patient for 30 minutes, monitoring for lidocaine toxicity. Peak plasma lidocaine concentrations 

occur 2 to 4 minutes after cuff defl ation, and are minimized by using the cyclic defl ation technique. Cardiac 

toxicity with EKG abnormalities to lidocaine occur 

between 5 μg/mL and 10 μg/mL plasma concentration. 

The maximum lidocaine plasma concentration from a 

Bier block after a properly cycled tourniquet release is 2

μg/mL to 4 μg/mL plasma concentration. Some patients 

will sense a temporary ringing in their ears, perioral tingling, or a metallic taste. Other reactions include dizziness, headache, and blurred vision. All of these reactions are temporary, occur in about 3% of cases, and 

no treatment is required. More serious complications 

include transient seizures, bradycardia, and hypotension 

which are treated as appropriate. These are most commonly caused by large lidocaine boluses resulting from 

a tourniquet mistake or failure. There are no reports of 

deaths from these complications.

Send the patient home with pain control. The tourniquet 

area will be sore for 1 to 2 days. Although no lingering effects are expected, Roberts and Hedges1

 recommend that the patient not drive for 6 to 8 hours after the 

procedure.

SAFETY MEASURES INCLUDED IN THE PROTOCOL

 Only use double pneumatic tourniquets. An acquisition process should be implemented detailing the 

specifi cations required, so that the various models 

of tourniquets can be compared objectively.

 There should be a Bier block tool box. Inside will 

be lipid rescue, diazepam, push-dose epinephrine, 

and sodium bicarbonate. It should also contain a 

laminated instruction guide and the brief evaluation forms for research documentation and tracking.

 The tourniquets will only be defl ated after 30 minutes, and then at cyclic defl ation. The tourniquets 

will not be infl ated for longer than 90 minutes.

 The toxic dose of IV lidocaine (3 mg/kg) should not 

be exceeded.

FUTURE RESEARCH QUESTIONS TO BE ADDRESSED 

BY THE PROTOCOL

 Do Bier blocks provide an enhanced means of antibiotic delivery to contaminated/infected wounds?

*Use of TPN was identifi ed by Weinberg, who noted in 1998 that animals were resistant to bupivacaine toxicity when they were cotreated 

with TPN.9

 Since then, TPN has become an accepted treatment modality for lidocaine overdose. It has also been proven effective for 

overdoses of beta blockers, bupropion, lamotrigine, calcium channel blockers, and tricyclic antidepressants.10
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

 Bier blocks have been used for complex regional 

pain syndrome in some locations. There is little data on the effectiveness. Is this a possible 

application?

 There is little study into the effectiveness of sodium bicarbonate pretreatment before cuff release. Is this a plausible option for minimizing 

adverse effects?

 Toradol has been used as an anesthetic enhancement. Is this effective adjunct?

 One of the issues of previous studies was the 

lack of long term follow-up for patients. This is 

important in determining the ultimate effectiveness of the procedure. An established method 

of contacting the patients should be established.

 An emergency department cost accounting 

method should be identifi ed. This will help in 

the determination of cost effectiveness as the 

protocol is implemented.

REFERENCES

1. Roberts JR, Hedges JR. Robert and Hedges Clinical Procedures in Emergency Medicine. 5th ed. 

Philadelphia, Pa: Saunders Elsevier; 2009:535-539.

2. Wheeless CR III, ed-in-chief; Nunley JA II, Urbaniak JR, managing eds. Wheeless’ Textbook of Orthopaedics [internet]. Duke University Department 

of Orthopaedic Surgery. Available at: http://www.

wheelessonline.com/. Accessed February 11, 2014.

3. Jakeman N, Kaye P, Hayward J, Watson DP, Turner 

S. Is lidocaine Bier’s block safe?. Emerg Med J. 

2013;30(3):214-217.

4. Mohr B. Safety and effectiveness of intravenous 

regional anesthesia (Bier block) for outpatient 

management of forearm trauma. Can J Emerg Med. 

2006;8(4):247-250.

5. Blasier RD, White R. Intravenous regional anesthesia for the management of children’s extremity 

fractures in the emergency department. Pediatr 

Emerg Care. 1996;12(6):404-406.

6. Handoll HH, Madhok R, Dodds C. Anesthesia for 

Treating Distal Radial Fracture in Adults (Review). 

Hoboken, NJ: John Wiley & Sons; 2009. Available 

at: http://www.thecochranelibrary.com/userfi les/

ccoch/fi le/CD003320.pdf. Accessed February 11, 

2014.

7. Crystal CS, McArthur TJ, Harrison B. Anesthetic and procedural sedation techniques for 

wound management. Emerg Med Clin North Am. 

2007;25(1):41-71.

8. Mattu A, Chanmugan AS, Swandron SP, Tibbles 

CD, Woolridge DP, eds. Avoiding Common Errors 

in the Emergency Department. Philadelphia, PA: 

Lipincott Williams & Wilkins; 2010:561.

9. Weinberg GL, VadeBoncouer T, Ramaraju GA, 

Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the doseresponse to bupivacaine-induced asystole in rats. 

Anesthesiology. 1998;88(4):1071-1075.

10. Weinberg G. Lipid emulsion infusion: resuscitation 

for local anesthetic and other drug overdose. Anesthesiology. 2012;117(1):180-187.

AUTHOR

CPT Stancil is an Emergency Medicine Resident at the 

Darnall Army Medical Center, Fort Hood Texas.

A BIER BLOCK IMPLEMENTATION PROTOCOL

Articles published in the Army Medical Department Journal are indexed in 

MEDLINE, the National Library of Medicine’s (NLM’s) bibliographic database 

of life sciences and biomedical information. Inclusion in the MEDLINE database 

ensures that citations to AMEDD Journal content will be identifi ed to researchers 

during searches for relevant information using any of several bibliographic search 

tools, including the NLM’s PubMed service.
 April – June 2014 57

Central odontogenic fi broma (COF) is an extremely rare 

(approximately 50 examples in literature, representing 

approximately 0.1% of all odontogenic tumors) benign 

neoplasm composed by varying amounts of inactivelooking odontogenic epithelium embedded in a neoplastic mature and fi brous stroma. The lesion may evolve 

from a dental germ (dental papilla or follicle) or from the 

periodontal membrane, and therefore may invariably be 

related to the coronal or radicular portion of teeth. Due 

to its nonexclusive histological features, this lesion is 

often confused with other entities, such as hyperplastic 

dental follicles, odontogenic myxomas, and desmoplastic fi bromas, which highliaght the importance of clinical 

pathological correlation in the diagnosis of odontogenic 

fi bromas.1

Currently, 2 subtypes of COF are recognized. The simple odontogenic fi broma composed of stellate fi broblasts, 

in a whorled pattern mixed into a back ground of ground 

substance with or without odontogenic rests. The second 

subtype is the World Health Organization (WHO) type, 

having a more complex pattern of cellular fi brous connective tissue with collagen fi bers in interlacing bundles. 

The WHO lesion has odontogenic epithelium in the form 

of long strands or isolated nests throughout the lesion. 

Enucleation with vigorous curettage in most cases is appropriate treatment with low recurrence.2,3

Central odontogenic fi bromas occur most frequently 

anterior to the molars in the maxilla and have a predilection for females. They have also occasionally been 

associated with an unerupted mandibular third molar. 

This report concerns a of a case of central odontogenic 

fi broma found in a young, male, posterior left mandible.

CASE REPORT

An 18-year-old male with a large lesion in the left body 

of the mandible involving multiple teeth that was found 

with panoramic radiograph on routine dental exam (Figure 1) presented to the Department of Oral and Maxillofacial Surgery at Womack Army Medical Center, Fort 

Bragg, NC, in the fall of 2010. The patient had no familial history of cancer or recent symptoms of systemic 

neoplasm. The lesion was nonpainful, all teeth tested 

vital, and there was clinical bicortical expansion. The 

patient did have a history of contact sports.

MATERIALS AND METHODS

Panoramic radiography as well as CT scan with contrast 

evaluation showed a radiolucent, well corticated, 6 cm 

oval, unilocular in appearance and extending from the 

mesial of #22 to the distal of #18. There was signifi cant 

lingual and buccal cortical expansion. The preoperative diagnosis consisted of traumatic bone cyst, central 

giant cell granuloma, or ameloblastoma. An incisional 

biopsy was performed under local anesthesia 

with a perioperative fi nding of nonvascular, 

thin-lined cystic lesion that peeled away easily. The cortical bone was very thick on the 

buccal without sign of decortications of tooth 

mobility. The decompressed specimen measuring 1.3 by 1.1 by 0.4 cm in size was sent to 

the pathologist. The lesion was determined to 

be a simple type central odontogenic fi broma. 

A CT of the lesion was obtained and a sterolithic model was created outlining the lesion 

(Figure 2). Under general anesthesia, enucleation and curettage of the lesion and meticulous periodontal scaling of teeth #18, 19, 20, 

and 21 were performed. A buccal osteotomy 

created a window to visualize the lesion 

(Figure 3). Enucleation followed by vigorous 

Central Odontogenic Fibroma:

 Case Report and Review

 MAJ John P. Batson, DC, USA

 Frank Strickland, DDS, MPH

Figure 1. Preoperative panoramic radiograph.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

curettage of the cavity and the teeth 

roots (Figure 4) provided a specimen 4.3 by 2.1 by 1.4 cm in size, tan 

brown in color. The inferior alveolar 

canal roof was identifi ed, however, 

the inferior alveolar nerve was never 

visualized. Tooth number 17 (Figure 

5) was extracted with associated soft 

tissue due to extension of the lesion 

to the cemento-enamel junction. The 

buccal cortical plate was placed back 

in the window and fi xated with 2 Xplates and 4 monocortical screws 

(Figure 6). The patient spent one night in the hospital 

for observation and was released 

the next morning following postoperative radiographs (Figures 7 and 

8). The results from the examination 

by pathology (Figures 9 and 10) was 

consistent with original biopsy results. The soft tissue associated with 

tooth #17 (Figure 5) was a hyperplastic dental follicle. The hardware was 

removed 10 weeks later once radiographic evidence of bone healing was 

apparent. Signifi cant bone fi ll was 

observed after 6 month and 18 month 

follow-ups on panoramic radiographs. After 18 months, 

the teeth in the area tested vital and no complications or 

signs of recurrence were noted (Figure 11).

COMMENT

The COF is a benign neoplasm reported in the literature 

usually diagnosed in the second and third decade of life. 

The most usual sign is swelling of the mandible and the 

maxilla with infrequent fi ndings of pain and parathesia. 

Though the COF is reported more in females than males, 

more frequently in the anterior/premolar area of the 

maxilla, our patient was an 18-year-old male with occurrence in the posterior mandible. The slow-growing, 

expansile lesion was unnoticed for several years due to 

lack of dental care sought by the patient. It was painless 

with minor swelling and thus the patient had not pursued treatment earlier. Despite the rarity of this lesion, 

it is important for providers to be aware of the clinical, 

radiographic, and histopathology of this intraosseous lesion in order to include it in the differential.

CENTRAL ODONTOGENIC FIBROMA: CASE REPORT AND REVIEW

Figure 3. The exposed lesion after a buccal osteotomy.

Figure 5. Extracted tooth #17 with associated soft tissue due to extension of the lesion 

to the cemento-enamel junction.

Figure 4. The cavity following enucleation of the lesion 

and curettage of the cavity and teeth roots.

Figure 2. Stereolithic model of the affected area with outline of the lesion.
 April – June 2014 59

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

REFERENCES

1. Neville, B, DDS, Damm, D, DDS, Allen, C, DDS, 

MSD: A text book of Oral and Maxillofacial Pathology (edition 2). Philadelphia, PA, Saunders, 

2002 pg. 633-634.

2. Brazão-Silva MT, Fernandes AV, DurighettoJúnior AF, Cardoso SV, Loyola AM. Central odontogenic fi broma: a case report with long term follow-up: Head Face Med [serial online]. 2010;6(20). 

Available at: http://www.head-face-med.com/content/6/1/20. Accessed January 9, 2013.

Figure 8. Following day postoperative radiograph.

Figure 10. The specimen exhibits dense fi brocollagenous tissue, 

a congested vascular channel, and basophilic mineralization. 

(hematoxylin and eosin stain; original magnifi cation 200).

Figure 6. The buccal cortical plate replaced and held in place 

with 2 X-plates attached with 4 monocortical screws.

Figure 9. The specimen exhibits a dense fi broblastic stroma 

with thin walled vascular channels and focal areas with basophilic mineralization (hematoxylin and eosin stain; original magnifi cation 40).

Figure 7. Following day postoperative panoramic radiograph.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

3. Tosios KI, Gopalakrishnan R, Koutlas IG. Socalled hybrid central odontogenic fi broma/central 

giant cell lesion of the jaws. a report on seven additional cases, including an example in a patient with 

cherubism, and hypotheses on the pathogenesis. 

Head Neck Pathol. 2008;2(4):333-338.

4. Daskala I, Kalyvas D, Kolokoudias M, Vlachodimitropoulos D, Alexandridis C. Central odontogenic 

fi broma of the mandible: a case report. J Oral Sci. 

2009;51(3):457-461.

5. Cercadillo-Ibarguren I, Berini-Aytes L, MarcoMolina V, Gay-Escoda C. Locally aggressive 

central odontogenic fi broma associated to an infl ammatory cyst: a clinical, histological and immunohistochemical study. J Oral Pathol Med. 

2006;35(8):513-516.

6. Lotay HS, Kalmar J, DeLeeuw K. Central odontogenic fi broma with features of central granular 

cell odontogenic tumor. Oral Surg Oral Med Oral 

Pathol Oral Radiol Endod. 2010;109(2):e63-e66.

7. Younis RH, Scheper MA, Lindquist CC, Levy B. 

Hybrid central odontogenic fi broma with giant cell 

granuloma-like component: case report and review. 

Head Neck Pathol. 2008;2(3):222-226.

8. Buchner A, Merrell PW, Carpenter WM. Relative 

Frequency of central odontogenic tumors: a study 

of 1,088 cases from northern California and comparison to studies from other parts of the world. J 

Oral Maxillofac Surg. 64:1343-1352, 2006.

9. Silva CO, Sallum AW, do Couto-Filho CE, Costa 

Pereira AA, Hanemann JA, Tatakis DN. Localized 

gingival enlargement associated with alveolar process expansion: peripheral ossifying fi broma coincident with central odontogenic fi broma. J Periodontol. 2007;78(7):1354-1359.

10. De Lima Mde D, de Aquino Xavier FC, Vanti LA, 

de Lima PS, de Sousa SC. Hybrid central giant cell 

granuloma and central odontogenic fi broma-like 

lesion of the mandible. Otolaryngol Head Neck 

Surg. 2008;139(6):867-868.

AUTHORS

MAJ Batson is an oral surgeon at the US Army Dental 

Activity, Fort Stewart, Georgia.

Dr Strickland is in private practice in Leesburg, Virginia. 

When this article was written, he was an oral surgeon 

at the US Army Dental Activity, Fort Bragg, North 

Carolina.

Figure 11. Panoramic radiograph taken 18 months postoperative.

CENTRAL ODONTOGENIC FIBROMA: CASE REPORT AND REVIEW
 April – June 2014 61

Focal epithelial hyperplasia (FEH), or Heck’s disease, 

is a virus-induced, local proliferation of oral squamous 

epithelium.1

 It is a rare contagious disease caused by the 

human papillomavirus (HPV), a nonenveloped DNA virus.2

 It was fi rst described in Navajo, Chavante Indian, 

and Alaskan Eskimo children in 1965 by Archard et al.3

Since 1965, the majority of published cases report FEH 

in Eskimos and North, South, and Central American Indians.4

 In more rare instances, FEH has been reported in 

western European, African, Caucasian, and Asian populations.5

 The frequency of this disease is variable with a 

wide range from 0.002% to 35%, depending on the population studied and the geographical region.6

 Worldwide, 

FEH is predominantly seen in children with no gender 

predilection. However, cases are reported in young, middle-aged, and older adults, with an almost 5:1 female to 

male ratio in some populations.4,7,8 Intraoral lesions associated with FEH have been seen to spontaneously regress, 

however, lesions can persist the lifetime of the affected 

individual. Many studies link FEH to malnutrition, poor 

oral hygiene, low socioeconomic status, and communal 

lifestyles.7

 Interestingly, recent reports have indicated the 

presence of FEH in HIV patients, indicating that immunosuppression leaves patients vulnerable to opportunistic infections, including HPV.4

 The etiology of FEH may 

have a genetic component, as it is found in the presence 

of HLA-DRB1*0404.8

 This HLA-DR allele is commonly present in some indigenous Americans, such as the 

Mazatecans, Nahuas, and Mexican mestizo populations.8

Remarkably, since 1965, FEH has been detected in animals, including chimpanzees (Pan troglodytes), pygmy 

chimpanzees (Pan paniscus), howler monkeys (Alouatta 

fusca), and Asian lions (Panthera leo persica).9

As established by Pfi ster et al10 and Ozden et al,4 HPV 

subtypes 13 and 32 have been identifi ed as the cause for 

FEH lesions through polymerase chain reaction (PCR) 

analysis and Southern blot hybridization, respectively. 

Other studies show that HPV DNA has been detected 

in 80.3% of FEH lesions.8

 A site-specifi c attraction for 

keratinized and nonkeratinized epithelial surfaces of the 

oral cavity has been observed in HPV subtypes 13 and 

32, respectively.4

 The lesions associated with FEH are 

usually multiple, generally involving the labial and lingual mucosa.1,4,11 Other sites include the lower lip, tongue, 

and less often on the upper lip, gingiva, palate, and 

tonsils.1,4,11 The lesions are 3 mm to 10 mm papules or 

nodules, varying in color from pink to white.8,12 Lesions 

are well demarcated, but they can often cluster closely 

together to form a cobblestone or fi ssured appearance.1

Focal epithelial hyperplasia has 2 clinical forms: papulonodular and papillomatous.8

 The papulonodular variant 

is more common. This clinical variant usually occurs 

on the buccal and labial mucosa, as well as on the commisures of the mouth.8

 The papillomatous variant is less 

common and is usually located on the masticatory mucosa such as the tongue and attached gingiva.8

 Although 

the diagnosis of FEH can sometimes be made by clinical 

examinations, biopsy is the gold standard for accurate 

diagnosis.8

Histologically, the trademark of FEH is dramatic acanthosis of the oral epithelium. The thickened oral mucosa 

extends upward, away from the underlying connective 

tissue with the lesional rete ridges at the same level as 

adjacent normal rete ridges. The lesional rete ridges are 

widened, elongated, thickened and fused.8

 Epithelial 

surface cells show vacuolated cytoplasm around irregular, pyknotic nuclei.12 Superfi cial keratinocytes can show 

viral koilocytic changes seen in other HPV infections. 

Viral particles and viral antigens have been identifi ed 

in lesional keratinocytes with electron microscopy and 

immunohistochemistry, respectively.6,13 Oral epithelial 

cells can exhibit an altered nucleus resembling a mitotic 

fi gure (mitosoid cell) with rare infl ammatory changes.1,14

Although FEH is associated with HPV, there seems to be 

no risk for dysplasia or malignant transformation.1

 Individual lesions generally show no ulceration or erosion.8

In this article, we report a histopathologically diagnosed 

case of FEH in a young adult male of Eskimo (Inuit) 

descent.

CASE REPORT

A 32-year-old male active duty Soldier of Eskimo descent 

reported to the Oral and Maxillofacial Surgery clinic at 

Womack Army Medical Center, Fort Bragg, NC. This 

Focal Epithelial Hyperplasia (Heck’s Disease):

 A Case Report and Review

 MAJ Zachary H. Highberger, DC, USA

 MAJ Joseph W. Ivory, DC, USA

 CPT Andre C. Ledoux, DC, USA

 COL Jeffrey Almony, DC, USA
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

patient had a chief complaint of long-standing mucosal 

colored lesions on the right and left lateral borders of 

his tongue, creating a cosmetic concern. His medical 

history was unremarkable. He took no medications and 

had no history of serious illness or operations. His risk 

factors were minimal, being a non-smoker with only occasional social alcohol intake. 

Upon clinical examination, 5 pink mucosal colored 

sessile papules were identifi ed on the patient’s lateral 

tongue borders. On the right lateral border, there were 

3 distinct 3 mm lesions. On the left lateral border, there 

were single 8 mm and 2 mm lesions observed anteriorly and posteriorly, respectively (Figures 1 and 2). As 

reported in past studies, removal of FEH lesions may 

not be necessary except in cases of chronic trauma and 

aesthetic concerns.4

 Possible treatment modalities have 

been reported, including surgical excision, laser ablation, cryotherapy, electrocauterization, interferon, and 

retinoic acid. Low recurrence is seen with all treatment 

methods. In our case, the patient had cosmetic concerns. 

We decided to perform an excisional biopsy of all tongue 

lesions to address his chief complaint and evaluate for 

more signifi cant pathology.

Excisional biopsies of all lesions were performed and 

sent to our facility’s Oral and Maxillofacial pathologist 

for histopathological examination (Figure 3). Setting 

the diagnosis of FEH is important to ensure differential 

diagnosis from other more serious conditions including 

infl ammatory fi brous hyperplasia, infl ammatory papillary hyperplasia, verruciform xanthoma, verrucous carcinoma, condyloma acuminatum, Cowden’s Syndrome, 

Crohn’s disease, and Amyloidosis.4,8 In our case, FEH 

was diagnosed based on the presentation of considerable 

acanthosis (Figures 4 and 5) of the oral epithelium and 

mitosoid cells present in superfi cial keratinocytes (Figures 6 and 7). Our patient progressed postoperatively 

FOCAL EPITHELIAL HYPERPLASIA (HECK’S DISEASE): A CASE REPORT AND REVIEW

Figure 1. Three separate FEH lesions of right lateral tongue 

border.

Figure 2. Two separate FEH lesions of left lateral tongue border.

Figure 3. Anterior FEH lesion (8 mm) of left lateral tongue border (excisional biopsy).

Figure 4. Photomicrograph of FEH lesion showing dramatic acanthosis (hematoxylin and eosin stain, 4).
 April – June 2014 63

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

without incident. The biopsy sites healed optimally 

without recurrence after a 12-month follow-up period.

COMMENT

Focal epithelial hyperplasia, or Heck’s disease, is a rare, 

viral-induced proliferation of oral squamous epithelium. 

As described in the literature, FEH is a benign condition that can regress spontaneously without surgical intervention. It has been linked to HPV subtypes 13 and 

32 using PCR analysis and Southern blot hybridization. 

Focal epithelial hyperplasia is benign with no risk of 

malignant transformation, however, evaluating lesions 

is prudent to rule out more serious conditions. Detection of oral disease can, in many cases, result in early 

diagnosis of HIV and other states of immune system 

compromise.

REFERENCES

1. Neville BW, Damm DD, Allen C, Boquot JE. Oral 

and Maxillofacial Pathology. 2nd ed. Philadelphia, 

PA: WB Saunders; 2002:320-321.

2. de Villers EM, Fauquet C, Broker TR, Bernard HU, 

zur Hausen H. Classifi cation of papillomaviruses. 

Virology. 2004;324(1):17-27.

3. Archard HO, Heck JW, Stanley HR. Focal epithelial hyperplasia: an unusual oral mucosal lesion 

found in Indian children. Oral Surg Oral Med Oral 

Pathol. 1965;20: 201-212. Cited by: Ozden B, Gunduz K, Gunhan O, Ozden FO. A case report of focal 

epithelial hyperplasia (Heck’s disease) with PCR 

detection of human papillomavirus. J Maxillofac 

Oral Surg. 2011;10(4):357-360.

4. Ozden B, Gunduz K, Gunhan O, Ozden FO. A case 

report of focal epithelial hyperplasia (Heck’s disease) with PCR detection of human papillomavirus. 

J Maxillofac Oral Surg. 2011;10(4):357-360.

5. Liu N, Li Y, Zhou X, Zeng X. Focal epithelial hyperplasia (Heck’s disease) in two Chinese females. 

Int J Oral Maxillofac Surg. 2012;41(8):1001-1004.

6. Hashemipour MA, Shoryabi A, Adhami S, Mehrabizadeh Honarmand H. Extensive focal epithelial 

hyperplasia. Arch Iran Med. 2010;13(1):48-52.

7. Harris AM, Van Wyk CW. Heck’s disease (focal 

epithelial hyperplasia): a longitudinal study. Community Dent Oral Epidemiol. 1993;21(2) ;82-58.

8. Said AK, Leao JC, Fedele S, Porter SR. Focal epithelial hyperplasia-an update. J Oral Pathol Med. 

2013;42(6):435-442.

9. Sa LR, DiLoreto C, Leite MC, Wakamatsu A, Santos RT, Catao-Dias JL. Oral focal epithelial hyperplasia in a howler monkey (Alouatta fusca). Vet 

Pathol. 2000;37(5):492-496.

10. Pfi ster H, Hettich I, Runne U, Gissmann L, Chilf 

GN. Characterization of human papillomavirus 

type 13 from focal epithelial hyperplasia Heck lesions. J Virol. 1983;47(2):363-366. 

11. Sapp JP, Eversole LR, Wysocki GR. Contemporary 

Oral and Maxillofacial Pathology. St. Louis, MO: 

Mosby, Inc; 1997:214.

12. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. 

Philadelphia, PA: Saunders Elsevier; 2006: chap 21, 

chap 29.

Figure 5. Photomicrograph of FEH lesion showing dramatic acanthosis (hematoxylin and eosin stain, 10).

Figure 6. Photomicrograph of FEH lesion showing mitosoid 

cell (hematoxylin and eosin stain, 20).
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

13. Stiefer RE, Solomon MP, Shalita AR. Heck’s disease (focal epithelial hyperplasia). J Am Acad Dermatol. 1979;1(6):499-502.

14. Tan KN, Medak H, Cohen L, Burlakow P. Focal 

epithelial hyperplasia in a Mexican Indian. Arch 

Dermatol. 1969;100(4):474-477.

AUTHORS

MAJ Highberger is Chief Resident, Oral/Maxillofacial 

Surgery, Womack Army Medical Center, Fort Bragg, 

North Carolina.

MAJ Ivory is a Staff Surgeon, Oral/Maxillofacial Surgery, Womack Army Medical Center, Fort Bragg, North 

Carolina.

CPT Ledoux is a Surgery Resident, Oral/Maxillofacial 

Surgery, Womack Army Medical Center, Fort Bragg, 

North Carolina.

COL Almony is Department Chief, Oral/Maxillofacial 

Surgery, Womack Army Medical Center, Fort Bragg, 

North Carolina.

FOCAL EPITHELIAL HYPERPLASIA (HECK’S DISEASE): A CASE REPORT AND REVIEW

Figure 7. Photomicrograph of FEH lesion showing mitosoid cell 

(hematoxylin and eosin stain, 40).
 April – June 2014 65

Median mononeuropathy at or distal to the wrist, or 

carpal tunnel syndrome, and other musculoskeletal dysfunction of the upper extremities is a well-documented 

problem in dental personnel, including dentists and dental hygienists. Median neuropathy at or distal to the wrist 

or carpal tunnel syndrome (CTS) is one of a number of 

muscle-, tendon-, and nerve-related disorders that affect 

people performing intensive work with their hands.1-3

Both dentists and dental hygienists have been reported 

to have a high prevalence of upper-extremity musculoskeletal disorders, including CTS.4-8 A 1997 American 

Dental Association survey reported that 9.2% of dentists 

had been diagnosed by a physician as having some type 

of repetitive motion disorder.9

A 2001 study by Hamann et al determined the prevalence in dentists of abnormal sensory nerve conduction 

and/or symptoms of carpal tunnel syndrome.10 In this 

Median and Ulnar Neuropathies in US Army

 Dental Personnel at Fort Sam, Houston, Texas

 COL Scott W. Shaff er, SP, USA CPT Ronald Miller, SP, USA

 1LT Kaitland Alexander, SP, USA COL Josef H. Moore, SP, USA

 1LT Daniel Huff man, SP, USA David G. Greathouse, PhD, PT

 1LT Charles Kambe, SP, USA

ABSTRACT

Background: Dental personnel have an increased prevalence of upper-extremity (UE) musculoskeletal (MSK) 

disorders, including carpal tunnel syndrome (CTS). Military dental personnel report more UE MSK complaints than their civilian counterparts. Literature using nerve conduction studies (NCS) to diagnose UE neuropathy in dental personnel is lacking.

Purpose: The purpose of this descriptive study was to determine the presence of electrodiagnostic abnormalities of the median and ulnar nerves in active duty military dental personnel assigned to Fort Sam Houston, TX.

Subjects: Twenty (14 male, 6 female) active duty, US Army dentists (n=9), preventive dental specialists (n=4), 

dental assistants (n=3), dental lab technicians (n=3), and dental logistics technician (n=1) assigned to the 

Dental Command at Fort Sam Houston, TX, volunteered to participate in the study. The mean age of the dental personnel was 38±9.8 years (range: 26 to 56 years). The mean time in dental practice was 13.3±7.96 years 

(range: 2 to 29 years). The mean length of time in the US Army dental services was 11.8±7.7 years (range: one 

to 26 years).

Methods and Materials: Subjects completed a history form, were interviewed, and underwent a physical examination of the cervical spine and bilateral upper extremities. Nerve conduction studies of the bilateral median 

and ulnar nerves were performed. Electrophysiological variables served as the reference standard for median 

and ulnar neuropathy and included distal sensory latencies, distal motor latencies, amplitudes, conduction velocities, and comparison study latencies. Descriptive statistics for subject demographics and nerve conduction 

study variables were also calculated.

Results: Seven of the 20 subjects (35%) presented with abnormal electrophysiologic values suggestive of an 

upper extremity mononeuropathy. Five of the subjects had abnormal electrophysiologic values of the median 

nerve at or distal to the wrist (3 bilateral, 2 unilateral). Two subjects had abnormal ulnar nerve fi ndings at or 

distal to the wrist (1 bilateral, 1 unilateral). Three of the 7 subjects with electrodiagnostic evidence of median 

and ulnar neuropathies had positive fi ndings on physical examination. However, there was no signifi cant correlation between the NCS and history/physical examination fi ndings.

Conclusions and Clinical Signifi cance: The prevalence of mononeuropathies in this sample of US Army dental 

personnel is similar to previous research involving dental assistants and preventive dental specialists and far 

exceeds that reported in the general population. This is the fi rst dental study to report electrodiagnostic fi ndings of ulnar mononeuropathy at or distal to the wrist. The NCS fi ndings did not correlate with subjective or 

physical exam fi ndings. Prospective research investigating screening, examination items, and injury prevention measures in dental personnel appears to be warranted.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

cross-sectional study, 1,079 dentists participating in the 

1997 and 1998 American Dental Association’s Annual 

Health Screening Program were screened by means of 

standard electrodiagnostic measures in the dominant 

hand and a self-reported questionnaire. Thirteen percent of screened dentists were diagnosed with a median 

mononeuropathy (using a 0.5 millisecond prolongation 

as the criterion), but only 32% of these had symptoms 

consistent with CTS (4.8% overall).

The prevalence of CTS among dental hygienists has also 

been documented.4,5,11-15 In a study that surveyed US 

Army dental personnel, Lalumandier and McPhee stated that 75% of dental hygienists reported having hand 

problems, and 56% exhibited probable or classic symptoms of CTS.11 Rice et al reported symptoms associated 

with CTS were noted by 75.6% of dental workers, 11% 

reported diagnosed CTS, and 53% reported back and 

shoulder pain.12 The dental hygienists and dental assistant-expanded function (DH/DAEF) group was found at 

greatest risk for developing upper extremity symptoms, 

CTS, and back pain. Other investigators have reported 

the prevalence of CTS among dental hygienists was 

6%14 and 7%,15 respectively.

Median mononeuropathy at or distal to the wrist or 

CTS has been demonstrated in US Army dental assistants (68E*) who had prior clinical experience and were 

enrolled in the Preventive Dental Specialist (68E-X2*) 

training course.16 Specifi cally, 26% of subjects exhibited electrophysiologic evidence consistent with median 

neuropathy at the wrist at the onset of training.16 The 12-

week Preventive Dental Specialist training course also 

did not increase the incidence of electrodiagnostic CTS 

in this population of students.17 Median mononeuropathy at or distal to the wrist or CTS was also found in 

11% of a sample of US Army dental assistants (68E) at 

the onset of their professional training and who had no 

experience as dental assistants.18

Literature using history, physical examination, and 

nerve conduction studies (NCS) to diagnose UE neuropathy in dental personnel is lacking. Therefore, the 

primary purpose of this descriptive study was to determine the presence of median and ulnar mononeuropathies in a population of dental personnel assigned to Fort 

Sam Houston, Texas. It is hypothesized that at least 5% 

of dental personnel would have abnormal electrophysiological fi ndings. The secondary objective of this study 

was to determine the inter-rater reliability of various 

clinical examination and nerve conduction items. We 

hypothesized that the majority of items would exhibit 

excellent reliability (intraclass correlation coeffi cients 

>0.75). This population of dental personnel included all 

active duty dentists, preventive dental specialists, dental 

assistants, and dental lab technicians assigned to Fort 

Sam Houston, TX, during the study period.

METHODS AND MATERIALS

All active duty US Army dental personnel at Fort Sam 

Houston, Texas (N=45) were approached to participate 

in this study. This included dentists, preventive dental 

specialists, dental assistants, dental lab technicians, and 

dental logistics technicians assigned to the Dental Command. Twenty (14 male/6 female) active duty US Army 

dentists (n=9), preventive dental specialists (n=4), dental 

assistants (n=3), dental lab technicians (n=3), and a dental logistics technician (n=1) volunteered to participate in 

the study. Five potential subjects declined to participate 

and 2 originally volunteered during recruitment but did 

not keep their appointment for the data collection session.

Experimental procedures, risks, and subject rights were 

discussed before participation in the study. All subjects 

signed an institutionally approved written consent form. 

Individuals were excluded if they were pregnant. The 

study was approved by the Institutional Review Board 

of Brooke Army Medical Center, Fort Sam Houston, 

TX (Approval #372631).

A history, physical examination, and upper quarter neuromuscular screen were performed to determine the 

musculoskeletal status of the neck and upper extremities and neural integrity of the median, ulnar, radial 

nerves and corresponding dermatomes/myotomes.

History

A history was taken from each patient in questionnaire 

format. The history included information pertaining to 

demographics, medical history, military background, 

work experience, hand dominance, and the amount of 

time using a computer.

Physical Examination

A physical (screening) examination was part of the 

evaluation process of each subject. The physical examination included assessment of active range of motion, 

manual muscle tests, sensory evaluation, refl ex testing, 

and select special tests.19,20 Active range of motion was 

assessed for the cervical spine, shoulders, elbows, and 

wrists and hands. Manual muscle testing was performed 

for all major muscle groups in both upper extremities 

with a focus to test at least 2 muscles from each corresponding myotome from C5-T1. Sensory assessment 

was determined with light touch, vibration, and pain/

pin prick assessment of the bilateral upper extremities. 

MEDIAN AND ULNAR NEUROPATHIES IN US ARMY DENTAL PERSONNEL AT FORT SAM HOUSTON, TX

*Military occupational specialty designation.
 April – June 2014 67

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

Light touch and pin prick sensation included the bilateral 

C4-T1 dermatomes. Vibration sensory testing was conducted using the Bio-Thesiometer (Bio-Medical Instrument Co, Newbury, OH). Testing was performed at the 

dorsal 1st metacarpal and distal tip of the thumbs, long 

fi ngers, and middle fi ngers. Muscle stretch refl exes (also 

known as deep tendon refl exes) were obtained from the 

biceps brachii, brachioradialis, and triceps in the upper 

extremities. Upper extremity pathological refl exes were 

assessed with the Hoffman sign.

Last, the special tests of Tinel’s sign of median and ulnar nerves at the wrist, Tinel’s sign of the ulnar nerve at 

the elbow, Phalen’s test, and the assessment of the radial 

pulses during positional changes of the upper extremities and neck (Adson’s maneuver) were examined.19,20

Additional special tests of the median and ulnar nerves 

were performed on both upper extremities of each subject and included the elbow hyperfl exion test to assess 

for ulnar neuropathy at the elbow,21 upper limb neural 

dynamic testing to determine irritation of the cervical 

nerve roots or upper extremity nerves,22 and wrist ratio 

tests that determines the ratio of both the anterior-posterior and medial-lateral widths measured at the distal 

crease of the wrist.23-25

Nerve Conduction Studies

At the time of volunteer solicitation, potential subjects 

were instructed to abstain from exercising for one hour 

prior to testing. Skin temperature at the wrist was measured using a digital thermometer model TM99A (Cooper Instrument Corp, Middlefi eld, CT), and was maintained at or above 32oC. If skin temperature fell below 

this value, the wrist, hand, and forearm were re-warmed 

with warm towels.

The Cadwell Wave electromyograph and stimulator 

(Cadwell Laboratories, Inc, Kennewick, WA) were 

used to measure the compound motor action potential 

(CMAP) and sensory nerve action potential (SNAP) 

latencies and amplitudes. The stimulating current was 

a monophasic pulse 0.1 millisecond long. The oscilloscope was set to a sweep duration of 2.0 milliseconds 

per division and a gain of 20 μV per division for the 

SNAPs. For the CMAPs, the oscilloscope was set to a 

sweep duration of 2.0 milliseconds per division and a 

gain of 5 mV per division. The fi lter settings were 10 

Hz–10 kHz for the motor potentials and 10 Hz–2 kHz 

for the sensory potentials. The sensory latency was measured at the negative peak of the SNAP, and the amplitude was measured from negative peak to positive peak. 

The motor latency was measured from the negative 

takeoff of the evoked CMAP, while the amplitude was 

measured from the baseline to the negative peak of the 

evoked response. The obtained results were recorded 

manually and on computer printout.

Specifi c details for performing the median and ulnar 

nerve conduction studies (NCS) were presented in studies by Harkins et al26 and Greathouse et al27 and follow 

procedures previously described.28-31 The median and 

ulnar nerve palmar and digital distal sensory latencies 

(DSLs), distal motor latencies (DMLs), and conduction 

velocities were obtained from both upper extremities. 

All NCS procedures included measuring the anatomic 

course of the nerve: median and ulnar palmar DSLs (8 

cm), median and ulnar digital DSLs (14 cm), and median and ulnar DMLs (8 cm). In addition to comparing 

median nerve palmar and digital DSLs, DMLs, and conduction velocities with a chart of normal values, comparison studies between median and ulnar palmar DSLs, 

digit DSLs (digit 2 and digit 5, digit 4 median/ulnar), 

and DMLs in the same and opposite extremities were 

obtained. Examination of median and ulnar latencies in 

the same extremity and median and ulnar latencies in opposite extremities has been shown to assist in early electrodiagnosis of CTS.28-31 The presence of median or ulnar 

neuropathy was operationally defi ned as one or more 

electrophysiological values outside the normal range 

(Table 1) or slowing on comparison studies (Table 2).

Preventive Guidelines and Exercises for the

Wrist and Hand

Upon completion of the examination, each Soldier received educational tips regarding stretching, strengthening, resting, and nerve gliding techniques to assist in the 

prevention of future musculoskeletal injury. The exercises focused on the forearm, wrist, and hand. The purpose of providing upper extremity exercises (mobility, 

strengthening, and stretching) was to increase the Soldier’s awareness of possible musculoskeletal problems in 

dental personnel. Additionally, the subjects were advised 

to incorporate these exercises into their dental practice.

In an effort to ensure consistency across subjects, one 

investigator (KA) collected history data, another investigator (RM) performed the physical examinations, and 

a third investigator (CK) performed the nerve conduction tests. The neural conduction assessment of the median and ulnar nerves that were performed by researcher 

number 3 (CK) was directly monitored by either investigator 1 (SS), 6 (JM), or 7 (DG). Investigators 1 and 7 

are board-certifi ed clinical specialists in clinical electrophysiology by the American Board of Physical Therapy 

Specialties of the American Physical Therapy Association. Investigators 1, 6, and 7 are or have been credentialed by the US Army to perform clinical electrophysiological testing (NCS and EMG studies).
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

DATA MANAGEMENT AND ANALYSIS

Descriptive statistics for subject demographics and 

nerve conduction study variables were calculated using SPSS V12.0 (IBM Corp, Armonk, NY). Subjects’ 

median and ulnar nerve function was also ranked as 0 

(normal nerve conduction studies) or 1 (abnormal nerve 

conduction or comparison studies). Signifi cant (P<.05) 

differences between groups (abnormal or normal nerve 

conduction) for demographic and clinical examination 

items was also investigated with independent sample t

tests for parametric variables and χ2

 tests for categorical 

data.

RESULTS

Twenty subjects participated in this study (14 male, 6 

female). The subjects’ ages ranged from 26 to 56 years 

(mean=38±9.8 years). All of the subjects were right hand 

dominant. The subjects’ time in dental practice varied 

from 2 to 29 years (mean=13.3±7.96 years), indicating 

a high average level of experience in clinical practice. 

The time spent in the military was similar with a range 

from one to 26 years (mean=11.8±7.7 years). The majority of these dentists and dental specialists had joined the 

military specifi cally to be part of the Dental Command.

Each dental specialty represented by individual study participants is shown in the Figure. 

The predominant specialty was dentists (n=9), 

followed by preventative dental specialists 

(n=4) who are the military equivalent of a 

dental hygienist, and dental assistants (n=3). 

The subjects all reported using dental tools in 

their daily practice. Three of the 20 subjects 

reported performing a regular warm-up prior 

to utilizing dental tools.

The results of the nerve conduction studies 

are presented in Table 1. The values for these 

electrophysiological variables for each subject were compared to a chart of normal values (Table 1). This chart of normal values was 

developed in the Clinical Electrophysiological Laboratory of the Texas Physical Therapy 

Specialists (San Antonio, TX), and validated 

at the Electrophysiological Laboratory, US 

Army-Baylor University Doctoral Program 

in Physical Therapy, Fort Sam Houston, TX. 

The chart of normal values depicted in Table 1 

is similar to other charts of normal values.28-31

Comparison of the results of the study with 

the chart of normal values revealed that 5 

subjects had electrophysiologic evidence of 

mononeuropathy of the median nerve at or 

distal to the wrist (Table 2), while 2 subjects 

had electrophysiologic evidence of ulnar neuropathy at 

the wrist (Table 2).

Overall, 5 of the 20 subjects (25%) presented with abnormal electrophysiologic values suggestive of median 

neuropathy at or distal to the wrist (carpal tunnel). In addition, 2 subjects had ulnar neuropathy at the wrist (Guyon’s canal). The total number of subjects in this study 

with electrophysiologic evidence of mononeuropathy in 

MEDIAN AND ULNAR NEUROPATHIES IN US ARMY DENTAL PERSONNEL AT FORT SAM HOUSTON, TX

Table 1. Mean, standard deviation, and range of values for neural conduction measurements.

Right Upper

Extremity

Left Upper

Extremity

Normal

Values

Median Nerve Mean SD Range Mean SD Range

Motor

DML (ms) 3.5 0.4 2.8-5.3 3.4 0.4 2.7-4.3 <4.2

Amp CMAP (mV) 11.0 3.4 5-18 10.0 2.8 5-18 >5.0

MNCV BE-W (m/sec) 59.6 3.7 51-67 59.6 4.0 52-69 >50.0

Sensory

Palmar DSL (ms) 1.9 0.2 1.6-2.5 1.8 0.2 1.7-2.8 <2.2

Palmar Amp SNAP (μV) 117.0 46.0 24-200 108.0 39.9 39-200 >15.0

2 Digit DSL (ms) 2.9 0.2 2.6-3.6 2.9 0.2 2.4-3.4 <3.5

2 Digit Amp SNAP (μV) 44.0 19.8 15-103 31.0 12 19-169 >15.0

Ulnar Nerve

Motor

DML (ms) 2.8 0.3 2.2-3.4 2.8 0.3 2.3-4.1 <3.6

Amp CMAP (mV) 9.3 2.5 5-17 8.4 2.3 5-14 >5.0

MNCV BE-W (m/sec) 63.9 4.1 54-73 62.2 4.4 51-74 >50.0

MNCV AE-BE (m/sec) 66.5 5.6 54-77 65.4 6.2 51-76 >50.0

Sensory

Palmar DSL (ms) 1.7 0.1 1.5-2.1 1.7 0.1 1.5-2.1 <2.2

Palmar Amp SNAP (μV) 44.2 27.0 15-153 48.2 26.8 16-130 >10.0

5 Digit DSL (ms) 2.8 0.2 2.5-3.6 2.9 0.2 2.5-3.8 <3.5

5 Digit Amp SNAP (μV) 22.6 6.8 14-52 26.1 10.8 12-79 >10.0

Glossary:

 AE - above elbow DML - distal motor latency

 Amp - amplitude DSL - distal sensory latency

 BE - below elbow MNCV - motor nerve conduction velocity

 CMAP - compound motor action SNAP - sensory nerve action potential

 potential W - wrist

Dentists

Dental Assistant

Dental Lab Tech

Medical Logistics

Preventive

 Dental Specialist

1

3

3

4

9

Study participants by dental specialty. 
 April – June 2014 69

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

the median and/or ulnar nerves was 7 (35%). The specific occupations of the 7 subjects with evidence of mononeuropathy were 4 dentists, 2 dental lab technicians, and 

one medical logistics specialist.

Of the subjects with electrophysiologic evidence of median neuropathy at or distal to the wrist, 3 of the subjects 

(Subjects 4, 5, and 13) had abnormal electrophysiologic 

values in both hands (Table 2). Of the 2 subjects with 

unilateral fi ndings of median neuropathy at or distal to 

the wrist, Subject 12 had abnormal fi ndings in the left 

hand and Subject 19 had abnormal fi ndings in the right 

hand (Table 2). Subject 13 had electrophysiologic abnormalities of both the motor and sensory fi bers, Subjects 4 

and 5 had abnormal fi ndings in only the sensory fi bers, 

and Subjects 12 and 19 had abnormal comparison studies in the absence of abnormal distal motor or sensory 

latencies (Tables 2 and 3).

Subjects 10 and 17, both dentists, 

had electrophysiologic evidence 

of neuropathy of the ulnar nerve 

at the wrist (Guyon’s canal). Subject 10 had abnormal electrophysiologic values in both hands whereas Subject 17 only had abnormal 

fi ndings in the right hand. Both 

subjects had electrophysiologic abnormalities in both 

the motor and sensory fi bers of the ulnar nerves (Tables 

2 and 3). Both of these subjects with electrophysiologic 

evidence of ulnar nerve mononeuropathy at the wrist 

had normal motor nerve conduction velocity of the ulnar nerve in the forearm (BE-W) and across the elbow 

(AE-BE).

Three of the 7 subjects with positive electrophysiological fi ndings had positive fi ndings on physical examination (Table 4). The 3 subjects had electrophysiologic 

evidence of median neuropathy at or distal to the wrist. 

Subjects 4 and 5 had a Tinel’s Sign over the median 

nerve at the wrist, Subject 4 had a Tinel’s sign over the 

ulnar nerve at the wrist, and Subjects 4, 5, and 12 had 

a Tinel’s sign over the ulnar nerve at the cubital tunnel. Other than those, there were no positive fi ndings on 

physical examination in the subjects with electrophysiologic evidence of median nerve 

mononeuropathy at or distal to the 

wrist. None of the subjects with 

electrophysiologic evidence of 

ulnar neuropathy at the wrist had 

positive fi ndings on the physical 

exam. Many of these tests have 

been described in previous research to be indicative of carpal 

Table 2. Subjects with Positive Findings on Neural Conduction Comparison Studies (all data are presented as 

milliseconds).

Palmar DSL Digital DSL DML D4 DSL

Subject Hand Median Ulnar Difference Median Ulnar Difference Median Ulnar Difference Median Ulnar Difference

4

R 2.3a 2.0 0.3 3.3 3.0 0.3 4.2 3.1 1.1 3.8 3.1 0.7

L 2.3a 1.9 0.4 3.3 3.1 0.2 3.8 3.0 0.8 3.4 2.9 0.5

5

R 1.8 1.8 0.0 2.8 3.2 0.4 3.9 2.8 1.1 3.4 2.8 0.6

L 2.8a 1.4 1.4 1.9 2.8 0.9 3.6 2.7 0.9 3.0 2.9 0.1

10

R 1.7 1.8 0.1 3.3 3.5 0.2 3.6 3.7c 0.1 3.4 3.1 0.3

L 1.9 1.6 0.3 3.2 3.8b 0.6a 3.4 3.4 0.0 3.0 2.9 0.1

12

R 2.1 1.8 0.3 3.3 3.0 0.3 3.4 2.6 0.8 3.5 3.1 0.4

L 2.2 2.0 0.2 3.3 3.4 0.1 3.9 2.7 1.2 3.3 3.2 0.1

13

R 2.5a 1.9 0.6 3.6 3.3 0.3 5.3c 3.3 2.0 3.4 2.8 0.6

L 2.4a 2.0 0.4 3.5 3.4 0.1 4.3c 3.0 1.3 3.6 3.0 0.6

17

R 2.1 2.1 0.0 3.4 3.6b 0.2 3.9 4.1d 0.2 3.1 2.9 0.0

L 2.1 2.1 0.0 3.1 3.1 0.0 3.9 3.4 0.5 3.1 2.9 0.0

19

R 2.1 1.7 0.4 3.2 2.7 0.5 3.9 2.8 1.1 3.1 2.8 0.3

L 2.1 1.6 0.5 3.0 2.7 0.3 3.8 3.0 0.8 3.2 2.9 0.3

DSL indicates distal sensory latency. DML indicates distal motor latency.

Notes:

Prolonged DSL (palmar and digit) difference ≥0.6 milliseconds (normal ≤0.5)

Prolonged DML difference ≥1.1 milliseconds (normal ≤1.0)

Prolonged D4 median/ulnar difference ≥0.6 milliseconds (normal ≤0.5) aProlonged median palmar DSL ≥2.3 milliseconds (normal ≤2.2) bProlonged ulnar digital DSL ≥3.6 milliseconds (normal ≤3.5) cProlonged median DML ≥4.3 milliseconds (normal ≤4.2) dProlonged ulnar DML ≥3.0 milliseconds (normal ≤3.6)

Table 3. Summary of Subjects with Abnormal 

Findings of Nerve Conduction Studies (NCS).

Median nerve distal sensory and motor latency 1

Median nerve distal sensory latency 2

Median nerve comparison studies* 2

Ulnar nerve distal sensory and motor latency 2

Total abnormal NCS fi ndings 7

*In absence of abnormal distal motor or sensory 

latency.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

tunnel syndrome. However, in the current study, none of 

the subjective or physical examination measures exhibited signifi cant group differences for subjects with either 

median or ulnar neuropathy at the wrist upon analysis 

with independent t tests and χ2

 tests (P>.05).

COMMENT

This study builds on previous studies that investigated 

the relationships between medical history, physical 

examination, and NCS fi ndings of median and ulnar 

neuropathy in US Army dental assistants and preventive dental specialists.16-18 Our study adds to this base of 

knowledge by including the addition of different Army 

medical dental personnel to include dentists and dental 

lab technicians. Additionally, our study supports the assumption that dental personnel have a higher percentage 

of criterion-related validity-based diagnosis of median 

neuropathy at or distal to the wrist (25%). This is the 

fi rst dental study to report electrodiagnostic fi ndings of 

ulnar mononeuropathy at or distal to the wrist. Of note, 

4 of the 9 dentists (44%) were found to have abnormal 

NCS fi ndings, which is signifi cantly higher than previously reported.3,6-10

The majority of previous research investigating the 

prevalence of median neuropathy in dental personnel 

has used survey data and not electrophysiologic testing 

(nerve conduction studies).11,12 Nerve conduction studies 

are considered the gold standard (criterion-related validity) for diagnosing peripheral neuropathy.28-45 Survey 

data of active duty military dental personnel found that 

the highest prevalence of 3 to 4 self-reported symptoms 

that were consistent with a high probability of having 

carpal tunnel syndrome were preventive dental specialists (33%), followed by laboratory technicians (28%), 

dentists (21%), and dental specialists (16%).11,12 Our 

study confi rms that dental personnel have a higher actual prevalence of CTS than nondental personnel. However, the difference between our research using NCS 

and the survey data indicating a higher prevalence of 

symptoms is likely understood by the low sensitivity of 

history questions and physical exam screening tests and 

measures in identifying true neuropathy. We believe 

that a focus on developing and identifying more sensitive screening measures for neuropathy is imperative 

for early detection of median and ulnar neuropathy in 

patients having mild clinical symptoms.

Our study is unique in that it is the fi rst to identify ulnar 

neuropathy at or distal to the wrist in this population 

of dental personnel. Both subjects with abnormal electrophysiologic fi ndings of ulnar neuropathy at the wrist 

were dentists. To our knowledge, only one previous occupational screening study has demonstrated the prevalence of ulnar neuropathy, and that was 

at the elbow (cubital tunnel syndrome, 

the second most common neuropathy of 

the upper extremity).27 No other studies 

document the fi ndings of ulnar nerve 

problems at or distal to the wrist in dental personnel.16-18 Dentists and dental personnel are predisposed to ulnar neuropathy due to repetitive and prolonged wrist 

positioning, use of small diameter tools, 

and exposure to vibratory tools.11-13 We 

encourage future researchers to include 

examination of the ulnar nerve at or distal to the wrist and elbow (cubital tunnel) 

in order to detect ulnar neuropathy.

A thorough history and physical examination are considered essential screening 

tools for detecting signs and symptoms 

of peripheral neuropathy.28-31 Nerve conduction measurement is often performed 

on the median and ulnar nerves to determine whether certain entrapment neuropathies are present. It is considered the 

gold standard or has criterion-related validation when assessing the electrophysiologic status of the peripheral nerve.28-45

MEDIAN AND ULNAR NEUROPATHIES IN US ARMY DENTAL PERSONNEL AT FORT SAM HOUSTON, TX

Table 4. Subjects with Positive Findings on Special Tests of the Upper Extremities.

Subject Hand Tinel’s Sign

at wrist

(median)

Tinel’s Sign

at wrist

(ulnar)

Tinel’s Sign

at

cubital tunnel

Wrist

Ratio

Vibrometry Phalen’s

Test

1R X

2R X

3 L X

R XX

4 L X* X*

R X* X* X*

5 R X* X*

6R X

11 L XX

RX X X

12 L X*

R X X

14 R X

15 L X

16 L X X X

R X X X

17 L X

R

18 R X X X X

20 L X

Total physical 

exam findings

6 4 14 5 6 1

Note: Subjects 10, 13, and 19 had abnormal nerve conduction velocity findings without 

positive physical exam findings.

*Denotes subjects with electrodiagnostic abnormalities on NCV.
 April – June 2014 71

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

Our history questionnaire included questions regarding the subjects’ pertinent medical history, premilitary 

occupational background, military background, and 

extra-curricular activities (such as computer use and/or 

gaming), none of which were found to be statistically 

correlated with positive fi ndings of median and ulnar 

neuropathy as determined by electrophysiologic testing. 

In addition, the physical exam fi ndings in these dental 

personnel were not correlated with positive fi ndings of 

median or ulnar neuropathy. Three of the subjects who 

were diagnosed with median neuropathy at or distal to 

the wrist had a completely negative physical examination. Similarly, 12 of the 20 patients who had no electrophysiologic evidence of median or ulnar neuropathy 

were found to have at least one positive physical exam 

fi nding. Thus, this fi nding further supports that the 

physical exam screening tests and measures used in this 

study were not sensitive for clinically detecting median 

and ulnar neuropathies.22-25

On physical examination, 2 subjects (3 hands) with abnormal electrodiagnostic fi ndings of the median nerve 

at or distal to the wrist had a positive Tinel’s test at the 

wrist for the median nerve, but otherwise had normal 

physical examination fi ndings suggestive of CTS. It is 

also interesting to note that 3 subjects with abnormal 

NCS values consistent with median mononeuropathy at 

or distal to the wrist did not show any positive clinical 

tests on physical examination suggestive of CTS.

In a population such as US Army dental personnel, it 

is reasonable to expect that subclinical upper extremity 

mononeuropathies secondary to repetitive overuse may 

be present. In the early stages of a mononeuropathy of 

this type, many individuals with a clinically detectable 

problem are not aware that their neural function has 

been impaired.43 Atroshi et al43 examined 125 asymptomatic controls with NCS of the median nerves and 

they reported that 18% (n=23) had electrophysiological 

evidence of carpal tunnel syndrome.

Atroshi et al43 reported that the estimation of prevalence 

of CTS in a general population may contribute to the 

early diagnosis and effective treatment of subjects, and 

provide useful data for the interpretation of results that 

estimate the prevalence of carpal tunnel syndrome in 

specifi c occupational groups. Franzblau and Werner44-46

further suggest that performing NCS on individuals 

without symptoms of CTS is important because it permits the assessment of the overall relationship between 

the electrophysiological properties of the nerve and 

other clinical features of carpal tunnel syndrome. Although no strong evidence regarding the prevention or 

progression of CTS exists, theoretically it makes sense 

to identify a problem early, when a minor intervention 

such as a resting night splint or ergonomic changes in 

the work environment might rectify the dysfunction.44-46

One limitation of this study is the small sample size of 

20 subjects who were recruited from a total pool of 27 

possible subjects at Fort Sam Houston, TX, for a 74% 

participation rate. We suggest that further research employ a multisite approach to increase the total number of 

subjects and improve the likelihood of an accurate prevalence of these neuropathies. The specifi c population of 

active duty personnel also limits the study’s external validity in comparing these fi ndings to nonmilitary dental 

personnel due to different job demands, work schedules, 

and other duties, including deployment and mandatory 

physical performance training.

A valuable extension to the current study would be an 

expansion to multiple active duty and civilian sites to 

increase the diversity of the study population as well 

as its total size. We provided an informational briefi ng 

to the subjects of the study at its conclusion, which included theoretically preventive exercises such as nerve 

and tendon gliding. A long-term study of the population to assess prevention using exercise has not yet been 

performed and would be of benefi t to the dental community. Additionally, a longitudinal study of these and 

other subjects may be valuable to assess the time course 

of median and ulnar neuropathies.

CONCLUSION

The prevalence of median mononeuropathies in our 

sample of US Army dental personnel far exceeded that 

previously reported in the general population.43 Our 

fi ndings also build on previous research suggesting increased prevalence of upper extremity mononeuropathies in US Army dental personnel.16-18 This is the fi rst 

dental study to report electrodiagnostic fi ndings of ulnar 

mononeuropathy at or distal to the wrist. Physical examination and historical items such as wrist ratio measurements, age, and years of service in the dental profession did not exhibit meaningful diagnostic accuracy. 

Prospective research is required to validate our fi ndings 

and future research examining additional examination 

items, intervention, and prevention techniques are needed to enhance performance and reduce upper extremity 

mononeuropathies in dental personnel.

ACKNOWLEDGEMENT

The authors thank COL Williard, Commander, and 

MSG Myers, Noncommissioned Offi cer-in-Charge, 

Fort Sam Houston Dental Activity, for their support 

of this study and assistance in recruiting US Army 

Dental Command Soldiers to participate.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

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17. Greathouse DG, Root TM, Carrillo CR, Jordan CL, 

Pickens BB, Sutlive, TG, Shaffer SW, Moore JH. 

Clinical and electrodiagnostic abnormalities of the 

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Army Med Dep J. January-March 2011:70-81.

18. Shaffer SW, Moore R, Foo S, Henry N, Moore JH, 

Greathouse DG. Clinical and electrodiagnostic 

abnormalities of the median nerve in US Army 

dental assistants (68E) at the onset of training. US 

Army Med Dep J. July–September 2012:72-81.

19. Dutton M. Orthopaedic Examination, Evaluation, 

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20. Magee DJ. Orthopaedic Physical Assessment. Philadelphia: W.B. Saunders; 1992.

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23. Moghtaderi A, Izadi S, Sharaafadinzadeh N. An 

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carpal tunnelsyndrome. Acta Neurol Scand. 

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humans. J Clin Electrophysiol 1989;1:10-13.

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 April – June 2014 73

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29. Dumitru D, Amato A, Zwarts M. Electrodiagnostic Medicine. 2nd ed. St. Louis, MO: Hanley & Belfus; 2002.

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Workplace surveillance for carpal tunnel syndrome: a comparison of methods. J Occup Rehabil. 

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AUTHORS

COL Shaffer is Associate Professor and Program Director, US Army-Baylor University Doctoral Program in 

Physical Therapy, Joint Base San Antonio (JBSA) Fort 

Sam Houston, TX. He is also Chief, Physical Therapist 

Section, and Assistant Chief, US Army Medical Specialist Corps.

1LT Alexander is a staff physical therapist at the William 

F. Beaumont Army Medical Center, Fort Bliss, TX. At 

the time of this study, she was a student in the US ArmyBaylor University Doctoral Program in Physical Therapy, 

JBSA Fort Sam Houston, TX.

1LT Huffman is a staff physical therapist at the BaynesJones Army Community Hospital, Fort Polk, LA. At the 

time of this study, he was a student in the US ArmyBaylor University Doctoral Program in Physical Therapy, 

JBSA Fort Sam Houston, TX.

1LT Kambe is a staff physical therapist at the Irwin Army 

Community Hospital, Fort Riley, KS. At the time of this 

study, he was a student in the US Army-Baylor University Doctoral Program in Physical Therapy, JBSA Fort 

Sam Houston, TX.

CPT Miller is a staff physical therapist at the Joint Base 

Elmendorf-Richardson Hospital, Alaska. At the time 

of this study, he was a student in the US Army-Baylor 

University Doctoral Program in Physical Therapy, JBSA 

Fort Sam Houston, TX.

COL Moore is Dean, Graduate School, Army Medical Department Center and School, and Professor, US 

Army-Baylor University Doctoral Program in Physical 

Therapy, Joint Base San Antonio Fort Sam Houston, TX.

Dr Greathouse is Director, Clinical Electrophysiology Services, Texas Physical Therapy Specialists, New 

Braunfels, TX, and Adjunct Professor, US Army-Baylor 

University Doctoral Program in Physical Therapy, JBSA 

Fort Sam Houston, TX.
74 http://www.cs.amedd.army.mil/amedd_journal.aspx
 April – June 2014 75

Overweight and obesity can be defi ned as ranges of 

weight greater than what is commonly considered 

healthy for a given height, which can increase the prevalence of health problems and certain diseases.1

 One of 

the most common and feasible means to determine overweight and obesity is by calculating body mass index 

(BMI). Being overweight or obese can be defi ned as having a BMI of 25.0-29.9, or 30 or higher, respectively.1,2

The number of overweight and obese individuals in the 

United States continues to increase and has now reached 

63%.2,3 One study suggested that if drastic intervention 

is not taken, 80% of US adults will be overweight or 

obese by the year 2022, and the associated health care 

costs could be as high as $956.9 billion by 2030, compared to $81.5 billion in 2001.4

This epidemic is also impacting Soldiers in the US 

military. A recent study indicated 27% of young adults 

aged between 17-24 years are unfi t for military service 

based on height-weight requirements.5

 Obesity has been 

found to be the most common reason for Army applicant disqualifi cation.6

 Prior to World War II, the military 

had concerns about Soldiers being underweight, which 

limited overall health and strength.7

 That was less than 

75 years ago, and today the concern has shifted to the 

opposite end of the spectrum, with obesity affecting 

overall health and operational effectiveness due to lower 

physical fi tness and adverse health effects such as high 

cholesterol, high blood pressure, diabetes or injury, and 

lost duty time as the result of these conditions.8-11 Current data suggest 64% of men and 40% of women on 

active duty are clinically overweight or obese.8

 Higher 

body fat not only elevates the individual Soldier’s health 

risk, but may also reduce Soldier combat readiness and 

physical performance; affects the Soldier’s eligibility 

for command positions, promotion, and attendance at 

professional military schools; and/or may result in early 

separation from service.12-14

Risk Factors Associated with Higher

 Body Fat in US Army Female Soldiers

 Morgan K. Anderson, MPH, CPH

 Tyson Grier, MS

 Michelle Canham-Chervak, PhD

 Timothy T. Bushman, MS

 Bruce H. Jones, MD, MPH

ABSTRACT

Increased body fat among US Soldiers is a continuing challenge that contributes to increased health risks and 

decreased combat readiness. Factors contributing to higher body fat among US Army female Soldiers have 

been minimally investigated.

Purpose: To investigate the risk factors associated with exceeding US Army body fat standards among active 

duty women in a light infantry brigade. Investigated risk factors include personal characteristics, physical 

training, physical fi tness, and injury history.

Methods: Data were obtained by survey from women in 3 US Army infantry brigades. Body fat percentage 

was calculated, and the women were categorized as either meeting or exceeding the maximum Army body fat 

standard of 30% for ages 17-20, 32% for ages 21-27, 34% for ages 28-39, and 36% for age 40 years or more. 

Army Physical Fitness Test (APFT) results were converted into tertiles (T), where T1=lowest 1⁄3 of performance 

and T3=highest 1⁄3 of performance. Odds ratios (OR) and 95% confi dence intervals (CI) were calculated from 

a multivariate analysis assessing risk associated with exceeding the Army body fat standards.

Results: Among the women surveyed (N=629), 22% exceeded Army body fat standards. Higher risk of being 

above the Army standard was associated with older age (≥29 years/≤23 years) (OR=2.47, 95% CI, 1.24-4.92), 

and poor aerobic fi tness (APFT 2-mile run) (T1/T3) OR=6.11, 95% CI, 2.62-14.24), (T1/T2) OR=2.66, 95% 

CI, 1.12-6.33). A marginal association was found for poor muscular strength (APFT sit-ups) (T1/T3).

Conclusion: The results suggest that women who are older, and/or have poor aerobic fi tness are more likely to 

exceed the maximum Army body fat standards.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

The US Army has enforced body fat standards to ensure 

Soldiers meet a certain level of physical fi tness. These 

standards, outlined in Army Regulation 600-9, vary by 

age.9,12,15 If the weight for a given height at a specifi ed 

age is exceeded, then specifi c body circumference measurements are taken, and a body fat percentage is calculated.12 If Soldiers do not meet the body fat standard, 

they are required to attend counseling and enter into a 

weight loss program. 

Even though women make up a small portion of the overall Army population (14%), their contributions to the 

Army are crucial.16,17 A recent policy change will permit 

women to assume certain infantry, armor, and special 

operations positions that were previously reserved for 

men only.18 The limiting factor for female Soldiers to 

assume these positions is their ability to pass the same 

physical requirements as male Soldiers.18 Addressing 

health concerns such as obesity within the female population would likely benefi t the women’s overall military 

performance and increase their opportunity to serve in 

these positions. This study investigated the risk factors 

associated with exceeding US Army body fat standards 

among active duty women in a light infantry brigade.

METHODS

Data Collection

Active duty US Army women in 3 light infantry brigades completed surveys as part of an ongoing physical training program evaluation. All of the women were 

located on a military post within the United States, with 

a majority of these women having been stationed at this 

location for more than one year. The surveys obtained 

data on the women’s personal characteristics, physical 

training, physical fi tness, and any injury that occurred 

during the previous 12 months. Military occupations 

were categorized according to Field Manual 7-21.13.

19

Age was calculated by subtracting the self-reported date 

of birth from the date the survey was completed. Smokers were identifi ed as those who had smoked at least 100 

cigarettes in their lifetime and had smoked at least 1 

cigarette in the 30 days prior to the survey date.

Each Soldier’s BMI (kg/m2

) was calculated from selfreported weight (kg) and height (m). Self-reported 

height and weight have been shown to be highly correlated with actual height and weight (r>0.97).20 The 

BMI was categorized based on the Centers for Disease 

Control and Prevention classifi cations for “underweight” 

(<18.5), “normal” (18.5-24.9), “overweight” (25.0-29.9), 

and “obese” (≥30).21 For this study, US Army body composition standards are based on the percentage of body 

fat estimated by means of the Deu renberg formula.22

The gender variable in this formula is 0 for women.23

Body Fat Percentage=(1.20×BMI)+(0.23×Age)-

(10.8×gender)-5.4

The physical training (PT) weekly running distance was 

calculated from average running frequency per week 

multiplied by average miles per run. Physical fi tness 

was assessed by means of performance on the Army 

Physical Fitness Test (APFT) in which scores consisted 

of a timed (2 minutes) push-up event, a timed (2 minutes) sit-up event, and a timed 2-mile run. Those scores 

were converted into tertiles (T) where T1 represented 

those Soldiers with the lowest 1⁄3 of performance, and 

T3 represented those with the highest 1⁄3 of performance. 

Two-mile run times were converted into minutes and 

fractions of a minute. An injury was defi ned by a selfreport of having been injured in the previous 12 months.

Body Fat Standards

Army Regulation 600-9 was developed to ensure that 

Soldiers are capable of meeting the physical demands 

of Army missions/tasks.12 The Army body fat standards 

require Soldiers to be measured and weighed during 

the semiannual APFT.21 In the Army, if a female Soldier exceeds her weight standard based on her height, 

her actual body fat is calculated by measuring the circumference of her neck, waist, and hips.12 After their 

body fat percentages were calculated, the women in this 

study were categorized as either meeting or exceeding 

the Army maximum body fat standards of 30% for ages 

17-20, 32% for ages 21-27, 34% for ages 28-39, and 36% 

for ages 40 years or more.

Data Analysis

Data were analyzed using IBM SPSS Statistics (V 19.0) 

software (IBM Corp, Chicago, IL). Descriptive statistics for demographics were calculated. Comparisons of 

BMI and body fat percentages by age and fi tness were 

made using χ2 and analysis of variance to determine any 

differences between categorical and continuous variables, respectively. An independent-samples t test was 

conducted to compare aerobic training between the 2 

groups. Logistic regression was used to assess the association of personal characteristics, physical fi tness, 

and unit physical training with risk of exceeding Army 

body fat standards. Risk ratios and 95% confi dence intervals (CI) were presented. Potential risk factors for the 

inability to meet Army body fat standards were entered 

into the multivariate logistic regression model based 

on univariate model results. Risk factors signifi cant 

at the P<.10 were entered into the starting model for 

a backward stepping logistic regression model. Odds 

ratios (OR) and 95% CI from the backward stepping 

RISK FACTORS ASSOCIATED WITH HIGHER BODY FAT IN US ARMY FEMALE SOLDIERS
 April – June 2014 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

multivariate analysis were calculated and reported. Risk 

factors at the P<.05 were considered statistically signifi -

cant in the multivariate model.

RESULTS

A total of 629 women were surveyed, representing 64% 

of the total female population in the 3 light infantry brigades surveyed. Women accounted for 8% of the total 

brigade population. Mean (±SD) age was 26.3 (±5.9) 

years. A majority of these female Soldiers were enlisted personnel (90%) and were serving in combat support military occupational specialties (98%). Of these 

women, 54% had reported an injury within the previous 12 months. Using Centers for Disease Control and 

Prevention (CDC) BMI categories, 38% (n=238) of the 

women were overweight (BMI=25.0-29.9 kg/m2) and 

5% (n=29) were obese (BMI≥30 kg/m2). Using the estimated body fat formula, 22% (n=135) of the women 

were over the maximum Army body fat percentage for 

their age group. Of the 135 women over the maximum 

body fat standard, 79% were overweight and 21% were 

obese according to the CDC BMI categorization. Table 

1 shows the BMI and mean body fat percentage by age 

groups. BMI and mean body fat percentage were higher 

with older age groups. Table 2 displays the proportion 

of women, by age group, who exceeded the Army body 

fat standard. There was a statistically signifi cant difference in the proportion of women exceeding the standard 

between age groups (P<.01), with the highest proportion 

exceeding the standard in the 40 or more years of age 

group (48%).

Table 3 compares average physical fi tness as measured 

by APFT performance for women who did and did not 

meet the Army body fat standards. There was no difference in push-up performance (P=.36). However, statistically signifi cant differences in performance on the sit-up 

and running events were observed. On average, women 

above the maximum body fat standard performed 6.7 

fewer sit-ups (P<.01) and were 1.74 minutes slower on 

the 2-mile run test (P=.04). 

Table 4 shows the association of personal characteristics, 

physical training, physical fi tness, and prior injury with 

the risk of exceeding Army body fat standards. The risk 

of exceeding Army body fat standards was lower for offi cers and warrant offi cers. Risk was higher among 

women over the age of 29 and women who did not 

run with their unit. Women who performed in the 

lowest tertile for sit-ups and push-ups and in the 

slowest 2 tertiles of 2-mile run time were also at 

higher risk. There was a dose-response relationship for all 3 components of the APFT (P≤.01) 

indicating that for successively lower fi tness levels, the risk of exceeding Army body fat standards 

increased. Prior injury and other unit physical 

training measurements were not risk factors for 

exceeding the Army body fat standards in women. 

We also investigated the average number of miles run 

per week for the women whose estimated body fat was 

above standards and those who met the standards. The 

average number of miles run per week was not signifi -

cantly different between the groups (12.0 miles for those 

above body fat standards versus 11.3 miles for those 

meeting the standards, P=.10).

Variables entered into the multivariate logistic regression model included age, weekly unit running mileage, 

and all 3 APFT events (push-up, sit-up, 2-mile run). 

Rank was not entered into the model as it was correlated 

with age. Table 5 shows independent risk factors associated with female Soldiers exceeding the Army body 

fat standard for their age category. Female Soldiers over 

Table 1. Mean BMI and Estimated Body Fat by Age 

Group Among Female Soldiers Surveyed (N=629).*

Age Group

(years)

n Mean BMI† n Mean Estimated

Body Fat Percentage‡

17-20 67 23.9±3.0 67 27.8±3.7

21-27 364 24.2±3.4 360 29.2±4.1

28-39 162 25.0±3.2 161 31.9±4.0

≥40 25 26.2±3.3 25 36.1±4.0

*Age and/or BMI not reported for 11 women.

†BMI ANOVA P<.01

‡Body fat percentage ANOVA P<.01

Table 2. Proportion of Female Soldiers Surveyed Exceeding Army Body Fat Standards by 

Age Group (χ2 P<.01 for all groups)

Age Group

(years)

No. of Female

Soldiers

(n)

Percentage of n 

Over Maximum Body 

Fat Percentage*

17-20 67 24%

21-27 364 19%

28-39 162 25%

≥40 25 48%

Total 618† 22%

*Maximum body fat allowed for age groups: 17-20, 

30%; 21-27, 32%; 28-39, 34%; ≥40, 36%.

†BMI (height and/or weight not reported for 11

women).

Table 3. Comparison of Physical Fitness by Body Fat Status Among 

Female Soldiers Surveyed (n=629).

Fitness

Measures*

Met Body Fat

Percentage

Standard

Did Not Meet Body 

Fat Percentage 

Standard

Mean

Difference

Pearson

χ2 P value

Sit-ups 

(repetitions) 66.8±12.9 60.1±13.3 -6.7 <.01

Push-ups 

(repetitions) 41.4±13.0 35.2±11.8 -6.2 .36

2-Mile Run 

(minutes) 17.2±1.9 18.9±2.3 +1.7 .04

*From Army Physical Fitness Test
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

the age of 29 were 2.47 times more likely to exceed the 

Army body fat standards. Women who performed the 

least amount of sit-ups were 1.77 times more likely to exceed the Army body fat standards, although results were 

marginally signifi cant. Women in the 2 slowest APFT 

2-mile run tertiles were 2.66 (T2) and 6.11 (T1) times 

more likely to exceed the Army body fat standards.

COMMENT

In this population of US Army women in light infantry 

brigades, it was found that 38% were overweight and 

5% were obese, based on the CDC BMI classifi cations. 

Twenty-two percent exceeded Army body fat standards 

for their age group. Considering a variety of personal 

characteristics, unit physical training, and physical fi tness, this study showed a higher risk of exceeding Army 

body fat standards among women over age 29 and those 

with lower levels of aerobic fi tness (ie, those running 

more slowly on the 2-mile run).

The Army relies on height, weight, and BMI to screen for 

body composition in men and women, thus limiting direct knowledge of the association of body fat with fi tness 

or job performance in women.23 As a result, there have 

been few investigations that have studied women and 

measured percentages of body fat in the military. Similar to the fi ndings of this analysis, a study by Bathalon 

et al analyzing active duty Soldiers (n=1,257) also found 

RISK FACTORS ASSOCIATED WITH HIGHER BODY FAT IN US ARMY FEMALE SOLDIERS

Table 4. Risk Factors for Exceeding Army Body Fat Standards Among Female Soldiers 

(n=629, unadjusted).

Variable Variable Level n Percentage of n

Not Meeting Army 

Body Fat Standard

Risk Ratio

(95% CI)

P

value

Age (years) ≤23 236 17% 1.00

24-28 217 22% 1.31 (0.89-1.92) .16

≥29 160 31% 1.85 (1.28-2.68) <.01

Enlisted Rank E1-E3 139 20% 1.00

E4-E5 354 24% 1.19 (0.82-1.74) .36

E6-E9 55 29% 1.44 (0.85-2.45) .18

Officer/Warrant Officer 60 7% 0.33 (0.12-0.90) .02

Military

Occupational 

Specialty

Combat Arms 10 0%

Combat Support 168 24% 1.10 (0.80-1.52) .56

Combat Service Support 430 22% 1.00

Tobacco Use Nonsmoker 427 21% 1.00

Smoker 184 25% 1.17 (0.86-1.61) .32

Unit Weekly

Running

Distance

Did not run with unit 186 25% 1.42 (0.98-2.06) .06

<10 miles 230 18% 1.00

10-20 miles 128 20% 1.14 (0.73-1.77) .56

>20 miles 42 26% 1.47 (0.82-2.62) .21

Unit Road

Marches

per wk

None/< 1 a wk 365 21% 1.00

1-2 times a wk 93 24% 1.12 (0.74-1.70) .59

3-4 times a wk 131 23% 1.09 (0.75-1.57) .67

Road March 

Distance

No Road Marches 72 18% 1.00

1-3 miles per wk 129 26% 1.42 (0.80-2.51) .22

4-6 miles per wk 233 21% 1.17 (0.67-2.02) .58

7 or more miles per wk 49 20% 1.13 (0.54-2.37) .75

Unit Resistance 

Training

None 419 20% 1.00

1-2 times per wk 142 26% 1.28 (0.92-1.80) .15

3 or more times per wk 36 25% 1.23 (0.68-2.24) .50

APFT Pushups

repetitions

(tertile)

≤34 (T1) 186 50% 2.44 (1.55-3.83) <.01

35-46 (T2) 190 31% 1.48 (0.90-2.43) .12

≥47 (T3) 164 18% 1.00

APFT Sit-ups

repetitions

(tertile)

≤60 (T1) 205 57% 2.29 (1.49-3.53) <.01

61-71 (T2) 157 22% 1.17 (0.69-1.97) .56

≥72 (T3) 169 21% 1.00

APFT 2 mile

minutes

(tertile)

≤16.50 (T3) 147 12% 1.00

16.51-18.20 (T2) 144 32% 2.65 (1.33-5.30) <.01

≥18.21 (T1) 142 56% 4.76 (2.50-9.07) <.01

Injured in the

past 12months

No 286 20% 1.00

Yes 326 24% 0.95 (0.87-2.55) .23
 April – June 2014 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

that 22% of female Soldiers did not meet the Army 

body fat standards.24 In a study by Friedl et al, 17% 

of women in an operational Army unit (n=347) 

were overweight according to military standards.9

This analysis found that women of increasingly 

older age exhibited higher average estimated body 

fat percentages. Other studies have reported similar results among female Soldiers.24,25 One investigation reported that 53% of women between the 

ages of 17 and 20 exceeded the Army body fat 

standards compared to 64% of women over 40 

years of age.24 There is limited information on 

body fat percentage and age in women, but there 

are several studies on BMI and age in women. One 

study showed a signifi cant correlation between age 

and BMI; women between the ages of 20 and 39 had an 

average BMI of 25.9 kg/m2

, while the average BMI was 

27.0 kg/m2

 among women aged 40-59 years.25 Another 

study, published in 2010, also reported BMI in women 

to increase with age and plateau at about 50 years of 

age.23 Specifi cally, women aged 20-29 had an average 

BMI of 24.3 kg/m2

, women aged 30-39 years had an 

average BMI of 25.6 kg/m2

, and women aged 40-49 had 

an average BMI of 26.3 kg/m2

.

26 One explanation as to 

why body fat increases with age in military women is a 

decrease in physical training with increasing rank and 

entry into more sedentary supervisory roles. 

Regarding the effects of body fat on fi tness, the APFT 

provided an overall assessment of health-related fi tness. 

According to Army Regulation 350-1,

21 participants acquiring a score of 270 (with a 90-point minimum per 

event) and passing the body composition standards will 

be awarded the Physical Fitness Badge for excellence.2

A previous investigation found 24% of female Soldiers 

exceeding body fat standards were able to score over 

270 out of 300 on the APFT. The study suggested that 

physiological differences in body fat thresholds could 

explain how participants exceeding body fat standards 

still performed well on the tests. The study characterized such participants as “fi t fat.” 9

 An earlier study of 

body composition and fi tness reported low but signifi -

cant correlations between BMI and measured body fat 

percentage and run times, sit-ups, and push-ups.28 Another study showed little correlation between body fat 

percentage and obstacle course performance. The investigators found those with greater fat mass also had 

greater fat-free mass, allowing them to carry excess fat 

without leading to a decrease in performance.29 However, this investigation found the average APFT total 

score for women exceeding the body fat standard was 

228.8±38.40, (n=78), with only 9 (12%) of them scoring 

270 and above. Women who did not exceed the body fat 

standard had an average total APFT score of 255.6 ±2.6, 

with 84 (25%) scoring 270 and above.

Women in this investigation who did not meet Army 

body fat standards on average did not perform well on 

the APFT 2-mile run. Fortunately, aerobic endurance is 

a modifi able risk factor that also affects body composition. One study with nearly 4,000 participants found 

endurance training for 4 weeks or longer reduced body 

fat by 1.4% on average (P≤.01).30 Gradually increasing 

the frequency of aerobic training in the participants’ 

training program, with supervision, may help to reduce 

the number of individuals exceeding the Army body 

fat standard. In contrast, several studies have shown 

increased running leads to an increase in injury incidence.31-33 Therefore, care must be taken when increasing running frequency and mileage. 

Alternatively, similar military populations have established new physical training programs that include alternatives to running for aerobic conditioning. A study by 

Walker et al describes a new physical training program 

that reduced running distance by 50% and replaced it 

with interval running and agility drills. With this program, overall injuries decreased by 67% while aerobic 

capacity increased.34 Another military study evaluated a 

new physical training program using cross-training and 

aerobic training by ability groups compared to a more 

traditional program with more distance running. Results showed women in the traditional program had a 1.8 

times greater risk of a time loss injury.35 Other aerobic 

exercises, such as swimming, should also be explored as 

alternatives to running.

STRENGTHS AND LIMITATIONS

Data were collected through self-reported surveys, 

which can be subject to recall bias as well as concerns 

about honesty in answers and lack of comprehension of 

Table 5. Multivariate Regression Results: Independent Risk Factors for 

Exceeding Army Body Fat Standards Among Female Soldiers (N=629).

Variable Variable Level n Odds Ratio

(95% CI)

P value

Age (years) ≤23 163 1.00

24-28 155 1.47 (0.78-2.76) 0.23

≥29 86 2.47 (1.24-4.92) 0.01

APFT Sit-ups

Tertiles

(repetitions)

≤60 (T1) 142 1.77 (0.91-3.46) 0.09

61-71 (T2) 119 0.87 (0.40-1.88) 0.73

≥72 (T3) 143 1.00

APFT 2 mile run

Tertiles

(minutes)

≤16.50 (T3) 132 1.00

16.51-18.20 (T2) 136 2.66 (1.12-6.33) 0.03

≥18.21 (T1) 136 6.11 (2.62-14.24) <0.01

Note: APFT indicates Army physical fitness test.

Variable(s) entered on step 1: Age, total unit weekly running miles,

APFT 2-mile run, APFT push-ups, APFT sit-ups
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

the questions. However, prior analyses have found high 

correlations between actual and self-reported APFT 

data.36 In this study specifi cally, actual unit-collected APFT data were available for a subset of the study 

sample (n=83 Soldiers). A comparison of actual (unitcollected) and self-reported APFT scores showed correlations over 80% for 2 of 3 APFT events: r=0.87 (n=87), 

r=0.83 (n=83), and r=0.54 (n=83), for the 2-mile run, 

sit-ups, and push-ups, respectively. 

In this analysis, body fat percentage was estimated using the Deurenberg formula, which has been found to 

have less than 2% mean difference between reported 

and predicted body fat percentage.22 Even though the 

Deurenberg formula is a validated formula with regard 

to its accuracy, it remains an estimation tool only. Other 

body composition formulas were considered, however, 

they required the identifi cation of ethnicity, which was 

unknown in our database. Using a body composition 

formula developed by Gallagher et al that was derived 

using Caucasian and African-American data,37 a comparison with estimated body fat percentages calculated 

using the Deurenberg equation indicated a correlation of 

0.96. Body mass index is considered to be a fairly reliable indicator of body fatness for population-based analyses.38 However, the BMI of some individuals may have 

increased from the 25-29.9 range as a result of increased 

muscularity. In addition, CDC BMI cut points may not be 

appropriate for all ethnic groups due to evidence showing associations between BMI, percentage of body fat, 

and body fat distribution among different populations.39

Given that the average miles run per week did not differ 

between the group that exceeded the body fat standards 

and the group that met the body fat standards, further 

investigation into modifi able behaviors such as dietary 

habits is warranted, but was beyond the scope of this 

study. Physical training and dietary environments may 

also vary by location, so further investigations in other 

military populations are needed in order to address increased body fat concerns within specifi c populations.

CONCLUSION

This study found the leading contributors for increased 

risk of exceeding the Army’s body fat standards in women were older age and low aerobic fi tness. Weight control and health promotion initiatives specifi cally geared 

toward women over 29 years of age may help reduce the 

number of women failing to meet the Army’s body fat 

standards. Fortunately, appropriate physical training improves aerobic fi tness and should reduce body fat. With 

increases in Army and nationwide obesity rates, weight 

control efforts should continue to be an important focus 

for Army medicine and public health activities.

RE LEVANCE TO THE PERFORMANCE TRIAD

Encouraging optimal physical activity and appropriate 

nutrition within the Army community are key aspects 

of the Army Surgeon General’s Performance Triad.40

More specifi cally, this study addresses APFT performance, a metric identifi ed for the Activity component 

of the Triad, as well as body weight, a key outcome of 

interest.40 Results of this study provide further evidence 

of the link between body weight and performance on 

the APFT run event, a measure of aerobic fi tness, in a 

population of active duty Army Soldiers, thus supporting Triad efforts designed to enhance aerobic fi tness in 

order to attain or maintain a healthy body weight.

ACKNOWLEDGEMENT

This study was determined to be Public Health Practice 

by the US Army Public Health Command Human 

Subjects and Public Health Review Board.

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JR, Polly DW, Frykman PN. Epidemiology of injuries associated with physical training among 

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13. McLaughlin R. The obesity epidemic: implications 

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MA, Williamson DA, Young AJ. Rationale and 

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003-x/2010001/article/11064-eng.pdf. Accessed 

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34. Walker T, Lennemann L, Zupan M, Anderson V, Lyons W. Adaptations to a New Physical Training Program in the Combat Controller 

Training Pipeline. Brooks City-Base, TX: Air 

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and fi tness outcomes among soldiers. Inj Prev.

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BH. The validity of self-reported physical fi tness 

test scores. Mil Med. 2007;172(2):115-120.

37. Gallagher D, Heymsfi eld SB, Heo M, Jebb HA, 

Murgatroyd PR, Sakamoto Y. Healthy percentage 

body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr.

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AUTHORS

Ms Anderson is an Epidemiologist for the Injury Prevention Program of the Epidemiology and Disease Surveillance Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.

Mr Grier is a Kinesiologist for the Injury Prevention 

Program of the Epidemiology and Disease Surveillance 

Portfolio, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

Dr Canham-Chervak is a Senior Epidemiologist for the 

Injury Prevention Program of the Epidemiology and 

Disease Surveillance Portfolio, US Army Public Health 

Command, Aberdeen Proving Ground, Maryland.

Mr Bushman is an Exercise Physiologist for the Injury 

Prevention Program of the Epidemiology and Disease 

Surveillance Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.

Dr Jones is a Program Manager for the Injury Prevention Program of the US Army Public Health Command, 

Aberdeen Proving Ground, Maryland.

RISK FACTORS ASSOCIATED WITH HIGHER BODY FAT IN US ARMY FEMALE SOLDIERS
 April – June 2014 83

Before Act Resilient, I was seriously thinking about 

suicide. Now I don’t think about it anymore.

Anonymous service member

Act Resilient is an innovative educational program that

has been improving the lives of service members and 

their families. Created in 2009 by author Genie Joseph, 

the program uses coping skills, emotional fl exibility, expressive arts, improvisation, and laughter to teach stress 

management. As a volunteer with the Tripler Army 

Medical Center’s (TAMC) Care Provider Support Program (CPSP), she and the dedicated CPSP Team present 

resiliency training which focuses on self-care and wellness for TAMC civilian and military staff.

Joseph is an award-winning fi lmmaker, with a background in cognitive behavioral therapy, creative writing, 

dance and drama therapy, expressive arts, and meditation mindfulness. She has drawn together components 

from several disciplines to create a training program targeted to military needs.

Act Resilient has been offered in several formats, both 

offsite and onsite, in one-hour, stress-breaking miniclasses and day-long workshops. The preferred method 

of delivery is a one-hour class meeting once a week for 

4 to 8 weeks. The program has been shown to be effective for all types of people, from those most shy to total 

extroverts.

BACKGROUND

Act Resilient was originally designed when Joseph encountered individuals with traumatic brain injury (TBI) 

among her college class students. Some of the students 

had been told they would not be able to pass college 

classes. Joseph considered this a pedagogical challenge, 

and believed that fl exible teaching styles and “a traumainformed classroom” could better serve the Soldier population dealing with challenges such as TBI or posttraumatic stress disorder (PTSD). Act Resilient is based on 

the concept of neural plasticity which explores the idea 

that with the right restimulation, a traumatized brain 

can begin to heal.

As Kleim notes:

The brain is the most complex biological system on the 

planet, and the sources of functional impairment are 

many, ranging from the sudden loss of tissue due to a 

stroke or traumatic injury, or to the decades long neurodegeneration associated with Parkinson’s or Alzheimer’s 

disease.1(p521)

Research continues to discover unknown aspects of the 

human brain with increasing regularity. Much ot that 

new research has been focused on “neural plasticity,” 

defi ned in 2008 by Kleim and Jones as:

The mechanism by which the brain encodes experience 

and learns new behaviors. It is also the mechanism by 

which the damaged brain relearns lost behavior in response to rehabilitation.2(pS225)

In a theoretical discussion of brain plasticity after a TBI, 

Bach-y-Rita noted:

Evidence has been accumulating that the brain can reorganize extensively after damage and that reorganization 

can be obtained even many years after the trauma with 

appropriate late rehabilitation.3(p643)

Research has delved into the infl uence of genetic factors on brain plasticity and recovery after neural injury. 

Pearson-Fuhrhop et al points out that:

After neural injury, signifi cant reorganization of brain 

networks occurs to a variable extent and can be associated with substantial behavioral recovery. Animal studies 

have provided important insights into the mechanisms of 

this plasticity, with molecular and cellular fi ndings based 

on direct examination of neural tissue. These molecular 

studies are of pivotal signifi cance....”4

Learning-dependent neural plasticity has been demonstrated with transcranial magnetic stimulation on subjects’ increase in human motor cortex such as those 

trained in one-handed, 5-fi nger piano playing.1(p522)

Applying the concept of neural plasticity, Act Resilient 

uses a number of techniques that encourage the brain to 

use new motor skills, discover new ways of thinking and 

Act Resilient

 Genie Joseph, MFA

 Wynona Bice-Stephens, EdD, RN
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

perceiving, and fi nd new choices for responding to stimulus. A basic principle of this method is to use the body 

to move emotions out of the system, because emotions 

are not just “in the head.” They exist in nerves and cells 

and the body as a whole, often as “fi ght or fl ight” responses. Animals can be seen “shaking out” the adrenaline of a stressful experience, and then quickly regaining homeostasis . In Act Resilient, participants learn to 

“shake out” energy and stressful emotions by vigorously 

shaking to a favorite song. This may help release the 

cascade of stress chemistry, and participants report feeling renewed and invigorated after this activity.

COMMENT

The Act Resilient Training method consists of 27 principles that inform over 100 interactive activities. One 

guiding principle is the idea that being in the present 

moment is very benefi cial for healing. Many of the 

activities are designed to bring people more fully into 

present time. One of the methods to create reengagement with the present is through humor. Laughter is a 

fast way to get people oriented to the present moment, 

which defeats the recurring lure of the past. As one Soldier explained, “It’s hard to be sad when you’re laughing.” There is no need to revisit or talk about painful 

or diffi cult events in order to succeed with this process. 

In fact, one of the strengths of the program is that additional ruminations on “bad things” are avoided, and 

not reinforced by repetition. Trauma pulls people into 

thinking about the past and worrying about the future. 

“Act Resilient” reengages attendees with the present. 

One of the fastest ways to reset the brain is through improvisational comedy, which is essentially a team sport 

where individuals connect to each other through play 

and laughter. The spontaneity of theater games helps 

stimulate the brain, and the repeated alternation of highbrain stimulation with relaxation seems to help the brain 

become more fl exible, and may restore neural plasticity. 

Another key strategy of the Act Resilient method is the 

use of team building and group cohesion, a concept that 

is very familiar to service members, in which the group 

supports individuals to perform at their highest level, 

rather than at their lowest. Act Resilient is social, builds 

team cohesion, is highly interactive, and addresses the 

sense of isolation experienced by many people suffering 

with PTSD.

Laughter and having fun together promote an uplifting 

experience. Using the benefi ts of camaraderie is pivotal 

in this context and is used to support healing. Act Resilient activities are whole brain exercises, which alternate brain activity from left to right, front to back, and 

with high and low stimulation levels alternating quickly. 

Using the body to express and move emotions is immediate, fun, and engaging, and rapidly counteracts some 

of the key symptoms of PTSD, such as avoidance and 

withdrawal.

The activities in Act Resilient are designed to induce 

the various parts of the brain to communicate with each 

other instead of being compartmentalized. A traumatized brain is analogous to working “off line.” The brain 

needs to be reintegrated to work as a cohesive whole, 

instead of existing in fragmented sections. Act Resilient 

restores confi dence in the attendees’ own brain, because 

they are using many elements, such as observation, imitation, imagination, creativity, whole-brain memory, 

and spontaneity. Applying the concept of neural plasticity, Act Resilient promotes using the healthy parts of the 

brain to engage and heal the parts that are not working 

well. 

Students learn to recognize their own emotional activation scale, from zero (0) stress to the highest level (10). 

For the service member, learning how to calibrate one’s 

own emotional response level is very useful. When 

close family members take this training, they learn what 

to notice and how to pay attention to nonverbal cues indicating rising stress levels. This is especially useful to 

identify while those levels are low (level 3-4 on the 0 to 

10 scale), as the early detection can prevent high level 

activations and strong triggers. This helps both the individual, as well as family members, who can then adjust their interaction to reduce the likelihood of intense 

reactivity. A person with PTSD may fi nd it challenging 

to control triggers and responses at high levels such as 

8, 9, or 10, when the stress chemistry may have hijacked 

the brain. Family members and friends can learn to prevent escalation by adjusting their behavior when they 

observe subtle changes in body language, and nonverbal 

cues in their spouse or parent. This is one way the program teaches spouses how to best interact with a partner 

with a TBI or PTSD. By understanding that a traumatized brain may respond differently than before injury, 

spouses who are now attentive to the nonverbal cues 

will have greater situational awareness of rising stress 

levels and may have more success in the prevention of 

further upset.

For example, something as simple as using too many 

words at one time, without a break, can become “data 

overload” and create an overwhelmed response, even if 

the information being delivered is mundane or routine. 

Spouses learn to watch for body cues such as changes in 

breathing rate or depth, eye movement, facial expression, 

posture, or changes in skin color. Correct observation 

of these nonverbal cues may indicate rising stimulation 

ACT RESILIENT
 April – June 2014 85

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

and stress levels that have been triggered from attempting to absorb too much information. When such signs 

are detected, more talk will likely diminish successful 

communication, and additional stress could even lead to 

physical violence or destructive arguments.

An example of this situation was experienced by a Soldier who had returned to his family after 4 deployments, 

during which he was twice wounded/injured in combat. 

His PTSD made it diffi cult to adjust to the dull routine 

of garrison life. His wife was prior military who had become a stay-at-home mom. She spent long hours every 

day without any adult interaction. After he returned to 

the normal workday routine at his home station, daily 

she routinely attempted to describe the events of her 

whole day to him as soon as he arrived home from work. 

Neither of them could understand why he could not deal 

with this stream of data, as often it was pleasant information about their son. In the Act Resilient program, she 

learned a hand signal that she taught her husband to use 

when he had heard enough. Using nonverbal messaging 

was faster than trying to put his response into words. 

It gave him increased control over these interactions, 

which lowered his trigger-response. Later, when he was 

less overwhelmed, he was ready to listen. This allowed 

both of them to better control his level of stimulation. 

It was very useful to understand that he had trouble 

dealing with so much data and sound in those moments 

when he was at an elevated stress level.

A traumatized brain may be weakened or exhausted, 

which makes it more susceptible to rapid stress reactions, and may cause the stressed individual to avoid 

situations which demand choices. This can trigger 

PTSD symptoms and behavior. For instance, a spouse 

can cause mental overload by asking, “Do you want to 

stay home, do you want to go to the beach, do you want 

to go to the movies, or do you want to go out to dinner?” 

While these choices may seem simple enough for a nontraumatized brain, for someone experiencing high stress 

with all the possible triggers attached to even enjoyable 

events, this can be potentially overwhelming. 

In Act Resilient, family members learn that it may be 

better to offer limited choices, such as 2 simpler choices 

at a time, “Do you want to stay home or go out?” Once 

that is resolved and the brain can settle into a simple 

decision, then another clarifi cation can be offered. For 

example, if the choice is to go out, “Do you want to go 

to the beach or walk the dog?”

Act Resilient creates a positive response to facing choices, through the use of creative spontaneity. For children, 

play is how they learn, and the same is possible for 

adults. Spontaneous improvisation games restore the 

willingness to play, and this contributes to more fl exible emotional choices and responses. Learning to make 

rapid-fi re, imaginative choices in improvisational comedy games helps the brain to “reset,” and even to enjoy 

the challenge. The program deploys a number of rapid 

and playful reset techniques that bring instant relief, and 

appears to help the brain “unstick.”

Teaching the entire family these rapid-reset, body-based 

techniques helps the affl icted brain quickly come back 

to neutral. Some examples from Act Resilient are the 

use of nonverbal interventions that are body-based, such 

as jumping, shaking, wiggling, and patting/tapping the 

body on specifi c meridian points. While most Soldiers 

respond favorably to these playful activities, others simply need a brief explanation as to how it can quickly reset the brain. When they realize it is effective for stressrelief, they readily engage with the process. Typically 

about 80% quickly participate enthusiastically. Others 

overcome their own initial resistance to letting go in this 

way at a somewhat slower pace. When all members of 

the family learn these methods, they can support each 

other to minimize stress and restore a feeling of wellbeing in seconds. In this way, the brain does not have to 

go through the draining cycle of overload, which makes 

even simple family interactions almost unmanageable.

Educating family members about what it is like to live 

with a person whose brain has experienced signifi cant 

trauma leads to understanding, builds compassion, and 

enhances more effective communication styles. The 

ironic realization is that a traumatized brain that has had 

to make too many life and death choices can become 

overwhelmed by making too many mundane choices.

SUMMARY

Attendees have reported changing from being fearful 

to serene, from listless to energized, from disengaged 

to connected, and becoming markedly less anxious in a 

few weeks. Anecdotally, self-reported stress levels have 

been reduced by over 50% after just one class. Attendees learn not to be afraid of their feelings by working 

with emotions in a playful manner. When a person can 

act angry, but separate himself from his personal story, 

the emotional energy exists in a separate form that is 

not attached to specifi c events, and can be more easily dealt with and neutralized. Attendees are taught to 

“take out the emotional trash” through expressive comedy. They become less intimidated by their own emotional intensity and triggers as they learn how even metaphorical buckets of anger, shame, guilt, and hurt can 
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

be emotionally emptied. The added benefi t is that this 

is accomplished without the disclosure of personal information or the requirement to reexperience past pain 

which can trigger its own cascade of stress.

Act Resilient is an innovative approach that has helped 

many handle their emotions and triggers to better cope 

with daily life. It teaches the entire family how to have 

a common vocabulary—verbal and nonverbal—to diminish the stress response. It has been highly successful in lowering stress and raising morale for active duty. 

It has renewed hope in veterans, spouses, and military 

children. Over time, the lessons learned help give an attendee a new start at home and on duty.

Future plans involve delivering Act Resilient through 

telemedicine, so that those in remote locations can benefi t from these methods.

REFERENCES

1. Kleim JA. Neural plasticity and neuro-rehabilitation: teaching the new brain old tricks. J Commun 

Disord. 2011;44(5):521-528.

2. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 

2008;51(1):S225-S239.

3. Bach-y-Rita P. Theoretical basis for brain plasticity 

after a TBI. Brain Inj. 2003;17(8):643-651.

4. Pearson-Fuhrhop KM, Burke E, Cramer SC. The 

infl uence of genetic factors on brain plasticity and 

recovery after neural injury. Curr Opin Neurol. 

2012;25(6):682-688.

ACT RESILIENT

The Tripler Army Medical Center is located in Honolulu, Hawaii. It is the only federal tertiary 

care hospital in the Pacific Basin. It also is the home of the Pacific Regional Medical Command.

AUTHORS

Ms Joseph is an Adjunct Professor at Chaminade University, and an American Red Cross Volunteer at Tripler Army 

Medical Center, Honolulu, Hawaii. 

Dr Bice-Stephens, a retired Army Nurse, is Telehealth Clinical Advisor, Pacifi c Regional Medical Command, Tripler 

Army Medical Center, Honolulu, Hawaii.
 April – June 2014 87

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

THE US ARMY MEDICAL DEPARTMENT REGIMENT

The US Army Medical Department was formed on July 27, 1775, when the Continental Congress authorized a Medical 

Service for an army of 20,000 men. It created the Hospital Department and named Dr Benjamin Church of Boston as 

Director General and Chief Physician. On 14 April, 1818 the Congress passed an Act which reorganized the staff departments of the Army. The Act provided for a Medical Department to be headed by a Surgeon General. Dr Joseph Lovell, 

appointed Surgeon General of the United States Army in April 1818, was the fi rst to hold this position in the new organization. The passage of this law marks the beginning of the modern Medical Department of the United States Army.

Throughout its early history, the size and mission of the US Army Medical Department would wax and wane in response to military events around the world. There was, however, no formal regimental organization until World War I. 

Then, in the late 1950s, the brigade replaced the regiment as a tactical unit. In the reorganization that followed, some 

Army units lost their identity, their lineage, their history. This loss did not go unnoticed. The US Army Regimental 

System was created in 1981 to provide soldiers with continuous identifi cation with a single regiment. Department of the 

Army Regulation 600-82, The US Army Regimental System, states the mission of the regiment is to enhance combat effectiveness through a framework that provides the opportunity for affi liation, develops loyalty and commitment, fosters 

a sense of belonging, improves unit esprit, and institutionalizes the war-fi ghting ethos.

The US Army Medical Department Regiment was activated on July 28, 1986, during ceremonies at Fort Sam Houston 

in San Antonio, Texas, the “Home of Army Medicine.” Lieutenant General Quinn H. Becker, the US Army Surgeon 

General and AMEDD Regimental Commander, was the reviewing offi cer. He was joined by general offi cers of the US 

Army Reserves and the Army National Guard, representing the signifi cant contributions and manpower of the reserve 

forces in the Total Army concept.

INSIGNIA

The AMEDD Regimental Distinctive Insignia was designed by the Institute of Heraldry and is one of the oldest crests 

In the Army today. The 20 stars on the crest correspond to the number of states in the Union between December 10, 1817, 

and December 3, 1818. The origin of the crest dates from the Act of April 14, 1818, by which the Medical Department 

of the Army was fi rst organized.

The alternating red and white stripes on the left side of the shield are the 13 stripes of the American Flag. The green 

staff is the staff of Asclepius (according to Greek mythology, the fi rst healer, the son of Apollo, the sun god); and green 

was a color associated with the Medical Corps during the last half of the 19th century. The phrase “To Conserve Fighting Strength” gives testimony to our mission as combat multipliers and guardians of our Nation's strength and peace.

INFORMATION

The Regimental web site (http://ameddregiment.amedd.army.mil/default.asp) is designed to provide you with useful 

information about the US Army Medical Department (AMEDD) Regiment. Through the web site, you can learn the 

history of the AMEDD Regiment, the symbolism behind our heraldic items, how to wear the Regimental Distinctive 

insignia, and various programs available to you and your unit.

The Offi ce of the AMEDD Regiment is located in Aabel Hall, Building 2840, on Fort Sam Houston, Texas. The 

Regimental staff can provide further information pertaining to the history of the Army Medical Department and the 

AMEDD Regiment, and assist with any of the services described in the web page.

For additional information please contact the Army Medical Department Regimental Offi ce at the following address:

Commander

US Army Medical Department Regiment 

ATTN: MCCS-GAR 

2250 Stanley Road 

Fort Sam Houston, Texas 78234-6100

The telephone number is (210) 221-8455 or DSN 471-8455, fax 8697. 

Internet: http://ameddregiment.amedd.army.mil/
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

The headquarters and primary instructional facility of the Army Medical 

Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas.
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, 

and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed 

print medium to encourage dialogue concerning health care issues and initiatives. 

REVIEW POLICY

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriate 

subject matter expert for further review and assessment. 

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personal 

relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state 

explicitly whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interest 

notification section on the title page, providing additional detail, if necessary, in a cover letter that accompanies the 

manuscript. 

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this 

assistance, if any. 

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done 

so in the manuscript. 

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis, 

and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source

had no such involvement, the authors should so state. 

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with 

the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki 

Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki 

Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body 

explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the 

institutional and national guide for the care and use of laboratory animals was followed. 

INFORMED CONSENT

Identifying information, including names, initials, or hospital numbers, should not be published in written descriptions, 

photographs, or pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives 

written informed consent for publication. Informed consent for this purpose requires that an identifiable patient be shown the 

manuscript to be published. Authors should disclose to these patients whether any potential identifiable material might be 

available via the Internet as well as in print after publication. Patient consent should be written and archived, either with the 

Journal, the authors, or both, as dictated by local regulations or laws. 

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Manuscripts may be submitted either via email (preferred) or by regular mail. Mail submissions should be in digital format 

(preferably an MS Word document on CD/DVD) with one printed copy of the manuscript. Ideally, a manuscript should be no 

longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. 

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles 

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. 

Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript, with the following required data: 

 Reference citations of published articles must include the authors’ surnames and initials, article title, publication title, 

year of publication, volume, and page numbers. 

 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if 

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited. 

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying 

information as possible (location, dates, presenters, sponsors, titles). 

4. Either color or black and white imagery may be submitted with the manuscript. Color produces the best print reproduction 

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, TIFF, GIF) are preferred.

Editable versions with data sets of any Excel charts and graphs must be included. Charts/graphs embedded in MS Word cannot 

be used. Prints of photographs are acceptable. If at all possible, please do not send photos embedded in PowerPoint or MS 

Word. Images submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of

each photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions 

and photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

information must be included on the title page of the manuscript. Submit manuscripts to: 

EDITOR, AMEDD JOURNAL

AHS CDD BLDG 2841 

3599 WINFIELD SCOTT RD STE B0204 

JBSA FORT SAM HOUSTON, TX 78234-4669 

DSN 471-6301 

Comm 210-221-6301 

Email: usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil 
PIN: 104011-000