The Veteran Experience of Chronic 

Pain from Musculoskeletal Injuries: 

Lessons from the War Related 

Illness and Injury Study Center 

Drew A. Helmer, MD, MS

Canaan Heard, BA
Learning Objectives

 Describe the prevalence and range of 

musculoskeletal injuries in active duty military 

populations 

 List common risk factors for musculoskeletal 

injuries 

 Relate the lifelong impact of musculoskeletal 

injuries experienced by servicemembers to 

VHA
Poll Question #1

 What is your primary role in VA (select 1)?

 student, trainee, or fellow

 clinician

 researcher

 manager or policy-maker

 Other
Outline

 Musculoskeletal injuries and their sequelae 

 Musculoskeletal injuries in military 

populations 

 Musculoskeletal concerns in a pilot combat 

conditioning program in active duty Marines

 Management of long-term impact of 

musculoskeletal injuries- The WRIISC 

perspective 
Musculoskeletal Injuries

 Damage to the muscles, bones, or connective 

tissues.

 Characteristics of Injury

 Mechanism

 Overuse

 Traumatic

 Locations

 Core/Axial

 Upper extremity

 Lower extremity

 Damage/Impact

 Alteration of structure

 Loss of function
Impact of Musculoskeletal 

Injuries 

 Alteration in body structure (deformity)

 Loss of function

 Limitation in activities and participation

 Loss of fun activities

 Loss of income/employment

 Increased exposure to healthcare

 Iatrogenic complications

 Time away from other activities

 $ 
Recovery from Musculoskeletal 

Injuries 

 Likelihood of recovery varies

 Critical Elements:

 Injury characteristics

 Timely recognition and assessment

 Appropriate treatment

 Time to heal/Return to activities

 Facilitators

 Barriers 
Cycle of Negative Outcome

 Common patterns which can perpetuate negative 

outcomes

 Failure to take rest and recover

 Reinjury/failure to heal

 Pain

 Accumulation of new injuries

 Failure to substitute activities

 Weight gain

 Isolation/Disruption of participation

 Depression

 Over-reliance on healthcare providers for ‘cure’

 Medications alone are unlikely to suffice

 Iatrogenesis
Musculoskeletal Injuries and 

Physical Fitness

 Physical fitness requires activity

 More activity, greater risk for musculoskeletal injuries

 Activities can be performed more or less safely

 Some activities are more risky than others

 Musculoskeletal injuries impact fitness

 Limit function and activity

 Contribute to deconditioning and weight gain

 Negatively impact mood and motivation

 Contribute to other injuries 
Barriers to Physical Fitness

 Baseline fitness

 Competing demands for time for physical 

training 

 Imperfect knowledge about best practices for 

physical training

 Negative behaviors (smoking, sleep 

deprivation, binge alcohol use)

 Under-recognition of injuries

 Access to evaluation and treatment

 Access to adequate time for recovery
Poll Question #2

 Have you served in the military (select 1)?

 Yes, in the past

 Yes, currently

 No
Physical Training in the 

Military

 ‘Healthy Warrior’ model

 Physically and mentally fit

 Resilient

 Core part of military training and service

(USMC Order 6100.13W/CH 1)

 Promote healthy lifestyles and combat 

readiness

 Five 30-minute sessions per week

 Under direction of the unit commander
Uses of Exercise in the Military

 Fitness

 Discipline

 Punishment

 Fill time

 Social

 Demonstrate excellence
Military Lifecycle

Pre-Military (18 years)

Active 

Military Boot Camp

Duty (3- (3-4 months) 20 years)

Deployment Garrison

Veteran (MANY years)
Framework for Musculoskeletal 

Injuries in the Military

Setting/Context

Basic Training Deployment Garrison 

Injury 

Mechanism

Training Leisure Training Combat Leisure Training Leisure

Trauma

Overuse

Injury

Location

Axial 

Upper 

Extremity 

Lower 

Extremity 
Rates of Injury in Active Du

Samples

• Basic training- 6-12 injuries per 100 male 

recruits/month

• Basic training (Army)- 25% men and 55% wom

Training Basic training (Army) 25% men and 55% wom

report to sick call with injury

• Navy Special Forces training- 30 injuries per 1

trainees/month

Training

• US Army Infantry special forces and Ranger u

US Army Infantry, special forces and Ranger u

10-12 injuries/100 soldier-months; 80-90% of duty days are related to physical training. 

• Infantry soldiers - 51% injured in 6 months (14

injuries per 100 soldiers/year).

• Operational infantry soldiers 95 injuries per 1

Garrison

Operational infantry soldiers- 95 injuries per 1

soldiers/year. 50% occurred during physical tr15% were related to running.

• Soldiers deployed to OEF- 45% injured in 12 m

(low back 17.4%, knee 12.7%, shoulder 10.0%

Deployment 8.0% occurred during physical training.
Combat Conditioning Assessment 

Program (CCAP)

 Research Question

 “Does a more systematic approach to physical 

training reduce musculoskeletal injuries?”

 Study Design

 Pilot Study randomized 29 Marines to a moderate 

or high-moderate 11 week training program. 

 Population/Sample 

 Volunteers from Active Duty USMC Clerical Unit
Combat Conditioning Program

 11 Week Intervention

 3 one-hour sessions/week (M, W, F)

 Exercises adapted from Combat 

Conditioning Manual of the Marine Corps 

Martial Arts Center for Excellence

 Intensity and volume of activity 

progressively cycled throughout the 11 

weeks.
Injury Outcomes of Interest

 Any musculoskeletal issue recorded on daily log

 Completed by participant

 Confirmed by coordinator

 Any missed sessions due to musculoskeletal injury

 Self-reported reason for missing

 Rate per 100 person days of physical training

 Calculated from actual sessions completed

 Description of the context and location of injuries

 From daily log and coordinator field notes
Characteristics of Interest

 Demographic

 Age, sex

 Health behaviors

 Cigarette use, alcohol use, 

activity level, nutritional 

supplement use, medication use

 Prior health issue

 Baseline musculoskeletal issue, 

baseline report of any health 

issue, PTSD, depression

 Body habitus

 Height, weight, % body fat

 Baseline 

fitness/performance on 

fitness tests

 Vertical jump

 Pull ups (hang time), Crunches, 

3 mile run, 1⁄2 mile run, ammo 

can lifts, time under fire 

 Adherence to regimen

 Attendance

 Drop out
Participants at Baseline (n=29)

Variable mean SD

Age (years) 23.1 4.4

Time in USMC (years) 3.47 3.52

PHQ 15 score (range 0-45) 2.79 3.18

CD-RISC score (range 0-100) 78.6 12.3

VR-36 PCS (range 0-100) 55.3 4.84

VR-36 MCS (range 0-100) 51.8 8.1

Yes No

Sex (male) 25 male 4 female

Deployed to combat theater 4 25

Current cigarette use 13 16

PTSD screen (positive) 4 25

Baseline musculoskeletal issue 4 25

Fitness supplement use 15 14

Prescription medication use 3 26

Problem alcohol use 3 26
Baseline Fitness & Performance

Variable Mean SD

Height (cm) 176.2 7.3

Weight (kg) 79.4 13.5

Body Mass Index (kg/m2) 26.6 3.2

% Body Fat 15.2 5.2

Total METS per week 4557.5 3740.4

Vertical jump (cm) 39.1 9.7

Fitness Test Performance

Pull ups- men 14.6 6.5

Hang time- women 

(minutes)

0.84 .41

Crunches 95.8 26.9

3 mile run (minutes) 22.9 3.4

1⁄2 mile run (minutes) 3.1 .33

Ammo can lifts 100.7 19.3
Results- Adherence

 Total enrolled= 29

 Total dropped out= 6 (21%)

 2 were transferred to different units

 2 were not adherent (missed 7 sessions)

 1 deployed to Afghanistan

 1 broke his wrist during leisure time on weekend

 Attendance- 

 Whole sample (n=29 completed 744 sessions)

 mean 25.7 sessions

 90.4% of sessions

 Completers (n=23 completed 677 sessions)

 Mean 29.4 sessions

 92.0% of sessions

 Reasons for missing sessions (total=79 missed sessions)

 Conflicting duties (80%)

 Leave/Other (15%)

 Injury (2.5%)

 Too tired/sick (1.3%)
Musculoskeletal Concerns

 8 Participants (8/29= 27.6%) recorded musculoskeletal concerns in 13 daily 

log entries (13/744=1.7%)

 Knee- 4 Ankle- 2

 Hamstring- 1 Calf- 1

 Shin splints- 1 Toe/foot- 1

 Low back- 1 Missing- 2

 11 notations did not impede successful completion of the session for which 

injury was noted and 12 injury notations did not prompt medical attention.

 Two sessions were missed due to injuries

 Shin splints (did not seek medical care)

 “Pulled groin” (skipped 1 session on medical advice. She sought medical care 

after running outside the CCP; she routinely ran 8-12 miles a week outside of the 

CCP)

 One participant dropped out due to an extracurricular traumatic injury to his 

wrist.

 0.06 injuries per participant/100 sessions (14.9 injuries/100 person months)

 0.04 injured participants/100 training sessions (9.2 injured/100 person 

months)
Bi-variate associations between baseline 

factors & any musculoskeletal injuries

Any injury (n=8) No injury (n=21)

mean SD mean SD P-value

Body fat % 19.1 5.6 13.6 4.2 0.009

Pull ups 10 5.6 16.4 5.9 0.021

Crunches 81.8 14.5 101.2 28.8 0.081

3 mile run 22.6 4.5 23.1 2.9 0.059

Vertical jump 

(cm) 

33.9 6.2 41.1 10.2 0.074

yes no yes no

Supplement use 2 6 13 8 0.075

Medication use 3 5 0 21 0.003
Two Illustrative Injury Examples

 The participant who dropped out after breaking his wrist on the 

weekend illustrates several issues. He did not document the wrist 

injury on his daily logs and requested a modified work out to 

continue training. He was reluctant to seek care because of the 

context of his injury, but did so at the urging of the coordinator. At 

initial evaluation, the diagnosis and management was a sprain and 

wrist brace. The fracture was not identified or cast until a week later.

 The participant who missed a session for the groin pull illustrates the 

balance between excelling and excessive training. Her extra- curricular running was motivated by a desire to impress her superior, 

who was “teaching her to run” despite knowing she was engaged in 

the CCP. She wanted to improve her run time and was concerned 

about “getting fat”. She sought medical attention over the weekend 

after running outside of the CCP. In addition to missing one session 

for the groin pull, she reported knee and ankle injuries on 3 

additional daily log sessions.
CCAP Summary

 Musculoskeletal concerns

 Incidence of injuries similar to published rates

 Most were lower extremity injuries

 Most were very minor- did not require medical attention or missed sessions

 The most significant (broken wrist, groin pull) were related to non-intervention 

activities (leisure, extra training)

 Risk factors for injuries were mostly expected

 Baseline fitness (vertical jump, % body fat)

 Performance (Pull ups, crunches, 3 mile run)

 Use of supplements (Protective? Highly correlated with baseline fitness?)

 Very small sample

 Limited generalizability

 Limited power to test hypotheses

 Demonstrated challenges in fitness research with USMC 

 High rate of missed sessions for competing duties

 Pressure to exercise outside of CCP
CCAP Lessons for VHA

 Window on military musculoskeletal 

injuries

 Think of your Veteran patients

 Lifetime of pain and negative impact on health 

and function

 Multiple, accumulated injuries

 Contextual significance of injury and its 

management
Poll Question #3

 Before this presentation, had you heard of 

the War Related Illness and Injury Study 

Center (WRIISC) (select 1)?

 Yes, I’ve referred one or more patients to the 

WRIISC

 Yes, I’ve interacted directly with the WRIISC 

(not for patient care)

 Not sure

 No
About the WRIISC

 Deployed Veterans have 

unique healthcare issues 

and concerns. 

 The WRIISC serves 

Veterans from any 

conflict with war related 

illnesses and injuries 

through clinical 

assessments, education, 

and research.
WRIISC Synergies

Clinical Care

Observations from clinical care

lead to research questions and 

testable hypotheses, highlight 

gaps in provider and patient 

knowledge.

Education

Education of patients and 

providers can improve patient 

outcomes and identify gaps in 

knowledge to be addressed 

by research.

Research

Research produces 

knowledge and evidencesupported interventions and 

tools that can improve patient 

care and can be packaged 

and disseminated through 

education activities.
WRIISC Service Areas

Patients at the WRIISC

Complex, symptomatic health problems

Work up prior to referral includes appropriate 

tests and treatment trials

Deployment-related environmental or 

occupational exposure concerns

Local expertise exhausted
Comprehensive Evaluation 

Components 

 History and Physical

 Psychological Evaluation

 Neuropsychological Evaluation

 Environmental & Occupational 

Exposure Assessment

 Social Work Interview

 Education Session

 Complementary and Alternative 

Medicine (CAM) 

 Diagnostic Testing
WRIISC Experience 

with Chronic Pain

 Characteristics

 Prevalence >60%

 Most often musculoskeletal in nature

 Often in multiple locations (e.g., shoulder + back + knee)

 Cause/inciting episode

 Sometimes attributable to a specific injury

 Often presumed to be due to overuse

 Context of injury matters

 Barriers to chronic pain management

 Inability to modify activities despite pain and incomplete healing

 Difficulty accessing other desired and appropriate services

 Ineffective interactions with healthcare providers

 Over-reliance on medications

 looking for an easy fix

 Complicated by comorbidities- depression, PTSD, substance abuse, 

sleep disruption, other musculoskeletal injuries/dysfunction
WRIISC Model of Pain Assessment 

and Care Planning

 Holistic/biopsychosocial approach

 Acknowledge and address ‘other’ aspects of 

chronic pain

 Multidisciplinary team

 Focus on optimizing health and function

 Emphasize self-management

 Include Complementary and Alternative 

techniques

 Goal and outcome oriented
The Road Map

 WRIISC and patient craft goals & next steps (Road 

Map)

 Provide Road Map to patient and referring provider

 Encourage appropriate & timely reassessment by 

PACT

 Educate patient about working with PACT

 Emphasize the importance of communication

 Patient self-assesses progress (e.g., symptom log) and 

shares with PACT

 WRIISC follows up with patient

 1, 6, and 12 months

 Problem solve barriers encountered
Outcomes Related to Pain at 

WRIISC 

 Upgrading our follow up assessments in 

conjunction with stronger partnerships with 

the referring PACT.

 Examine:

 Patient’s personal goal achievement

 Societal Participation (global measure of 

function)

 Process measures of progress (e.g., 

scheduling and attending appropriate 

appointments)
Summary

 Musculoskeletal injuries are common in military service

 Setting, context and injury characteristics vary

 Barriers to recovery are common and some are relatively unique 

to military

 Injuries from military service may result in lifelong morbidity

 Chronic pain

 Dysfunction

 Limitations of activities and participation

 A holistic, multidisciplinary approach focused on optimizing 

health and function is achievable

 Goal oriented

 Self management

 Timely access to appropriate healthcare team member

 Outcome assessment
WRIISC Contact Information

NJ WRIISC: 

• 1-800-248-8005 

• WRIISC.NJ@VA.GOV

CA WRIISC: 

• 1-888-482-4376 

• WRIISC.CA@VA.GOV

DC WRIISC: 

• 1-800-722-8340 

• WRIISC.DC@VA.GOV 

www.WarRelatedIllness.va.gov