MILITARY MEDICINE, 184, 3/4:511, 2019

Prevalence of Musculoskeletal Injuries Sustained During Marine

Corps Recruit Training
Andrew E. Jensen*; LT Melissa Laird, USN†; Jason T. Jameson‡; Karen R. Kelly†

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ABSTRACT Musculoskeletal injuries cost the U.S. Marine Corps approximately $111 million and 356,000 lost duty
days annually. Information identifying the most common types of injuries and events leading to their cause would help
target mitigation efforts. The purpose of this effort was to conduct an archival data review of injuries and events lead-
ing to injury during recruit training. An archival dataset of Marine recruits from 2011 to 2016 was reviewed and
included 43,004 observations from 28,829 unique individuals. Injuries were classified as mild, moderate, and severe
and categorized into new overuse, preexisting overuse, and traumatic. Injury classification and categorization were
stratified by event in which the injury occurred. The majority of injuries were due to overuse, and the most common
types were sprains, strains, iliotibial band syndrome, and stress fractures, which constituted over 40% of all injuries.
Conditioning hikes were the primary event leading to injury, with 31% of all injuries occurring during this training;
running claimed 12%. Most injuries sustained during basic training comprised sprains and strains. Marines who
remained uninjured during basic training outperformed those who reported at least one injury on fitness tests. These
results point to enhanced conditioning as a potential entry point to target future intervention efforts.

INTRODUCTION studies with military personnel have shown that performance

Personnel loss compromises military readiness and represents
a significant problem for the military. Musculoskeletal injuries
(MSKIs) are a leading source of personnel loss or the classifi-
cation of “not fit for full duty” among warfighters. These
losses are estimated to cost the U.S. Marine Corps approxi-
mately $111 million and 356,000 lost duty days each year.1
Epidemiological studies have reported statistically significant
associations between MSKIs and low fitness levels,2,3 sug-
gesting that improvements in physical fitness could potentially
decrease the incidence of MSKI. Further, several recent
*Innovative Employee Solutions, 9665 Granite Ridge Road, #420, San
Diego, CA 92123.
†Naval Health Research Center, Department of Warfighter Performance,
140 Sylvester Road, San Diego, CA 92106.
‡Leidos, 140 Sylvester Road, San Diego, CA 92106.
I am a military service member (or employee of the U.S. Government).
This work was prepared as part of my official duties. Title 17, U.S.C. §105
provides the “Copyright protection under this title is not available for any
work of the United States Government.” Title 17, U.S.C. §101 defines a U.
S. Government work as work prepared by a military service member or
employee of the U.S. Government as part of that person’s official duties.
Report No. 18-XX was supported by the Office of Naval Research under
work unit no. N1627. The views expressed in this article are those of the
authors and do not reflect the official policy or position of the Department
of the Navy, Department of the Army, Department of the Air Force,
Department of Veterans Affairs, Department of Defense, or the US
Government. Approved for public release; distribution is unlimited. Human
subjects participated in this study after giving their free and informed con-
sent. This research has been conducted in compliance with all applicable
federal regulations governing the protection of human subjects in research
(Protocol NHRC.2016.0023).
doi: 10.1093/milmed/usy387
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2019. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
on the functional movement screen, Y-Balance Test, dorsiflex-
ion range of motion test, single-leg hop test, and aerobic fitness
tests have the potential to detect MSKIs in personnel perform-
ing intense training evolutions.4,5 Among U.S. Marine Corps
personnel, the prevalence of MSKI is the greatest in young
Marines and during training periods requiring high volumes of
vigorous exercise. Accordingly, interventions aimed at decreas-
ing MSKI may be most beneficial when initiated before or dur-
ing periods of vigorous, high-volume training. However, there
is little understanding as to the source of MSKIs sustained dur-
ing recruit training and which specific training events induce
injury and the type of injury sustained.
A recent report from the Center for Naval Analyses
(CNA) found that greater fitness levels were associated with
lower rates of injury in a large sample of both male and
female Marines: 4.6% for the least fit, 3.6% for the moder-
ately fit, and 2.4% for the fittest groups.6 The CNA report
concluded that performance on the Initial Strength Test
(IST) was a good predictor of injury in training. However, it
is important to note that while fitness may be associated with
injury, it is not an adequate predictor of injury (i.e., even
those in the “poorest” fitness category, as defined by the
IST, still had a greater than 95% chance of remaining unin-
jured throughout training). Therefore, an important next step
is to identify critical training events that are most likely to
lead to injury (distinguished by type and severity of the
injury sustained). Thus, the purpose of this effort was to con-
duct an archival data review and determine: (1) the preva-
lence of MSKI, (2) the events in which the most injuries
occur, and (3) if there is a relationship between performance
on annual physical fitness assessments and injury. The over-
all goal was to identify the event and injury type, as well as
the fitness level required to reduce risk of injury, so that

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 Prevalence of Musculoskeletal Injuries Sustained During Marine Corps Recruit Training
effective interventions may be implemented to reduce injury
risk.
METHODS
Database Search
Prevention program data and injury data within the Marine
Corps Training Information Management System were searched
to determine the prevalence of reported MSKI among male
infantry Marines (military occupational specialty [MOS] 03XX;
designations listed in Table I) at Marine Corps Recruit Depot
(MCRD), San Diego, California prior to entry into the School
of Infantry. Data were stratified by injury type (e.g., stress frac-
ture, fractures, and soft-tissue injuries, such as sprains and
strains) and general causal type (e.g., traumatic, new over-
use, or a preexisting overuse injury). The main training event
(e.g., conditioning hike, running, the “Crucible”) on which the
Marine was injured was also recorded. The injury data were
studied in the context of each fitness test conducted at MCRD
(IST, Physical Fitness Test [PFT], and Combat Fitness Test
[CFT]); reported fitness scores were expressed as means.
This study was approved by the Institutional Review Board
at Naval Health Research Center and adhered to the Department
of the Navy’s human research protection policies (Protocol
NHRC.2016.0023).
The master archival dataset of injuries used in this study
spanned 6 years, from 2011 to 2016. In total, the dataset
included 43,004 observations across these years from 28,829
unique individuals (in some cases, multiple observations were
reported for a single individual to indicate multiple injuries).
Furthermore, to address cases in which measured values (e.g.,
PFT pull-ups) failed to reside within plausible bounds for those
variables (e.g., pull-ups >200 repetitions, run time = 0 s), a
trimmed version of the records were used—values between the
1st and 99th percentiles of the data. To quantify differences in
fitness components, Welch’s unpaired t-tests were employed to
account for unequal sample size variation and the α-level was
set to 0.01 to reduce Type I error rate. To quantify the magni-
tude of the fitness differences between injured and uninjured
recruits, the size of each effect, expressed as a standardized
mean difference (Cohen’s d), was calculated for each com-
parison. Following Cohen’s conventions, interpretations of
effects are as follows: d = 0.20 as small, d = 0.50 as medium,
and d ≥ 0.80 as large. Results are reported as mean ± stan-
dard deviation (SD).
Fitness Test Design
There are three designated fitness tests performed by Marine
recruits at MCRD: IST, PFT, and CFT. The IST is per-
formed on the first day at MCRD (Forming Day) and
includes a maximum pull-up and crunch test (2-minute time
limit), as well as a 1.5-mile timed run. Minimum repetitions
for male recruits for the three IST events are: 2 pull-ups, 35
crunches, and 13 min 30 s (810 s) run. The PFT is completed
512
on training days 22, 48, and 57 of MCRD boot camp and
includes a maximum pull-up and crunch test (2-minute time
limit), as well as a 3-mile timed run. The CFT is completed
twice during boot camp on days 41 and 51 and consists of
an 800-m sprint, simulating movement to contact, immedi-
ately followed by 2-min of overhead ammunition can lifts
(30 lb). Directly after ammunition can lifts, recruits move to
the maneuver under fire (MANUF) task, which is a series of
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sprints, crawls, casualty drags, and ammunition carries (300
yd). The IST, PFT, and CFT are then scored on a sliding
scale and a composite score is generated.
RESULTS
Injuries and the Initial Strength Test, Physical
Fitness Test, and Combat Fitness Test
The first analysis of injury data was from individuals who
had at least one IST score paired with an injury, with the fit-
ness test occurring before the injury. This particular dataset
contained 4,298 observations of injury from 2,881 unique
individuals; therefore, some subjects had more than one IST
score. In comparison, the dataset from uninjured Marines
contained 26,130 observations from 25,885 unique indivi-
duals. Thus, the prevalence of injuries observed is 14.1% of
total IST observations. The MOSs included in this analysis
were: 0300, 0302, 0311, 0313, 0321, 0331, 0341, 0351, and
0352 for those who were injured, with frequencies identified
in Table I. Breakdown of injury types for the IST is provided
in Table II and listed by frequency and proportion. The most
common injuries were strains, sprains, and iliotibial band
syndrome (ITBS), which accounted for 47% of all injuries
(rare injuries <1% total proportion were excluded). Further
analysis revealed the frequency and proportion of activities
being performed when injuries were sustained, with 30% of
injuries attributed to overuse-nonspecific activities (rare
activities <1% total proportion were excluded; Table III).
The next analysis of the injury data was from individuals
who had at least one PFT score paired with an injury, with
the fitness test occurring before the injury. This particular
dataset contained 1,024 observations of injury from 490
unique individuals. In comparison, the dataset from unin-
jured Marines contained 28,459 observations from 15,927
unique individuals. Thus, the prevalence of injuries observed
is 3.5% of total PFT observations. The MOSs included in
this analysis were: 0300, 0302, 0311, 0313, 0321, 0331,
0341, 0351, 0352, and 0365 for those who were injured,
with frequencies provided in Table I. Breakdown of injury
types for the PFT is provided in Table II and listed by fre-
quency and proportion. The most common injuries were
strains, sprains, and tendinitis, which accounted for 43% of
all injuries (rare injuries <1% total proportion were excluded).
Further analysis of injuries and PFT data revealed the fre-
quency and proportion of activities being performed when
injuries were sustained, with 31% of all injuries occurring
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 Prevalence of Musculoskeletal Injuries Sustained During Marine Corps Recruit Training

TABLE I. Injury Frequencies by MOS by Various Fitness Test

MOS IST Frequency PFT Frequency CFT Frequency

0300: Basic Infantry Marine 681 86 97
0302: Infantry Officer 9 1 1
0311: Rifleman 2,256 572 245
0313: Light Armor Vehicle Marine 106 23 23
0321: Reconnaissance Marine 48 5 2

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0331: Machine Gunner 384 104 82
0341: Mortarman 465 131 82
0351: Infantry Assault Marine 172 49 20
0352: Anti-tank Missile Gunner 177 51 18
0365: Infantry Squad Leader 0 2 0

CFT, combat fitness test; IST, initial strength test; MOS, military occupational specialty; PFT, physical fitness test.

TABLE II. Injury Frequencies and Proportions for Specific Injury Type by Various Fitness Test

IST PFT CFT

Injury Type Frequency (%) Proportion Frequency (%) Proportion Frequency (%) Proportion
Sprain 831 (2.7) 0.19 193 (0.7) 0.19 93 (0.5) 0.17
Strain 732 (2.4) 0.17 135 (0.5) 0.13 87 (0.5) 0.16
ITBS 466 (1.5) 0.11 85 (0.3) 0.08 50 (0.73) 0.09
PFPS 433 (1.4) 0.1 78 (0.3) 0.08 36 (0.2) 0.07
MTSS 346 (1.1) 0.08 43 (0.1) 0.04 29 (0.2) 0.05
Contusion 266 (0.9) 0.06 39 (0.1) 0.04 36 (0.2) 0.07
Inflammation 249 (0.8) 0.06 19 (0.1) 0.02 3 (<0.1) 0.01
Tendinitis 238 (0.8) 0.06 112 (0.4) 0.11 43 (0.2) 0.08
Stress fracture 195 (0.6) 0.05 86 (0.3) 0.08 59 (0.3) 0.11
Fracture 91 (0.3) 0.02 16 (0.1) 0.02 9 (<0.1) 0.02
Spasm 66 (0.2) 0.02 77 (0.3) 0.08 52 (0.3) 0.1
Bursitis 60 (0.2) 0.01 27 (0.1) 0.03 11 (<0.1) 0.02
Fasciitis 49 (0.2) 0.01 13 (<0.1) 0.01 6 (<0.1) 0.01
Nerve palsy 33 (0.1) 0.01 6 (<0.1) 0.01 – –
Periostitis 32 (0.1) 0.01 – – – –
Plica syndrome – – 12 (<0.1) 0.01 6 (<0.1) 0.01
Impingement – – 14 (<0.1) 0.01 5 (<0.1) 0.01
Avulsion fracture – – 8 (<0.1) 0.01 4 (<0.1) 0.01
Dislocation – – 8 (<0.1) 0.01 3 (<0.1) 0.01
Nerve impingement – – 9 (<0.1) 0.01 3 (<0.1) 0.01
Cellulitis – – 10 (<0.1) 0.01

The most common injuries were strains, sprains, and stress fractures, accounting for 44% of all injuries (rare activities < 1% were excluded). Frequency is
the absolute number of injuries observed per injury type and (%) is the incidence rate of injuries observed related to the total number of observations.
Proportion is the portion of a particular injury compared to the total number of observed injuries. CFT = Combat Fitness Test; IST = Initial Strength Test;
MTSS = medial tibial stress syndrome; PFT = Physical Fitness Test; PFPS = patellofemoral pain syndrome. – represents no value or value <1% of
proportion.

during a conditioning hike (rare activities <1% total propor-
tion were excluded; Table III).
Subsequent analysis of the injury data was from individuals
who had at least one CFT score paired with an injury, with the
fitness test occurring before the injury. This particular dataset
contained 545 observations of injury from 261 unique indivi-
duals. In comparison, the dataset from uninjured Marines con-
tained 17,419 observations from 10,900 unique individuals.
Thus, the prevalence of injuries observed is 3.0% of total CFT
observations. The MOSs included in this analysis were: 0300,
0302, 0311, 0313, 0321, 0331, 0341, 0351, and 0352 for
those who were injured, with frequencies provided in Table I.
Breakdown of injury types for the CFT is provided in
Table II and listed by frequency and proportion. The most
common injuries were strains, sprains, and stress fractures,
which accounted for 44% of all injuries (rare injuries <1%
total proportion were excluded). Further analysis of injuries
and CFT data revealed the frequency and proportion of activi-
ties being performed when injuries were sustained, with 26%
of all injuries occurring during a conditioning hike (rare activ-
ities <1% total proportion were excluded; Table III).
Additionally, the examination of the frequency distribution
of IST, PFT, and CFT scores across the broad classification of
injury types, revealed a substantial majority of injuries were
new overuse injuries, regardless of fitness test association
(Table IV).

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 Prevalence of Musculoskeletal Injuries Sustained During Marine Corps Recruit Training

TABLE III. Injury Frequencies and Proportions Across Type of Events in Which Injuries Occurred

IST PFT CFT

Injury Site Frequency (%) Proportion Frequency (%) Proportion Frequency (%) Proportion
Overuse-nonspecific 1,288 (4.2) 0.30 83 (0.3) 0.08 36 (0.6) 0.07
Conditioning hike 621 (2.0) 0.14 320 (1.1) 0.31 142 (0.8) 0.26
Running 574 (1.9) 0.13 118 (0.4) 0.12 32 (0.2) 0.06
Crucible events 402 (1.3) 0.09 86 (0.3) 0.08 66 (0.4) 0.12

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Admin movement 192 (0.6) 0.04 32 (0.1) 0.03 4 (<0.1) 0.01
Obstacle course 184 (0.6) 0.04 22 (0.1) 0.02 8 (<0.1) 0.01
Basic daily routine 177 (0.6) 0.04 93 (0.3) 0.09 48 (0.3) 0.09
Martial arts 170 (0.6) 0.04 11 (<0.1) 0.01 13 (0.1) 0.02
PFT/IST 144 (0.5) 0.03 37 (0.1) 0.04 41 (0.2) 0.08
Close order drill 120 (0.4) 0.03 – – – –
Confidence course 76 (0.2) 0.02 – – 4 (<0.1) 0.01
Basic warrior training 61 (0.1) 0.01 16 (0.1) 0.02 17 (0.1) 0.03
CRT 57 (0.1) 0.01 19 (0.1) 0.02 13 (0.1) 0.02
Incentive training 49 (0.1) 0.01 59 (0.2) 0.06 54 (0.3) 0.10
Weapons training 44 (0.1) 0.01 38 (0.1) 0.04 12 (0.1) 0.02
Calisthenics 40 (0.1) 0.01 – – – –
Land navigation, orienteering 23 (0.1) 0.01 44 (0.1) 0.04 25 (0.1) 0.05
Recreation – – 16 (0.1) 0.02 8 (<0.1) 0.01
ADL sports – – 9 (<0.1) 0.01 8 (<0.1) 0.01
Motor vehicle – – – – 6 (<0.1) 0.01
Endurance course – – – – 4 (<0.1) 0.01
MOUT training – – – – 4 (<0.1) 0.01

Activities that require extensive exertion, or powerful ballistic movement, are the highest culprit of injury. Frequency is the absolute number of injuries
observed per injury type and (%) is the incidence rate of the number of injuries observed related to the total number of observations. Proportion is the portion
of a particular injury compared to the total number of observed injuries. – represents no value or value <1%.

Comparing Fitness Between Injured and Uninjured
Marines
Comparison of the IST and PFT scores revealed significant
differences between the number of pull-ups performed (IST:
13 ± 4.8 vs. PFT: 15 ± 4.2; P < 0.01), the number of
crunches performed (IST: 87 ± 16.1 vs. PFT: 98 ± 5.7; P <
0.01), and the total composite score (IST: 217 ± 40.1 vs.
PFT: 251 ± 28.2; P < 0.01).
Comparison of IST fitness scores between injured and unin-
jured Marines revealed that uninjured Marines outperformed
injured Marines on every fitness component (Table V). On
average, uninjured Marines completed 1 more pull-up than
their injured counterparts (p < 0.01). Uninjured marines also
completed an average of 3 more crunches than their injured
counterparts (p < 0.01); and uninjured Marines ran the 1.5-mile
timed run an average of 10.2 seconds faster than their injured
counterparts (p < 0.05). Cumulatively, uninjured Marines
scored an average of nine points higher on their IST composite
score than injured Marines (p < 0.01). Furthermore, com-
parison of the mean differences in IST fitness scores between
injured and uninjured Marines, revealed small effect sizes
(Fig. 1) for the overall IST composite score and run compo-
nent; with the largest separation between injured and unin-
jured Marines exhibited with the IST composite score.
Comparison of PFT fitness scores between injured and
uninjured Marines revealed that uninjured Marines outper-
formed injured Marines on nearly every fitness component
(Table VI). On average, uninjured Marines completed 1
more pull-up than their injured counterparts (p < 0.01); and
uninjured Marines ran the 3-mile timed run an average of
17.7 seconds faster than their injured counterparts (p <
0.01). There was, in addition, a very small, but statistically
significant difference between uninjured and injured Marines
for the number of crunches completed (p > 0.01, d = 0.10).
Cumulatively, uninjured Marines scored an average of 7
points higher on their PFT composite score than injured
Marines (p < 0.01). Furthermore, comparison of the mean
differences in PFT fitness scores between injured and unin-
jured Marines, revealed small effect sizes (Fig. 2) for the
overall PFT composite score, run, and pull-ups; with the
largest separation between injured and uninjured Marines
exhibited with the PFT composite score.
Comparison of CFT scores between injured and uninjured
Marines revealed that uninjured Marines outperformed
injured Marines on nearly every component (Table VII). On
average, uninjured Marines completed the movement to con-
tact 3.3 seconds faster than their injured counterparts (p <
0.01); and uninjured Marines ran the MANUF an average of
6.0 seconds faster than their injured counterparts (p < 0.01).
However, there were no differences between uninjured and
injured Marines for the number of ammo can lifts completed
(p > 0.01). Cumulatively, uninjured Marines scored an aver-
age of four points higher on their CFT composite score than
injured Marines (p < 0.01). Furthermore, comparison of the

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TABLE IV. Injury Frequencies and Proportions Across Broad Category Distinctions

IST PFT CFT

Injury Type (Broad) Frequency (%) Proportion Frequency (%) Proportion Frequency (%) Proportion
New overuse 2,576 (8.5) 0.61 363 (1.2) 0.36 189 (1.1) 0.37
Traumatic 1,185 (3.9) 0.28 399 (1.4) 0.40 188 (1.0) 0.36
Preexisting overuse 462 (1.5) 0.11 248 (0.8) 0.25 139 (0.8) 0.27

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Frequency is the absolute number of injuries observed per injury type and (%) is the incidence rate of the number of injuries observed related to the total
number of observations. Proportion is the portion of a particular injury compared to the total number of observed injuries.

TABLE V. Descriptive Summary of the IST Composite and Component Scores, Separated by Injury Status (Total vs. Injured vs.
Uninjured)

IST Scores Status n Mean SD Median Min Max

Pull-ups (# completed) Total 28,127 13 4.8 13 3 24
Uninjured 25,320 13 4.8 13 3 24
Injured 2,807 12* 4.8 12 3 24
Crunches (# completed) Total 27,904 87 16.1 88 49 127
Uninjured 25,125 87 16.0 89 49 127
Injured 2,779 84* 17.1 84 49 127
Run (s) Total 27,973 656.4 57.0 657 540 1,500
Uninjured 25,135 655.3 57.1 655 540 1,500
Injured 2,838 666.5* 55.2 670 540 858
Composite score Total 28,766 217 40.1 218 0 300
Uninjured 25,885 218 40.0 219 0 300
Injured 2,881 209* 40.5 209 65 300

Numerical summary of the IST data, comparing results between total, injured, and uninjured Marines. IST, initial strength test; SD, standard deviation;
min = minimum value in dataset; max = maximum value in dataset. *p < 0.01, significantly different from uninjured.

mean differences in CFT scores between injured and unin-
jured Marines, revealed small effect sizes (Fig. 3) for the
MANUF and overall CFT composite score; with the largest
separation between injured and uninjured Marines exhibited
with the MANUF.
DISCUSSION
Overall, it can be concluded that the majority of injuries sus-
tained by Marines during basic training were new overuse
injuries, resulting in: sprains, strains, ITBS, and stress frac-
tures. Injuries occurring during a defined activity (i.e., less
overuse-nonspecific) were most likely to occur during condi-
tioning hikes and running. Injury prevalence tended to
decrease as training progressed and fitness levels increased,
suggesting that improved fitness leads to reductions in injury
rates.
In regards to potential protective factors against injury, pre-
liminary data analyses across the three fitness tests (IST, PFT,
and CFT) conducted at MCRD were consistent with the claim
that fitness is associated with reduced injury risk. Commonly,
uninjured Marines had higher overall composite scores for
each fitness test and faster run times. Performance on the
MANUF component (obstacle course) of the CFT produced
the greatest differentiation between injured and uninjured
Marines, as measured by Cohen’s d. PFT crunches and CFT
ammunition can lifts, in contrast, produced comparatively
little differentiation, suggesting that core and upper body fit-
ness are not as related to injury rates as running and functional
whole body movements. These findings may be explained as
a consequence of most injuries occurring to lower extremities
(i.e., as a result of overuse injuries); or may be a ceiling effect
as observed in the average scores of the CFT components and
composite score, which were high for both injured and unin-
jured Marines. To further illustrate the potential ceiling effect,
both injured and uninjured Marines scored in excess of the 91
maximum ammunition can lifts for 100 points (uninjured
mean average: 97 lifts; injured mean average: 96 lifts), and
composite averages for both groups were well within the
270–300 point range for a first class score average (uninjured
mean average: 287; injured mean average: 283). However,
this analysis is based on taking the averages of any multiple
scores for a particular individual; thus, it is likely that averag-
ing these scores over the course of a 12-week regimen mask
initial physical deficiencies and/or the overall training effect
for an individual. For example, there are three times (day 22,
48, and 57) during basic training at MCRD that the PFT is
conducted. If the Marine took the PFT all three times, then
their scores were averaged for each component (e.g., pull-ups)
and the mean was reported. Similarly, the CFT is conducted
twice during the 12-week regimen (day 41 and 51) and the
IST is only conducted once on Forming Day. For future
analyses, rather than averaging all fitness tests taken during
the training period, a repeated measures approach with order

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FIGURE 1. Comparing IST performance differences between injured and uninjured trainees. The relationship is quantified by a standardized mean differ-
ence (Cohen’s d).

TABLE VI. Descriptive Summary of the PFT Composite and Component Scores, Separated by Injury Status (Total vs. Injured vs.
Uninjured)

PFT Scores Status n Mean SD Median Min Max

Pull-ups (# completed) Total 16,292 14.9 4.2 15 3 24
Uninjured 15,811 15.0 4.2 15 3 24
Injured 481 14.1* 4.3 14 3 23
Crunches (# completed) Total 16,341 98.4 5.7 100 51.5 124
Uninjured 15,858 98.4 5.7 100 51.5 127
Injured 483 97.8⊥ 6.2 100 64.5 121
Run (s) Total 16,407 1,286.4 96.4 1,287 785 1,634
Uninjured 15,924 1,285.7 96.3 1,286 785 1,634
Injured 483 1,310.2* 96.2 1,317.5 1,040 1,620
Composite score Total 16,408 251.1 28.2 253.5 89 300
Uninjured 15,925 251.3 28.3 253.5 89 300
Injured 483 244.0* 30.0 248.0 91 300

Numerical summary of the PFT data, comparing results between total, injured, and uninjured Marines. PFT, physical fitness test; SD, standard deviation;
min, minimum value in dataset; max, maximum value in dataset. *p < 0.01, ⊥p < 0.05, significantly different from uninjured.

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FIGURE 2. Comparing PFT performance differences between injured and uninjured trainees. The relationship is quantified by a standardized mean differ-
ence (Cohen’s d).

TABLE VII. Descriptive Summary of the CFT Composite and Component Scores, Separated by Injury Status (Total vs. Injured vs.
Uninjured)

CFT Scores Status n Mean SD Median Min Max

Ammunition can lifts (reps) Total 11,040 97 10.8 100 42 132
Uninjured 10,780 97 10.8 100 42 132
Injured 260 96 12.2 98.5 45.5 131
Movement to contact (s) Total 11,059 173.5 13.0 173 144 237
Uninjured 10,802 173.4 12.9 172.5 144 237
Injured 257 176.7* 13.8 177 145 218
Maneuver under fire (s) Total 10,893 149.7 15.9 148 117 230
Uninjured 10,633 149.5 15.9 148 117 230
Injured 260 155.5* 17.0 154.5 118 210.5
Composite score Total 11,160 287 10.8 289 223 300
Uninjured 10,900 287 10.8 289 223 300
Injured 260 283* 12.2 284.8 244 300

Numerical summary of the CFT data, comparing results between total, injured, and uninjured Marines. CFT, combat fitness test; SD, standard deviation;
min, minimum value in dataset; max, maximum value in dataset. *p < 0.01, significantly different from uninjured.

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 Prevalence of Musculoskeletal Injuries Sustained During Marine Corps Recruit Training
FIGURE 3. Comparing CFT performance differences between injured and uninjured trainees. The relationship is quantified by a standardized mean differ-
ence (Cohen’s d).
effects may be more revealing. Additionally, examining the
injury data relative to the most recent fitness test data could
provide evidence of any training effect (improvement in fit-
ness levels) within individuals during the 12-week course and
potentially identify physical deficiencies, as well as injury
risk, based on a particular fitness metric.
Despite the limitations, the results presented in this study
add to a growing body of literature demonstrating that fitness
is associated with injury risk.7 In fact, in this study, injury
prevalence was reduced over the course of training, while fit-
ness levels tended to increase. The current findings are ech-
oed in epidemiological studies of Army basic training,
which consistently find that low levels of aerobic fitness, as
measured by 1- or 2-mile run times, are associated with
higher risks of injury.3,7–9 Specifically, injury risk for
women tested during a 1-mile run increased 25%, from 36%
to 61%, when mile times increased 16%, from 9 min to 10.4
518
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min.10 Similarly, injury risk for men tested during a 1-mile
run increased 28%, from 14% to 42%, when mile times
increased 20%, from 6.4 min to 7.7 min.10 A review con-
ducted by Knapik et al3 also illustrated that slower male or
female trainees exhibited higher rates of injuries, across a
larger population of new military recruits and cadets
from other military services (Air Force or Marine Corps).3
Additionally, just as in the case of aerobic fitness, perfor-
mance on muscular endurance tasks is also associated with
injury risk.
Furthermore, gender differences in injury risk could have
important implications for training methods and long-term
sustained effort over a career cycle. One way to examine these
gender differences is to consider body composition as a poten-
tial explanatory variable, given the known average group dif-
ferences between men and women on key body composition
variables (e.g., lean muscle mass, height). Unfortunately, the
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 Prevalence of Musculoskeletal Injuries Sustained During Marine Corps Recruit Training
data sources used in this study did not contain body composi-
tion information. Accordingly, future research should continue
to examine the relationship between these variables (e.g.,
height, weight) and injury risk to better differentiate potential
underlying causes of the relationship between injury risk and
fitness. The current understanding of the relationship between
injury risk and a prominent body composition variable – per-
centage body fat (or estimates based on body mass index
[BMI]) – is limited. Discrepant data exist on whether lower or
higher levels of body fat are associated with injury, while
others show inconsistent findings: mixed associations11; males
bimodal association, females no association8; and no associa-
tion.3,12 Along these lines, a particularly notable study, con-
ducted by the National Research Council, demonstrated a
direct relationship between run times and injury risk in women;
however, regardless of run time, the highest risks of injury
were associated with the leanest women (those with the lowest
BMIs).11 Analyses carried out for men showed a similar pat-
tern; the highest risk of injury (28.7%) occurred among the
leanest men; and importantly, men who were fast runners with
higher BMIs were not as protected from injury as women with
higher BMIs. Thus, BMI may be a useful tool or predictor in
the determination of injury risk, irrespective of gender.
The results of this study implicate running and condition-
ing hikes as higher risk events, in terms of producing inju-
ries. However, these events, as part of a comprehensive
preparatory training program, are unavoidable. Dismounted
military personnel are required to have a high level of aero-
bic fitness and engage in weight-bearing type activities, such
as running and hikes (marching with load), as part of their
occupational requirements. It is well understood that load
carriage: induces lumbar spine changes, decreases mobility,
increases fatigue, increases injury risk, and exacerbates foot
blisters, spinal injury and degeneration, muscle tightness, and
soreness of the legs, feet, back, and shoulders.13–18 Consistent
with these past findings, the results of this study also show a
greater risk of injury during conditioning hikes. However,
what is not known is if certain body composition or fitness
levels may protect against injury during conditioning hikes.
Furthermore, if such a relationship exists, it is important to
determine the true underlying cause of injuries (e.g., are fitter,
leaner trainees at lower injury risk because they are better con-
ditioned) and identify optimal levels of fitness or body com-
position that may be protective against injury.
CONCLUSIONS
The emerging conclusion, from this and past studies, is that
fitness is associated with injury risk (and potentially body
composition). Critical training events, such as running and
conditioning hikes, tend to exhibit the most injuries during
recruit training. However, there is insufficient data bearing on
how all of these factors influence injury when collected in con-
cert and analyzed together. The cited literature has focused on
one possible predictor – BMI – but this measure is limited since
MILITARY MEDICINE, Vol. 184, March/April Supplement 2019
it fails to account for fat mass and fat free mass. Furthermore,
the association does not necessarily imply predictive value and,
while correlations are evident, causation is not. Future work is
needed to develop reliable prediction models that will provide
direct, actionable information of injury risk and modifiable
characteristics that could mitigate injury risk. Genetics, socio-
economic status, race, age, gender, body composition, nutrition,
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prior injury history, and training load and volume are all known
factors that influence musculoskeletal health. However, of the
aforementioned factors, only body composition, nutrition, and
training load and volume are modifiable – these factors should,
accordingly, figure prominently in any future analyses aimed at
developing predictive models of injury risk.
While definitive revelations about the mechanisms of
injury have yet to be determined, prospective Marines, sol-
diers, sailors, and airmen can minimize injury risk. Based on
the current findings, in general, if one wants to minimize
injury susceptibility during boot camp, they should increase
their physical fitness, particularly in activities that require
lower body strength and endurance. Another potential mech-
anism to combat injury prevalence would be to have recruits
focus on basic soldiering skills (i.e., load carriage) prior to
boot camp entrance; as events that contain load carriage or
operationally functional movements tend to be more predic-
tive of injury susceptibility. Currently, the U.S. Army
employs an occupational physical assessment test (OPAT)
prior to entrance into a combat MOS; a similar test may be
useful for the Marine Corps, to identify those who may need
further training prior to their entrance to boot camp.
In summary, the findings from this effort demonstrate that
injuries sustained during recruit training are primarily new
sprains and strains and the products of overuse (and potential
overtraining and insufficient recovery). Moreover, these injuries
are most likely due to aerobic conditioning and extended dura-
tion tasks, such as running and conditioning hikes, rather than
more static, strength-based events. While the data suggest that
initial screening tests for Marine Corps recruits could be an
indicator of injury risk, more work is needed to expand on
these collective findings and to determine mitigation strategies.
PREVIOUS PRESENTATIONS
Presented at the 2017 Military Health System Research Symposium,
Kissimmee, FL; abstract # MHSRS-18-0937.
FUNDING
This research study was supported by the Office of Naval Research-Code 30
under work unit no. N1627. This supplement was sponsored by the Office
of the Secretary of Defense for Health Affairs.
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