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A 30-year-old soldier can have the knees of a 60-year-old. Not from one bad injury, but from carrying a load every single day for years. Family medicine and sports medicine physician Ann Lebeck returns to explain why she came to see soldiers as tactical athletes, and what that means for their bodies. This episode is based on her article “Military sports medicine and the cost of readiness,” published on KevinMD. You will hear why young recruits who never played sports kept saying the Army broke them, how early joint damage shows up predictably with years of service, and why a soldier is a year-round athlete for two decades, not a four-year career. Ann shares the program she built that taught running mechanics, strengthening, and even the right shoes, and the results after 1,200 soldiers came through. You will come away seeing soldiers, and every physically demanding job, through the eyes of the doctor who learned to treat the body that carries the load.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Ann Lebeck. She’s a family medicine and sports medicine physician. Today’s KevinMD article is “Military sports medicine and the cost of readiness.” Ann, welcome to the show.

Ann Lebeck: Hey, thanks, Kevin. I’m glad to be here today.

Kevin Pho: All right, so let’s start by briefly sharing your story and then telling us why you decided to write this particular article on KevinMD.

Ann Lebeck: First of all, I’m family medicine, sports medicine fellowship trained, and over the past 20 years I have had the opportunity to work in three countries: Canada, the U.K., and the United States. During that time, I’ve also gotten to experience many different health care systems, including military medicine, commercial private practice, and currently Kaiser Permanente.

What struck me most is that there is a commonality among physicians, that we are all serving the same goals. Even though we’re in a different system, with different resources and different circumstances, what I did find is that despite these differences, physicians were all trying to achieve the same goal, and they were focusing on patients’ health, preserving their function, and basically helping patients recover.

And then, fairly spontaneously, I ended up in military medicine, which was actually very unexpected. I was working in Honolulu at the MEPS, which is a military entrance processing station where new recruits come in to get evaluated before they join the military, and the chief medical officer and I were talking about sports medicine. One day he said, “Did you know that they’re starting a sports medicine program in Fort Huachuca, southern Arizona? You should apply.”

I actually had no idea there was a connection between sports medicine and the Army, so that was my first question to him. But once I started treating soldiers, I started to see the commonality of what I had to bring to soldiers, and everything clicked at that point, because I wasn’t leaving athletes behind. I had simply found them essentially wearing a different uniform.

Kevin Pho: So when you say military medicine, tell us about some of the common scenarios and cases that you would see specifically with the military population.

Ann Lebeck: It’s very interesting. When I started taking care of the soldiers, there were two different groups that I was identifying. There were the AIT students, who are young soldiers that have just come out of basic training, and they line up at sick call first thing in the morning. What I was finding is that they all had very similar complaints.

So we started asking questions, and one of the first questions I started asking was, “Did you do any sports or formal athletics in high school?” And with the folks that I was seeing, the answer was essentially either no or marching band. The folks that had done some athletics training, where they participated in football or soccer, I never actually saw them.

And that’s what really piqued my attention, because of what we were seeing in these kids. I say kids; these are young soldiers. What I found is that they just didn’t have the wherewithal to understand the difference between, say, pain and an injury, and they really didn’t have any resilience or endurance.

So what we found is that they’d end up in sick call for what they perceived as pain. And what would happen is they would be placed on a kind of short-term rest, or a profile. Then they’d come back after that rest, and now they’re more deconditioned and in fact in more pain. And so in their words they’d say, “The Army broke me.” In fact, they just hadn’t learned the proper conditioning or training at that point.

Kevin Pho: So you would think that being in the military, they would observe this and develop custom protocols to guard against things like this. But you’re seeing these soldiers and people in the military saying that, “The Army broke me.” Is that something that we need to look into in terms of the approach the military is taking in terms of injury prevention?

Ann Lebeck: Not at all. Not at all. And it was an observation that we were seeing in a very specific population set, in that the folks that I was training and teaching at Fort Huachuca were military intelligence. So they weren’t infantry. This is a different type of soldier, where we are dealing with very intelligent folks, but they’re drone operators. They’re in cyberspace. So the profile of a soldier now is not infantry. It’s a different type of wear and tear.

But the training, I found, was very consistent. It didn’t matter what your job was, it didn’t matter who you were, that “soldier is a soldier” concept was still being played out. So the conditioning was exactly the same no matter who you were, and that’s where we started to see this “The Army broke me.” They just had never conditioned.

And when the young soldiers came to Fort Huachuca, they expected that their training and their running days through basic training had finished. In fact, this is a daily occurrence. They run, they strength train, they carry, every day, every day for 20 years. I think that is the revelation that we missed, so we decided at that point to ask how we help these soldiers, not necessarily treat their knee pain, but how do we treat or train them to be more resilient soldiers?

And that’s really where we developed a program very specific to these soldiers, and we called it the SOAR program, Soldier Optimization and Accelerated Rehabilitation. And basically, for those soldiers that had never run, had never had any athleticism at all, we taught them the running mechanics and the lifting, and that eventually got incorporated into their actual battalions as well. So we do have master fitness trainers. We do have that. But this was a very, very formal program to teach running.

Kevin Pho: Now I’m going to ask you about that program specifically in a little bit. But before I do, just give me an idea. You’re a sports medicine physician, so the approach that you use to train athletes, is it different from the approach that you use to train soldiers? And if so, just philosophically, how different are those two approaches?

Ann Lebeck: It’s very, very interesting, and this was a huge revelation to me, in that, yes, in sports medicine we learn to take care of elite athletes, professional athletes, and it really becomes about return to sport. But if you look at sports, I’m going to take football for example, because I spent most of my time with football, it’s a relatively short season for when they’re competing, and then there’s an off-season, and then there’s a pre-season. And this is where a lot of them will get their hands-on recovery mechanics, looking at film and studying this.

And now you have a soldier that I don’t think was looked at as an athlete. One of the coined phrases is tactical athlete, and they really are, but they are year-round athletes for 20 years. This isn’t a four-year career. And that’s where I think we really started to look at them differently. Not only are we trying to keep them in their season, but I have to help them negate the breakdown, the load mismanagement that they’re putting on their bodies, and how do we keep them so that they can continue to serve for 20 years?

Kevin Pho: And in your article, one of the things that you are finding are things like knee osteoarthritis in soldiers who are 30 years old, right?

Ann Lebeck: Absolutely. Yeah, and that’s something that was new for me, that we were seeing early degenerative changes. At first I was like, “Wow, you have the knee of a 60-year-old.” But compared to a non-athlete, or even a non-soldier, the wear and tear that they’re putting on their joints every day was the huge revelation for me. It is an everyday occurrence, and we’re not going to see that in the normal civilian population. Yes, we can be weekend warriors, and yes, we can have a college football career and have some war stories to tell, but these guys are living this every day.

So the degenerative changes happened almost predictably, though. One of the things I started noticing in our permanent party, the soldiers that have been in 10, 15, 20, 20-plus years, it almost became predictable for me, where I could say, “How long have you been in?” Their MRI was very consistent with years of service. And so at 10 years we were seeing specific changes, and then at 20 years, the exact same changes. So I just had to know how long they had been in.

And then again, how we manage these guys is not, “OK, you’ve got some knee pain,” coming into your office. I’m like, “OK, you’re in for 20 years. You still have 10 years to go. And oh, by the way, you need to do this again tomorrow.” So our treatment and management style had to be different, because we had to keep up with their load. One of the focuses was on, well, how are you running? How are you lifting? How are you managing carrying 50 pounds on your back while you’re rucking up these crazy uneven pathways in the mountains? And that is something that I found to be probably the biggest challenge, that these were everyday year-round athletes.

Kevin Pho: So you mentioned the SOAR program, specifically tailored to the situation. So tell us what is unique about it and some of the specific techniques and approaches that you use to adapt to what we’re describing today, these year-round athletes that soldiers are.

Ann Lebeck: Yeah, so what we did, and I’m kind of trying to say all of it at once here, I would see a young soldier, but I’d see 20 in the same day, all the exact same. They would have medial knee pain, on the inside of their knee. So just having them do simple stances. I’d have them stand on one leg and bend that knee slightly, 30 degrees, and you would see this collapse right away. So quad and glutes were not holding the hip and the knee in alignment, so that running is going to break them down.

And for most people, if you had this misalignment, you could probably run one to two miles, and that’s what I would say to them. “You’re going to get to one to two miles, then the knee pain’s going to happen.” You’d see them running holding their hip, grasping it, because they’re trying to help support the muscles. But after that, there is no endurance.

So what we started doing was putting them through a glute and quad strengthening program to get the hip and knee in alignment. And a lot of times foot exercises, because they’ve been running medially, and they’re collapsing their arch, so then we’re starting to get foot pain. We found they all came in with very unsupportive running shoes. They don’t have access to go get their feet evaluated, so we had to really work on the type of shoe that they needed, and then the running mechanics.

So we had folks that would come in from our sports medicine team and just really teach them, very simply, more Pose running, where I want you to be going forward. You let your body work for you a little bit. And then we would videotape them. So they would come in at 5:00 in the morning, or we were down at the field at 5:00 in the morning, because now you have a time constraint too with these young folks. What would happen is they can’t take time out of their training to learn their military occupation, because then they get recycled. So that’s why at 8:00 they have to be ready to go. Are they on a profile, not on a profile? So we would go down and work with them, to minimize their time away from their training, and so that’s where we had to take our clinic out to them.

And they did amazing. Also, this is one of the phrases, my motivation speech was, “You are part of one of the largest athletic teams in the world.” And a lot of them had never been coined an athlete before. So giving them that identification too, that you are going to hurt. That’s a good sign. Your muscles are going to be sore tomorrow. And teaching them a lot of athletic terms and symptoms so that they would be able to recognize an injury from just muscle soreness.

Kevin Pho: Now, tell us how long this particular intervention would be for a typical soldier, and are there any outcomes data just to give us some context in terms of how much of a difference you guys are making?

Ann Lebeck: Yeah. So one of the things that was being measured was, the 111th Battalion runs all of military intelligence here at Fort Huachuca, and you have to do a PT test, a physical test, and you have to pass on how fast you run and basically how many pushups and sit-ups you can do until fatigue. Not a great concept at the time. It has since changed, but they were seeing a lot of med boarding, where these young soldiers, the term that they would use, “They broke me.” If they can’t pass, they can’t continue.

And so that was becoming kind of an expensive venture, because these guys are being trained to do some of the most incredible things. Flying these drones at night is something to see. And that can be millions of dollars invested in some of these.

So they were looking at attrition. They were looking at how do we improve that. And we actually did measure that, so we were able to look at the folks that went through this program. We had about 1,200 that came through, and how many of those actually were able to continue and complete their training. And the numbers were staggering. So those numbers are there. They own that number, but it was enough to acknowledge the program, and I was fortunate enough to receive a civilian medal for service for that.

And that program is still going on, in a much different way, because I did leave the military as a civilian. But they have brought in those trainers I was saying too, close to the students, so that now, as they’re developing or challenging with their running style, they are starting to implement the same program that we had. A little differently, but it’s still being run.

Kevin Pho: We’re talking to Ann Lebeck. She is a family medicine and sports medicine physician. Today’s KevinMD article is “Military sports medicine and the cost of readiness.” And as always, with my guests, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Ann Lebeck: I think what I would like to leave with your audience is that I hope people, when they hear the phrase, “Thank you for your service,” think of it a little differently. I think we all genuinely mean it, and we should when we say that. But after spending 10-plus years caring for soldiers, I also came to appreciate what those years of service asked of their body.

For me, this was never really about military medicine. It was also understanding that every profession leaves its mark on the body, whether athletes, nurses, construction workers, firefighters, but certainly soldiers. And the difference is that soldiers are expected to maintain physical readiness year-round. And as I said earlier, they are one of the largest collective bodies of athletes, and calling them tactical athletes I think gives that identity as to what they really are doing.

And we’re talking about more than a million active-duty soldiers and service members who are out there, and they are expected to maintain this readiness every single day. But eventually that cumulative load is going to leave its mark. So when I hear someone say, “Thank you for your service,” I also think, “Thank you for what your body carried.” Because eventually that uniform is going to come off, and the body’s going to keep wearing that load. And I think as physicians, we owe it to ourselves to think of them as both.

Kevin Pho: Ann, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Ann Lebeck: Thank you.