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Musculoskeletal Injuries in Astronauts: Review of Pre-flight, In-flight, Post-

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Current Pathobiology Reports
https://doi.org/10.1007/s40139-018-0172-z

EFFECTS OF THE SPACE ENVIRONMENT ON HUMAN PATHOBIOLOGY (R KERSCHMANN, SECTION EDITOR)

Musculoskeletal Injuries in Astronauts: Review of Pre-flight, In-flight,

Post-flight, and Extravehicular Activity Injuries
Vignesh Ramachandran 1 & Sawan Dalal 1,2 & Richard A. Scheuring 3 & Jeffrey A. Jones 1

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of the Review To provide a comprehensive review of musculoskeletal injuries in astronauts during pre-flight, in-flight
(including extravehicular activity), and post-flight periods. The discussion is inclusive of etiology and nature of the injury,
preventative measures, and future considerations.
Recent Findings The most common injuries were to the hand, shoulder, and back/spine. Patterns and location of injury depend on
the phase of flight during which they occurred. Current countermeasures are effective for some concerns, but do not ameliorate all
musculoskeletal risks, thus new countermeasure and preventative approaches are warranted in some arenas.
Summary During pre-flight preparations, the shoulder is a site with the most concerning injuries, and they occur during extra-
vehicular activity training, usually secondary to interaction with the planar hard upper torso. Suit redesign is under consideration,
for both the pre- and in-flight environments. Hand injuries are also common in both pre-flight training and in-flight extravehicular
activity. Countermeasures include reducing moisture and protective bandaging of fingertips. Space-adaptation back pain and
herniated nucleus pulposus occur in-flight and post-flight, respectively. In-flight exercise countermeasures may mitigate many in-
flight and post-flight spinal pathologies. In-flight loss of bone mineral and trabecular architecture can be mediated via both
pharmacologic and exercise countermeasures. The advanced resistive exercise device has shown ability to reduce not only bone
loss, but also muscular atrophy. Standardized and anonymous injury reporting is essential to track the full range of injuries over
time. Participation of physical medicine and orthopedic-trained physicians and therapists, working alongside the ASCR
(Astronaut Strength, Conditions, and Rehabilitation) group during astronaut exercise, training, and rehab should be considered
value added.

Keywords Astronaut . Extravehicular . Training . Injury . Musculoskeletal . Spaceflight

Introduction effects in space voyagers, including cardiovascular dysfunc-

Since human space exploration began with Vostok 1 in 1961,
astronauts, cosmonauts, and taikonauts have been subjected to
microgravity, which alters the normal physiology of cells and
tissues observed on Earth [1–3]. This results in several adverse
This article is part of the Topical Collection on Effects of the Space
Environment on Human Pathobiology
* Jeffrey A. Jones
jajones@bcm.edu
1
Center for Space Medicine, Baylor College of Medicine, SDU/McNair
Suite 10.133 7200, Cambridge Houston, TX 77030, USA
2
University of Houston, Houston, TX, USA
3
National Aeronautics and Space Administration, Houston, TX, USA
tion, impaired immune response, vision changes, and genito-
urinary complications [4–7]. Spaceflight also impacts the
musculoskeletal system (Fig. 1) [8–10].
Specifically, spaceflight reduces body mass and causes atro-
phy of muscles that oppose gravity [11]. Twenty to thirty per-
cent reduction in extensor leg muscle strength has been report-
ed prior to the use of the Advanced Resistive Exercise Device
(ARED) in 2010 [11]. At a microscopic level, rats flown in a
microgravity environment demonstrate a shift towards Type II
muscle fibers, which more easily fatigue with activity [11].
Meanwhile, bone loss in spaceflight is secondary to increased
resorption most prominent in the pelvis (− 1.15%/month
change in femoral neck bone mineral density [BMD] and
− 1.56%/month change in trochanter BMD) and lumbar spine
(− 1.06%/month change in BMD) regions [11–13]. There are
also objective changes that occur in the spinal column [14].

Fig. 1 Depiction of common injuries experience by astronauts during pre-flight training, in-flight (including extravehicular activity), and post-flight
periods
These musculoskeletal physiologic changes in spaceflight
may predispose astronauts to injury during spaceflight or
post-flight [15–19]. Furthermore, rigorous tasks in space-
flight may cause injury. Between 1999 and 2003, 39 extra-
vehicular activities (EVA), tasks performed by astronauts
outside of the spacecraft, were performed compared to 42
total EVAs performed in the previous 18 years of the Space
Shuttle Program. EVA complexity gas also increased, con-
tributing to injury [20]. In the post-flight period, musculo-
skeletal deconditioning may lead to injury. Johnston et al.
reported an increased risk of herniated nucleus pulposus
(HNP) in US astronauts after spaceflight secondary to deg-
radation of the annulus fibrosus [21]. Other astronauts have
experienced landing injuries and increased rates of musculo-
skeletal complaints months post-flight [18, 22, 23].
Furthermore, astronauts may have musculoskeletal injury
histories, especially since many astronauts have flown
high-performance military jets, subjecting themselves to
high gravitational forces [24]. Additionally, astronauts have
experienced injury pre-flight while training in the Weightless
Environment Training Facility (WETF) and the Neutral
Buoyancy Lab (NBL), facilities utilized by the National
Aeronautics and Space Administration (NASA) to train
Curr Pathobiol Rep
astronauts in simulated microgravity environments for mis-
sion tasks [20, 25, 26]. These ailments may be exacerbated
in spaceflight or predispose astronauts to more serious pa-
thologies [25].
Musculoskeletal injuries have not resulted in outright
mission failure, but they risk future missions, especially
long-duration missions such as to Mars [26]. These voyages
may require intricate EVAs causing injury distant from mod-
ern medical care. While it is unknown how many crew work
hours have been lost to spaceflight injuries, pre-flight inju-
ries have certainly caused alterations in planned mission
activities [27]. This could severely hinder future missions.
The high costs of spaceflight and training justify the study,
mitigation, and prevention of musculoskeletal injuries in as-
tronauts during pre-flight, in-flight, and post-flight periods
(Table 1) [28].
This article provides a comprehensive review of the
literature regarding musculoskeletal injuries in astronauts
during the pre-flight, in-flight (including EVA), and post-
flight periods. In doing so, the authors aim to present a
discussion inclusive of etiology of injury, future consider-
ations, and preventative measures that may be considered
for each flight period.
Table 1 A summary of original research papers elucidating the extent of musculoskeletal injuries experiences by astronauts in the pre-flight, in-flight, and post-flight periods
Curr Pathobiol Rep

Author Year Number of subjects Injury Pre-flight In-flight Post-flight

Bailey et al. 2018 6 ISS astronaut crewmembers Spine, lumbar back pain, ✓ ✓
lumbar disc herniation
Laughlin and Murray 2016 45 ISS astronauts Cervical, thoracic, lumbar, ✓
sacral, and coccyx spine
Laughlin et al. 2016 338 astronauts between April 1959 Shoulder orthopedic consults ✓
to December 31, 2014
Anderson et al. 2015 35 NBL group astronauts and 62 Shoulder ✓ ✓
Active duty group astronauts
McFarland and Reid 2015 179 astronauts (4000 series or Phase Hand ✓ ✓
IV EVA glove)
Laughlin et al. 2014 330 astronaut medical records Shoulder ✓
Kerstman et al. 2012 772 astronaut flights (Mercury, Apollo, Back pain ✓
Apollo-Soyuz Test Project (ASTP),
Skylab, Mir, ISS, and Shuttle program)
Scheuring et al. 2012 330 U.S. astronauts during NBL training Shoulder ✓
between 1995 and 2011
Johnson et al. 2010 321 U.S. astronauts Herniated discs ✓
(lumbar and cervical)
Opperman et al. 2010 232 crewmembers’ injury records Fingernail ✓
Kim, Hyung-Jin April 30 2009 1 South Korean astronaut Back pain ✓
(Associated Press writer)
Scheuring et al. 2009 21 female astronauts and 198 Hand, back, and shoulder ✓
male astronauts
Jones et al. 2007 8 astronauts during NBL training Fingernail ✓
Scheuring et al. 2007 Apollo mission astronauts during EVA Shoulder, wrist, hands, and fingers ✓
Strauss et al. 2005 86 astronauts during NBL Shoulder, hands, and feet ✓
(770 EMU training sessions)
Viegas et al. 2004 83 astronauts during NBL Shoulder, hands ✓
(548 EMU training sessions)
Williams and Johnson 2003 22 astronauts in EVA training Shoulder ✓
Longitudinal Study of 1999 Astronauts who flew on a shuttle Neck, back, shoulder, hip, ✓ ✓
Astronaut Health (NASA) mission between April 1981 knee, and ankle
and January 1998
Wing et al. 1991 58 orbiter crewmember Back pain, spine (50% lumbar) ✓

Methods
Search Strategy
A systematic review (1950–2018) was conducted using
PubMed, Google Scholar, and NASA’s Technical Reports
Server. PubMed was initially used followed by additions from
Google Scholar and NASA’s Technical Reports Server.
Information was collected from various sources, including
original studies, earlier narrow-focus reviews, and conference
presentations and papers. References were cross-referenced.
Search terms were the following: “musculoskeletal”/“extrave-
hicular activity”/“extramobility unit”/“fracture” AND “space-
flight”/“injury”/“astronaut”.
Selection Criteria and Data Extraction
The exclusion criteria included articles not discussing topics
related to musculoskeletal injury in astronauts or possible eti-
ologies, animal model studies, and simulated microgravity
papers. The inclusion criteria were broad to include all possi-
ble pertinent papers involving musculoskeletal injuries in as-
tronauts, including probability models, conference papers/
posters, unpublished data, and analog studies for etiology of
injury.
Quality Assessment and Exclusion
Two investigators (V.R. and S.D.) independently reviewed the
titles and abstracts of all papers pulled from the search terms
for exclusion. Afterwards, full manuscripts of included studies
were assessed for inclusion. Articles were placed into catego-
ries: (1) pre-flight, (2) in-flight (including EVA), and (3) post-
flight. Extracted data was compiled into a Microsoft Excel
document.
Results
Background
The US space program began with short-duration missions to
lower earth orbit (LEO) via Mercury and Gemini missions at
altitudes of 160 to 2000 km above the Earth’s surface. These
flights lasted between 28 s and 15 min on the first US manned
suborbital flights and up to 14 days in duration on Gemini 7
[29, 30]. These experimental flights occurred during The
Space Race between the United States and the Soviet Union
for dominance in spaceflight capability and paved the way for
NASA to reach the moon in 1969 under the Apollo program.
During these early years, injury reporting was scarce and lim-
ited to personal accounts [16]. Following Apollo’s 10- to 12-
day missions was Skylab, a short-lived US space station with
Curr Pathobiol Rep
the first longer duration missions (28, 50, and 84 days). Post-
Skylab came the Shuttle era (2- to 17-day missions) and the
creation of the International Space Station (ISS) for which the
average mission duration is 6 months. As mission durations
lengthened, the effects of long-duration spaceflight and its
impact on the musculoskeletal system injuries in-flight and
post-flight became more evident. With revamped EVA train-
ing during the Shuttle and ISS eras, EVA training injuries
became more common in the WETF and NBL.
Pre-flight Injuries
Astronaut pre-flight training is rigorous. Training environ-
ments implicated in musculoskeletal injury have been the
WETF, NBL, vacuum chamber, and pressure training.
Approximately 6–10 h of NBL training is performed per hour
of spaceflight EVA [31]. Studies from the early US Space
Shuttle Program (referred to as Space Transportation System
or STS) via the STS-1 to STS-89 missions (1981–1998) show
that within the pre-flight period, there is a significant differ-
ence in injury rates inside (1 year before launch, 38.6) and
outside (7.7) the mission period (p < 0.001). The presumed
cause is high physical demands of pre-flight training [19].
Scheuring highlights the breadth of general extravehicular
mobility unit (EMU) training injuries (shoulder, elbow, fore-
arm, and wrist) during training [17].
Strauss et al. aimed to quantify and characterize the injuries
from EVA NBL training between July 2002 and January
2004. Questionnaires administered to 86 astronauts over 770
training sessions showed that 190 tests (24.6%) resulted in
symptoms from 70% of astronauts. The hands were most
commonly affected (47.16%; severity 1.13), followed by the
shoulders (20.73%; severity 1.86), feet (11.37%; 1.66), arms
(5.97%; 1.65), legs (5.68%; 1.56), neck (5.68%; 0.80), trunk
(2.84%; 0.40), groin (0.28%), and head (0.28%) with 0
representing no pain and 5 representing severe symptoms
[25]. Neck pain was mostly due to incorrect placement of
shoulder inserts and trunk complaints were due to hard contact
with suit components [32]. In fact, Viegas et al. showed (data
from July 2002 and July 2003) that in 51% of 548 training
sessions, astronauts had suit fit problems, 202 of which were
in the upper extremity (122 hand, 14 elbow, and 66 shoulder).
Remaining suit fit problems involved the feet, leg, groin,
trunk, and neck [26].
Several studies analyze shoulder injuries during EVA train-
ing. Shoulder pain is reported by 0% of astronaut candidates
to 45% of those performing EVA skills and 56% of those
undergoing mission-specific training [20]. Laughlin and
Murray report that between 1959 and 2012, approximately
40 shoulder injuries occurred from EVA training with incident
rates (per 100 astronauts) of 0.00 (1950s–1970s), 1.17
(1980s), 14.73 (1990s), and 54.19 (2000s) [33], possibly cor-
relating with increased EVA complexity. Three astronauts in a
Curr Pathobiol Rep
December 2002 to June 2003 cohort underwent shoulder sur-
gery. Causal mechanisms elucidated are the following:
inverted position (25.8%); use of planar hard upper torso
(HUT, the central component of spacesuits) (22.6%); heavy
tool use (16.1%); frequent NBL sessions (6.5%); particular
arm position (6.5%); and even extravehicular mobility unit
(EMU, the Space Shuttle program’s reusable spacesuit) don-
ning itself (3.2%). Considering these findings, a shoulder in-
jury tiger team, a diverse expert panel, was put together at
NASA’s Johnson Space Center to identify the possible rela-
tionship between shoulder injuries and NBL EVA training.
Twenty-two astronauts were surveyed, 64% of whom had
shoulder pain. Most resolved within 48–72 h. Major risk fac-
tors were the following: limited range of motion of the shoul-
der due to the planar HUT vs pivoted design; inverted tasks;
overhead tasks; repetitive motions; heavy tool use; and fre-
quent training sessions. Suboptimal suit fit and lack of appro-
priate suit padding were minor factors [34]. While the EMU
may be neutrally buoyant, the astronaut is not weightless with-
in the suit. When inverted, the astronaut “falls into” the
spacesuit head, pressing the shoulders into the HUT [35].
Limited scapulothoracic motion of the shoulder increases
shoulder strain and injury with overuse of rotator cuff muscles
[20, 34]. Other contributing factors include less recovery time
between NBL runs, frequent training, upper body anthropo-
metric dimensions, and prior injury history [34, 36]. DeWitt,
et al, evaluated the use of an internal harness in the EMU
during NBL training to reduce symptoms associated with
shoulder interaction with the HUT [37, 38].
Chappell et al. reported that pre-flight hand injuries were
usually due to fingernail delamination, secondary to excess
EVA glove moisture and fingertip loading. Abrasions, bruising,
and two cases of peripheral nerve impingement due to com-
pression were also documented [35]. Injury analysis of EMU
glove-associated hand/arm trauma from 1981 to 2010 (Shuttle
and ISS mission training) showed 90 total incidents (82 NBL, 2
WETF, and 6 unknown locations). Eleven incidents were elbow
injuries while the other 79 injuries were hand injuries (76% of
which was pain, erythema or onycholysis of the fingernail,
metacarpophalangeal joint and fingertips) [39].
Meanwhile, foot injuries occur on the dorsal aspect and
distal toes. The lack of arch support in the EMU boot also
does not protect the feet from hard contact [32].
In-flight Injuries
The second most common in-flight medical complaint is mus-
culoskeletal in nature (3.34 events/person-year) [11].
Compared to age-matched controls, Shuttle astronauts on mis-
sions between STS-1 and STS-89 had higher rates of in-flight
injury than controls [19].
Back pain is a common complaint (52–68% incidence)
with lumbar pain being most common presenting soon after
entering microgravity. This is often referred to as space-
adaptation back pain (SABP) [15, 40, 41]. Up to 28% of
astronauts reported moderate-severe back pain [40]. Further
characterization by Shuttle payload specialists showed that 14
(74%) reported pain: lower back location (50%); dull (62%);
and with 2/5 intensity. Maximum pain was experienced be-
tween 1 and 6 days of spaceflight [40]. A retrospective study
of US space program astronauts showed that SABP was ex-
perienced in 58% of STS astronauts, 39% of ISS astronauts,
31% of Mir astronauts, and 0% of Skylab astronauts [15]. The
overall incidence rate of SABP was 52% (males 52%, females
58%) with 86% mild, 11% moderate, and 3% severe. The
location of the pain was lumbar (86%), thoracic (12%), and
cervical (2%) with most cases occurring in the first 2 days with
peak prevalence on day 2 and none past 12 days. Symptoms
occurred at night in 75% of astronauts, in the day in 15% of
astronauts, and both in 10%. A higher incidence was observed
on the first mission (53%) than subsequent ones (≤ 47%) [15].
The “fetal tuck” position reduced symptoms [42].
Thompson et al. conducted another in-flight study
reporting finger injury. In STS astronauts, the injuries reported
were the following: tender nails and damage/trauma post-
EVA; subungual bruising/bleeding; sore cuticles; and
bruised/dry fingertips. On ISS missions, the hand complaints
reported were the following: mild-to-moderate crush injury to
the index finger in one astronaut and small subungual contu-
sions with delayed nail growth. Overall, 10 cases of finger
injuries were reported (5 Apollo, 3 STS, 2 ISS) during a total
of 216 EVAs by US astronauts [43].
Scheuring evaluated the US space program revealing 369
in-flight musculoskeletal conditions derived from 219 injuries
(21 in women; 198 in men). The overall incidence of muscu-
loskeletal injuries over the course of the space program (1961
through 2006) was 0.021 per flight day for men and 0.015 for
women [27]. The leading causes were crew activity (mostly
unknown and impacting structures) and the EVA suit (mostly
hand injuries) [11, 27].
Other locations of in-flight musculoskeletal injury have been
reported. In Shuttle/ISS missions, a 0.26 injury per EVA inci-
dence rate has been observed with predominant injuries in the
hands and feet with abrasions and small lacerations being the
most common manifestations. Others include onycholysis,
shoulder complaints, and paresthesia from compression [17].
McFarland and Reid’s analysis of injuries (1981–2010)
revealed 126 EVA flight injuries to the distal upper extremity
(33 hand, 25 metacarpophalangeal, 24 finger, 12 thumb, 11
fingernail, 9 fingertip, 9 forearm, and 3 elbow) [39].
The Apollo Medical Operations Project surveyed 14 of 22
living Apollo astronauts (64%). One Apollo astronaut suffered
a wrist laceration from the suit wrist ring while drilling and
another had wrist soreness from suit friction. Another
crewmember hurt his shoulder during a lunar EVA and subse-
quently required large aspirin doses. Finger injuries were also

common. One astronaut stated, “EVA 1 was clearly the
hardest…particularly in the hands. Our fingers were very
sore”. Another astronaut reported after the third EVA his
metacarpophalangeal and proximal interphalangeal joints
were extremely edematous and abraded from poor glove fit
making additional EVAs very challenging, if not impossible
[16].
Post-flight Injuries
Astronauts return from spaceflight with deconditioned
muscles/stamina and bone loss that is maladaptive for the
gravitational environment on Earth. Astronauts who during
STS-1 to STS-89 had several post-flight injuries: 2 neck, 9
back, 4 shoulder, 1 hip, 5 knee, and 4 ankle [19].
An area of focus in post-spaceflight literature is spinal
health, specifically back pain and herniated nucleus pulposus
(HNP). Post-flight back pain resulted in a hospitalization [18].
Analog terrestrial studies point to loss of spinal curvature and
intervertebral disc (IVD) swelling as factors leading to
unloading-induced spinal elongation [44, 45]. Alternatively,
Bailey et al. implicated multifidus muscle atrophy in post-
flight back pain experienced by astronauts (n = 6).
Multifidus atrophy decreased spinal join stabilization and di-
rectly affects IVDs. Furthermore, multifidus atrophy, not IVD
swelling, was strongly associated with lumbar flattening and
increased stiffness, predisposing astronauts to HNP [14, 42].
Forty-four HNP cases have been reported in astronauts’
post-flight [21]. Astronauts have a 4.3× increased incidence
of lumbar spine HNP than the general population with the
greatest risk immediately post-flight (35.9× increased risk).
Most cases present within a year or two after spaceflight.
Risk of cervical HNP is especially high [17].
Post-flight exercise and sports can cause injury. Between
1987 and 1995, Jennings et al. documented a total of 26 frac-
tures, 36 ligament, cartilage, or soft tissue injuries (knee inju-
ries were most common), 6 ankle ligament injuries, 4 shoulder
injuries, and 3 Achilles tendon ruptures occurring as a result of
physical activities. Most implicated activities were sports such
as basketball and running. These findings signify that astro-
nauts, in spite of their excellent physical conditioning, are
susceptible to injury from sporting activities in pre- and
post-flight periods [46].
Laughlin and Murray showed that, compared to a control
population, astronauts sought orthopedic care for shoulder
complaints significantly more frequently (p < 0.001).
However, shoulder surgery rates were not different between
astronauts and controls (p = 0.938) [23].
To date, there have been over 50 fractures in US astronauts
with nearly 50% in the lower extremities. However, none of
these fractures have been attributed to microgravity exposure
[47]. Notably, two fractures that deserve mentioning occurred
after ~ 6-month missions on ISS. One occurred when a
Curr Pathobiol Rep
crewmember slipped and fell, resulting in a fibular fracture.
The other occurred followed an approximately 2.5-ft jump
causing a femoral neck fracture [48]. Again, it is not clear that
spaceflight contributed to either fracture; however, the previ-
ously measured losses in bone mineral density, and changes in
trabecular bony architecture, and bone resorption markers, all
indicate that prolonged microgravity may place the bone at
added risk for post-flight fracture [47, 48].
Discussion
Shoulder injuries are one of the most common injuries
encountered during EVA training. The EMU restricts
scapulothoracic motion in the HUT, preventing normal
movement. Astronauts compensate by using rotator cuff
muscles for arm movement, causing overuse injuries.
When inverted, gravity causes astronauts to fall into the
EMU head which puts further pressure on shoulders,
causing bursitis and tendinitis [34]. Use of harnesses in
the HUT to prevent inversion injuries have increased
shoulder comfort but resulted in a greater decrease in
shoulder range of motion. Improving harness design to
incorporate a balance between range of motion and com-
fort is ideal [49]. Additionally, there are two types of
HUT used in the EMU: planar and pivoted. The pivoted
HUT allows for 2-axis rotation with the shoulder bearing
attached to gimbals [33]. Due to its potential for critical
gimbal failure, the pivoted HUT was replaced with the
planar HUT, a fixed and less flexible design which sub-
sequently contributed to more shoulder injuries by
restricting shoulder internal rotation and causing impinge-
ment [31, 34, 36]. HUT redesign is of utmost importance
in preventing shoulder injuries. Current development of
new EVA suits (PXS, Z2) should incorporate a HUT that
mimics the pivoted HUT with increased shoulder flexibil-
ity but without risk of critical failure [50, 51].
Furthermore, Anderson et al. describe anthropometric var-
iable measurements (e.g., bideltoid breadth, and shoulder
circumference) that are strongly associated with injury
[36]. These measurements describe how astronauts may
fit into the HUT. Historically, injuries have even occurred
upon merely donning the HUT [34]. We recommend care-
ful evaluation of HUT design, consideration of a “custom-
ized suit” for better individualized fit, and an internal
harness to prevent inversion injury. Other risk factors dur-
ing pre-flight training include frequency of training and
history of shoulder injury. Astronauts with history of
shoulder injury should especially train using the pivoted
HUT [31]. Consulting professional trainers/sports medi-
cine physicians should be considered in designing optimal
training and rest intervals for astronauts to lessen injury
risk or exacerbations of chronic shoulder ailments.
Curr Pathobiol Rep
Hand injuries were recorded frequently in pre-flight and in-
flight periods. McFarland and Reid identified the following
risk factors associated with EVA glove-related injuries: small
hand anthropometry, improper glove fit, duration of training/
spaceflight EVA exposure, greater transverse than longitudi-
nal strain, and use of the Phase VI glove, the current glove
design in use [36]. Fingertip hyper-perfusion past 20 N of
force with EMU gloves may also be a significant risk factor
contributing to onycholysis [52]. The authors again recom-
mend a customized glove design and reconsideration of the
Phase VI glove, which has resulted in significantly more in-
juries (61 total) than the previous design (4000 Series, 27
injuries) [39]. Additionally, an EMU glove ventilation tube
(to reduce moisture and grip slippage) could reduce the inci-
dence of onycholysis and other finger/hand injuries [53]. Self-
hygiene, such as trimming fingernails and applying adhesives/
materials such as dermabond/tegaderm/tape, may be an instru-
mental, low-cost method in preventing injury, especially to the
fingertips [25].
The pathophysiology of lower back pain in-flight impli-
cates IVD swelling from spine unloading. Specifically, disc
expansion deforms collagen of annuli, stimulating mechanical
pain receptors. Furthermore, diurnal hydrostatic fluid shifts
may result in lack of normal nutrition to the disc [54]. A more
recent study implicates multifidus muscle atrophy as a proba-
ble cause of lumbar flattening and increased stiffness post-
flight rather than intervertebral disc swelling [14]. Greater
sample size and thorough study is required to determine the
exact etiology of SABP and HNP to precisely prescribe
countermeasures.
Nevertheless, countermeasures have been described.
Astronauts report the “fetal tuck” position to relieve in-flight
back pain. A device maintaining this position for extended
time, such as during sleep, may mitigate symptoms or serve
as a prophylactic measure. The may allow astronauts to obtain
proper rest in order to perform at a high level the following
day. Symptomatic treatment may include anti-inflammatory
medications. However, medications may degrade during
spaceflight altering potency, clouding dosage recommenda-
tions, and side effect profiles. As such, conservative counter-
measures are preferred [55]. To this end, Sayson et al. suggest
the following three exercise countermeasures: (1) continuous
axial loading using a torso compression harness to mimic
diurnal loading and prevent excess disc swelling and spinal
elongation (2) using an internal/external arm rotation pulley
exercise to prevent atrophy of spine muscle stabilizers (includ-
ing the multifidus) and (3) continuous spine movement/
loading without resistance, mimicking daily loading activities
like walking on Earth [54]. One such device aboard the ISS is
the Treadmill Vibration Isolation System (TVIS). Used for
walking and running, TVIS simulates 60–70% of the loading
on Earth [11]. Adding a torso compression harness and pulley
exercises to crewmembers’ daily exercise routines may help
prevent back pain and HNP post-flight [54]. However, an
existing device on the ISS called the ARED has been associ-
ated with post-flight back pain. Causality cannot be attributed
secondary to confounding factors [56]. Nevertheless, this calls
for careful reassessment of the safety of existing and future
equipment aboard the ISS/future spacecraft. Nevertheless,
studies show that continuous use of the TVIS, Cycle
Ergometer with Vibration Isolation System, and the ARED
prevent muscle atrophy and bone degradation during flight
[57].
Integral to musculoskeletal injury countermeasures is
NASA’s Exercise Physiology and Countermeasures
(ExPC) team and the Astronaut Strength, Conditioning,
and Rehabilitation (ASCR) team. The ExPC team de-
signs hardware (like the TVIS and ARED) and exercise
protocols for use in microgravity, which are continually
evaluated under aerobic capacity and biomechanical stud-
ies on the ISS. The ASCR team is responsible for ensur-
ing the physical well-being of the astronaut corp. ASCR
physicians, conditioning specialists, and athletic trainers
work together to (1) design exercise plans with primary
goals to prevent injury and reach flight readiness, (2)
rehabilitate and treat musculoskeletal injuries, and (3)
educate the corps on injury prevention and proper exer-
cise technique [48]. Cervical pain and cervical HNP have
occurred in astronauts’ post-spaceflight, especially high-
performance jet aircraft pilots, who have experienced sig-
nificant spinal g-loading [21]. There is not a specific
cervical exercise countermeasure device developed for
use in spaceflight, but one is currently under study which
may fill this gap [48].
In addition to exercise, pharmaceutical countermeasures
for bone degradation include bisphosphonate supplements,
which maintain bone strength and decrease fracture risk
[58–61]. Osteoprotegerin, a receptor activator of nuclear fac-
tor kappa-Β (RANK) ligand inhibitor, has also been shown to
inhibit bone resorption and maintain BMD in mice flown in
space; the drug is undergoing clinical trials for final Food and
Drug Administration approval [62]. Sclerostin antibodies and
myostatin inhibitors are also being studied for their effects on
promoting bone formation and reducing muscle atrophy, re-
spectively [63–66]. Additional pharmaceuticals in consider-
ation include parathyroid hormone analogues to retain blood
calcium and prevent urinary calcium excretion and peptide
supplements to quell muscle atrophy [11].
In the post-flight period, the authors recommend a gradual,
stepwise increase in activity and limited or closely supervised
sports participation [46]. NASA has designed a post-flight
reconditioning program; however, it has been unable to return
some astronauts to baseline performance. Furthermore, it has
not prevented injury post-flight, spurring possible regimen
reconsideration [67, 68]. As with athlete training, an individ-
ualized regimen may be needed.

Finite element (FE) analysis has long been used by engi-
neers to estimate failure loads of complex structures, a concept
that has been translated to human bone. Growing concerns over
using BMD as the sole means to assess bone injury risk led to a
FE Strength Task Group at NASA. This group compiled a
dataset using computer tomography and magnetic resonance
imaging to assess trabecular bone for use in assessing astronaut
candidacy and qualifying astronauts for long-duration mission
or subsequent missions. These are all important considerations
for extended voyage into our solar system [69].
The current literature on musculoskeletal astronaut injuries
is limited. Even then, injuries have been historically
underreported out of fear of impact on an astronauts’ flight
status and career. Developing standardized reporting process
for all musculoskeletal injuries is essential. Effective injury
countermeasures are of utmost importance before astronauts
venture out beyond LEO to asteroids, the moon, and eventu-
ally Mars. Severe injuries during these missions will certainly
jeopardize missions and risk astronaut lives. Our knowledge
of planetary exploration is limited to the Apollo program, and
sufficient preparation is required before astronauts walk on the
surface of another celestial body.
Conclusions
Musculoskeletal injuries in astronauts are common during the
pre-flight, in-flight, and post-flight periods. MSK injuries in
the pre-flight period (mostly hand and shoulder) during train-
ing and may be exacerbated/reinjured in-flight and post-flight.
Meanwhile, the most common manifestations in-flight and
post-flight are injuries to the distal extremity (especially the
hand) and SABP (early in-flight) and lumbar back pain and
HNP post-flight. Overall, present countermeasures have been
successful in maintaining bone and muscle function, but not
proprioception. Nevertheless, the astronaut population has ex-
perienced musculoskeletal symptoms which may be due to
exacerbation of underlying disease (e.g., osteoarthritis in
weight bearing joints). Redesign of training EMUs, rethinking
training schedules, use of targeted resistive exercises in space-
flight, pharmaceuticals to counteract bone and muscle loss
upon unloading, and gradual stepwise exercise, among other
countermeasures, may all limit musculoskeletal injuries. This
is of importance with extended-duration endeavors to Mars
and beyond in conception. By exploring these countermea-
sures and others, we are working towards solutions to one of
the major complications facing the space medicine
community.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Curr Pathobiol Rep
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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