MILITARY MEDICINE, 172, 9:988, 2007
Injury Rates and Injury Risk Factors among U.S. Army Wheel
Vehicle Mechanics
Guarantor: Joseph J. Knapik, ScD
Contributors: Joseph J. Knapik, ScD*; Sarah B. Jones, MPH*; Salima Darakjy, MPH*;
Keith G. Hauret, MSPT MSPH*; LTC Steven H. Bullock, SP USA*; Marilyn A. Sharp, MS†; Bruce H. Jones, MD MPH*
This study describes injury rates, injury diagnoses, anatomi-
cal locations of injuries, limited duty days, and activities as-
sociated with injuries in a sample of Army mechanics. Medical
records of 518 male and 43 female Army mechanics were
screened for injuries during 1 year at a large U.S. Army instal-
lation. Weight, height, age, and ethnicity were also extracted
from the medical records. Body mass index was calculated as
weight/height2. Overall injury rates for men and women were
124 and 156 injuries/l00 person-years, respectively, with a rate
of 127 injuries/100 person-years for all soldiers combined.
Women had higher overuse injury rates while men had higher
traumatic injury rates. Limited duty days for men and women
were 2,076 and 1,966 days/100 person-years, respectively. The
lower back, knee, ankle, foot, and shoulder involved 61% of the
injuries. Activities associated with injury included (in order of
incidence) physical training, mechanical work, sports, air-
borne-related activities, road marching, garrison/home activi-
ties, and chronic conditions. Among the men, elevated injury
risk was associated with higher body weight and higher body
mass index. It may be possible to prevent many injuries by
implementation of evidenced-based interventions currently
available in the literature.
Introduction
espite long-term declines in occupational injury mortali-
D ty,1,2 nonfatal occupational injuries continue to be a major
medical problem in the United States. There were a total of
⬃4,000,000 nonfatal workplace injuries reported in 2004 with
68% of these occurring in the service industries. In the “repair
and maintenance” sector, the nonfatal injury rate was 3.9 cas-
es/100 full-time workers.3 For automotive mechanics, the cost
of fatal and nonfatal occupational injury was estimated to be
about $65 million per year, ranking 21st among 419 occupa-
tions in the United States.4 A study of mortality among Danish
auto mechanics found that mortality due to “external causes”
(International Classification of Diseases, 9th Revision, Clinical
Modification E-codes E-800 to E-999, primarily accidents and
poisoning) was 1.3 times higher than in a comparable occupa-
*U.S. Army Center for Health Promotion and Preventive Medicine, 1570 Stark
Road, Aberdeen Proving Ground, MD 21010.
†U.S. Army Research Institute of Environmental Medicine, 42 Kansas Street,
Natick, MA 01760.
Reprint requests: Dr. Joseph J. Knapik, Research Physiologist, Directorate of
Epidemiology and Disease Surveillance, U.S. Army Center for Health Promotion and
Preventive Medicine, 1570 Stark Road, Aberdeen Proving Ground, MD. E-mail ad-
dress: joseph.knapik@us.army.mil.
The views, opinions, and/or findings contained in this report are those of the
authors and should not be construed as official Department of the Army position,
policy, or decision, unless so designated by other official documentation. Approved for
public release; distribution is unlimited.
This manuscript was received for review in November 2006. The revised manu-
script was accepted for publication in May 2007.
Military Medicine, Vol. 172, September 2007
Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019
tional group with similar strength/fitness demands, social
class, and geographic distribution (carpenters, electricians, in-
strument makers, dairy workers, upholsterers, and glaziers).5
One unique group of vehicle mechanics is those serving in the
U.S. Army. Although there are currently no mechanic-specific
data, it is likely that these soldier mechanics are exposed to
occupation-related hazards which might include slips, falls, ob-
jects dropped on the body, slipping wrenches, and the like. In
addition, these individuals participate in vigorous exercise ac-
tivity as part of their military obligation to maintain a high level
of physical fitness6 and also perform specific soldiering activities
like airborne operations and field exercises. These activities may
expose them to additional perils.
Based on these assumptions, it is likely that there are dis-
tinctive and complex risks associated with military service as a
U.S. Army vehicle mechanic. In an effort to quantify these risks,
this investigation was designed to describe injury rates, ana-
tomical locations of injuries, activities associated with injuries,
and potential injury risk factors among U.S. Army vehicle me-
chanics.
Methods
U.S. Army soldiers with a military occupational specialty
(MOS) code of 63B are classified as “light wheel-vehicle mechan-
ics.” Personnel Offices (G-l) at Fort Bragg, North Carolina, com-
piled a list of all male and female soldiers on the installation with
a MOS code of 63B. This list was extracted from a database
system called the Standard Installation Division Personnel Sys-
tem. This list was subsequently provided to the administrators
of all medical treatment facilities at Fort Bragg including the
three health clinics (Joel Health Clinic, Clark Health Clinic, and
Robinson Health Clinic), the hospital (Womack Army Medical
Center), and the battalion aid stations. The administrators and
surgeons provided individual soldier medical records to the in-
vestigators for screening in accordance with Army Regulation
40-66 which provides for the examination of medical records
following ethical guidelines and formal approval from the U.S.
Army Patient Administration and the Office of the Army Surgeon
General.
Injury Data
To identify injured soldiers, individual medical records were
examined for the period March 1, 2003 to February 29, 2004 (1
year). Experienced medical records reviewers identified each
visit to a medical care provider as either a visit for an injury or
for other medical care. For each injury visit, reviewers extracted
the date of visit, type of visit (initial or follow-up), activity asso-
988
Injury Rates and Risk Factors among U.S. Vehicle Mechanics
ciated with the injury, diagnosis, anatomical location of injury,
disposition (final outcome of the visit), and days of limited duty
(if any).
There were many injuries for which the medical care provider
did not include an activity associated with the injury. In these
cases, attempts were made to contact the soldiers in person (at
his/her work site), by phone, or by electronic mail to obtain the
activity associated with the injury. Soldiers were provided the
date of the injury, the diagnosis, and the involved body part and
asked how the specific injury had occurred.
Injury Case Definitions
An injury case was a soldier who sustained physical damage to
the body7 and sought medical care one or more times between
March 1, 2003 and February 29, 2004 as recorded in the medical
record. Using the diagnosis in the medical records, injuries were
grouped by “type”: any injury, overuse injury, traumatic injury,
environmental injury, or lower extremity overuse injury. Injury
types were determined primarily by the recorded diagnoses.
An overuse injury was presumably due to or related to long-
term energy exchanges resulting in cumulative microtrauma.8
Specific overuse diagnoses included musculoskeletal pain (not
otherwise specified), stress fractures, stress reactions, tendon-
itis, bursitis, fasciitis, overuse syndromes, strains (where his-
tory indicates muscle injury due to overuse), patellofemoral pain
syndrome, degenerative joint conditions, and shin splints. A
traumatic injury was presumably due to sudden energy ex-
changes resulting in abrupt overload with tissue trauma. Spe-
cific diagnoses included pain (due to a traumatic event), sprains,
dislocations, fractures, blisters, abrasions, lacerations, strains,
and contusions. An environmental injury was due to unusual
exposure to chemicals, weather, or animals. Environmental in-
jury diagnoses included heat-related injuries, cold-related inju-
ries, burns, and animal bites. A lower extremity overuse injury
was an overuse injury (as defined above) that involved the lower
extremity or lower back. “Any injury” included overuse and
traumatic diagnoses as described above.
We examined two “levels” of injury that were assumed to
relate to different levels of severity. The first level included all
visits to health care providers for any type of injury regardless of
whether limited duty was prescribed. The second level (a time-
loss injury) included only those injuries for which the medical
care provider prescribed one or more days of limited duty (a
physical profile). By combining injury types and levels, eight
injury measures were obtained: any injury, overuse injury, trau-
matic injury, lower extremity overuse injury, any time-loss in-
jury, time-loss overuse injury, time-loss traumatic injury, and
time-loss lower extremity overuse injury.
An encounter was defined as a visit in the medical record for
any type of injury. Initial injury visits were first encounters
resulting in a particular diagnosis at a particular anatomical
location. Follow-up injury visits were encounters within a
6-month period resulting in the same diagnosis at the same
anatomical location as the initial visit. If the period was ⬎6
months between encounters (initial or follow-up), the encounter
was considered a new initial visit even if the diagnosis and
anatomical location were the same.
989
Physical Characteristics and Ethnicity
Also extracted from the medical records were date of birth,
height, weight, and ethnicity. Date of birth and ethnicity were
obtained from a form in the medical record (Standard Form 88,
Report of Medical Examination) that recorded these items dur-
ing the soldiers physical examination given on entry to military
service. Height and weight were obtained from a medical visit
closest to March 1, 2003.
Deployment Data
Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019
Medical records did not include medical visits for periods of
military deployment away from Fort Bragg. During the screen-
ing period, many of the soldiers had been deployed for extended
periods. Information on soldier deployments were obtained from
the Defense Manpower Data Center (DMDC). Extracted from the
DMDC database were the start and end date of any deployments
in which the soldier participated. The number of days deployed
within the medical records screening time frame was calculated
and designated the “deployment time.” Deployment time was
subtracted from the total time in the study to derive the person-
time of exposure for each soldier.
Data Analysis
Frequencies were obtained for injury diagnoses, anatomical
locations, and activities associated with injury. Descriptive sta-
tistics were calculated for the demographic and physical vari-
ables. Body mass index (BMI) was calculated as body weight/
stature.9 Age was calculated as the number of years from the
date of birth to February 28, 2003.
Time at risk (year or a fraction thereof) within the screening
time frame was calculated as: 366 ⫺ deployment time.
Injury incidence rates (injured soldiers/100 person-years)
were calculated as: ⌺soldiers with ⱖ1 initial injury visits/(⌺total
time at risk of all soldiers) ⫻ 100. Injury rates (injuries/100
person-years) were calculated as: ⌺initial injury visits/(⌺total
time at risk for all soldiers) ⫻ 100. Limited duty day rates
(days/100 person-years) were calculated as: ⌺limited duty
days/(⌺total time at risk for all soldiers) ⫻ 100.
By considering in the numerator only, the specific diagnoses
noted above in the injury case definitions, injury incidence
rates, and injury rates were subcategorized into any injury,
overuse injury, traumatic injury, lower extremity overuse injury,
any time-loss injury, time-loss overuse injury, time-loss trau-
matic injury, and time-loss lower extremity overuse injury. Lim-
ited duty day rates were similarly subcategorized into any time-
loss injury, time-loss overuse injury, time-loss traumatic injury,
and time-loss lower extremity overuse injury. A ␹2 test for per-
son-time data was performed to test the hypothesis of no gender
difference in injury incidence rates and injury rates.10 Cox re-
gression (a survival analysis technique) was used to examine the
association between injury risk and the physical characteristics
and ethnicity. For this analysis, height, weight, and BMI were
separated into quartiles based on the distribution of these vari-
ables. Age was separated into four groups.
Results
Standard Installation Division Personnel System data indi-
cated that there were 837 soldiers with the MOS of 63B at Fort
Military Medicine, Vol. 172, September 2007
990 Injury Rates and Risk Factors among U.S. Vehicle Mechanics

Bragg, North Carolina. Of these, 608 (73%) medical records were
obtained. Reason for missing medical records included: 1) the
personnel rosters were not totally up-to-date; 2) there was a
2-week lag between obtaining the list of 63B soldiers and send-
ing that list to the medical clinics (some soldiers departed the
installation); 3) some soldiers maintained possession of their
medical records; and 4) unknown reasons, including the possi-
bility that some records were lost. If a soldier’s medical record
was not in the medical records section of the treatment facilities,
diligent efforts were made to find the record in other locations in
(n ⫽ 43), 162 ⫾ 7 cm (n ⫽ 43), 66 ⫾ 10 kg (n ⫽ 43), and 24.5 ⫾
3.2 kg/m2 (n ⫽ 43). Among the men, 64% were Caucasian, 22%
were African American, and 13% were of other races (n ⫽ 484);
among women, 39% were Caucasian, 51% were African Ameri-
can, and 10% were of other races (n ⫽ 41).
Medical Encounters, Total Injuries, and Person-Time
Men had a total of 1,162 medical encounters while women
had a total of 102 medical encounters. Men had a total of 464

Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019

the facilities and/or to contact the soldier.
If a medical record lacked a Standard Form 88 (Report of
Medical Examination), it was likely that the record was incom-
plete since this is one of the first forms entered in the soldier’s
medical record on entry to service. Medical records lacking this
form were not considered for this analysis. There were 47 in-
complete medical records (44 male records and 3 female
records). Thus, the final cohort considered for analysis included
518 men and 43 women.
Physical Characteristics and Ethnicity
In some of the medical records, specific demographic and
physical data were missing from the relevant forms so the sam-
ple sizes are shown. Men had an average ⫾ SD age, height,
weight, and BMI of 27.1 ⫾ 6.8 years (n ⫽ 518), 175 ⫾ 8 cm (n ⫽
498), 80 ⫾ 13 kg (n ⫽ 498), and 25.8 ⫾ 3.8 kg/m2 (n ⫽ 498),
respectively. For the women, these values were 28.1 ⫾ 6.3 years
injuries and women had a total of 50 injuries (initial injury
visits, exclusive of follow-up visits). The total person-time at risk
(nondeployment time) for the men was 132,170 days with a
mean ⫾ SD of 255 ⫾ 116 days. The total person-time at risk for
the women was 11,764 days with a mean ⫾ SD of 274 ⫾ 111
days. Deployment time was 57,418 days for the men and 3,974
days for the women. As a group, male soldiers were deployed
30% of the total survey time while female soldiers were deployed
25% of the survey time.
Injury Incidence Rates and Injury Rates
Table I shows the injury incidence rates and compares rates
by gender. The overall injury incidence rate (any injury) is sim-
ilar for men and women. However, the incidence rates for over-
use injuries, lower extremity overuse injuries, time-loss overuse
injuries, and time-loss lower extremity overuse injuries all

TABLE I
INJURY INCIDENCE AND INJURY RATES OF MEN AND WOMEN

Men Women
Injury Incidence Rate Injury Incidence Rate Injury Incidence
Occurrences (injured soldiers/100 Occurrences (injured soldiers/100 Rate Ratio p
(n) person-years) (n) person-years) (women/men) (men vs. women)a
Injury incidence
Any 260b 72.0 26b 81.0 1.13 0.57
Overuse 149 41.3 20 62.3 1.51 0.08
Traumatic 158 43.8 10 31.2 0.71 0.29
Lower extremity 126 34.9 18 56.1 1.62 0.06
overuse
Any time loss 213 59.0 22 68.5 1.16 0.50
Time loss overuse 124 34.3 16 49.8 1.45 0.14
Time-loss traumatic 125 34.6 5 15.6 0.45 0.07
Time-loss lower 105 29.1 15 46.7 1.60 0.09
extremity
overuse
Injuries
Any 448b 124.1 50b 155.8 1.26 0.13
Overuse 220 60.9 34 105.9 1.74 ⬍0.01
Traumatic 228 63.1 16 49.8 0.79 0.34
Lower extremity 111 30.7 22 68.5 2.23 ⬍0.01
overuse
Any time loss 301 83.4 32 99.7 1.20 0.33
Time-loss overuse 145 40.2 22 68.5 1.70 0.02
Time-loss traumatic 156 43.2 10 31.2 0.72 0.32
Time-loss lower 86 23.8 16 49.8 2.09 ⬍0.01
extremity
overuse
a
From ␹2 for person-time (Ref. 10).
b
Does not include environmental injuries.

Military Medicine, Vol. 172, September 2007

Injury Rates and Risk Factors among U.S. Vehicle Mechanics 991

tended to be higher in women. On the other hand, the incidence
rates traumatic injuries and time-loss traumatic injuries tended
to be higher among men.
Table I shows that the overall injury rates (any injury) were
slightly higher for the women compared to the men. Women had
higher rates for overuse injury, lower extremity overuse injury,
overall time-loss injury, time-loss overuse injury, and time-loss
lower extremity overuse injury. On the other hand, men had higher
injury rates for traumatic injury and time-loss traumatic injury.
Injury Anatomical Locations and Diagnoses
male injuries and 32% of the female injuries. Environmental
injuries made up 3% of the male injuries; women did not have
any environmental injuries.
Activities Associated with Injuries
There were 336 of the 464 male injuries (72%) and 36 of the 50
female injuries (72%) that had an associated training event
listed in the medical records. An additional 81 male injury ac-
tivities and 9 female injury activities were obtained by interview.
Thus, an associated activity was obtained for 90% (417 of 464)

Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019

Table II shows the injuries by anatomical location. For the
men, 34% of the injuries occurred in the upper body, 19% in
the lower back, and 46% in the lower body. The single sites
with the largest proportion of male injuries (in order of inci-
dence) were the lower back, knee, ankle, foot, and shoulder. For
women, 24% of the injuries occurred in the upper body, 10% in
the lower back and 62% in the lower body. The single sites with
the largest proportion of female injuries (in order of incidence)
were the knee, lower back and foot, ankle, neck, and shoulder.
In the combined male and female data, the lower back, knee,
ankle, foot, and shoulder were involved in 61% of all injuries.
Table III shows the distribution of injuries by diagnosis. Over-
use injuries accounted for 47% of the male injuries and 68% of
the female injuries. Traumatic injuries accounted for 49% of the
of male injuries and 90% (45 of 50) of female injuries.
Table IV shows that physical training accounted for the larg-
est proportion of injuries. Running was associated with 62% of
the male physical training injuries (58 of 93) and 50% of the
female physical training injuries (8 of 16). Of the male mechan-
ical work injuries, activities related to vehicle tires were associ-
ated with 14% (7 of 49), wrenches slipping with 10% (5 of 49),
objects dropped on the body with 10% (5 of 49), and vehicle
starters with 10% (5 of 49). Of the female mechanical work
injuries, objects dropped on the body accounted for 38% (3 of 8).
Of the male sports injuries, basketball was associated with 36%
(17 of 47), football with 21% (10 of 47), softball with 17% (8 of
47), and bicycling with 6% (3 of 47). Most airborne injuries were
associated with parachute landing problems: 87% (33 of 38) for
men and 100% (4 of 4) for women.

TABLE II
DISTRIBUTION OF ALL INJURIES BY ANATOMICAL LOCATION

Men Women
Anatomical Proportion of All Proportion of All
Body Area Location Cases (n) Injuries (%) Cases (n) Injuries (%)
Head 11 2.4 1 2.0
Face 5 1.1 0 0.0
Eyes 5 1.1 0 0.0
Neck 19 4.1 3 6.0
Chest 10 2.2 1 2.0
Abdomen 4 0.9 0 0.0
Shoulder 32 6.9 3 6.0
Upper body
Elbow 8 1.7 1 2.0
Upper arm 1 0.2 0 0.0
Lower arm 5 1.1 0 0.0
Wrist 14 3.0 1 2.0
Hand 14 3.0 5 2.0
Finger 20 4.3 1 0.0
Upper back 9 1.9 2 2.0
Lower back 87 18.8 0 10.0
4 0.9 0 2.0
Pelvic area
Hip 5 1.1 2 4.0
Posterior thigh 5 1.1 0 0.0
Anterior thigh 5 1.1 0 0.0
Knee 73 15.7 13 26.0
Calf 2 0.4 2 4.0
Lower body
Shin 19 4.1 2 4.0
Ankle 56 12.1 4 8.0
Foot 34 7.3 5 10.0
Toe 11 2.4 2 4.0
Multiple areas 4 0.9 1 2.0
Unknown 2 0.4 1 2.0
464 100.0 50 100.0
Total

Military Medicine, Vol. 172, September 2007

992 Injury Rates and Risk Factors among U.S. Vehicle Mechanics

TABLE III
DISTRIBUTION OF INJURIES BY DIAGNOSES

Men (n ⫽ 518) Women (n ⫽ 43)

Proportion of All Proportion of All
Cases (n) Injuries (%) Cases (n) Injuries (%)
Overuse injuries
Pain (NOS) 103 22.0 17 34.0
Strain (muscle injury associated with overuse) 30 6.5 3 6.0
Tendonitis 23 5.0 1 2.0

Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019

Patellofemoral pain syndrome 15 3.2 2 4.0
Joint-related overuse 10 2.2 1 2.0
Stress fractures/stress reactions 8 1.7 1 2.0
Degenerative joint conditions 5 1.1 1 2.0
Bursitis 5 1.1 1 2.0
Fasciitis 5 1.1 2 4.0
Shin splints 4 0.9 3 6.0
Other overuse 1 2.6 2 4.0
Traumatic injuries
Sprain (joint injury associated with trauma) 60 12.9 0 0.0
Pain associated with trauma 41 8.8 4 8.0
Contusion 33 7.1 7 14.0
Strain (muscle injury associated with trauma) 31 6.7 1 2.0
Abrasion/laceration 22 4.7 2 4.0
Fracture 17 3.7 1 2.0
Other traumatic injuries 14 3.0 0 0.0
Blister 7 1.5 1 1.0
Dislocation 3 0.6 0 0.0
Environmental injuries
Animal bites 8 1.7 0 0.0
Heat injury 1 0.2 0 0.0
Contact dermatitis/burns 7 1.5 0 0.0

TABLE IV
ACTIVITIES ASSOCIATED WITH INJURY

Men Women
Proportion of Proportion of Injuries Proportion of Proportion of Injuries
All Injuries with Known Associated All Injuries with Known Associated
Cases (n) (n ⫽ 464) (%) Activity (n ⫽ 417) (%) Cases (n) (n ⫽ 50) (%) Activity (n ⫽ 45) (%)
Physical training 93 20.0 22.3 16 32.0 35.6
Mechanical work 49 10.6 11.8 8 16.0 17.8
Sports 47 10.1 11.3 0 0.0 0.0
Airborne activity 38 8.2 9.1 4 8.0 8.9
Road marching 31 6.7 7.4 4 8.0 8.9
Garrison/home activity 29 6.3 7.0 4 8.0 8.9
Chronic conditions 26 5.6 6.2 3 6.0 6.7
Motor vehicle accidents 18 3.9 4.3 2 4.0 4.4
Field training 18 3.9 4.3 1 2.0 2.2
Environmental 16 3.4 3.8 0 0.0 0.0
Fall from military vehicle 9 1.9 2.2 0 0.0 0.0
Lifting 9 1.9 2.2 0 0.0 0.0
Getting out of bed 6 1.3 1.4 0 0.0 0.0
Ice 5 1.1 1.2 0 0.0 0.0
Fighting/horseplay 4 0.9 1.0 0 0.0 0.0
Other 19 4.1 4.6 3 6.0 6.7
Unknown 47 10.1 0.0 5 10.0 0.0

Days of Limited Duty traumatic injury, and for time-loss lower extremity overuse in-
For the men, the total number of days of limited duty days for jury were 7,502, 4,203, 3,299, and 3,414 days, respectively. For
any time-loss injury, for time-loss overuse injury, for time-loss women, these values were 631, 549, 82, and 489 days. For men,

Military Medicine, Vol. 172, September 2007

Injury Rates and Risk Factors among U.S. Vehicle Mechanics 993

the limited duty day rates (days/100 person-years) for any time-
loss injury, for time-loss overuse injury, for time-loss traumatic
injury, and for time-loss lower extremity overuse injury were
2,074, 1,164, 914, and 945, respectively. For women, these
values were 1,966, 1,710, 255, and 1,523, respectively.
Injury Risk Factors
Because of the small number of women, Cox regressions were
only performed on the men. Any attempt to develop female risk
subgroups for the covariates would have resulted in very small
7:30 a.m.). The soldiers then had ⬃1.5 hours for personal
hygiene (shower, dress) and breakfast (7:30 –9:00 a.m.). The
soldier reported to the work areas at 9:00 a.m., where they
performed mechanical work on vehicles for the remainder of
the day which normally lasted until 5:00 p.m. While working,
mechanics were involved in testing equipment, troubleshoot-
ing, and changing and repairing vehicle parts. Generally, a
break was taken at approximately 12:00 p.m. to 1:00 p.m. for
lunch and, at the end of the work day, soldiers cleaned up the
working area. Senior personnel spend some time in the shop

Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019

numbers of women in each subgroup which would have severely
limited statistical power. Table V shows the univariate Cox re-
gression results for any injury and any time-loss injury. There
was increased risk of injury with greater body weight or higher
BMI.
Discussion
This investigation found that the overall injury rate among
U.S. Army wheel vehicle mechanics was 127 injuries/100
person-years (men and women combined). Each year an av-
erage of ⬃20 days of limited duty were prescribed per me-
chanic. The largest proportions of injuries were experienced
in the lower back, knee, and ankle areas. Physical training
and mechanical work were the two activities associated with
the highest proportion of injuries. Among men, higher body
weight and BMI were associated with higher overall injury
risk.
Occupational Activities of Army Mechanics
Informal interviews with the mechanics indicated that their
normal duties involved mechanical work as well as physical
training and soldiering activities. A typical day in garrison
began with morning physical training for about 1 hour (6:30 –
office doing paperwork while junior personnel typically spent
the entire day working on vehicles in the shop.
Besides these activities, about half a day each week was
devoted to military professional development classes con-
ducted in the classroom or field. Airborne operations were
conducted about one time per month or at least once per
quarter. About once every 3 months, soldiers were involved in
a field training exercise where they spent 3 to 7 days (some-
times longer) in the field. In the field, soldiers were generally
awakened at 5:00 a.m., performed hygiene, and spent the rest
of the day repairing and recovering vehicles. Sleep time in the
field was dependent on the amount of equipment requiring
attention. All soldiers rotated on guard duty both day and
night, and the amount of time on guard duty was dependent
on the operational scenario.
Gender Differences
Gender differences emerged but the small number of
women suggests a cautious approach in examining these
differences. Although men had about an equal number of
traumatic and overuse injuries, almost 70% of female injuries
were in the overuse category. A large portion of the total
injuries involved the lower body/low back areas in both gen-
ders but the women had a larger proportion of injuries in

TABLE V
UNIVARIATE COX REGRESSION RESULTS FOR ANY INJURY AND ANY TIME-LOSS INJURY (MEN)

Any Injury Any Time-Loss Injury

Variable Level of Variable n Hazard Ratio 95% CI p Hazard Ratio 95% CI p
Age 18.1–25.0 years 277 1.00 Reference Reference 1.00 Reference Reference
25.1–30.0 years 73 1.02 0.72–1.48 0.88 1.09 0.73–1.63 0.69
30.1–35.0 years 84 0.87 0.62–1.25 0.45 0.95 0.64–1.42 0.81
⬎35.0 years 84 1.23 0.88–1.71 0.23 1.19 0.82–1.73 0.35
Height 57–66 inches 130 0.91 0.64–1.29 0.63 0.81 0.55–1.20 0.30
67–69 inches 135 0.82 0.57–1.14 0.21 0.84 0.57–1.23 0.37
70–71 inches 116 1.08 0.76–1.53 0.67 1.01 0.69–1.49 0.95
72–80 inches 117 1.00 Reference Reference 1.00 Reference Reference
Weight 114–154 lb 129 1.00 Reference Reference 1.00 Reference Reference
155–172 lb 123 1.60 1.08–2.37 0.02 1.95 1.23–3.09 ⬍0.01
173–193 lb 128 2.18 1.50–3.19 ⬍0.01 2.78 1.78–4.32 ⬍0.01
194–270 lb 118 2.01 1.38–2.95 ⬍0.01 2.57 1.64–4.03 ⬍0.01
BMI 16.0–23.3 kg/m2 124 1.00 Reference Reference 1.00 Reference Reference
23.4–25.7 kg/m2 128 1.71 1.16–2.51 ⬍0.01 1.81 1.15–2.83 ⬍0.01
25.8–28.1 kg/m2 123 2.35 1.60–3.46 ⬍0.01 2.57 1.66–3.97 ⬍0.01
28.2–38.0 kg/m2 123 2.00 1.36–2.95 ⬍0.01 2.31 1.48–3.58 ⬍0.01
Ethnicity Caucasian 311 1.00 Reference Reference 1.00 Reference Reference
African American 107 0.97 0.70–1.32 0.82 0.94 0.66–1.34 0.74
Other 66 1.21 0.84–1.75 0.31 1.21 0.81–1.80 0.35

Military Medicine, Vol. 172, September 2007

994
these areas (72% vs. 65%). Investigations in Army Basic Com-
bat Training and Advanced Individual Training generally
agree with these results showing that women have a larger
proportion of overuse and lower extremity overuse injuries.11–13
In the present investigation, much of the higher overuse in-
jury rate in women was accounted for by a higher proportion
of pain not otherwise specified (NOS) making it difficult to
interpret this gender difference. Examination of gender differ-
ences in pain NOS by associated activity or by anatomical
location did not provide any additional insight.
A study by Tomlinson et al.14 examining injuries among sol-
diers at Fort Lewis, Washington, used an injury case definition
that involved primarily traumatic injuries (i.e., fractures,
sprains, dislocations, lacerations, abrasions, contusions, lower
back strains, eye injury, internal injury of the head, chest,
abdomen, heat/cold injury). They found that men were 1.20
(95% confidence interval (CI) ⫽ 1.1–1.4) times more likely to
be injured than women (secondary data analysis). This gen-
erally agrees with the results reported here in which male
mechanics experienced a traumatic injury rate that was 1.27
times higher than that of the female mechanics. Some studies
have shown that compared to women, men and male adoles-
cents are more likely to engage in risk-taking behavior and/or
report higher scores on tests designed to measure risk-taking
behavior,15–19 although there is some contradictory evi-
dence.20 Risk-taking behaviors may be more likely to result in
traumatic (acute) injuries due to a sudden overload event
(falls, stepping into a hole, tripping, etc.). Overuse injuries are
assumed to be due to the repetitive use of a body part and the
female mechanics were more susceptible to injuries of this
type.
Activities Associated with Injuries
Examination of activities associated with injuries is impor-
tant because these activities provide targets for prevention
efforts. However, caution is called for in interpreting the data
because soldiers may report an event that was not necessarily
the “cause” of the injury but rather activities that aggravated
the injury and caused the pain. Furthermore, overuse injuries
are generally related to repetitive stress over time and not a
single event, although individuals can often identify this re-
petitive stress.
The single physical training activity that was most associ-
ated with injury was running. Running alone was related to
14% (58 of 417) of all male injuries and 18% (8 of 45) of all
female injuries (denominators are injuries with an identified
associated activity). In a previous study of military students
in occupational training, running was associated with 45% to
49% of all injuries.21 Running is a popular physical training
exercise in the military and is performed regularly. Some
soldiers in this investigation informed us that they ran 5 days
per week. The 2-mile run is an Army Physical Fitness Test
event for which all soldiers must meet certain age- and gen-
der-adjusted standards twice yearly to be retained in service.
Both civilian22–25 and military26,27 investigations have shown
that as the volume of running increases, so does the incidence
of injury. Specific reductions in running mileage have been
shown to reduce injury risk without having significant effects
on aerobic fitness improvements.28 –30
Military Medicine, Vol. 172, September 2007
Injury Rates and Risk Factors among U.S. Vehicle Mechanics
Mechanical work was the second activity most associated
with injury. This category accounted for a larger proportion of
the female injuries than the male injuries (18% vs. 12%).
Based on an analysis of the critical tasks performed by me-
chanics,31 it was found that much of the occupational work
involved the upper body and lower back in the use of hand
tools (torque applied to tools like wrenches and screwdrivers),
and for removing and replacing (lifting) vehicle parts like
radiators, fuel pumps, alternators, batteries, starters, brakes,
tires, axles, wheels, and hubs. A closer examination of these
Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019
tasks with a view to reduce injuries could develop some helpful
interventions.
Sports activity accounted for the third largest proportion of
injuries. This was associated with 11% of the male injuries but
women did not have any sports injuries. Basketball was the
sport most commonly associated with injury and accounted for
4% of all injuries. Prophylactic ankle bracing has been shown to
reduce the incidence of basketball ankle injuries32 but high-top
basketball shoes do not appear to influence injury rates.33 Foot-
ball, softball, and bicycling were the other major sports activities
associated with injuries. Mouthguards are effective in reducing
orofacial injuries in football.34 Breakaway bases have been
shown to reduce injuries in softball35,36 and other proposed
methods might also be successful.37 Bicycle helmets are very
effective in reducing head, brain, and facial injuries while
bicycling.38
Landings in association with airborne operations ac-
counted for the fourth largest proportion of injuries, 9% of
both the male and female injuries. Approximately 26% (11 of
42) of these injuries involved the ankle which is somewhat
lower than the 32% reported in other studies of airborne
operations.39 – 41 Outside-the-boot ankle braces have been
shown to reduce the incidence of ankle injuries during air-
borne operations.42– 44 The use of ankle braces on airborne
operations was required from 1994 to 2001 but ankle braces
were discontinued in 2001 because of cost considerations and
anecdotal reports that they caused other types of injuries.43 Ankle
braces were reinstated in 2005 due to a mandate from the Defense
Safety Oversight Council which should assist in reducing injuries
in this operational activity.
BMI and Injury
Higher BMI was associated with higher injury risk among the
men in the present project. In consonance with these data,
higher BMI has also been shown to be a risk factor for injuries in
other military occupational investigations.45–47 Many studies
have used BMI as a marker of overweight and obesity.48,49 There
are several advantages to the use of this index. BMI “corrects”
body weight for the height of an individual, essentially removing
the dependency of weight on height. BMI is easy to obtain and
data from the large studies cited above can be used to describe
populations and trends. The correlation between body fat and
BMI is ⬃0.7 in both civilian samples50 and in military recruits.9
However, a correlation of 0.7 indicates that only approximately
one-half of the variance in BMI is accounted for by body fat.
There is evidence that BMI may be associated with different
proportions of body fat in different racial groups and that leg
length and body build can affect the association between fat and
Injury Rates and Risk Factors among U.S. Vehicle Mechanics
BMI.51 An individual can have a high BMI because of a high
proportion of any tissue in the body, not just fat (e.g., bone,
muscle).
Thus, some caution is called for in relating BMI to body fat.
Despite this, the data here indicate that individuals who carry
more body weight for their height are at higher injury risk. The
greater weight may result in greater forces on body tissues
during physical activity (physical training and occupational
tasks) resulting in a greater likelihood of injury.
Summary
This investigation quantified the injury rates, anatomical loca-
tions of injuries, lost work time, and activities associated with
injuries among male and female Army wheel vehicle mechanics.
Further investigations of other MOS could provide insight on com-
mon and occupation-specific injury risks in the Armed Forces.
Acknowledgments
We thank Ms. Nikki Jordan for the DMDC data and MAJ Siefer and
MSG Ferguson for providing the personnel data. Clinic, hospital, and
battalion aid station administrators that assisted our medical records
screening included Ms. Sherri Lasater, Ms. Laura Mota, Ms. Lavonne
Halbumt, Ms. Diane Mobley, and LTC Edward Boland. Thanks also to Ms.
Stephanie Morrison for the technical review of this article and Ms. Ann
Gibson for the editorial review.
References
1. Loomis D, Bena JF, Bailer AJ: Diversity of trends in occupational injury mortality
in the United States. Inj Prev 2003; 9: 9 –14.
2. Stout NA, Jenkins L, Pizatella TL: Occupational injury mortality rates in the
United States: changes from 1980 –1989. Am J Public Health 1996; 86: 73–7.
3. Bureau of Labor Statistics: Incidence rate and number of nonfatal occupational
injuries by selected industries. News, United States Bureau of Labor Statistics,
November 17, 2005. Available at http://www.bls.gov/news.release/osh.t05.htm;
accessed March 29, 2006.
4. Leigh JP, Miller TR: Ranking of occupations based on the costs of job-related
injuries and diseases. J Occup Med 1997; 39: 1170 – 82.
5. Hansen ES: Mortality of auto mechanics. Scand J Work Environ Health 1989; 15:
43– 6.
6. Physical Fitness Training. U.S. Army Field Manual (FM) 21-20. Washington, DC,
Headquarters, Department of the Army, 1992.
7. Haddon W: Energy damage and ten countermeasure strategies. J Trauma 1973;
13: 321–31.
8. Pinter MA: Pathophysiology of overuse injuries in the hand and wrist. Hand Clin
1990; 6: 355– 64.
9. Knapik JJ, Burse RL, Vogel JA: Height, weight, percent body fat and indices of
adiposity for young men and women entering the U.S. Army. Aviat Space Environ
Med 1983; 54: 223–31.
10. Kahn HA, Sempos CT: Statistical Methods in Epidemiology. New York, Oxford
University Press, 1989.
11. Knapik JJ, Sharp MA, Canham ML, et al: Injury incidence and injury risk factors
among U.S. Army Basic Trainees at Ft. Jackson, SC (including fitness training
unit personnel, discharges, and new starts). Epidemiological Consult Report
29-HE-8370-99. Aberdeen Proving Ground, MD, U.S. Army Center for Health
Promotion and Preventive Medicine, 1999.
12. Jones BH, Bovee MW, Harris JM, Cowan DN: Intrinsic risk factors for exercise-
related injuries among male and female Army trainees. Am J Sports Med 1993;
21: 705–10.
13. Henderson NE, Knapik JJ, Shaffer SW, McKenzie TH, Schneider GM: Injuries and
injury risk factors among men and women in U.S. Army combat medic advanced
individual training. Milit Med 2000; 165: 647–52.
14. Tomlinson JP, Lednar WM, Jackson JD: Risk of injury in soldiers. Milit Med
1987; 152: 60 – 4.
15. West GB, Moskal PD, Dziuban CD, Rumbough LP: Gender and marital differ-
ences for risk taking among undergraduates. Psychol Rep 1996; 78: 315–20.
995
16. Jelalian NS, Spirito A, Rasile D, Vinnick L, Rohrbeck C, Arrigan M: Risk taking,
reported injury and perception of future injury among adolescents. J Pediatr
Psychol 1997; 22: 513–31.
17. Redeker NS, Smeltzer SC, Kirkpatrick J, Parchment S: Risk factors of adolescent
and young adult trauma victims. Am J Crit Care 1993; 4: 370 – 8.
18. Cherpitel CJ: Alcohol, injury, and risk-taking behavior: data from a national
sample. Alcohol Clin Exp Res 1993; 17: 762– 6.
19. Bonomo Y, Coffey C, Wolfe R, Lynskey M, Bowes G, Patton G: Adverse outcomes
of alcohol use in adolescents. Addiction 2001; 96: 1485–1496.
20. Bell NS, Amoroso PJ, Yore MM, Smith GS, Jones BH: Self-reported risk taking
behavior and hospitalizations for motor vehicle injury among active duty Army
personnel. Am J Prev Med 2000; 18: 85–95.
Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019
21. Knapik JJ, Bullock SH, Canada S, et al: The Aberdeen Proving Ground Injury
Control Project: influence of a multiple intervention program on injuries and
fitness among Ordnance School students in Advanced Individual Training. Tech-
nical Report 12-HF-7990-03. Aberdeen Proving Ground, MD, U.S. Army Center
for Health Promotion and Preventive Medicine, 2003.
22. Koplan JP, Rothenberg RB, Jones EL: The natural history of exercise: a 10-yr
follow-up of a cohort of runners. Med Sci Sports Exerc 1995; 27: 1180 – 4.
23. Marti B, Vader JP, Minder CE, Abelin T: On the epidemiology of running injuries.
The 1984 Bern Grand-Prix study. Am J Sports Med 1988; 16: 285–94.
24. Powell KE, Kohl HW, Caspersen CJ, Blair SN: An epidemiological perspective on
the causes of running injuries. Physician Sportsmed 1986; 14: 100 –14.
25. Pollock ML, Gettman LR, Milesis CA, Bah MD, Durstine L, Johnson RB: Effects of
frequency and duration of training on attrition and incidence of injury. Med Sci
Sports Exerc 1977; 9: 31– 6.
26. Jones BH, Cowan DN, Knapik JJ: Exercise, training and injuries. Sports Med
1994; 18: 202–14.
27. Trank TV, Ryman DH, Minagawa RY, Trone DW, Shaffer RA: Running mileage,
movement mileage, and fitness in male U.S. Navy recruits. Med Sci Sports Exerc
2001; 33: 1033– 8.
28. Shaffer RA: Musculoskeletal injury project. In: Proceedings of the 43rd Annual
Meeting of the American College of Sports Medicine, May 29 –June 1, 1966,
Cincinnati, OH.
29. Knapik JJ, Hauret KG, Arnold S, et al: Injury and fitness outcomes during imple-
mentation of Physical Readiness Training. Int J Sports Med 2003; 24: 372–81.
30. Knapik JJ, Darakjy S, Scott SJ, et al: Evaluation of a standardized physical
training program for basic combat training. J Strength Condit Res 2005; 19:
246 –53.
31. Lopez M, Chervak S, Adika Y: Ergonomic task analysis of MOS 63B, Light
Wheeled Vehicle Mechanic. Ergonomic Consultation 88-MR-3062-01. Aberdeen
Proving Ground, MD, U.S. Army Center for Health Promotion and Preventive
Medicine, 2001.
32. Sitler M, Ryan J, Wheeler B, et al: The efficacy of a semirigid ankle stabilizer to
reduce acute ankle injury in basketball. Am J Sports Med 1994; 22: 454 – 61.
33. Barrett JR, Tanji JL, Drake C, Fuller D, Kawasaki RI, Fenton RM: High- versus
low-top shoes for the prevention of ankle sprains in basketball players. Am J
Sports Med 1993; 21: 582–5.
34. Knapik JJ, Marshall SW, Lee RB, et al: Mouthguards in sport activities: history,
physical properties, and injury prevention effectiveness. Sports Med 2007; 37:
117– 44.
35. Janda DH, Wojtys EM, Hankin FM, Benedict ME: Softball sliding injuries: a
prospective study comparing standard and modified bases. JAMA 1988; 259:
1848 –50.
36. Janda DH, Wojtys EM, Hankin FM, Benedict ME, Hensinger RN: A three phase
analysis of the prevention of recreational softball injuries. Am J Sports Med 1990;
18: 632–5.
37. Janda DH, Hankin FM, Wojtys EM: Softball injuries: cost, cause and prevention.
Am Fam Physician 1986; 33: 143– 4.
38. Thompson DC, Patterson MQ: Cycle helmets and prevention of injuries: recom-
mendations for competitive sports. Sports Med 1998; 25: 213–9.
39. Amoroso PJ, Bell NS, Jones BH: Injury among female and male parachutists.
Aviat Space Environ Med 1997; 68: 1006 –11.
40. Craig SC, Morgan J: Parachuting injury surveillance, Fort Bragg NC, May 1993 to
December 1994. Milit Med 1997; 162: 162– 4.
41. Hallel T, Naggan L: Parachute injuries: a retrospective study of 83,718 jumps.
J Trauma 1975; 15: 14 –9.
42. Amoroso PJ, Ryan JB, Bickley B, Leitschuh P, Taylor DC, Jones BH: Braced for
impact: reducing paratrooper’s ankle sprains using outside-the-boot braces.
J Trauma 1998; 45: 575– 80.
43. Schmidt MD, Sulsky SI, Amoroso PJ: Effectiveness of an external ankle brace in
reducing parachute-related ankle injuries. Inj Prev 2005; 11: 163– 8.
44. Shumacher JT, Creedon JF, Pope RW: The effectiveness of the parachutist ankle
Military Medicine, Vol. 172, September 2007
996
brace in reducing ankle injuries in an airborne ranger battalion. Milit Med 2000;
165: 944 – 8.
45. Darakjy S, Hauret KG, Canada SE, et al: Injuries and injury risk factors among
armor battalion soldiers at Ft. Riley, KS. Med Sci Sports Exerc 2003; 35: S278.
46. Hauret KG, Darakjy S, Canada S, Knapik JJ: Injury incidence and risk factors for
male military police (Army). Med Sci Sports Exerc 2003; 35: S279.
47. Reynolds KL, Heckel HA, Witt CE, et al: Cigarette smoking, physical fitness, and
injuries in infantry soldiers. Am J Prev Med 1994; 10: 145–50.
Military Medicine, Vol. 172, September 2007
Injury Rates and Risk Factors among U.S. Vehicle Mechanics
48. Harlan WR, Landis JR, Flegal KM, Davis CS, Miller ME: Secular changes in body
mass in the United States 1960 –1980. Am J Epidemiol 1988; 128: 1065–74.
49. Flegal KM, Carroll MD, Ogden CL, Johnson CL: Prevalence and trends in obesity
among U.S. adults, 1999 –2000. JAMA 2002; 288: 1723–7.
50. Roche AF, Siervogel RM, Chumlea WM, Webb P: Grading body fatness from
limited anthropometric data. Am J Clin Nutr 1981; 34: 2831– 8.
51. Kyle UG, Genton L, Pichard C: Body composition: what’s new? Curr Opin Clin
Nutr Metab Care 2002; 5: 427–33.
Downloaded from https://academic.oup.com/milmed/article-abstract/172/9/988/4283418 by abdou-dr@live.fr on 12 April 2019