accounted for 8 percent of all upper extremity failures, and rotator cuff conditions accounted for 2 percent. Elbow, forearm, and upper arm conditions accounted for 3 percent, finger and wrist fractures and amputations for 3 percent, and presence of an orthopedic device or complications of medical care for 7 percent. The remaining 75 percent comprised a wide variety of conditions, no single one of which is larger than 2 percent.

There is no systematic linkage of the information from the MEPCOM medical failure database to medical data on incident injury in basic training. There is also no routine linkage of the medical failure database to administrative data on basic training attrition. Because of the lack of linkage to outcomes and the great diversity and lack of specificity of the musculoskeletal conditions reported above, the committee did not make any further use of this data source.

Incidence of Injury and Attrition

Musculoskeletal injuries resulting from basic and advanced individual training pose the single most significant medical impediment to military readiness (Jones and Hansen, 2000). In 1994 and 1995, these types of injuries were the leading cause of disability in all the Services and were the leading cause of hospitalizations for the Army, the Navy, and the Marine Corps (DoD Injury Surveillance and Prevention Work Group, 1999). High incidence rates of musculoskeletal injuries impose enormous consequences on the military, including monetary costs, lost work or training time, and recruit attrition. Depending on the data source and the type of injury, average days lost per injury can range from 2.3 days for strains and sprains to over 100 days for more acute conditions, such as bone fractures (DoD Injury Surveillance and Prevention Work Group, 1999; Knapik et al., 1993; Lauder et al., 2000; Reynolds et al., 1994). Overuse bone injuries such as stress fractures also account for a significant number of lost duty days (averaging 6.2 days per injury) (Reynolds et al., 1994). In addition, studies have shown that musculoskeletal injuries are responsible for a significant number of limited-duty days. Common soft-tissue overuse injuries such as tendonitis and muscle strains have resulted in 3 to 7 limited-duty days per injury (Knapik et al., 1993).

Training injury rates have been estimated from 10 to 15 per 100 recruits per month for male recruits, 10 to 25 per 100 recruits per month for female recruits, and 6 to 12 per 100 recruits per month for infantry (Almeida et al., 1999; Bell et al., 2000; Jones et al., 1993b; Knapik et al., 1993; Kowal, 1980; Reinker and Ozburne, 1979; Riddell, 1990; Shaffer et al., 1999b; Tomlinson, Lednar, and Jackson, 1987). Among these populations, the cumulative incidence of musculoskeletal injuries that required medical attention has been reported to be between 8 and 55 percent for



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