Article Text

Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review
  1. Garrett S Bullock1,2,
  2. Carolyn E Dartt3,4,
  3. Emily A Ricker3,4,
  4. Joanne L Fallowfield5,
  5. Nigel Arden6,7,
  6. Daniel Clifton3,4,
  7. Kerry Danelson1,
  8. John J Fraser8,
  9. Christina Gomez9,
  10. Tina A Greenlee10,
  11. Alexandria Gregory3,4,
  12. Timothy Gribbin3,4,
  13. Justin Losciale11,12,
  14. Joseph M Molloy13,
  15. Kristen F Nicholson1,
  16. Julia-Grace Polich1,
  17. Anu Räisänen14,15,
  18. Karishma Shah6,
  19. Michael Smuda3,4,
  20. Deydre S Teyhen16,
  21. Rhonda J Allard17,
  22. Gary S Collins18,
  23. Sarah J de la Motte19,
  24. Daniel I Rhon10,20
  1. 1 Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  2. 2 Centre for Sport, Exercise, and Osteoarthritis, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
  3. 3 Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
  4. 4 Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
  5. 5 Environmental Medicine and Sciences Division, Institute of Naval Medicine, Gosport, UK
  6. 6 Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
  7. 7 University of Southampton MRC Lifecourse Epidemiology Centre, Southampton, UK
  8. 8 Directorate for Operational Readiness & Health, Naval Health Research Center, San Diego, California, USA
  9. 9 College of Health Sciences, Western University of Health Sciences, Pomona, California, USA
  10. 10 Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
  11. 11 Department of Rehabilitation, The University of British Columbia, Vancouver, British Columbia, Canada
  12. 12 Arthritis Research Canada, Richmond, British Columbia, Canada
  13. 13 Office of the Army Surgeon General, Falls Church, Virginia, USA
  14. 14 Department of Physical Therapy Education, Oregon, College of Health Sciences, Western University of Health Sciences, Lebanon, Oregon, USA
  15. 15 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  16. 16 Army Medical Specialist Corps Chief, Office of the Army Surgeon General, Falls Church, Virginia, USA
  17. 17 Learning Resource Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  18. 18 Centre for Statistics in Medicine, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
  19. 19 Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland, USA
  20. 20 Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
  1. Correspondence to Dr Daniel I Rhon, Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, MD 20814, USA; daniel.rhon{at}


Introduction Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities.

Methods A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified.

Results From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions.

Conclusion Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

  • systematic review
  • implementation / translation
  • military
  • community

Data availability statement

Data are available in a public, open access repository. All raw extracted data are available on the Open Science Framework:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Many military injury mitigation and prevention programmes in the military have shown efficacy and effectiveness but have been limited by implementation challenges in real-world settings.

  • Barriers and facilitators to implementation have not been adequately assessed and summarised, and it is unknown how well these have been reported in the current literature.


  • While hundreds of injury mitigation and prevention programmes have been implemented in military settings, factors hindering or facilitating programme implementation have not been systematically identified, until now.

  • This review has identified gaps in understanding and/or reporting of programme implementation, lack of international consensus on definitions and programme reporting standards and programmes addressing members’ unique needs are greatly lacking.


  • Understanding barriers and facilitators for military musculoskeletal injury mitigation and prevention programmes enables military stakeholders (researchers, clinicians, policymakers, leaders and service members) to improve future implementation efforts.


Musculoskeletal injuries (MSK-I) in military service members are a significant problem worldwide,1–5 adversely impacting work, combat readiness and national security.6 In the USA and the UK, MSK-I are the leading cause for seeking medical care1 and discharge from military service.7 In 2019, 53% of all US soldiers had an MSK-I, accounting for over >2 million medical encounters and 10 million limited duty days.8 The proportion of MSK-I is similar in other US military branches. Musculoskeletal conditions also account for the largest proportion of service-connected disabilities in the Department of Veterans Affairs.9 With an average cost of US$2000 per injury, estimated annual direct costs exceed US$3 billion across the US military.10 Indirect costs can exceed direct costs by fourfold.11 Lifetime costs for injured US service members (including those with combat trauma) are estimated at US$2 million per individual.12 The British Army estimated the financial burden of MSK-I in 2016 with the prevailing MSK-I rate at the time would result in capitation costs alone exceeding £1.2 billion over 15 years (2016–2031).13 These figures are considered conservative estimates; the full economic impact of MSK-I in military populations remains unknown. Several US reports suggest the true incidence of MSK-I is even higher than reported. In some settings, at least half of all MSK-I sustained by US service members have gone unreported to medical providers,14 15 a phenomenon also noted in UK personnel.13

In response to the high burden of MSK-I,1 2 16 MSK-I mitigation and prevention programmes (MSK-IMPP) have been developed and studied across different global militaries and within different military arms and branches.17–20 MSK-IMPPs have focused on various strategies to mitigate injury risk, including embedding medical assets,21 modifying physical training programming (eg, decreasing running mileage),22 neuromuscular warm-ups,23 bracing and equipment,24 nutritional interventions and dietary supplementation.25 26 Although several MSK-IMPPs have demonstrated success at reducing injuries,21 27 28 a recent systematic review revealed that some programmes increased injury rates compared with control groups.29 Reported reasons for varied effectiveness across military studies are numerous. First, conducting research in military environments is difficult due to large populations with heterogenous backgrounds and responsibilities (eg, services with different priorities and focuses; large variations in occupational demands), coupled with time/resource constraints resulting in insufficient prioritisation of MSK-IMPPs. Additionally, MSK-IMPPs are often subgroup-specific and have primarily been designed, implemented and evaluated in western military populations, limiting their international scalability and generalisability.24 30 31 Comparing military MSK-IMPP effectiveness across studies is also challenging, as the methodology to measure outcomes varies.30 32 Importantly, even programmes with documented success in reducing injuries cannot always be well-implemented, hindering their long-term effectiveness.

Feasibility of implementation, including the translating and executing intervention components in real-world practice, can facilitate or impede MSK-IMPP adoption. Findings from injury prevention studies conducted in sport settings have cited implementation barriers (eg, cost, resources, knowledge, self-efficacy) to the adoption and scalability of MSK-IMPPs, and implementation fidelity (eg, programme adherence) as specifically influencing programme outcomes.33–36 Known barriers to implementing and adopting military MSK-IMPPs include leadership priorities not aligning with programme implementation, competing time and resource demands specific to training or missions, accommodating large populations, unpredictable schedules and operational demands.6 30 37 However, detailed descriptions of barriers and facilitators to military MSK-IMPP implementation, adoption and fidelity have not been adequately and systematically summarised.

In 2022, an international expert panel convened to identify and address barriers concerning implementation and scalability of military MSK-IMPPs. The expert panel first conducted the scoping review of the MSK-I prevention literature presented here to synthesise current knowledge about military MSK-IMPP implementation. Additional aims included identifying gaps in military MSK-IMPP research and identifying future research priorities for MSK-I mitigation in military settings. The panel’s conclusions will inform military leaders, policymakers, human performance teams, clinicians and researchers about knowledge gaps limiting MSK-IMPP development and implementation. This should promote greater MSK-IMPP effectiveness and a healthier, fitter fighting force.


Scoping review panel formation

A 15-person panel consisting of active-duty service members, veterans, military leaders, medical professionals (athletic trainers, physicians and physiotherapists), epidemiologists, researchers and exercise physiologists working in US and UK military settings with experience in policy, execution or investigation of military MSK-IMPPs were included in the research question development. A group subset led the planning and execution of the scoping review and met virtually to develop the search strategy, deliver training for a consistent review process, review preliminary results and interpret findings, review manuscript drafts and plan for dissemination of findings.

Study design

A scoping review was deemed most appropriate to address the research question; scoping reviews are broad in nature and designed to describe all available evidence, capturing findings from all possible sources.38–40 Best practice methods were used for the scoping review’s design and implementation38–41; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews was followed when reporting the results.42 A five-stage process was performed: identify the research question; identify relevant studies; select articles using a priori inclusion/exclusion criteria; chart data and collate, summarise and report results.39–41 The current study protocol was developed and uploaded a priori on Open Science Framework (

Stage 1: identify the research question

The research question, developed through a combination of literature searches and research panel group discussion, was ‘What are the barriers and facilitators to implementing and scaling military MSK-IMPPs?’ An MSK-IMPP was defined as any intervention or measure that was introduced to help reduce the risk of sustaining an MSK-I.44 45 Implementation could include the insertion, adoption (ie, use) and/or assessment of an MSK-IMPP and/or its fidelity. MSK-I was defined using the Defense Centers for Public Health-Aberdeen (DCPH-A) injury taxonomy definition of mechanical energy injury: ‘damage of or interruption to the normal functioning of body tissues that results when mechanical energy transfer exposure exceeds the threshold of tissue tolerance either suddenly (acute traumatic injury) or gradually (cumulative microtraumatic injury)’. 46 While the UK adopts the international codes for injury reporting, a similar taxonomy was not available. Thus, the US definitions were used. Within the DCPH-A taxonomy, mechanical injury is delineated into musculoskeletal and non-musculoskeletal; only MSK-I were investigated in the current review.46

Stage 2: identify relevant studies

A preliminary search was conducted of the major clinical and grey literature databases to evaluate literature density and identify keywords.39–41 Databases included MEDLINE and the Defense Technical Information Center (DTIC). Exploratory search terms were kept broad, to maximise inclusivity.41 Search terms included ‘military’, ‘injury prevention’, ‘barriers’, ‘facilitators’ and ‘review’. Sixty-six articles were identified as pertinent from MEDLINE and DTIC. The references of these 66 articles were then searched for further relevant articles, with none identified in this preliminary search. Titles and abstracts of these 66 articles were then analysed for relevant search terms. From this process, the final search strategy was created to cast a broad net ensuring greatest inclusion while excluding specific irrelevant studies identified through the preliminary search. A medical librarian (RA) assisted in creating the final search strategy for each database and compiled the final search results.

Search strategy

Five databases (MEDLINE, CINAHL, Embase, Cochrane Library and Web of Science) were electronically searched. DTIC was searched for grey literature. The search was performed on 21 April 2022 (search terms available in online supplemental appendix SA.1).

Supplemental material

Stage 3: study selection

The research team was divided into eight pairs to screen articles for eligibility. All screeners attended a training session to review specific inclusion and exclusion criteria (online supplemental appendix SA.2). Following training, a priori selection of titles and associated abstracts were randomly assigned in equal numbers to the screening pairs for eligibility screening. The same screening pairs then obtained and screened all full-text articles deemed eligible per title and abstract screening.41 Each screening pair resolved title, abstract and full-text article, handling disputes by consensus. If consensus could not be reached, the lead author (GSB) provided final resolution after consensus with panel members if necessary. Full-text articles were obtained through university online library or interlibrary loans. If necessary, the authors were contacted to request full text. If a full-text article could not be retrieved, the article was excluded from the review (including conference abstracts without a corresponding full-text report). Multiple manuscripts describing the same study (eg, secondary analyses) were all included as reports about barriers and facilitators could vary. All screening was performed using the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia).

Stage 4: data extraction

Data were extracted from full-text articles by the screening pairs and entered into a customised electronic database, abiding by recommended practice guidelines.47 The customised electronic database was based on the National Institute for Health and Care Excellence evidence tables.48 Each screening pair member independently extracted data. Screening pairs resolved discrepancies by consensus. The lead author (GSB) settled unresolved discrepancies. Data extracted included author, title, publication year, journal, country of origin, military branch, study design, level of prevention (primary, secondary), prevention programme description, body part(s) or segment(s) targeted by the MSK-IMPP, implementation barriers, implementation facilitators, fidelity, injury mitigation results and recommended injury mitigation/prevention strategies (systematic/scoping reviews only). Extracted data were uploaded into the Open Science Framework.43

Stage 5: collating, summarising and reporting the results

Data and key findings were initially collated and summarised for descriptive analysis (GSB), with themes and categories finalised after group discussion and consensus. There was no minimum number of articles necessary to specify a theme. Individual article data were meta-aggregated to explore reported barriers and facilitators for implementing military MSK-IMPPs, which were then reviewed for final analysis and interpretation (GSB, CED, EAR, NA, JLF, DIR, SJdlD). Publication rates by year were also calculated, using R V.4.02.49 The dplyr package was used for cleaning, coding and analyses. The ggplot2 package was used for data visualisation.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.


Study characteristics

A total of 7835 titles and abstracts were screened, with 132 total articles included (figure 1). Study characteristics are summarised in online supplemental appendix SA.3. After only 11 relevant studies published up through 1994, a steady increase in publications began with the greatest 5-year publication rate between 2000 and 2004 (29 studies; 22.0%), followed by 2010–2014 (27 studies, 20.5%; figure 2). Of the 132 articles, 49.2% (n=65) addressed US military populations. Most articles (n=76; 57.6%) investigated Army populations. Most articles used a primary study design (n=90; 68.2%), primarily randomised controlled trials (n=49; 54.4% of primary design studies). The remaining 42 (31.8%) articles used a secondary study design (eg, review paper). Among articles using a primary study design, 62 (68.9%) included only men, 3 (3.3%) included only women and 25 (27.8%) included men and women.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. CINAHL, Cumulated Index to Nursing and Allied Health Literature; DTIC, Defense Technical Information Center; MEDLINE, US National Library of Medicine bibliographic database.

Figure 2

Publication rates by 5-year period and military branch.

MSK-IMPP types

The types of interventions delivered in MSK-IMPPs described in primary research studies could be grouped into 10 categories (studies with the intervention out of total n=90): education (n=5; 5.5%), embedding medical personnel (n=1; 1.1%), equipment (n=33; 36.7%), adding an exercise intervention (n=25; 27.8%), data-driven approach (n=1; 1.1%), modifying existing physical training (n=13; 14.4%), nutrition/supplementation (n=3; 3.3%), pharmacological (n=1; 1.1%), postinjury treatment/rehabilitation (n=1; 1.1%) and pretraining injury symptom screening and referral (n=1; 1.1%). Six studies (6.7%) implemented multiple interventions.

Barriers to successful MSK-IMPP implementation

Reported barriers were categorised into four common themes: lack of stakeholder engagement, limited resources, competing military priorities and equipment-related factors (table 1). These themes are not mutually exclusive; some barriers were categorised into multiple themes. Examples to illustrate each theme are presented in the ‘Discussion’ section.

Table 1

Barriers and facilitators to implementation themes from MSK-IMPP by study

Facilitators of successful MSK-IMPP implementation

Reported facilitators were grouped into six themes: strong stakeholder engagement, targeted design of MSK-IMPP, involvement/proximity of experts, providing injury mitigation education, low burden and emphasising end-user acceptability (table 1). Like the barriers, some facilitators fell under multiple themes. Examples to illustrate each theme are presented in the ‘Discussion’ section.


This review identified 132 articles forming the current knowledge base about military MSK-IMPP implementation. A structured analysis of the results from the review identified four common barrier and six common facilitator themes affecting implementation. The results highlight relevant knowledge and translation gaps and underscore future research priorities.

Implementation barriers

MSK-IMPP implementation barriers were summarised by four themes. These barriers impeded military MSK-IMPP implementation, even if the programmes effectively reduced injuries.

Lack of stakeholder/end-user engagement

MSK-IMPP implementation may be hindered by insufficient engagement with and/or from stakeholders, including leaders responsible for programme implementation and programme end-users. It can be challenging to convince leadership about the benefits of MSK-IMPPs to the extent necessary to change current training routines and protocols merely to implement MSK-IMPPs. One report noted resistance among supervisors to adhere to the MSK-IMPP being implemented in the organisation.50 Drill sergeants leading physical training disregarded MSK-IMPP training guidance as ‘merely a suggestion’, leading to programme non-adherence. The authors also noted deeply held cultural beliefs among supervisors about the type and volume of training (eg, long distance runs) necessary to prepare for military physical fitness testing. Some of these beliefs did not align with MSK-IMPP’s training principles.50 This highlights how conflicting beliefs and practices between MSK-IMPP designers and those responsible for implementing the programme may decrease fidelity and compromise implementation.

Successful MSK-IMPP implementation also relies on end-user adherence (eg, exercise programming participation, taking recommended nutritional supplements, using recommended equipment). Partial or non-adherence poses a barrier to implementation. For example, in a programme requiring participants to take supplements to mitigate MSK-I (eg, calcium or vitamin D), some participants did not reliably take the supplements.25 26 MSK-IMPP implementation may also be compromised due to changes in military training schedules, as seen in a study assessing the effect of hamstring stretching on lower extremity injuries. In one MSK-IMPP, compliance with the recommended hamstring stretching intervention was limited while trainees underwent multiday field training exercises.27

Limited resources

Limited financial, time and personnel resources may serve as barriers to military MSK-IMPP implementation. Limited financial resources can constrain implementation of equipment-related programmes, such as those using orthoses, shoe insoles and ankle braces.24 51–54 Despite low cost of many equipment-related programmes24 51–54 and a significant reduction of back and lower extremity injuries during a trial testing custom foot orthoses across 3 months of military training in Denmark, the high cost of the orthoses made the intervention infeasible beyond the confines of the research study.51

Limited time resources can also be a barrier, especially when military training schedules are already constrained. When implementing an exercise intervention during military training, there may be insufficient time during the training course to accommodate a recommended gradual increase in exercise volume and/or intensity or appropriate surveillance time to evaluate effectiveness.23 55 Limited time is also reflected in the ‘competing military priorities’ barrier, described in detail in the next immediate section.

Limited personnel resources may also serve as a barrier to implementation. For certain interventions, personnel must be adequately educated and trained to conduct or supervise the programme. However, trained individuals may not be available to ensure the programme is properly performed.50 56–58 In a study assessing the ability of a screening tool and referral process to reduce MSK-I during advanced training, a noted limitation was reliance on drill sergeants’ abilities to assess whether a soldier had an injury and refer them appropriately. This may have been impacted by the drill sergeants’ inexperience and lack of training in identifying injuries.56 Other investigators noted the importance of adequate programme oversight to ensure fidelity of the intervention.58 High turnover among training cadre, supervisory or leadership personnel can also pose a barrier, as awareness of the MSK-IMPP or the ability to adequately facilitate programme implementation may disappear when personnel familiar with the programme leave the organisation.50 Successful implementation of any MSK-IMPP will require resources in some capacity, the absence of which may impede implementation, regardless of demonstrated programme efficacy.

Competing military priorities

High priority duty requirements, tightly controlled training schedules and varying routines based on current operations serve as competing demands, potentially disrupting MSK-IMPP implementation. Competing demands can limit consistent exercise programming implementation; highlighting time as a limited resource.59 60 Physical training sessions as part of an MSK-IMPP for Canadian Infantry trainees were sometimes ‘unexpectedly replaced with prioritised (military) training’ or supplanted by frequent ‘unscheduled tasking requests’, highlighting how MSK-IMPPs can be deprioritised for other activities.60 Similarly, researchers studying a strengthening programme to reduce neck pain in Air Force pilots reported that although the intervention was to be performed three times weekly, competing training requirements resulted in most participants performing the intervention less than twice weekly.59

Many military training courses have rigorous schedules which significantly alter an individual’s availability; this may interfere with performing MSK-IMPP interventions. Decreased adherence to MSK-IMPP during field training may be due to lack of end-user buy-in and/or competing military field training demands on service members’ time.27

Lack of stakeholder engagement can also manifest as competing or conflicting military priorities. As previously noted in one report, supervisors’ beliefs about the type and volume of training (eg, long distance runs) necessary to prepare for military physical fitness testing conflicted with their MSK-IMPP’s training guidance.50 The supervisors were evaluated on their trainees’ physical fitness test performances, but not on their adherence to the MSK-IMPP. Supervisors were thus reluctant to alter their traditional physical training practices. Their competing or conflicting priorities (fitness test performance vs MSK-IMPP adherence) compromised MSK-IMPP implementation.50

Equipment-related factors

Besides high equipment costs, equipment-related discomfort, lack of trust in the equipment or equipment compromising military task performance can also pose as barriers. Several studies noted non-adherence with MSK-IMPP equipment wear/use due to discomfort.61–67 One study investigated foot orthoses worn by Royal Australian Air Force Recruits; half of the participants failed to wear the orthoses as directed due to discomfort, the orthoses fitting poorly in recruits’ footwear, cumbersomeness of use, burden of switching orthoses among multiple pairs of shoes and perception that the orthoses would not help or might even cause injury.61 In another study, the single available shoe width accommodated only 50% or less of the recruits. Consequently, recruits with wider feet compensated for the lack of available shoe widths by choosing larger shoe sizes. Three shoe widths for each shoe length are recommended to adequately accommodate the population.68

Perceptions that MSK-IMPP equipment interfered with military tasks also impacted use. When testing parachuting ankle braces, some Army airborne students reported poorly fitting braces slipping off their heels and hindering walking. Two students attributed brace use to causing injuries during parachute landing falls.65 Sustained MSK-IMPP implementation will likely fail if perceived harm or risk outweighs perceived benefits.

Implementation facilitators

MSK-IMPP implementation facilitators were summarised into six themes that could potentially improve programme effectiveness. Some facilitators can even help overcome barriers, demonstrating the need for careful evaluation, and understanding of which barriers might be mitigated with certain facilitators.

Strong stakeholder engagement

Engaging stakeholders throughout the implementation process can facilitate programme adoption and fidelity. Intuitively, while lack of stakeholder engagement was a noted barrier, strong stakeholder engagement was as a facilitator to MSK-IMPP implementation, with studies noting that leadership buy-in and support were key to successful implementation.50 69 70 Leadership buy-in and support can have a top-down effect, leading to end-user engagement that facilitates implementation. Leadership buy-in and support can also facilitate MSK-IMPP adherence; many researchers noted successful implementation when leaders enforced programme implementation as standard operating procedure and/or held subordinate leaders responsible for MSK-I rates or programme adherence.3 18 27 50 55 71–77

Collaborating with leadership and stakeholders before MSK-IMPP implementation can also facilitate success.60 78 79 A structured, collaborative process between programme designers and Canadian military training personnel included leadership, training, fitness and medical personnel while planning and designing a modified physical training programme.60 The authors emphasised early collaboration with relevant stakeholders to optimise potential for MSK-IMPP success.60 Pre-implementation collaboration enables those implementing the programme to proactively identify and mitigate potential barriers, and promote further leadership buy-in and support. Continued stakeholder engagement ensures consistent MSK-IMPP visibility from inception to implementation, subsequently improving adherence to programme guidelines and improving its effectiveness.58

Targeted design of MSK-IMPP

Military MSK-IMPP can be tailored to facilitate implementation by accounting for the military setting’s unique needs and constraints (eg, target population, environment) and pertinent timing for targeted prevention during programme design.18 80–84 Working with unit personnel to design the content of an educational guidebook about back safety for Finnish military conscripts improved the guidebook’s relevance to the conscripts,81 likely improving its adoption. Tailoring exercise programming to individual end-users was an important facilitator for MSK-IMPPs implementing exercise training interventions.59 Tailoring exercise programmes to groups of individuals with similar fitness levels (ie, streaming) was both recommended if individually tailored exercise programmes were infeasible.83 Collaborating with the organisation’s personnel facilitates programme implementation.18 20 23 27 85

In some cases, designing interventions led by existing military personnel, rather than requiring embedded subject matter experts, can improve MSK-IMPP practicality, adoption and scalability. Having committed instructors or unit leaders delivering and supporting the programme creates group accountability and buy-in to improve implementation.18 20 23 Several studies implemented MSK-IMPPs using ‘train-the-trainer’ models, where programme designers taught organisational personnel to administer the intervention. One study described a pilot phase after training the trainers, during which the trained drill sergeants conducted the exercise programming. Programme designers and the trained drill sergeants collaborated daily (including focus group sessions) during the pilot phase to modify the programme as necessary.80 This ensured a programme was tailored to the trainers’ and specific service members’ needs, further facilitating implementation. Accounting for end-user characteristics and their operational environment enables targeted programme designs having better chances of success versus ‘one-size-fits-all’ solutions.

Involvement/Proximity of MSK-I experts

Involvement and/or proximity of experts can facilitate MSK-IMPP implementation in multiple ways. Ensuring end-users’ proximity and/or access to embedded medical providers or other relevant experts (eg, human performance coaching staff) has improved programme adoption by end-users.16 21 86 87 Unit personnel familiarity with embedded medical staff increased their interactions and acceptance of the MSK-IMPP interventions.86 87 Embedding medical providers and human performance professionals in multidisciplinary care teams can foster collaboration with unit staff, creating a team approach to facilitate programme implementation.16 21 87 Having subject matter experts (eg, athletic trainers and physiotherapists) provide end-users with ongoing, performance-related feedback may facilitate programme implementation, adherence and fidelity.25 54 59 88–92 Having organisational personnel implement MSK-IMPPs (eg, via train-the-trainer model) can also facilitate implementation, but continued involvement of experts is recommended to maintain programme fidelity. Ongoing collaboration between subject matter experts and organisational personnel optimises MSK-IMPP adoption, adherence and fidelity.

Providing MSK-I mitigation education

Incorporating MSK-I mitigation education into MSK-IMPPs may improve stakeholders’ understanding of the programme’s importance.58 93 94 Providing leadership with education and prevention recommendations led to senior leaders acknowledging the need to proactively reduce overuse injuries.58 Subject matter experts (eg, athletic trainers, health coaches, physiotherapists) can provide stakeholders with timely, relevant updates about injury rates and/or high-risk activities. Injury advisory committees can increase collaboration between experts and organisational members.50 93 95 Informing stakeholders about their MSK-I burden can improve recognition of the need for MSK-IMPPs, increase buy-in and foster an environment supporting implementation efforts. Educational materials (eg, posters, training cards, websites) can facilitate adherence through visual reminders, and optimise fidelity through accurate MSK-IMPP delivery and performance.20 23 96

Low burden on resources

MSK-IMPPs must compete with multiple organisational demands for prioritisation of effort. The primary goal of ‘mission readiness’ may require diverting resources, (eg, finances, time, personnel) from these programmes. MSK-IMPPs that minimise resources and burden on stakeholders have greater likelihood of adoption. Low intervention cost and end-user burden (eg, minimal time commitment) facilitate MSK-IMPP implementation.25 26 97 Integrating MSK-IMPP into existing training facilitates adoption and adherence.23 25 27 98 99 MSK-IMPP education easily taught (by experts or organisational personnel) in a short period of time can also facilitate programme adoption.23 98 100 This was demonstrated in a course taught for only 2 hours to the Danish Army Sergeants who led the programme.23 MSK-IMPPs that contain exercise interventions with low technical demands (eg, body weight-resisted exercises vs specialised equipment requirements) more easily integrate into group settings (eg, basic military training), and can be scaled for varying fitness levels. For example, adherence was improved when an exercise intervention relied only on body weight resistance rather than weights or other exercise equipment.72 Stakeholders are more likely to adopt and adhere to programmes that are perceived to be a low burden.

Emphasising end-user acceptability

MSK-IMPP can only be effective when accepted and used by those they are designed for—that is, the end-user. Educating end-users on the importance and effectiveness of MSK-IMPP, how specific interventions can lead to that end state and soliciting and incorporating feedback from end-users can improve MSK-IMPP acceptance and implementation. End-users in several studies reported that MSK-IMPPs improved their performance on military duties or tasks, likely contributing to programme adherence.23 67 101 When modifying physical training to reduce pelvic stress fracture risk in female Australian Army recruits, training instructors perceived the programme to help achieve training objectives by reducing recruit injuries and fatigue.101 Several studies noted improvements in physical performance measured via methods such as the Cooper test, broad jump distance, shuttle run or sprint times.23 67 In addition to educating end-users on a programme’s positive impact on unit training objectives, this impact can also increase leadership support, acting as a positive feedback loop.

Equipment-based MSK-IMPPs must gain end-user acceptance for the equipment to be worn or used. Some participants reported a greater feeling of safety and confidence when wearing a knee brace after anterior cruciate ligament reconstruction; this may have improved adherence to the equipment intervention.102 Equipment that is comfortable to wear or use (eg, foot orthoses or shoe inserts) likely facilitates implementation.91 103 End-user acceptability of MSKI-MPPs can be measured, understood and where indicated, implementation of MSKI-MPPs can be adjusted; in these studies, methods for obtaining user feedback and measuring acceptability included questionnaires,91 102 informal conversations,101 visual analogue scales for assessing comfort.103 Successful MSK-IMPP implementation and adherence rely heavily on end-user acceptance; acceptance often depends on the intervention’s perceived impact on military task performance, comfort and/or safety.

Identified gaps and research priorities for MSK-IMPP in the military

Research gaps that should be prioritised in future research are highlighted in table 2. Specific outcomes regarding MSK-IMPP implementation should be evaluated and reported by systematically assessing the implementation context and using implementation frameworks when designing and delivering military MSK-IMPPs (eg, Translating Research into Injury Prevention Practice framework,104 Reach, Effectiveness, Adoption, Implementation and Maintenance planning and evaluation framework,105 106 Standards for Reporting Implementation studies statement107 and Consolidated Framework for Implementation Research).108 From an implementation science perspective, implementation outcomes include factors such as fidelity, maintenance and scalability (table 3).

Table 2

Identified research gaps for implementation of military injury mitigation and prevention programmes

Table 3

Key implementation outcomes to evaluate and report


Although the literature search was exhaustive, only articles in English were included. This limited the geographical spread of the data evaluated. Articles could have potentially been missed due to using different keywords, grey literature search or manuscript access. Most studies reported findings in North America, Western Europe or Australasia. Including non-English studies would have likely resulted in more diverse representation. Risk of bias was not formally assessed for each individual study. There was heterogeneity in the settings where the studies took place, even within the same countries, and the barriers and facilitators to MSK-IMPP implementation are likely more relevant to some settings than others.


This scoping review identified a variety of barriers and facilitators to military MSK-IMPP implementation. Barriers included lack of stakeholder engagement, limited resources, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted MSK-IMPP design, involvement/proximity of MSK-I mitigation/prevention experts, providing mitigation education, low burden and end-user acceptability. MSK-IMPP implementation context, strategy and/or outcomes were not often formally evaluated or reported; MSK-I outcomes varied widely across all studies. Future MSK-IMPP research should systematically evaluate84 and formally report details about implementation context (including barriers, facilitators and implementation strategies). Reporting both implementation outcomes and effectiveness outcomes will improve MSK-I mitigation and prevention efforts in the military.

Data availability statement

Data are available in a public, open access repository. All raw extracted data are available on the Open Science Framework:

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.


Supplementary materials

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  • SJdlM and DIR are joint senior authors.

  • Twitter @DrGSBullock, @NavyPT, @sarahdlm, @danrhon

  • SJdlM and DIR contributed equally.

  • Contributors DIR, GSB, NA, DST, JLF and SJdlM derived the initial study concept. GSB drafted the initial protocol draft. GSB, SJdlM, CED, EAR and RJA conducted the literature search. CWD, EAR, JJF, DC, KD, JJF, CG, TAG, AG, TG, JL, JMM, KFN, J-GP, AR, KS, MS and DIR screened abstracts, reviewed full-text articles and extracted data. GSB synthesised results and created first draft of themes. GSB, CED, EAR, SJdlM and DIR finalised themes and helped interpret the data. GSC and NA provided supervision. GSB, CED, EAR, SJdlM and DIR created the initial draft of the manuscript. All authors reviewed and contributed to the draft and approved the final manuscript. DIR is the guarantor of the study, taking full responsibility for the work, conduct of the study, had full access to the data and controlled the decisions for publication.

  • Funding This research was supported in part by the Uniformed Services University, Department of Physical Medicine & Rehabilitation, Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR HU00011920011).

  • Disclaimer The view(s) expressed here are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University, the US Department of the Army, the US Department of the Navy, the US Defense Health Agency, the US Department of Defense, the UK Department of Defense or the US or the UK Governments. Some authors are military service members or employees of the US Government, and this work was prepared as part of their official duties. Title 17, USC, §105 provides that ‘Copyright protection under this title is not available for any work of the US Government’. Title 17, USC, §101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person's official duties. Mention of trade names, commercial products or organisations does not imply endorsement by the US Government. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of The Henry M Jackson Foundation for the Advancement of Military Medicine.

  • Competing interests NA reports grants from Centre for Sport, Exercise & Osteoarthritis Research Versus Arthritis, outside of the submitted work. SdlM reports grants from the Congressionally Directed Medical Research Programme and the Veterans Affairs/Department of Defense Health Affairs Joint Incentive Fund, outside of the submitted work. JJF reports grants from Congressionally Directed Medical Research Programme and the Office of Naval Research, outside of the submitted work. In addition, JJF has a patent pending for an Adaptive and Variable Stiffness Ankle Brace, US Provisional Patent Application No. 63254,474. AR reports grants from the Concussion in Sport Group, Alberta Bone and Joint Strategic Clinical Network, Tonal Strength Institute, outside of the submitted work. DIR reports grants from the Congressionally Directed Medical Research Programme and the National Institutes of Health, outside of the submitted work, and grant support for the submitted work from the Uniformed Services University, Department of Physical Medicine & Rehabilitation, Musculoskeletal Injury Rehabilitation Research for Operational Readiness programme (MIRROR HU00011920011).

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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