Original research| Volume 99, ISSUE 2, P348-354.e1, February 2018

Incidence of Overuse Musculoskeletal Injuries in Military Service Members With Traumatic Lower Limb Amputation

Published:October 31, 2017DOI:



      To describe the incidence of overuse musculoskeletal injuries in service members with combat-related lower limb amputation.


      Retrospective cohort study.


      Military treatment facilities.


      Service members with deployment-related lower limb injury (N=791): 496 with a major lower limb amputation and 295 with a mild lower limb injury.


      Not applicable.

      Main Outcome Measures

      The outcomes of interest were clinical diagnosis codes (International Classification of Diseases–9th Revision) associated with musculoskeletal overuse injuries of the lumbar spine, upper limb, and lower limb regions 1 year before and 1 year after injury.


      The overall incidence of developing at least 1 musculoskeletal overuse injury within the first year after lower limb amputation was between 59% and 68%. Service members with unilateral lower limb amputation were almost twice as likely to develop an overuse lower or upper limb injury than those with mild combat-related injury. Additionally, service members with bilateral lower limb amputation were more than twice as likely to develop a lumbar spine injury and 4 times more likely to develop an upper limb overuse injury within the first year after amputation than those with mild combat-related injury.


      Incidence of secondary overuse musculoskeletal injury is elevated in service members with lower limb amputation and warrants focused research efforts toward developing preventive interventions.


      List of abbreviations:

      AIS (Abbreviated Injury Scale), ICD-9 (International Classification of Diseases–9th Revision), ISS (Injury Severity Score)
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        • Rábago C.A.
        • Wilken J.M.
        • Hill O.T.
        • et al.
        The extremity trauma and amputation center of excellence: overview of the research and surveillance division.
        Mil Med. 2016; 181: 3-12
        • Dougherty A.L.
        • Mohrle C.R.
        • Galarneau M.R.
        • Woodruff S.I.
        • Dye J.L.
        • Quinn K.H.
        Battlefield extremity injuries in operation Iraqi Freedom.
        Injury. 2009; 40: 772-777
        • Owens B.D.
        • Kragh Jr., J.F.
        • Macaitis J.
        • Svoboda S.J.
        • Wenke J.C.
        Characterization of extremity wounds in operation Iraqi freedom and operation enduring freedom.
        J Orthop Trauma. 2007; 21: 254-257
        • Pasquina P.F.
        • Fitzpatrick K.F.
        The Walter Reed experience: current issues in the care of the traumatic amputee.
        J Prosthet Orthot. 2006; 18: P119-P122
        • Gajewski D.
        • Granville R.
        The United States armed forces amputee patient care program.
        J Am Acad Orthop Surg. 2006; 14: S183-S187
        • Krueger C.A.
        • Wenke J.C.
        • Ficke J.R.
        Ten years at war: comprehensive analysis of amputation trends.
        J Trauma Acute Care Surg. 2012; 73: S438-S444
        • Morgenroth D.C.
        • Gellhorn A.C.
        • Suri P.
        Osteoarthritis in the disabled population: a mechanical perspective.
        Phys Med Rehabil. 2012; 4: S20-S27
        • Dougherty P.J.
        Transtibial amputees from the Vietnam War.
        J Bone Joint Surg Am. 2001; 83: 383
        • Dougherty P.J.
        Long-term follow-up of unilateral transfemoral amputees from the Vietnam war.
        J Trauma Acute Care Surg. 2003; 54: 718-723
        • Smith D.G.
        • Ehde D.M.
        • Legro M.W.
        • Reiber G.E.
        • del Aguila M.
        • Boone D.A.
        Phantom limb, residual limb, and back pain after lower extremity amputations.
        Clin Orthop Relat Res. 1999; : 29-38
        • Kušljugić A.
        • Kapidžić-Duraković S.
        • Kudumović Z.
        • Čičkušić A.
        Chronic low back pain in individuals with lower-limb amputation.
        Bosn J Basic Med Sci. 2006; 6: 67-70
        • Ehde D.M.
        • Smith D.G.
        • Czerniecki J.M.
        • Campbell K.M.
        • Malchow D.M.
        • Robinson R.L.
        Back pain as a secondary disability in persons with lower limb amputations.
        Arch Phys Med Rehabil. 2001; 82: 731-734
        • Hammarlund C.S.
        • Carlstrom M.
        • Melchior R.
        • Persson B.M.
        Prevalence of back pain, its effect on functional ability and health-related quality of life in lower limb amputees secondary to trauma or tumour: a comparison across three levels of amputation.
        Prosthet Orthot Int. 2011; 35: 97-105
        • Foote C.E.
        • Kinnon J.M.
        • Robbins C.
        • Pessagno R.
        • Portner M.D.
        Long-term health and quality of life experiences of Vietnam veterans with combat-related limb loss.
        Qual Life Res. 2015; 24: 2853-2861
        • Ephraim P.L.
        • Wegener S.T.
        • MacKenzie E.J.
        • Dillingham T.R.
        • Pezzin L.E.
        Phantom pain, residual limb pain, and back pain in amputees: results of a national survey.
        Arch Phys Med Rehabil. 2005; 86: 1910-1919
        • Kulkarni J.
        • Gaine W.J.
        • Buckley J.G.
        • Rankine J.J.
        • Adams J.
        Chronic low back pain in traumatic lower limb amputees.
        Clin Rehabil. 2005; 19: 81-86
        • Ebrahimzadeh M.H.
        • Fattahi A.S.
        Long-term clinical outcomes of Iranian veterans with unilateral transfemoral amputation.
        Disabil Rehabil. 2009; 31: 1873-1877
        • Ebrahimzadeh M.H.
        • Hariri S.
        Long-term outcomes of unilateral transtibial amputations.
        Mil Med. 2009; 174: 593-597
        • Norvell D.C.
        • Czerniecki J.M.
        • Reiber G.E.
        • Maynard C.
        • Pecoraro J.A.
        • Weiss N.S.
        The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees.
        Arch Phys Med Rehabil. 2005; 86: 487-493
        • Lemaire E.D.
        • Fisher F.R.
        Osteoarthritis and elderly amputee gait.
        Arch Phys Med Rehabil. 1994; 75: 1094-1099
        • Melzer I.
        • Yekutiel M.
        • Sukenik S.
        Comparative study of osteoarthritis of the contralateral knee joint of male amputees who do and do not play volleyball.
        J Rheumatol. 2001; 28: 169-172
        • Mussman M.
        • Altwerger W.
        • Eisenstein J.
        • Turturro A.
        • Glockenberg A.
        • Bubbers L.
        Contralateral lower extremity evaluation with a lower limb prosthesis.
        Am Podiatr Med Assoc. 1983; 73: 344-346
        • Kulkarni J.
        • Adams J.
        • Thomas E.
        • Silman A.
        Association between amputation, arthritis and osteopenia in British male war veterans with major lower limb amputations.
        Clin Rehabil. 1998; 12: 348-353
        • Struyf P.A.
        • van Heugten C.M.
        • Hitters M.W.
        • Smeets R.J.
        The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees.
        Arch Phys Med Rehabil. 2009; 90: 440-446
        • Gennarelli T.A.
        • Wodzin E.
        AIS 2005: a contemporary injury scale.
        Injury. 2006; 37: 1083-1091
        • Baker S.P.
        • O'Neill B.
        • Haddon Jr., W.
        • Long W.B.
        The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.
        J Trauma Acute Care Surg. 1974; 14: 187-196
        • Hauret K.G.
        • Jones B.H.
        • Bullock S.H.
        • Canham-Chervak M.
        • Canada S.
        Musculoskeletal injuries: description of an under-recognized injury problem among military personnel.
        Am J Prev Med. 2010; 38: S61-S70
        • Silverman A.K.
        • Neptune R.R.
        Three-dimensional knee joint contact forces during walking in unilateral transtibial amputees.
        J Biomech. 2014; 47: 2556-2562
        • Miller R.H.
        • Krupenevich R.L.
        • Pruziner A.L.
        • Wolf E.J.
        • Schnall B.L.
        Medial knee joint contact force in the intact limb during walking in recently ambulatory service members with unilateral limb loss: a cross-sectional study.
        PeerJ. 2017; 5: e2960
        • Farrokhi S.
        • Yoder A.
        • Grant K.
        • Mazzone B.
        • Wyatt M.
        A narrative review of the prevalence and risk factors associated with development of knee osteoarthritis after traumatic unilateral lower limb amputation.
        Mil Med. 2016; 181: 38-44
        • Mazzone B.N.
        • Eskridge S.L.
        • Shannon K.
        • Hill O.
        • Moore J.
        • Farrokhi S.
        Early physical therapy utilization patterns and incidence of secondary musculoskeletal conditions after lower limb amputation.
        J Orthop Sports Phys Ther. 2017; 47: A17
        • Sansam K.
        • Neumann V.
        • O'Connor R.
        • Bhakta B.
        Predicting walking ability following lower limb amputation: a systematic review of the literature.
        J Rehabil Med. 2009; 41: 593-603
        • Laferrier J.Z.
        • McFarland L.V.
        • Boninger M.L.
        • Cooper R.A.
        • Reiber G.E.
        Wheeled mobility: factors influencing mobility and assistive technology in veterans and servicemembers with major traumatic limb loss from Vietnam war and OIF/OEF conflicts.
        J Rehabil Res Dev. 2010; 47: 349
        • Curtis K.A.
        • Drysdale G.A.
        • Lanza R.D.
        • Kolber M.
        • Vitolo R.S.
        • West R.
        Shoulder pain in wheelchair users with tetraplegia and paraplegia.
        Arch Phys Med Rehabil. 1999; 80: 453-457
        • Dyson-Hudson T.A.
        • Kirshblum S.C.
        Shoulder pain in chronic spinal cord injury, part 1: epidemiology, etiology, and pathomechanics.
        J Spinal Cord Med. 2004; 27: 4-17
        • Gailey R.
        Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use.
        J Rehabil Res Dev. 2008; 45: 15
        • Devan H.
        • Carman A.B.
        • Hendrick P.A.
        • Ribeiro D.C.
        • Hale L.A.
        Perceptions of low back pain in people with lower limb amputation: a focus group study.
        Disabil Rehabil. 2015; 37: 873-883
        • Turner J.A.
        • Cardenas D.D.
        • Warms C.A.
        • McClellan C.B.
        Chronic pain associated with spinal cord injuries: a community survey.
        Arch Phys Med Rehabil. 2001; 82: 501-508