Influence of Rehabilitation After Ankle Injuries in Active Duty Service Members: The Impact of Timing and Dosing on Downstream Healthcare Utilization Costs

The number one physical health condition affecting US military Service members is neuromusculoskeletal (NMSK) injuries. At the end of fiscal year 2014, 26% of Service members were not fully medically ready to deploy. Musculoskeletal injuries plague the Military Health System (MHS), affect return to duty, and are a primary source of disability in the U.S. Military. In 1 year, musculoskeletal injuries resulted in approximately 2.4 million medical visits to military treatment facilities and accounted for $548 million dollars in direct patient care costs. This translates into over 25 million limited-duty days and over 900,000 Service members affected each year. Foot and ankle injuries ranked third in contributing to Global Burden of Disease for lost work time of US Armed Forces in 2002, following closely behind back/abdomen and knee injuries. In 2009, foot and ankle injuries were the fourth most unfitting condition in terms of frequency of occurrence, and the lower extremity is the most common site for musculoskeletal injury sustained by Army trainees. When looking at U.S. Army Service members only, the incidence rate of ankle sprains is almost double that of civilian counterparts.

While an abundance of research describing the high rates of injury to military Service members is present and has been accumulating over the last few decades, there are still many things left unknown about the nature of these injuries. This makes it difficult to come up with and test appropriate interventions. Most of the data provides primarily frequency and count data (incidence ratios, etc.), stratified by various demographic variables (sex, age, race, and enlisted/officer status). This information is extremely helpful for informing that a problem exists, but very limited in its ability to describe the nature of the problem beyond demographic variables which are for the most part non-modifiable. There is no information about the severity of injuries or healthcare management pathway associated with various types of injuries. These additional variables are necessary to provide a more informed assessment of how rehabilitation may influence outcomes following a NMSK injury. Much of this needed data is already currently collected from consultations and medical care visits within the MHS, but has not been evaluated in depth.

The overall objective of this project is to (1) organize ankle injuries by various severity classifications (not every ankle sprain is the same), (2) understand the role of rehabilitation on outcomes in individuals with ankle injuries (Is there a difference in those that receive rehabilitation after an injury compared to those that do not?) and to (3) investigate influential comorbidities (e.g., sleep, mental health, etc.) that might influence outcomes and prognosis, and therefore provide additional treatment targets to consider. At present, there is a very little information available in the medical literature that helps us understanding ankle injury types, predict which classifications lead to higher downstream costs, secondary health deficits, delayed return to duty and function. The role of formalized rehabilitation on outcomes has only been investigated in small trials and the influence of management through physical rehabilitation within a system remains uninvestigated. The value of this project is that we can assess these variables in thousands of Service members, looking at the care and management they actually received over a longer period of time. Results from our exploration will be used to better understand the role of rehabilitation, comorbidities, and the severity of the condition on outcomes such as downstream costs, secondary health deficits, and utilization. The information will be used to design well-informed prospective trials that assess dose, timing, and impact of rehabilitation on long-term disability and healthcare utilization within the MHS. It will also be used to improve our clinical practice guidelines and learn how we can improve delivery of care within the MHS.

The project should be complete within 18 months, from all the regulatory requirements, through data abstraction, cleaning, coding, and analysis of final results. This is a relatively short time frame from which to produce robust findings immediately impactful to clinical practice.