VERONIQUE HAUSCHILD, MPH
Directorate of Clinical Public Health and Epidemiology 
U.S. Army Public Health Center 
Aberdeen Proving Ground, Maryland

Over the past year, select units have piloted the new Army Combat Fitness Test. The test was designed to better assess Soldiers’ abilities to perform common tasks that reflect combat readiness through six events: the dead lift, standing power throw, hand-release push up, sprint-drag-carry, leg tuck hold and 2-mile run. This field-test period is the first phase of replacing the Army Physical Fitness Test, which has been in use since 1980. Several members in units testing the ACFT say it is more rigorous but better than the APFT. While studies are still underway, the Army’s transition to the ACFT is on the horizon. 

The ACFT will be conducted by all Soldiers Army-wide starting October 1, 2019. Soldiers will also conduct the APFT as the official test of record during a one-year transition until October 1, 2020. While some aspects of standards, training, and administration are being finalized, procedures and techniques are documented in Field Manual (FM) 7-22, Army Physical Readiness Training (PRT), 2012.

The ACFT and associated training requires Soldiers to use several parts of their bodies not previously addressed by the APFT. This supports a more holistic, balanced approach to Army physical readiness. While the ACFT is intended to improve Soldiers’ physical performance while reducing injuries in the long term, as with any new physical activity, it comes with new injury risks. 

Observations by Army experts suggest certain injuries may be anticipated (see Table 1 below). While the Army is sending out ACFT trainers to every unit to help train Soldiers, everyone should be aware of potential new problems and how to avoid them.

Why the change?
Leaders and Soldiers alike have long expressed concerns that the APFT doesn’t adequately measure abilities to perform common required tasks important during deployment. Not all aspects of the APFT are bad, however. Studies have demonstrated that the 2-mile run is an excellent way to test Soldiers’ cardiorespiratory endurance, also known as aerobic fitness. Aerobic capacity is linked to the performance of more military tasks than any other aspect of fitness. 

“Aerobic capacity is the most important measure of a Soldier’s fitness,” said Dr. Bruce Jones, a retired Army colonel and medical doctor with the U.S. Army Public Health Center. “And weight-bearing physical activities such as running or marching are inescapable routine military aerobic activities.” 

Jones further explained that, “Poor run times are not only associated with poor performance; they are associated with higher risk of injury.” So the 2-mile run time is a reliable way to monitor both aerobic fitness and injury risk. 

The push-up test is also linked to key military tasks and is a good measure of upper-body muscle endurance. However, evidence did not support the value of using the sit-up test to measure military task performance. 

An in-depth review of key fitness elements and their association with military tasks found that muscle strength and power are critical to military task performance, as are agility and speed. The APFT does not measure these key fitness elements. The ACFT will now ensure Soldiers’ combat readiness determinations include these additional fitness components.

ACFT injury risks
Historically, the majority of Soldiers’ injuries have occurred in the lower back and lower body, which includes the knee, lower leg, ankle and foot. Excessive physical training emphasis on distance running and long foot marches have been to blame. 

“While lower body injuries may be reduced with more cross-training, they are expected to remain a primary concern,” said Tyson Grier, an APHC kinesiologist. “Soldiers spend the majority of their time on their feet. Their lower body is constantly absorbing forces from carrying their body weight in addition to other loads.” 

The Army updated its training doctrine to the physical readiness training (PRT) program in 2012 to reduce lower body injuries. The PRT deemphasizes distance running and encourages a mix of training activities to promote strength, agility, balance and power. The program has been associated with a reduction of injuries in initial-entry training; however, Army operational units have not shown comparable trends in injury reduction. Since the APFT has continued to be the test of record, these units may not have fully embraced the PRT.

With the implementation of the ACFT, the Army will still monitor Soldiers’ aerobic fitness with the 2-mile run, but training time will also need to be devoted to a variety of other activities. The new tests are not risk-free, but the goal is to slowly build up the body’s ability to perform activities that might cause Soldier injuries on the job. While this is to enhance physical performance, Army experts recognize that the training for and conduct of the ACFT could also increase risk of injuries to the upper body, such as the back and spine, knee, shoulder and elbows. 

Some items used for the ACFT, such as the trap/hex bar for the deadlift, have been specifically selected to reduce injury risk. To avoid injuries caused by excessive weight lifts, the maximum weight for the deadlift was limited to 340 pounds, which is considered a moderate weight by serious lifters. Procedures are designed to avoid injury. For example, the grader must spot the Soldier during the leg tuck to reduce falling injury. A required warm up before the ACFT and a specific deadlift warm-up period will reduce injuries. Despite these efforts, there will be a learning curve.

“A primary reason for injury resulting from the new test and training activities will be due to improper form and technique,” Grier said. “These are new activities to learn. It is very important that Soldiers learn proper technique from the start and avoid developing bad habits.” 

Maj. Timothy Benedict, an Army physical therapist, added: “We also worry that ‘too much too soon’ will cause injuries. Some Soldiers will start this training by lifting too much weight, conducting too many repetitions or not allowing days of rest between sessions that stress specific muscles.” 

While only future surveillance of Soldiers’ injuries will be able to identify actual changes to the Army’s injury trends, a review of existing evidence suggests potential injury risks associated with the new tests and associated training. Table 1 highlights key injury concerns. 

Some injuries associated with the ACFT will be sudden acute injuries. Acute injuries are usually associated with sudden sharp pain and typically require immediate medical attention. These include strains or tears in arm, shoulder, chest or back muscles, torn knee ligaments, dislocated shoulders, herniated discs in the back, pinched nerves or fractured bones (such as from falling during the leg tuck). 

While these acute injuries can occur when Soldiers are conducting military tasks or other personal activities, specific training activities may raise the risk. For example, studies of both professional and amateur weightlifters and power lifters have indicated that use of extremely heavy weights during the dead left is associated with lower back disc herniation and knee injuries. On the other hand, some rehabilitation studies have suggested that using lighter weights during the dead lift may be useful to strengthen the back and knees. 

An acute tear of fatigued muscles and tendons in the chest, arm or shoulder while bench pressing heavy weights, such as a pectoralis major rupture, is another highly studied injury. This injury is almost uniquely associated with the bench press activity, and only a couple of past military cases were other causes (parachuting and push-up training). Though the bench press is not part of the ACFT, there is concern that Soldiers may use this activity to train for the ACFT. 

Injuries that develop gradually over time from overtraining are known as cumulative or overuse injuries. Overuse injuries occur when a repeatedly used set of body tissues haven’t had adequate time to heal and rebuild. 

“Continuing to stress tissues already injured from improper or excessive use or weight will only make the condition worse,” Benedict said. 

While delayed muscle soreness can be a normal sign muscles are rebuilding stronger, pain in a joint or bone is not normal. Pain associated with overuse injuries may dull or only occur during the activity. Soldiers may shrug off this pain, but it can become more serious if use continues. 

Overuse injuries to the lower body are the most common type of Soldier injury. Overuse to joints in the shoulders, elbows, as well as knees and spinal joints, are concerning because of the new ACFT. A common shoulder overuse injury is a torn rotator cuff. Though it can occur suddenly, tissues have often already been worn from excessive use. Other common overuse injuries include tendonitis, bursitis and pain syndromes in the knee and lower back. These injuries may lead to long-term chronic or permanent tissue damage.

Why it matters
Injuries critically impact individuals, units and Army performance and cost the Army billions of dollars annually for medical treatment, rehabilitation and re-training, medical disability, and reduced productivity from restricted duties and attrition. Training-related musculoskeletal injuries are the leading reason for temporary medical non-deployment status. Injury can mean Soldiers being out of commission for some time and can notably increase their chances of getting injured again or developing chronic life-long conditions as they age. Though injuries will continue to be experienced by Soldiers, most are preventable.

What can you do? 
In order to optimize U.S. military performance, Soldiers and leaders must do their part to train smarter, which includes avoiding injury. Table 2 (see below) provides some general guidance. Using proper technique, slowly building up intensity and weight levels to acclimate your body, and allowing rest days between similar activities are the primary keys to minimizing your risk. In addition, follow procedures as taught by ACFT trainers and seek guidance from Army Fitness Centers; doctrine in Field Manual 7-22; certified trainers, such as a master fitness trainer; and use the buddy system to warn one another of poor form and for hands-on help as a spotter to ensure proper balance and range of motion.

If you are injured, stop activities at early signs of pain and seek medical advice. Taking a break from activities temporarily to let the tissues heal can minimize the likelihood of a more serious injury. An injured knee can require weeks or months of rehabilitation. A worn rotator cuff tear can mean surgery. Lower back pain can result in a long-term health condition. To learn more about safely conducting and training for the ACFT, visit www.armyh2f.com.