Soldiers on the battlefield need physical prowess, decision dominance and emotional resilience to win the nation’s wars. The U.S. Army achieves this through doctrine like Field Manual 7-22: Holistic Health and Fitness, and unit-based Holistic Health and Fitness teams. These teams integrate into commands to optimize soldier performance by addressing five readiness domains: physical, mental, nutrition, sleep and spiritual. Since its 2018 pilot, the Army continues to roll out Holistic Health and Fitness teams across the total force, emphasizing a comprehensive approach to soldier health and performance.
A key measure of improved physical prowess is the percentage of soldiers who remain free of musculoskeletal injuries. For almost 30 years, Army Medicine has worked to decrease the readiness impact these types of injuries pose. Operational clinicians noted that care from within the units offered the best chance for injury prevention, early recognition, treatment and return to duty.
Early pilots undertaken in the special operations community, like embedding physical therapists with the 75th Ranger Regiment, decreased lost duty time while increasing combat readiness. These successes led to the assignment of physical therapists, occupational therapists and dietitians throughout U.S. Army Special Operations Command and, eventually, brigade combat teams. The success of these programs underpins a Holistic Health and Fitness (H2F) tenet: When barriers to subject-matter experts are reduced, soldiers achieve superior outcomes.
However, musculoskeletal injuries continue to significantly limit soldier readiness, impacting some 55% of soldiers annually, with 70% of these injuries due to overuse. These injuries result in 10 million limited duty days per year and cost $577 million in patient care. Unfortunately, even after recovering, 38% of soldiers sustain a subsequent duty-limiting injury. This represents a substantial loss of physical performance and training availability any physically demanding organization would work hard to reverse.
To combat this problem, the Army has invested significantly in H2F, which has resulted in great progress. For example, in the first 28 brigades to field H2F performance teams, the Army’s Center for Initial Military Training found a decrease in both injury and physical profile rates compared to units without H2F. These initial results also indicated fewer soldiers were on profiles for over 90 days, demonstrating an improved ability to return soldiers to training and into the fight.
However, not all units have H2F teams or access to H2F resources. For equipped units, there is variability in their integration into the brigade staff as a commander’s resource. Some see H2F and a unit’s own medical team as separate resources, when they should be complementary. As leaders learn to leverage H2F’s best practices, H2F teams aim to decrease injuries and their impact on readiness. There are three successful strategies to build physical performance and lethality while limiting the impact of musculoskeletal injuries:
• Preempt and prevent.
• Early identification, early intervention and early return to duty.
• Rehabilitate and reintegrate.
Preempt and Prevent
The best way to prevent musculoskeletal injuries during physical training is a well-rounded and holistic physical therapy program that follows sports best practices. Field studies found injury risk could be reduced by up to 45% when units integrated FM 7-22 tenets. Just as preventive maintenance ensures weapon systems function optimally, physical training serves the same purpose for the human weapon system.
Well-rounded tactical fitness programs empower H2F strength and conditioning coaches to work with unit NCOs. NCO leadership remains the bedrock of unit readiness and training excellence. At Joint Base Lewis-McChord, Washington, I Corps’ H2F team found that this partnership fosters a culture of fitness and readiness, improves training schedule development through active collaboration, addresses injury management protocols and adapts training for mission-specific requirements while building soldier resilience.
At the same time, H2F teams must be fully integrated with Army medical personnel at the unit level to help leaders design evidence-based programming, provide specialized expertise, deliver mental skills and cognitive performance enhancement and integrate interdisciplinary approaches to holistic soldier readiness. Stronger, fitter soldiers conditioned with tactical training perform better and are more resilient, serving to preempt and prevent potential musculoskeletal injuries.
Screening soldiers for injury risk also helps with prevention. While authority, direction and control of military treatment facilities transitioned to the U.S. Defense Health Agency, the Army maintains responsibility for the health and welfare of soldiers. Army medical personnel have a role in screening, early identification and treatment of injuries. Adopting musculoskeletal injury-prediction algorithms at the unit level is key to preempting soldier injuries.
Army Medicine knows early access to physical therapy decreases the impact of musculoskeletal injuries on lost duty time. A 2018 Department of Defense study of 3,653 soldiers at Joint Base Lewis-McChord found that direct access to a physical therapist after a musculoskeletal injury decreased the average time to access definitive care from 57 days to six days, decreased average profile length from 75 days to 27 days and decreased permanent profile risk from 36% to 9%, while saving the Army approximately $3.6 million in just 18 months. These are predictable results of investing in physical performance optimization.
Sooner Than Later
The impact of early access to care cannot be overstated. In a DoD study of ankle sprains, researchers found earlier access to care decreased recurrent ankle sprain risk, while delayed care resulted in higher medical costs and increased time away from training. Researchers found similar results for common running-related knee pain. These high-volume injuries cause significant performance and training loss annually. Rapid access to care can reverse this.
While evidence clearly shows early identification and intervention for musculoskeletal injuries lead to an earlier return to duty, achieving these results for individual units requires a team approach. First, Army leaders at all echelons must create and enforce cultural change. Too often, a grin and bear it mentality persists with new injuries. Soldiers often try to tough it out rather than seek help. Sharing this powerful data on early access to care can change the culture and encourage soldiers to seek care early when they experience pain.
Unit physical training leaders and H2F strength and conditioning coaches must be trained to recognize abnormal performance and signs of movement pain. This allows them to recognize new injury onset and encourages soldiers to seek care from unit medical providers, augmented by the H2F team. Just as NCOs are trained to recognize incorrect weapons handling, they also can be trained to recognize early injury indications in soldiers. Not every NCO is an armorer or a medic, but they can all recognize a common language of performance and function, taught and reinforced by integrated H2F and medical personnel. Physical training leaders serve as sensors to provide early warning to mitigate injury risk.
Units with assigned combat medics and physician assistants must utilize these medical resources to accelerate H2F goals. In preparation for Iraq and Afghanistan, Army Medicine developed a point-of-care decision support function called “Musculoskeletal Screening and Referral Tools” to aid with early management of acute musculoskeletal pain and injury. Reintegrating this triage tool at the unit level will enhance H2F teams by leveraging unit medics to screen for musculoskeletal injuries.
Augmenting medic training in garrison with this decision-support tool, led by physician assistants with oversight from unit surgeons, could decrease the burden of musculoskeletal injuries on readiness and prepare medics for their roles in large-scale combat operations. Since combat medics deploy with the unit, training them in this role in garrison supports the unit during deployments by keeping soldiers in the fight, returning them to duty faster if injured, while improving trust between medics and the rest of the unit’s soldiers.
Rehabilitate and Reintegrate
Just as mindfulness training strengthens a soldier’s cognitive abilities, physical training is the one hour every day dedicated to strengthening the warrior spirit. As retired Sgt. Maj. of the Army Daniel Dailey reminded leaders, physical training might not be the most important thing you do in a day, but it is the most important thing you do every day. It is the one hour a day focused on building the physical prowess, decision dominance and emotional resilience that enhance lethality and performance in soldiers. This should be no different for those on physical profiles outlining any functional limitations.
H2F provides opportunities to optimize profile physical training at the brigade level and below. Subject-matter experts from the H2F performance team can assist in developing holistic programs to speed recovery and reintegration. Leveraging H2F strength and conditioning coaches, cognitive performance specialists and registered dietitians as part of profile physical training enables those on profile to benefit from their expertise while they recover.
This is even more critical for soldiers requiring orthopedic surgery. A Society of Federal Health Professionals study published in February on H2F’s impact on recovery from orthopedic surgery found a 93% return to duty rate, compared to 75% without H2F. Easy access to care within a unit’s footprint that integrates the five H2F domains builds readiness and performance.
H2F subject-matter experts work with a unit’s medical team to provide critical input to commanders during profile review boards and medical readiness reviews. Collectively, these experts ensure that soldiers on profile have the best chance of returning to full duty by improving communication between unit leadership and medical subject-matter experts. For soldiers unable to return to duty, H2F members can help them prepare to reintegrate back to civilian life.
Moving Forward
For fiscal 2026, the Army will compare two H2F team models, using data to determine the most effective and efficient approach to building soldier lethality. Over the next year, the U.S. Army Research Institute of Environmental Medicine will compare physical readiness, injury rates and musculoskeletal injury rehabilitation between the models. This study will inform data-driven decisions regarding the optimal staffing of the H2F program. The Army is committed to ensuring our soldiers are prepared to meet the physical demands of any duty position, accomplish the mission and return home.
Lt. Gen. Mary Izaguirre is the 46th surgeon general of the U.S. Army and the commanding general of U.S. Army Medical Command, Joint Base San Antonio-Fort Sam Houston. Previously, she served as commanding general of U.S. Army Medical Readiness Command, East. She deployed multiple times to Iraq and Afghanistan. She is a doctor of osteopathic medicine who is board-certified in family medicine and is a Fellow of the American Academy of Family Physicians. She has three master’s degrees: one in public health from the University of Washington; one in military arts and science from the U.S. Army Command and General Staff College; and the third in national security and resource strategy from the Eisenhower School for National Security and Resource Strategy.
Brig. Gen. Deydre Teyhen is the commanding general, Medical Readiness Command, Pacific and director of the Defense Health Network Indo-Pacific, Honolulu. Previous commands include Brooke Army Medical Center, Texas; Walter Reed Army Institute of Research; Schofield Barracks Health Clinic, Hawaii; and Public Health Command-Region South. She holds a Doctor of Physical Therapy from Baylor University, Texas; a doctorate in biomechanics from the University of Texas; and a master’s in strategic studies from the U.S. Army War College.