Physical Fitness Test Failure Risk Among Active-Duty Service Members With a History of Fracture

Musculoskeletal injuries may require specialty care to maximize return to duty (RTD) for active-duty service members (ADSM). An Investigator General's report revealed specialty care shortages may challenge RTD in ADSM. About half of US military bases reside in federally designated healthcare deserts. This study examines how extremity fractures sustained within healthcare deserts affect rehabilitation, impacting readiness and retention.

This retrospective observational study analyzed de-identified data from the Medical Assessment and Readiness System (MARS). We identified ADSM with fractures, mapped military installations against healthcare deserts, and compared outcomes against rehabilitation services utilization. We assessed the impact of social and community factors, including the social deprivation index (SDI), on fitness outcomes, including physical fitness scores (Army Physical Fitness Test [APFT]), using survival analysis. Key metrics included time to treatment appointments and retention outcomes.

From 2011 to 2021, 138,649 ADSM experienced fractures (10.8%). Three-quarters received physical therapy (PT) within 6 months of diagnosis. Among those, 12,828 (9.3%) failed their postinjury APFT. Postfracture APFT failure risk increased nearly 15% when time to first PT session exceeded 3 months (4-6 months: AHR = 1.18; 95% CI: 1.09-1.27; P < .001). Increased clinic SDI associated with a slight increase failure risk (Clinic SDI 26-50: AHR = 1.04; 95% CI: 1.00-1.09; P = .047). However, high clinic SDI unexpectedly correlated with decreased APFT failure (Clinic SDI 76-100: AHR = 0.87; 95% CI: 0.77-0.98; P = .024). Highest APFT failure risk occurred after wrist or hand fractures (AHR = 1.30; P < .001). Demographic risk factors included female sex, younger age, lower rank, non-White race, and higher BMI.

Delayed PT increased postfracture APFT failure risk. Concomitant stress fractures correlated with increased postinjury APFT failure, as did fracture occurrence in low-income locations. Early access to rehabilitation was associated with approximately 30% decreased risk of postfracture APFT failure. Treatment effects estimates demonstrated that PT/rehabilitation services afforded 11 months of additional active service time postinjury.