A silent service-treatment record is not the same thing as proof that an injury or symptom never occurred.
Published Army research shows that underreporting and self-management of musculoskeletal injuries can be common in active-duty populations. That evidence can make an undocumented history medically plausible—but it cannot establish the facts of an individual Veteran’s case. The opinion still has to be built from the Veteran’s duties, chronology, lay evidence, later pathology, biomechanics, treatment history, and competing causes.
What the Smith and Sauers studies actually found
Smith and colleagues surveyed 1,388 Soldiers assigned to an Infantry Brigade Combat Team about injuries sustained during the prior 12 months. Participants identified 3,202 musculoskeletal injuries. Of those injuries, 1,566—approximately 49%—had not been reported to medical personnel. Common reasons for underreporting included concern that an injury could affect future career opportunities and avoidance of duty-limiting military profiles.
In a companion analysis of the same Brigade population, Sauers and colleagues found that 808 Soldiers—58% of respondents—acknowledged at least one musculoskeletal injury they had not reported to a medical provider. Among Soldiers with unreported injuries, over-the-counter pain medication was the most frequently identified self-management strategy, reported by 81%.
Why this matters when service records are incomplete
A record can be silent for many reasons. A Soldier may continue working, self-treat, avoid a profile, believe the injury will improve, or decide that seeking care is not worth the perceived professional or operational consequence. The Smith and Sauers studies demonstrate that these behaviors occurred often enough in a studied Army population that a physician should not automatically equate “no clinic note” with “no injury.”
That does not mean silence is irrelevant. The absence of expected documentation may still carry weight, especially when the record contains repeated examinations, affirmative denials, objective testing, or contemporaneous evidence inconsistent with the later account. The point is narrower: silence should be weighed, not mechanically converted into a negative medical fact.
How the literature can be used appropriately in a nexus review
| Question | Proper medical use |
|---|---|
| Silent service-treatment record | Use the studies as contextual evidence that underreporting and self-management are medically plausible; then test the Veteran’s account against the rest of the record. |
| Lay history of injury or symptoms | Assess consistency, specificity, duty demands, mechanism, onset, continuity, later treatment, and objective findings rather than accepting or rejecting the account solely because a clinic note is absent. |
| Later degenerative or structural disease | Determine whether the claimed in-service mechanism is biomechanically compatible with the later pathology and whether intervening injuries, age, body habitus, occupation, or other causes provide a stronger explanation. |
| Negative C&P opinion | Determine whether the examiner treated silence as dispositive without considering lay evidence, military treatment behavior, later objective evidence, or competing causal pathways. |
The evidence still has to be individualized
The useful question is not “Did Soldiers sometimes fail to report injuries?” The literature answers that at the population level. The useful question is whether this Veteran’s history remains medically coherent after the complete record is reviewed.
A strong opinion therefore looks for affirmative support: a duty or mechanism capable of producing the claimed injury, consistent lay statements, later clinical history, imaging or examination findings, a plausible disease course, and the absence—or appropriate weighing—of stronger alternative causes. A long treatment gap, major post-service trauma, age-related degeneration, occupational loading, obesity, or other risk factors may materially weaken the proposed service pathway and should be addressed directly.
Primary medical literature
- Smith LB, Westrick RB, Sauers SE, et al. Underreporting of Musculoskeletal Injuries in the US Army: Findings From an Infantry Brigade Combat Team Survey Study. Sports Health. 2016;8(6):507-513. PMID 27789871. DOI 10.1177/1941738116670873.
- Sauers SE, Smith LB, Scofield DE, Cooper A, Warr BJ. Self-Management of Unreported Musculoskeletal Injuries in a U.S. Army Brigade. Military Medicine. 2016;181(9):1075-1080. PMID 27612356. DOI 10.7205/MILMED-D-15-00233.