Thousands of Minnesota soldiers are returning from war to live with chronic pain from internal injuries and musculoskeletal disorders that leave many impaired.
An MPR News analysis of data from the Department of Veterans Affairs shows a steep increase such injuries over the last decade.
In 2012, doctors at VA hospitals in Minneapolis and St. Cloud, Minn., Fargo, N.D., and Sioux Falls, S.D. saw veterans with joint disorders at least 35,000 times, a 133 percent increase over 2003.
• Hearing, breathing problems most prevalent
Over that period, back disorders have risen by 106 percent, from 16,340 in 2003 to 33,237 in 2012. VA doctors saw a 129 percent increase in neck disorders, from 3,645 in 2003 to 8,364 in 2012.
Nationally, musculoskeletal conditions were the number one service-connected disability for veterans every year from 2007 to 2011, according to a report by the federal Veterans Benefits Administration.
Earlier this year, the federal Government Accountability Office found the most frequent diagnosis for service members was lower back pain. The same report found that back pain and other musculoskeletal disorders were among the most frequent causes of medical evacuations for service members from Iraq and Afghanistan.
Although some are injured in combat, others are hurt doing dangerous jobs overseas, and some have pain caused by the very equipment meant to protect soldiers from harm.
Among those in constant pain is Patrick Nelson, a former U.S. Army paratrooper from Eden Prairie, Minn., a veteran of three tours in Iraq and Afghanistan. Doctors diagnosed him with a shoulder injury, bulging discs and a degenerative arthritis condition in his back. Nelson, 30, also suffers from post-traumatic stress disorder and a possible brain injury.
The VA has classified Nelson as 90 percent disabled and sends him a disability check every month. Despite his high disability rating, he works as an event coordinator for a nonprofit golf organization and spends much of every day trying to ignore his pain.
"I would give anything to be pain-free right now and to not get that check every month and just to live a normal life," he said.
When Nelson met with a VA chiropractor in early May, he complained of pain "all over."
"It's my entire back but specifically the worst pain is the mid-back on both sides of the spine," he said.
Nelson also suffers from migraine headaches and severe shoulder and neck pain. He moves stiffly and has trouble bending over to reach his toes. He is just one of thousands of Minnesota veterans living with chronic pain from a group of service-related conditions known as musculoskeletal disorders. Brought on by sudden injuries or developing over time, the conditions affect bones, muscles, joints, ligaments, nerves and tendons.
His injuries stem from a June 2005 explosion in Afghanistan during an attack on a landing strip in a remote village. Two other soldiers died. His body is still riddled with shrapnel.
Covering Nelson's biggest scar is a tattoo of a cross on his back that he got after the explosion. Inscribed on the cross is the date of the attack and the initials of a friend who died. Since that day, he has been taking painkiller. He's up to eight Vicodin pills a day, but it no longer dulls his ache.
After he was injured Nelson wanted to continue serving in the military and thought he would have to accept the persistent back pain in combat. In the mountains of Afghanistan, medics would sometimes administer muscle relaxer to ease his pain.
"It was my job at the time. I didn't really have an option," he said. "I wasn't the type of guy to go and raise my hand and say, 'Ah, I can't do this one,'" he said. "You train with those guys for so long, and I had already deployed twice. It's not like I was scared or didn't know what I was getting into."
But his injuries affected his military service. Ailing and no longer able to keep up with younger paratroopers, he left the military in 2008.
"The pain just progressively got worse and worse," Nelson said. "It makes me feel a lot older than I am, I think."
But not all cases of back, neck and joint pain are caused by injuries as dramatic as Nelson's. It's likely the increase in such disorders is directly related to the equipment soldiers carry and the body armor they wear to stay safe, doctors and soldiers say.
At a Minnesota National Guard Armory in St. Paul, two soldiers unhook the Velcro straps on a body armor vest made of Kevlar. Inside are pockets for inserts of hard ceramic or metal. High-tech plates on the front, back and side of the vest protect a soldier's vital organs from bullets and shrapnel.
The vests weigh about 30 pounds, but that's before it is adapted for a war zone.
"When you're over in combat we actually get a little bit thicker plate," National Guard Sgt. 1st Class Tavis Pike said. "Then with the side stuff and then all of your ammunition it probably gets closer to 60."
Guard soldiers on foot also wear helmets and backpacks loaded with equipment, ammunition, batteries, food and water. They also carry rifles weighing at least 16 pounds.
The soldiers are resigned to their heavy loads, Minnesota National Guard Staff Sgt. Scott Stodola said.
"As far as the weight of the equipment, it's uncomfortable and people complain about it like crazy because it's so heavy and it seems like an outrageous amount of weight," Stodola said. "But it's really not that bad once you've gotten used to it a little bit. You definitely don't want to be walking 20 miles a day, but the one or two times you have to take a long walk it's not that terrible."
To soldiers in the field, it's better to be uncomfortable but safe. But the weight of added protection could mean more damage to troops. According to the U.S. Army, the combat load for a rifleman on operation weighs as much as 170 pounds. In 2001, the Army chief of staff recommended that, by 2010, soldiers lug no more than 50 pounds. The Army is still struggling to meet that goal.
"There is an old saying in the Army that they used to treat the soldiers like Christmas trees and see how much stuff they could hang on them," said Dr. Paul Huddleston, an orthopedic surgeon at Mayo Clinic.
A colonel in the Army Reserve Medical Corps who deployed three times to Iraq and once to Afghanistan, Huddleston notes that soldiers' equipment is lighter than it once was.
However, he said, there is now more of it, including the latest body armor.
"With those big heavy packs on it's hard to even stand," he said. "People hurt their knees and backs acutely just from walking around with all that. Shoulder injuries are not uncommon."
Huddleston believes National Guard and Reserve soldiers may be at even greater risk for injury. "And I say that from having worn that equipment but also having been a physician in the field taking care of the soldiers who were injured carrying that stuff."
National Guard and Reserve soldiers tend to be older than their active-duty counterparts. They are more susceptible to musculoskeletal injuries.
In the last decade, the military has relied on National Guard and reserve troops at historic levels. So-called "weekend warriors" who in the past served stateside are now sent to combat zones overseas, often multiple times.
That's taking a toll on their health.
The Army has acknowledged that too much weight can fatigue, injure and slow soldiers down in dangerous situations. With that in mind, the military is working on developing technology to provide better protection for troops while also cutting their weight.
Meanwhile, record numbers of returning veterans are seeking help for injuries related to the weight they carry. Still, those injuries have not received the attention given more dramatic injuries like PTSD, said Ramsey County Veteran Services Director Maria Wetherall.
"Unfortunately it's not a very glamorous issue," Wetherall said of injuries caused by heavy equipment. "'You've got a back problem? We've all got a back problem.' I mean, sometimes I think they are not as sympathetic and don't present as well."
Wetherall said the Department of Defense and the VA need to do more to prevent injuries in the first place, and to help injured troops once they're home.
But many likely will return with constant pain, as Nelson has.
His search for relief has led him to a clinic in Bloomington. It offers military veterans free chiropractic, acupuncture and other treatments. The chiropractor works on Nelson's back with his hands.
After an adjustment, Nelson feels better. But he knows his pain will return in a few hours.
In April, the VA scheduled Nelson to meet with a surgeon about his back -- but his appointment is not until July. While he waits to see the surgeon, doctors are considering putting him on morphine.