s ravyts, t fleagle, e staguhn, d scharfstein, r aaron, s cohen, r hurley, s raja, j haythornthwaite, l allen, e edwards, l arendt-nielsen, med, c campbell, r castillo

Objective: The current study sought to evaluate the psychometric properties of a newly developed Knee OsteoArthritis Pain Index (KOAPI), derived from the Brief Pain Inventory (BPI), among individuals with knee osteoarthritis (KOA).

Methods: This study consisted of secondary data analysis of two clinical trials. In study 1, 241 individuals with KOA were evaluated before total knee arthroplasty and six months post-surgery. In study 2, 37 individuals with KOA participated in a randomized, double-blind, placebo controlled, two-way crossover study in which they received either a COX-2 inhibitor followed by a placebo or a placebo followed by a COX-2 inhibitor. The KOAPI was derived from the BPI and included three BPI pain severity items (worst, average, current) and the BPI pain interference item related to pain when walking.

Results: The KOAPI showed excellent model fit (CFI = 0.99; TFI: 0.98-0.99; RMSEA: 0.08-0.001), good reliability (Cronbach’s alpha: 0.84-0.87) and high convergent validity with the Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.66; 95% CI: 0.44, 0.81) and the Pain Catastrophizing Scale (r = 0.50; 95% CI: 0.39, 0.60).

Conclusions: Overall, the psychometric properties of the KOAPI were comparable or better than those produced by the original BPI pain severity subscale. The KOAPI may be a helpful screening and outcome measure for individuals with KOA that more closely captures symptoms which drive patients to seek clinical care.

Scott G Ravyts, Timothy R Fleagle, Elena Staguhn, Daniel Scharfstein, Rachel V Aaron, Steven Paul Cohen, Robert W Hurley, Srinivasa N Raja, Jennifer Haythornthwaite, Lauren Allen, Robert R Edwards, Lars Arendt-Nielsen, Claudia M Campbell, Renan Castillo, Psychometric properties of the knee osteoarthritis pain index, Pain Medicine, 2025;, pnaf067, https://doi.org/10.1093/pm/pnaf067

s suttles, r boeth, m frazier, m garrison b isaacson

Objective: Describe an innovative Sports Medicine clinic design implemented in an outpatient Physical Therapy (PT) clinic within a Military Treatment Facility (MTF) for both referral and direct access (DA) entry portal pathways, and to investigate the modifying effect of medical system initial entry pathway for musculoskeletal injury (MSI) on time from injury to begin care for outcomes of duration of care, recurrence of MSI care for the same condition out to 2 years from discharge after initial care, and physical profile status at time of initial discharge.

Design: Quasi-experimental prospective longitudinal cohort study of active duty Army Soldiers in a MTF who sought care for an initial MSI over a 2-year period.

Materials and Methods: Four hundred eighty-eight individuals were classified by the pathway they entered the Military Health System through: early access pt (EAPT) referral pathway EAPT (n = 290), or DA (n = 198) pathway. The primary analysis considered the relationship between time from injury to treatment, care duration, and effect modification via pathway. Linear regression models were used. Secondary analysis investigated the relationship between injury recurrence and time from injury to treatment, and effect modification of care pathway. Logistic regression models predicted whether at least one recurrence event occurred within 3 to 24 months after discharge from initial care. Another analysis considered return to duty outcomes relative to pathway group. Logistic regression models predicted full return to duty relative to return to duty with physical limitation, whether temporary or permanent.

Results: Forty-one percent of Soldiers reporting for initial MSI care entered the health system through the DA pathway versus 59% in the EAPT pathway. Longer time from injury to treatment initiation was weakly associated with longer duration of care when considered alone (coefficient: 0.05, P = .01). When pathway was introduced into the model, only pathway showed a significant effect (coefficient: 9.6, P = .01), indicating longer duration of care was associated with the EAPT pathway. There was a significant effect of time from injury to treatment initiation on recurrence prevalence. For each additional day between injury and treatment initiation, recurrence likelihood was 30% higher (odds ratio [OR]: 1.0003, P = .01). When pathway was introduced, it again emerged as the only significant predictor, superseding the time from injury to treatment initiation as well as the interaction between the 2 (OR: 1.95, P = .02). Recurrence was 95% higher for those who went through the EAPT pathway relative to the DA pathway. Early access physical therapy patients were 224% more likely to return to duty with limitation than DA patients (OR: 3.24, P < .01).

Conclusions: Within an MTF it is possible to design MSI clinical operations to emulate a Sports Medicine training room model that includes expedited referral processes as well as DA care which allows for more patient encounters and dramatically decreases time from injury to initiation of MSI treatment than the traditional clinic model. Within this model, the expedited referral pathway was associated with longer duration of care, increased recurrence, and increased likelihood that Soldiers would be discharged with continued physical limitations.

Sean Suttles, Riley R Boeth, Mathew Frazier, Michael Garrison, Brad Isaacson, The Impact of a Unique Military Treatment Facility-Based Sports Medicine Model on Readiness in the Army: A Prospective Longitudinal Analysis Comparing 2 Military Health System Entry Portal Pathways on the Duration of Healthcare Management and the Incidence of Recurrence Within 24 Months, Military Medicine, 2025;, usaf423, https://doi.org/10.1093/milmed/usaf423

lai s, soriano j, pham k, wu m, jeon j, o’donovan k, aderm m, trump j, curtain j, gee s, donohue m, cameron k

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Cases of osteoarthritis (OA) are a common cause of disability among medically separated military service members and rates of OA in the military have been observed at higher rates than the general population. Emerging evidence has revealed an association between intra-articular soft tissue injuries [e.g. meniscus or anterior cruciate ligament (ACL) tears] and cases of OA resulting in total joint replacements. These acute, traumatic soft-tissue injuries typically result in significant hemarthrosis containing inflammatory biochemicals and cells associated with OA. To attain a better understanding of the OA development process, the purpose of this study was to identify whether mesenchymal stem cells (MSC) are present acutely after an intra-articular knee injury and quantify their concentration.

Methods: A prospective case-series study design was conducted among participants enrolled at a United States Service Academy from 2021-2024. Potential subjects with a knee joint injury were referred to and screened by a military orthopedic surgeon to determine eligibility for the study. Eligible subjects underwent informed consented and provided pertinent demographic and injury history information. An aspiration of the knee was conducted during this initial evaluation. Samples were collected within 96 hours of the injury incident. The aspirate sample was tested on a WOLF cell sorter to determine the presence of specific cell surface markers (CD90, CD105, CD73, CD45, CD34, CD19, CD11b, HLA-DR) representative of MSC presence.

Results: It was determined through the WOLF flow cytometer output analysis that cell surface markers consistent with MSC presence were identified in some samples. However, the concentration of cells containing MSC biomarkers remains low and is inconsistent. The observed cell populations demonstrated a biomarker profile more closely resembling peripheral blood mononuclear cells (PBMCs), though varying degrees of MSC marker expression were present.

Conclusion: Preliminary findings suggest that MSCs may be present in the acute phase following intra-articular knee injuries in varying amounts and low quantities. High variability in data across several samples suggests that variability in the mechanism and severity of injury may result in varying physiological responses. Further research controlling for these factors may be needed to better understand the role of MSCs in post-traumatic osteoarthritis development to help inform targeted OA treatment for military personnel.

hughes n, cornell b, rossi r, metzger e, hager n, ketz a, yuan x, wagner l, isaacson b, pasquina p

Abstracted accepted for a podium presentation at the 2025 Military Health System Research Symposium

Introduction: Special Operations Forces (SOF) train continually to maintain peak performance. Thus, they are nearly always in a state of recovery and in need of noninvasive therapies to address the taxing workload. Photobiomodulation therapy (PBMT) is a noninvasive treatment where a therapeutic laser is applied to the body to enhance healing, recovery, and performance. Army Tactical Human Optimization Rapid Rehabilitation and Reconditioning (THOR3) provides a consistent venue for implementation of PBMT as a modality. Studies in athletes have shown performance and recovery benefits with pre-and post-workout focal application of PBMT. While there is less evidence on the potential cognitive/behavioral effects after application of PBMT, self-reported fatigue has also been found to be significantly lower in groups receiving PBMT. Further, PBMT research in healthy elite Warfighters is limited. PBMT may be a promising tool for enhancing physical performance by accelerating musculoskeletal and psychological recovery in the SOF population. We are investigating the physiologic and behavioral effects of PBMT application post-exercise on performance in SOF Operators.

Methods: We are conducting a single-blind, randomized-control trial in a healthy SOF population. Participants are randomly assigned to receive either PBMT or sham-PBMT post-THOR3, coach-led physical training. Treatment is administered 3 times/week for 3 weeks to both quadriceps. Baseline measurements include body fat percentage, height, weight, and military/demographic information.  The following measurements are collected at baseline and 3-week follow-up: isokinetic/isometric quad and hamstring strength, Borg CR10 Rating of Perceived Exertion, and Elloumi short questionnaire of fatigue. Countermovement jump and self-reported delayed muscle soreness via the Visual Analog Scale are measured at baseline and weekly for three weeks. The Defense and Veterans Pain Rating Scale, self-reported activity, and recovery and sleep via the Oura ring are tracked daily.

Results: The study recently launched. Preliminary results forthcoming at time of conference with an estimated N of 38 completed participants.

Conclusion: PBMT shows promise in accelerating musculoskeletal repair and psychological resilience, reducing injury risk, and enhancing performance in these domains. This study may inform standards of training and care to maximize readiness among elite warfighting units.

rossi r, cin l, grogan s, persinger j, schroeder j, hager n, mincey c, metzger e, gabler g, wagner l, yuan x, isaacson b, pasquina p

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Lower extremity injuries are common sources of limited duty days for military Service Members. Microvascular flow (MVF) & shear wave elastography (SWE) are postulated to be non-invasive, efficient, & cost effective in early diagnosis/treatment of musculoskeletal injuries (MSKIs). Normative values for MVF, SWE, & related tendon echo-characteristics in the lower leg & Achilles tendon do not exist to our knowledge. Studies reported gender variability of the patellar tendon on ultrasound. Further investigation is needed to determine if there are similar variations in the Achilles tendon. This study aimed to establish normative values for routine tendon echo-characteristics, presence of plantaris tendon, MVF vs P ower Doppler (PD), & SWE measurements in the posterior lower leg & Achilles tendon.

Methods: Ultrasound was performed on asymptomatic participants on a Samsung RS-85 Prestige. Measurements: Achilles calcaneal insertion (CI), avascular zone (AVZ), gastro-soleus junction (GSJ), medial gastrocnemius, & soleus. Outcomes: thickness/width 2D measurements, vessel quantification (PD vs MVF), SWE, plantaris tendon presence, Body Mass Index (BMI), ankle Range of Motion (ROM), & surveys.

Results: 106 limbs scanned (n=55). MVF detected flow in 9 limbs vs 1 limb by PD. Increased BMI increased tendon/gastroc measurements: (p < .01); SWE [r(63) = 0.41] & AVZ SWE [r(63) = .33]. No correlations found between activity levels & ultrasound or ROM measures (p>0.1). Mean SWE of AVZ Short-Axis (SAX) significantly different in males vs females [79.3 kPa (SD: 25.5) vs 64.0 kPa (SD: 10.3), respectively], p=.01). Mean SWE CI: Males: 133.1 kPa (SD: 25.0), females: 124.2 (SD: 31.7); no significant gender differences (p>.01). Median GSJ height Long-Axis (LAX): 0.2 cm. Median CI LAX: 0.4 cm. AVZ height LAX: 0.5 cm. SAX, mean AVZ width: 1.5 cm (SD: 0.2) males & 1.4 cm (SD: 0.2) females; no significant gender differences (p>.01). Plantaris tendons found in 56% of participants. Mean ankle dorsiflexion: males = 13.1° (SD: 10.1), females = 7.2° (SD: 9.9), p=.01.ion.

Conclusion: SWE varied between genders & ultrasound sites. Increased BMI increased tendon/gastroc measurements; higher activity levels did not. Tendon architecture greater in males than females & MVF more sensitive than PD. These findings will inform normal, routine, & novel ultrasound values for the Achilles tendon complex to improve diagnosis & treatment of MSKIs in Military Treatment Facilities

cin l, schroeder j, mincey c, persinger j, hager n, rossi r, metzger e, yimyam c, ketz a, wagner l, isaacson b, yuan x, pasquina p

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Plantar Fasciitis (PF) is the most common cause of heel pain, affecting 10% of the US population, with a rising annual incident rate. In the United States military, musculoskeletal injuries, including PF, are responsible for 25 million lost duty days, resulting in 2.2 million medical visits. Even if effective, current PF treatment protocols may require 6-12 months of therapy to return individuals to pain-free activity. Photobiomodulation therapy (PBMT) uses non-ionizing light forces to enhance performance, alleviate pain and inflammation, modulate recovery, and promote healing. A recently completed pilot study demonstrated a positive effect of two PBMT parameters on function and pain levels in participants with PF when combined with stretching and ice. This follow-up study assessed the clinical effectiveness of PBMT compared to sham-PBMT in helping individuals return to duty without the use of chronic pain medication or surgical interventions for PF.

Methods: Blinded participants were randomized to PBMT or sham-PBMT 3x/week x 3 weeks at 10 J/cm2, 25W output power using the LightForce XPi and home exercises x 6 weeks. Sham-PBMT participants could crossover after 6-weeks. Outcomes included Defense and Veterans Pain Rating Scale (DVPRS), Foot Functionality Captured via Foot and Ankle Ability Measure (FAAM), and ultrasound measured fascial thickness.

Results: 68 randomized participants (PBMT: n=33, sham-PBMT: n=35) were analyzed. FAAM scores showed improvement for both groups at 6-weeks [PBMT (Mean: 17.2, SD:16.1; p<.01); sham-PBMT (Mean: 10.9, SD:17.1; p=.08)]; no statistically significant intergroup differences (p>.05). Ultrasound measurements reported a median change in PF thickness for PBMT (Mdn: -0.1, IQR: [-0.5;0.5]), and for sham-PBMT (Mdn: 0.3, IQR: [-0.2,0.6]). Regarding pain, both groups experienced improvement in their DVPRS scores [Mdn absolute change -1.0 points (IQR: -2.5;0)]. There were no statistically significant intergroup differences in the above measures.

Conclusions: Both groups met the predefined threshold for a minimum clinically important difference in the FAAM (≥ 8-point decrease) and a decrease in pain (improved DVPRS scores). The PBMT+UC group experienced a small PF thickness decrease compared to sham-PBMT+UC. These findings indicate that PBMT may be an effective adjunctive treatment for PF pain and function.

Goss d, rochester k, melton c, reilly n, marshall a, hess g, ford k

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: All Military Service Members run. The shin and and knee are the most frequently reported injury locations representing 48% of new injuries and 59% of re-injuries (Rauh 2006, Tenforde 2011). Powers et al, (2010) observed that abnormal frontal and transverse plane hip movements have led to patellofemoral pain in runners. Additional work is needed outside the lab to analyze running kinematics. Markerless motion capture systems with cameras has been validated for running and walking data collections.

Methods: Markerless motion capture with 12 cameras were used outside on a track at Fort Bragg, NC. Kinematic running data were collected on 665 Soldiers running through the motion capture volume in 2024. Prospective injury data were mined from the electronic medical record. Kinematic data was processed and analyzed for each step between initial contact to toe off. Two-tailed statistical parametric mapping using a two-sampled t-tests were conducted comparing those presenting with a lower extremity injury to those who did not report a running related injury in the first six months following a data collection in June 2024 to December 2024. The first date of data capture (33 runners) were analyzed and prospectively followed for the initial 6 months to identify those who sustained an injury to those who did not sustain an injury.

Results: Thirty three runners were included in this preliminary analysis. Two hundred and seventy-two steps were analyzed for these 33 runners. There were 136 left and 136 right steps.  Mean steps per participant were 8.24 steps.  Four runners reported to the medical clinic for running-related injuries, while 29 did not. Of the 4 who reported for injury, they demonstrated greater hip adduction for 21% of stance phase  than the 29 healthy Soldiers/runners (t = 2.74, p < .05). No other hip, knee, or ankle sagittal, frontal, or transverse plane differences were observed between the injured and uninjured runners.

Conclusion: These preliminary results are consistent with previous studies that have indicated that increased hip adduction may lead to patellofemoral knee pain in a lab setting. This is the first study of its kind to include markerless motion capture running data of over 30 runners outside. We have over 600 more Soldiers/runners to continue to prospectively track injuries and will have that done prior to the August 2024 MHSRS meeting.

kasper m, smith m, wimmonw w, campbell c, cohen s, wilson s

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Knee osteoarthritis (KOA) is a pervasive degenerative joint disease that can lead to increased pain, and decreased mobility. Active-duty Service Members (ADSMs) may be at increased risk for developing KOA due to the fitness demands and predisposition for traumatic joint injuries. Patients who have trialed conservative treatments, but do not require surgery, may benefit from alternative procedures including genicular radiofrequency ablations (RFA). Non-surgical interventions are being studied for pain and functional improvement in military and civilian populations.

Methods: The following cases feature participants enrolled in a multi-site study at Walter Reed National Military Medical Center (WRNMMC) [WRNMMC-EDO-2022-0968].  Case 1 is a 56-year-old male retiree with chronic knee pain (> 5 years) and radiographic evidence of left KOA [Kellgren-Lawrence (KL) Score: 2]. Case 2 is a 79-year-old male retiree with chronic right knee pain (1-5 years) and radiographic evidence of right KOA (KL Score: 1). Both patients received genicular RFA procedures targeting nine nerve sites: superomedial, superolateral, inferomedial, inferolateral genicular nerves, nerve to vastus medialis, medial branches of nerve to vastus intermedius, nerve to vastus lateralis, lateral branches of nerve to vastus intermedius, and infrapatellar branch of the saphenous nerve. Patient-reported outcome measures including Knee Injury and Osteoarthritis Outcome Score-12 (KOOS-12) and Modified 4-Item Brief Pain Inventory Scale (mBPI) were collected at baseline and 12 weeks post-procedure.

Results: By day 7 post-procedure, both patients reported their knee pain to be very much improved and 0/10. mBPI scores (Case 1: -4.75; Case 2: -3) and KOOS-12 subscale scores for pain (Case 1: -1; Case 2: -6), function (Case 1: -3; Case 2: -6), and quality of life (Case 1: -1; Case 2: -3) improved in both patients at 12 weeks post-procedure.

Conclusion: Investigating the efficacy of modified genicular RFA technique may lead to more comprehensive relief for military beneficiaries. These cases demonstrate this treatment can yield symptom relief as soon as 1-week post-procedure, with improving symptoms and function out to 12 weeks. They are consistent with non-randomized studies demonstrating better improvement with more nerves than the traditional 3-nerve technique.  These study results may support expansion of effective conservative treatment options for military beneficiaries with KOA.

kasper m, smith m, yuan x, noble e, mo

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Knee osteoarthritis (KOA) is a degenerative joint disease that is five times more likely to affect the military compared to the general population. Patients who have rheumatoid arthritis (RA), in which proinflammatory cytokines can lead to cartilage damage and bone erosion, can also suffer from KOA. Few studies have investigated the use of platelet-rich plasma (PRP) injections in RA patients. The purpose of this prospective case-control series is to compare the safety and efficacy of PRP injections for KOA in patients with and without RA.

Methods: Military beneficiaries (18+ years) with clinical and radiographic [Kellgren-Lawrence Score ≥ 2] evidence of KOA referred for knee PRP injections were enrolled at a military treatment facility (WRNMMC-2022-0406). The RA cohort additionally met diagnosis criteria with current disease dormancy. Exclusion criteria include prior injections (PRP ≤ 6 months; corticosteroid ≤ 3 months), joint replacement, comorbid autoimmune disease, or medical condition that is a PRP contraindication.

Patient-reported outcome measures included Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) collected at baseline, 1-, 3- and 6-months post-procedure..05).

Results: To date, 7 patients have been enrolled (6 KOA, 1 RA+KOA; 42.9% Active duty; 57.1% female). 4 patients (3 KOA, 1RA+KOA) have reached 1-month follow-up for interim analysis, demonstrating symptomatic and functional improvement on their average WOMAC scores (mean ± standard deviation) from baseline to 1-month (24.50 ± 13.82), exceeding the minimal clinically important difference (MCID: 17). Improvement was also seen in all KOOS subscales, although only the pain (8.25 ± 6.13) and activities of daily living (ADL) (17± 9.63) subscales exceeded the MCID threshold (MCID: 8-10). No adverse events (AE) were reported in either group.

Conclusion: Preliminary outcomes of this study demonstrate functional and symptomatic improvement in military beneficiaries with KOA with or without comorbid RA receiving PRP injections. Results of this study will yield additional insight into longer-term functional outcomes and safety of PRP for patients with KOA and RA.

smith m, yuan x, smith j, deal jr j, nanos g, tintle s, reece d, miller m

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Carpal tunnel release (CTR) using a mini-open (mOCTR) or endoscopic approach is the current standard of care in the Military Health System (MHS) for management of refractory carpal tunnel syndrome (CTS). CTR techniques have evolved to reduce injury risk and post-operative pain. CTR using Ultrasound Guidance (CTR-US) is a promising intervention under study in a trial comparing CTR-US and mOCTR outcomes in MHS beneficiaries.

Methods: This single-site randomized controlled trial at a military treatment facility was approved by the Institutional Review Board (IRB #: WRNMMC-2020-0278). Eligible participants were randomized to receive CTR-US by Physical Medicine and Rehabilitation physicians or mOCTR by Orthopedic Hand Surgeons in clinic procedure room with local anesthesia. CTR-US was performed under continuous ultrasound guidance with device featuring inflatable balloons to create space and a retractable blade to release transverse carpal ligament in retrograde manner.

Primary outcome was Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) at 1 month. Additional outcomes including Boston Carpal Tunnel Questionnaire – Symptom Severity Scale (BCTQ-SSS), Modified 2-item CTS Palmar Pain Scale, and adverse events (AEs) were collected up to 1 year. Descriptive analyses reported central tendencies. Inferential analyses included two-sample Welch’s T-tests (α = 0.01) and generalized additive models (α = 0.05).

Results: 41 patients (58.5% F, 49.5 ± 14.4 years, 41.5% Active duty) were treated (21 CTR-US, 20 mOCTR). Mean CTR-US procedure time was significantly greater (CTR-US: 32.2 ± 14.7 min; mOCTR: 16.2 ± 4.2 min; p < 0.01) and mean CTR-US incision length significantly less than that for mOCTR (CTR-US: 5.4 ± 0.8 mm; mOCTR: 28.0 ± 4.2 mm; p < 0.01). 1 serious AE (infection) was reported in CTR-US group. CTR-US group reported statistically significantly less incisional pain and less impact of incisional pain on function during first 4 weeks and 3 weeks, respectively (p < 0.05).  Both groups had improved QuickDASH and BCTQ-SSS scores out to 1 year with no statistically significant differences (p > 0.05).

Conclusion: Preliminary trial data suggest that CTR-US can be performed within clinic environment by non-operative physicians with advanced training, resulting in decreased incisional pain and non-inferior outcomes compared to mOCTR out to 1 year. Outcomes of WRNMMC trial may expand CTS management and improve operational readiness.

smith m, yuan x, harris e, lechanski l, parson n, condon r

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Trigger point dry needing (TPDN), also known as dry needling, is an intervention employed by a myriad of providers to treat musculoskeletal (MSK) conditions. This technique uses the insertion of a solid filament needle without medication to treat scarring, myofascial pain and mobility, and muscle motor recruitment dysfunction. Active duty Service Members (ADSMs) are at an increased risk for developing MSK conditions due to their occupational and fitness requirements. Although studies have explored TPDN within this population, supporting use within clinic and deployed environments, most of current literature is lower quality and heterogenous. The study aims to obtain quantitative and qualitative data regarding the current TPDN practices of clinical providers within the Military Health System (MHS).

Methods: This cross-sectional survey-based study was approved with exempt determination by the U.S. Army Medical Center of Excellence Office of Research and Human Subject Protections (24-00027e). Active duty and civilian clinical providers within the MHS are invited to complete the 33-question survey with the aim of attaining 250 respondents. Training, experience level, safety, outcomes, and barriers to clinical practice will be evaluated. Continuous variables will be presented as means with standard deviations or medians with interquartile ranges. Categorical variables will be presented as counts and proportions. Hypothesis testing will be performed at the 5% significance level, as applicable.

Results: To date, 13 clinicians (13 physical therapists) have completed the survey. 12 respondents currently perform TPDN, and 1 respondent has performed TPDN in the past. Additional analyses will be available at time of report.

Conclusion: MHS providers have been employing TPDN as a cost-effective, low risk and minimally invasive intervention to treat MSK conditions. Considering military personnel can be deployed in a variety of environments, where resources may be scarce, having a minimally invasive intervention at the fingertips of deployed medical personnel is valuable. The results of this study will better inform prospective research protocols to determine the TPDN efficacy in terms of pain reduction, functional improvement, and operational readiness. The survey will also help guide the establishment and standardization of training and clinical practice guidelines, optimize safety and maximize level of confidence/comfort with performing TPDN.

e super, m smith, m miller, j smith, x yuan

Objectives: Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Anatomic variations of the median nerve (MN) and carpal tunnel (CT) may predispose patients to CTS or increase procedural complexity and risk during carpal tunnel release (CTR). This study aimed to systematically evaluate the prevalence of 25 MN and CT anatomic variations and measurements using ultrasound (US) in patients referred for electrodiagnostic testing (EDX).

Methods: In this cross-sectional observational study, patients underwent diagnostic US exams of the MN (mid-brachium to distal CT), focused on variant anatomy that may predispose to CTS (bifid MN, Gantzer's muscle, lumbrical intrusion) or increase procedural complexity/risk (transligamentous thenar motor branches [TMBs], MN orientation ulnar to the palmaris longus [PL] tendon).

Results: Two hundred and twenty patients (mean age: 45.3 ± 13.0 years; 63.6% male; 294 UEs) were evaluated by US. Hundred and eight UEs met EDX criteria for CTS (EDX-CTS). The most common variations identified were lumbrical intrusion (81.3%), Gantzer's muscle (39.5%), and persistent median artery (22.8%), which were not associated with EDX-CTS. US revealed transligamentous (2.4%) and ulnar origin (4.5%) TMBs, which may increase injury risk during CTR. MN location was ulnar to the PL tendon in 70.4% of wrists, which can predispose to injury during landmark-guided CT injections.

Conclusions: This study demonstrated that US complements EDX and can systematically identify anatomic variations, including variants at risk during CTS interventions. No differences in the prevalence of variations were detected between patients with and without EDX-CTS. Diagnostic US can support procedural planning, improve safety, and lower injury risk.

Super EJ, Smith MS, Miller ME, Smith J, Yuan X. Ultrasonographic Assessment of Median Nerve and Carpal Tunnel Variations: Implications for the Interventional Management of Carpal Tunnel Syndrome. J Ultrasound Med. 2025 Jun 18. doi: 10.1002/jum.16733. Epub ahead of print. PMID: 40530498.

c fellin, r steiner, x yuan, s jariwala

Collagen-based biomaterial inks for digital light processing (DLP) 3D printing are particularly attractive due to their inherent biocompatibility, cell-adhesion properties, and biodegradability. However, there have been relatively few examples of collagen-based biomaterial inks without the use of synthetic co-monomers or specialized printing equipment. Furthermore, photo-crosslinked collagen hydrogels are often brittle, limiting their use in biomedical applications and regenerative medicine. In this study, we present the development of a novel collagen-based biomaterial ink for DLP 3D printing, enabling the fabrication of robust hydrogel constructs through a post-print tannic acid (TA) treatment. The biomaterial ink, composed of collagen methacrylate (ColMA) and a natural co-monomer, hyaluronic acid methacrylate (HAMA), achieves high-resolution printing of biomimetic structures. The post-print TA treatment (0.25–30 mg/mL) significantly increases mechanical strength, improves degradation rates, and reduces the size and porosity of the resulting dual-crosslinked, hybrid network structures. The biocompatibility of these constructs was assessed using adult human dermal fibroblasts, revealing optimal cell viability and adhesion at low TA concentrations (0–0.25 mg/mL). Furthermore, the antioxidant capacity of TA-treated biomaterials was evaluated, demonstrating potential for applications in environments with high reactive oxygen species (ROS). Overall, this collagen-based biomaterial ink and post-print TA treatment offers a promising solution for the DLP 3D printing of tough, biodegradable, and biocompatible constructs for biomedical applications in regenerative medicine.

Fellin, C. R., Steiner, R., Yuan, X., & Jariwala, S. H. (2025). A collagen-based biomaterial ink for the digital light processing 3D printing of tough, dual-crosslinked hydrogels via post-print tannic acid treatment. Bioprinting, 50, e00422. https://doi.org/10.1016/j.bprint.2025.e00422

d dmytriiev, q liu, m barsa, a khomenko, a strokan, p pasquina, s cohen

Introduction This exploratory study investigates the potential of perineuromal hydrodissection as an adjunct to opioid therapy for postamputation pain, specifically focusing on residual limb and phantom limb pain (PLP). Given the correlations between acute pain and the development of chronic pain, the primary aims were to estimate the effect size of early hydrodissection of scar tissue around residual limb neuroma(s) and to identify the best time frame for treatment.

Methods Seventy-four patients with war-related limb amputations and painful neuromas were included in this observational analysis. Thirty-eight Ukrainian patients with war-related limb amputation and a painful neuroma(s) who underwent hydrodissection and opioid therapy within 6 months of amputation were compared with 36 patients who received opioids alone. Co-primary outcome measures were median reduction from baseline in average residual limb and PLP at 12 weeks. The composite positive outcome was designated as a ≥2-point decrease or 30% reduction in average residual limb and PLP, satisfaction with treatment, and not requiring an increase in analgesics.

Results Hydrodissection as an add-on to opioids resulted in a greater reduction in average residual limb pain at 12 weeks (−2.00±1.00 vs −1.00±1.00; p<0.001) and earlier time periods, but PLP only through 4 weeks. At 12 weeks, Hospital Anxiety and Depression Scale anxiety (10.00±2.00 vs 11.00±1.00; p<0.001) but not depression score was lower in the hydrodissection group. Opioid use in the hydrodissection group significantly declined from 41.32±9.63 to 33.42±8.78 morphine equivalents per day (p=0.001) over the study, but not in the opioid-only group (p=0.20). Differences in 12-week satisfaction rates were not significant.

Conclusions This exploratory study suggests perineuromal hydrodissection may improve residual limb pain and to a lesser degree phantom limb pain, particularly when implemented early in the course of postamputation pain. The study provides preliminary effect size estimates and identifies acute pain as a potential characteristic of patients who may respond more favorably to this intervention. Randomized controlled trials are needed to confirm these findings and control for the confounding variables identified.

Dmytriiev D, Liu W, Barsa M, Khomenko A, Strokan A, Pasquina P, Cohen S. Perineuromal Hydrodissection for Acute Postamputation Pain? An Observational Study in a Time of War. Regional Anesthesia & Pain Medicine Published Online First: 19 February 2025. doi: 10.1136/rapm-2024-106307

w liu, e gelderen, r mawalkar, e wang, g treisman, s cohen

Background: Difficult encounters represent an enormous burden and drain on resources in pain medicine, but their effect on outcomes has not been studied.

Objective: To determine the effect of “difficult” encounters on chronic pain outcomes.

Methods: In this prospective study, new chronic pain visits were rated by an attending physician and trainee on a 6-point Likert scale and stratified into “difficult” and “non-difficult.” The main outcome was successful treatment, defined as a ≥2-point reduction in average pain 4 weeks after initiation of pharmacological, integrative, or simple injection therapy, or 12 weeks after more invasive procedures. The secondary outcome was being lost to follow-up.

Results: Among 428 patients seen for new-patient evaluations, 299 patients had follow-up, of whom 127 (42.5%) experienced a positive outcome. Patients involved in difficult encounters were less likely to experience a positive outcome (28% vs 46%; P = .02) than those not involved in difficult encounters. When stratified into quartiles, difficulty continued to be associated with an unsuccessful outcome, with the easiest encounters translating to a 53% success rate, versus 28% for patients involved in the most difficult encounters (P = .02). Difficult encounters were not associated with loss to follow-up. In multivariable analysis evaluating factors associated with difficultness, missing ≥10% of appointments (OR 0.69, 95% CI: 0.48–0.97; P = .04), non-organic signs (OR 0.42, 95% CI: 0.18–0.90; P = .03), visit taking longer than expected (OR 0.49, 95% CI: 0.25–0.96; P = .04), and refusal to try a treatment (OR 0.25, 95% CI: 0.08–0.70; P = .01) were associated with poor outcome.

Winnie L Liu, Evelien van Gelderen, Resham Mawalkar, Eric J Wang, Glenn Treisman, Steven P Cohen, Do difficult encounters affect pain treatment outcomes? A prospective cohort study, Pain Medicine, 2025;, pnaf027, https://doi.org/10.1093/pm/pnaf027

m Mullinax, i sorensen, j dintaman, e hisle-gorman

Research suggests injury/disability type and individual demographic factors both impact return-to-work trajectories of those with injuries/disabilities. These questions of disability and return to work/service are particularly relevant to the military where service members are at increased risk of experiencing work-related physical and mental health injuries. The Army Warrior Care and Transition Program (WCTP) is a comprehensive rehabilitation program launched in 2007 to address injured service members’ needs. We sought to understand the WCTP’s efficacy in returning soldiers with physical and mental health injuries to military service (including active duty, Reserve, and Guard).

Melissa Mullinax, Ian Sorensen, Jay Dintaman, Elizabeth Hisle-Gorman, Effect of Serious Mental Health and Physical Injuries and Their Treatment on Career Trajectories for Military Service Members, Military Medicine, 2025;, usaf191, https://doi.org/10.1093/milmed/usaf191

goss d, gaunaurd i, rochester k, helton m, marshall a, reilly n, melton c, gailey r

Abstract accepted for podium presentation at the 2025 Naval Medical Center Camp Lejeune Research Symposium

Musculoskeletal injuries (MSI) are very common in the military population and even more common with very active and elite paratroopers in the 82nd Airborne Division.  Potter et al. published a one-year prospective cohort study in 2002 in Military Medicine outlining these injuries.  They followed 1,965 paratroopers in from Fort Bragg in 1996. These soldiers suffered 508 overuse injuries (including 38 stress fractures), 1,415 traumatic injuries (including 100 fractures), and 101 unclassified injuries. Injury rates were 6.8% per soldier per month for traumatic injury and 2.4% for overuse injury (totaling 1.2 injuries per soldier per year). Injuries resulted in 22,041 limited duty days, averaging 11 days per injury and 13 days per soldier (4.5% of total workdays). Fractures and stress fractures/reactions produced the most days lost per case. Most of these injuries resulted from military specific activities.

As part of a prospective injury prediction protocol involving knee sensors analyzing single leg stance and a side shuffle task, our Musculoskeletal Injury Rehabilitation Research for Optimal Readiness (MIRROR) team enrolled and screened 1183 soldiers from the 82nd Airborne Division at Fort Bragg/Liberty, NC from fall 2022 to fall 2023 with 6- month and 12-month MSI incidence evaluated in the electronic medical record (AHLTA and Genesis).

These results highlight the types of injuries an active group of soldiers from the 82nd Airborne Division are experiencing and can help to guide prevention and treatment strategies going forward.

m kasper, m smith, s simmons, c campbell, s cohen, s wilson

Abstract accepted for poster presentation at USU Research Days 2025.

Active duty Service Members may be at increased risk for developing knee osteoarthritis  (KOA) due to the fitness demands and predisposition for traumatic joint injuries. Military and civilian  patients may benefit from alternative procedures including genicular radiofrequency ablations (RFA).

Case 1 is a 56-year-old male retiree with chronic knee pain (> 5 years) and radiographic evidence of left KOA [Kellgren-Lawrence (KL) Score: 2]. Case 2 is a  79-year-old male retiree with chronic right knee pain (1-5 years) and radiographic evidence of right KOA (KL Score: 1). Both patients received genicular RFA procedures targeting nine nerve sites: superomedial, superolateral, inferomedial, inferolateral genicular nerves, nerve to vastus medialis, medial branches of  nerve to vastus intermedius, nerve to vastus lateralis, lateral branches of nerve to vastus intermedius,  and infrapatellar branch of the saphenous nerve. Patient-reported outcome measures [i.e., Knee Injury  and Osteoarthritis Outcome Score-12 (KOOS-12), Modified 4-Item Brief Pain Inventory Scale (mBPI)] were collected at baseline and 12 weeks post-procedure.

By day 7 post-procedure, both patients reported their knee pain to be very much improved and  0/10. mBPI scores (Case 1: -4.75; Case 2: -3) and KOOS-12 subscale scores for pain (Case 1: -1; Case 2: - 6), function (Case 1: -3; Case 2: -6), and quality of life (Case 1: -1; Case 2: -3) improved in both patients at  12 weeks post-procedure.

These cases demonstrate the modified genicular RFA technique can yield symptom relief as  soon as 1-week post-procedure, with overall improvement out to 12 weeks, which is consistent with  non-randomized studies demonstrating better improvement with targeting more nerves (nine versus  traditional three). These study results may support expansion of effective conservative treatment  options for military beneficiaries with KOA.

j galvin, p rooney, a Egan, j tokish, j grassbaugh, b masini, k free, m bastian, l gillette, z colburn

The purpose of this study was to compare gene expression differences in the blood and tissue of patients with anterior shoulder instability with and without significant glenoid bone loss (GBL). The hypothesis was that the severity of GBL would be associated with the expression level of genes in the blood and capsular tissue of patients with anterior shoulder instability.

Consecutive patients with anterior shoulder instability undergoing arthroscopic and open shoulder stabilization were prospectively enrolled. Blood and anterior capsular tissue specimens obtained during surgery were compared between patients with significant GBL (≥10%) and patients without significant GBL (<10%). RNA was extracted, and a panel of 277 inflammatory genes was utilized to quantify gene expression at the RNA level using a probe-based RNA quantification platform. Differential expression analysis was performed to identify genes expressed at different levels between patients with and without significant GBL. The expression levels of the subset of genes identified were used to generate a ridge regression model to predict the severity of GBL. Quantitative polymerase chain reaction was performed to confirm probe-based RNA findings.

A total of 17 patients were included, with a mean age of 26 years. Overall, 7 patients had <10% GBL (mean, 2.3%), and 10 patients had ≥10% GBL (mean, 16.4%). There were 9 genes that were identified as significantly differentially expressed in the blood, and 5 of these (IFIT1, IFIT3, IFI44, PRKCB, and OAS2 with P values of 1 × 10−5, 1 × 10−4, 1 × 10−4, 1 × 10−4, and 6 × 10−4, respectively) were confirmed using nonparametric tests. The authors developed a model using the 5 genes to predict the severity of GBL, and this had an accuracy of 88% (95% CI, 64%-99%). By quantitative polymerase chain reaction, IFIT3 was confirmed to be significantly differentially expressed (P = .012).

Galvin JW, Rooney P, Egan A, Tokish JM, Grassbaugh JA, Masini B, Free KE, Bastian MK, Gillette LH, Colburn ZT. Transcriptomics of Anterior Shoulder Instability: Differences in Gene Expression in the Blood of Patients With and Without Significant Glenoid Bone Loss. Orthopaedic Journal of Sports Medicine. 2025;13(5). doi:10.1177/23259671251336394

D rhon, s george, n parsons, j fritz

Beliefs can affect perceived harms and benefits of a treatment. The purpose of this study was to assess the relationship between beliefs about exercise and surgery effectiveness and pain interference and physical function in patients with non-specific low back pain. This was a cohort of 629 pooled clinical trial participants receiving non-pharmacological pain management. Participants either agreed (somewhat or completely) or disagreed that surgery would be beneficial or that exercise would make their symptoms worse. Those that agreed were categorized as having high expectations about the treatment. The influence of high expectations on short-term (6-week) and long-term (6-month) PROMIS Pain Interference scores was modeled with generalized linear (Gaussian) models. In a subset of 510 patients, the same analysis was conducted using PROMIS Physical function scores. The cohort was 28.8% female, mean(SD) age of 33.4(8.3) years and 83.1% active-duty. In all 67.1% had low expectations of exercise and 11.0% had high expecations of surgery. High expectations for surgery were not a significant predictor of pain interference or physical function. High expectations for exercise predicted lower pain interference (ß=−2.146, 95CI −3.366, −0.926; P<0.001) and higher physical function (ß=1.807, 95CI 0.586, 3.027; P=0.004) at 6 weeks and 6 months. High expectations for exercise were uncommon (about 33%) but associated with better outcomes out to six months. One in 10 patients had high expectations for surgery but this was not associated with outcomes. A better understanding of treatment expectations may present opportunities to improve engagement and education strategies for patients with low back pain.

Rhon D, George S, Parsons N, Fritz J. Expectations About the Benefit of Exercise, Not Surgery, are Associated with Future Pain and Physical Function in Patients with Non-Specific Low Back Pain. The Journal of Pain, Volume 31. 2025. 1526-5900. https://doi.org/10.1016/j.jpain.2025.105414.