K Rochester, N reilly, c tucker, a marshal, g hess, b holloway, d masalleras, k ford, d goss

Abstracted accepted for a poster presentation at the 2025 American Physical Therapy Association North Carolina Chapter Annual Conference

Running is the primary form of cardiovascular exercise in all four branches of the United States military (Lovalekar, 2021). Running related injuries (RRIs) are the most common lower extremity injuries among military service members (MSMs) (Lovalekar, 2021).  Increased body mass index (BMI) has been associated with greater stress on runners’ bodies (Shiotani 2023, Jha 2023, Naderi 2020, van Poppel 2020, Wilson 2021).  This study compared three-dimensional running biomechanics between those of different BMIs three-dimensional that those with a greater BMI would run with less desirable biomechanics.

Soldiers completed an IRB approved consent form and were given a race bib with a number on it to run with it affixed with tape on their chests.  Soldiers ran 900 meters through a 12-camera (200Hz) markerless motion capture system three times. Data were processed utilizing machine learning algorithms to track the running motion and create 3D pose estimations. Soldiers were compared between BMI groups (normal BMI (NO < 25), overweight (OW >25 <30), and obese (OB >30) according to the American College of Sports Medicine criteria.) across lower extremity Hip, Knee and Ankle angles during stance phase using a one-way ANOVA with statistical parametric mapping (SPM) (p < .05).  Prospective injuries across 12 months are still ongoing and not presented in this abstract. 

A main effect was observed for a minimum of a percentage of stance phase between BMI groups for the Hip (X: 29.7%, t = 5.39; Y: 46.5%, t=5.47; Z: 34.7%, t=5.44) Knee (X: 57.4%, t=5.36; Y: 45.5%, t=5.36) and Ankle (X: 38.6%, t=5.68; Z: 22.8%, t=5.41).  Being mostly concerned with kinematics in the sagittal and frontal planes, we highlight those differences now.  Heavier Soldiers demonstrated decreased hip flexion and hip adduction.  Heavier Soldiers ran with decreased knee flexion at midstance and increased knee adduction.  Heavier Soldiers used the most plantar flexion at initial contact and not as much flexion in late stance.  There were no differences in ankle kinematics in the frontal plane.

Running with decreased sagittal plane motion at the hip and knee and increased adduction at the hip and knee may predispose heavier Soldiers for injury.  Increased hip and knee adduction has led to increased risk for injury in previous studies (Venable, 2022).  We hypothesize that running related injuries will be greater in Soldiers running with these kinematics and will have the 12-month prospective period completed NOV 2025 in time to share those results as well at CSM 2026.

N Hogaboom, m Smith, v morris, m st. laurent, x yuan, m nordstrom

Abstracted accepted for a poster presentation at the 2025 American Congress of Rehabilitation Medicine Annual Fall Conference

Neck pain is a significant problem among active-duty Service Members (ADSMs). A neck orthosis was designed as a minimally invasive device to correct forward head posture (FHP) and reduce associated neck pain. The primary study objective was to investigate the efficacy of the neck orthosis to reduce pain and improve function. Secondary objectives included evaluation of safety and treatment protocol adherence.

Participants were randomized into either immediate treatment (IT) or waitlist-control (WC) groups. Participants in the IT group received the collar and were instructed to wear it 20 minutes daily for 6 consecutive weeks. Those in the WC group continued with standard of care (SOC) treatment during first 6 weeks of study participation.

Thirty-five individuals completed the protocol (treatment n=18, control n=17). Changes in NPRS (U=259.5, p<.001, r=0.59) and NDI (U=89.5, p<.05, r=0.36) scores were significantly different between IT and WC groups. Post analyses revealed a significant main effect of time on NPRS in the IT group. Decreases of 2.0 points were observed (p<.001, r=.64), which surpassed the minimal clinically important difference of 1.3. No changes were observed in the WC group. No main effects of time on NDI were reported in either group (p>.05). Thirteen participants reported full adherence to the protocol (72.2%). Those who did not fully adhere to the protocol reported an average of 4.0±2.8 days of usage per week for 15.0±8.9 minutes per day. No serious AEs related to the protocol were reported.

The treatment protocol, which involved daily usage of the neck orthosis for six consecutive weeks, was safe and resulted in marked decreases in pain compared to a control group who received SOC treatment for neck pain. Improvements in function were observed, but these changes were not significant. Efforts should be made to improve adherence, as it is unclear how it impacted outcomes.

h allen, m holena, l allen, s zhao, r castillo, s cohen, r hurley, d scharfstein, j haythornthwaite, s raja, s wegener, c rini, f keefe, j bridges, r reeder, r thompson, d hanley, c campbell, SKOAP consortium

Treatment guidelines for knee osteoarthritis (KOA) vary across organizations, partly due to the lack of high-quality evidence. Experts disagree on the role of psychological management, pharmacologic treatments including opioids, and interventional therapies.

The Sequenced strategy for Knee OsteoArthritis Pain (SKOAP) trial is a multi-site, randomized, pragmatic clinical trial that uses a two-phase sequential design to evaluate the effectiveness of several interventions in individuals reporting KOA pain. Described here is the protocol for Phase 1 of the trial sequence which focuses on conservative treatments. All participants receive Best Practices (BP), a guideline-based approach to care that includes physical therapies, alternative treatments, and over-the-counter medications. Participants are then randomized to one of three groups: (1) BP alone, (2) BP plus duloxetine (30–120 mg/day), or (3) BP plus duloxetine and painTRAINER, a web-based, Cognitive Behavioral Therapy (CBT)-informed pain coping skills training. Phase 1 aims to determine whether the combination of duloxetine and BP improves pain compared to BP alone, and whether the combination of painTRAINER, duloxetine and BP provides additional benefit compared to duloxetine combined with BP. The analysis will include a modified Intention to Treat (mITT) approach and two Per-Protocol (PP) analyses; Receipt of Prescription (PP-ROP) and Minimum Effective Dose (PP-MinED). A third aim of Phase 1 is to identify clinical characteristics, patient-level factors, and psychosocial phenotypes that predict short- and long-term outcomes.

Findings from Phase 1 of the SKOAP trial will provide evidence on the effectiveness of non-opioid pharmacologic and psychological interventions for the treatment of painful KOA beyond established best practices. It may also help refine personalized treatment strategies.

Allen HM, Holena MM, Allen LE, Zhao S, Castillo RC, Cohen SP, Hurley RW, Scharfstein DO, Haythornthwaite JA, Raja SN, Wegener ST, Rini CM, Keefe FJ, Bridges J, Reeder R, Thompson RE, Hanley D, Campbell CM; SKOAP Consortium. Study design and protocol of a randomized, pragmatic, comparative effectiveness trial evaluating a sequenced strategy for improving outcomes in people with knee osteoarthritis pain (SKOAP): Conservative treatment evaluation. Seminars in Arthritis and Rheumatism. Volume 75. 2025. 152834. ISSN 0049-0172; doi.org/10.1016/j.semarthrit.2025.152834.

g bullock, j fallowfield, s De la motte, n arden, b fisher, a dooley, n forrest, j fraser, a gourlay, b hando, k harrison, d hayhurst, j molloy, p newman, e robitaille, d teyhen, j tiede, e williams, s williams, d van tiggleen, j van wyngaarden, r westrick, c emery, g collins, d rhon, ROMMIL Group

Introduction: A systematic approach to collecting and reporting injury data in military settings is necessary to maximize the impact of musculoskeletal injury-related research. An international consensus on recommended core data set of elements to capture and report is necessary. The purpose was to summarize the process and results from an international consensus study to establish recommended common minimum data elements for surveillance and Reporting Of Musculoskeletal injuries in the MILitary (ROMMIL).

Methods: A 10-step hybrid consensus process was performed. Knowledge users were embedded in the process for co-creation of pertinent questions, data elements, and voting. Evidence synthesis included a scoping review on the barriers and facilitators to implementing injury prevention programs, followed by a knowledge user survey. A sequential three round Delphi study refined and validated the final elements in the recommendation checklist. Consensus recommendations were presented to an international audience of stakeholders. Participants voted on each statement with 0 representing no importance, 5 somewhat important, and 10 maximum importance.

Results: The consensus recommendation includes one data principle of keeping continuous data continuous and 33 minimum data elements. Data elements include demographics, lifestyle, service branch, musculoskeletal/surgical history, exposure, and injury characteristics. The data principle endorsed by knowledge users recommends that continuous variables (e.g., age, weight, exposure) remain continuous and not categorized into groups. Dissenting viewpoints are detailed to provide fair and balanced consensus recommendations.

Conclusions: The ROMMIL checklist could be leveraged by clinicians, researchers, and knowledge users working in military settings when comparing and harmonizing data across studies, service branches, and countries. The ROMMIL checklist will support improved data synthesis to better inform evidence-based practice in military medicine, and the ability to generate more useful prognostic models to quantify injury risk.

Bullock GS, Fallowfield JL, DE LA Motte SJ, Arden N, Fisher B, Dooley A, Forrest N, Fraser JJ, Gourlay A, Hando BR, Harrison K, Hayhurst D, Molloy JM, Newman PM, Robitaille E, Teyhen DS, Tiede JM, Williams E, Williams S, VAN Tiggelen D, VAN Wyngaarden JJ, Westrick RB, Emery CA, Collins GS, Rhon DI; ROMMIL GROUP. Minimal Data Elements for Surveillance and Reporting Of Musculoskeletal injuries in the MILitary (ROMMIL) International Consensus Statement. Medicine & Science in Sports & Exercise 57(9):p 1914-1922, September 2025. | DOI: 10.1249/MSS.0000000000003737

p upadhyay, a banstola, b bhayana m wu

Photobiomodulation therapy (PBMT) alleviates fatigue and enhances mitochondrial bioenergetics, yet effects are modest when applied only to the thighs. Here, it is demonstrated that brief, non-invasive abdominal PBMT with 980 nm light (0.1 J cm−2) substantially improves endurance by preserving gut epithelial integrity and modulating microbiota. In graded treadmill protocols under anaerobic stress, combined abdomen-and-legs PBMT nearly doubles time to exhaustion versus sham by day 20 (70.23 vs 32.38 min; P < 0.0001) and remains superior at day 30 (55.56 vs 32.38 min; P < 0.0001). PBMT preserves mitochondrial cristae and mass in gastrocnemius and soleus muscles (P ≤ 0.0018), achieving a fourfold increase over sham (P < 0.0001). Abdominal PBMT maintains seven major gut phyla disrupted by intense exercise, enriches SCFA-producing taxa, reduces pathobionts, and elevates circulating and fecal butyrate, spermidine, L-carnitine, and acetylL-carnitine (all P ≤ 0.0001). Ex vivo assays under anaerobic, acidic conditions confirm PBMT-driven expansion of key anaerobes (P < 0.05–0.0001). In a lactic-acidosis model, abdominal PBMT reduces peak weight loss (≈5% vs ≈10%) and accelerates recovery. These findings establish abdominal PBMT as a non-invasive modality that reverses epithelial injury and dysbiosis, revealing translational potential for enhancing performance, rehabilitation, and managing disorders associated with dysbiosis or mitochondrial dysfunction.

P. Upadhyay, A. Banstola, B. Bhayana, and M. X. Wu, “ Photobiomodulation Strengthens Muscles via Its Dual Functions in Gut Microbiota.” Adv. Sci. (2025): e11582. https://doi.org/10.1002/advs.202511582

g bullock, j fallowfield, s De la motte, n arden, b fisher, a dooley, n forrest, j fraser, a gourlay, b hando, k harrison, d hayhurst, j molloy, p newman, e robitaille, d teyhen, j tiede, e williams, s williams, d van tiggleen, j van wyngaarden, r westrick, c emery, g collins, d rhon

The objective was to summarize the methodology used to develop the international minimum data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement. This is a recommended list of elements to be collected and reported when conducting injury surveillance research in military settings.

A Delphi methodology was employed to reach consensus. Preliminary steps included conducting a literature review and surveying a convenience sample of military stakeholders to 1) identify barriers and facilitators of military musculoskeletal injury (MSKI) prevention programs, 2) identify relevant knowledge gaps, and 3) establish future research priorities. A sequential three-round Delphi consensus survey followed, including relevant stakeholders from militaries around the world, using results to conduct an asynchronous knowledge user meeting (mixture of in-person and live video conference and recording) to explore the level of agreement among subject matter experts. Knowledge users, including former and current military service members, civilian practitioners working in military health networks, and international subject matter experts having experience with policy, execution, or clinical investigation of MSKI mitigation programs, MSKI diagnoses, and MSKI risk factors in military settings. For each round, participants scored questions on a Likert scale of 1-5. Scores ranged from No Importance (1) to Strong Importance (5).

Literature review and surveys helped inform the scope of potential variables. Three rounds were necessary to reach minimum consensus. Ninety-five, 65, and 42 respondents participated in the first, second and third rounds, respectively.

Achieving consensus across relevant knowledge users representing military organizations globally can be challenging. This paper details the methodology employed to reach consensus for a core minimum data elements checklist for conducting MSKI research in military settings and improve data harmonization and scalability efforts. These methods can be used as a resource to assist in future consensus endeavors of similar nature.

Bullock GS, Fallowfield JL, de la Motte SJ et al. Methodology used to develop the minimum common data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2025, 13:1044 https://doi.org/10.12688/f1000research.152514.2

D Rhon, P pasquina, D Teyhen

Noncombat musculoskeletal injuries are the single greatest threat to medical readiness. They also impart a tremendous burden on the Military Health System, accounting for the most medical encounters of any kind, more than double the next most common cause, mental health disorders. This has mobilized efforts to better understand injury causes, risk factors, and methods to mitigate the onset and impact of injuries. However, lack of standardization has led to great variability in how injury, risk factors, and injury-related outcomes have been defined. The variability in the definition of these terms limits the comparisons that can be made. Ultimately, this variability impacts our ability to understand the generalizability and applicability of current research. It also limits the ability to conduct meta-analysis, where data from multiple studies is combined and analyzed in aggregate, improving the precision of current research, and answering additional questions that could not be addressed by the original individual studies alone. The recent conclusion of an international effort led by the Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) workgroup to reach consensus on the recommended minimum data elements that should be collected and reported when assessing injury risk in military populations aims to help close this gap. The value of injury-related research in military medicine has the potential to substantially improve with widespread adoption of the ROMMIL checklist. Scientists working in military settings should use this checklist when planning their studies and when reporting their findings. Funders and journal editors should encourage use of the ROMMIL common data elements checklist whenever applicable.

Daniel I Rhon, Paul F Pasquina, Deydre S Teyhen, Improving the Quality of Musculoskeletal Injury Research in Military Settings: Introducing the Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) Common Data Element Checklist, Military Medicine, 2025;, usaf363, https://doi.org/10.1093/milmed/usaf363

A tenforde, l pham, l gaudette, m funk, k vogel, m bruneau, x yuan, j schroeder, b isaacson, N hager, e metzger, d nolan, j tam, k silbernagel

Non-insertional Achilles tendinopathy (AT) is a common running injury. Exercise loading programme (EXER) is the primary treatment. Other options include radial pressure wave (RPW, commonly referred to as shockwave) and photobiomodulation therapy (PBMT). We hypothesised that EXER+RPW and EXER+RPW+PBMT would result in greater reduction in symptoms measured using the eight-item Victorian Institute of Sports Assessment-Achilles (VISA-A) and greater improvement in functional outcomes compared with EXER. A secondary aim was to explore outcomes using elective treatment for three additional months.

Forty-six runners enrolled (24 males, 22 females; average age±SD:40±12 years). Runners assigned EXER+RPW had a greater improvement than EXER at 3 months in VISA-A (mean 33 vs 18 points, p=0.023; 95% CI 28.4 to 2.4), and no differences were detected between EXER+RPW+ PBMT and EXER (25 vs 18 points, p=0.12; 95% CI 25.9 to –10.8). There were greater improvements in running index measures, pain interference and social roles in EXER+RPW compared with EXER. VISA-A increased over 3 month crossover to EXER+RPW and EXER+RPW+PBMT (11 points, both p<0.05 compared with EXER).

There were 246,041 unique individuals in the cohort with a mean(SD) age of 37.9(12.3) years, 21.9% female, 63.1% on active duty, and 76.3% enlisted. Most patients were initially seen in a primary care setting (80.2%), followed by specialty care (16.7%) and emergency care(3.1%), and 44.4% of the patients were seen by physicians. Across all settings and clinician types, non-specific shoulder diagnosis (i.e. non-specific or unspecified shoulder pain) was the most common (73.9%), followed by rotator cuff-related pain disorders (15.9%), multiple specific diagnoses (3.7%), glenohumeral osteoarthritis (2.0%), and hypomobility disorders (1.8%). Patients who saw a specialty care non-physician were more likely to receive exercise or physical therapy than other clinician-location types, which was fairly consistent across all diagnostic groups.

Combined EXER and RPW had the largest measured reduction in symptoms at 3 months. However, all groups met clinical improvement, highlighting the importance of EXER. Larger studies in other physically active populations may clarify clinical benefits of each treatment.

Tenforde AS, Pham L, Gaudette LW, Funk MM, Vogel KE, Bruneau MM, et al. Exercise, radial pressure waves, and photobiomodulation for management of non-insertional Achilles tendinopathy in runners: a three-arm non-blinded randomised control trial. BMJ Open Sport & Exercise Medicine. 2025;11:e002442. https://doi.org/10.1136/bmjsem-2024-002442

D Rhon, M horn, h Lee, s Morton-Oswald, S George

Shoulder pain is common, can arise from various causes and has a highly variable prognosis. Treatment may differ based on the clinician delivering the care and initial care settings (primary, specialty, or emergency care). The purpose of this study was to investigate how the management of shoulder pain differs depending on clinical care settings and clinician type.

This was an observational cohort study. Using routinely collected health information from Military Health System electronic medical records and claims data, we assessed initial care setting and provider types for common shoulder disorders that occurred between July 1, 2013, and March 31, 2019. We identified shoulder-related care using current procedural terminology (CPT) and ICD-10 diagnosis codes marked in encounters within three months of initial diagnosis. Care was categorized into pharmacological treatment, non-pharmacological treatment, and imaging procedures, and compared across initial care settings and provider types.

There were 246,041 unique individuals in the cohort with a mean(SD) age of 37.9(12.3) years, 21.9% female, 63.1% on active duty, and 76.3% enlisted. Most patients were initially seen in a primary care setting (80.2%), followed by specialty care (16.7%) and emergency care(3.1%), and 44.4% of the patients were seen by physicians. Across all settings and clinician types, non-specific shoulder diagnosis (i.e. non-specific or unspecified shoulder pain) was the most common (73.9%), followed by rotator cuff-related pain disorders (15.9%), multiple specific diagnoses (3.7%), glenohumeral osteoarthritis (2.0%), and hypomobility disorders (1.8%). Patients who saw a specialty care non-physician were more likely to receive exercise or physical therapy than other clinician-location types, which was fairly consistent across all diagnostic groups.

Diagnostic subgroups of shoulder pain and initial care settings influence practice variability between physician and non-physician management of shoulder pain. Additionally, three out of every 4 patients received a non-specific shoulder diagnosis. These findings highlight the lack of coding using specific diagnostic labels, which prevents a deeper assessment of care care variability across specific shoulder diagnostic subgroups. Initial care settings should also be considered when exploring variability in care pathways for shoulder disorders.

Rhon DI, Horn ME, Lee HJ, Morton-Oswald S, George SZ. Treatment variability for shoulder pain between physician and non-physician clinicians based on initial setting and specific shoulder diagnosis: a health system analysis. BMC Health Serv Res. 2025 Oct 16;25(1):1370. doi: 10.1186/s12913-025-13175-w. PMID: 41094472; PMCID: PMC12529843.

a Champagne, j levin, e hurley, j dowe, b lau, o anakwenze, m provencher, c klifto, j dickens, Service academy shoulder instability study group

Quantitative means of characterizing glenoid bone loss (GBL) remain a growing field of interest. Here, a 3D volumetric GBL estimation is compared against standard 2D methods for GBL computation to elucidate the effect of morphological differences in glenoid anatomy as a culprit for mis-estimating GBL. Twenty-two shoulder MRIs from healthy participants (19 ± 0.5 years) were segmented to isolate the glenoid. Anterior and posterior bone defects (5%–25%) were simulated according to established patterns of GBL in shoulder instability. Circle-of-best-fit and surface-based measurements of percent GBL were compared against the proposed 3D volumetric computation using Spearman correlations. Discrepancies in 2D measurements relative to 3D parameters were analyzed in the context of glenoid bony morphology derived from depth-based projection mapping. Very weak to moderate agreement was documented for both anterior and posterior defects. Direct comparison of 2D perfect-circle and surface-area methods against 3D measurements showed that 2D methods often over- or under-estimate percent GBL, which varies according to bone morphology. Greater variability in 3D volumetric GBL measurements was observed across all defects, suggesting greater morphological variability captured by the 3D-based computation. MRI-based volumetric analysis of 3D glenoid reconstruction may provide relevant insight for understanding the role of morphological differences in estimating critical bone loss toward improving clinical decision making for surgical management of shoulder instability.

Champagne A, Levin J, Hurley E, Dowe J, Lau B, Anakwenze O, Provencher M, Klifto C, Dickens J, The Service Academy Shoulder Instability Study Group. “Quantitative Underestimation of Two-Dimensional Anterior and Posterior Glenoid Bone Loss Measurements Varies According to Bone Morphology,” Journal of Orthopaedic Research® 43 (2025): 1924–1933. https://doi.org/10.1002/jor.70055.

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.