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.

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.

t velasco, n reilly, c hulsopple, k roberts, s wise, d goss, j leggit

Abstract accepted for poster presentation at the ATAMMC Research Symposium 2025.

Background and Purpose: Chronic exertional compartment syndrome (CECS) is a debilitating condition for soldiers marked by lower-limb pain, paresthesia, and weakness1,2. While the gold standard treatment has long been fasciotomy, anecdotal data shows mixed results and limited predictive success following the procedure3,4. Alternative approaches to treating CECS have included pharmaceutical interventions (i.e., Botulinum toxin, BoTN-A)5,6 and structured gait retraining to ameliorate movement patterns7. However, the incorporation of a combination of non-surgical interventions for CECS has not been extensively studied in military personnel. Thus, the purpose of this case study was to evaluate a multimodal combination of treatment approaches for CECS in a soldier to identify an efficacious way to address running parameters and reduce pain to improve function.  

Case Description: A 27-year old female Soldier diagnosed with bilateral anterior and lateral lower leg CECS was recruited to participate in a larger cohort study.  She received saline injections and supervised gait retraining, including strengthening and flexibility exercises. The participant had their running gait assessed using pressure-sensitive insoles (LoadSol, Novel USA, St. Paul, MN) at the initial treatment, after 8-weeks, 3-months, and 6-months. Time points of 12- and 24-months running assessments were not collected as she moved out of network. Between the 3- and 6-months visit, the participant elected to cross-over treatment therapies and received BoTN-A. Clinical metrics included numeric pain rating scale (NPRS), the Single Assessment Numerical Evaluation (SANE) and University of Wisconsin Running Index (UWRI), as well as the Global Rating of Change scale (GROC). These metrics were obtained up to 24 months post initial injection.

Outcomes: From baseline to the 3-month mark, the participant showed improvement on clinical metrics including a 90.9% increase in UWRI and a GROC of 5. These metrics are accompanied by a 22.5% increase in cadence and a 10.2% decrease in peak ground reaction force (GRF). Notably, the patient still reported an NPRS of 5/10 (7/10 baseline) with running at 3-months. Following the BoTN-A injections, the participant at 6-months displayed a 17.9% decrease in average vertical loading rate (AVLR) and a 2.0% decrease in peak GRF. Clinically, she displayed improvements in UWRI of 47.6%, SANE of 20.0%, and a GROC of 6, along with NPRS of 0/10 with running. At 12-months, NPRS remained at 0/10 with running, but UWRI and GROC scores slightly decreased, likely from her reported knee injury. At 24-months, the participant reported no pain with running and perfect SANE, UWRI, and GROC scores.

Discussion: This case study demonstrates gait retraining can be beneficial for improving pain and function in soldiers with lower leg CECS.  The addition of BoTN-A injections in this case suggests it may be a useful supplemental modality in rehabilitation for long-term benefits for CECS patients. However, further research is needed to confirm these findings in a larger population.

k Foster, s wang-price, l brizzolara, m weber, r boeth, x yuan, d rhon

Abstract accepted for platform presentation at the 2025 Combined Sections Meeting- American Physical Therapy Association

Exercise is a treatment recommended in clinical practice guidelines for low back pain (LBP). The primary purpose was to determine the impact of receiving therapeutic exercise (TE) for the management of LBP on time-to-occurrence of subsequent lower extremity (LE) injury within 1 year, in beneVciaries of the Military Health System (MHS). The secondary purpose was to examine the dosing impact (number of TE sessions) on time-to-occurrence of subsequent LE injury in beneVciaries who received TE.

Participants were placed into one of two groups: those receiving TE or those not receiving TE. Cox proportional hazards regression models were used to examine the utilization of TE and the number of TE sessions along with the demographic factors of interest on the time-to-occurrence of subsequent hip, knee, and ankle injury, respectively.

There were 452,668 patients in this cohort (mean age (SD) = 35.5(12.3), 65.2% male, 62.8% active duty; 80.6% of active duty enlisted). Only 16.5% of patients received TE, but each additional TE visit signiVcantly decreased subsequent LE injury risk. In addition, several demographic factors signiVcantly increased the risk of subsequent hip, knee, or ankle/foot injury including age, being on active duty, receiving the initial diagnosis in the emergency room (ER) or urgent care (UC), and being in the Army, whereas other factors such as being in the Navy or Coast Guard, or being an ohcer signiVcantly reduced the risk of LE injury in the year following an initial LBP diagnosis.

Following LBP diagnosis, individuals who did not receive TE had an increased risk of subsequent LE injury in the year following the episode of LBP. Further, in individuals who did receive TE, the risk of subsequent LE injury signiVcantly decreased with each additional session. The results of the study highlight the potential downstream impact and health implications of LBP, as well as information to guide to treatment and return to duty decisions after LBP.

e metzger, n hager, r ory, w lucio, l wagner, b isaacson, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Photobiomodulation therapy (PBMT) involves applying non- ionizing forms of  light from various sources including lasers, light-emitting diodes (LEDs), and broadband light, in  the visible and near infrared spectrum, to biologically modulate cellular activity to enhance  healing. PBMT can enhance repair and regeneration of tissue, stimulate metabolism, and reduce  inflammation and pain during injury recovery. This program investigates the use of PBMT to treat musculoskeletal injury (MSKI) and enhance performance and recovery in United States  (US) military Service Members (SMs).

We conducted five clinical trials and one observational study at US military  installations to assess the application PBMT for MSKIs and performance and recovery.  Currently, 344 participants have enrolled. Data included objective measures and self-reports. 

When applied for plantar fasciitis (PF) and Achilles tendinopathy (AT), there were  improvements in self-reports across the injuries and treatment groups [vs. Sham for PF, and vs.  Standard of Care, extracorporeal shockwave therapy (SWT), PBMT alone, and in combination  with SWT for AT] in the Foot Functionality Captured via Foot and Ankle Ability Measure  (FAAM), Defense and Veteran Pain Rating Scale (DVPRS),Victorian Institute of Sport  Assessment-Achilles (VISA-A), University of Wisconsin Running Injury and Recovery Index  (UWRI), and Lower Extremity Functional Scale (LEFS). Objective ultrasound measures also  trended towards improvement. Further results for treating bone stress injury, general  wellness/recovery, and planned projects for performance will be available at the time of the  conference.

n hughes, b cornell, r rossi, e metzger, n hager, g gabler, l wagner, b isaacson, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Special Operations Forces (SOF) train continually to maintain peak performance,  thus, are always in a state of recovery. Photobiomodulation therapy (PBMT) is a noninvasive  low-level laser treatment to enhance healing, recovery, and performance. Studies have shown  performance and recovery benefits with focal applications of PBMT. While less evidence exists  for psychological effects of systemic PBMT applications, self-reported fatigue was found to be  lower with focal PBMT compared with placebo. Further, PBMT research in elite warfighters is  limited. The Army Tactical Human Optimization Rapid Rehabilitation and Reconditioning  (THOR3) provides a consistent setting for strength and cardiovascular training, conditioning,  nutritional and behavioral health monitoring and is an optimal setting to assess the effect of  PBMT on performance and behavioral measures. We aim to study the physiologic and  behavioral effects of PBMT, post-exercise, on performance in SOF.

We will conduct a single-blind, randomized-control trial in healthy SOF operators, assigned to receive PBMT or sham-PBMT post- training. Treatment will be administered 3  times/week for 3 weeks to both quadriceps. Objective measures include body fat percentage,  height/weight, isokinetic/isometric leg strength, Oura ring sleep/activity data, and  countermovement jump. Subjective measures include demographics, Rating of Perceived  Exertion, Short Questionnaire of Fatigue, delayed muscle soreness scale, Defense Veterans Pain  Rating Scale, and activity logs.

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

R rossi, j schroeder, s grogan, n hager, e metzger, g gabler, j persinger, n karikari, s mckee, b isaacson, l wagner, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Non-insertional Achilles Tendinopathy (AT) is a common overuse injury in athletes and United States military Service Members. Photobiomodulation therapy (PBMT)  delivers non-ionizing light to produce beneficial outcomes. Extracorporeal shockwave therapy  (SWT) delivers mechanical energy to the tendon and has been shown to be effective for AT. The  addition of PBMT to SWT is hypothesized to enhance these effects by increasing cellular  function and healing. Our primary aim was to evaluate PBMT, SWT, and Physical Therapy (PT)  on non-insertional AT.

Forty-five participants were randomized to: PT only, PBMT+PT, PBMT+SWT+PT, or SWT+PT. SWT treatment: 1x/week/3 weeks at 15hz for 3000 pulses. PBMT treatment: 2x/week/3 weeks at 10 J/cm2, 25W. Study duration was 6 months. Outcomes: activity logs,  pain/functional surveys, ultrasound tendon thickness measurements, and Range of Motion (ROM). 

At 3-months, all groups improved in Defense and Veterans Pain Rating Scale, Lower  Extremity Functional Scale, University of Wisconsin Running Injury and Recovery Index (PBMT+SWT+PT: + 7.1 units; p = 0.1), Patient-Reported Outcomes Measurement Information  System (6-week function scores: SWT+PT > PBMT+PT; p < .1), & Victorian Institute of Sport  Assessment-Achilles. PBMT+SWT+PT group had a Long Axis Maximal Circumference decrease of 3.1 mm (p = 0.1). Treatment with SWT increased Knee Flexed Passive Dorsiflexion  by 5.37° (p = .01). No significant intergroup differences in the above outcomes at 12-weeks (p > 0.1).

These results justify further investigation in the optimal dose/treatment frequency  of SWT+PBMT. Our findings can inform clinical treatment options for AT to optimize recovery  and return to activity.

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

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

On average, two million patients receive treatment annually for Plantar Fasciitis  (PF) in the United States. Athletes and Active-Duty Service Members are more prone to PF from repetitive foot stresses and biomechanical predispositions (high arches, excessive pronation, etc.) Photobiomodulation therapy (PBMT) uses non-ionizing light forces to enhance performance,  alleviate pain/inflammation, promote healing and may be effective in treating PF. This study  assessed the clinical effectiveness of PBMT compared to sham-PBMT for PF in Active-Duty Service Members.

Blinded participants were randomized to receive PBMT or sham-PBMT 3x/week x3  weeks at 10 J/cm2, 25W output power using the LightForce XPi and home exercises x6 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.

FAAM scores improved for the PBMT group (N = 33) at 6-weeks: -17.2 points (SD:16.1; p < .01); sham-PBMT group (N = 35): -11 points (SD:17.1; p = .08); no statistically  significant intergroup differences (p > .05). Both groups experienced median absolute change in  DVPRS scores at 6 weeks: -1.0 points; no significant intergroup differences (p > .05). 6-week  median absolute change in thickness: PBMT: -.01 mm; sham-PBMT: 0.3 mm.

Both groups met the threshold for a minimum clinically important difference on the FAAM (≥ 8-point decrease) and decreased DVPRS. The PBMT group experienced a small  PF thickness decrease. These findings indicate that PBMT may be an effective adjunctive  treatment for PF pain/function.

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

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Lower extremity injuries are common sources of disability and time loss for  athletes and military servicemembers. Microvascular flow (MVF) and shear wave elastography  (SWE) may be non-invasive, efficient, and cost effective in early diagnosis and treatment of  musculoskeletal injuries (MSKIs). This study aimed to establish normative values for routine  tendon echo-characteristics, presence/absence of plantaris tendon, MVF vs Power Doppler (PD),  and SWE measurements in the posterior lower leg and Achilles tendon.

Ultrasound was performed on asymptomatic participants using a Samsung RS-85  Prestige. Orthogonal measurements were obtained along the Achilles at the calcaneal insertion  (CI), avascular zone (AVZ), gastro-soleus junction (GSJ), medial gastrocnemius, and soleus.  Outcomes included: thickness/width 2D imaging measurements, vessel quantification in PD &  MVF, SWE analysis, plantaris tendon visualization, Body Mass Index (BMI), ankle Range of  Motion (ROM), and self-reports (demographics & activity).

MVF detected flow in 9 limbs vs 1 by PD (n = 106). Increased BMI resulted in  increased tendon/gastroc measurements: (p < .01); SWE [r(63) = 0.41] & AVZ SWE [r(63) =  .33]. Long-Axis median: GSJ height = 0.2 cm, CI = 0.4 cm, & AVZ height = 0.5 cm. Short-Axis  mean AVZ width: males = 1.5 cm (SD: 0.2), females = 1.4 cm (SD: 0.2). Plantaris tendons  identified in > 50% of study population (59 out of 106 limbs).

Our findings will inform the normal, routine, and novel ultrasound values for the  Achilles tendon complex and its related structures. This may help improve the diagnosis and  treatment of MSKIs.

r rossi, j persinger, n hager, s grogan

Abstract accepted for poster presentation at the 2025 Association for Medical Ultrasound Convention in Orlando, Florida.

The current study was initiated to help inform and validate a parallel study being conducted in the same clinical setting. This was done to elucidate the normative values for routine tendon echo-characteristics, presence/absence of plantaris tendon, microvascular flow (MVF), shear-wave elastography (SWE), Power Doppler (PD), & Young’s moduli in the posterior lower leg & Achilles tendon. Both the parallel study and the current one used the Samsung RS-85 Prestige ultrasound and TeleRay Remote for image review/remote exam observation. Additionally, an EZ Exam protocol was standardized across all users and image acquisition was done exclusively by RMSK-certified staff. Imaging was obtained from the gastroc-soleus complex to the Achilles insertion with stop points at the gastrocnemius, soleus, gastroc-soleus junction (GSJ), avascular zone (AVZ), and calcaneal insertion (CI). Our findings confirmed the sensitivity of MVF at detecting flow over PD. We were able to establish normative values for both SWE and in routine Achilles tendon architecture. Additionally, plantaris tendon prevalence in our study population was found to challenge current existing literature. These findings will inform the normal state of the Achilles tendon complex & its related structures with novel ultrasound values in order to improve the diagnosis and treatment progression of musculoskeletal injuries.

Galvin J, Milam r, patterson b, mepola j, buckwalter j, wolf b, say f, free k, yohannes e

Abstract accepted for platform presentation at the 2024 Society of Military Orthopaedic Surgeons (SOMOS) Annual Meeting

The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury.

Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis.