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

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

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

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

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

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

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

c fellin, r steiner, x yuan, s jariwala

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D rhon, s george, n parsons, j fritz

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

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

A Sheean, m tenan, M defoor, d cognetti, a bedi, a lin, t dekker, motion collaborative, j dickens

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population’s fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve–based MCIDs and baseline-adjusted ROC curve MCIDs.

All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive).

A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7.

When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Sheean AJ, Tenan MS, DeFoor MT, Cognetti DJ, Bedi A, Lin A, Dekker TJ; MOTION Collaborative; Dickens JF. Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery. J Shoulder Elbow Surg. 2024 Nov;33(11):e596-e605. doi: 10.1016/j.jse.2024.02.044. Epub 2024 Apr 16. PMID: 38614369.

E Anies, r Waltz, S lacey

A 49-year-old man presented with repeated episodes of right posterior knee effusions 11 months following right knee medial meniscus debridement. He was referred to Physical Medicine & Rehabilitation (PM&R) by his orthopaedic surgeon for further non-operative management. He had previously undergone ipsilateral vein stripping procedures with vascular surgery 5 months following his meniscal procedure. MRI of the knee with contrast along with a subsequent ultrasound evaluation with no evident power doppler flow confirmed the presence of a right posterior-medial gastrocnemius fluid collection extending extramuscularly into the proximal 1/3rd of the medial head of the gastrocnemius muscle. These imaging findings combined with the yellow-clear aspirate consistent with synovial fluid confirmed the presence of a Baker’s cyst with unusually distal extramuscular extension and subcutaneous location just superficial to the medial head of the gastrocnemius muscle. Successful implementation of platelet rich plasma (PRP) and Doxycycline tissue sclerosis emphasised the key role that nonoperative modalities have in treating Baker’s cysts. The patient continues to respond appropriately with resolution of his symptoms noted 3 weeks after his initial sclerotherapy session and an additional treatment performed with half the initial dose of doxycycline. This case demonstrates the successful treatment of a baker’s cyst with an unusually distal location.

Anies E P, Waltz R A, Lacey S (January 15, 2025) A Baker’s Cyst with Distal Extramuscular Extension: A Case Report. Cureus 17(1): e77502. doi:10.7759/cureus.77502

a weart, l brown, e florkiewics, g fresinger, k east, n reilly, j song, d goss

Background: Running biomechanics have been linked to the development of running-related injuries in recreational and military runners.

Purpose/Hypothesis: The purpose of this study was to determine if personal characteristics or running biomechanical variables are associated with running-related injury incidence or time to injury in military cadets undergoing training. It was hypothesized that a rearfoot strike pattern, greater rate of impact, or a lower step rate would be related to a greater running-related injury incidence and a decreased time to injury.

Study Design: Cohort study; Level of evidence, 2.

Methods: Military cadets wore an on-shoe wearable sensor that analyzed biomechanical variables of foot strike pattern, rate of impact, running pace, step rate, step length, and contact time during cadet basic training (60 days). Running-related injuries during cadet basic training were determined by medical record review. Personal and running variables between the injured and uninjured cadets were compared using independent t tests and chi-square analyses. Time to injury and hazard ratios (HRs) were estimated using Kaplan-Meier survival curves and Cox proportional hazard regression models, respectively.

Results: Of the 674 cadets who completed the study, 11% sustained a running-related injury. A significantly greater proportion of the injured participants were female (χ2 = 7.95; P = .005) and had a prior history of injury (χ2 = 7.36; P = .007). Univariate Cox proportional hazard regression models revealed greater injury risk in females (HR, 1.96; 95% CI, 1.22-3.16; P = .005) and cadets with a prior injury history (HR, 1.86; 95% CI, 1.18-2.93; P = .008). After adjusting Cox models for prior injury, females were found to be at a 1.89 times (95% CI, 1.17-3.04; P = .009) greater risk of injury. Running biomechanical variables were not associated with injury risk.

Conclusion: Study results indicated that non-modifiable risk factors such as female sex and prior injury history increased the risk of running-related injury in cadets undergoing military training. Running biomechanical variables measured by the wearable sensor were not associated with injury in this study.

Weart A., Brown L., Florkiewicz E., Freisinger G., East K., Reilly N., Song J., Goss D. (2025) Using Wearable Sensor Technology to Analyze Running Technique and Prospective Running-Related Injuries During United States Military Cadet Basic Training. Orthopaedic Journal of Sports Medicine. https://doi: 10.1177/23259671241309273