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.