a sheean, k spinder, d jin, l withrow, l harris, m bradley

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

INTRODUCTION: Increased knee pain prior to ACL reconstruction (ACLR) may portend worse post-op pain, difficult rehabilitation, prolonged recovery, and/or increased knee pain at 2 years. We aimed to identify demographic and injury factors influencing baseline (BL) pain and knee function in military Service Members (SMs) undergoing ACLR. We hypothesized that female sex, enlisted status, smoking history, presence of meniscal and/or chondral injuries, and prior history of mental health diagnosis (MH dx) predict increased pain and decreased physical and knee-related function. 

METHODS: The Military Orthopaedic Tracking Injuries and Outcomes Network (MOTION) was queried for CPT code 29888 to compile a list of all primary & revision ACLR and primary ACL repairs performed by MOTION surgeons from 2016-2023. A fellowship trained surgeon reviewed all operative reports noting graft type, procedure type, meniscal and chondral pathology, and treatments. Inclusion required primary ACLR with available operative reports and BL PROMs (SANE, PROMIS-PF, PROMIS-PI, IKDC). Multivariable linear regressions were used to model BL PROMIS PI and BL IKDC. The predictors in the model included age, sex, previous meniscus surgery, officer or enlisted SM status, smoking, MH dx, presence of grade 3/4 chondral injuries, meniscal tears, race, and BL PROMIS PI, and IKDC models. All tests were two-sided, with an α = 0.05.

RESULTS: 606 SM that underwent primary ACLR were included in the final analysis. There were 443 males (73.1%) and163 females (26.9%) with a mean age of 26.0 years (22.0; 33.0 years.) Overall, enlisted SM status was significantly associated with BL PROMIS PI. After controlling for other predictors in the model, those who are officers have lower BL PROMIS PI compared to those who are enlisted (Estimates = -2.93 (-4.17, -1.69), P < 0.001). The top two predictors of increased BL pain were enlisted SM status and previous history of MH dx. After controlling for other predictors in the model, BL PROMIS PI was significantly associated with BL IKDC. Those with a higher BL PROMIS PI had lower BL IKDC ((-7.66 (-9.18, -6.14), P-value < 0.001). 

CONCLUSION: Enlisted SM status and previous history of MH dx significantly predicted more pain and worse knee-specific function prior to ACLR. These results help to forecast those SM at risk for greater pain and worse function and should inform strategic efforts to appropriately allocate resources to address perioperative SM outcomes and force readiness.

a sheean, k spinder, m scarcella, d jin, j arner, a athiviraham, s defroda, c nuelle, j ernat, d cognetti, t dekker, l harris

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

INTRODUCTION: Anterior cruciate ligament (ACL) injury is a leading contributor to NMSKI, lost duty days, and limited deployability in Service Members (SMs). Despite advances in ACL reconstruction (ACLR), return-to-duty (RTD) rates remain suboptimal. Psychological factors, including resilience and mental health (MH), may affect recovery and readiness, but baseline resilience (BR) is not well characterized. This study aimed to describe BR, assess sex differences, and examine its relationship with MH, with the hypothesis that females and those with poorer MH would report lower resilience.

METHODS: From 2023–2025, patients undergoing ACLR were prospectively enrolled across an eight-site network (six civilian, two military treatment facilities). Preoperative patient-reported outcome measures included the Connor-Davidson Resilience Scale (CD-RISC-10) and PROMIS Mental Health (MH). Continuous variables are reported as medians (IQR), and Pearson correlations assessed the relationship between resilience and MH. Analyses were conducted in SPSS v30, two-sided, with α=0.05.

RESULTS: One thousand sixty-one patients (541 males [50.6%], 528 males [49.4%]; median age 26.0 years (IQR 19.0, 37.0) were included in the final analysis. Median baseline MARX activity score was 11.0 (IQR: 1.0, 16.0), PROMIS Physical Function (PF) 15.0 (IQR: 14.0, 17.0), PROMIS MH 16.0 (IQR: 14.0, 18.0.) The median CD-RISC 10 was 32.0 (IQR: 29.0, 38.0.) Correlational analysis between biological sex and continuous study outcomes indicated that, compared to males, female subjects reported significantly lower physical activity level (r= 0.77, P = 0.021), worse MH r= 0.79, P = 0.024), and more pain at baseline (r = -0.073, P = 0.017). No other significant differences in continuous study variables were identified between males and females. Regardless of biological sex, there was moderate positive correlation between baseline MH and resilience (r = 0.547, P = 0.01.)

DISCUSSION/CONCLUSION: BR did not differ by sex despite differences in other readiness-relevant measures. The association between resilience and MH identifies a potentially modifiable factor influencing recovery trajectories and RTD. Early identification of at-risk individuals may enable targeted psychological interventions to improve functional recovery, reduce limited duty time, and enhance force readiness. These findings support integration of psychological optimization strategies into perioperative care pathways for SMs undergoing ACLR.

m smith, n hogaboom, v morris, x yuan, m nordstrom

Abstract accepted for podium presentation at the 2026 Military Health System Research Symposium (MHSRS)

Introduction: Chronic neck pain impacts active-duty Service Members (ADSMs) across all occupational specialties. Reduction of cervical lordosis in forward head posture (FHP) can lead to myofascial restrictions, and increased neck pain. This study investigated the safety and efficacy of a novel, non-invasive therapy collar to improve FHP and neck pain among ADSMs.

Methods: This single-site, randomized, waitlist-controlled trial at WRNMMC was approved by the Institutional Review Board (WRNMMC-2021-0347). ADSMs (18-55 years) with chronic neck pain and FHP were enrolled and randomized into one of two groups: Immediate Treatment (IT) or 6-Week Waitlist-Control (WC). Participants were instructed to wear the collar for 20 minutes daily for 6 weeks. Outcome measures [e.g., Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI)] and radiographs were collected at baseline, 6-, and 12-weeks post-enrollment. Linear mixed-effects models were used to estimate between-group differences in change from baseline to 6 weeks for each outcome and to assess longitudinal changes within the IT group out to 12 weeks. Statistical significance was set at p < 0.05 for all tests.

Results: 35 participants (IT: n = 18; 72.2% F, 37.9 ± 6.8 years; WC: n = 17; 47.1% F, 39.0 ± 6.6 years) completed the 6-week intervention and were eligible for analysis at 6- and 12-weeks (n = 34). At 6 weeks, the age-adjusted between-group differences in NPRS and NDI change scores were -2.59 points (SE = 0.52, p < 0.0001) and -6.37% (SE = 2.73, p = 0.026), respectively, demonstrating statistically significant between-group differences favoring the IT group. The IT group additionally met the MCID for the NPRS (-2.00 ± 1.78) compared to WC group (+0.59 ± 1.23), but neither group met the MCID for the NDI (IT: -3.67 ± 7.89 %; WC: +2.71 ± 8.24 %). There were no significant differences noted in radiographic measures. At 12 weeks, the IT group demonstrated sustained improvement on the NPRS and NDI. 

Conclusion: Evaluating the effects of a wearable, take-home device for neck pain due to FHP is highly relevant to ADSMs considering their occupational requirements. Preliminary results suggest donning a therapy collar for 6 weeks can yield pain reduction and functional improvement compared to conventional treatment out to 12 weeks, despite no significant radiographic changes. This suggests the short-term pain reduction may be in part due to improvements in myofascial restrictions, although further research is needed.

m bradley, j dowe, MOTION Collaborative

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

Introduction: Patient-reported outcomes (PROs) are essential for value-based orthopaedic care, yet achieving high pre-operative completion rates remains challenging. The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) is an ongoing effort enrolling TRICARE beneficiaries undergoing orthopaedic surgeries (upper extremity, lower extremity, or spine). Validated PROs are collected as part of pre- and post-operative standards of care. This study evaluates best practices for pre-operative PRO completion by comparing different implementation strategies across multiple centers.

Methods: Completion rates were calculated by comparing total patient enrollments to surveys completed before surgery. A total of 20 sites were categorized based on workflow strategy: [1] dedicated staff-driven (employees) vs. clinical staff-driven (surgeons/nurses), and [2] high-input (staff-driven interactions) vs. low-input (no staff interactions). Qualitative analysis assessed staff training, engagement levels, and technology usage (tablets, QR codes, or emails). Data from 2,792 patients were analyzed over a 6- month period.

Results: Cross-sectional analysis revealed that a "hybrid approach"—combining automated pre-visit emails with in-clinic assistance (tablet/QR code)—achieved the highest completion rates (average >80%). Clinics relying solely on patient-initiated QR code scanning had the lowest completion rates (average <50%). Sites utilizing dedicated employees (site coordinators) for collection achieved an average of 10-20% higher completion rates than those relying solely on existing clinical staff (surgeons/nurses). Furthermore, highly engaged staff who integrated PRO completion into the routine patient encounter increased compliance by an average of 30% compared to disengaged sites. While QR code availability was intended to reduce barriers, reliance on QR code-only methods in- clinic resulted in lower completion rates (range 0-50%).

Discussion: Optimal pre-operative PRO implementation requires a proactive hybrid approach, integrating automated pre-visit notifications with dedicated staff assistance in the clinic to overcome logistical barriers. Successful, long-term implementation depends heavily on active staff engagement and reducing the reliance on patient-initiated, remote-only enrollment. A structured hybrid approach is sustainable, effective, and crucial for high-fidelity data collection across diverse clinical settings.

d gordon, a whitfield, n lawson, m humphrey, e starr, m aderman, j trump, j curtin, k o’donovan, m donahue, k cameron

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

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 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 determine the expression profile of inflammatory cytokines in the patient plasma near the time of injury.

Methods: A prospective case-series study design was conducted among Cadets enrolled at a US Service Academy. Potential subjects with a knee joint injury were referred to and screened by a military orthopaedic surgeon to determine eligibility for the study. Subjects underwent informed consent and provided demographic and injury history information. In addition to an aspiration of the knee during initial evaluation, blood plasma samples were collected within 96 hours of injury.  Plasma samples were collected, stored, and batch-screened by ELISA to probe for the presence of a panel of pro- and anti-inflammatory cytokines and select other blood-based biomarkers.

Results: We performed ELISAs on plasma collected from 15 enrolled suspected knee joint injury subjects. Preliminary analyses show that while some cytokines like IL8 and VEGFA were mostly undetectable, other biomarkers like OPN, MMP3, and A2M, as well as pro-inflammatory markers IL6, TNFA, MIP1, and MCP1were readily detected and largely consistent across all subjects. Notably, however, anti-inflammatory cytokines IL10, IL1RA, and TGFB1 were elevated in several subjects with concordance across some subjects. 

Conclusion: These observations suggest several conclusions: 1) undetectable IL8 and VEGFA are consistent with limited angiogenesis and a lack of neutrophil recruitment; 2) consistent levels of several biomarkers suggests ongoing but regulated immune signaling, low-grade matrix turnover, and protective counterbalance against excessive extracellular matrix degradation; and 3) the elevation of IL10, IL1RA, and TGFB1 suggests some patients may be exhibiting inflammation resolution and joint homeostasis, while others may remain in a more persistent inflammatory equilibrium.

j dowe, m aderman, m bradley, a hartin, j robins, t dekker, r waltz, l leclere, m slabaugh, s gee, m donahue, k cameron, j dickens

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

INTRODUCTION: Compared to the general population, US service academy members have a 20x higher risk of sustaining a shoulder instability event during their time of enrollment. With such prevalence exists an impact on military medical readiness, necessitating the need to identify and treat this common condition efficiently to optimize recovery. This study aims to understand the relationship between demographic and injury history variables and the incidence of future instability events.

MATERIALS AND METHODS: This prospective cohort study recruited cadets entering their first-year at the US Air Force Academy. Demographic, health history, and sports participation information was collected at the time of enrollment. Those who experienced glenohumeral joint instability (GHJI) events during their time at the academy were identified and followed for additional analysis. Univariate and multivariable logistic regression models were used to assess the association between potential risk factors and incidence of injury. Statistical significance was set at p<0.05.

RESULTS: 1,445 participants (41.11% female; 18.93±1.00y; 175.14±10.01 cm; 71.53±12.03 kg) completed baseline demographics and injury history. 49 individuals (58.06% female; 20.62±1.23y; 176.09±9.22 cm; 73.21±12.82 kg) were identified as having experienced GHJI during the surveillance period. Of those injured, 10 experienced multiple instability events (5 bilateral, 5 unilateral), resulting in a total of 59 instability events for analysis. 33 of the injuries were subluxations, and 26 were dislocations of the shoulder. Indication of a history of shoulder instability at baseline was the key factor significantly associated with a 2.82x increased likelihood of subsequent injury (OR=2.82; 95% CI, 1.33-5.99; p=0.007). Additionally, participation in an overhead sport (OR=1.71, p=0.094) and a history of previous shoulder surgery (OR=6.82, p=0.068) showed positive trends toward an increased chance of injury. No significant association was found for sex, or subjective feelings of instability.

CONCLUSIONS: As shoulder instability is a known threat to readiness and delayed return to duty, it is essential to place those at higher risk in a position to succeed through proper recognition and treatment. Applying this knowledge early in a service member’s career may increase longevity and further enhance duty capabilities. Addressing key factors associated with GHJI is critical for future duty optimization.

j dowe, m bradley, h gibbs, j robins, r waltz, l Leclere, k cameron, m donahue, m slabaugh, t dekker, j dickens

Abstract accepted for podium presentation at the 2026 Military Health System Research Symposium (MHSRS)

INTRODUCTION: US service academy members have a 20x higher risk of sustaining a shoulder instability event during their time of enrollment compared to the general population. As a result, great efforts have been made to identify risk factors, optimize treatment, and promote return to duty strategies. The purpose of this study was to understand rates of morphological variations in shoulders and how this relates to injury risk.

MATERIALS AND METHODS: This IRB-approved study voluntarily recruited freshman at the beginning of their enrollment at three major service academies (USAFA, USMA, and USNA). Participants consented to provide bilateral shoulder magnetic resonance imaging (MRI) studies, injury history details, and baseline functional assessments. Shoulder instability events after enrollment were identified for further analysis. All MRIs of those with pre-existing shoulder injuries were measured and evaluated for comparison to the MRI of the uninjured shoulder. A paired t-test was performed to compare morphological measurements within subjects.

RESULTS: 10 individuals were removed due to having a history of bilateral instability. 66 individuals with a prior instability event in a single shoulder completed screening MRIs post-enrollment. A total of 132 shoulder MRIs were measured and analyzed. Mean glenoid bone loss (GBL) was significantly greater in injured shoulders compared to healthy shoulders (9.1% vs 6.2%, p<0.001). Injured shoulders also demonstrated significantly greater glenoid retroversion (8.2° vs 1.5°, p<0.001), and reduced posterior acromial tilt (36.2° vs 53.1°, p<0.001) relative to healthy shoulders. Hill-Sachs lesions (HSL) were present in 65 of 66 injured shoulders, with a mean lesion area of 0.7mm2. As of June 2025, 10 of these 66 shoulders with a pre-existing injury went on to have subsequent injury and shoulder stabilization surgery.

CONCLUSIONS: Shoulder instability events are especially common in individuals during their military career. We identified 66 service academy freshmen presenting with pre-existing shoulder instability pathology on MRI, and 15.2% went on to have subsequent shoulder instability events and surgery. In the injured shoulders, we identified a moderate rate of GBL and glenoid retroversion, and a 98% rate of HSL on screening MRIs. These findings highlight the incidence of shoulder instability injuries early in military careers, emphasizing the importance of efficient management to allow for enhanced long-term readiness.

T velasco, n reilly, c hulsopple, r boeth, k roberts, d hoellen, c dickison, d goss, j leggit

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

Introduction: Chronic exertional compartment syndrome (CECS) significantly limits the running capacity and operational readiness of active-duty service members (ADSMs) and often leads to medical discharge. While fasciotomy is the traditional standard treatment, its success in the military population has mixed results. Emerging non-surgical treatments include Botulinum toxin A (BoTN-A) and gait retraining. This clinical trial investigated the effects of these interventions on intra-compartmental pressures (ICP) the current diagnostic gold standard for diagnosis. 

Materials and Methods: 35 ADSMs with suspected CECS underwent ICP testing of the anterior compartment (AC) and lateral compartment (LC). Participants were randomized into a 2x2 factorial design: injection (BoTN-A vs normal saline injection) and gait retraining (supervised gait retraining (SGR) vs home-based gait retraining (HBGR). ICP was measured at baseline and six months post-intervention. A positive diagnosis was defined by Pedowitz criteria.

Results: At baseline, a total of 65 legs and 37 legs met Pedowitz criteria for AC and LC CECS, respectively. While AC pressures showed no significant differences between intervention groups over time, LC pressures demonstrated significant reductions. Specifically, the BoTN-A + HBGR showed statistically significant decreases in LC pressures from baseline to 6 months (p < 0.05). Furthermore, the BoTN-A + SGR group trended toward lower pressures compared to saline-control groups at the 6-month follow-up.                                                                                                                 

Conclusions: These findings suggest that non-surgical interventions can successfully reduce ICP in ADSMs with CECS, particularly in the lateral compartment. The combination of BoTN-A and gait retraining may provide a viable alternative to surgery, potentially improving functional outcomes. These results support the integration of multimodal conservative management to maintain the tactical athlete’s adherence to readiness standards and ability to deploy.

v pav, c colahan, g hileman, b hando, p pasquina, x yuan, b isaacson

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

INTRODUCTION: Musculoskeletal injuries (MSKIs) are the leading cause of limited duty and non-deployability across the Military Health System (MHS), yet variation in access to MSKI-related surgical care remains poorly defined. Delays related to travel distance, time from referral, and time away from duty may hinder recovery and return to duty. We developed a replicable framework to evaluate surgical distribution and travel burden among active duty service members (ADSMs). Shoulder instability was selected as a proof-of-concept condition due to its prevalence and impact on performance and readiness. We hypothesized that private sector care (PC) would be associated with greater travel distance than direct care (DC).

METHODS: MHS Data Repository (MDR) was used to identify ADSMs (<64 years) undergoing shoulder stabilization surgery during FY2024–2025 using CPT codes. Median [interquartile range] travel distance between residence and surgical location zip codes was calculated using the MDR drivetime file. Surgical volume and median travel distance were compared across DC, resource sharing (RS), and PC. Differences were assessed using Kruskal–Wallis and post-hoc Wilcoxon rank-sum tests with Bonferroni correction. 

RESULTS: Among 4,225 shoulder stabilization procedures, DC accounted for 51.6%, PC 35.0%, and RS 13.4%. The highest procedure volumes were observed in NC (13.18%; n=557), CA (12.76%; n=539), CO (9.14%, n=386), and TX (8.02%; n=339). Median travel distance differed significantly by setting (p<0.0001): DC (2.58 miles [0–22.41]), RS (12.15 miles [7.53–19.64]), and PC (23.13 miles [11.18–49.37]). Regional variation was substantial. High-volume states (e.g., CA, NC) showed low travel burden, while select PC markets had extreme distances (e.g., Houston, TX: 203.7 miles and Bismarck, ND 123.1 miles). Several DC facilities demonstrated zero-distance travel, indicating on-installation residence and care.

CONCLUSION: Shoulder stabilization surgery among ADSMs is delivered across a geographically variable system, with greater travel burden in PC. Increased travel may result in more time away from duty and delays in postoperative care, especially co-occurring with longer referral times, which are being added to the analysis. High-volume military regions may result in more efficient access, whereas selected regions rely on referral pathways. Optimizing access to surgical care may help accelerate recovery timelines for shoulder instability and other MSKIs.

d rhon, n parsons, t greenlee, e metzger, s hole, n hager

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

Background: Lower extremity stress fractures are one of the most consequential injuries in military service members, disproportionately affecting trainees. They represent a substantial source of morbidity, training disruption, and health care utilization, with incidents as high as 40% reported in trainees. The purpose of this study was to compare the effectiveness of active versus sham low-level laser therapy (LLLT) on graduation rates in military trainees with lower extremity stress fractures. The secondary aims were to compare pain and physical function outcomes.

Methods: Participants were trainees at the Medical Education and Training Campus, San Antonio, Texas, with an MRI-confirmed metatarsal and/or tibial stress fracture, enrolled between June 2023 and November 2024. All participants received standard-of-care treatment and were randomized to either active or sham LLLT. The primary outcome was on-time graduation at four months, and secondary outcomes included the Defense and Veterans Pain Rating Scale (DVPRS) and Lower Extremity Functional Scale (LEFS), also at four months. Changes in bone healing were assessed on magnetic resonance imaging from baseline to four months.

Results: The mean age (SD) was 23.7 (4.7) years, 54.4% female, and 80.6% in the US Army. In 46.6% of the cohort, both extremities were affected; tibia involvement was 69.9% and metatarsal 30.1%, with severity of stress fractures ranging from grade I to IV. Only 36.9% of participants graduated without delays. There was no statistically significant difference in graduation rates between sham or active treatment groups. Furthermore, sex, laterality, and stress fracture location did not predict successful graduation rates. Pain (mean difference[95CI] DVPRS -0.7312 [-2.308,0.8456]) and function (mean difference[95CI] LEFS 5.8101 [-8.0288,19.649]) were also not significantly different.

Conclusion: Graduation rates, pain intensity, and physical function did not differ significantly between military trainees who received LLLT and those who received sham. Given the substantial resource investment, the routine use of LLLT may impose unnecessary burdens on both trainees and healthcare systems and is not recommended.

M smith, x yuan, v morris, e harris, l lechanski, n parsons, r condon

Abstract accepted for poster presentation at the 2026 Military Health System Research Symposium (MHSRS)

Introduction: Dry needling (DN) is an intervention employed by a myriad of providers to treat musculoskeletal (MSK) conditions. Active duty Service Members (ADSMs) are at an increased risk of developing MSK conditions due to their occupational and fitness requirements. Prior surveys within the United States have focused on physical therapists (PTs) within orthopedic treatment settings. This study aims to compare the current DN practices across different medical 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 including PTs, athletic trainers (ATs), and physician associates (PAs) within the MHS were eligible to complete the survey. The survey was disseminated through relevant professional networking. The survey is comprised of 33 questions focused on provider characteristics, training/experience, clinical practice trends, and barriers. Categorical variables will be presented as counts and proportions. Unadjusted and adjusted logistic regression models were used to discern relationship between provider characteristics and current DN use.

Results: 755 participants (61.3% active duty) completed the entirety of the survey. 58.3% (n = 440) reported that they currently perform DN in their practice. Occupation, specialty certification and treatment setting were associated with current DN use. PTs with an orthopedics specialty certification (p < 0.0001) had statistically higher odds of current DN use. In addition, treating in a human performance/sports medicine model increased the odds of DN use (p = 0.003). The shoulder, head/neck, and low back/pelvis were within the top three most frequently reported treated body regions for PTs, ATs, and PAs, the occupations most frequently performing DN within the MHS. 

Conclusion: MSK injuries remain a prevalent barrier to military readiness, therefore, having a minimally invasive intervention at the fingertips of medical personnel is valuable. PTs followed by ATs and PAs are most often using this modality as an adjunct to treat the shoulder, head/neck, and low back/pelvis within the MHS. Survey results support the need for practice and training standardization, streamlined credentialing processes, and more prospective research protocols to help shape policy and clinical practice guidelines.