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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Blinded participants were randomized to receive PBMT or sham-PBMT 3x/week x3  weeks at 10 J/cm2, 25W output power using the LightForce XPi and home exercises x6 weeks.  Sham-PBMT participants could crossover after 6-weeks. Outcomes included Defense and  Veterans Pain Rating Scale (DVPRS), Foot Functionality Captured via Foot and Ankle Ability  Measure (FAAM), and ultrasound measured fascial thickness.

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

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

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

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

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

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

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

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

r rossi, j persinger, n hager, s grogan

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

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

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

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

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

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

m Crowell, e florkiewicz, j morris, j mason, w pitt, t benedict, k cameron, d goss

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

Purpose/hypothesis: Shoulder instability is common in active young athletes and military personnel, often requiring shoulder stabilization surgery. Acute post-operative pain is usually managed with opioid pain medications, which have adverse effects that reduce military readiness. Battlefield Acupuncture (BFA) has demonstrated promise as a non-pharmaceutical intervention for acute post-operative pain. The purpose of this randomized clinical trial was to assess the effectiveness of BFA on post-surgical pain and opioid medication usage.

i gaunaurd, m sumner, p pasquina, a symsack, j haynes, c bennett, r gailey

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

Purpose/hypothesis: Veterans with lower limb loss (LLL) are a complex population with their own unique challenges with rehabilitation but share many commonalities with the general population. This case series highlights two examples of a physical therapist and patients with LLL who participated in the Mobile Device Outcomes Based Rehabilitation Program at the Bruce W. Carter VA Medical Center, Miami, FL using a novel mobile sensor system and application called Rehabilitative Lower Limb Orthopaedic Assistive Device (ReLOAD) to augment rehabilitation.

i gaunaurd, p pasquina, a symsack, m sumner, j haynes, t fields, a munoz-boyle, l prasso, christina sole-plasa, j stevens, c bennett, b applegate, b isaacson, r gailey

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

Purpose/hypothesis: Supported by the DoD/VA Joint Incentive Fund, Mobile Device Outcomes-based Rehabilitation Program (MDORP) utilizes mobile technology, called Rehabilitative Lower Limb Orthopedic Assistive Device (RELOAD) to enhance the rehabilitation of Services Members (SMs) and Veterans with lower limb loss (LLL). The ReLOAD system assesses walking quality, provides auditory feedback to correct gait deviations, and recommends patient-speci c exercises that target their impaired function and limitations. The purpose of this study is to examine the use of the RELOAD system in the clinical practice of Physical Therapists (PTs) to optimize assessment and care of SMs and Veterans with LLL.

A Symsack, i gaunaurd, j haynes, m sumner, c bennett, b isaacson, p pasquina, r gailey

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

Purpose/hypothesis: The home-based exercise program (HEP) for patients in rehabilitation following lower limb loss (LLL) is an integral part of the continuity of care outside the clinic for the maintenance and improvement of strength, mobility, and functional goals. However, clinical evidence shows that patients have varying degrees of exercise adherence to HEPs. Evidence-based exercise prescription to improve HEP adherence has suggested dosing of 20 minutes daily, minimum of three times per week or the completion of two-thirds of the prescribed exercise routine. The purpose of this study is to determine patient adherence to their HEP among SMS and Veterans with LLL using the Rehabilitative Lower Limb Orthopaedic Assistive Device (ReLOAD).

A Symsack, i gaunaurd, j haynes, m sumner, c bennett, b isaacson, p pasquina, r gailey

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

Purpose/hypothesis: The rehabilitation for Service Members (SMS) and Veterans with lower limb loss (LLL) can involve months of prosthetic training and targeted exercises intended to improve gait quality and functional mobility. During this time, Physical Therapists (PTS) prescribe home exercise programs (HEP) as part of the plan of care, which serve to augment treatment and improve or maintain patient function while outside the clinic. The purpose of this study is to identify the targeted exercise prescription trends following initial evaluation (eval) among PTS who are participating in the Mobile Device Outcomes Based Rehabilitation Program (MDORP) for SMS and Veterans with LLL.

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

Abstract accepted for poster presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

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

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

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

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

m smith, x yuan, j smith, j banks deal jr, g nanos, s tintle, d reece, m miller

Abstract awarded the Jamie Dianne Bulken-Hoover Memorial- Best Hand Paper at The Society of Military Orthopedic Surgeons Annual Meeting in Nashville, TN- December 2024

Carpal tunnel release (CTR) using a mini-open (mOCTR) or endoscopic approach is the current standard of care (SOC) in the Military Health System (MHS) for management of refractory carpal tunnel syndrome (CTS), the most common peripheral entrapment neuropathy. CTR techniques have evolved over time to reduce iatrogenic tissue trauma and post-operative pain, promoting quicker recovery and improved outcomes. CTR using Ultrasound Guidance (CTR-US) is a promising treatment option under study for military beneficiaries with CTS in a trial comparing outcomes of CTR-US and mOCTR.

This single-site pragmatic randomized controlled feasibility trial at Walter Reed National Military Medical Center (WRNMMC) was approved by the Institutional Review Board (WRNMMC-2020-0278). Military beneficiaries (18-89 years) with clinical, electrodiagnostic, and sonographic findings consistent with CTS were enrolled. Exclusion criteria included prior wrist surgery, median nerve trauma, or sonographic findings precluding safe and effective CTR-US.

Participants were randomized to receive either CTR-US by board-certified Physical Medicine and Rehabilitation physicians with advanced training in ultrasound-guided procedures in a clinic procedure room with local anesthesia, or mOCTR by board-certified Orthopedic Hand Surgeons in a clinic procedure room with local anesthesia or operating room (OR) with moderate sedation. CTR-US was performed under continuous ultrasound guidance with a device featuring inflatable balloons to create space within the carpal tunnel and a retractable blade that releases the transverse carpal ligament in a retrograde manner.

Demographics and patient-reported outcome measures (PROMs) were collected at baseline. Follow-up PROMs were collected at 1, 2, 3, 4, 6 weeks, 3, 6, 12, and 24 months post-procedure. The primary outcome was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) at 1 month. Additional outcomes included Boston Carpal Tunnel Questionnaire – Symptom Severity Scale (BCTQ-SS), Numerical Pain Rating Scale (NPRS), Global Assessment of Satisfaction, Global Rating of Change (GROC), modified 2-item CTS Palmar Pain Scale; grip and pinch strength (3 and 12 months); procedure time and incision length; and adverse events. Descriptive analyses reported central tendencies in terms of location (e.g., mean) and scale (e.g., standard deviation) for all study variables. Inferential analyses included two-sample Welch’s T-tests (α = 0.01) for procedural data and complete-case, intention-to-treat, generalized additive models incorporating multi-level structures through patient-level random effects for all other outcomes. No confidence interval (α = 0.05) overlaps on generalized additive models indicated statistical significance.

CTS is the most common peripheral entrapment neuropathy, impacting the health of military beneficiaries. CTS treatment barriers within the MHS include limited access to subspecialty care, lack of resources, and OR procedural costs. Preliminary data from this trial suggest that CTR-US can be performed within a clinic environment by non-operative physicians with advanced training, resulting in decreased post-procedural incisional pain and non-inferior outcomes compared to mOCTR approach out to 2 years. Outcomes of this WRNMMC trial can facilitate expansion of available CTS management options within the MHS, improving access to care and operational readiness.

cheema n, ghag n, wise e, pham l, nazarian a, fuchs c, tam j, anderson r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Fatigue is defined by the reduction of a muscle’s strength and performance during exercise, and it is affected by different parts of the motor pathway controlling muscle contractions. Fatigue limits performance and unless allowed to recover, continuous activity will result in musculoskeletal injuries that are commonly observed in military personnel. Light therapy has been shown to have several beneficial physiologic effects in a wide range of tissues. The musculoskeletal system can be irradiated with wavelengths in red and near infrared (NIR) regions which penetrate deep into the body. Recent studies are suggesting that photobiomodulation therapy (PBMT) can reduce pain, inflammation and enhance physical performance. However, the mechanism(s) of cellular responses by PBM in muscle is not clearly understood. There is no standardization in parameters for PBMT, with researchers and clinicians using a wide range of wavelengths, fluences, etc. Therefore, the goal of this study is to improve our understanding of the mechanism(s) of action of PBM effects on the musculoskeletal system, ultimately to inform the choice of clinical treatment parameters. We investigate the application of 830 nm and its effect on fatigue induced in intense exercise in mice. We performed a treadmill fatigue assay on mice and collected muscle tissue for histological and biochemical analysis. We observed that PBMT mice ran twice as long. Electron microscopy of fatigued muscle had some evidence of cellular stress where mitochondrial structure is altered whereas 830 nm treated muscle had a preservation of mitochondrial morphology. RNAseq data from fatigue muscle suggests that treated mice have an upregulation of genes involved in tissue remodeling, specifically cytoskeletal and vasculature markers. During muscle regeneration, mechanoreceptors, known as muscle spindle fibers form after innervation by the motor neuron. We saw increased number of muscle spindle fibers, which stimulate muscle contraction in response to stretch. Other signs of muscle regeneration, also observed in our treated muscle, are myoblast fusion and central localization of the myonucleus. In conclusion, our study suggests that 830 nm may have altered the muscle by activating regenerative genes that protect the muscle from cellular stress from intense exercise. 

Guastaldi f, monteiro j, giorgino r, tynan m, leartprapun n, nadkarni s, randolph m, redmond r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Articular cartilage and the meniscus are essential for smooth joint movements, but often degenerate due to trauma and overuse. Conventional repair methods like microfracture and autologous cell implantation frequently yield fibrocartilage instead of hyaline cartilage. Tissue engineering, exemplified by dynamic Self-Regenerating Tissue (dSRT), offers a promising solution by leveraging regenerative potential of cells. Fractional laser treatment, proven effective in skin regeneration, can be an adjunct for cartilage repair. This study evaluated the use of dSRT for cartilage and meniscus repair in a swine knee model. Laser Speckle Rheological Microscopy (SHEAR) was also employed to assess biomechanical properties.

dSRT displayed successful matrix formation, with good integration observed in laser-ablated channels in cartilage. This innovative approach holds promise for articular tissue resurfacing, albeit requiring further in vivo validation for knee meniscus repair.

giorgina r, rossi n, bejar-chapa m, monteiro j, guastaldi f, kostyra d, hussey m, tynan m, peretti g, randolph m, redmond r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Inflammation in shoulder and knee joints typically results in pain, stiffness and loss of function. Shoulder injuries in the military (rotator cuff tears, dislocations, etc) can lead to adhesive capsulitis ("frozen shoulder"). Similarly, arthritis involves inflammatory processes subsequent to injury. Both conditions are managed using non-steroidal anti- inflammatory drugs (NSAIDs), steroids, or surgery, with varying effectiveness and side effects. Photochemical tissue passivation (PTP) drastically reduces inflammation in wound healing and in this study we investigate PTP for reducing progressive inflammatory damage in both joints.

Reduced inflammation associated with frozen shoulder and knee osteoarthritis using PTP in rat models are highly encouraging. Findings highlight the important role of the joint capsule in frozen shoulder and the synovial tissue in the knee in the pathogenesis of arthritis.

giorgina r, monteiro j, guastaldi f, hussey m, tynan m, peretti g, randolph m, redmond r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Severe ligament injuries are associated with trauma involving excessive force to the knee joint, and are common in the military. Ligaments are fundamental for the structural and functional integrity of the knee and effective strategies for surgical repair are of paramount importance for return to active duty and long-term joint health. Photochemical tissue bonding (PTB) has good potential for treating complex orthopedic conditions, PTB using light and a photoinitiator to generate crosslinks between collagen molecules to augment mechanical strength. Advantages include focal precision, a barrier to adhesion between healing and surrounding tissues, and the ability to promote healing without foreign materials or invasive mechanical devices. In cases of complete injuries, the preferred treatment is generally surgical and reconstructive. In instances of isolated and non-complete injuries, non-operative treatment is indicated. However, partial ligament injuries pose a challenge as they often do not optimally respond to conservative treatments and can lead to long-term compromise of knee stability. This study examined the application of PTB in partial ligament injuries using the medial collateral ligament (MCL) in a swine model.

Self-healing of partial ligament injuries can lead to chronic instability, increased rupture risk, and early arthritis. Improvement of partial knee ligament repair with PTB would result in better outcomes through maintaining optimal biomechanical properties.