Velasco t, Reilly n, Roberts k, Hulsopple c, Hoellen d, Wise S, Dickison c, Goss d, Leggit j

Abstract accepted for a poster presentation at the 2024 Alexander T. Augusta Military Medical Center (ATAMMC) Research Day

Chronic exertional compartment syndrome (CECS) is characterized by intense localized pain, weakness, or paresthesia in the lower limb muscles, exacerbated by running.1,2 This condition significantly impairs active-duty service members (ADSMs) who regularly engage in running activities. While surgical interventions have shown mixed results, the exploration of non-surgical and pharmaceutical options, particularly botulinum toxin A (BoNT-A) and gait retraining, has gained attention.2-5 The purpose of this case series was to examine the biomechanical gait patterns observed in ADSMs with CECS pre and post non-surgical treatment.

In this case serires, the administration of BoNT-A was shown to be associated with more positive outcomes on pain reduction during running without leading to the adoption of gait patterns associated with injury risk. More extensive research is warranted to examine the effectiveness of BoNT-A for CECS from longitudinal perspectives.

Galvin J, egan a, Rooney P, Grassbaugh J, Masini B, Free K, Bastian M, Gillette L, Colburn Z

Abstract accepted for a poster presentation at the 2024 Madigan Research Day

Little is known about the pathobiology of unidirectional anterior and posterior shoulder instability. The purpose of this study was to compare gene expression differences in the peripheral blood and capsular tissue of young patients with recurrent anterior shoulder instability and those patients with unidirectional posterior shoulder instability.

There are significant gene expression differences in the shoulder capsule of anterior and posterior shoulder instability patients. This transcriptomic data may provide an improved understanding of the pathobiology of various forms of shoulder instability which could lead to future precision medicine approaches.

Galvin J, Rooney P, Tokish J, Grassbaugh J, Masini B, Free K, Bastian M, Gillette L, Colburn Z

Abstract accepted for poster presentation at the 2024 Madigan Research Day

Currently the measurement of serum or synovial biomarkers does not have a role in diagnosis or monitoring of injury severity in young patients with recurrent anterior shoulder instability. The purpose of this study was to compare gene expression differences in the peripheral blood and tissue of young patients with recurrent anterior shoulder instability with and without significant glenoid bone loss (GBL). Additionally, we sought to determine a peripheral blood transcriptomic biomarker for the reliable delineation of the severity of GBL in anterior shoulder instability patients.

There are significant gene expression differences in the peripheral blood of anterior shoulder instability patients with and without significant (≥10%) GBL. The differential expression of 5 genes allowed development of an accurate predictive model and transcriptomic classifier to predict the severity of GBL. This novel peripheral blood transcriptomic biomarker may assist in tracking glenoid bone loss and injury severity and progression in young patients with recurrent anterior shoulder instability.

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

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.

Juman l, schneider e, koehlmoos t

Abstract accepted at the 2024 Association of Military Surgeons of the United States

The U.S. military consists of approximately 1.4 million active-duty personnel and is responsible for providing a combat-ready force to protect the nation. Deployment limiting medical conditions (DLMCs) affect up to 7% of the military’s total force. Musculoskeletal injuries (MSKIs) degrade the physical fitness of individual service members through lost duty time & reduced training. In 2018, MSKIs accounted for >2 million outpatient medical encounters among military service members & are the leading reason for lost training time among Army personnel. It has been estimated that MSKIs result in >25 million limited duty days annually across all the Services.

This research makes a first attempt at identifying a standardized set of common data elements for musculoskeletal injuries across the DoD. This list of common data elements will enhance the capabilities of the MHS to study MSKIs in hopes of empowering the research community to drive meaningful understandings of the epidemiology of MSKIs in the MHS.

Persinger J, Hager N

The Incidence of stress fractures in military members has been reported to range from .8%-6.9% for men and from 3.4% - 21% for women.   The early identification is critical to optimizing treatment for bone stress injuries (BSI). The current gold standard for diagnosing BSI is either triple-phase, Bone scintigraphy technetium-99m, MRI or CT. Diagnostic, high frequency ultrasound (US) has been demonstrated to identify early periosteal changes in BSI.

This case report concluded that high frequency ultrasound is a relibale and accurate modality for early diagnosis of BSI and assiting with return to duty decision making. This diagnostic imaging tool for BSI is valuable, inexpensive, and easily accesible. Future studies are warranted to determine whether US could be a competitive screening tool vs MRI for initial BSI diagnosis

Persinger j, gabler g, hager n

Successful delivery of a Diagnostic Musculoskeletal US program requires a combination of hands-on experience with the ultrasound system, a thorough review of applicable, regional pathophysiology, and an overview of the technology aspects of the US acquisition system. Most often, these programs are delivered over several months in an in-person, academic setting that allows for student-educator, student-equipment, and student-patient interactions. During the initial COVID-19 outbreak and in response to campus policy and public mandates for distant learning, the Department of Physical Medicine and Rehabilitation at Uniformed Services University of the Health Sciences (USUHS) transformed a musculoskeletal (MSK) ultrasound clerkship into a virtual platform - training students deployed locally, nationally, and internationally. This modification of the educational approach allowed for delivering a high quality MSK Ultrasound Curriculum in a safe and often remote environment. Further, many of the successes gleaned from this experience during the pandemic enhanced future MSK educational programs for both medical students and physicians.

The implementation of the virtual MSK US clerkship at USUHS represents a paradigm shift for the department in providing training in hands-on skills for diagnostic sonography with direct application to clinical care. The ability to link students and instructors without geographical limitations provided a positive long-term impact on future similarly patterned courses. It also enabled this team to take lessons learned from the program and apply them to remote clinical education opportunities in the future.

Persinger J, Hager N, Grogan S, Mincey C

The Geneva Foundation (Tacoma, WA) in conjunction with Uniformed Services University of the Health Sciences (USUHS), and the Podiatry Clinic at Madigan Army Medical Center (MAMC) is conducting a research study to establish normative values for thickness and cross-sectional area (CSA), microvascular flow states, power Doppler flow states, and Young’s modulii in the posterior lower leg muscles (gastroc/soleus) and Achilles tendon. This study supports a concurrent study attempting to validate shear-wave elastography (SWE) and microvascular flow (MVF) as a novel, sensitive, and non-invasive means of determining the health and recovery state of the above structures.

Achilles tendinopathy, plantar fasciitis, and chronic exertional compartment syndrome (CECS) are commonly seen in the active-duty service member and military recruit population. These conditions are common contributors to significant warfighter disability, impacting operational readiness. Non-invasive technology such as microvascular flow and shear wave elastography may prove to be timely and cost effective.

Persinger J, Hager N, Gabler G, Karikari N, Rossi R, Schroeder J

Non-insertional Achilles Tendinopathy (AT) is a common overuse injury in adults whether athletes or inactive individuals. In the US military, lower extremity issues due to overuse, such as AT, are the most common category of injuries, with the highest occurrence in the Army. The current management of AT is largely conservative, although approximately 25%-29% of patients require surgical intervention. Photobiomodulation Therapy (PBMT) has been shown to decrease inflammation while increasing cell proliferation and metabolism which has been reported to aid in healing and more specifically with tendon repair. Additionally, Extracorporeal shockwave therapy (ESWT or SWT) is a process in which energy is delivered to muscles and tendons for pain relief and improved function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT. Diagnostic MSK Ultrasound with high frequency linear transducer has become the standard of care in the evaluation of AT, being used as a screening modality, to monitor disease process, and to direct treatment interventions. Additionally, more advanced & complementary ultrasound capabilities, such as elastography (SWE), and microvascular flow (MVF) have been developed to improve diagnostic acumen. The Geneva Foundation (Tacoma, WA) in conjunction with Uniformed Services University of the Health Sciences (USUHS), and the Family Medicine Department at Madigan Army Medical Center (MAMC) is conducting a Randomized Control Trial to evaluate and contrast the effectiveness of standard PT, SWT, vs PBMT in treating non-insertional Achilles tendinopathy. Diagnostic MSK Ultrasound is serving a pivotal role in screening and monitoring the treatment effects and this abstract/presentation will focus on describing this role through discussion of the equipment capabilities and findings as well as the relative changes in echo-architecture with each of the comparative arms.

Diagnostic MSK ultrasound serves a critical role in the screening, diagnosis and monitoring of these Achilles tendinopathy patients. No other imaging modality would permit the level of discrimination of pathology required in this Achilles tendinopathy study. Diagnostic MSK ultrasound with the unique, complimentary upgrades (described above) served to greatly improve overall assessment of the ongoing pathophysiologic changes within the tendon fibers throughout the course of treatment for Achilles tendinopathy. There are various pitfalls and technique optimizations that should be considered when evaluating the Achilles as described above. Accounting for these can greatly enhance the diagnostic acumen of the US Study.

Rhon D, de la motte S, Fraser J, hando b, Molloy J, Teyhen D, Tiede J, Van Wyngaarden J, Westrick R, Bullock G

Abstract accepted for ePoster at the 2024 IOC World Conference on Prevention of Injury and Illness in Sport

Injuries are the primary cause of lost duty in the US Military, leading to a widespread focus on, and implementation of injury mitigation programs. The effectiveness of these programs is often questioned, usually related to program fidelity. The objective of this cross-sectional survey study was to identify and characterize barriers and facilitators for implementing injury mitigation programs in the military.

While most stakeholders agree that injury mitigation programs are important, there appears to be a perceived disconnect between the tasks and training associated with operational readiness and the implementation of injury prevention programs.

Galvin J, Rooney P, Tokish J, Grassbaugh J, Masini B, Free K, Bastian M, Gillette L, Colburn Z

Abstract accepted for platform presentation at the 2024 Extremities War Injury Symposium

Currently the measurement of serum or synovial biomarkers does not have a role in diagnosis or monitoring of injury severity in young patients with recurrent anterior shoulder instability. The purpose of this study was to compare gene expression differences in the peripheral blood and tissue of young patients with recurrent anterior shoulder instability with and without significant glenoid bone loss (GBL). Additionally, we sought to determine a peripheral blood transcriptomic biomarker for the reliable delineation of the severity of GBL in anterior shoulder instability patients.

There are significant gene expression differences in the peripheral blood of anterior shoulder instability patients with and without significant (≥10%) GBL. The differential expression of 5 genes allowed development of an accurate predictive model and transcriptomic classifier to predict the severity of GBL. This novel peripheral blood transcriptomic biomarker may assist in tracking glenoid bone loss and injury severity and progression in young patients with recurrent anterior shoulder instability.

Crowell M, Thomasma E, Miller E, Brindle R, Roach M, Goss D, Pitt W

Abstract accepted as a platform presentation for the 2024 American Physical Therapy Association Combined Sections Meeting

Static balance is often impaired in patients after ankle sprains. The ability to identify balance control impairments is dependent on an effective balance assessment tool. The Sway Balance Mobile Application (Sway Medical, Tulsa, OK) uses a smart phone or tablet to assess static balance and shows promise as an accessible method to quantify changes in balance control after injury. The purpose of this study was to determine the validity and responsiveness of the Sway Balance Mobile Application (SWAY) to assess balance control after an acute ankle sprain. We hypothesized the application could differentiate individuals with an ankle sprain from healthy controls, measure improvements in balance control over time, and demonstrate strong correlation with the laboratory assessments of static balance control.

The SWAY mBESS is a valid and responsive clinical tool for evaluating static balance. The tool demonstrated discriminant validity detecting balance differences between a healthy and injured group, convergent validity demonstrating moderate to good correlation with established laboratory measures, and responsiveness to changes in static balance in military Cadets during recovery from an acute ankle sprain.

Carreno L, Miller E, Goss D, Mason J, Pitt W, Crowell M

Abstract accepted as a platform presentation for the 2024 American Physical Therapy Association Combined Sections Meeting

Ankle sprains are one of the most common injuries sustained in the military, resulting in lost time from duty and persistent disability. Transcranial direct current stimulation (tDCS) is a novel intervention used to rehabilitate athletic injuries and improve sports performance and may contribute to improved outcomes following ankle sprains. The purpose of this study was to evaluate the effectiveness of tDCS in addition to standard rehabilitation compared to standard rehabilitation alone on pain, self-reported function, strength, functional performance, and postural stability following acute inversion ankle sprain.

Future studies may consider investigating tDCS targeted to patients more likely to demonstrate changes in cortical excitability or neuroplasticity in addition to whether the application of tDCS following acute ankle sprain reduces the likelihood of developing chronic ankle instability.Future studies may consider investigating tDCS targeted to patients more likely to demonstrate changes in cortical excitability or neuroplasticity in addition to whether the application of tDCS following acute ankle sprain reduces the likelihood of developing chronic ankle instability.

Goss D, Gaunaurd I, Helton M, Applegate B, Bennett C, Haltiwanger H, Reilly N, Gonnella M, Black J, Deol G, Garr E, Thompson C, Gailey R

Abstract accepted as a platform presentation for the 2024 American Physical Therapy Association Combined Sections Meeting

The Region of Limb Stability (ROLS) quantifies static lower limb (LL) balance and stability by assessing segmental excursion during single limb stance (SLS). Previous research has established that the ROLS metric predicts LL musculoskeletal (MSK) injury occurrence in Division I Collegiate Athletes. Lower Limb injuries are a prevalent reason for Soldiers seeking medical care; therefore, predicting injuries has large implications on readiness. ROLS can be used as screening tool for identifying at-risk SMs who may require additional physical therapy assessment and/or pre-injury/prehab interventions to reduce the risk of MSK injury. The purpose of this study is to characterize ROLS in Active Duty SMs.

Nearly 30% of the SMs tested were at a high risk for LL MSK injury during baseline screening. Those at highest risk included Non-Commissioned Officers (E5-E9 rank). These findings suggest that ROLS can be used as a screening assessment tool to identify individuals at risk for LL MSK injuries and proactively intervene with further assessment and/or the implementation a pre-injury/prehab intervention. Further research is warranted to determine the effectiveness of ROLS SI as a routine tool for the reduction of injuries in Active Duty SMs.

Ignacio Alejandro Gaunaurd I, Helton M, Goss D, Applegate B, Bennett C, Gonnella M, Haltiwanger H, Reilly N, DeMichele S, Linowes S, Hunt A, Troiano M, Besowshek A, Gailey R

Abstract accepted as a platform presentation for the 2024 American Physical Therapy Association Combined Sections Meeting

Service Members (SMs) are at risk for musculoskeletal (MSK) injuries, especially injuries that affect the lower limbs (LL) and the ability to perform their duties. Therefore a screening measure designed to determine risk for LL MSK injuries would be meaningful. Recently, wireless sensors have been used to measure joint kinematics with the purpose of assessing performance and by extension quantifying risk of injury. Unique metrics derived from novel algorithms, such as the Transitional Angular Displacement of Segment (TADS), have been validated to assess dynamic balance, lower limb stability, and agility during the four-meter sidestep test (FmSST) in Collegiate Athletes. The purpose of this study is to characterize TADS in Active Duty SMs.

Eight percent of the SMs tested are at a high risk for LL MSK injury based on TADS screening. This is a considerable number of SMs who potentially could be injured resulting in limited duty, increased health costs or not achieving career goals.

Whitehurst r, Romanello a, Davis s, Reilly n, Goss d

Abstract accepted for the 2024 American Physical Therapy Association Combined Sections Meeting

By the nature of their work, Soldiers are regularly subjected to vigorous physical activity and corresponding increases in musculoskeletal injury risk1,2. Holistic Health & Fitness (H2F) is an interdisciplinary approach developed for the implementation of multidimensional care and attainment of optimal performance within the U.S. Army. Specifically, H2F was developed to enhance physical, mental, spiritual, nutritional and sleep readiness for Soldiers in contrast to reactive management of injury-induced symptomology observed in many hospital settings3. This study examined the clinical outcomes and corresponding efficacy of the H2F program in comparison to standards of practice currently in place across the U.S. Military Health System.

The H2F program saw more expedient treatment operations for Soldiers with musculoskeletal injury and observed significantly improved clinical outcomes compared to standard practices conducted at major hospitals.

Mabry L, Ross M, Reilly N, Young B, Keil A, Gisselman A, Davenport T, Goss D

Abstract accepted as a platform presentation for the 2024 American Physical Therapy Association Combined Sections Meeting

The purpose of this study was to examine physical therapist awareness and utilization of diagnostic imaging referral privileges. A secondary purpose was to determine if self-reported direct access frequency impacted diagnostic imaging referral or utilization of diagnostic imaging skills.

 There is a general lack of awareness of imaging privileges among physical therapists which appears to be influenced by level of jurisdictional scope. Awareness of imaging privileges significantly impacts its likelihood of incorporation into practice. The American Physical Therapy Association (APTA) should consider working with state boards to raise imaging privilege awareness potentially via integration into a jurisprudence exam. Additionally, this study further links diagnostic imaging referral as an essential tool for direct access. This further supports expansion of physical therapist diagnostic imaging referral to all 50 states consistent with direct access authority.

Galvin J, egan a, Rooney P, Grassbaugh J, Masini B, Free K, Bastian M, Gillette L, Colburn Z

Abstract accepted for the 2024 American Academy of Orthopaedic Surgeons Annual Meeting

Little is known about the pathobiology of unidirectional anterior and posterior shoulder instability. The purpose of this study was to compare gene expression differences in the peripheral blood and capsular tissue of young patients with recurrent anterior shoulder instability and those patients with unidirectional posterior shoulder instability.

There are significant gene expression differences in the shoulder capsule of anterior and posterior shoulder instability patients. This transcriptomic data may provide an improved understanding of the pathobiology of various forms of shoulder instability which could lead to future precision medicine approaches.

Galvin J, Rooney P, Tokish J, Grassbaugh J, Masini B, Free K, Bastian M, Gillette L, Colburn Z

Abstract accepted for the 2024 American Academy of Orthopaedic Surgeons Annual Meeting

Currently the measurement of serum or synovial biomarkers does not have a role in diagnosis or monitoring of injury severity in young patients with recurrent anterior shoulder instability. The purpose of this study was to compare gene expression differences in the peripheral blood and tissue of young patients with recurrent anterior shoulder instability with and without significant glenoid bone loss (GBL). Additionally, we sought to determine a peripheral blood transcriptomic biomarker for the reliable delineation of the severity of GBL in anterior shoulder instability patients.

There are significant gene expression differences in the peripheral blood of anterior shoulder instability patients with and without significant (≥10%) GBL. The differential expression of 5 genes allowed development of an accurate predictive model and transcriptomic classifier to predict the severity of GBL. This novel peripheral blood transcriptomic biomarker may assist in tracking glenoid bone loss and injury severity and progression in young patients with recurrent anterior shoulder instability.

Smith m, Abboud Chalhoub c, Hogaboom n, Dellanno r, St Laurent m, Yuan x, Nordstrom m

Abstract accepted for a platform presentation at the 2024 American Physical Therapy Association Combined Sections Meeting

Chronic neck pain is a common health condition for military personnel across all occupational specialties. A recent (2023) systematic review highlighted the need for higher level evidence regarding the efficacy of conservative interventions for musculoskeletal pain conditions in this population. The etiology of neck pain is often multi-factorial and can include mechanical (e.g., poor posture), occupational (e.g., desk work, manual labor), and psychosocial factors (e.g., anxiety, depression). The reduction of cervical lordosis in forward head posture (FHP) can lead to muscular imbalances, degenerative spinal changes, and heightened neck pain. The efficacy of a FHP therapy collar is being explored within the military population with chronic neck pain in an ongoing randomized waitlist-controlled trial at a military medical center.

Evaluating the treatment effect of a simple, non-invasive, wearable device for neck pain is highly relevant to the military considering the unique occupational and fitness requirements. Recent studies have suggested that current treatment strategies may be less effective within this population. This participant demonstrated improved posture, neck pain reduction and improved function after wearing the FHP therapy collar for 6 weeks in comparison to 6 weeks of no collar use. This ongoing trial will shed further light on the potential utility of this novel device in reducing neck pain due to FHP, and thereby improve functional outcomes and operational readiness.