Rhon d, arden n, motte s, fallowfield j, fisher b, bullock g

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

Musculoskeletal injuries threaten military readiness. The ability to aggregate data and make valid comparisons across settings, military branches, and nations is only possible when data can be harmonized. The purpose was to reach international consensus on the minimum core data elements that should be collected and reported when conducting injury surveillance in military settings.

Steering committee members were selected to balance expertise across clinical and research backgrounds, country, and military branches, along with policy, implementation, or clinical/scientific investigation related to musculoskeletal injuries in military settings (n=45). Pertinent parties were engaged to improve the overall question, understand research implications, and facilitate knowledge translations. A synchronous mixed pertinent party meeting (n=62) was performed to explore level of agreement by experts who were identified through the closeness continuum. The moderator presented each statement with discussion prior to voting. Participants voted anonymously. Each statement was scored on a scale of 0-10, with 0 representing no importance and 10 representing maximum importance. Comments could be submitted to facilitate further discussion and elaboration. A majority was needed for inclusion. Dissenting opinions were discussed and included in the final consensus document.

33 minimal data elements were recommended when conducting surveillance and reporting of injuries. This core checklist can be leveraged by clinicians, researchers and stakeholders when comparing and harmonizing data across studies, military service branches, and countries.

Colahan c, pav v, yuan x, isaacson b, wagner l, hando b

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

Musculoskeletal injuries (MSKIs) are highly prevalent and costly conditions among active duty Service members (ADSMs). Female Service members sustain MSKIs at higher rates than males. However, lack of female-specific MSKI research in the US Military has limited Department of Defense leaders from assessing and addressing their burden. The purposes of this study were to report the incidence, prevalence, and types of MSKIs sustained by female ADSMs across four Services in direct care (DC) and private sector care (PC) settings from fiscal years (FYs) 2016-21, and to quantify and describe MSKI-related healthcare utilization and private sector costs in females over the same period.

This retrospective, longitudinal population study included ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence/incidence rates for Head/Neck, Upper Extremity (UE), Spine, and Lower Extremity (LE) MSKIs in female ADSMs, associated healthcare utilization, and PC costs were derived by querying electronic health records from the Military Health System (MHS) Data Repository from FY16-21. Utilization associated with MSKIs among females for each Body Region in DC and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs in Service women were captured for each year, Service, Body Region, and setting.

This is the first population-level assessment of MSKI prevalence, incidence rates, healthcare utilization, and PC costs over a 6-year period for Service women in the MHS. Given the critical role of Service women in the military, MHS leaders, researchers, and public health officials should explore the underlying causes of these disparities in MSKI rates between the sexes, by expanding research efforts to all Services and military settings.

smith m, hogaboom n, dellanno r, st laurent m, yuan x,

nordstrom m

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

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 muscular imbalances, degenerative spinal changes, 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.

Recent literature suggests current treatment strategies for neck pain may not be as effective for the active duty population, given their occupational, training, and external load carriage requirements. Therefore, evaluating the effects of a wearable, take-home device for neck pain due to FHP is highly relevant to ADSMs. Preliminary results suggest donning a non-invasive therapy collar for 6 weeks can yield pain reduction and postural improvement compared to conventional treatment.

blasini r, stewart e, smith m, kasuske a, bradley m, yuan x

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

Musculoskeletal injuries (MSKI) affect 800,000 service members annually. Significant need exists to investigate strategies that impact the health, performance, and readiness of service members with MSKI. Platelet-rich plasma (PRP) offers a non-pharmacologic, minimally invasive approach to expedite tissue healing, recovery, and return to duty (RTD). Little is known on PRP outcomes in the military. The purpose of this practice improvement project is to evaluate outcomes following PRP injections at the Walter Reed National Military Medical Center Physical Medicine and Rehabilitation Clinic.

Greenlee t, george s, pickens b, rhon d

Abstract accepted for oral presentation at the Symposium of the International Musculoskeletal, Mental, and Social Health (I-MESH) Consortium

A recent trial in the Military Health System (MHS) found risk-stratified care not superior to usual care for low back pain (LBP) for a primary outcome of self-reported disability. Because risk-stratified care follows a biopsychosocial framework and aims to target maladaptive beliefs, the question remains whether the intervention adequately addresses pain attitudes and maladaptive beliefs. We aimed to compare improvements in (1) pain attitudes related to harm and (2) pain knowledge and beliefs in patients with LBP based on assigned intervention (riskstratified versus usual care).

Risk-stratified care significantly improved maladaptive attitudes and beliefs about pain at six weeks compared to usual care. An attenuated treatment effect, regardless of treatment, was seen in high or medium versus low-risk patients. Although these changes did not translate to better clinical outcomes in the clinical trial, they reflect short-term success of risk-stratified care in decreasing maladaptive attitudes and beliefs about pain.

Rhon d, Arden n, motte s, fallowfield j, fisher b, bullock g

Abstract accepted for oral presentation at the 2024 ICMM World Congress on Military Medicine.

Musculoskeletal injuries are a significant threat to military readiness; sustained by over half of individuals in many military units each year. These injuries threaten mission capabilities through reduced workforce. Mitigating injury risk requires accurate representation of the problem and adequate data to properly inform decisions. Additionally, the ability to aggregate data and make valid comparisons across settings, military branches, populations and nations is only possible when the same data elements exist. The purpose of this project was to reach international consensus on the minimum core data elements that should be collected and reported when conducting musculoskeletal injury surveillance in military settings.

Consensus was reached for two data principles and 33 minimal data elements. These elements include demographics, health behaviors, service branch, health history, exposure, and injury characteristics. This core checklist can be leveraged by clinicians, researchers and stakeholders working in military settings when comparing and harmonizing data across studies, military service branches, and countries. Ultimately, this will lead to better synthesis of evidence-based practice and ability to generate a greater number of useful prognostic models in the future.

rhon d, Drysdale l, radcliffe c, newman p

Stress fractures are common in military personnel, with training that often leads to overload and repetitive bone stress. These injuries limit duty, affect military readiness, and can end a military career. Injury mitigation is a high priority for military leadership and health, but risk profiles for stress fractures have not been fully explored. Many studies have evaluated risk factors, but meta-analyses of risk with aggregated study data are few. The purpose of this review was to conduct a systematic review of the literature to identify risk factors for stress fracture in military populations, and through meta-analysis, calculate aggregate risk profiles.

The search assessed studies published between January 1995 and September 2023 in PUBMed and CINAHL. Any study assessing risk factors for any type of stress fracture in a military population was considered, as long as an English translation was available. We excluded studies predicting disability, return to duty, or any variable not representing a stress fracture occurrence. When raw data were unavailable, we exported risk statistics as reported (e.g. risk ratios[RR], odds ratios[OR], hazard ratios [HR], rate ratios[RR]) as point estimates with 95% confidence intervals (CI) for categorical variables and means with standard deviations or 95% CI for continuous variables. We used imputation tools in Revman to estimate RR when values were not provided. We used the Prediction model Risk Of Bias ASsessment (PROBAST) Tool to assess methodological quality. We conducted a meta-analysis on unique predictor variables. We assessed heterogeneity of predictors using I2 statistics, and when heterogeneity was moderate to high (> 25%), we used a random effects model.

Despite the abundance of literature assessing risk factors for stress fractures, the variability in the capture and reporting of risk factors made data harmonization challenging. Only 3 factors were significantly associated with risk of developing a stress fracture: decreased bone mineral density in females, increased body weight, and female sex. Standardization of collecting and reporting risk factors is necessary in the future to improve the quality of meta-analysis and collective understanding or stress fracture risk factors.

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 Arthroscopy Association of North America (AANA) 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.

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.