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.

Sheean a, defoor m, spindler k, arner j, athiviraham a, bedi a, defroda s, ernat j, frangiamore s, nuelle c

Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed.

General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR.

The impact of psychology on patients’ responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

Sheean AJ, DeFoor MT, Spindler KP, Arner JW, Athiviraham A, Bedi A, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW. The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions. Sports Health. 2024 Feb 19:19417381241226896. doi: 10.1177/19417381241226896. Epub ahead of print. PMID: 38374636.

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.

Defoor m, cognetti d, bedi a, carmack d, arner j, defroda s, enrat j, frangiamore s, nuelle c, sheean a

To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery.

A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines.

Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn.

DeFoor MT, Cognetti DJ, Bedi A, Carmack DB Jr, Arner JW, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW, Sheean AJ. Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist. Arthrosc Sports Med Rehabil. 2024 Feb 13;6(2):100812. doi: 10.1016/j.asmr.2023.100812. PMID: 38379604; PMCID: PMC10877194.

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.

Jariwala S, Fellin C, Steiner R, Buchen J, ANders J

Peripheral nerve injuries (PNI) pose a significant clinical issue for patients, especially in the most severe cases where complete transection (neurotmesis) results in total loss of sensory/motor function. Nerve guidance conduits (NGCs) are a common treatment option that protects and guides regenerating axons during recovery. However, treatment outcomes remain limited and often fail to achieve full reinnervation, especially in critically sized defects (> 3 cm) where a lack of vascularization leads to neural necrosis. A multi-treatment approach is therefore necessary to improve the efficacy of NGCs. Stimulating angiogenesis within NGCs can help alleviate oxygen deficiency through rapid inosculation with the host vasculature, while photobiomodulation therapy (PBMT) has demonstrated beneficial therapeutic effects on regenerating nerve cells and neovascularization.

In this review, we discuss the current trends of NGCs, vascularization, and PBMT as treatments for peripheral nerve neurotmesis and highlight the need for a combinatorial approach to improve functional and clinical outcomes

Fellin CR, Steiner RC, Buchen JT, Anders JJ, Jariwala SH. Photobiomodulation and Vascularization in Conduit-Based Peripheral Nerve Repair: A Narrative Review. Photobiomodul Photomed Laser Surg. 2024 Jan;42(1):1-10. doi: 10.1089/photob.2023.0103. Epub 2023 Dec 18. PMID: 38109199.

greenlee t, bullock g, teyhen d, rhon d

Psychologic variables have been shown to have a strong relationship with recovery from injury and return to work or sports. The extent to which psychologic variables predict successful return to work in military settings is unknown.

Psychologic variables alone were unable to adequately predict who would have a subsequent injury after an initial musculoskeletal injury. This study does not minimize the value of assessing psychologic profiles of injured athletes, but rather suggests that models looking to identify injury risk should consider a multifactorial approach that also includes other nonpsychologic factors such as injury history. These findings do, however, pro- voke curiosity surrounding which outcomes best capture relevant psychologic constructs and which assessment timepoints or change scores could be the most informative.

Greenlee, Tina A. PhD1; Bullock, Garrett PT, DPT, DPhil2; Teyhen, Deydre S. PT, PhD3; Rhon, Daniel I. PT, DSc, PhD1,4. Can a Psychologic Profile Predict Successful Return to Full Duty After a Musculoskeletal Injury?. Clinical Orthopaedics and Related Research 482(4):p 617-629, April 2024. | DOI: 10.1097/CORR.0000000000002935

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.

crowell ms, brindle ra, miller em, reilly n, ford kr, goss dl

Running is the most common cardiovascular exercise in the military. However, there is a high incidence of running-related overuse injuries that reduces military readiness. Gait retraining is a common intervention to treat running-related injuries, but the high cost of equipment and lack of clinician expertise and availability reduces utilization. Gait retraining intervention in a telehealth format might improve feasibility. The purpose of this randomized clinical trial is to determine the effectiveness of a telehealth gait retraining intervention on pain, self-reported function, and biomechanical risk factors for injury in service members who present to a Military Health System physical therapy clinic with an overuse knee injury.

Crowell, M.S., Brindle, R.A., Miller, E.M. et al. The effectiveness of telehealth gait retraining in addition to standard physical therapy treatment for overuse knee injuries in soldiers: a protocol for a randomized clinical trial. Trials 24, 672 (2023). https://doi.org/10.1186/s13063-023-07502-x

Cohen S, larkin t, weitzner a, dolomisiewicz e, wang e, hsu a, anderson-white m, smith m, zhao z

There are few efficacious treatments for mechanical neck pain, with controlled trials suggesting efficacy for muscle relaxants and topical non-steroidal anti-inflammatory drugs. Although studies evaluating topical lidocaine for back pain have been disappointing, the more superficial location of the cervical musculature suggests a possible role for topical local anesthetics.

For the primary outcome, the median reduction in average neck pain score was -1.0 (IQR -2.0, 0.0) for the lidocaine phase vs. -0.5 (IQR -2.0,.0) for placebo treatment (p=0.17). 27.7% of patients experienced a positive outcome during lidocaine treatment vs. 14.9% during the placebo phase (p=0.073). There were no significant differences between treatments for secondary outcomes, though a carryover effect on pain pressure threshold was observed for the lidocaine phase (p=0.015). 27.5% of patients in the lidocaine group and 20.5% in the placebo group experienced minor reactions, the most common of which was pruritis (p=0.036).

The differences favoring lidocaine were small and non-significant, but the trend towards superiority of lidocaine suggests more aggressive phenotyping and applying formulations with greater penetrance may provide clinically meaningful benefit.

Steven P. Cohen, Thomas M. Larkin, Aidan S. Weitzner, Edward Dolomisiewicz, Eric J. Wang, Annie Hsu, Mirinda Anderson-White, Marin S. Smith, Zirong Zhao; Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain. Anesthesiology 2024; 140:513–523 doi: https://doi.org/10.1097/ALN.0000000000004857

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.