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.