b barlow, a sheean, b gillingham

Despite the dedicated efforts of a wide breadth of musculoskeletal (MSK) physicians and providers across the Military Health System (MHS), musculoskeletal injuries (MSKIs) continue to represent the most significant threat to the readiness, deployability and retention of United States military personnel. MSK readiness is warfighter readiness. There is a compelling need to align and integrate the multitude of programs and initiatives currently in place and to increase the number and value of civilian military partnerships. We must use and share existing data repositories, such as the Military Orthopaedic Tracking Injuries and Outcomes Network, to guide our MSK research agenda with the goal of eliminating preventable injuries and to optimize the care we provide for unavoidable MSK injuries and diseases. Formalizing relationships among the current military and civilian organizations and programs focused on MSK prevention and treatment is also a critical necessity. Enhanced collaboration between the Society of Military Orthopedic Surgeons, the Military Advanced Surgical Training initiative, the Consortium for Health and Military Performance and the Musculoskeletal Injury Rehabilitation Research for Operational Readiness programs at the Uniformed Services University will pay tremendous readiness dividends when their efforts are formally aligned and integrated with the Defense Health Agency and the service medical departments. This will also create the foundation necessary for the MHS to establish itself as a national exemplar for the provision of value based MSK care. Despite the existence of a robust database, skilled practitioners, and the backing of academic and civilian expertise, there is room for improvement in our ability to improve the outcomes of the MSK care we provide. We need to integrate and share siloed data to optimize the operative and non-operative MSK care we provide. We also need to foster enhanced collaboration among all the entities dedicated to decreasing the burden of MSK injuries and disease on both our warfighters and our veterans. The essential elements are there but lack the alignment and integration necessary to optimize MSK readiness. With the commitment of engaged MHS leadership, concerted effort at the point of care, and increased collaboration by key stakeholders we can maximize readiness while creating a cohesive system of value-based MSK care worthy of national emulation. The time to act is now.

Brian T Barlow, Andrew J Sheean, Bruce L Gillingham, Enhancing Military Musculoskeletal Readiness: A Proposal for Collaboration, Military Medicine, 2026: usag006. https://doi.org/10.1093/milmed/usag006

m crowell, e florkiewicz, a weart, n reilly, j morris, p mchenry, k rochester, k ford

Abstract accepted for platform presentation at the 2026 American Physical Therapy Association Combined Sections Meeting

Running-related overuse injuries, particularly of the knee, are common in military personnel and impair readiness. While gait retraining is a common intervention, broad implementation is limited by costs, expertise, and time. The purpose of this study was to determine the effectiveness of telehealth gait retraining (THGR) on pain, self-reported function, and footstrike pattern in service members with running-related knee pain.

One hundred eighty active-duty soldiers and cadets aged 18–60 were enrolled. Inclusion criteria included running-related knee pain rated 3–7/10 during or after running and a rearfoot strike pattern.

This single-blind, randomized clinical trial used concealed allocation to assign participants to standard physical therapy (PT) or standard PT plus THGR. Standard PT included interventions aligned with clinical practice guidelines and a return-to-run program without gait retraining cues. THGR participants received auditory and visual feedback via commercially available video coaching software to increase cadence and transition to a non-rearfoot strike (NRFS) pattern. Feedback was delivered weekly during weeks 1–4, and at weeks 6 and 8. Outcomes, including pain via Visual Analog Scale and function via the Single Assessment Numeric Evaluation (SANE), Anterior Knee Pain Scale (AKPS), and University of Wisconsin Running Injury and Recovery Index (UWRI), were assessed at baseline, post-intervention (8 weeks), and a retention follow-up (12 weeks). Footstrike was assessed with 2D sagittal video analysis. Group-by-time interactions were evaluated using 2×3 mixed-model ANOVA for continuous outcomes and chi-square tests for footstrike pattern. Alpha was set at 0.05.

Of the 180 participants, 38 were excluded during baseline screening, and 42 withdrew, leaving 100 in the final analysis (44 THGR, 56 PT). Mean age was 29.9 (8.5) years; 22% were female. Mean symptom duration was 29.8 (28.4) months and weekly running volume was 14.1 (12.9) km. No significant group-by-time interactions were observed for overall pain (F=0.47, p=.61), pain during (F=0.57, p=.54) or after running (F=0.44, p=.61), SANE (F=0.94, p=.38), AKPS (F=0.18, p=.80), or UWRI (F=0.30, p=.70). There were significant time main effects for all variables (p<.001). A group main effect was observed only for pain during running (F=4.19, p=.04). Clinically meaningful improvements were seen in pain and UWRI scores, but not in the AKPS. A significantly greater proportion of THGR participants transitioned to NRFS (65%) compared to standard PT (16%) (χ²=24.12, p<.001).

Telehealth gait retraining combined with standard PT produced similar improvements in pain and function compared to standard PT alone, with both groups showing meaningful clinical improvements in pain and function.

t velasco, n reilly, c hulsopple, k roberts, r boeth, d hoellen, c dickison, d goss, j leggit

Abstract accepted for poster presentation at the 2026 American Physical Therapy Association Combined Sections Meeting

Chronic exertional compartment syndrome (CECS) presents a significant challenge for active-duty service members (ADSMs), with exercise-induced lower-limb pain, weakness, and in extreme cases, disability impacting military readiness. While various treatments have been described, from surgery to structured exercise programs, no consensus on an optimal treatment approach currently exists for CECS2-6. This randomized, placebo-controlled trial’s objective was to determine how different components of a multifaceted, non-surgical treatment program—specifically botulinum toxin A (BoTN-A) injections and structured gait retraining—were associated with improvements in distinct clinical and biomechanical outcomes.

36 ADSMs diagnosed with CECS via Pedowitz’s criteria were randomized to receive BoTN-A (n=20) or saline injections (n=16) into the anterior and lateral lower leg compartments. All participants received structured gait retraining with corrective exercises and running form instruction.

A multiple regression model was developed to analyze the relationship between the interventions and various biomechanical and clinical metrics over the course of rehabilitation. Biomechanical metrics were collected during treadmill running using instrumented shoe insoles (Loadsol, Novel USA, St. Paul, MN)7 to measure cadence, average vertical loading rate (AVLR), and peak ground reaction forces (GRF). Clinical metrics included self-reported current and worst pain, as well as functional scores during running and day-to-day activities via the University of Wisconsin Running Index (UWRI), and Single Assessment Numerical Evaluation (SANE), respectively. All metrics were collected at baseline, 8 weeks, and 3 months.

The analysis revealed that participation in the structured gait retraining program was significantly associated with reduction in self-reported current pain (Est: -1.52, p=0.03) and worst pain (Est: -2.86, p<0.01) at the 3-month follow-up. BoTN-A use was significantly associated with reduced AVLR during running at 3 months (Est: -10.74, p<0.01). While the overall model was significantly associated with improved UWRI scores (p=0.03), no single intervention independently reached significance for this outcome.

A combined, non-surgical approach is beneficial for treating CECS in ADSMs. The components of the multimodal intervention target different aspects of the condition—structured gait retraining was most associated with pain reduction (clinical outcome), while BoTN-A was most associated with improved loading mechanics (a biomechanical outcome). 

t velasco, n reilly, c hulsopple, k roberts, r boeth, d hoellen, c dickison, d goss, j leggit

Abstract accepted for poster presentation at the 2026 American Physical Therapy Association Combined Sections Meeting

Chronic musculoskeletal injuries are the leading cause of disability among the active-duty service member (ADSM) population. Chronic exertional compartment syndrome (CECS) can significantly hinder ADSMs' physical training, especially running, due to exercise-induced pain, numbness, and muscle weakness in the lower limbs. Many affected individuals ultimately require surgical intervention. Further complicating CECS management is that the condition is often overlooked as a cause for reported lower leg symptoms, leading to diagnostic delays of several months to years following initial onset.

A 23-year-old male ADSM presenting with unilateral lower limb CECS as defined by Pedowitz’s criteria was recruited to participate as part of a larger, multi-site randomized controlled trial assessing non-surgical interventions for CECS. His main complaints were pain and symptoms limiting his ability to run for his physical fitness test. Of the 36 participants recruited, he was the only ADSM diagnosed within 6 months of symptom onset. He received structured gait retraining and botulinum toxin A (BoTN-A) injections to the anterior and lateral compartments of his involved leg. Numerical pain rating scale (NPRS), single assessment numeric evaluation (SANE), and University of Wisconsin Running Index (UWRI) were administered at baseline, 8 weeks, 6 months, and 12 months post injection.

This ADSM started with lower SANE scores (indicating worse function) and comparable lower UWRI scores (indicating worse running ability) at baseline compared to the other groups with a symptom onset of more than 7 months. At 8-weeks, 6-, and 12-months follow-ups, this individual continually scored  higher on these measures (SANE and UWRI), indicating greater improvement compared to his cohort. His NPRS score at baseline was also higher than the groups with a longer symptom duration history and improved to 0/10 by 6-months, which remained at the one-year follow-up. Functionally, at 6-months post-injection, the ADSM was able to complete the running portion of his physical fitness test without limitations, pain, or symptoms.

This case demonstrates that timing of diagnosis and seeking early non-surgical treatments for lower limb CECS can be beneficial for improving function and running capability. Clinicians trained to identify the signs and symptoms of CECS early in ADSMs may positively impact their career longevity. However, further research is needed to confirm that early detection in this population can lead to long-term optimal outcomes.

d rhon, n parsons, r greenlee, e metzger, s hole, n hager

Abstract accepted for platform presentation at the 2026 American Physical Therapy Association Combined Sections Meeting

The purpose of this study was to compare the effectiveness of low-level laser therapy (photobiomodulation - PBMT) to sham on graduation rates in military trainees with lower extremity stress fractures. Based on prior reports about the influence of PBMT on bone repair, it was hypothesized that patients receiving PBMT would have significantly better outcomes than patients receiving sham.

Participants were trainees in the Combat Medical Specialist Training Course (CMSTC) in San Antonio, Texas, with an MRI-confirmed diagnosis of metatarsal and/or tibial stress fracture, enrolled between June 2023 and November 2024. All participants received standard of care treatment (activity modification, relative rest, a home exercise program, and physical therapy) and were then randomized to either active or sham PBMT. The PBMT protocol called for three sessions/week up to six weeks (10 to 16 minutes per treatment). Participants in the sham group were prescribed an identical number of sessions, with the device remaining in standby mode. The primary outcome was graduation without delay at four months, and secondary outcomes included the Defense and Veterans Pain Rating Scale (DVPRS) and the Lower Extremity Functional Scale (LEFS), also at four months. Patients with fractures to the 5th metatarsal, anterior tibia, a non-union fracture, pregnant, or with an open wound or tattoo over the area of treatment were excluded.

The mean age (SD) was 23.7 (4.7) years, 54.4% female, and 80.6% in the United States Army. In 46.6% of the cohort, both extremities were affected, with tibia involvement in 69.9% and metatarsal involvement in 30.1%, with severity ranging from grades I to IV. Distribution of severity was similar between groups, with slightly higher proportion of Grade III in the sham group (53.2% vs 30.6%) and slightly higher proportion of Grade II in the active PBMT group (49.0% vs 23.4%). Only 36.9% of all participants graduated without delays (20 from PBMT group; 18 from sham group). There was no statistically significant difference in graduation rates between groups. Furthermore, sex, laterality, and stress fracture location did not predict successful graduation rates. Pain (mean difference[9CI] DVPRS -0.7312 [-2.308, 0.8456]) and function (mean difference[95CI] LEFS 5.8101 [-8.0288, 19.649]) were also not different between groups at 4 months.

Graduation rates, pain intensity, and physical function at four months were not significantly different between military trainees that received low-level laser therapy compared to sham.

m smith, x yuan, v morris, e harris, l lechanski, n parsons, r condon

Abstract accepted for platform presentation at the 2026 American Physical Therapy Association Combined Sections Meeting

The primary objective of this descriptive survey-based study was to characterize the current trigger point dry needling (TDN) practices of clinical providers within the Military Health System (MHS).

The target sample size was 1,000 participants to ensure at least 250 completed surveys including at least 15-20 responses from each specialty and other categories to facilitate subgroup analysis.

This study was approved with exempt determination by the U.S. Army Medical Center of Excellence Office of Research and Human Subject Protections (24-00027e). Active duty and civilian clinical providers (≥ 18 years of age) within the MHS were eligible to complete the survey. Clinical provider types included Physical Therapists (PT), Athletic Trainers (AT), and Physician Assistants (PA). The survey was disseminated through relevant professional networking for convenience sampling. The survey is comprised of 33 questions focused on provider characteristics, training/experience, clinical practice, perceived outcomes, and barriers. Categorical variables will be presented as counts and proportions.

To date, 847 clinicians have accessed the survey. 755 participants (61.3% active duty) completed the entirety of the survey. Most respondents were PTs (43.8%), followed by ATs (22.6%) and PAs (20.7%). 58.3% (n = 440) reported that they currently perform TDN in their practice. Training sources included military (45.6%) or civilian (35.6%) courses, and training by providers from same (15.6%) or different (10.5%) specialties. The body regions treated most often were the shoulder (92.5%), low back/pelvis (87.6%), and head/neck (85.9%). A small provider cohort of 4.6% (n = 24) reported experiencing a major adverse event. The primary barriers to clinical practice were lack of training (20.0%), difficulty obtaining credentialing privileges (18.8%), and insufficient time (15.8%).

TDN is currently employed by a myriad of providers as a cost-effective, low risk and minimally invasive intervention to treat musculoskeletal (MSK) conditions. PTs are most often using this modality to treat the shoulder, low back/pelvis and head/neck within the MHS. Survey results support the need for practice standardization, better access to training, streamlined credentialing processes, and formal clinical practice guidelines to reduce barriers to TDN use in clinical practice, maximize provider confidence, and further optimize safety.

k Rochester, n reilly, c tucker a marshall, g hess, r holloway, d masalleras, k ford, d goss

Abstract accepted for platform presentation at the 2026 American Physical Therapy Association Combined Sections Meeting

Running is the primary form of cardiovascular exercise in all four branches of the United States military (Lovalekar, 2021). Running related injuries (RRIs) are the most common lower extremity injuries among military service members (MSMs) (Lovalekar, 2021).  Increased body mass index (BMI) has been associated with greater stress on runners’ bodies (Shiotani 2023, Jha 2023, Naderi 2020, van Poppel 2020, Wilson 2021).  This study compared three-dimensional running biomechanics between those of different BMIs three-dimensional that those with a greater BMI would run with less desirable biomechanics.

Soldiers completed an IRB approved consent form and were given a race bib with a number on it to run with it affixed with tape on their chests.  Soldiers ran 900 meters through a 12-camera (200Hz) markerless motion capture system three times. Data were processed utilizing machine learning algorithms to track the running motion and create 3D pose estimations. Soldiers were compared between BMI groups (normal BMI (NO < 25), overweight (OW >25 <30), and obese (OB >30) according to the American College of Sports Medicine criteria.) across lower extremity Hip, Knee and Ankle angles during stance phase using a one-way ANOVA with statistical parametric mapping (SPM) (p < .05).  Prospective injuries across 12 months are still ongoing and not presented in this abstract. 

A main effect was observed for a minimum of a percentage of stance phase between BMI groups for the Hip (X: 29.7%, t = 5.39; Y: 46.5%, t=5.47; Z: 34.7%, t=5.44) Knee (X: 57.4%, t=5.36; Y: 45.5%, t=5.36) and Ankle (X: 38.6%, t=5.68; Z: 22.8%, t=5.41).  Being mostly concerned with kinematics in the sagittal and frontal planes, we highlight those differences now.  Heavier Soldiers demonstrated decreased hip flexion and hip adduction.  Heavier Soldiers ran with decreased knee flexion at midstance and increased knee adduction.  Heavier Soldiers used the most plantar flexion at initial contact and not as much flexion in late stance.  There were no differences in ankle kinematics in the frontal plane.

Running with decreased sagittal plane motion at the hip and knee and increased adduction at the hip and knee may predispose heavier Soldiers for injury.  Increased hip and knee adduction has led to increased risk for injury in previous studies (Venable, 2022).  We hypothesize that running related injuries will be greater in Soldiers running with these kinematics and will have the 12-month prospective period completed NOV 2025 in time to share those results as well at CSM 2026.

M hollander and j hagen

Abstract accepted for platform presentation at SPIE Photonics West 2026

Photobiomodulation Therapy (PBMT) uses visible and near-infrared (600-1100 nm) light to enhance physical and cognitive performance, promote recovery, and support overall wellness. While medical-grade laser-based PBMT is well studied in clinical settings, the recent proliferation of LED-based consumer devices has outpaced the development of validated measurement standards or evidence-based protocols.

This presentation highlights two sequential studies. The first establishes validated methodologies for measuring irradiance and spectral output from PBMT devices, including panels, wearables, and full-body light beds. Using various measurement devices, such as a spectroradiometer, silicon photodiode meter, and thermopile sensor, we documented significant variability in the measured irradiance value, up to 763 mW/cm², depending on the measurement configuration employed. Less concern was found with spectral measurements, where most devices aligned within ±10 nm of manufacturer claims. The vastly variable irradiance findings, however, emphasize the necessity of standardized protocols to ensure accurate dosimetry and device comparisons. In this presentation, we will detail the proposed validation methodology for the three categories of PBMT devices tested. 

The second study applied this validated measurement framework to inform device selection and application of PBMT in a single-blinded, randomized, sham-controlled clinical trial. Military-affiliated participants completed two 4-week blocks (sham and active) using full-body LED PBMT devices. Blood samples were analyzed for inflammatory and stress biomarkers (e.g., TNF-α, IL-6, cytokines), and participants completed numerous validated wellness surveys throughout their time in the study. Comprehensive analyses of heart rate and sleep data collected via wearable devices, subjective survey measures, and objective blood biomarkers will be finalized and presented at the time of the conference.

Together, these studies improve the technical accuracy of PBMT measurements and expand knowledge of its clinical effects, providing a solid foundation for researchers and practitioners to develop evidence-based guidelines and implement LED-based wellness interventions more effectively.

N Hogaboom, t dyson-hudson, n hager, x yuan,

Abstract accepted for poster presentation at the 2026 Association of Academic Physiatrists Annual Meeting

Objectives: Meniscus tears are one of the most common knee injuries and are often associated with pain and functional limitations.1, 2 Acute treatment includes rest, activity modification, pharmacological agents, and physical therapy. Patients refractory to conservative care often progress to corticosteroid injections and, ultimately, surgery if pain and function do not improve. Surgical efficacy is contested3, 4 and has potentially significant short- and longer-term consequences.5 Treatment with orthobiologics has shown promise, but there is no evidence to conclude their long-term effectiveness for meniscus tears. The purpose of this pilot study was to evaluate and compare patient-reported outcomes of knee pain and function up to four years after trephination and injection of either micro-fragmented adipose tissue (MFAT) or normal saline (NS).

Design: Two individuals with knee pain secondary to meniscus tears were recruited. One participant (male, age 38) was injected with 3 mL MFAT with 3 trephinations into the lateral meniscus, and 6 mL into the joint. The other (female, age 44) was injected with 1.5 mL NS with four trephinations into the medial meniscus, and 5 mL into the joint. Pain, function, and quality of life (QOL) outcomes were collected at baseline (treatment); 1, 2, 3, and 6 months; and 1- and 4-years post-injection.

Results: Both individuals reported improvements in four-year outcomes, including PROMIS Mobility v2.06 (MFAT: 8%, NS: 21.3%); Numerical Rating Scale score (MFAT: 80%, NS: 100%); PROMIS Global Physical Health v2.07 (MFAT: 11.8%; NS: 5.8%); and scores of Knee Injury and Osteoarthritis Outcome Score (KOOS)8 Symptom (MFAT: 27.3%; NS: 30.8%), Pain (MFAT: 62.5%; NS: 83.3% NS), Function (MFAT: 72.7%; NS: 100%), Sports/Recreation (MFAT: 69.2%; NS: 57.1%), and QOL subscales (MFAT: 61.5%; NS: 57.1%). Both treatments were well-tolerated with no reported adverse events.

Conclusions: While these results are promising, a larger, randomized controlled trial is needed to show efficacy for either treatment.