Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy and affects 3-6% of adults in the United States at a total annual cost of over 2 billion dollars. In patients with severe or refractory symptoms, carpal tunnel release (CTR) represents the definitive management option, and over 500,000 CTRs are performed annually in the United States with over 90% of patients reporting clinical improvement. Although initially performed via a large palmar incision (3-5 cm), CTR techniques have continually evolved to reduce surgical trauma with the goal of improving cosmesis, reducing post-operative pain, and promoting faster recovery. Currently available CTR techniques include mini-open CTR via a single, 1-3 cm palmar incision (mOCTR), endoscopic CTR via one (wrist) or two (wrist and palm) 1-2 cm incisions (ECTR), and ultrasound guided CTR via a single < 1 cm wrist or palmar incision (USCTR).

According to Defense Medical Epidemiology Database information, in 2016, there were 16,823 active duty service members, across the Army, Navy, Air Force and Marines diagnosed with carpal tunnel syndrome. This amounts to approximately 13/1000 service members a year. The ability to have adequate numbers of orthopedic providers to conduct the necessary carpal tunnel release surgeries to meet this demand can be limited for various reasons such as a remote location or general lack of specialty care at the MHS site. As described above, point-of-care musculoskeletal providers now have the capability to conduct these procedures outside of the operating room environment. Further, early evidence of USCTR vs. traditional mOCTR indicates a more rapid recovery and likely quicker return to duty.

Regardless of technique, the primary goal of CTR is to transect the transverse carpal ligament (TCL) while avoiding injury to nearby neurovascular structures. Although ECTR may promote a faster recovery compared to mOCTR, concerns have been raised regarding the potential for increased complications due to limited visualization of surrounding structures during TCL transection. USCTR techniques combine a single small incision with direct visualization of at-risk structures such as the median nerve and its thenar motor ranch/recurrent motor branch, ulnar vessels, and superficial palmar arterial arch. To date, over 630 cases of USCTR have been reported in the peer-reviewed literature with a >98% success rate and no documented neurovascular injuries. Furthermore, a recently published, single surgeon, prospective randomized clinical trial comparing mOCTR to USCTR reported that patients treated with USCTR experienced significantly faster recovery with respect to functional scores, pain reduction, and pain medication discontinuation.

Meniscus tears are among the most common knee injuries in both general and military populations. This is not surprising, as military training and deployments often expose soldiers to high physical demands that can affect the knee. A 2012 study found a meniscal tear incidence rate of 8.3 per 1,000 person-years among active-duty service members, compared with about 0.61 per 1,000 in the general population. Incidence increased with age; however, incidence in the youngest members (<20 years old) was 3.0 per 1,000, a 5-fold increase compared to the general population. Soldiers who were in the enlisted ranks, were men, and served in the Army and Marines had the highest incidence of meniscal tears.

Non-battle musculoskeletal injuries are the leading cause of medical evacuation among deployed soldiers, and are derived from injuries caused by physical training and sports. During a 15-month period, 1.0% of lower extremity non-battle injuries in an Army Brigade Combat Team (Operation Iraqi Freedom) were related to the meniscus. Goodman et al. found that 19.3% of soldiers who had not been medically evaluated during combat consulted an orthopedic surgeon upon return for a musculoskeletal complaint. Of these consultations, a staggering 20.8% of lower extremity procedures were meniscal debridement or repair.

While the immediate consequences of meniscal injuries can be troublesome, long-term effects may be devastating to the soldier and the military at large. Galvin, et al. reported that out of 178 individuals who received meniscal repairs, 18.5% were separated from the military for an average time of 29 months while 28% required a permanent activity limiting duty profile. Meniscal tears may also increase the risk for other knee injuries such as osteoarthritis (OA), which is one of the most common medical reasons for discharge from active duty service. In a 2017 study, 23% of soldiers who were diagnosed with meniscal injuries ultimately received total knee replacements as a result of OA. Out of 14 subjects who were interviewed by the Army Physical Evaluation Board, 11 were medically discharged because of OA and/or their total knee replacement. It is imperative to evaluate alternative rehabilitative treatments that limit the negative outcomes, discharge rates, and time of separation associated with meniscal injuries.

The opioid epidemic affects all walks of life in the United States, with the percentage of servicemen and women addicted to opioids higher than the general population. In 2016, opioids were involved in over 60% of drug overdose deaths. Use and abuse of prescribed opioids negatively impacts the deployment readiness of DoD service members. Side effects from narcotic pain medications directly increase duty limitations. There is a clear need for alternative and integrative methods of treating acute and chronic pain.

Battlefield Acupuncture (BFA) was developed by Dr. Richard Niemtzow in 2001 to treat acute and chronic pain in austere environments. Since its inception, BFA has been used in integrative medical treatments for a myriad of conditions. Medical providers and researchers have used BFA to treat neuropathic symptoms, sore throats, thoracic pain from chronic obstructive pulmonary disease, and post-surgical musculoskeletal pain.

BFA provides an integrative pain treatment option for service members to decrease prescription medication usage. BFA research indicates clinically significant reduction in NSAID use, shorter admission times and greater perceived pain reduction (p <0.0001) within the first 24 hours of BFA treatment that persisted up to 48 hours. Cadets at the United States Military Academy are faced with the challenges of returning to academic classes as little as 2 days after orthopedic surgery often prior to controlling their post-operative pain. Collectively, current studies elicit short term reduction in pain medication use and perceived pain (up to 72 hours), but show no significant difference at long term follow ups (up to 30 days post treatment) relative to perceived pain. To date, there are no studies investigating BFA’s effectiveness in reducing post-operative shoulder pain and pain medication use.

Compared to the general population, military service members are at increased risk for acute traumatic knee joint injury, such ACL rupture. Those who sustain these injuries are more likely to develop post-traumatic osteoarthritis (PTOA) during their military career. PTOA is a major source of disablement and discharge. Current recommendations for managing PTOA include weight management, low impact exercise to reduce load on the affected joint, biomechanical corrections, and education about joint health. Despite widespread agreement on these treatments, their implementation in current clinical medicine is sporadic at best. Thus, these strategies, although effective, are widely under-utilized. Furthermore, the diagnosis of PTOA in an individual service member is often made late in the clinical course of the disease, when these approaches are less effective. There is a need for a novel therapeutic intervention to address prevention of PTOA post-injury. Increasing patient self-efficacy for managing PTOA is a highly promising approach.

Traditionally, the management of acute traumatic knee joint injuries has terminated when service members are returned to duty. Treatment has simply focused on restoring anatomic structures and initial functional capabilities through surgical repair and a course of rehabilitation. Thus, patients are often fully discharged from follow-up care approximately 6 months post-surgery. However, there is strong evidence that severe knee injuries are the starting point for a cascade of progressive degenerative joint changes that, over the course of several years, lead to chronic pain and impaired function, resulting in physical limitations that affect performance of duties and activities of daily living. As a result of this major gap in clinical care, acute knee joint injuries frequently progress into PTOA, resulting in high rates of dysfunction and discharge among military service members.

To address this gap in clinical care, we have developed a mobile device telehealth platform for service members at risk of PTOA. The intervention is designed to facilitate behavior change through increased knowledge and patient self-efficacy, integrated quantitative tools that allow patients and healthcare providers to monitor their OA risk factors. The telehealth platform utilizes a set of novel, evidence-based behavioral intervention strategies. These behavioral intervention strategies address known risk factors associated with OA initiation and progression. The telehealth education is supplemented by quantitative tools for physical activity tracking and assessing biomechanics. By actively engaging patients in their own care through novel technologies and strategies, we aim to address this major gap in clinical care and prevent progression to PTOA following knee injury. This study examines the effect of this therapeutic intervention that delivers novel, evidence-based behavioral health strategies through an innovative clinical intervention platform. The intervention is designed to be a major disease-prevention therapeutic tool that greatly reduces the onset of progression of PTOA following knee injury by empowering military service members to manage, and seek care for, their personal risk factors for PTOA.

This study involves a novel prospective, multi-center randomized controlled trial of shoulder arthritis candidates randomized to leukocyte-poor platelet-rich plasma (LP-PRP) and corticosteroid (CSI) groups for comparative analysis of patient satisfaction scores and clinical outcomes. These results may delineate the utility of LP-PRP as an intermediary treatment modality in sub-surgical candidate’s refractory to conventional measures. This multi-center prospective randomized study will be the first to evaluate the potential benefit of PRP in the treatment of glenohumeral osteoarthritis in young patients not yet candidates for arthroplasty surgery.

Non-battle injuries are the most common cause of service-member attrition and there is a high incidence of neck pain in the medical personnel who take care of injured soldiers. In recent operations (e.g. Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn), musculoskeletal complaints were among the most common reason for hospitalization and medical evacuation; medical hardships represented up to one-third of all injuries. Among the broad spectrum of these musculoskeletal injuries, spinal injuries comprised nearly 25%.

Treatments for spinal pain in military personnel are generally drawn from the civilian population. Spinal pain treatment tends to be multimodal, relying upon physical therapy, pharmacological agents, spinal manipulation, and psychotherapy. However, there are drawbacks to some of these treatment modalities. Opioids and other pharmacological agents may not only lead to addiction and accidental overdose, but can elicit cognitive detriments that may lead to adverse consequences; for example, motor vehicle collisions and balance and memory impairments. Physical therapy is well-studied in the civilian population, yet may not generalize to the active-duty military population due to environmental and occupational differences. As well, there does not exist a wide body of evidence to support many of these treatments in active-duty military. The Cervigard Forward Head Posture (FHP) Neck Collar was developed for patients with severe neck pain due to forward head posture. It accomplishes the correction by applying posterior forces to the zygomatic bones and clavicles, and an anterior force to the cervical spine. This three-point pressure system allows the cranium to translate posteriorly over the shoulders without compromising the cervical lordotic curve.

The objective of this study is to evaluate the treatment effect and safety of a the Cervigard FHP Neck Collar for the treatment of neck pain using self-reported pain and function measures, as well as objective radiological measures of cervical lordosis and head posture.

Opioids are most commonly administered for the treatment of pain and are among the most prescribed drugs in the United States. Between 2003 and 2011, opioid prescriptions increased from 149 million to 238 million. In 2004, while constituting only 4.5% of the world’s population, the US consumed 99% of the global supply of hydrocodone. These trends resulted in the Centers for Disease Control and Prevention recognizing opioid abuse as an epidemic. 

Pain management after orthopaedic arthroscopic procedures is mandatory regardless of the surgical technique. Cold therapy (cryotherapy) has been widely used for many years in the treatment of postoperative pain management in orthopaedic surgery, and most studies have reported better pain scores and reduced drug consumption. Cryotherapy involves applying a cold device to the skin surrounding the injured soft tissues to reduce the intraarticular temperature. It reduces local blood flow by vasoconstriction, which in turn also reduces local inflammatory reaction, swelling, and heat. It also decreases the conduction of nerve signals, potentially reducing pain transmission. Several cryotherapy options are available: first generation cold therapy like crushed ice in a plastic bag, cold or gel packs; second-generation cold therapy with circulating ice water with or without compression, and third-generation advanced computer-assisted devices with continuous controlled cold therapy.

Our goal is to analyze the analgesic efficacy of cryotherapy after shoulder, knee, and hip arthroscopic procedures using Game Ready® which is a second-generation cryotherapy with compression system. We hypothesize this may decrease postoperative opioid usage, as well as be more cost effective when compared to first-generation cryotherapy (ice packs without compression) for medical healthcare systems.