MSI negatively affect military readiness, and accounted for 36.3% of all injury-related ambulatory visits in active duty service members in 2016. The high intensity of combat preparedness has elucidated that the greatest nonfatal threat to soldiers in non-deployed settings are MSI sprains, strains, and overuse injuries of the spine, back, and upper and lower extremities. In fact, the top five MSIs ranked by their contribution to the highest days of limited duty (DLD) contributed between 14 and 22 DLD per injury—or approximately 9 million DLD annually. While multiple epidemiological studies have been commissioned over the past 20 years to characterize the burden of specific MSIs in the MHS, information is fragmented and cannot be used to decrease DLD and predict the economic burden of MSIs in the MHS.

This study will provide critical MSI surveillance by developing a standardized, service-wide epidemiological report which will be used to understand the frequency and prevalence of injuries in the military. Data will be published quarterly and distributed to key stakeholders and sponsors to identify clinical and operational gaps in care.

Throughout the campaigns in Iraq and Afghanistan, the Army has been determined to improve the health, welfare, and preparedness of wounded soldiers. The Warrior Care and Transition Program (WCTP) was established in 2004 and subsequently expanded and formalized in 2007 to serve as a comprehensive clinical rehabilitation program for the U.S. Army’s ill and/or injured soldiers. The primary focus of the WCTP is to fulfill the Army’s goal of enhancing wounded soldiers’ transitions back into the fighting force or into a veteran’s status, with full reintegration into the community. Since the WCTP’s inception in 2004, more than 77,000 soldiers have transitioned through the WCTP, and over 30,000 have returned to military duty. The program is designed to provide robust social and clinical care to active and reserve soldiers who require significant support, including case management, social work, and/or transition assistance. While entrance criteria have changed over the duration of the WCTP program, soldiers are generally required to have complex medical needs that will require significant care for a period of at least 3-6 months.

To meet the goal of comprehensive care, warrior transition units (WTU) integrate a diverse staff of primary care physicians, nurse case managers, rehabilitation specialists (OT/PT), social workers, counselors, and others. In addition to assistance with soldier transition, WTU programs also offer mental health and occupational therapy programs (Erickson, 2008). Coordinating efforts across all staff members is important to ensure the delivery of quality patient care. Recently, the Recovering Warrior Task Force, established by Congress in 2010, evaluated DoD wounded warrior services across the military. They synthesized 87 recommendations, which included efforts to better coordinate continuity of care in ways such as integrating IT systems and implementing more user-friendly electronic health records. At WTUs, a large amount of attention is placed on properly managing each patient’s electronic health record to maintain compliance.

WTU patient populations have changed in response to the nature of modern warfare and its intrinsic risks. As the needs of the Army and active combat operations have evolved over the past 10 years, the types of injuries and illnesses sustained by soldiers entering the WCTP have also changed, with the majority of entrants now falling into a disease NBI category. At present, there are fourteen WTUs co-located with MTFs, which reflects a >40% reduction in WTUs from the height of the program. Although military operations in Iraq and Afghanistan have declined significantly, resulting in fewer wounded warriors returning home and a decline of the WCTP population (currently around 2,600 soldiers), the Army is committed to supporting and caring for transitioning soldiers and their families, and remains flexible to changes in the future population.

To the best of our knowledge, this is the first study of its kind to characterize the patient population within the WCTP. Despite the WCTP’s focus on effectively coordinating efforts, there has been minimal systematic research on the WCTP, and the potential exists to identify relevant trends and anomalies that may inform decision-makers within the medical command (MEDCOM) and WCTP. Certain patterns and anomalies may even prove relevant to other military medical efforts and highlight clinical gaps. There are several large, well-maintained databases that track WCTP patients and are available for records-based research (provided the requisite data use agreements and institutional oversight), but this must be evaluated by MIRROR.

Chronic exertional compartment syndrome (CECS) is a debilitating disorder affecting mostly an active population. The proposed pathophysiology is increased pressure in muscle compartments causing pain, paresthesia, and inability to tolerate exercise in the affected fascial compartment. CECS involves the lower extremities, primarily affects young active adults, and limits running and/or endurance activities. While the incidence of CECS in the general population is unknown, the prevalence in the military population has been found to be 0.49 cases per 1000 patient-years.

The current standard for definitive treatment of CECS is surgical fasciotomy of the involved compartments. According to a 2016 systematic review, surgical intervention for CECS is successful in only 66% of those affected, with 13% of patients reporting complications from surgery, and 6% needing a repeat procedure. A 2014 retrospective review of military members showed that only 59% of patients who underwent elective fasciotomy for CECS were able to return to full duty while 22% of the patients that were treated with fasciotomy were eventually medically discharged. One of the reasons for the limited success rate, is an incomplete understanding of the pathophysiology coupled with proper patient selection.

Gait retraining is an attractive alternative to fasciotomy. It aims to influence the effect of foot contact and running kinematics to reduce leg compartment pressures which relieves pain. Diebal et al. published a case series of 10 military members with CECS who underwent a gait retraining program that emphasized forefoot running. At six-weeks and one-year post-intervention, running distance, pain, and performance all significantly improved. Despite high rates of success in limited case studies, real world application of gait retraining has limitations. Many patients struggle to make and/or sustain adaptations in their running style. Some patients have severe pain with exercise which limits efforts at effective gait re-training.

A newer proposed treatment is the intramuscular administration of onabotulinumtoxin A, also known as botulinum toxin A or BoNT-A into the muscles of the involved compartment(s). One case series studying botulinum toxin injections for CECS demonstrated normalized intramuscular pressure up to nine months post-injection in 87.5% (14/16) of patients, and exertional pain was completely eliminated in 94% (15/16) of patients. Eleven patients experienced reduced muscle strength that was without functional consequences and transient, with only 1 of the 16 patients who complained of new posterior leg pain that did not appear to be related to BoNT-A injections. There were no other adverse effects reported.

Military sports medicine clinics at Fort Belvoir Community Hospital (FBCH) and USU have been utilizing BoNT-A injections for the non-surgical treatment of CECS. A retrospective review of patients with CECS treated with BoNT-A at FBCH Sports Medicine Clinic from 2014 to 2017 provided data on twenty-nine patients who were treated with BoNT-A for CECS. Prior to treatment, none of the 29 patients were able to perform their desired activity and 24% were unable to run one mile without severe leg pain. After botulinum injections, these numbers improved to 66% and 72% respectively. Sixty-nine percent of patients reported that they were satisfied or somewhat satisfied with their treatment, twelve patients continued to have sustained relief by the time they were contacted, and seven patients experienced a recurrence of symptoms. In those with recurrence, the mean duration of improvement was 7.8 months. Of note,11 patients received both BoNT-A and fasciotomy during their treatment course. Only one patient reported a favorable response to fasciotomy and failure with BoNT-A, suggesting that BoNT-A injections might be predictive of success with fasciotomy.

BoNT-A is FDA approved for intramuscular, intradetrusor, or intradermal use for muscle spasticity, migraine headaches, detrusor instability and severe forehead lines, lateral canthal lines, and glabellar lines in adults. To avoid side effects and predict treatment success, a recently published case review of pre-treatment with xylocaine injections prior to proposed BoNT-A injection for frontalis and glabellar rhytides was issued. Further, a yet unpublished case using the pre-treatment xylocaine protocol was conducted at FBCH. The subject improved her running symptoms with the xylocaine injection and subsequently underwent BoNT-A treatment. One month after the BoNT-A she is able to now walk/run up to 1 mile with no exertional symptoms.

The purpose of this grant application is to create a registry across all MTFs for CECS to compare diagnostic and therapeutic data. We will simultaneously assess the effectiveness of non-surgical treatments options for chronic exertional compartment syndrome as well as test the use of xylocaine injections to predict success for non-surgical or surgical options at selected sites. This study will also determine if successful gait retraining, either home based or supervised, is essential to positive results Furthermore this study will also determine if BoNT-A injections plus gait retraining is better than either treatment alone. Finally, this study would determine if xylocaine injections could predict who will benefit from BoNT-A injections or fasciotomy.

Training room clinical models have been in use in sport at all levels for generations. This approach employs rapid initial assessment and triage by highly trained MSI treatment and rehabilitation experts (e.g. Athletic Trainers, Physical Therapists, Orthopedic surgeons and Sports Medicine physicians). These skilled providers work in concert to mitigate the secondary effects of injury and return athletes to activities as quickly/safely as possible. Traditional sports medicine models revolve around quick access to multi-disciplinary care teams including allied health providers with unique expertise in sports nutrition, strength and conditioning, and sports psychology.

In the current standard of care, healthcare providers organize operationally to allow for more patients to be seen in a shorter period of time. This model allows a multidisciplinary team to treat patients simultaneously during designated clinic hours and consult with one another on diagnoses and treatment plans—this is highly efficient for both the patient and the organization. The Sports Medicine Model is equally focused on primary injury prevention, because primary prevention is the best way to keep athletes on the field and in the game.

In contrast, the military medicine model, outside of trained combat medics who provide pre-hospital battlefield trauma care and resuscitation at point of injury during field training and combat, provides traditional problem-based clinic visits for MSI of active duty service members. Providers outside of the primary MTFs who most typically are not specialized in MSI, evaluate patients and refer them to an appropriate consultant such as a physical therapist, radiology, sports medicine trained family physician, or orthopedic surgeon. Inherent time lags between providers often delays care, which is suboptimal when treating MSI. For active duty members, these delays may result in disbarment or failures from training schools, missed deployments, and decreases in medical readiness for deployable units.

Telehealth-based gait retraining has the potential to improve outcomes for Warfighters recovering from running-related injuries in remote and austere environments. Since 1992, the U.S. military has valued the use of telehealth to meet its unique obligations and missions. The goal of telehealth is to provide seamless communication of medical information between a patient and medical provider. Studies have shown statistically significant improvement in healthcare endpoints in the military as a direct result of telehealth care. Through the use of telehealth, it is possible to monitor, train, consult and inform end users in their deployed environment. It enables healthcare professionals to maintain or even improve an end user’s condition and quality of life, and at the same time reduce in-hospital and travel costs.

Forty-five percent of physical training and sports-related injuries in the military are due to running. Nearly all military service members run for physical training. Annual running injury incidence has recently been reported between 19-79%. While running-related injuries are multifactorial, average vertical loading rate has been the variable most linked to running related injury. Approximately 80% of runners use a rearfoot strike (RFS) pattern whereby the heel hits the ground first on each step. Runners using a RFS pattern have been shown to have up to 3.4 times greater risk of sustaining a running-related injury compared to runners who use a non-rearfoot strike (NRFS). Alterations in running gait, to include foot strike pattern may reduce injuries.

Recently, running with biofeedback in a lab setting has been used effectively for rehabilitation of runners recovering from patellofemoral knee pain (PFPS) and for reducing stress fracture risk. Florkiewicz et al. trained nine runners recovering from various lower-extremity injuries in 8 sessions over 10 weeks to increase cadence and transition from a RFS to a (NRFS) pattern. While gait retraining in a lab setting has been successful with the use of real-time in-clinic biofeedback, to our knowledge, this is the first research project that uses gait retraining via video telehealth to modify gait of previously injured runners.

Musculoskeletal injuries (MSKI) remain the largest source of disability, readiness impairment, non-deployable status, and separation within the United States (US) Military. The Department of Defense (DoD) pays $3.7 billion annually for MSKI care; while the Department of Veterans Affairs pays in excess of $5.5 billion annually for MSKI related compensations. The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) is the first tri-service, multi-center DoD-wide initiative to optimize military-specific and clinically-relevant patient outcome metrics for MSKI.

MOTION has more than 15,000 enrolled patients who received various orthopaedic treatment interventions on upper extremity, lower extremity, or spine MSKI. Validated patient reported outcome data are collected as part of the standard of care during the pre-operative visit and during follow-up visits at 6 weeks, 6 months, 12 months, 2 years, 5 years, 10 years, 15 years, and 20 years after surgery. Patient data are then linked with clinical provider intra-operative assessments and other relevant clinical data to optimize patient outcomes, improve procedural efficiency, and increase healthcare value and cost effectiveness.

Future outcomes-driven changes require advanced predictive models and integration within the DoD. MOTION will develop, conduct, and disseminate original and innovative military relevant clinical research focusing on outcomes and return to duty following MSKI. This research will result in improved military health and readiness, the development of improved evidence-based clinical practice guidelines, mitigating long-term physical detriments following injury, promoting greater military career longevity, and improved post-military service quality of life. Under MIRROR, the MOTION platform will be enhanced with additional analytical resources to improve military medical readiness, enhance value-based healthcare improvement, and support continuous quality improvement.

Sites w/ MIRROR Personnel:

-Walter Reed National Military Medical Center

-Brooke Army Medical Center

-Naval Medical Center San Diego

-Tripler Army Medical Center

-US Air Force Academy

-US Naval Academy

Sites Utilizing Remote Coordinator Support:

-Eglin Air Force Base

-Landstuhl Regional Medical Center

-Naval Medical Center Camp Lejeune

-Naval Medical Center Portsmouth

Chronic exertional compartment syndrome (CECS) is a condition provoked by exercise that is caused by a marked increase in tissue pressure within a closed fascial plane. It is most commonly seen in athletes who participate in ball and puck sports, military recruits, and long distance/high mileage runners. The incidence in the military has been shown to be .49 cases per 1000 patient years. Patients typically present with complaints of pain, recurrent leg cramping, and pressure, that is often identified at a specific point during training. Neurological symptoms may also occur, and include paresthesias or weakness in the distribution of a peripheral nerve.

Current gold standard for diagnosis of CECS is intramuscular compartment pressure measurement. Other methods of diagnosis have been proposed and include magnetic resonance imaging and near infrared spectroscopy (NIRS). However, MRI has been stated to be less reliable than compartment pressure and infrared spectroscopy. The cost, practicality, and availability of MRI or NIRS is a confounding factor in using these technologies for diagnostic decision making.  There remains a need for a reliable, non-invasive, accessible, and cost-effective tool to confirm clinical diagnosis. We hypothesize that this can be done with ultrasound shear wave muscle elastography. Shear wave elastography is an ultrasound-based technique that can characterize tissue mechanical properties.

The long-term objective of this project is to develop a sensitive and non-invasive method of diagnosing CECS using shear wave muscle elastography (SWE) and to compare non-invasive shear wave muscle elastography to invasive pressure monitoring. After intervention, we will assess for objective changes within the symptomatic compartment using ultrasound shear wave elastography.

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.