More than 800,000 military service members are injured each year, leading to an estimated 25 million days of limited duty annually. Musculoskeletal injuries (MSI) are the greatest threat to force readiness during both peacetime and combat operations. Although the more severe trauma during combat can lead to a significant loss of military personnel, even seemingly mild injuries during sport and exercise could contribute to a lack of readiness and poorer overall fitness. Furthermore, non-combat MSI (during physical training, tactical training, recreational activity, and sport) are endemic within the military population accounting for 85% of all MSI among United States (U.S.) military personnel. Athletic injuries are also the leading cause of disability discharge among service members (SM) in the U.S. Army, according to Physical Evaluation Board data. Thus, prevention and care of these sports and physical training injuries are top priorities for leaders in the Department of Defense (DoD).

Most sports-related MSI affect the lower limb. Forty percent of these injuries occur at the knee, making it the most common site of MSI. Specifically, soft tissue injuries are the most frequently encountered and represent 47% of all knee injuries. In the U.S., fibrocartilage, ligamentous, and tendinous integrity compromise about the knee can lead to joint instability. Knee joint instability can have short-term and/or long-term negative effects, affecting force readiness and return-to-duty/return-to-sport (RTD/RTS) decisions. Objective measures of knee stability could be used to determine those at risk for injury thus decreasing the rate of injury. In addition, objective measures of knee stability could be used throughout the rehabilitation process to determine healing and neuroadaptation of soft tissue and surrounding contractile musculature, respectively, enabling the SM to RTD/RTS without fear of re-injury and with a greater potential to achieve their pre-injury level of performance.

Effective measures of injury risk and function are urgently needed in the military and athletic populations. Traditional functional assessment tests such as the hop test and vertical drop jump tests are currently used to determine time of return to preoperative physical activity level following knee injury and used as a clinical screening tool for anterior cruciate ligament (ACL) injury, respectively. However, the sensitivity for detecting functional weaknesses, i.e. single-leg hop test for distance, is reported to be between 38-52%. It was also recently reported that none of the vertical drop jump test variables were associated with increased ACL injury risk in a cohort study of 710 athletes. Often, by the time the test results are known the functional status of the healing individual has changed or the individual has made the decision to return to activity.

The use of mobile technologies and body-worn devices for the classification of at-risk SMs with MSI can be performed in a matter of minutes with real-time analysis. Predicting which SMs are at risk for injury prior to an adverse event can have a major impact on their health, career, and the cost of care for the military.

To assess the risk for knee injury efficiently, we have previously developed a novel mobile lower limb motion capture system (known as CaneSenseTM) consisting of small wireless inertial measurement units (IMUs) that communicate via Bluetooth to a custom mobile app on a mobile tablet. Data is processed in real time and includes kinematics and kinetics to improve functional outcomes.

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.

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.

Knee injuries, such as those to the meniscus or anterior cruciate ligament (ACL), are common in the military due to lower-extremity demands placed on soldiers. These injuries are difficult to heal and predispose soldiers to the development of osteoarthritis (OA), which can limit their function and quality of life. Surgery is not always the preferred course of treatment, and is not completely effective in preventing post-traumatic OA when performed. It is hypothesized that the acute inflammatory reaction to these injuries plays a role in the development of OA via exposure of synoviocytes to noxious stimuli.

The primary objective of this study is to evaluate the biochemical and cellular composition of hemarthroses after acute knee injuries. Secondarily, we seek to create a platelet-rich plasma (PRP) product using hemarthroses collected after aspiration and characterize the biochemical and cellular composition of the product. This study will provide the preliminary data needed to design, fund, and implement a future interventional study, which will use the PRP product in a clinical trial for acute knee soft-tissue injuries.

Chronic and persistent pain after orthopaedic injury is one of the primary barriers to readiness across all military services. Currently, the ability to accurately predict which military service members will develop chronic and persistent pain conditions after surgery for an orthopaedic injury is lacking. This information will allow the medical team to intervene early, or perhaps reconsider surgical options for those who will be known to have poor outcomes. This study is focused on current active duty military service members. It is imperative that we understand how to minimize lost work days and disability in these specific beneficiaries. Even modest reductions in persistent pain and disability will improve patient-centered outcomes and reduce cost for the Department of Defense.

This study will develop and validate an innovative predictive framework to provide clinical point-of-care algorithms to accurately identify 12-month outcomes related to military readiness, clinical outcomes, and healthcare utilization to improve prediction accuracy of who will do well post-surgery and who will not.

Knee osteoarthritis (KOA) is one of the leading causes of chronic pain and disability worldwide, affecting over 30% of older adults. It represents a major global health and economic burden to individuals and society. The rates of KOA have more than doubled in the past 70 years and continue to grow sharply, given increases in life expectancy and population body mass index (BMI). Surgery is often employed to treat KOA, but it is associated with a high rate of persistent pain and is not a permanent solution. 

Numerous nonsurgical therapies have been advocated to treat pain in patients with KOA. However, standalone conservative treatments including non-opioid medications and joint injections provide only limited pain relief and functional improvement in a subset of knee OA sufferers. This has led to a high rate of opioid use and disability in this population. 

The overarching goal of this study is to conduct a sequential parallel group randomized controlled trial (RCT) to evaluate the comparative effectiveness of conservative behavioral and non-opioid pharmacological treatments (Phase 1) and, among those that indicate interest in obtaining further treatment and those inappropriate for conservative treatment, the benefits of procedural interventions (Phase 2). This study will also evaluate whether clinical and psychosocial phenotypes predict short- and longer-term treatment response. 

The results of this study, which will follow pragmatic principles in order to maximize the information provided to stakeholders, will examine not only the effectiveness of each tested intervention but also provide meaningful information regarding effectiveness across key subgroups of participants. The knowledge gained will contribute to the development of translatable therapeutic strategies for the treatment of KOA pain that will lead to opioid sparing.

As of September 1, 2014, 1,573 US Military servicemembers have sustained a major limb amputation since 2001. In addition to the inherent mobility challenges posed by amputation, this population suffers from a variety of comorbidities, including osteoarthritis (OA). Osteoarthritis is the primary source of long-term disability in wounded servicemembers and the inability to return to active duty following traumatic injury. Osteoarthritis of the knee specifically is among the most prevalent and costly chronic diseases in the USA. The estimated lifetime incidence rate of knee OA among all American adults ages 25+ is at least 14%. Knee OA, particularly on the medial knee joint, is the most common form of OA and the leading cause of mobility impairment in older adults.

The risk of knee OA in the intact limb is especially concerning for young service members with amputations. At Walter Reed National Military Medical Center (WRNMMC), service members with amputations are treated by a large multidisciplinary team through physical and occupational therapy, prosthesis fitting and training, and gait and motion analysis, with generally successful outcomes, and advances in prosthesis technology have greatly improved the mobility of amputees and their ability to engage in physical activity. However, very little is currently done towards the objective of preventing knee OA, and the incidence and prevalence of chronic comorbidities in amputees remain high. Most servicemembers with amputations are relatively young when they receive their injuries and will live with any associated disabilities for many years. The incidence of knee OA increases with age and typically peaks at around 60 years old. Service members with amputations will thus live with a substantial and progressive risk of knee OA for many years.

In order to ultimately reduce the prevalence and healthcare burden of knee OA among servicemembers with amputations and salvaged limbs, we must first gain a better understanding of the mechanisms that increase knee OA risk in this population. This knowledge will facilitate development and evaluation of more effective preventive therapies for avoiding detrimental knee joint loading while maintaining a high level of mobility in service members with amputations.

The objective of this study is to develop clinical guidelines for using instrumented gait analysis and biomechanical modeling as a diagnostic tool for assessing knee OA risk in service members with unilateral amputation or limb salvage.

This study will longitudinally evaluate the effects of vibration embedded in rehabilitation on quadriceps function, gait biomechanics, patient self-report outcomes, knee cartilage composition, and post-traumatic knee osteoarthritis incidence over the first year following ACL reconstruction.