Military service members are the most at-risk population for shoulder instability and 80% of these individuals have a re-injury (recurrent instability). Of particular concern are military trainees who are 40X more likely to have a shoulder instability event than their civilian counterparts. The spectrum of shoulder instability includes shoulder subluxations (transient instability that maintains glenohumeral continuity) and frank dislocations (complete glenohumeral disassociation requiring reduction). Following a first-time shoulder instability event, both operative and non-operative management are routinely employed. Both treatment approaches yield outcomes that span the spectrum from complete success (no future instability events) to complete failure (recurrent instability events). Furthermore, there is no evidence to guide the optimal rehabilitation strategy (supervised versus self-managed rehabilitation). Thus, there is no clear indication for what treatment approach is superior and should be employed across the military. The ramifications of incorrect acute management of shoulder instability, will likely have long-term consequences for the individual. Improperly managed shoulders may lead to progressive articular cartilage damage, loss of humeral head or glenoid osseous support and labral-ligamentous injury. Collectively, these progressive sequelae increase the risk for recurrent shoulder instability events. Chronic recurrent instability results in increasing bone loss, higher surgical failure rates, and post-traumatic osteoarthritis. Conversely, immediate surgical stabilization following a single instability event may result in unnecessary surgery that could have been successfully managed with non-operative treatment. Due to the dearth of definitive evidence for the optimal initial method of treatment (operative versus non-operative), a large-scale trial is needed to optimize the outcomes for these most readiness-impairing and burdensome injuries. The findings of this study will inform military specific clinical practice guidelines (CPGs) that will lead to optimized management of shoulder instability in a young, physically active military population. Optimal management of shoulder instability will result in improved patient outcomes, maximize warfighter return to duty/activity (RTD/A) and mitigate re-injury in Service Members with shoulder instability. Collectively, the results of this study will result in improved Force medical readiness. This proposal also directly responds to the surgical and rehabilitation techniques and outcomes for soft tissue trauma of common musculoskeletal injuries for enhanced RTD/A techniques and outcomes for soft tissue trauma of common musculoskeletal injuries for enhanced RTD/A.

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.

Ultrasound (US) is frequently used to diagnose shoulder pathology, and can be used in an office setting to quickly and cost-effectively assess the quality of the rotator cuff musculature. Diagnostic imaging of the rotator cuff muscle quality can help determine prognosis as well as appropriate management. For instance, we know that maximum cross-sectional area (CSA) of the rotator cuff muscles is closely related to that muscle’s isokinetic strength and predicts rotator cuff pathology and surgical outcomes. Fatty degeneration of the rotator cuff is predictive of deficits in strength and function, specifically for abduction, external rotation, and internal rotation. Though the thickness or CSA of a rotator cuff can easily be obtained, there is much variation in in a healthy rotator cuff muscle’s CSA based on patient age and gender, which makes it difficult to deduce whether there is pathology based on only CSA, making a ratio involving muscle size more predictive of pathology than CSA only.

Literature suggests that use of ratios of rotator cuff CSA or thickness may be predictive of rotator cuff pathology than thickness or CSA alone, and that supraspinatus and infraspinatus size can be reliably measured under ultrasound. Therefore, we propose establishing normative measurements of three different ratio involving the rotator cuff muscles: the trapezius : supraspinatus thickness ratio, the supraspinatus : infraspinatus CSA ratio, and the infraspinatus : teres minor CSA ratio.

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.

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.

Shoulder pain is in the top five reasons related to musculoskeletal disorders that care is sought within the Military Health System. While acromioclavicular joint (ACJ) disorders, a subset of all shoulder pain disorders, are a high-volume condition seen in primary clinics, very little is known about the epidemiology in the military. At the United States Military Academy in West Point, 162 new cases were identified over a four-year period, which equaled an incidence rate of 9.2 per 1000 person-years. 

Onset of pain in athletes is most commonly related to activities which strain the ACJ, to include push-ups, military press, overhead press, as well as any forceful contact to the shoulder which provides a shear on the ACJ (falling on outstretched hand, direct blow to the elbow, landing forcefully on the side of the shoulder). These are all very common activities and often part of the daily routine for service members, as part of their physical and readiness training. Consequently, pain and inability to absorb normal stress in this joint after injury creates tremendous disability and greatly limits service members from being able to complete many of their daily duties. Ultimately, this affects military readiness substantially. Recovery is often slow and depends on the severity of the injury, but usually taking a minimum of six weeks and in many cases with recalcitrant symptoms lasting out to a year or more. Interventions that can speed up recovery and maximize pain-free function on return to duty are in high demand for service members, as they have the potential to directly impact the state of medical readiness for our service members.

Platelet-Rich Plasma (PRP) is a new treatment that shows promise for treating musculoskeletal disorders. The driving therapeutic mechanism is to leverage the restorative biological mechanisms in red blood cells using the patient’s own red blood cells to accelerate and promote healing. PRP is currently utilized in the clinic, but its cost can be prohibitive. Corticosteroid injections may be as clinically effective as PRP for managing acromioclavicular pain, but at a fraction of the price. This study aims to assess whether corticosteroid injections are non-inferior to PRP.

Military personnel are the most at-risk population for shoulder instability and more than 80% of these individuals have recurrent instability with non-operative treatment. Traumatic and recurrent shoulder instability produces progressive bone loss to the stabilizing structures of the glenoid and humerus, which contributes to failure following surgery, impairments of physical performance, and prolongs limited duty/disability. To date, there are no prospective comparative studies to determine optimal surgical treatment for shoulder instability with subcritical glenoid bone loss (10-20%). Further, there are no studies to assess functional recovery and return to military duty, work, and sports after the most common stabilization procedures. Therefore, this clinical trial will investigate the effects of three surgical procedures and the associated post-operative rehabilitation to mitigate the risk of re-injury, minimize time away from duty, and optimize military readiness.

This study will recruit military personnel and civilians between 17 and 45 with a traumatic anterior shoulder dislocation with associated 10-20% bone loss and randomize to one of three surgeries and their associated rehabilitation, with progressive-individualized strengthening and functional training in a 1:1:1 allocation. Participants will be followed for 24 months, with primary outcomes consisting of patient-reported physical function and time to return to pre-injury military duty, work, and sports. Secondary outcomes will include shoulder-specific and generic patient-reported measures of physical function, health/quality of life, and recurrent instability.