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.

Neck pain is one of the five most common pain conditions and leading causes of disability worldwide. According to one systematic review, the estimated mean point, annual, and lifetime prevalence rates were 7.6%, 37.2% and 48.5%, respectively. In the only study examining the breakdown of neck pain according to mechanism, approximately 50% of people with chronic neck pain had neuropathic (i.e. radicular) pain. 

Among individuals with neuropathic neck pain, epidural steroid injections (ESI) are arguably the most effective non-surgical treatment, though questions remain regarding long-term benefit. Over the past 20 years, utilization of ESI in general and cervical ESI in particular almost tripled, leading to increased scrutiny on ESI and an Food & Drug Administration (FDA) panel discussion in November 2014. Cervical ESI may be associated with significant complications including paralysis, stroke and death, which led to calls to refine patient selection.

The use of non-organic signs to predict treatment outcomes has recently experienced a resurgence in interest. In 1980, the British orthopedic surgeon Gordon Waddell published a landmark article detailing eight non-organic clinical signs in five categories that they recommended be used as part of routine surgical screening. They found that people with multiple (> three out of five) non-organic signs (a.k.a. Waddell signs) were more likely to experience negative surgical outcomes for low back pain and to be identified as “problem patients.” Whereas subsequent studies have yielded mixed results for the ability of non-organic signs to predict low back pain treatment outcomes, these studies have generally been of poor quality, and until recently did not evaluate non-surgical interventional treatment outcomes (e.g. ESI). However, last year our group performed the first prospective study showing that non-organic signs were strongly correlated to low back pain (LBP) interventional treatment failure, including for lumbar ESI.

The main objectives of this study are to determine whether physical exam signs, including non-organic signs, predict cervical ESI outcomes; to validate the non-organic signs being published by determining their association with factors that may be associated with non-organic illness including psychopathology, secondary gain, and co-existing pain conditions; and to determine the prevalence of the various physical exam signs, including the non-organic signs, in patients with cervical radiculopathy.

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.

Neck pain is one of the 5 most common pain conditions and leading causes of disability worldwide. According to one systematic review, the estimated mean point, annual, and lifetime prevalence rates were 7.6%, 37.2% and 48.5%, respectively. In the Global Burden of Disease 2010 study, neck pain was ranked as the fourth most common cause of disability in the United States.

Among individuals with chronic neck pain, injections work for only a small percentage of patients and their effects are generally short-lived, while studies evaluating the long-term effectiveness of surgery are mixed. Among randomized, placebo-controlled trials evaluating medications for chronic neck pain, only topical diclofenac has been shown to be effective, suggesting that muscles and other superficial tissues play an important role.

Topical local anesthetics have been shown in randomized trials to alleviate some forms of neck pain (trapezius muscle) associated with myofascial trigger points, but a well-designed placebo- controlled trial found no evidence of efficacy for low back pain. This suggests that the pain generators in the neck may be more superficial than in the low back. The erector spinae and deep intrinsic muscles in the low back generally lie several inches beneath the surface, while the penetration of topical lidocaine is typically limited to around 1 cm without penetration enhancers.

A drawback of topical local anesthetic creams is that they can adhere to clothing, making absorption unreliable. They may also be messy and, on exposed skin, unsightly. This has led to the widespread adoption of topical local anesthetics embedded in patch form. Limitations of the current, commercially available formulations of topical lidocaine patches (Lidoderm, Endo Pharmaceuticals, Chadds Ford, PA) include poor bioavailability, estimated at 3%, and poor adherence. A newer formulation of topical lidocaine (ZT Lido, Scilex, San Diego, CA) that contains higher bioavailability (36 mg provides equivalent exposure to 700 mg of Lidoderm) and less variability, along with better adherence (> 90% adherence in 75% of individuals at 12 hours vs. 13.6% for Lidoderm), was recently approved for post-therapeutic neuralgia. A high adherence rate is necessary to maximize benefit in a physically active (i.e. military and VA population) cohort.

In this randomized, double-blind, placebo-controlled crossover study, patients with non-radicular neck pain will be allocated in a 1:1 ratio to receive up to three topical lidocaine or placebo patches, to be applied 12 hours per day. At the end of four weeks, patients will return for their post-phase I treatment evaluation. One to two weeks after the initial treatment, patients will crossover to receive the treatment they did not receive originally, to be applied in the same fashion for the same 4-week period. The primary outcome measure will be average neck pain over the past week, 4 weeks post-treatment.

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.

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.

The goal of this study is to identify and develop a syntax of ICD (diagnosis) and CPT (procedures) codes that are able to accurately identify amputees in the MHS, and all LBP-related care, describe and characterize the amputee patient population with low back pain, and calculate the total 1-year LBP-related costs in the year following the initial index visit for LBP.

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.