Photo By Danae Johnson | Subject demonstrates Close Kinetic Chain Upper Extremity Stability test. Pictured, two...... read more read more
FORT DETRICK, Md. – Service members must meet unique physical requirements, often performing movements where upper extremity strength, endurance, and agility are essential for mission fulfillment. Shoulder injuries are common, yet historically, rehabilitation protocols have been slower to advance than those for lower extremity injuries. Recognizing this gap, Dr. Marisa Pontillo, a Musculoskeletal Rehabilitation Research Scientist with the Defense Health Agency Research and Development’ s Extremity Trauma and Amputation Center of Excellence, is redefining efforts to improve shoulder recovery for warfighters.
While lower limb injuries have long been the focus of clinical innovation, the complexities of shoulder rehabilitation have often been overlooked. This disproportion in upper extremity research has left service members and their care teams seeking more effective ways to restore function and ensure readiness for duty.
“Shoulder and upper extremity research are 10 to 20 years behind compared to the lower extremity,” says Pontillo. “There has always been more focus on lower extremity injuries than the upper extremity—not just in sports, but also in orthopedics and within the military. For service members, the upper extremity is just as important for tasks like lifting, carrying, and operating equipment.”
So, after years of treating high school, collegiate, and professional athletes, Pontillo observed that traditional upper extremity assessments focused primarily on strength and range of motion. However, these tests often overlooked other critical factors--like endurance, power, and agility–that are essential for full recover. This gap becomes even more significant for service members, whose duties require a higher level of physical performance. As a result, there was a clear need for assessment tools that could bridge the gap between standard rehabilitation to the demanding tasks required in military service.
Now, drawing on her years of clinical experience and work to advance upper extremity rehabilitation, Pontillo is leading the new Criteria-based Rehabilitation for Injured Shoulders Paradigm, referred to as CRISP, a grant-funded shoulder study that brings together her ongoing efforts to improve outcomes for service members. Conducted across three major military sites— the Naval Medical Center in San Diego, California, the Naval Hospital at Camp Pendleton, California and Brooke Army Medical Center in San Antonio, Texas—the study focuses on service members with non-operative shoulder pain, representing a wide range of military occupations and physical activity levels.
“We are using several different functional tests to move service members between phases of shoulder rehabilitation, so that we have optimal discharge criteria. Service members must hit as many benchmarks as possible before being cleared to return to duty,” said Pontillo.
The CRISP protocol is designed to be flexible and individualized. Instead of a fixed timeline, service members progress through rehabilitation phases based on their functional abilities. The study’s battery includes range of motion, strength, endurance, patient-reported outcomes, and functional tests such as the Single Arm Shot Put and the Closed Kinetic Chain Upper Extremity Stability Test referred to as CKCUEST.
“These tests measure not just strength, but power, agility, precision, and speed—qualities essential for military tasks like moving in body armor, racking weapons, and performing overhead lifts,” said Pontillo.
Among the functional tests included in the CRISP protocol, the CKCUEST is particularly important for its reliability. It provides clinicians with a reliable method to assess both future upper extremity injury risk and readiness to return to activity. However, interpreting scores requires careful comparison to normative values, so clinicians must reference large-scale studies to ensure accurate assessment. Dr. Pontillo established its predictive validity for future injury risk in a 2014 article, making it unique among upper extremity functional tests.
CRISP’s approach ensures that rehabilitation is not just about healing, but about preparing warfighters for the realities of their duties. Unlike civilian health insurance, which often restricts therapy to a set number of visits, CRISP allows service members the medical visits they need to truly regain function. Some recover in six weeks, others can take months depending on their individual progress, but all with the goal to safely return to duty.
“Service members need more than strength and range of motion to determine whether they are deployable and can perform their military occupational specialty,” Pontillo emphasized.
The CRISP study’s design also accommodates the diverse nature of military occupations. Service members from desk jobs to avid weightlifters are included, ensuring the protocol is relevant across the force. The research team is currently recruiting participants and expects to continue data collection for another year and a half, with follow-up surveys extending twelve months after a patient’s discharge.
“We’re seeing multiple branches and a variety of shoulder injuries, from instability to rotator cuff issues. The tests are written into the study to determine readiness for higher-level exercise and return to duty,” said Pontillo.
Despite these advances, barriers to adoption for shoulder rehabilitation remain, particularly among clinicians unfamiliar with the latest research. Recently, Pontillo conducted a systematic review of 60 articles to evaluate how well common upper extremity functional tests assess return-to-activity readiness in service members and found that the Single Arm Shot Put and CKCUEST tests demonstrated strong reliability. These tests are practical, requiring minimal equipment, and have been validated across age, sex, activity level, and even in those with shoulder pain. A reference guide to these measurement properties is essential for choosing the proper test to determine readiness after an upper extremity injury.
“There needs to be self-awareness among clinicians, especially depending on their level and type of experience,” Pontillo said. “But with open access to this particular systematic review and growing use in Doctor of Physical Therapy programs and journal clubs, the tide is turning toward better should rehabilitation protocols that will benefit the warfighter.”
Looking ahead, Pontillo sees the future of warfighter shoulder rehabilitation as increasingly personalized and evidence based. The CRISP study aims to identify which tests best predict the ability to return to duty, potentially shaping protocols for years to come.
“There's so much opportunity in the return to duty area,” said Pontillo. “I could easily spend the rest of my career just on return to duty, retire, and still not be done researching the needs for the warfighter."
For more information on the CRISP study and Dr. Pontillo’s research, https://scholar.google.com/citations?hl=en&user=CyY7D18AAAAJ.
| Date Taken: | 06.02.2026 |
| Date Posted: | 06.02.2026 15:20 |
| Story ID: | 566700 |
| Location: | FORT DETRICK, MARYLAND, US |
| Web Views: | 19 |
| Downloads: | 0 |
This work, Bridging the Gap: EACE’s Research Advances Upper Extremity Rehabilitation for Warfighters, by Danae Johnson, identified by DVIDS, must comply with the restrictions shown on https://www.dvidshub.net/about/copyright.
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