Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis

Infrapatellar fat pad volume and Hoffa-synovitis after ACL reconstruction: Association with early osteoarthritis features and pain over 5 years

Infrapatellar fat pad (IPFP) morphology and Hoffa-synovitis may be relevant to the development and progression of post-traumatic osteoarthritis (OA). We aimed to compare IPFP volume and Hoffa-synovitis in participants with anterior cruciate ligament reconstruction (ACLR) and uninjured controls, and to determine their association with prevalent and worsening early knee OA features and pain in participants post-ACLR. We assessed IPFP volume and Hoffa-synovitis from magnetic resonance imaging (MRI) in 111 participants 1-year post-ACLR and 20 uninjured controls. Patellofemoral and tibiofemoral cartilage and bone marrow lesions (BMLs) were assessed from MRIs at 1 and 5 years post-ACLR, and worsening defined as any longitudinal increase in lesion size/severity. IPFP volume and Hoffa-synovitis prevalence were compared between groups with analysis of covariance and χ ² tests, respectively. Generalized linear models assessed the relation of IPFP volume and Hoffa-synovitis to prevalent and worsening features of OA and knee pain (Knee injury and Osteoarthritis Outcome Score-Pain Subscale, Anterior Knee Pain Scale). No significant between-group differences were observed in IPFP volume (ACLR 34.39 ± 7.29cm³ , Control 34.27 ± 7.56cm³ ) and Hoffa-synovitis (ACLR 61%, Control 80%). Greater IPFP volume at 1-year post-ACLR was associated with greater odds of patellofemoral BMLs at 1-year (odds ratio [OR] [95% confidence intervals]: 1.104 [1.016, 1.200]) and worsening tibiofemoral cartilage lesions at 5-year post-ACLR (OR: 1.234 [1.026, 1.483]). Hoffa-synovitis at 1-year post-ACLR was associated with greater odds of worsening patellofemoral BMLs at 5-year post-ACLR (OR: 7.465 [1.291, 43.169]). In conclusion, IPFP volume and Hoffa-synovitis prevalence are similar between individuals 1-year post-ACLR and controls. Greater IPFP volume and Hoffa-synovitis appear to be associated with the presence and worsening of some early OA features in those post-ACLR, but not pain.

Treatment of post-meniscectomy knee symptoms with medial meniscus replacement results in greater pain reduction and functional improvement than non-surgical care

PURPOSE

Partial meniscectomy is a common orthopedic procedure intended to improve knee pain and function in patients with irreparable meniscal tears. However, 6-25% of partial meniscectomy patients experience persistent knee pain after surgery. In this randomized controlled trial (RCT) involving subjects with knee pain following partial meniscectomy, it was hypothesized that treatment with a synthetic medial meniscus replacement (MMR) implant provides significantly greater improvements in knee pain and function compared to non-surgical care alone.

METHODS

In this prospective, multicenter RCT, subjects with persistent knee pain following one or more previous partial meniscectomies were randomized to receive either MMR or non-surgical care. This analysis evaluated the 1-year outcomes of this 2-year clinical trial. Patient-reported knee pain, function, and quality of life were measured using nine separate patient-reported outcomes. The primary outcomes were the pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS) and the average of all five KOOS subscales (KOOS Overall). Treatment cessation was defined as permanent device removal in the MMR group and any surgical procedure to the index knee in the non-surgical care group.

RESULTS

Treated subjects had a median age of 52 years old (range 30-69 years) and one or more previous partial meniscectomies at a median of 34 months (range 5-430 months) before trial entry. Among 127 subjects treated with either MMR (n = 61) or non-surgical care (n = 66), 11 withdrew from the trial or were lost to follow-up (MMR, n = 0; non-surgical care, n = 11). The magnitude of improvement from baseline to 1 year was significantly greater in subjects who received MMR in both primary outcomes of KOOS Pain (P = 0.013) and KOOS Overall (P = 0.027). Treatment cessation was reported in 14.5% of non-surgical care subjects and only 4.9% of MMR subjects (n.s.).

CONCLUSION

Treatment with the synthetic MMR implant resulted in significantly greater improvements in knee pain, function, and quality of life at 1 year of follow-up compared to treatment with non-surgical care alone.

LEVEL OF EVIDENCE

I.

Bone in osteoarthritis: imaging and interventions

PURPOSE OF REVIEW

To review the recent literature on bone in osteoarthritis (OA), with a focus on imaging and intervention studies.

RECENT FINDINGS

Most studies focused on knee OA; hip and hand studies were uncommon. Bone shape studies demonstrated that shape changes precede radiographic OA, predict joint replacement, and have demonstrated high responsiveness. Novel quantitative 3D imaging markers (B-score) have better characterized OA severity, including preradiographic OA status. The addition of computerized tomography-derived 3D metrics has improved the prediction of hip joint replacement when compared to radiographs alone.Recent studies of bisphosphonates for knee OA have reported no benefits on pain or bone marrow lesion (BML) size. A meta-analysis on Vitamin D supplementation in knee OA suggested minimal symptom improvement and no benefits on the structure. Cathepsin K inhibition demonstrated reduction in OA bone change progression, but with no symptom benefit. Studies of injections of bone substitutes into BMLs (subchondroplasty) have generally been small and potential benefits remain unclear.

SUMMARY

Subchondral bone features are associated with pain, incidence and progression of OA. Recent studies have validated quantitative bone shape as a biomarker for OA trials. Trials of bone-targeted OA therapies have been disappointing although cathepsin K inhibition may slow structural progression.

Osteoarthritic changes in the knees of recently retired male professional footballers: a pilot study

Background

Knee osteoarthritis (OA) is common amongst retired male professional footballers. There is limited understanding with respect to the interplay between imaging findings, clinical presentation and patient-reported outcome measures (PROMs) in retired professional footballers with knee OA.

Objectives

This pilot study aimed to evaluate the extent of radiological and clinical knee OA in a cohort of retired male professional footballers, and to explore the relationship between these findings and knee-related PROMs.

Methods

Fifteen retired male professional footballers underwent knee radiographs and were surveyed on their history of clinical OA, severe knee injury and previous knee surgery. The Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS) and the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) were used to assess health outcomes, such as level of function and pain.

Results

Radiological knee OA was diagnosed in six out of 15 participants. Seven of the participants had a clinical diagnosis of knee OA. Evidence of clinical and radiological OA was present amongst four participants. Radiological knee OA and clinical OA was significantly associated with a history of severe knee injury and previous knee surgery. Low correlations (ρ<-0.40) were found between knee OA severity and knee-related PROMs. Moderate correlation (ρ=-0.65) was found between clinical knee OA and KOOS-SP.

Conclusion

Clinical knee OA correlates with PROMs amongst retired professional footballers but radiological OA does not. Further studies are required to understand the relationship between imaging findings, clinical presentation and PROMs amongst retired professional footballers with knee OA.

Evaluating the Effectiveness of Soft Tissue Therapy in the Treatment of Disorders and Postoperative Conditions of the Knee Joint-A Systematic Review

The term "soft tissue therapy" (STT) refers to mechanical methods of treatment involving passive kneading, pressing and stretching of pathologically tense tissues in supporting the process of recovery after surgery or trauma to the musculoskeletal system. The objective of this study was to review current scientific reports evaluating the effectiveness of the use of STT in patients with diseases or after surgical procedures of the knee joint. A systematic search of the popular scientific databases PubMed, Scopus and Embase was performed from inception to 15 October 2021. Eight articles met eligibility criteria and were included in the review. Six papers were related to disorders of the knee joint, while the remaining two studies were related to dysfunctions associated with the conditions after surgical intervention. The findings presented confirmed the effectiveness of STT in orthopaedic patients who showed an increase in lower limb functional parameters. The research has shown that the use of various methods of STT has a significant impact on increasing muscle activity and flexibility as well as increasing the range of motion in the knee joint. The physiotherapeutic methods used had a significant impact on reducing pain and increasing physical function and quality of life. The techniques used reduced the time to descend stairs in patients with knee osteoarthritis. This review summarises the effectiveness of STT as an important form of treatment for orthopaedic patients with various knee joint dysfunctions.

Knee extensor muscle weakness is a risk factor for the development of knee osteoarthritis: an updated systematic review and meta-analysis including 46 819 men and women

OBJECTIVE

To update a systematic review on the association between knee extensor muscle weakness and the risk of incident knee osteoarthritis in women and men.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Systematic searches in PubMed, EMBASE, SPORTDiscus, CINAHL, AMED and CENTRAL in May 2021.

ELIGIBLE CRITERIA FOR SELECTING STUDIES

Longitudinal studies with at least 2 years follow-up including baseline measure of knee extensor muscle strength, and follow-up measure of symptomatic or radiographic knee osteoarthritis. Studies including participants with known knee osteoarthritis at baseline were excluded. Risk of bias assessment was conducted using six criteria for study validity and bias. Grading of Recommendations Assessments, Development and Evaluation assessed overall quality of evidence. Meta-analysis estimated the OR for the association between knee extensor muscle weakness and incident knee osteoarthritis.

RESULTS

We included 11 studies with 46 819 participants. Low quality evidence indicated that knee extensor muscle weakness increased the odds of symptomatic knee osteoarthritis in women (OR 1.85, 95% CI 1.29 to 2.64) and in adult men (OR 1.43, 95% CI 1.14 to 1.78), and for radiographic knee osteoarthritis in women: OR 1.43 (95% CI 1.19 to 1.71) and in men: OR 1.39 (95% CI 1.07 to 1.82). No associations were identified for knee injured populations except for radiographic osteoarthritis in men.

DISCUSSION

There is low quality evidence that knee extensor muscle weakness is associated with incident symptomatic and radiographic knee osteoarthritis in women and men. Optimising knee extensor muscle strength may help to prevent knee osteoarthritis.

PROSPERO REGISTRATION NUMBER

CRD42020214976.

Occupational risk factors for meniscal lesions: a systematic review and meta-analysis

BACKGROUND

Meniscal lesions are common and are associated with the development of knee osteoarthritis. Knee-straining activities at work such as kneeling or squatting cause high biomechanical stresses on the knee joints that can lead to acute or chronic injuries. The objective of this systematic review is to update the evidence on the potential relationship between occupational risk factors and meniscal lesions.

METHODS

We searched the Medline, Embase and Web of Science databases until August 2021 to identify epidemiological observational studies on the association between occupational risk factors and meniscal lesions. Study selection, data extraction and risk of bias assessment were performed independently by two reviewers. Effect measures were extracted from individual studies and pooled with random effects meta-analysis. Heterogeneity analyses were conducted. We used GRADE (Grades of Recommendations, Assessment, Development and Evaluation) to assess the overall quality of evidence.

RESULTS

The database search resulted in 11,006 references, and 46 additional studies were identified through hand search. Twenty-two studies (represented in 25 publications) met the predefined eligibility criteria and nine records were included in the meta-analysis. There was only one study with an overall low risk of bias. Significant associations between occupational risk factors and the development of meniscal lesions were found for kneeling (effect size (ES) 2.15, 95% CI 1.67-2.76), squatting (ES 2.01, 95% CI 1.34-3.03), climbing stairs (ES 2.28, 95% CI 1.58-3.30), lifting and carrying weights ≥ 10 kg (ES 1.63, 95% CI 1.35-1.96), lifting and carrying weights ≥ 25 kg (ES 1.56, 95% CI 1.08-2.24), playing football on a professional level (ES 5.22, 95% CI 3.24-8.41), working as a hard coal miner (ES 5.23, 95% CI 2.16-12.69) and floor layers (ES 1.99, 95% CI 1.43-2.78). The overall quality of evidence according GRADE was moderate to low.

CONCLUSION

We found consistent evidence of an increased risk of meniscal lesions by occupational knee-straining exposures. Our findings are important for the development of preventive strategies to reduce work-related knee disorders and work absence.

TRIAL REGISTRATION

PROSPERO (registration no. CRD42020196279 ).

Local neuromuscular characteristics associated with patellofemoral pain: A systematic review and meta-analysis

BACKGROUND

Local neuromuscular deficits have been reported in people with patellofemoral pain. We synthesised the neuromuscular characteristics associated with patellofemoral pain to help identify interventional targets and potential mechanisms.

METHODS

Five databases were searched for local neuromuscular characteristics in case-control studies. Electromyography, flexibility, muscle performance and cross-sectional area data were derived from functional or isolated task investigations and synthesised accordingly. An evidence gap map was constructed.

FINDINGS

Sixty-seven studies were included. In functional tasks, electromyographic investigations showed moderate evidence of small effect for vastus medialis onset-delays relative to vastus lateralis (0.44 [0.03, 0.85]) during stepping/stair negotiation tasks, and higher biceps femoris mean excitation amplitudes (0.55 [0.06, 1.04]) in single-leg triple-hop test. In isolated tasks, we found moderate evidence of medium effect for lower Hoffman-reflex amplitude of vastus medialis (-1.12 [-1.56, -0.67]). Muscle performance investigations showed; strong evidence with medium and small effects for lower extensors concentric (-0.61 [-0.81, -0.40]) and eccentric (-0.56 [-0.79, -0.33]) strength, and moderate evidence of medium effect of lower isometric (-0.64 [-0.87, -0.41]) strength, moderate evidence with small effect for rate of force development to 30% (-0.55[-0.89, -0.21]), 60% (-0.57[-0.90, -0.25]) and medium effect to 90% (-0.76[-1.43, -0.10]) of maximum voluntary contraction, and small effect for lower flexors concentric strength (-0.46 [-0.74, -0.19]) and extensors total work (-0.48 [-0.90, -0.07]). Flexibility investigations showed tighter hamstrings (-0.57 [-0.99, -0.14]).

INTERPRETATION

Differences within quadriceps and hamstrings motor-control, hamstrings tightness, and quadriceps and hamstrings weakness are associated with patellofemoral pain, and can be used to guide investigations of treatment effects.

Should return to pivoting sport be avoided for the secondary prevention of osteoarthritis after anterior cruciate ligament reconstruction? A prospective cohort study with MRI, radiographic and symptomatic outcomes

OBJECTIVE

To evaluate if returning to pivoting sport following anterior cruciate ligament reconstruction (ACLR) is associated with longitudinal structural and symptomatic osteoarthritis outcomes.

DESIGN

Eighty-one adults aged 18-50 years were followed prospectively 1- to 5-years post-ACLR. Return to pivoting sport was assessed at 1-, 3- and 5-years. Longitudinal changes in osteoarthritis features were evaluated from 1- and 5-year magnetic resonance imaging (MRI)s using MRI Osteoarthritis Knee Score (MOAKS). Radiographic osteoarthritis and self-reported knee symptoms, function and quality of life were assessed using the Osteoarthritis Research Society International (OARSI) atlas and Knee injury Osteoarthritis Outcome Score (KOOS), respectively, at 5 years post-ACLR. Generalised linear models (adjusted for baseline characteristics) assessed whether returning to pivoting sport was associated with risk of worsening osteoarthritis features on MRI, radiographic osteoarthritis and KOOS.

RESULTS

Thirty participants returned to pivoting sport 1-year post-ACLR and 50 returned at any time (i.e., 1-, 3- or 5-years). Returning to pivoting sport was not associated with worsening of any MRI osteoarthritis feature (risk ratio (RR) range: 0.59-2.91) or 5-year KOOS (β range: -2.73-3.69). Returning to pivoting sport at 1-year and up to 5-years post-ACLR was associated with a 50% (RR 0.49, 95%CI 0.10-2.37) and 40% (RR 0.60, 95%CI 0.16-2.17) reduced risk of radiographic osteoarthritis, respectively, but these risk reductions were inconclusive due to wide confidence intervals.

CONCLUSION

After ACLR, returning to pivoting sport was not associated with increased risk of worsening knee osteoarthritis features on MRI, radiographic osteoarthritis or knee symptoms. Participation in pivoting sport need not be avoided as part of osteoarthritis secondary prevention strategies.

Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex

Background

The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown.

Purpose/Hypothesis

The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs.

Study Design

Cohort study; Level of evidence, 3.

Methods

Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis.

Results

Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008).

Conclusion

Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

"But it feels swollen!": the frequency and clinical characteristics of people with knee osteoarthritis who report subjective knee swelling in the absence of objective swelling

Supplemental Digital Content is Available in the Text.

The present results support the coexistence of altered body image (subjective without objective swelling) and pain, disability, and maladaptive beliefs in people with knee osteoarthritis.

Introduction:

There are complex interactions between pain and perceptions of the painful body part in musculoskeletal disorders, and disruption of various body representations in people with chronic pain.

Objectives:

The purpose of this study was to investigate how frequently people with knee osteoarthritis (OA) complain of swelling without objective evidence of swelling, and describe the clinical characteristics of this population.

Methods:

Forty-six people with knee OA (68.1 ± 8.8 years) participated in this cross-sectional study. Subjective and objective swelling was evaluated by knee-specific body perception questionnaire and ultrasonography, respectively. Pain intensity, disability, pain-related beliefs, 2-point discrimination threshold, and quadriceps muscle strength were also evaluated.

Results:

Approximately 1/3 of participants (n = 15) had subjective feelings of knee swelling in the absence of objective swelling (S only). Fifteen participants had both subjective and objective knee swelling (S + O group) and 16 had neither subjective nor objective knee swelling (No S/O group). Participants in the S only group had similar pain or disability as those in the S + O group but had more severe pain or disability than those with in the No S/O group. Those in the S only group also had larger 2-point discrimination distance threshold at the medial knee (impaired tactile acuity) than those in the S + O group and had more dysfunctional pain catastrophizing and pain-related self-efficacy than both other groups.

Conclusion:

Our results suggest that about 30% of people with knee OA perceive swelling of the knee in the absence of any objective swelling and that this is accompanied by severe pain and functional disability. Considering altered body image of the knee may reveal relevant treatment-based subgroups in people with knee OA.

Effect of Micro-/Nanoparticle Hybrid Hydrogel Platform on the Treatment of Articular Cartilage-Related Diseases

Joint diseases that mainly lead to articular cartilage injury with prolonged severe pain as well as dysfunction have remained unexplained for many years. One of the main reasons is that damaged articular cartilage is unable to repair and regenerate by itself. Furthermore, current therapy, including drug therapy and operative treatment, cannot solve the problem. Fortunately, the micro-/nanoparticle hybrid hydrogel platform provides a new strategy for the treatment of articular cartilage-related diseases, owing to its outstanding biocompatibility, high loading capability, and controlled release effect. The hybrid platform is effective for controlling symptoms of pain, inflammation and dysfunction, and cartilage repair and regeneration. In this review, we attempt to summarize recent studies on the latest development of micro-/nanoparticle hybrid hydrogel for the treatment of articular cartilage-related diseases. Furthermore, some prospects are proposed, aiming to improve the properties of the micro-/nanoparticle hybrid hydrogel platform so as to offer useful new ideas for the effective and accurate treatment of articular cartilage-related diseases.

Consumer understanding of terms used in imaging reports requested for low back pain: a cross-sectional survey

OBJECTIVES

To investigate (1) self-reported societal comprehension of common and usually non-serious terms found in lumbar spine imaging reports and (2) its relationship to perceived seriousness, likely persistence of low back pain (LBP), fear of movement, back beliefs and history and intensity of LBP.

DESIGN

Cross-sectional online survey of the general public.

SETTING

Five English-speaking countries: UK, USA, Canada, New Zealand and Australia.

PARTICIPANTS

Adults (age >18 years) with or without a history of LBP recruited in April 2019 with quotas for country, age and gender.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported understanding of 14 terms (annular fissure, disc bulge, disc degeneration, disc extrusion, disc height loss, disc protrusion, disc signal loss, facet joint degeneration, high intensity zone, mild canal stenosis, Modic changes, nerve root contact, spondylolisthesis and spondylosis) commonly found in lumbar spine imaging reports. For each term, we also elicited worry about its seriousness, and whether its presence would indicate pain persistence and prompt fear of movement.

RESULTS

From 774 responses, we included 677 (87.5%) with complete and valid responses. 577 (85%) participants had a current or past history of LBP of whom 251 (44%) had received lumbar spine imaging. Self-reported understanding of all terms was poor. At best, 235 (35%) reported understanding the term 'disc degeneration', while only 71 (10.5%) reported understanding the term 'Modic changes'. For all terms, a moderate to large proportion of participants (range 59%-71%), considered they indicated a serious back problem, that pain might persist (range 52%-71%) and they would be fearful of movement (range 42%-57%).

CONCLUSION

Common and usually non-serious terms in lumbar spine imaging reports are poorly understood by the general population and may contribute to the burden of LBP.

TRIAL REGISTRATION NUMBER

ACTRN12619000545167.

Musculoskeletal pain intensity in different body regions and risk of disability pension among female eldercare workers: prospective cohort study with 11-year register follow-up

Background

Musculoskeletal pain is a risk factor for leaving the labour market temporarily and permanently. While the presence of multi-site pain increases the risk of disability pension, we lack detailed knowledge about pain intensity as a risk factor. This study investigated the association between musculoskeletal pain intensity in different body regions and risk of future disability pension among eldercare workers.

Methods

Eight thousand seven hundred thirty-one female eldercare workers replied to a questionnaire on work and health in 2005 and were followed for 11 years in the Danish Register for Evaluation of Marginalization. Time-to-event analyses estimated hazard ratios (HR) for disability pension from pain intensities (0–9 numeric rating scale (NRS)) in the low-back, neck/shoulders, and knees during the previous 3 months. Analyses were mutually adjusted for pain regions, age, education, lifestyle, psychosocial work factors, and physical exertion at work.

Results

During 11-year follow-up, 1035 (11.9%) of the eldercare workers received disability pension. For all body regions among all eldercare workers, dose-response associations were observed between higher pain intensity and risk of disability pension (p < 0.001). The risk for disability pension was increased when reporting “very high” pain levels (≥7 points on the 0–9 NRS) in the low-back (HR 2.19, 95% CI 1.70–2.82), neck/shoulders (HR 2.34, 95% CI 1.88–2.92), and knees (HR 1.89, 95% CI 1.44–2.47). Population attributable risks (PAR) were 15.5, 23.2, and 9.6% for pain > 2 on NRS in the low-back, neck/shoulders, and knees, respectively, indicating that 15.5, 23.2, and 9.6% fewer eldercare workers would likely receive disability pension if the pain intensity was reduced to 2 or less. For workers ≤45 years and > 45 years, PAR was highest for neck/shoulder pain (27.6%) and low-back pain (18.8%), respectively.

Conclusions

The present study found positive dose-response associations between pain intensity in the low-back, neck/shoulders, and knees, and risk of disability pension during 11-year follow-up. Moderate to very high levels of musculoskeletal pain in eldercare workers should, therefore, be considered an early warning sign of involuntary premature exit from the labour market. These findings underscore the importance of preventing, managing, and reducing musculoskeletal pain to ensure a long and healthy working life.

Importance of patellofemoral and tibiofemoral cartilage lesions on trajectory of self-reported outcomes in patients at high risk of knee OA: 4-6 years follow-up of patients undergoing meniscal surgery

OBJECTIVE

We evaluated whether patient-reported outcome trajectories (i.e., changes over time) differed by intraoperative compartmental cartilage lesion pattern over 4-6 years following arthroscopic meniscal surgery.

METHODS

In this ancillary study of the Knee Arthroscopy Cohort Southern Denmark cohort, we intraoperatively categorized cartilage lesions as isolated patellofemoral, isolated tibiofemoral, or combined patellofemoral/tibiofemoral. Participants completed the Knee injury and Osteoarthritis Outcome Score (KOOS) pre-operatively, at 3 and 12 months, and at 4-6 years post-operatively and reported overall satisfaction at final follow-up. Our main outcome was KOOS₄ (grand mean of four subscale means). We evaluated whether KOOS₄ scores changed over time according to cartilage lesion patterns using adjusted mixed linear regression. We also estimated probability of treatment satisfaction using logistic regression.

RESULTS

Of 630 participants with complete cartilage scores, 280 (44%) were women, mean (standard deviation) age was 49 (13) years, and BMI was 27.3 (4.4) kg/m². KOOS₄ scores at baseline were slightly lower in all lesion groups compared to the no lesion group, yet only the combined group was statistically significantly lower. KOOS₄ trajectories were similar across cartilage lesion patterns, but by final follow-up, adjusted mean KOOS₄ scores were 6.8 (95% CI 2.2, 11.4) to 9.8 (1.1, 18.5) points lower in groups with cartilage lesions compared to the no lesion group. Probability of patient-reported satisfaction did not differ statistically by group.

CONCLUSIONS

Though KOOS₄ scores were slightly lower in groups with arthroscopically assessed cartilage lesions compared to the no lesion group, trajectories were similar across all groups.

Higher psychological distress in patients seeking care for a knee disorder is associated with diagnostic discordance between health care providers: a secondary analysis of a diagnostic concordance study

Background

Knee disorders are highly prevalent and may be a disabling condition. An accurate diagnosis is necessary to guide toward a rapid and efficient management of knee disorders. However, the ability to make a valid diagnosis is often complex for clinicians and evidence is mainly focused on clinician cognitive biases or errors produced during clinical reasoning. The aim of this secondary exploratory analysis is to identify patient-specific characteristics associated with diagnostic discordance between health care providers in making a diagnosis for a new knee disorder.

Methods

We performed a secondary analysis of a diagnostic study comparing the diagnostic ability of a physiotherapist to medical musculoskeletal specialists. Patients’ socio-demographic, psychosocial and clinical characteristics were compared between the concordant and discordant diagnostic groups. Psychosocial symptoms were evaluated using the validated Kessler 6 (K6) questionnaire. We performed multivariable logistic regressions using the Bayesian Information Criterion to identify the most probable model including patients’ characteristics associated with diagnostic discordance. Overall probability of identified variables to explain diagnostic discordance and associated odd ratios (OR) with 95% credibility intervals (95% CrI) were calculated.

Results

Overall, 279 participants were evaluated by a physiotherapist and medical musculoskeletal specialists. The mean age of the participants was 49.1 ± 15.8 years and 57.7% were female. The most common disorder was osteoarthritis (n = 117, 18.8% of cases were discordant). The most probable model explaining diagnostic discordance (11.13%) included having depressive symptoms, which was associated with an increased probability of diagnostic discordance (OR: 3.9; 95% CrI: 1.9 – 8.0) and having a higher number of comorbidities, which was associated with a decreased probability of diagnostic discordance (OR: 0.6; 95% CrI: 0.5 – 0.9). The depression item of the K6 questionnaire had a 99.4% chance to be included in a model explaining diagnostic discordance. Other variables taken separately had less than 50% chance to be included in a model explaining diagnostic discordance and cannot be considered significant.

Conclusion

Our results suggest that depressive symptoms may increase the risk of knee diagnostic discordance. Clinicians may be more likely to make diagnostic errors and should be more cautious when evaluating patients with knee disorders suffering from psychological distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04534-9.

The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain

BACKGROUND

Routine knee radiographs are discouraged for individuals with non-traumatic knee pain, but they are often still ordered despite limited evidence for their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs.

OBJECTIVE

To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence.

STUDY DESIGN

Retrospective cohort.

SETTING

United States Military Health System civilian and military clinics.

PATIENTS

23,332 individuals aged 18 to 50 diagnosed with PFP between 2010 and 2011 in the United States Military Health System who received physical therapy.

INTERVENTIONS

Physical therapy provided to individuals who did or did not receive an initial radiograph.

MAIN OUTCOME MEASURES

Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs).

RESULTS

If radiographs were used, the odds of initiating physical therapy (aOR = 0.78; 95% CI 0.64 to 0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1 to 16.1) if patients had radiographs versus 6.9 (95% CI 5.2 to 9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR = 1.01; 95% CI 0.83 to 1.22).

CONCLUSIONS

Receiving knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment. This article is protected by copyright. All rights reserved.

What factors are associated with perceived disease onset in patients with hip and knee osteoarthritis?

Introduction

Newly symptomatic osteoarthritis (OA) is often misinterpreted as new pathology or injury, which is associated with pain intensity and incapability.

Methods

Adult patients with hip and knee OA completed measures of catastrophic thinking, depression, capability, symptom duration, and perceived injury.

Results

Symptom duration was associated with OA grade and symptoms of depression. Perceived injury was common (31%) and associated with men and knee arthritis. Capability was associated with misinterpretation of symptoms and the work status 'other,' but not radiographic severity.

Conclusions

Misinterpretation of OA symptoms is common and has a greater influence on capability than radiographic grade of pathophysiology.

Blood flow restriction training in patients with knee osteoarthritis: Systematic review of randomized controlled trials

INTRODUCTION

Knee osteoarthritis (KOA) is one of the most common musculoskeletal disorders in the elderly. The patient experiences reduction in muscle strength, pain, joint stiffness and consequently a reduction in quality of life. Whereas high intensity training (HI-TR) is the most effective in the general elderly population, in KOA patients, painless alternatives might be more suitable, since pain can be a deterrent for exercising. Research interest has increased in blood flow restriction training (BFR-TR) due to the observation that, in this specific population, BFR-TR results in equal muscular adaptions to HI-TR but with less join discomfort/pain.

OBJECTIVE

We aimed to: (1) determine the value of BFR-TR in patients with KOA and (2) examine which exercise guidelines applied to healthy elderly populations can be adopted for patients suffering from this knee pathology.

METHODOLOGY

We searched the literature from the database inception to 2019 through PubMed, Cochrane, and Medline (EBSCO). The inclusion criteria were determined using PICOS principles. We assessed methodology using the Risk of Bias 2 tool and the Pedro scale. Conclusions were extracted with the use of best evidence synthesis.

RESULTS

The literature search yielded 45 articles. After screening, three studies matched the inclusion criteria. The included studies were analyzed and discussed. All the included studies reported within group improvements for BFR-TR regarding pain and strength.

CONCLUSION

Although the evidence of BFR-TR efficacy on KOA remains scarce, the results favor its use for muscle strengthening and pain reduction in KOA. Further high-quality studies with larger samples are required.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

The suitability and utility of the pain and movement reasoning model for physiotherapy: A qualitative study

Introduction: The Pain and Movement Reasoning Model is a tool to assist clinical reasoning. It was created for physiotherapists to use in musculoskeletal outpatient clinics but may be appropriate in other clinical contexts. The Model has also been used in physiotherapy education.Objective: To determine physiotherapists' perceptions of the appropriateness (suitability) and benefit (utility) of the Pain and Movement Reasoning Model across clinical contexts in hospital and community practice. Methods Physiotherapists from two health networks in Melbourne, Australia, received training in using the Model and over 4-6 weeks applied it in their clinical interactions. Drawing on a deductive phenomenological approach, transcripts from focus groups and interviews were analysed to determine the suitability and utility of the Model across clinical areas.Results: Twenty-nine physiotherapists from 12 different clinical areas participated. Two themes represented the participants' comments: Suitability for Practice and Utility in Practice. Participants reported the approach to clinical reasoning, promoted by the Model, aligned with existing physiotherapy practice. Enhancements to practice included more comprehensive assessment, selection of broader management techniques and increased confidence with reasoning and explaining the complexity of pain to patients. Participants described using the Model for developing junior staff and training postgraduate students. They also saw potential in adapting the Model for other disciplines and for other multifactorial conditions.Conclusion: Physiotherapists working in a range of clinical contexts considered the Pain and Movement Reasoning Model appropriate and beneficial in clinical practice and in teaching. Further evaluation of the Model in wider settings is warranted.

Pressure pain thresholds in individuals with knee pain: a cross-sectional study

Background

Knee osteoarthritis (KOA), chronic widespread pain (CWP) and overweight/obesity are public health problems that often coincide, and there is a multifactorial and unclear relationship between them. The study aimed to (1) investigate pain sensitivity, assessed by pressure pain thresholds (PPTs), among women and men with knee pain and (2) associations with, respectively, radiographic KOA (rKOA), CWP, and overweight/obesity.

Methods

Baseline data from an ongoing longitudinal study involving 280 individuals with knee pain in the 30–60 age group. Pain sensitivity was assessed by PPTs on eight different tender points using a pressure algometer. The participants’ knees were x-rayed. Self-reported CWP and number of pain sites were assessed with a pain figure, and overweight/obesity was measured using body mass index (BMI), visceral fat area (VFA), and body fat percentage, assessed with a bioimpedance. Associations were analysed using regression analyses.

Results

Women reported lower PPTs than men (p < 0.001), but no PPTs differences were found between those with and without rKOA. Low PPTs was associated with female sex, more pain sites, CWP, and a higher VFA and body fat percentage. The tender points second rib and the knees were most affected. The prevalence of CWP was 38 %.

Conclusions

The modifiable factors, increased VFA, and body fat could be associated with increased pain sensitivity among individuals with knee pain. Longitudinal studies are needed to further investigate the associations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04408-0.

The Relationship Between Body Mass Index and Pain Intensity Among Veterans with Musculoskeletal Disorders: Findings from the MSD Cohort Study

OBJECTIVE

To examine the relationship between body mass index (BMI) and pain intensity among veterans with musculoskeletal disorder diagnoses (MSDs; nontraumatic joint disorder; osteoarthritis; low back, back, and neck pain).

SETTING

Administrative and electronic health record data from the Veterans Health Administration (VHA).

SUBJECTS

A national cohort of US military veterans with MSDs in VHA care during 2001-2012 (N = 1,759,338).

METHODS

These cross-sectional data were analyzed using hurdle negative binomial models of pain intensity as a function of BMI, adjusted for comorbidities and demographics.

RESULTS

The sample had a mean age of 59.4, 95% were male, 77% were white/Non-Hispanic, 79% were overweight or obese, and 42% reported no pain at index MSD diagnosis. Overall, there was a J-shaped relationship between BMI and pain (nadir = 27 kg/m2), with the severely obese (BMI ≥ 40 kg/m2) being most likely to report any pain (OR vs normal weight = 1.23, 95% confidence interval = 1.21-1.26). The association between BMI and pain varied by MSD, with a stronger relationship in the osteoarthritis group and a less pronounced relationship in the back and low back pain groups.

CONCLUSIONS

There was a high prevalence of overweight/obesity among veterans with MSD. High levels of BMI (>27 kg/m2) were associated with increased odds of pain, most markedly among veterans with osteoarthritis.

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions.

DATA SYNTHESIS

Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity.

RESULTS

We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I²>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant.

CONCLUSION

There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. J Orthop Sports Phys Ther 2021;51(5):232-252. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9970.

Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the pooled prevalence of, and factors associated with, the presence of patellar tendon abnormalities observed on imaging in people without symptoms.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

We searched Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of asymptomatic patellar tendon abnormalities on imaging. We excluded studies of participants with current tendon pain, a history of tendon pain, or other systemic conditions.

DATA SYNTHESIS

Stratification and meta-regression of studies based on study-level descriptive statistics (mean age, body mass index, proportion of female participants, physical activity participation, imaging modality) were performed using a random-effects model to account for between-study heterogeneity. Risk of bias was assessed using the modified Newcastle-Ottawa scale.

RESULTS

Meta-analysis of 64 studies (7125 limbs from 4616 participants) found significant between-study heterogeneity (I²≥90%, P<.01), which precluded a summary prevalence estimate. Heterogeneity was partially explained by studies that included participants who were physically active and studies that assessed tendon abnormalities using magnetic resonance imaging compared to ultrasound (P<.05). Mean age, body mass index, proportion of female participants, and sample size did not explain the remaining heterogeneity.

CONCLUSION

There was substantial variability in the reported prevalence of asymptomatic patellar tendon abnormalities. A clear and valid method is needed to assess and report the presence of patellar tendon abnormalities to increase research capacity and establish the clinical value of imaging the patellar tendon. J Orthop Sports Phys Ther 2021;51(5):216-231. Epub 28 Mar 2021. doi:10.2519/jospt.2021.10054.

Update on pain in arthritis

PURPOSE OF REVIEW

Osteoarthritis is a degenerative joint disease that features pain as a hallmark symptom. This review summarises progress and obstacles in our understanding of pain mechanisms in arthritis.

RECENT FINDINGS

Pain phenotypes in osteoarthritis are poorly characterized in clinical studies and animal studies are largely carti-centric. Different animal models incur variable disease progression patterns and activation of distinct pain pathways, but studies reporting both structural and pain outcomes permit better translational insights. In patients, classification of osteoarthritis disease severity is only based on structural integrity of the joint, but pain outcomes do not consistently correlate with joint damage. The complexity of this relationship underlines the need for pain detection in criteria for osteoarthritis classification and patient-reported outcome measures.

SUMMARY

Variable inflammatory and neuropathic components and spatiotemporal evolution underlie the heterogeneity of osteoarthritis pain phenotypes, which must be considered to adequately stratify patients. Revised classification of osteoarthritis at different stages encompassing both structural and pain outcomes would significantly improve detection and diagnosis at both early and late stages of disease. These are necessary advancements in the field that would also improve trial design and provide better understanding of basic mechanisms of disease progression and pain in osteoarthritis.

Knowledge and attitudes toward musculoskeletal pain neuroscience of manual therapy postgraduate students in the Netherlands

BACKGROUND

Health care practitioners' knowledge and attitudes influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. It is unclear to what extent physiotherapists undertaking a postgraduate master in manual therapy (MT students) possess the knowledge and attitudes toward pain neuroscience to be able to apply the biopsychosocial model in patients with MSK pain.

OBJECTIVES

The aim of this study was to assess the knowledge and attitudes toward pain neuroscience in MT students.

DESIGN

A cross-sectional study.

METHOD

Self-reported knowledge and attitudes were measured among students (n = 662) at baseline and in all years of the MT postgraduate programs in the Netherlands. The Knowledge and Attitudes of Pain questionnaire (KNAP) was used as a primary measure. Difference in KNAP-scores between baseline (0), year 1, year 2 and year 3 was tested using a one-way ANOVA (hypothesis: 0 < 1<2 < 3). A two factor ANOVA was used to determine the interaction effect of focused pain education and year in the curriculum with KNAP.

RESULTS

There was an overall significant difference of KNAP scores with a medium effect size (F(3, 218.18) = 13.56, p < .001, ω² = 0.059). Differences between years ranged from small to medium. Interaction effect of knowledge and attitudes and focused pain education was significant with a small effect size (F(6) = 2.597, p = .017, ω² = 0.012). Sensitivity analyses were consistent with the main results.

CONCLUSIONS

Positive differences in knowledge and attitudes toward pain neuroscience in MT students occur between the progressing years of the curriculum. Differences may be related to the provision of focused pain education.

Early anterior cruciate ligament reconstruction does not affect 5 year change in knee cartilage thickness: secondary analysis of a randomized clinical trial

OBJECTIVE

To compare 5-year change in femorotibial cartilage thickness in 121 young, active adults with an acute anterior cruciate ligament (ACL) tear randomized to a strategy of structured rehabilitation plus early ACL reconstruction (ACLR) or structured rehabilitation plus optional delayed ACLR.

DESIGN

62 patients were randomized to early ACLR, 59 to optional delayed ACLR. Magnetic resonance imaging (MRI) was acquired within 4 weeks of injury, at two- and 5-years follow-up. Main outcome was 5-year change in overall femorotibial cartilage thickness. Secondary outcomes included the location-independent cartilage ChangeScore, summarizing thinning and thickening in 16 femorotibial subregions. An exploratory as-treated comparison was performed additionally.

RESULTS

Baseline and at least one follow-up MRI were available for 117 patients. Over 5 years, a comparable increase in overall femorotibial cartilage thickness was observed for patients randomized to early ACLR (n = 59) and patients randomized to optional delayed ACLR (n = 58, adjusted mean difference: -5 μm, 95% CI: [-118, 108]μm). However, the location-independent cartilage ChangeScore was greater in those treated with early ACLR than in patients treated with optional delayed ACLR (adjusted mean difference: 403 μm [119, 687]μm). As-treated analysis showed no between-group differences for the main outcome, while the location-independent cartilage ChangeScore was greater for patients treated with early (adjusted mean difference: 632 μm [268, 996]μm) or delayed ACLR (adjusted mean difference: 449 μm [108, 791]μm) than for patients treated with rehabilitation alone.

CONCLUSIONS

In young active adults with acute ACL-injury, choice of treatment strategy for the injured ACL did not modify the magnitude of 5-year change in overall femorotibial cartilage thickness.

TRIAL REGISTRATION

ISRCTN84752559.

Clinical application of polyurethane meniscal scaffold: A meta-analysis

OBJECTIVE

In patients with partial meniscus defect, the implantation of polyurethane meniscal scaffold has become a common method for the treatment of meniscus vascular entry and tissue regeneration. However, it is unclear whether polyurethane meniscal scaffold will yield better clinical and MRI results after surgery. This meta-analysis compared the clinical and MRI results of polyurethane meniscal scaffold in some patients with meniscus defects.

METHODS

By searching PubMed, Embase, and Cochrane Library, a systematic review of studies evaluating the clinical outcomes of patients with polyurethane meniscal scaffold implantation. The search terms used are: "meniscus", "meniscal", "scaffold", "Actifit" "polyurethane" and "implant". The study was evaluated based on the patient's reported outcome score, accompanying surgery, and radiology results. Genovese scale was used to evaluate morphology and signal intensity, and Yulish score was used to evaluate the imaging performance of articular cartilage.

RESULTS

There were 16 studies that met the inclusion criteria, a total of 613 patients, and the overall average follow-up time was 41 months. The clinical scores at the final follow-up, such as VAS, IKDC, Tegner, and KOOS, were significantly improved compared with preoperatively. The MS, SI, and IIRMC scores evaluated in MRI showed no significant difference between preoperative and final follow-up. However, for AC (OR 0.34, 95% CI 0.11-1.00; P = 0.05) and AME (OR 0.08, 95% CI 0.03-0.22; P < 0.01), the final follow-up results were worse than preoperatively.

CONCLUSIONS

This meta-analysis found that compared with preoperative, the clinical effect of the final follow-up was significantly improved. However, MS, SI, and IIRMC in MRI parameters did not change significantly. In addition, the final follow-up results of AC and AME showed a deteriorating trend. Therefore, for patients with partial meniscus defects, polyurethane meniscal scaffold seem to be a viable option, and further research is needed to determine whether the deterioration of AC and AME is clinically relevant.

Osteoarthritis year in review 2020: imaging

This narrative "Year in Review" highlights a selection of articles published between January 2019 and April 2020, to be presented at the OARSI World Congress 2020 within the field of osteoarthritis (OA) imaging. Articles were obtained from a PubMed search covering the above period, utilizing a variety of relevant search terms. We then selected original and review studies on OA-related imaging in humans, particularly those with direct clinical relevance, with a focus on the knee. Topics selected encompassed clinically relevant models of early OA, particularly imaging applications on cruciate ligament rupture, as these are of direct clinical interest and provide potential opportunity to evaluate preventive therapy. Further, imaging applications on structural modification of articular tissues in patients with established OA, by non-pharmacological, pharmacological and surgical interventions are summarized. Finally, novel deep learning approaches to imaging are reviewed, as these facilitate implementation and scaling of quantitative imaging application in clinical trials and clinical practice. Methodological or observational studies outside these key focus areas were not included. Studies focused on biology, biomechanics, biomarkers, genetics and epigenetics, and clinical studies that did not contain an imaging component are covered in other articles within the OARSI "Year in Review" series. In conclusion, exciting progress has been made in clinically validating human models of early OA, and the field of automated articular tissue segmentation. Most importantly though, it has been shown that structure modification of articular cartilage is possible, and future research should focus on the translation of these structural findings to clinical benefit.

Exercise-therapy and education for individuals one year after anterior cruciate ligament reconstruction: a pilot randomised controlled trial

BACKGROUND

Guided rehabilitation beyond 6-months is rare following anterior cruciate ligament reconstruction (ACLR), despite high prevalence of unacceptable symptoms and quality of life (QoL). Our primary aim was to determine the feasibility of a randomised controlled trial (RCT) evaluating a physiotherapist-guided intervention for individuals 1-year post-ACLR with persistent symptoms. Our secondary aim was to determine if a worthwhile treatment effect could be observed for the lower-limb focussed intervention (compared to the trunk-focussed intervention), for improvement in knee-related QoL, symptoms, and function.

DESIGN

Participant- and assessor-blinded, pilot feasibility RCT.

METHODS

Participant eligibility criteria: i) 12-15 months post-ACLR; ii) < 87.5/100 on the Knee injury and Osteoarthritis Outcome Score (KOOS) QoL subscale; and either a one-leg rise test < 22 repetitions, single-hop < 90% limb symmetry; or Anterior Knee Pain Scale < 87/100. Participants were randomised to lower-limb or trunk-focussed focussed exercise and education. Both interventions involved 8 face-to-face physiotherapy sessions over 16-weeks. Feasibility was assessed by eligibility rate (> 1 in 3 screened), recruitment rate (> 4 participants/month), retention (< 20% drop-out), physiotherapy attendance and unsupervised exercise adherence (> 80%). Between-group differences for knee-related QoL (KOOS-QoL, ACL-QoL), symptoms (KOOS-Pain, KOOS-Symptoms), and function (KOOS-Sport, functional performance tests) were used to verify that the worthwhile effect (greater than the minimal detectable change for each measure) was contained within the 95% confidence interval.

RESULTS

47% of those screened were eligible, and 27 participants (3 participants/month; 48% men, 34±12 years) were randomised. Two did not commence treatment, and two were lost to follow-up (16% drop-out). Physiotherapy attendance was > 80% for both groups but reported adherence to unsupervised exercise was low (< 55%). Both interventions had potentially worthwhile effects for KOOS-QoL and ACL-QoL, while the lower-limb focussed intervention had potentially greater effects for KOOS-Sport, KOOS-Pain, and functional performance.

CONCLUSIONS

A larger-scale RCT is warranted. All feasibility criteria were met, or reasonable recommendations could be made to achieve the criteria in future trials. Strategies to increase recruitment rate and exercise adherence are required. The potential worthwhile effects for knee-related QoL, symptoms, and function indicates a fully-powered RCT may detect a clinically meaningful effect.

TRIAL REGISTRATION

Prospectively registered ( ACTRN12616000564459 ).

Health-related quality-of-life improvement with lumbar fusion in patients with lower-extremity arthritis

OBJECTIVE

Lumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back-specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back-specific PROs compared to patients without lower-extremity arthritis.

METHODS

Patients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0-10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.

RESULTS

Baseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).

CONCLUSIONS

The presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

Comparative Study of Encoder-decoder-based Convolutional Neural Networks in Cartilage Delineation from Knee Magnetic Resonance Images

BACKGROUND

Osteoarthritis (OA) is a common degenerative joint inflammation that may lead to disability. Although OA is not lethal, this disease will remarkably affect patient's mobility and their daily lives. Detecting OA at an early stage allows for early intervention and may slow down disease progression.

INTRODUCTION

Magnetic resonance imaging is a useful technique to visualize soft tissues within the knee joint. Cartilage delineation in magnetic resonance (MR) images helps in understanding the disease progressions. Convolutional neural networks (CNNs) have shown promising results in computer vision tasks, and various encoder-decoder-based segmentation neural networks are introduced in the last few years. However, the performances of such networks are unknown in the context of cartilage delineation.

METHODS

This study trained and compared 10 encoder-decoder-based CNNs in performing cartilage delineation from knee MR images. The knee MR images are obtained from the Osteoarthritis Initiative (OAI). The benchmarking process is to compare various CNNs based on physical specifications and segmentation performances.

RESULTS

LadderNet has the least trainable parameters with the model size of 5 MB. UNetVanilla crowned the best performances by having 0.8369, 0.9108, and 0.9097 on JSC, DSC, and MCC.

CONCLUSION

UNetVanilla can be served as a benchmark for cartilage delineation in knee MR images, while LadderNet served as an alternative if there are hardware limitations during production.

Psychological and Pain Sensitization Characteristics Are Associated With Patellofemoral Osteoarthritis Symptoms: The Multicenter Osteoarthritis Study

OBJECTIVE

Determine the relation of symptomatic and structural features of patellofemoral osteoarthritis (PFOA) to psychological characteristics and measures of pain sensitization, in older adults with or at risk of knee osteoarthritis (OA).

METHODS

This study included 1112 participants from the Multicenter Osteoarthritis Study (713 females, mean age 66.8 ± SD 7.6 yrs, body mass index 29.5 ± 4.8 kg/m2). Participants were grouped based on the presence of PFOA symptoms (anterior knee pain and pain on stairs) and magnetic resonance imaging (MRI) PFOA (full-thickness cartilage lesion with bone marrow lesion): (1) patellofemoral (PF) symptoms with MRI PFOA; (2) PF symptoms without MRI PFOA; (3) MRI PFOA without PF symptoms; and (4) no PF symptoms or MRI PFOA (no PFOA). Relation of PFOA classification to depressive symptoms, catastrophizing, temporal summation (TS) and pressure pain thresholds (PPT) was evaluated using logistic (categorical variables) and linear regression (continuous variables).

RESULTS

Compared with no PFOA, those with PF symptoms with or without MRI PFOA had significantly greater odds of depressive symptoms, catastrophizing, and patellar TS (OR range 1.5-2.01), and those with PF symptoms without MRI PFOA had significantly greater odds of wrist TS (OR 1.66). Males with PF symptoms without MRI PFOA had significantly lower pressure PPT at the patella compared with no PFOA and those with MRI PFOA only (no symptoms). There were no significant differences at the wrist for males, or the patella or wrist for females.

CONCLUSION

Persons with PFOA symptoms, regardless of MRI PFOA status, are more likely to demonstrate depressive symptoms, catastrophizing, and TS. Males with PFOA symptoms without MRI PFOA demonstrate local hyperalgesia.

Is patellofemoral pain preventable? A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the effectiveness of interventions to reduce the risk of incident patellofemoral pain.

DESIGN

Systematic review and meta-analysis, with strength of evidence evaluated separately for each intervention type.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials evaluating the effectiveness of interventions to reduce patellofemoral pain risk compared with a control/non-exposed group.

RESULTS

Thirteen trials of mostly military recruits and young athletes analysed six different interventions. There was low certainty evidence from two trials (227 participants) that patellofemoral braces worn during physical activity (compared with no brace) effectively reduced the risk of patellofemoral pain (risk ratio (RR) 0.40, 95% CI 0.22 to 0.73; I2=24.0%). There was low certainty evidence from one trial (320 participants) that running technique retraining to (run softer) reduced patellofemoral pain risk (RR 0.21, 95% CI 0.07 to 0.60). There was low certainty evidence from four trials (3364 participants) that multicomponent (strengthening/neuromuscular) exercise programmes did not significantly reduce the risk of patellofemoral pain (RR 0.49, 95% CI 0.18 to 1.36; I2=64.9%), although broad CIs may reflect exercise dose variations among studies. There was very low certainty evidence from four trials (2314 participants) that foot orthoses (compared with flat inserts/no orthosis) did not significantly reduce the risk of patellofemoral pain (RR 0.63, 95% CI 0.35 to 1.13; I2=0.0%). Static stretching and a running programme that progressed intensity (compared with volume) did not significantly influence patellofemoral pain risk (single studies).

CONCLUSION

There is low-level evidence that patellofemoral braces and running technique retraining can reduce the risk of patellofemoral pain by 60%-79%.

Longitudinal changes in location-specific cartilage thickness and T2 relaxation-times after posterior cruciate ligament reconstruction for isolated and multiligament injury

BACKGROUND

Knee cartilage undergoes pathological changes after anterior cruciate ligament rupture. However, little is known about the development and progression of structural pathology after posterior cruciate ligament (PCL) injury. This study aimed to determine the location-specific longitudinal changes in knee cartilage morphology (thickness) and composition (T2 relaxation-times) after PCL rupture and reconstruction (PCLR) and compare these to uninjured controls.

METHODS

Fifteen adults (mean age 39 years (standard deviation 10), 12 men) with PCLR for isolated and multiligment injury had MRIs acquired at a minimum 5 years post-PCLR and 1 year later. Location-specific changes in knee cartilage thickness and T2 relaxation-times were determined quantitatively after segmentation, and compared with annualised cartilage changes in 13 active controls (mean age 45 years (standard deviation 4), 6 men).

FINDINGS

Following PCLR, the annual loss of cartilage thickness was greatest in the medial femoral condyle (mean -4.0%, 95% confidence interval [95% CI] -6.7, -1.4), medial tibia (mean -3.7%, 95% CI -6.1, -1.3), and patella (mean -3.2%, 95% CI -4.7, -1.6). In the medial femoral condyle and trochlea, the PCLR group lost significantly more cartilage thickness than uninjured controls (mean difference -3.7%, 95% CI -0.9, -6.5; and -1.8%, 95% CI -0.1, -3.6, respectively). Deep and superficial zone T2 relaxation-times were relatively constant over time, without longitudinal differences between PCLR and control knees.

INTERPRETATION

PCL reconstructed knees displayed substantially greater rates of cartilage loss in the medial tibiofemoral and patellofemoral compartments compared to uninjured controls, highlighting that the process of degeneration remains active many years after injury.

The Prevalence of Abnormalities in the Pediatric Spine on MRI: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to provide an overview of the prevalence of reported musculoskeletal abnormalities on magnetic resonance imaging (MRI) of the pediatric spine.

SUMMARY OF BACKGROUND DATA

Back pain is a common complaint and significant health issue, already in children. Several studies have investigated musculoskeletal abnormalities of the pediatric spine as possible cause of low back pain (LBP). However, it is not clear which abnormalities are the most prevalent among children.

METHODS

A systematic literature search on the prevalence of musculoskeletal spinal abnormalities on MRI in children was conducted in the Embase, Medline Ovid, and Cochrane CENTRAL databases. Risk of bias (RoB) was assessed using a checklist based on the Downs and Black checklist. General information on study and patient characteristics and the prevalence of spinal abnormalities were extracted from the studies. Prevalence data were presented in three subgroups: nonathletes without LBP, participants with LBP, and athletes. Prevalence data of the most reported abnormalities were pooled using random-effects proportion meta-analysis. The study protocol was prospectively registered in PROSPERO (CRD42017080543).

RESULTS

The search resulted in 16,783 articles, of which 31 articles (2373 participants) were included in this systematic review. Two-thirds of the studies had a low RoB. The pooled prevalence in nonathletes without LBP, participants with LBP, and athletes without LBP was respectively 22%, 44%, and 22% for disc degeneration, 1%, 38%, and 13% for herniated discs, 5%, 22%, and 11% for endplate changes, and 0%, 30%, and 6% for pars fractures.

CONCLUSION

Disc degeneration, herniated discs, endplate changes, and spondylolysis are the most reported spinal abnormalities on MRI in children in literature. Spinal abnormalities seen in adults are already prevalent in children with LBP, with the highest prevalence for disc degeneration and herniated discs.

LEVEL OF EVIDENCE

2.

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Background:

A large number of systematic reviews and meta-analyses regarding the meniscus have been published.

Purpose:

To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study.

Results:

A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%).

Conclusion:

This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

Low Level Laser Therapy in Knee Osteoarthritis: A Narrative Review

Knee osteoarthritis (KOA) is the most common musculoskeletal disorder, especially in middle up to old age. KOA also results in many complications like changes in gait. Nowadays, changes in lifestyle and the reduced physical activity make people more vulnerable to KOA. Therefore, considering the increasing prevalence of KOA in many societies and the costs imposed on the afflicted people and their governments, providing conservative management approaches with a view to saving time and money is important. There are an assortment of conservative strategies in the management of KOA including low level laser therapy (LLLT). Since the introduction of lasers in the medical field in 1960, various types of lasers with widespread administration programs are used for medical conditions from cosmetics to surgery. However, there are conflicting findings on the application of lasers in osteoarthritis. To discuss the basis of the highest level of evidence, only systematic reviews with or without meta-analyses published up to January 2019 were included in the present work. In this regard, Scopus, PEDro, Medline, ISI Web of Science, Cochrane, PubMed, Irandoc, Iran Medex, Magiran, and SID were searched to retrieve articles in English or Persian. A total of 22 systematic reviews and meta-analyses were found, 14 of which were included in this study. The accepted articles were published between 1991 and up to 2019. The purpose of this narrative review was to investigate the effect of LLLT on pain and function in subjects with KOA. The result of the present review may help clinicians in making evidence-based decisions on optimal care in relation to administering LLLT.

Remarkably high prevalence of overuse-related knee complaints and MRI abnormalities in youth competitive alpine skiers: a descriptive investigation in 108 athletes aged 13-15 years

Background/aim

Competitive alpine skiing is known to be associated with a high risk of traumatic knee injuries. However, little is known about the exact prevalence of knee overuse injuries and their associations with structural changes, particularly in youth skiers. Accordingly, the aim of the present study was to describe the overuse-related knee complaints and MRI abnormalities in a cohort of youth skiers around the growth spurt.

Methods

108 youth competitive alpine skiers aged 13–15 years were examined using an MRI of both knees, an interview on existing knee complaints and a physical examination. As a common baseline for these assessments, skiers were prospectively monitored by the use of the Oslo Sports Trauma Research Centre questionnaire on health problems over a period of 12 months preceding the major investigations.

Results

88.0% of the youth skiers showed at least one MRI abnormality in the knees. The most frequent findings were distal femoral cortical irregularities (63%), focal periphyseal oedema (FOPE) zones (25.0%) and cartilage lesions (18.5%). 47.2% of all skiers suffered from at least one overuse-related knee complaint during the 12 months preceding the MRI examination, mostly at the distal and proximal patellar tendon. However, despite a certain association with corresponding MRI abnormalities, the sensitivity of an MRI-based detection of such complaints was strongly limited.

Conclusion

Youth competitive alpine skiers suffer from a remarkably large number of knee overuse injuries. Accordingly, an effective prevention strategy should include a systematic screening of clinical complaints, ideally already starting around the growth spurt.

The Effect of Training Experience and Leg Dominance on the Prevalence of Asymptomatic Intraarticular Changes of the Knee Joints in Adult Professional Male Soccer Players

Background

Currently, no data is available regarding the association between professional experience or limb dominance and the prevalence of asymptomatic knee joint lesions in adult professional male soccer players.

Hypothesis

The prevalence of the accumulated changes increases with training experience. This is especially true for the dominant leg, which is involved in a large proportion of the athletes’ movements.

Study Design

Level 2 cross-sectional cohort study

Methods

MRI was used to assess the condition of 94 knee joints in 47 adult professional male soccer players (mean age 25.7 ± 4.6 years, BMI 22.8 ± 1.4). Previous surgery on joints was an exclusion criterion. No football player had knee injuries (including fresh bruises) for at least 3 months before the examination. All the scans were performed using a 1.5T MRI scanner and a slice thickness of 3 mm. The images were blindly analyzed by two experienced radiologists. We analyzed all the three compartments of the knee joint. We consider a chondral lesion already from grade I in modified Noyes and Stabler classification system. To assess the influence of soccer training experience, all players were divided into two groups: group 1 formed from players with less than 20 years of experience and group 2 with more than 20 years of experience.

Results

One hundred percent of the soccer players had at least one chondral and meniscal lesion.

In both legs, the posterior horn of the medial meniscus (95.6%) was the most frequent site of injury. Most of the injuries were classified as grade II injuries (73.3% for the dominant and 75.6% for the non-dominant leg).

Experience and age of the athletes significantly increased the probability of subcortical bone lesions. They were significantly positively correlated with the grades of patellar lesions and lesions of the patellar surface of the femur and significantly negatively correlated with the grades of lesions of posterior horn of lateral meniscus and anterior horn of medial meniscus.

No statistically significant differences in the prevalence and grades of cartilage and meniscal lesions in the dominant and non-dominant limb were observed.

Conclusion

Soccer practice is associated with the increased prevalence of asymptomatic chondral and meniscal lesions.

The probability of subcortical bone lesions significantly increases with training experience and age. These factors are also positively correlated with the grades of patellar lesions and lesions of the patellar surface of the femur.

The prevalence and grade of asymptomatic chondral and meniscal lesions is independent of leg dominance.

Intrinsic foot joints adapt a stabilized-resistive configuration during the stance phase

BACKGROUND

This study evaluated the 3D angle between the joint moment and the joint angular velocity vectors at the intrinsic foot joints, and investigated if these joints are predominantly driven or stabilized during gait.

METHODS

The participants were 20 asymptomatic subjects. A four-segment kinetic foot model was used to calculate and estimate intrinsic foot joint moments, powers and angular velocities during gait. 3D angles between the joint moment and the joint angular velocity vectors were calculated for the intrinsic foot joints defined as follows: ankle joint motion described between the foot and the shank for the one-segment foot model (hereafter referred as Ankle), and between the calcaneus and the shank for the multi-segment foot model (hereafter referred as Shank-Calcaneus); joint motion described between calcaneus and midfoot segments (hereafter referred as Chopart joint); joint motion described between midfoot and metatarsus segments (hereafter referred as Lisfranc joint); joint motion described between first phalanx and first metatarsal (hereafter referred as First Metatarso-Phalangeal joint). When the vectors were approximately aligned, the moment was considered to result in propulsion (3D angle <60^o) or resistance (3D angle >120^o) at the joint. When the vectors are approximately orthogonal (3D angle close to 90°), the moment was considered to stabilize the joint.

RESULTS

The results showed that the four intrinsic joints of the foot are never fully propelling, resisting or being stabilized, but are instead subject to a combination of stabilization with propulsion or resistance during the majority of the stance phase of gait. However, the results also show that during pre-swing all four the joints are subject to moments that result purely in propulsion. At heel off, the propulsive configuration appears for the Lisfranc joint first at terminal stance, then for the other foot joints at pre-swing in the following order: Ankle, Chopart joint and First Metatarso-Phalangeal joint.

CONCLUSIONS

Intrinsic foot joints adopt a stabilized-resistive configuration during the majority of the stance phase, with the exception of pre-swing during which all joints were found to adopt a propulsive configuration. The notion of stabilization, resistance and propulsion should be further investigated in subjects with foot and ankle disorders.