A comprehensive MRI investigation to identify potential biomarkers of Osgood Schlatter disease in adolescents: A cross sectional study comparing Osgood Schlatter disease with controls

BACKGROUND

Osgood-Schlatter disease (OSD) is the most common knee pain complaint among adolescents playing sports. Despite this, there remains controversy over the pathophysiology and whether specific anatomical characteristics are associated with OSD.

PURPOSE

This study aimed to systematically and comprehensively characterize adolescents with OSD using magnetic resonance imaging (MRI) compared to pain-free controls, including both tissue abnormalities that may be associated with OSD, as well as anatomical characteristics. A secondary objective was to identify potential imaging biomarkers associated with pain.

STUDY DESIGN

Cross-sectional study.

METHODS

Adolescents with OSD and controls were recruited from 2020 to 2022. Following a clinical exam, demographics, pain, sports participation, and Tanner stage were collected. Knee MRI was conducted on the participants' most symptomatic knee (OSD) or the dominant leg (controls).

RESULTS

Sixty-seven adolescents (46 with OSD and 30 controls) were included. 80% of participants with OSD had at least one tissue alteration compared to 54% of controls. Compared to controls, OSD had 36.3 (95%CI 4.5 to 289.7) higher odds of bony oedema at the tibial tuberosity, and 32.7 (95%CI 4.1 to 260.6) and 5.3 (95%CI 0.6 to 46.2) higher odds of bony oedema at the  tibial epiphysis and metaphysis respectively. Participants with OSD also had higher odds of fluid/oedema at the patellar tendon (12.3 95%CI 3.3 to 46.6), and superficial infrapatellar bursitis (7.2).  Participants with OSD had a more proximal tendon attachment (mean tibial attachment portion difference, -0.05, 95% CI: -0.1 to 0.0, p = 0.02), tendon thickness (proximal mean difference, -0.09, 95% CI: -0.4 to 0.2, p = 0.04; distal mean difference, -0.6, 95% CI: -0.9 to -0.2, p = 0.01). Those with bony/tendon oedema had 1.8 points (95% CI: 0.3 to 3.2) higher pain on palpation than those without (t = -2.5, df = 26.6, p = 0.019), but there was no difference between these groups in a functional single leg pain provocation.

CONCLUSION

Adolescents with OSD present with tissue and structural abnormalities on MRI that differed from age-matched controls. The majority had findings in the patellar tendon and bone, which often co-occurred. However, a small proportion of OSD also presents without alterations. It appears these findings may be associated with clinical OSD-related pain on palpation of the tibial tuberosity.

CLINICAL RELEVANCE

Our highlight the pathophysiology on imaging, which has implications for understanding the mechanism and treatment of OSD.

How do we explain painful non-traumatic knee conditions to adolescents? A multiple-method study to develop credible explanations

BACKGROUND

Perceived diagnostic uncertainty can leave adolescents confused about their condition and impede their ability to understand "what's wrong with me". Our aim is to develop credible explanations about the condition for adolescents suffering from non-traumatic knee pain.

METHODS

This multiple-method study integrated findings from two systematic literature searches of qualitative and quantitative studies, an Argumentative Delphi with international experts (n = 16) and think-aloud interviews with adolescents (n = 16). Experts provided feedback with arguments on how to communicate credible explanations to meet adolescents' needs; we analysed feedback using thematic analysis. The explanations were tailored based on the adolescent end-users' input.

RESULTS

We screened 3239 titles/abstracts and included 16 papers exploring diagnostic uncertainty from adolescents' and parents' perspectives. Five themes were generated: (1) understanding causes and contributors to the pain experience, (2) feeling stigmatized for having an invisible condition, (3) having a name for pain, (4) controllability of pain, and (5) worried about something being missed. The Argumentative Delphi identified the following themes: (1) multidimensional perspective, (2) tailored to adolescents, (3) validation and reassurance, and (4) careful wording. Merging findings from the systematic search and the Delphi developed three essential domains to address in credible explanations: "What is non-traumatic knee pain and what does it mean?", "What is causing my knee pain?" and "How do I manage my knee pain?"

CONCLUSIONS

Six credible explanations for the six most common diagnoses of non-traumatic knee pain were developed. We identified three domains to consider when tailoring credible explanations to adolescents experiencing non-traumatic knee pain.

SIGNIFICANCE

This study provides credible explanations for the six most common diagnoses of non-traumatic knee pain. Additionally, we identified three key domains that may need to be addressed to reduce diagnostic uncertainty in adolescents suffering from pain complaints. Based on our findings, we believe that clinicians will benefit from exploring adolescents' own perceptions of why they experience pain and perceived management strategies, as this information might capture important clinical information when managing these young individuals.

National population-based reference data for the Hip Disability and Osteoarthritis Outcome Score (HOOS)

INTRODUCTION

Interpretation of patient-reported outcome scores such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) can be improved with use of reference values. The aim of the study was to establish population-based reference values for the HOOS' five subscales and its short-form HOOS-12.

MATERIALS AND METHODS

A representative sample of 9997 Danish citizens 18 years and older were identified. The population record-based sample was based on seven predefined age groups and an equal sex distribution within each age group. A national secure electronic system was used to send the HOOS questionnaire and one supplementary question regarding previous hip complaints to all participants.

RESULTS

2277 participants completed the HOOS, 947 women (42%) and 1330 men (58%). The mean HOOS subscale scores were: pain 86.9 (95% CI 86.1-87.7), symptoms 83.7 (95% CI 82.9-84.5), ADL 88.2 (95% CI 87.5-89.0), sport and recreation function 83.1 (95% CI 82.0-84.1), QOL 82.7 (95% CI 81.8-83.6). The youngest age group reported better mean scores in four subscales compared to the oldest age group (pain 91.7 vs. 84.5, mean difference 7.2 95% CI 0.4-14.0), (ADL 94.6 points vs. 83.2, mean difference 11.4 95% CI 4.9-17.8), (sport and recreation function 91.5 points vs. 73.8 points, mean difference 17.7 95% CI 9.0-26.4), (QOL 88.9 points vs. 78.8, mean difference 10.1 points 95% CI 2.0-18.2). Participants with a self-reported hip complaint had worse HOOS scores across all subscales (mean difference range 22.1-34.6). Super obese patients (BMI > 40) had > 12.5 points worse scores across the five HOOS subscales. Results were similar for the HOOS-12.

CONCLUSION

This study provides reference values for the HOOS and its short form HOOS-12. Results show that older patients and patients with a BMI over 40 have worse HOOS and HOOS-12 scores that may be of clinical importance in the interpretation of scores both when evaluating potential for improvement and post-treatment results.

Foot and Ankle Outcome Score (FAOS): Reference Values From a National Representative Sample

Background

The Foot and Ankle Outcome Score (FAOS) is widely used in clinical practice and research. However, FAOS reference values are missing to aid interpretation. This study aimed to establish national record-based reference values for the FAOS.

Methods

A national representative sample of 9996 adult Danish citizens was derived from the Danish Civil Registration System. The FAOS questionnaire was sent to all participants, including 2 supplemental questions regarding previous foot and ankle problems and body mass index (BMI). A threshold of 10 FAOS points was predefined as a clinically relevant difference across all 5 subscales.

Results

A total of 2759 participants completed the FAOS. Mean age of participants was 60.5 years, and 51% were women. The mean FAOS subscale scores were as follows: pain, 87.1 (95% CI 86.4-87.8); symptoms, 85.1 (95% CI 84.5-85.8); activity of daily living (ADL), 88.9 (95% CI 88.2-89.6); sport and recreation function 78.5 (95% CI 77.4-79.6); and quality of life (QOL), 79.9 (95% CI 79.0-80.9). The mean difference between men and women was small and not clinically relevant (ranged from 0.9 in ADL to 3.4 in QOL). The largest differences in mean scores between age groups ranged from 4.3 in symptoms to 16.4 in sport/rec. Except for the subscale sport/rec, all age-related differences were below the predefined threshold of 10 for clinical relevance. The difference in mean subscale scores between the lowest BMI group (<24.7) and the obese group (>30) ranged from 19.6 in ADL to 39.1 in sport/rec.

Conclusion

We found in our population that BMI severely impacted FAOS scores. We recommend using BMI-specific reference FAOS values. Separate FAOS reference values for men and women appear not needed. Stratifying reference values for age is likely not needed except for the subscale sport and recreation function.

Level of evidence

Level III, cohort study.

Knee injury and osteoarthritis outcome score (KOOS) - National record-based reference values

BACKGROUND

Knee Injury and Osteoarthritis Outcome Score (KOOS) and the short form KOOS-12 are commonly used in clinical practice and research but there are no national record-based reference values to aid interpretation. The aim of this study was to establish national record-based reference values for the KOOS and its short form KOOS-12.

PATIENTS AND METHODS

A national record-based representative sample of 9996 adult citizens were derived from the Danish Civil Registration System. The selection of citizens was based on seven predefined age groups with an equal sex distribution across each age strata. The KOOS questionnaire was sent to all participants, together with two supplemental questions regarding previous knee problems and body mass index (BMI).

RESULTS

A total of 2842 participants completed the KOOS, 1463 women (51.4%) and 1379 men (48.6%). The mean KOOS subscale scores were: pain 85.3 (95% confidence interval (CI): 84.6-85.9), symptoms 85.1 (95% CI: 84.5-85.8), activities of daily living (ADL) 86.7 (95% CI: 86.0-87.3), sport and recreation function 70.9 (95% CI: 69.8-72.0), quality of life (QOL) 74.9 (95% CI: 73.9-75.8).Age- and sex-specific reference values showed small differences in mean scores between the five KOOS subscales and all were below the threshold for clinically relevant improvement (10 points).Knee problems were associated with worse KOOS scores across all subscales. The difference in the mean subscale scores between the lowest (<24.9) and highest (>40) BMI groups ranged from 12.9 to 24.1. Comparable results were observed for KOOS-12.

CONCLUSION

KOOS and KOOS-12 reference values can, in most situations, be used without stratification for age and sex. Sport/recreation reference values stratified for age and BMI may be of importance.

What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map

ABSTRACT

Evidence and gap maps (EGMs) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the past 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or others. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality, and 15% rated high quality. Physical interventions (eg, exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic MSK pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.

Patient-centered management strategy for concurrent musculoskeletal complaints in elbows, shoulders, and neck after an isolated hand/forearm complaint: A prospective interventional study

The aim was to evaluate patient-reported outcomes before and after a patient-centered management strategy targeting concurrent proximal musculoskeletal complaints (MSCs) in patients with an isolated hand/forearm complaint. A prospective interventional study included 66 patients. Intervention targeting concurrent MSCs was implemented as a patient-centered add-on to standard treatment for primary hand/forearm complaints. The patient-centered management strategy included patient education, individualized exercises, and manual therapy. Patient-reported outcome measures and pain questionnaires regarding the location, frequency, and intensity of pain in hands, elbows, shoulders, and neck were collected at baseline, after the last session of the patient-centered management strategy, and at 3-month follow-up. There were significant improvements in all patient-reported outcomes between baseline and follow-up. DASH scores improved significantly, by 17-29 points on the 3 subscales. There was a significant improvement of 6 points in PCS, 2 points in HADS, and 0.051 points in EQ-5D index. Median pain intensity on NRS decreased from 6 (4-8) to 5 (2.5-7) in hands, 3 (0-6) to 0 (0-3) in elbows, 5 (2-7) to 2.5 (0-5) in shoulders, and 3 (0-6) to 2 (0-3) in the neck, between baseline and discharge. Patients reporting concurrent MSCs in the elbow, shoulder, and neck after an isolated hand/forearm complaint may benefit from patient-centered management comprising patient education, individualized exercises, and manual therapy targeting pain and functional deficits in the upper-limb and neck. LEVEL OF EVIDENCE: IV.

Participatory research: a Priority Setting Partnership for chronic musculoskeletal pain in Denmark

OBJECTIVES

Patient and stakeholder engagements in research have increasingly gained attention in healthcare and healthcare-related research. A common and rigorous approach to establish research priorities based on input from people and stakeholders is the James Lind Alliance Priority Setting Partnership (JLA-PSP). The aim of this study was to establish research priorities for chronic musculoskeletal (MSK) pain by engaging with people living with chronic MSK pain, relatives to people living with chronic MSK pain, healthcare professionals (HCP), and researchers working with chronic MSK pain.

METHODS

This JLA-PSP included a nation-wide survey in Denmark, an interim prioritisation, and an online consensus building workshop. The information gained from this was the basis for developing the final list of specific research priorities within chronic MSK pain.

RESULTS

In the initial survey, 1010 respondents (91% people living with chronic MSK pain/relatives, 9% HCPs/researchers) submitted 3121 potential questions. These were summarised into 19 main themes and 36 sub-themes. In the interim prioritisation exercise, 51% people living with pain/relatives and 49% HCPs/researchers reduced the list to 33 research questions prior to the final priority setting workshop. 23 participants attended the online workshop (12 people/relatives, 10 HCPs, and 1 researcher) who reached consensus for the most important research priorities after two rounds of discussion of each question.

CONCLUSIONS

This study identified several specific research questions generated by people living with chronic MSK pain, relatives, HCPs, and researchers. The stakeholders proposed prioritization of the healthcare system's ability to support patients, focus on developing coherent pathways between sectors and education for both patients and HCP. These research questions can form the basis for future studies, funders, and be used to align research with end-users' priorities.

Defining Growing Pains: A Scoping Review

BACKGROUND AND OBJECTIVES

Up to one third of children may be diagnosed with growing pains, but considerable uncertainty surrounds how to make this diagnosis. The objective of this study was to detail the definitions of growing pains in the medical literature.

METHODS

Scoping review with 8 electronic databases and 6 diagnostic classification systems searched from their inception to January 2021. The study selection included peer-reviewed articles or theses referring to "growing pain(s)" or "growth pain(s)" in relation to children or adolescents. Data extraction was performed independently by 2 reviewers.

RESULTS

We included 145 studies and 2 diagnostic systems (ICD-10 and SNOMED). Definition characteristics were grouped into 8 categories: pain location, age of onset, pain pattern, pain trajectory, pain types and risk factors, relationship to activity, severity and functional impact, and physical examination and investigations. There was extremely poor consensus between studies as to the basis for a diagnosis of growing pains. The most consistent component was lower limb pain, which was mentioned in 50% of sources. Pain in the evening or night (48%), episodic or recurrent course (42%), normal physical assessment (35%), and bilateral pain (31%) were the only other components to be mentioned in more than 30% of articles. Notably, more than 80% of studies made no reference to age of onset in their definition, and 93% did not refer to growth. Limitations of this study are that the included studies were not specifically designed to define growing pains.

CONCLUSIONS

There is no clarity in the medical research literature regarding what defines growing pain. Clinicians should be wary of relying on the diagnosis to direct treatment decisions.

Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: a randomized dose-response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial)

OBJECTIVE

To investigate firstly the efficacy of three different dosages of one home-based, knee-extensor resistance exercise on knee-extensor strength in patients eligible for knee replacement, and secondly, the influence of exercise on symptoms, physical function and decision on surgery.

METHOD

One-hundred and forty patients eligible for knee replacement were randomized to three groups: 2, 4 or 6 home-based knee-extensor resistance exercise-sessions per week (group 2, 4 and 6 respectively) for 12 weeks.

PRIMARY OUTCOME

isometric knee-extensor strength.

SECONDARY OUTCOMES

Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6-min walk test, stair climbing test, exercise adherence and "need for surgery".

RESULTS

Primary analysis: Intention-to-treat analysis of 140 patients did not find statistically significant differences between the groups from baseline to after 12 weeks of exercise in isometric knee-extensor strength: Group 2 vs 4 (0.003 Nm/kg (0.2%) [95% CI -0.15 to 0.15], P = 0.965) and group 4 vs 6 (-0.04 Nm/kg (-2.7%) [95% CI -0.15 to 0.12], P = 0.628). Secondary analysis: Intention-to-treat analyses showed statistically significant differences between the two and six sessions/week groups in favor of the two sessions/week group for Oxford Knee Score: 4.8 OKS points (15.2%) [1.3 to 8.3], P = 0.008) and avg. knee pain last week (NRS 0-10): -1.3 NRS points (-19.5%) [-2.3 to -0.2], P = 0.018. After the 12-week exercise intervention, data were available for 117 patients (N = 39/group): 38 (32.5%) patients wanted surgery and 79 (67.5%) postponed surgery. This was independent of exercise dosage.

CONCLUSION

In patients eligible for knee-replacement we found no between-group differences in isometric knee extensor strength after 2, 4 and 6 knee-extensor resistance exercise sessions per week. We saw no indication of an exercise dose-response relationship for isometric knee-extensor strength and only clinically irrelevant within group changes. For some secondary outcome (e.g., KOOS subscales) we found clinically relevant within group changes, which could help explain why only one in three patients decided to have surgery after the simple home-based exercise intervention.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02931058. Preprint: https://doi.org/10.1101/2021.04.07.21254965.

Medical imaging for plantar heel pain: a systematic review and meta-analysis

Background

Medical imaging can be used to assist with the diagnosis of plantar heel pain. The aim of this study was to synthesise medical imaging features associated with plantar heel pain.

Methods

This systematic review and meta-analysis conducted searches in MEDLINE, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to 12th February 2021. Peer-reviewed articles of cross-sectional observational studies written in English that compared medical imaging findings in adult participants with plantar heel pain to control participants without plantar heel pain were included. Study quality and risk of bias was assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Sensitivity analyses were conducted where appropriate to account for studies that used unblinded assessors.

Results

Forty-two studies (2928 participants) were identified and included in analyses. Only 21% of studies were rated ‘good’ on quality assessment. Imaging features associated with plantar heel pain included a thickened plantar fascia (on ultrasound and MRI), abnormalities of the plantar fascia (on ultrasound and MRI), abnormalities of adjacent tissue such as a thickened loaded plantar heel fat pad (on ultrasound), and a plantar calcaneal spur (on x-ray). In addition, there is some evidence from more than one study that there is increased hyperaemia within the fascia (on power Doppler ultrasound) and abnormalities of bone in the calcaneus (increased uptake on technetium-99 m bone scan and bone marrow oedema on MRI).

Conclusions

People with plantar heel pain are more likely to have a thickened plantar fascia, abnormal plantar fascia tissue, a thicker loaded plantar heel fat pad, and a plantar calcaneal spur. In addition, there is some evidence of hyperaemia within the plantar fascia and abnormalities of the calcaneus. Whilst these medical imaging features may aid with diagnosis, additional high-quality studies investigating medical imaging findings for some of these imaging features would be worthwhile to improve the precision of these findings and determine their clinical relevance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00507-2.

Tendoscopic peritendon shaving of midportion Achilles tendinopathy: A randomized, placebo-controlled study

Achilles tendinopathy is among the most frequent tendon injuries in sport. Despite evidence-based management, a significant proportion of patients continue to experience symptoms. This is the first randomized trial to investigate the effect of tendoscopic treatment of midportion Achilles tendinopathy compared with placebo at baseline, 3, 6 and 12 months. Patients with midportion Achilles tendinopathy (non-responsive to more than 6 months of nonsurgical treatments) were randomly assigned to receive either tendoscopic peritendon shaving or placebo tendoscopic treatment. The primary outcome measure was the total score of the Victorian Institute of Sport Assessment Achilles (VISA-A) questionnaire. Due to three adverse events (sural nerve injuries), in the group receiving tendoscopic treatment, the trial was stopped short of the planned 48 participants. All 23 patients included completed 3 months' follow-up (100%), 22 (96%) 6 months' and 19 (83%) completed 12 months' follow-up. The between-group estimates favored endoscopic treatment and ranged from 19 points (95% confidence interval [CI]: 1-38) at 3 months, 14 points (-7 to 34) at 6 months and 5 points (95% CI: -19 to 28) at 12 months. After 12 months, the tendoscopic group improved 47 points (95% CI: 29-65) versus 40 points (95% CI: 22-57) in the placebo-operated group. Despite a smaller sample size due to adverse events, VISA-A indicate faster recovery from tendoscopic treatment compared to placebo. These data suggest that tendoscopic treatment of midportion Achilles tendinopathy should be tested in further research; however, the technique needs to be refined to avoid sural nerve injuries.

The relationship between prescribed pre-operative knee-extensor exercise dosage and effect on knee-extensor strength prior to and following total knee arthroplasty: a systematic review and meta-regression analysis of randomized controlled trials

OBJECTIVE

The aim of this systematic review was to evaluate the relationship between prescribed knee-extensor strength exercise dosage in pre-operative exercise intervention and the effect on knee-extensor muscle strength prior to and following TKA. Additional meta-analyses report the effect of pre-habilitation on outcomes prior to and following TKA.

DESIGN

A systematic literature search was performed including RCT's evaluating the effect of pre-operative exercise prior to and following TKA. Meta-regression analysis was performed to evaluate the dose-response relationship between prescribed exercise dose and the pooled effect, measured as standardized mean difference (SMD). The prescribed exercise dose was quantified using a formula accounting for as many exercise descriptors as possible. Risk of bias in the included trials was assessed using the Cochrane Risk of Bias Tool.

RESULTS

Twelve trials with 616 patients were included. Meta-regression analysis showed no relationship between prescribed pre-operative knee-extensor exercise dosage and change in knee-extensor strength neither prior to (slope 0.0005 [95%CI -0.007 to 0.008]) or 3 months following TKA (slope 0.0014 [95%CI -0.006 to 0.009]). Prior to TKA, a moderate effect favoring pre-operative exercise for increase in knee-extensor strength was found (SMD 0.50 [95%CI 0.12 to 0.88]), but not at 3 months following TKA (SMD -0.01 [95%CI -0.45 to 0.43]). Risk of bias was generally assessed as unclear.

CONCLUSION

Meta-regression analysis of existing trials suggests no relationship between the prescribed pre-operative knee-extensor exercise dosage and the change in knee-extensor strength observed prior to and following TKA. Pre-operative exercise including knee-extensor muscle strength exercise increased knee-extensor strength moderately prior to but not 3 months following TKA.

PROTOCOL REGISTRATION

PROSPERO ID (CRD42018076308) (http://www.crd.york.ac.uk/PROSPERO/).

Activity Modification and Knee Strengthening for Osgood-Schlatter Disease: A Prospective Cohort Study

Background:

Osgood-Schlatter disease (OSD) affects 1 in 10 adolescents. There is a lack of evidence-based interventions, and passive approaches (eg, rest and avoidance of painful activities) are often prescribed.

Purpose:

To investigate an intervention consisting of education on activity modification and knee-strengthening exercises designed for adolescents with OSD.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 51 adolescents (51% female; age range, 10-14 years) with OSD. The 12-week intervention consisted of an activity ladder designed to manage patellar tendon loading and pain, knee-strengthening exercises, and a gradual return to sport. The primary outcome was the global reporting of change at 12 weeks, evaluated with a 7-point Likert scale (successful outcome was considered “much improved” or “improved”). Additional endpoints were at 4, 8, 26, and 52 weeks. Secondary outcomes included the Knee injury and Osteoarthritis Outcome Score (KOOS), objective strength, and jump performance.

Results:

Adolescents reported a mean pain duration of 21 months at enrollment. After 12 weeks, 80% reported a successful outcome, which increased to 90% at 12 months. At 12 weeks, 16% returned to playing sport, which increased to 69% at 12 months. The KOOS subscores of Pain, Activities of Daily Living, Sport and Recreation, and Quality of Life improved significantly (7-20 points), and there were improvements in knee extension strength (32%; P < .001), hip abduction strength (24%; P < .001), and jumping for distance (14%; P < .001) and height (19%; P < .001) at 12 weeks.

Conclusion:

An intervention consisting of activity modification, pain monitoring, progressive strengthening, and a return-to-sport paradigm was associated with improved self-reported outcomes, hip and knee muscle strength, and jumping performance. This approach may offer an alternative to passive approaches such as rest or wait-and-see, often prescribed for adolescents with OSD.

Registration:

NCT02799394 (ClinicalTrials.gov identifier)

Surgical versus conservative treatment for ankle fractures in adults - A systematic review and meta-analysis of the benefits and harms

INTRODUCTION

Despite fractures of the ankle being very common, there is a lack of clarity regarding the relative effectiveness of conservative versus surgical treatment. The purpose of this systematic review and meta-analysis was to investigate the clinical effects, benefits, and harms of surgical versus conservative treatment of ankle fractures in adults.

METHODS

A systematic search strategy was conducted in the databases: Pubmed, Embase, Web of Science, and Cochrane up until the 16th of August 2017. Eight available randomized controlled trials, regardless of fracture type, reported on patient-reported ankle-specific functional outcome and were included. Analyses were based on random effects models.

RESULTS

The 8 included studies randomly allocated 1237 patients to either surgical or conservative treatment. Mean age of patients ranged from 38.1 to 71.4 years. Five studies evaluated short-term patient-reported ankle function, with no significant difference between surgery and conservative treatment (SMD=-0.14, 95%CI=-0.57 to 0.29, P=0.51, I²=84%). Three studies evaluated health-related quality of life, with no significant difference in treatment effect between surgery or conservative treatment (SMD=0.13, 95%CI=-0.01 to 0.27, P=0.06, I²=0%).

CONCLUSIONS

The best available current evidence supports that clinicians can manage ankle fractures by both surgical and conservative means with equal short-term results in selected patient groups with stable and unstable nondisplaced ankle fractures. However, more research is needed including high-quality RCTs investigating the long-term effects. This is especially the case in younger patients, before making significant interpretations about clinical practice.

Associations between number of pain sites and sleep, sports participation, and quality of life: a cross-sectional survey of 1021 youth from the Midwestern United States

BACKGROUND

Musculoskeletal pain in youth is common but little is known about the influence of the number of pain sites on pain characteristics. The objective of this study was to compare pain characteristics, quality of life, sleep, sport participation between adolescents without pain, those with single site pain, and those with multi-site pain and investigate the relationship between pain duration and number of pain sites.

METHODS

An online survey was sent via email to 7177 possible middle- and high-school students. The students completed a survey containing questions about their pain (including location, duration, intensity, frequency), health-related quality of life, sleep quantity and quality, and sports participation. Quantitative variables were analysed with one-way ANOVAs or t-tests and qualitative variables were analysed with Pearson Chi-squared tests. Relationships were investigated with a Pearson Correlation.

RESULTS

Of the respondents (n = 1021), 52.9% reported no pain, 17.2% reported pain in a single-site, and 29.9% reported pain in multiple sites. Those with multi-site pain reported significantly lower quality of life than both pain-free youth (p < 0.001) and those with single-site pain (p < 0.001); those with single-site pain had lower quality of life than pain-free youth (p < 0.001). Those with pain reported worse sleep than those without pain (P < 0.05). No differences in sport participation were found (p > 0.10). Those with multi-site pain reported greater intensity (p = 0.005) and duration (p < 0.001) than those with single-site pain. A positive, moderate, and significant correlation (r = 0.437, p < 0.001) was found between the pain duration and number of pain sites.

CONCLUSIONS

A large percentage of youth experience regular pain that affects their self-reported quality of life and sleep, with greater effects in those with multi-site pain.

Patellar fractures are associated with an increased risk of total knee arthroplasty: A Matched Cohort Study of 6096 Patellar Fractures with a mean follow-up of 14.3 Years

AIMS

The aim of this study was to investigate the incidence of knee arthroplasty and arthroscopy following patellar fractures, and to compare this with an age- and gender-matched group without a prior patellar fracture.

PATIENTS AND METHODS

A national matched cohort study based on the Danish National Patient Register including all citizens of Denmark (approximately 5.3 million) was undertaken. A total of 6096 patients who sustained a patellar fracture in Denmark between 1 January 1996 and 31 December 2000 were included. The median age of these patients was 50.6 years (interquartile range (IQR) 28.5 to 68.9); 49.1% were women. Patients were followed-up until 31 December 2015, with regard to treatment with knee arthroplasty and/or knee arthroscopy.

RESULTS

Patients with a patellar fracture had an increased risk of knee arthroplasty (hazard ratio (HR) 1.83, 95% confidence interval (CI) 1.57 to 2.13) compared with citizens without a patellar fracture, and the effect was strongest during the first five years (HR 3.02, 95% CI 2.26 to 4.03). Patients with a patellar fracture also had a higher risk of knee arthroscopy (HR 3.94, 95% CI 3.49 to 4.46), and the effect was highest during the first five years after the fracture (HR 7.40, 95% CI 6.32 to 8.66).

CONCLUSION

Patellar fractures are associated with an increased risk of knee arthroplasty and knee arthroscopy. The consequences of a patellar fracture may be more severe than previously considered, and patients must expect a lifelong increased risk of knee arthroplasty. Cite this article: Bone Joint J 2018;100-B:1477-81.

Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials

OBJECTIVES

To compare 2-year outcomes of total knee replacement (TKR) followed by non-surgical treatment to that of non-surgical treatment alone and outcomes of the same non-surgical treatment to that of written advice.

DESIGN

In two randomized trials, 200 (mean age 66) adults with moderate to severe knee osteoarthritis (OA), 100 eligible for TKR and 100 not eligible for TKR, were randomized to TKR followed by non-surgical treatment, non-surgical treatment alone, or written advice. Non-surgical treatment consisted of 12 weeks of supervised exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the mean score of the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, activities of daily living (ADL), and quality of life (QOL).

RESULTS

Patients randomized to TKR had greater improvements than patients randomized to non-surgical treatment alone (difference of 18.3 points (95% CI; 11.3 to 25.3)), who in turn improved more than patients randomized to written advice (difference of 7.0 points (95% CI; 0.4 to 13.5)). Among patients eligible for TKR, 16 (32%) from the non-surgical group underwent TKR during 2 years and among those initially ineligible, seven patients (14%) from the non-surgical group and ten (20%) from the written advice group underwent TKR.

CONCLUSIONS

TKR followed by non-surgical treatment is more effective on pain and function than non-surgical treatment alone, which in turn is more effective than written advice. Two out of three patients with moderate to severe knee OA eligible for TKR delayed surgery for at least 2 years following non-surgical treatment.

TRIAL REGISTRATION

ClinicalTrials.gov numbers NCT01410409 and NCT01535001.

Exercise therapy, patient education, and patellar taping in the treatment of adolescents with patellofemoral pain: a prospective pilot study with 6 months follow-up

Background

Patellofemoral pain (PFP) is the most common knee condition among adolescents, with a prevalence of 6–7% resulting in reduced function and quality of life. Exercise therapy is recommended for treating PFP, but has only been tested in older adolescents (15–19 years). This pilot study aimed to investigate the adherence to, and clinical effects of, exercise and patient education in young adolescents (12–16 years), with PFP.

Methods

Twenty adolescents (16 females) with PFP were recruited from a population-based cohort to undergo a 3-month multimodal intervention. This comprised of a 30-min patient education and group-based exercise therapy. Exercises included supervised lower extremity strength exercises three times per week, in addition to similar home-based strength exercises. Outcomes included a 7-point global rating of change scale (ranging from “completely recovered” to “worse than ever”), the Knee injury and Osteoarthritis Outcome Score (KOOS), physical activity scale (PAS), weekly sports participation and health-related quality of life measured by European Quality of Life 5 dimensions Youth (EQ-5DY) and isometric knee and hip muscle strength. Pain was measured on a visual analogue scale (VAS), and satisfaction treatment was measured on a five-point Likert scale ranging from “highly satisfied” to “not satisfied at all”. These were collected at 3- and 6-month follow-ups. Adherence to supervised exercise was measured as session attendance, and adolescent self-reported adherence to home-based exercises.

Results

Adherence to the exercise therapy was poor, with adolescents participating in a median of 16 (IQR 5.5–25) out of 39 possible supervised training session. Five out of 18 adolescents had a successful outcome after both 3 and 6 months. There were no relevant changes in isometric muscle strength.

Conclusion

This was the first study to investigate adherence to, and clinical effects of, exercise therapy and patient education in young adolescents with patellofemoral pain. Adherence to the exercise therapy was low with little to no clinical effects making a full clinical trial impractical. Future studies need to explore how an intervention can be successfully tailored to young adolescents with patellofemoral pain to obtain good adherence while improving pain and function.

Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis

BACKGROUND

Plantar heel pain (PHP) is common. Foot orthoses are often applied as treatment for PHP, even though there is little evidence to support this.

OBJECTIVE

To investigate the effects of different orthoses on pain, function and self-reported recovery in patients with PHP and compare them with other conservative interventions.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A systematic literature search was conducted in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL and Google Scholar up to January 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing foot orthoses with a control (defined as no intervention, sham or other type of conservative treatment) reporting on pain, function or self-reported recovery in patients with PHP.

RESULTS

Twenty studies investigating eight different types of foot orthoses were included in the review. Most studies were of high quality. Pooled data from six studies showed no difference between prefabricated orthoses and sham orthoses for pain at short term (mean difference (MD) of 0.26 (95% CI -0.09 to 0.60)). No difference was found between sham orthoses and custom orthoses for pain at short term (MD 0.22 (95% CI -0.05 to 0.50)), nor was there a difference between prefabricated orthoses and custom orthoses for pain at short term (MD 0.03 (95% CI -0.15 to 0.22)). For the majority of other interventions, no significant differences were found.

CONCLUSIONS

Foot orthoses are not superior for improving pain and function compared with sham or other conservative treatment in patients with PHP.

PROSPERO REGISTRATION NUMBER

CRD42015029659.

Capturing patient-reported area of knee pain: a concurrent validity study using digital technology in patients with patellofemoral pain

BACKGROUND

Patellofemoral pain (PFP) is often reported as a diffuse pain at the front of the knee during knee-loading activities. A patient's description of pain location and distribution is commonly drawn on paper by clinicians, which is difficult to quantify, report and compare within and between patients. One way of overcoming these potential limitations is to have the patient draw their pain regions using digital platforms, such as personal computer tablets.

OBJECTIVE

To assess the validity of using computer tablets to acquire a patient's knee pain drawings as compared to paper-based records in patients with PFP.

METHODS

Patients (N = 35) completed knee pain drawings on identical images (size and colour) of the knee as displayed on paper and a computer tablet. Pain area expressed as pixel density, was calculated as a percentage of the total drawable area for paper and digital records. Bland-Altman plots, intraclass correlation coefficient (ICC), Pearson's correlation coefficients and one-sample tests were used in data analysis.

RESULTS

No significant difference in pain area was found between the paper and digital records of mapping pain area (p = 0.98), with the mean difference = 0.002% (95% CI [-0.159-0.157%]). A very high agreement in pain area between paper and digital pain drawings (ICC = 0.966 (95% CI [0.93-0.98], F = 28.834, df = 31, p < 0.001). A strong linear correlation (R2 = 0.870) was found for pain area and the limits of agreement show less than ±1% difference between paper and digital drawings.

CONCLUSION

Pain drawings as acquired using paper and computer tablet are equivalent in terms of total area of reported knee pain. The advantages of digital recording platforms, such as quantification and reporting of pain area, could be realized in both research and clinical settings.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

BACKGROUND

Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient's pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

METHODS

Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.

RESULTS

The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference.

CONCLUSION

Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders.

PROSPERO REGISTRATION

CRD42016038882.

Distribution and symmetrical patellofemoral pain patterns as revealed by high-resolution 3D body mapping: a cross-sectional study

Background

Detailed pain mapping of extent and distribution in individuals with patellofemoral pain (PFP) within and around a complex structure such as the knee has yet to be explored.

Methods

Perceptions of on-going pain from adolescents and young adults (N = 35) with long-standing (>10 months) PFP were collected on high-resolution 3D digital body-schema of the knees. Location, area of pain, pain intensity, laterality, worse side of knee pain, symptom duration, and symmetry in bilateral knee pain were recorded. A threshold for naturally occurring variations in symmetrical knee pain drawings were collected from 18 healthy controls and used in combination with the development a symmetry index (0–1) to create a fuzzy rule for classifying symmetrical and non-symmetrical PFP patterns as compared to a PFP expert. The symmetry index was computed and tested using a correlation coefficient alone or in combination with the Jaccard index and the true and false positive rates (TPR and FPR, respectively) determined.

Results

The peripatellar region was the common report of pain location however, novel and nonconforming PFP patterns were identified and the majority of individuals (22 of 27) with bilateral PFP expressed highly-symmetric mirror-image pain. Individuals with symptom duration of 5 years or more had a greater area of pain, compared to those with symptoms for less than 5 years. The total area of pain was correlated to symptom duration for those with extended symptoms durations and a progression towards an “O” shaped pattern emerged. A TPR of 100% for identifying symmetrical knee pain patterns was found however the expert PFP tended to be stricter, as reflected in FPR of 20%.

Conclusions

A high proportion of PFP patterns or symptoms occur in mirrored locations and are exceptionally symmetrical, and long duration of symptoms appear to converge to an ‘O’ shape. Classifying symmetrical pain patterns is subjective however simple fuzzy rules and correlations can be used to increase objectivity. This study highlights a gap in knowledge of PFP symptom presentation, reveals what may be a natural progression of symptoms, and provides valuable clinical insight for both pain management and treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1521-5) contains supplementary material, which is available to authorized users.

Can we predict the outcome for people with patellofemoral pain? A systematic review on prognostic factors and treatment effect modifiers

BACKGROUND

Patellofemoral pain (PFP) is a multifactorial and often persistent knee condition. One strategy to enhance patient outcomes is using clinically assessable patient characteristics to predict the outcome and match a specific treatment to an individual.

AIM

A systematic review was conducted to determine which baseline patient characteristics were (1) associated with patient outcome (prognosis); or (2) modified patient outcome from a specific treatment (treatment effect modifiers).

METHODS

6 electronic databases were searched (July 2016) for studies evaluating the association between those with PFP, their characteristics and outcome. All studies were appraised using the Epidemiological Appraisal Instrument. Studies that aimed to identify treatment effect modifiers underwent a checklist for methodological quality.

RESULTS

The 24 included studies evaluated 180 participant characteristics. 12 studies investigated prognosis, and 12 studies investigated potential treatment effect modifiers. Important methodological limitations were identified. Some prognostic studies used a retrospective design. Studies aiming to identify treatment effect modifiers often analysed too many variables for the limiting sample size and typically failed to use a control or comparator treatment group. 16 factors were reported to be associated with a poor outcome, with longer duration of symptoms the most reported (>4 months). Preliminary evidence suggests increased midfoot mobility may predict those who have a successful outcome to foot orthoses.

CONCLUSIONS

Current evidence can identify those with increased risk of a poor outcome, but methodological limitations make it difficult to predict the outcome after one specific treatment compared with another. Adequately designed randomised trials are needed to identify treatment effect modifiers.

New exercise-integrated technology can monitor the dosage and quality of exercise performed against an elastic resistance band by adolescents with patellofemoral pain: an observational study

QUESTION

Is the exercise-integrated Bandcizer™ system feasible for recording exercise dosage (time under tension (TUT) and repetitions) and pain scores among adolescents with patellofemoral pain? Do adolescents practise the exercises as prescribed (TUT and repetitions)? Do adolescents accurately report the exercises they do in an exercise diary?

DESIGN

Observational feasibility study.

PARTICIPANTS

Twenty adolescents between 15 and 19 years of age with patellofemoral pain.

INTERVENTION

Participants were prescribed three exercise sessions per week (one with and two without supervision) for 6 weeks. The exercises included three hip and one knee exercise with an elastic resistance band. Participants were instructed to perform three sets with a predefined TUT (3seconds concentric; 2seconds isometric; 3seconds eccentric; 2seconds pause), equating to 80seconds for 10 repetitions (one set).

OUTCOME MEASURES

The exercise-integrated system consisted of a sensor attached to the elastic resistance band that was connected to the Bandtrainer app on an electronic tablet device. Pain intensity was reported on a visual analogue scale on the app. Participants also completed a self-report exercise diary.

RESULTS

No major problems were reported with the system. Participants performed 2541 exercise sets during the 6 weeks; 5% were performed with the predefined TUT (ie, within 10seconds of the 80-second target) and 90% were performed below the target TUT. On average, the participants received 15% of the instructed exercise dosage based on TUT. The exercise dosage reported in the exercise diaries was 2.3 times higher than the TUT data from the electronic system. Pain intensity was successfully collected in 100% of the exercise sets.

CONCLUSION

The system was feasible for adolescents with patellofemoral pain. The system made it possible to capture detailed data about the TUT, repetitions and sets during home-based exercises together with pain intensity before and after each exercise. [Rathleff MS, Bandholm T, McGirr KA, Harring SI, Sørensen AS, Thorborg K (2016) New exercise-integrated technology can monitor the dosage and quality of exercise performed against an elastic resistance band by adolescents with patellofemoral pain: an observational study.Journal of Physiotherapy62: 159-163].

A case report of a completely displaced stress fracture of the femoral shaft in a middle-aged male athlete - A precursor of things to come?

BACKGROUND

Displaced stress fractures of the femoral shaft are very uncommon. The proportion of middle-aged and older age groups participating in long-distance running, triathlon and other high intensity sports is increasing. As a consequence stress fracture of the femoral shaft may be on the rise in the future.

CASE PRESENTATION

The patient was 43 years old male caucasian triathlete. The authors met the patient after he was admitted with a displaced femoral shaft fracture. The fracture occurred during running at the national championship in ½ Ironman. The patient reported that his symptoms had gradually developed over the last month before the fracture with pain localized anterior to the thigh. The patient interpreted the symptoms as local muscle damage. A clinical examination was conducted by a physiotherapist and the symptoms were interpreted as a simple muscle injury in the quadriceps.

CONCLUSION

When presented with a patient with non-traumatic, diffuse anterior thigh pain in an individual of this age, who is participating in high-level endurance running; clinicians should consider the possibility that the cause of the symptoms may be a femoral shaft stress fracture.

Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain

BACKGROUND

The prevalence of adolescent knee pain is 33%, and patellofemoral pain (PFP) is the most common diagnosis with a nontraumatic onset. The 2-year prognosis of adolescent PFP compared with other types of knee pain is unknown.

PURPOSE

To investigate the 2-year prognosis of knee pain among adolescents with and without a diagnosis of PFP.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

In 2011, a cohort of 2200 adolescents aged 15 to 19 years answered an online questionnaire on musculoskeletal pain. Of these, 504 reported knee pain, and 153 of these were clinically diagnosed with PFP. After 2 years, the 504 adolescents, as well as 252 randomly selected adolescents who did not report knee pain in 2011, were contacted again. Primary outcome at follow-up was the proportion of adolescents with knee pain during the last week prior to follow-up.

RESULTS

Overall, 55.9% (95% CI, 50.8%-60.9%) of those reporting knee pain at baseline also reported pain 2 years later. Adolescents diagnosed with PFP had a 1.26 (95% CI, 1.05-1.50) higher relative risk (RR) of knee pain at follow-up compared with other types of knee pain. Adolescents with PFP were significantly more likely to reduce or stop sports participation compared with adolescents with other types of knee pain. Of those without knee pain at baseline, 12.8% (95% CI, 8.4%-17.2%) reported knee pain at follow-up in 2013. Adolescents with knee pain at baseline had a 4.51 (95% CI, 3.15-6.45) higher RR of knee pain at follow-up compared with adolescents without knee pain at baseline.

CONCLUSION

Knee pain during adolescence, and PFP in particular, is in most cases present after 2 years and thus may not be self-limiting. A greater focus on early detection and prevention of knee pain during adolescence is needed.

Effect of exercise therapy on neuromuscular activity and knee strength in female adolescents with patellofemoral pain-An ancillary analysis of a cluster randomized trial

BACKGROUND

Female adolescents with patellofemoral pain are characterized by altered neuromuscular knee control and reduced maximal quadriceps torque. The purpose of this study is to investigate whether exercise therapy and patient education are associated with larger improvements in neuromuscular knee control and maximal quadriceps torque compared with patient education alone.

METHODS

This is an ancillary analysis of a cluster randomized controlled trial investigating the effect of patient education and exercise therapy on self-reported recovery in 121 adolescents with patellofemoral pain. A random subsample of 57 female adolescents was included and tested at baseline and after 3months. Neuromuscular control of the knee was quantified as the complexity of surface electromyography of the vastus lateralis and vastus medialis during stair descent. Secondary outcomes were complexity of knee flexion/extension kinematics and maximal quadriceps torque.

FINDINGS

There was an 8-15% greater decrease in the complexity of surface electromyography suggesting an improvement in neuromuscular knee control among those randomized to exercise therapy (0.08<p<0.30). Adolescents randomized to exercise therapy had a 0.28-Nm/kg (95% CI: 0.05-0.52; p=0.02) larger increase in maximal quadriceps torque.

INTERPRETATION

Female adolescents randomized to patient education and exercise therapy had a significantly larger increase in maximal quadriceps torque and greater improvement in neuromuscular knee control during stair descent than those receiving patient education alone. This suggest that exercise therapy has an effect not only on self-reported outcome measures but also on objective measures of thigh muscle function in female adolescents with patellofemoral pain.

Translation and validation of the Child and the Adolescent HARDSHIP (Headache-attributed restriction, disability, social handicap and impaired participation) questionnaire into Danish language

Background. The prevalence of headaches among children and adolescents varies considerably between countries. This may be due to a lack of appropriate instruments to capture the prevalence. The purpose of this study was to translate the Child and Adolescent HARDSHIP questionnaires from English into Danish language, conduct cross-cultural adaptation, face validation by cognitive interviewing and conduct a pilot study exploring time requirements.

Methods. The questionnaire was translated using the guidelines proposed by “The Global Campaign to Reduce the Burden of Headache.” A total of 25 children from 6 to 12 years of age completed the questionnaire with 24 h between test and retest to assess reliability. A total of 169 children and adolescents from 6 to 17 years of age completed the translated questionnaire to assess time requirements for completing it.

Results. Only minor discrepancies were observed in the translation process. Test-retest reliability of the translated questionnaire showed substantial agreement (kappa: 0.65–0.78). The questionnaires were completed within 30 min (age 6–11 years of age) and within 15 min (age 12–17 years of age) respectively.

Discussion. No major problems were observed in the forward translations of the questionnaires. The face validation prompted no major changes in the questionnaire. The face-to-face interviews showed that pupils of different ethnic backgrounds than Danish and pupils in the age group of 6–11 had more difficulty in understanding a minority of the questions. The Danish Child and Adolescent HARDSHIP questionnaire therefore complies with the intentions of the originators, aiming at a maximal completion time of 45 min and in comparison with actual completion time. The test-retest study showed substantial agreement between test and retest in the headache, migraine and MOH domains and questions referring to time.The Child and Adolescent HARDSHIP questionnaire, includes a section specifically recording a four-week period.The Child and Adolescent HARDSHIP questionnaire is intended to measure burden of headache in large populations and there is therefore no need to reflect the states of individuals. We therefore find the substantial reliability of the Danish version of the Child and Adolescent HARDSHIP questionnaire to be adequate, without supplementing with a diary. The pilot study indicates that headache is a major problem among children and adolescents in Denmark. A total of 95.3% of the pupils have experienced headache in their life, 76.6% during the last year. A total of 14% left school early because of their headache and 14.9% missed school during the last four weeks, due to headache. 49.2% have experienced headaches during the last week and 47% describe the headache as “quite bad.” A total of 24.1% have taken pills or medicine during the last week due to headache. This pilot study clearly demonstrates the need to investigate the burden of headache among Danish schoolchildren as it seems to have a profound effect on their lives.

'Managing My Patellofemoral Pain': the creation of an education leaflet for patients

Study design

Qualitative, including consultation with international experts and patients.

Purpose

Develop a brief yet comprehensive evidence-based education leaflet to be used as an adjunct in the management of patellofemoral pain (PFP) through consultation with both experts (clinical academics) and individuals with PFP.

Background

Appropriate patient education is an essential component of effective PFP management. However, there are currently no published educational resources for clinicians and researchers treating individuals with PFP to help translate current evidence into clinical practice.

Methods

A preliminary education leaflet titled ‘Managing My Patellofemoral Pain’ was created using information from the ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’ and educational content used in published research. Feedback was sought from 21 experts (clinical academics) for accuracy, adequacy and clarity of the information in the leaflet using a semistructured questionnaire, and a number of suggested modifications were made as a result. Further feedback was sought from 20 patients diagnosed with PFP regarding the clarity and adequacy of information contained in the leaflet, and to determine additional educational resource needs.

Results

The leaflet created is titled ‘Managing My Patellofemoral Pain’ and the main topics of the leaflet are ‘What might cause my knee pain?’ and ‘Treatment options’, which are divided into exercise and additional treatments. Patient feedback was positive, and included a number of considerations for further education resource development.

Conclusions

The ‘Managing My Patellofemoral Pain’ education leaflet may provide a valuable resource for patients, clinicians and researchers to assist the provision of education and translation of the current evidence.

Criteria used when deciding on eligibility for total knee arthroplasty--Between thinking and doing

BACKGROUND

Clinical decision-making in total knee arthroplasty (TKA) is a complex process needing further clarification. The aim of this study was to compare TKA eligibility criteria considered most important by orthopedic surgeons (OSs) to characteristics of patients with knee osteoarthritis (OA) eventually found eligible for TKA.

METHODS

Nine OSs chose the five criteria most important when deciding on TKA eligibility. Cross-sectional data from 200 patients found either eligible (n=100) or not eligible (n=100) for TKA by one of the nine OS, were analyzed in a regression analyses with TKA eligibility as the dependent variable.

RESULTS

Radiographic severity (n=8), pain (n=9), functional disability (n=8) and not responding to the recommended non-surgical treatment (n=7) were considered most important by OSs. Associations (P<0.25) between TKA eligibility and criteria found important by the OS were demonstrated for worse radiographic severity and more functional limitations, but not for pain and not responding to the recommended non-surgical treatment. Furthermore, more comorbidities and higher Body Mass Index (BMI) were associated with TKA-eligibility, but not found important for TKA eligibility by the OS.

CONCLUSION

Radiographic severity and functional limitations were confirmed as drivers for TKA eligibility, while pain was not. Not responding to non-surgical treatment was not included in the decision-making, suggesting low uptake of clinical guidelines in clinical practice. This study highlights the complexity of the decision-making with some overlap between the criteria that OSs think they apply and what is actually applied in clinical practice.

The STAP-study: The (cost) effectiveness of custom made orthotic insoles in the treatment for plantar fasciopathy in general practice and sports medicine: design of a randomized controlled trial

BACKGROUND

Plantar fasciopathy is a common cause of foot pain, accounting for 11 to 15% of all foot symptoms requiring professional care in adults. Although many patients have complete resolution of symptoms within 12 months, many patients wish to reduce this period as much as possible. Orthotic devices are a frequently applied option of treatment in daily practice, despite a lack of evidence on the effectiveness. Therefore, the objective is to study the (cost)-effectiveness of custom made insoles by a podiatrist, compared to placebo insoles and usual care in patients with plantar fasciopathy in general practice and sports medicine clinics.

METHOD/DESIGN

This study is a multi-center three-armed participant and assessor-blinded randomized controlled trial with 6-months follow-up. Patients with plantar fasciopathy, with a minimum duration of complaints of 2 weeks and aged between 18 and 65, who visit their general practitioner or sport physician are eligible for inclusion. A total of 185 patients will be randomized into three parallel groups. One group will receive usual care by the general practitioner or sports physician alone, one group will be referred to a podiatrist and will receive a custom made insole, and one group will be referred to a podiatrist and will receive a placebo insole. The primary outcome will be the change from baseline to 12 weeks follow-up in pain severity at rest and during activity on a 0-10 numerical rating scale (NRS). Secondary outcomes include foot function (according to the Foot Function Index) at 6, 12 and 26 weeks, recovery (7-point Likert) at 6, 12 and 26 weeks, pain at rest and during activity (NRS) at 6 and 26 weeks and cost-effectiveness of the intervention at 26-weeks. Measurements will take place at baseline and at, 2, 4, 6, 12 and 26 weeks of follow-up.

DISCUSSION

The treatment of plantar fasciopathy is a challenge for health care professionals. Orthotic devices are frequently applied, despite a lack of evidence of the effectiveness on patient reported outcome. The results of this randomized controlled trial will improve the evidence base for treating this troublesome condition in daily practice.

TRIAL REGISTRATION

Dutch Trial Registration: NTR5346 . Date of registration: August 5(th) 2015.

A Randomized, Controlled Trial of Total Knee Replacement

BACKGROUND

More than 670,000 total knee replacements are performed annually in the United States; however, high-quality evidence to support the effectiveness of the procedure, as compared with nonsurgical interventions, is lacking.

METHODS

In this randomized, controlled trial, we enrolled 100 patients with moderate-to-severe knee osteoarthritis who were eligible for unilateral total knee replacement. Patients were randomly assigned to undergo total knee replacement followed by 12 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only the 12 weeks of nonsurgical treatment (nonsurgical-treatment group), which was delivered by physiotherapists and dietitians and consisted of exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4); scores range from 0 (worst) to 100 (best).

RESULTS

A total of 95 patients completed the 12-month follow-up assessment. In the nonsurgical-treatment group, 13 patients (26%) underwent total knee replacement before the 12-month follow-up; in the total-knee-replacement group, 1 patient (2%) received only nonsurgical treatment. In the intention-to-treat analysis, the total-knee-replacement group had greater improvement in the KOOS4 score than did the nonsurgical-treatment group (32.5 vs. 16.0; adjusted mean difference, 15.8 [95% confidence interval, 10.0 to 21.5]). The total-knee-replacement group had a higher number of serious adverse events than did the nonsurgical-treatment group (24 vs. 6, P=0.005).

CONCLUSIONS

In patients with knee osteoarthritis who were eligible for unilateral total knee replacement, treatment with total knee replacement followed by nonsurgical treatment resulted in greater pain relief and functional improvement after 12 months than did nonsurgical treatment alone. However, total knee replacement was associated with a higher number of serious adverse events than was nonsurgical treatment, and most patients who were assigned to receive nonsurgical treatment alone did not undergo total knee replacement before the 12-month follow-up. (Funded by the Obel Family Foundation and others; MEDIC ClinicalTrials.gov number, NCT01410409.).

Nonoperative treatment improves pain irrespective of radiographic severity. A cohort study of 1,414 patients with knee osteoarthritis

BACKGROUND AND PURPOSE

The discrepancy between symptoms and radiographic severity of knee osteoarthritis (OA) is well described. However, little is known about whether radiographic severity is predictive of the clinical result of nonoperative treatment. We investigated whether radiographic severity and treatment type were associated with improvements in pain after nonoperative treatment of patients with knee OA.

PATIENTS AND METHODS

A 5-year consecutive series of patients deemed not eligible for total knee arthroplasty (TKA) by an experienced orthopedic surgeon was contacted 1-5 years later. Radiographic severity, age, sex, and BMI were registered at the consultation. At follow-up, patients were asked to answer a questionnaire on type of treatment and improvements in pain after treatment.

RESULTS

Of 1,848 patients who were not eligible for TKA, 1,414 (77%) completed the follow-up questionnaire (mean age 66 (24-96) years; 55% women). Radiographic severity was not associated with improvements in pain even after adjusting for treatment type, age, sex, and BMI (p > 0.1). The odds ratio of improvement was higher by a factor of 2 in patients who received physiotherapy or multimodal treatment than in patients who did not.

INTERPRETATION

Radiographic severity was not associated with improvements in pain after nonoperative treatment. Patients who are not eligible for TKA can confidently be referred to nonoperative treatment even if they have severe radiographic OA. The treatment should preferably be multimodal, including physiotherapy, as recommended in Danish and international clinical guidelines.

The efficacy of 12 weeks non-surgical treatment for patients not eligible for total knee replacement: a randomized controlled trial with 1-year follow-up

OBJECTIVE

To compare the efficacy of a 12-week non-surgical treatment program with usual care in patients with knee osteoarthritis (OA) not eligible for total knee replacement (TKR).

METHOD

This two-arm parallel group assessor-blinded randomized controlled trial (RCT) included 100 adults from secondary care with knee OA, confirmed by radiography (Kellgren-Lawrence grade ≥1), but not eligible for a TKR. The 12-week non-surgical treatment program consisted of individualized progressed neuromuscular exercise, patient education, insoles, dietary advice and prescription of pain medication if indicated, while usual care comprised two leaflets with information and advice on knee OA and recommended treatments. The primary outcome was the change from baseline to 12 months in the Knee injury and Osteoarthritis Outcome Score (KOOS)4 defined as the average score for the KOOS subscales of pain, symptoms, activities of daily living (ADL), and quality of life (QOL).

RESULTS

91% of the patients completed the 12 months follow-up on the primary outcome. Compared with usual care, patients undergoing the treatment program improved more in KOOS4 (adjusted mean difference (95% CI) of 9.6 (4.4-14.8)) with no serious treatment-related adverse events (AE). The number needed to treat (NNT), defined as the number of patients needed to treat for one person to improve 15% was 7.2. Secondary outcomes supported the primary findings.

CONCLUSION

In patients with mostly moderate to severe knee OA not eligible for TKR, a 12-week individualized, non-surgical treatment program is more efficacious at 12 months compared with usual care and has few treatment-related AE.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01535001).

Dynamic navicular motion measured using a stretch sensor is different between walking and running, and between over-ground and treadmill conditions

Background

Non-invasive evaluation of in-shoe foot motion has traditionally been difficult. Recently a novel ‘stretch-sensor’ was proposed as an easy and reliable method to measure dynamic foot (navicular) motion. Further validation of this method is needed to determine how different gait analysis protocols affect dynamic navicular motion.

Methods

Potential differences in magnitude and peak velocity of navicular motion using the ‘stretch sensor’ between (i) barefoot and shod conditions; (ii) overground and treadmill gait; and/or (iii) running and walking were evaluated in 26 healthy participants. Comparisons were made using paired t-tests.

Results

Magnitude and velocity of navicular motion was not different between barefoot and shod walking on the treadmill. Compared to walking, velocity of navicular motion during running was 59% and 210% higher over-ground (p < 0.0001) and on a treadmill (p < 0.0001) respectively, and magnitude of navicular motion was 23% higher during over-ground running compared to over-ground walking (p = 0.02). Compared to over-ground, magnitude of navicular motion on a treadmill was 21% and 16% greater during walking (p = 0.0004) and running (p = 0003) respectively. Additionally, maximal velocity of navicular motion during treadmill walking was 48% less than walking over-ground (p < 0.0001).

Conclusion

The presence of footwear has minimal impact on navicular motion during walking. Differences in navicular motion between walking and running, and treadmill and over-ground gait highlight the importance of task specificity during gait analysis. Task specificity should be considered during design of future research trials and in clinical practice when measuring navicular motion.

Translation and validation of the Danish Foot Function Index (FFI-DK)

The objective of this study was to translate the Foot Function Index (FFI) for use in Danish-speaking patients with foot complaints. The FFI consists of 23 items scored on a numeric rating scale from 0 to 10. The 23 items are grouped into three subscales: pain (nine items), activity limitation (five items), and disability (nine items). The Danish FFI was developed according to the recommended forward/backward translation protocol. The data analysis included reliability [intraclass correlation coefficient (ICC) 2.1] and internal consistency (Cronbach's alpha). Excellent internal consistency was shown for the three subscales: pain (0.99), disability (0.98), and activity limitation (0.98), as for the total score (0.97). The test-retest reliability was excellent: pain subscale: ICC 0.98 [95% confidence interval (CI): 0.97-0.99]; activity limitation subscale: ICC: 0.95 (95% CI: 0.91-0.98); disability subscale: ICC 0.97 (95% CI: 0.95-0.98); total score: ICC: 0.95 (95% CI: 0.91 to 0.98). The mean difference between test and retest was below 1 point and P > 0.08. Bland-Altman plots showed no significant or clinically relevant differences from test to retest in any of the subscales or in the total score. The Danish version of the FFI was found to be valid and reliable and therefore acceptable for use in the Danish population.

Increased medial foot loading during drop jump in subjects with patellofemoral pain

PURPOSE

To compare medial-to-lateral plantar forces during drop jump and single leg squat in individuals with and without patellofemoral pain.

METHODS

This cross-sectional study compared 23 young adults with patellofemoral pain to 20 age- and sex-matched controls without knee pain. The plantar pressure distribution was collected during drop jump and single leg squat using pressure-sensitive Pedar insoles, inserted into a standard flat shoe. The primary outcome was the medial-to-lateral force, quantified as the peak force under the medial forefoot as the percentage of force under the total forefoot during drop jump. Secondary outcomes included peak medial-to-lateral force during single leg squat and mean forces during drop jump and single leg squat.

RESULTS

The primary outcome showed that individuals with patellofemoral pain had a 22% higher medial-to-lateral peak force during drop jump, (p=0.03). Secondary outcomes showed 32% higher medial-to-lateral peak force during single leg squat (p=0.01) and 19-23% higher medial-to-lateral mean force during drop jump and single leg squat (p=0.02-0.04).

CONCLUSION

These findings indicate that individuals with patellofemoral pain display a more medially oriented loading pattern of the forefoot compared to individuals without knee pain. This loading pattern may be associated with the distribution of forces acting on the patellofemoral joint and suggest treatment of PFP should consider interventions that target normalisation of foot loading.

LEVEL OF EVIDENCE

III.

Reliability and concurrent validity of a novel method allowing for in-shoe measurement of navicular drop

Background

Increased navicular drop is associated with increased risk of lower extremity overuse injuries and foot orthoses are often prescribed to reduce navicular drop. For laboratory studies, transparent shoes may be used to monitor the effect of orthoses but no clinically feasible methods exist. We have developed a stretch-sensor that allows for in-shoe measurement of navicular drop but the reliability and validity is unknown. The purpose of this study was to investigate: 1) the reliability of the stretch-sensor for measuring navicular drop, and 2) the concurrent validity of the stretch-sensor compared to the static navicular drop test.

Methods

Intra- and inter-rater reliability was tested on 27 participants walking on a treadmill on two separate days. The stretch-sensor was positioned 20 mm posterior to the tip of the medial malleolus and 20 mm posterior to the navicular tuberosity. The participants walked six minutes on the treadmill before navicular drop was measured. Reliability was quantified by the Intraclass Correlation Coefficient (ICC 2.1) and agreement was quantified by Limits of Agreement (LOA). To assess concurrent validity, static navicular drop was measured with the stretch-sensor and compared with static navicular drop measured with a ruler on 27 new participants. Linear regression was used to measure concurrent validity.

Results

The reliability of the stretch-sensor was acceptable for barefoot measurement (intra- and inter-rater ICC: 0.76-0.84) but lower for in-shoe measurement (ICC: 0.65). There was a significant association between static navicular drop measured with the stretch-sensor compared with a ruler (r = 0.745, p < 0.001).

Conclusion

This study suggests that the stretch-sensor has acceptable reliability for dynamic barefoot measurement of navicular drop. Furthermore, the stretch-sensor shows concurrent validity compared with the static navicular drop test as performed by Brody. This new simple method may hold promise for both clinical assessment and research but more work is needed before the method can be recommended.

High prevalence of daily and multi-site pain--a cross-sectional population-based study among 3000 Danish adolescents

Background

Daily pain and multi-site pain are both associated with reduction in work ability and health-related quality of life (HRQoL) among adults. However, no population-based studies have yet investigated the prevalence of daily and multi-site pain among adolescents and how these are associated with respondent characteristics. The purpose of this study was to investigate the prevalence of self-reported daily and multi-site pain among adolescents aged 12–19 years and associations of almost daily pain and multi-site pain with respondent characteristics (sex, age, body mass index, HRQoL and sports participation).

Methods

A population-based cross-sectional study was conducted among 4,007 adolescents aged 12–19 years in Denmark. Adolescents answered an online questionnaire during physical education lessons. The questionnaire contained a mannequin divided into 12 regions on which the respondents indicated their current pain sites and pain frequency (rarely, monthly, weekly, more than once per week, almost daily pain), characteristics, sports participation and HRQoL measured by the EuroQoL 5D. Multivariate regression was used to calculate the odds ratio for the association between almost daily pain, multi-site pain and respondent characteristics.

Results

The response rate was 73.7%. A total of 2,953 adolescents (62% females) answered the questionnaire. 33.3% reported multi-site pain (pain in >1 region) while 19.8% reported almost daily pain. 61% reported current pain in at least one region with knee and back pain being the most common sites. Female sex (OR: 1.35-1.44) and a high level of sports participation (OR: 1.51-2.09) were associated with increased odds of having almost daily pain and multi-site pain. Better EQ-5D score was associated with decreased odds of having almost daily pain or multi-site pain (OR: 0.92-0.94).

Conclusion

In this population-based cohort of school-attending Danish adolescents, nearly two out of three reported current pain and, on average, one out of three reported pain in more than one body region. Female sex, and high level of sports participation were associated with increased odds of having almost daily pain and multi-site pain. The study highlights an important health issue that calls for investigations to improve our understanding of adolescent pain and our capacity to prevent and treat this condition.