Publications by authors named "Adam G Culvenor"

58 Publications

Patellofemoral and tibiofemoral joint loading during a single-leg forward hop following ACL reconstruction.

J Orthop Res 2021 Apr 19. Epub 2021 Apr 19.

La Trobe Sports & Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia.

Altered biomechanics are frequently observed following anterior cruciate ligament reconstruction (ACLR). Yet, little is known about knee-joint loading, particularly in the patellofemoral-joint, despite patellofemoral-joint osteoarthritis commonly occurring post-ACLR. This study compared knee-joint reaction forces and impulses during the landing phase of a single-leg forward hop in the reconstructed knee of people 12-24 months post-ACLR and uninjured controls. Experimental marker data and ground forces for 66 participants with ACLR (28 ± 6 years, 78 ± 15 kg) and 33 uninjured controls (26 ± 5 years, 70 ± 12 kg) were input into scaled-generic musculoskeletal models to calculate joint angles, joint moments, muscle forces, and the knee-joint reaction forces and impulses. The ACLR group exhibited a lower peak knee flexion angle (mean difference: -6°; 95% confidence interval: [-10°, -2°]), internal knee extension moment (-3.63 [-5.29, -1.97] percentage of body weight × participant height (body weight [BW] × HT), external knee adduction moment (-1.36 [-2.16, -0.56]% BW × HT) and quadriceps force (-2.02 [-2.95, -1.09] BW). The ACLR group also exhibited a lower peak patellofemoral-joint compressive force (-2.24 [-3.31, -1.18] BW), net tibiofemoral-joint compressive force (-0.74 [-1.20, 0.28] BW), and medial compartment force (-0.76 [-1.08, -0.44] BW). Finally, only the impulse of the patellofemoral-joint compressive force was lower in the ACLR group (-0.13 [-0.23, -0.03] body weight-seconds). Lower compressive forces are evident in the patellofemoral- and tibiofemoral-joints of ACLR knees compared to uninjured controls during a single-leg forward hop-landing task. Our findings may have implications for understanding the contributing factors for incidence and progression of knee osteoarthritis after ACLR surgery.
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http://dx.doi.org/10.1002/jor.25053DOI Listing
April 2021

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.

J Orthop Sports Phys Ther 2021 05 28;51(5):216-231. Epub 2021 Mar 28.

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 (I≥90%, <.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 (<.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. .
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http://dx.doi.org/10.2519/jospt.2021.10054DOI Listing
May 2021

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

J Orthop Sports Phys Ther 2021 05 28;51(5):232-252. Epub 2021 Mar 28.

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 (I>90%, <.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%; = .015) and participation in physical activity per limb, and mean age of 40 years old or older ( = .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. .
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http://dx.doi.org/10.2519/jospt.2021.9970DOI Listing
May 2021

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

J Orthop Res 2021 Jan 17. Epub 2021 Jan 17.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia.

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 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 ± 7.29cm , Control 34.27 ± 7.56cm ) 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.
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http://dx.doi.org/10.1002/jor.24987DOI Listing
January 2021

Infographic. When is abnormal normal? Reframing MRI abnormalities as a normal part of ageing.

Br J Sports Med 2021 Jan 12. Epub 2021 Jan 12.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia.

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http://dx.doi.org/10.1136/bjsports-2020-103563DOI Listing
January 2021

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

BMC Musculoskelet Disord 2021 Jan 11;22(1):64. Epub 2021 Jan 11.

La Trobe Sport & Exercise Medicine Research Centre, School of Allied Health, Humans Services and Sport, La Trobe University, Bundoora, 3086, Australia.

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 ).
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http://dx.doi.org/10.1186/s12891-020-03919-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802328PMC
January 2021

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

Br J Sports Med 2020 Oct 28. Epub 2020 Oct 28.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, Australia.

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; I=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; I=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; I=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%.
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http://dx.doi.org/10.1136/bjsports-2020-102973DOI Listing
October 2020

Limb symmetry index on a functional test battery improves between one and five years after anterior cruciate ligament reconstruction, primarily due to worsening contralateral limb function.

Phys Ther Sport 2020 Jul 8;44:67-74. Epub 2020 May 8.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Australia. Electronic address:

Objective: Evaluate change in functional performance from 1- to 5-years after anterior cruciate ligament reconstruction (ACLR).

Methods: 59 participants (38 men) aged 29 ± 16 years completed three hops and one-leg rise 1- and 5-years following ACLR. Linear mixed-effects models evaluated differences in change between the ACLR and contralateral limbs. Participants were classified with stable, improving or worsening function relative to previously published minimal detectable change thresholds. Healthy controls completed the three hops (n = 41) and one-leg rise (n = 31) as reference data.

Results: The contralateral limb had a significantly greater decrease in functional performance between 1- and 5-years for the three hops, compared to the ACLR limb. Worsening was more common in the contralateral limb than the ACLR limb; resulting in significant improvements in the LSI for the single hop (mean 87% at 1-year to 95% at 5-years), side hop (77%to 86%) and one-leg rise (76% to85%). Performance of both ACLR and contralateral limbs and the LSI remained below the healthy controls.

Conclusion: Functional performance changes differ between limbs between 1- and 5-years post-ACLR. The LSI should not be used in isolation to evaluate functional performance changes after ACLR, as it may overestimate functional improvement, due to worsening contralateral limb function.
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http://dx.doi.org/10.1016/j.ptsp.2020.04.031DOI Listing
July 2020

Between-Limb Differences in Patellofemoral Joint Forces During Running at 12 to 24 Months After Unilateral Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2020 06 6;48(7):1711-1719. Epub 2020 May 6.

School of Allied Health, La Trobe University, Victoria, Australia.

Background: Patellofemoral joint (PFJ) osteoarthritis may occur after anterior cruciate ligament reconstruction (ACLR). The mechanisms underpinning the development of PFJ osteoarthritis are not known but may relate to altered PFJ loading. Few studies have assessed PFJ loads during high-impact tasks, such as running, beyond the acute rehabilitation phase (ie, >12 months) after ACLR.

Purpose/hypothesis: The purpose was to compare between-limb joint angles, joint moments, and PFJ contact force during running in individuals at 12 to 24 months after unilateral ACLR. We hypothesized that peak knee flexion angle, knee extension moment, and PFJ contact force during stance would be lower in the ACLR limb compared with the uninjured limb.

Study Design: Controlled laboratory study.

Methods: A total of 55 participants (mean ± SD age, 28 ± 7 years), 12 to 24 months after ACLR, ran at a self-selected speed (2.9 ± 0.3 m/s). Measured kinematics and ground-reaction forces were input into musculoskeletal models to calculate joint moments and muscle forces. These values were subsequently input into a PFJ model to calculate contact force peak and impulse. Outcome measures were compared between the ACLR and uninjured limbs.

Results: In the ACLR limb, compared with the uninjured limb, the PFJ contact force displayed a lower peak (ACLR, 6.1 ± 1.3 body weight [BW]; uninjured, 6.7 ± 1.4 BW; < .001) and impulse (ACLR, 0.72 ± 0.17 BW*seconds [BWs]; uninjured, 0.81 ± 0.17 BWs; < .001). At the time of the peak PFJ contact force, the knee extension moment was lower in the ACLR limb (ACLR, 14.0 ± 2.4 %BW*height [%BW*HT]; uninjured, 15.5 ± 2.5 %BW*HT; < .001). The opposite was true for the ankle plantarflexion moment (ACLR, 12.1 ± 2.6 %BW*HT; uninjured, 11.5 ± 2.7 %BW*HT; = .019) and the hip extension moment (ACLR, 2.3 ± 2.5 %BW*HT; uninjured, 1.6 ± 2.3 %BW*HT; = .013). The foot-ground center of pressure was located more anteriorly with respect to the ankle joint center (ACLR, 5.8 ± 0.9 %height [%HT]; uninjured, 5.4 ± 1.0 %HT; = .001). No differences were found for the sagittal plane hip, knee, and ankle angles.

Conclusion: The ACLR limb experienced lower peak PFJ loads during running, explained by a small anterior shift in the foot-ground center of pressure during stance that offloaded the torque demand away from the ACLR knee.

Clinical Relevance: Lower net PFJ loading during running in the ACLR limb more than 12 months after ACLR suggests that underloading might play a role in the onset of PFJ osteoarthritis after ACLR.
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http://dx.doi.org/10.1177/0363546520914628DOI Listing
June 2020

Making football safer for women: a systematic review and meta-analysis of injury prevention programmes in 11 773 female football (soccer) players.

Br J Sports Med 2020 Sep 6;54(18):1089-1098. Epub 2020 Apr 6.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia

Objective: To evaluate the effects of injury prevention programmes on injury incidence in any women's football code; explore relationships between training components and injury risk; and report injury incidence for women's football.

Design: Systematic review and meta-analysis.

Data Sources: Nine databases searched in August 2019.

Eligibility Criteria: Randomised controlled trials evaluating any injury prevention programme (eg, exercise, education, braces) were included. Study inclusion criteria were: ≥20 female football players in each study arm (any age, football code or participation level) and injury incidence reporting.

Results: Twelve studies, all in soccer, met inclusion criteria, with nine involving adolescent teams (aged <18 years). All studies (except one) had a high risk of bias. Eleven studies examined exercise-based programmes, with most (9/11) including multiple (≥2) training components (eg, strength, plyometric, balance exercises). Multicomponent exercise programmes reduced overall (any reported) injuries (incidence rate ratio (IRR) 0.73, 95% CI 0.59 to 0.91) and ACL injuries (IRR 0.55, 95% CI 0.32 to 0.92). For exercise-based strategies (single-component and multicomponent), hamstring injuries were also reduced (IRR 0.40, 95% CI 0.17 to 0.95). While exercise-based strategies resulted in less knee, ankle and hip/groin injuries, and the use of multiple training components was associated with greater reductions in overall and knee injuries, further studies would be required to increase the precision of these results. The incidence of overall injuries in women's football was 3.4 per 1000 exposure hours; with ankle injuries most common.

Conclusion: In women's football, there is low-level evidence that multicomponent, exercise-based programmes reduce overall and ACL injuries by 27% and 45%, respectively.

Prospero Registration Number: CRD42018093527.
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http://dx.doi.org/10.1136/bjsports-2019-101587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497572PMC
September 2020

Impact of Diabetes Mellitus on Knee Osteoarthritis Pain and Physical and Mental Status: Data From the Osteoarthritis Initiative.

Arthritis Care Res (Hoboken) 2021 04 17;73(4):540-548. Epub 2021 Mar 17.

Chondrometrics GmbH, Ainring, Germany, and Paracelsus Medical University, Salzburg, Austria.

Objective: Diabetes mellitus (DM) appears to increase osteoarthritic knee pain, which may be related to greater adiposity and more advanced disease status often observed in individuals with osteoarthritis (OA) and DM. We aimed to assess whether OA knee pain and health status are worse in individuals with OA and DM, independent of these potential confounders.

Methods: We included 202 OA participants with DM and 2,279 without DM from the Osteoarthritis Initiative. Knee pain was evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and a numeric rating scale (NRS). Physical and mental status were assessed by the Medical Outcomes Study Short Form 12 (SF-12) questionnaire, physical component summary (PCS) score and mental component summary (MCS) score, and by the Center for Epidemiologic Studies Depression Scale (CES-D). Linear regression models assessed the influence of DM, adjusted for age, sex, body mass index (BMI), and radiographic severity.

Results: OA participants with DM reported worse knee pain and greater physical and mental issues compared with participants without DM. Individuals with DM had worse KOOS pain (β = -4.72 [95% confidence interval (95% CI) -7.22, -2.23]) and worse NRS pain (β = 0.42 [95% CI 0.04, 0.80]) independent of BMI, OA severity, age, and sex. The negative influence of DM was also apparent for SF-12 PCS (β = -3.49 [95% CI -4.73, -2.25]), SF-12 MCS (β = -1.42 [95% CI -2.57, -0.26]), and CES-D (β = 1.08 [95% CI 0.08, 2.08]).

Conclusion: Individuals with knee OA experience on average higher pain intensity and a worse physical and mental health status if they have DM. Linear regression models show that DM is a risk factor for higher pain, in addition to and independent of greater BMI and radiographic OA severity.
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http://dx.doi.org/10.1002/acr.24173DOI Listing
April 2021

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

Clin Biomech (Bristol, Avon) 2020 10 23;79:104935. Epub 2019 Dec 23.

Institute of Anatomy, Paracelsus Medical University Salzburg & Nuremburg, Salzburg, Austria. Electronic address:

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.
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http://dx.doi.org/10.1016/j.clinbiomech.2019.12.017DOI Listing
October 2020

Worse knee confidence, fear of movement, psychological readiness to return-to-sport and pain are associated with worse function after ACL reconstruction.

Phys Ther Sport 2020 Jan 22;41:1-8. Epub 2019 Oct 22.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Victoria, Australia. Electronic address:

Objectives: To determine whether knee confidence, fear of movement, psychological readiness to return-to-sport or pain are associated with patient-reported and performance-based function and return to pivoting sport in individuals one-year after anterior cruciate ligament reconstruction (ACLR).

Design: Cross-sectional study.

Setting: University-laboratory.

Participants: 118 individuals one-year post-ACLR.

Main Outcome Measures: The KOOS-sport/recreation and IKDC and three hopping tasks were used to assess patient-reported and performance-based function, respectively. Questions regarding return to pivoting sport assessed return-to-sport status. Fear of movement (Tampa Scale), knee confidence (an item from KOOS, Visual Analogue Scale-VAS confidence during hopping tasks), knee pain (KOOS-pain, VAS pain during hopping tasks) and psychological readiness to return-to-sport (ACL-RSI) were also assessed.

Results: Worse fear of movement (p = 0.019), KOOS-pain (p < 0.001), ACL-RSI (p < 0.001), task-specific knee confidence and pain were associated with poorer patient-reported function. Worse task-specific knee confidence (p < 0.001) and pain (p < 0006) and ACL-RSI (p < 0.016) were associated with poorer performance-based function. Higher ACL-RSI scores were associated with higher odds of returning to pivoting sport one-year post-ACLR (p < 0.001).

Conclusion: Individual's fear of movement, knee confidence, psychological readiness to return-to-sport and pain are related to function. Evaluating and considering knee confidence, fear of movement, and psychological readiness should be an important part of comprehensive post-ACLR rehabilitation.
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http://dx.doi.org/10.1016/j.ptsp.2019.10.006DOI Listing
January 2020

Rethinking patellofemoral pain: Prevention, management and long-term consequences.

Best Pract Res Clin Rheumatol 2019 02 22;33(1):48-65. Epub 2019 Feb 22.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia; Institute of Anatomy, Paracelsus Medical University Salzburg and Nuremberg, Salzburg, Austria. Electronic address:

Patellofemoral pain is one of the most common knee complaints, particularly among physically active young individuals. Although once thought to be self-limiting, prospective studies have demonstrated the propensity towards the chronicity of patellofemoral pain (PFP). The pathogenesis of PFP is complex, with multiple interactive pathways suggested to contribute to its onset and persistence. Quadriceps weakness is one of the few risk factors of PFP, with at least moderate evidence from prospective studies, although limited clinical trials of lower limb strengthening have generally not been successful in preventing PFP. The challenge of managing PFP is reflected by a lack of evidence-based clinical guidelines. International consensus and current evidence recommends exercise therapy, focussed on hip and knee strengthening, as a cornerstone of management to reduce PFP. Rethinking management approaches beyond exercise therapy to incorporate movement retraining, education and psychosocial aspects provides potential avenues to enhance outcomes for patients with PFP.
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http://dx.doi.org/10.1016/j.berh.2019.02.004DOI Listing
February 2019

Reduction in Thigh Muscle Strength Occurs Concurrently but Does Not Seem to Precede Incident Knee Pain in Women: Data From the Osteoarthritis Initiative Cohort.

Am J Phys Med Rehabil 2020 01;99(1):33-40

From the Institute of Anatomy, Department of Imaging and Functional Musculoskeletal Research, Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria (AR, WW, AGC, FE); Department of Orthopedic Surgery and Traumatology, Landesklinik Tamsweg, Tamsweg, Austria (AR); and La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, School of Allied Health, Bundoora, Melbourne, Victoria, Australia (AGC).

Objective: The aim of the study was to investigate whether muscle strength declines before or concurrent with incident knee pain in subjects with and without radiographic knee osteoarthritis.

Design: Osteoarthritis initiative participants with incident knee pain (occurrence of infrequent/frequent knee pain during the past 12 mos at two consecutive follow-up time points (either years Y3 + Y4 or Y4 + Y5) were compared with controls (no incident knee pain) with 2-yr changes in knee extensor strength during BL➔Y2 (before) and Y2➔Y4 (concurrent).

Results: Two hundred two knees (49% women, 40% radiographic knee osteoarthritis) displayed incident pain, and 439 did not (46% women, 23% radiographic knee osteoarthritis). Women with radiographic knee osteoarthritis displayed a significantly greater (P = 0.04) reduction in knee extensor strength concurrent with incident pain compared with controls (mean = -17.6 N vs. +4.5 N), but men did not. A similar trend was observed in women without radiographic knee osteoarthritis, but this was not statistically significant (P = 0.08). There was no significant relationship with change in extensor strength before incident pain (P ≥ 0.43).

Conclusions: These results suggest that in women, incident knee pain is accompanied by a concurrent reduction in knee extensor strength, whereas loss in strength does not precede incident knee pain. The findings encourage interventional studies that attempt to attenuate a decline in extensor strength once knee symptoms occur.
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http://dx.doi.org/10.1097/PHM.0000000000001271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6920538PMC
January 2020

Does patellar alignment or trochlear morphology predict worsening of patellofemoral disease within the first 5 years after anterior cruciate ligament reconstruction?

Eur J Radiol 2019 Apr 31;113:32-38. Epub 2019 Jan 31.

La Trobe Sport & Exercise Medicine Research Centre, La Trobe University, Bundoora, Australia; Institute of Anatomy, Paracelsus Medical University Salzburg & Nuremburg, Salzburg, Austria. Electronic address:

Purpose: We described patellofemoral alignment and trochlear morphology at one and five years after anterior cruciate ligament reconstruction (ACLR), and evaluated the associations between alignment and trochlear morphology (at one year) and worsening patellofemoral osteoarthritis (OA) features by five years. We also evaluated the associations between alignment and morphology to self-reported pain and function (Knee injury and Osteoarthritis Outcome Score, KOOS) at five years.

Materials And Methods: In this longitudinal observational study, we followed 73 participants (mean age 29[9] years, 40% women) from one- to five-years after ACLR. Using MRI, we measured alignment and morphology, and scored cartilage and bone marrow lesions at both time points. We used mixed effects and linear regression models to achieve our stated aims.

Results: Greater lateral patella displacement increased risk of cartilage worsening (Odds Ratio [95% CI]: 1.09 [1.01, 1.16]); while less lateral tilt (0.91 [0.83, 0.99]) and greater trochlear angle (0.88 [0.77, 1.00]) were protective. Greater medial trochlear inclination increased risk of bone marrow lesion worsening (1.12 [1.04, 1.19]); while greater trochlear angle was protective (0.80 [0.67, 0.96]). Greater lateral displacement was associated with worse self-reported KOOS sport and recreation scores (β [95% CI]: -11.0 [-20.9, -1.2]) and quality of life scores (-10.5 [-20.4, -0.7]).

Conclusions: Lateral displacement, lateral tilt, and morphology at 1 year post-ACLR altered the risk of worsening patellofemoral OA features four years later. Lateral displacement was the only measure associated with worse self-reported symptoms at five years. These findings may lead to novel treatment strategies for secondary prevention after ACLR.
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http://dx.doi.org/10.1016/j.ejrad.2019.01.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6473803PMC
April 2019

Patient-Reported Outcomes One to Five Years After Anterior Cruciate Ligament Reconstruction: The Effect of Combined Injury and Associations With Osteoarthritis Features Defined on Magnetic Resonance Imaging.

Arthritis Care Res (Hoboken) 2020 03;72(3):412-422

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.

Objective: Persistent symptoms and poor quality of life (QoL) are common following anterior cruciate ligament reconstruction (ACLR). We aimed to determine the influence of a combined ACL injury (i.e., concomitant meniscectomy and/or arthroscopic chondral defect at the time of ACLR and/or secondary injury/surgery to ACLR knee) and cartilage defects defined on magnetic resonance imaging (MRI), bone marrow lesions (BMLs), and meniscal lesions on patient-reported outcomes 1 to 5 years after ACLR.

Methods: A total of 80 participants (50 men; mean ± SD age 32 ± 14 years) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) questionnaires as well as a 3T MRI assessment at 1 and 5 years after ACLR. Median patient-reported outcome scores were compared between isolated and combined ACL injuries and with published normative values. Using multivariate regression, we evaluated the association between compartment-specific MRI cartilage, BMLs, and meniscal lesions and patient-reported outcomes at 1 and 5 years.

Results: Individuals with a combined injury had significantly worse scores in the KOOS subscale of function in sport and recreation (KOOS sport/rec) and in the IKDC questionnaire at 1 year, and worse scores in the KOOS subscales of pain (KOOS pain), symptoms (KOOS symptoms), and QoL (KOOS QoL) and in the IKDC questionnaire at 5 years compared to those with an isolated injury. Although no feature on MRI was associated with patient-reported outcomes cross-sectionally at 1 year, patellofemoral cartilage defects at 1 year were significantly associated with worse 5-year KOOS symptoms (β = -9.79, 95% confidence interval [95% CI] -16.67, -2.91), KOOS sport/rec (β = -7.94, 95% CI -15.27, -0.61), KOOS QoL (β = -8.29, 95% CI -15.28, -1.29), and IKDC (β = -4.79, 95% CI -9.34, -0.24) scores. Patellofemoral cartilage defects at 5 years were also significantly associated with worse 5-year KOOS symptoms (β = -6.86, 95% CI -13.49, -0.24) and KOOS QoL (β = -11.71, 95% CI -19.08, -4.33) scores.

Conclusion: Combined injury and patellofemoral cartilage defects shown on MRI are associated with poorer long-term outcomes. Clinicians should be vigilant and aware of individuals with these injuries, as such individuals may benefit from targeted interventions to improve QoL and optimize symptoms.
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http://dx.doi.org/10.1002/acr.23854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693993PMC
March 2020

Loss of patellofemoral cartilage thickness over 5 years following ACL injury depends on the initial treatment strategy: results from the KANON trial.

Br J Sports Med 2019 Sep 8;53(18):1168-1173. Epub 2019 Feb 8.

Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lunds Universitet, Lund, Sweden.

Objectives: To evaluate changes in patellofemoral cartilage thickness over 5 years after anterior cruciate ligament (ACL) injury and to determine the impact of treatment strategy.

Methods: 121 adults (ages 18-35 years, 26% women) had an ACL injury and participated in the KANON randomised controlled trial. Of those, 117 had available MRIs at baseline (<4 weeks post-ACL rupture) and at least one follow-up measurement (2, 5 years). Patellofemoral cartilage thickness was analysed by manual segmentation (blinded to acquisition order). Patellar, trochlear and total patellofemoral cartilage thickness changes were compared between as-randomised (rehabilitation+early ACL reconstruction (ACLR) (n=59) vs rehabilitation+optional delayed ACLR (n=58)) and as-treated groups (rehabilitation+early ACLR (n=59) vs rehabilitation +delayed ACLR (n=29) vs rehabilitation alone (n=29)).

Results: Patellofemoral cartilage thickness decreased -58 µm (95% CI -104 to -11 µm) over 5 years post-ACL rupture, with the greatest loss observed in trochlea during the first 2 years. Participants randomised to rehabilitation+early ACLR had significantly greater loss of patellar cartilage thickness compared with participants randomised to rehabilitation+optional delayed ACLR over the first 2 years (-25 µm (-52, 1 µm) vs +14 µm (-6 to 34 µm), p=0.02) as well as over 5 years (-36 µm (-78 to 5 µm) vs +18 µm (-7, 42 µm), p=0.02). There were no statistically significant differences in patellofemoral cartilage thickness changes between as-treated groups.

Conclusion: Patellofemoral (particularly trochlear) cartilage thickness loss was observed in young adults following acute ACL rupture. Early ACLR was associated with greater patellofemoral (particularly patellar) cartilage thickness loss over 5 years compared with optional delayed ACLR, indicating that early surgical intervention may be associated with greater short-term structural patellofemoral cartilage deterioration compared with optional delayed surgery.

Trial Registration Number: ISRCTN84752559; Post-results.
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http://dx.doi.org/10.1136/bjsports-2018-100167DOI Listing
September 2019

Moderate Physical Activity and Prevention of Cartilage Loss in People With Knee Osteoarthritis: Data From the Osteoarthritis Initiative.

Arthritis Care Res (Hoboken) 2019 02;71(2):218-226

Paracelsus Medical University Salzburg and Nuremberg, Salzburg, Austria, and La Trobe University, Bundoora, Australia.

Objective: To examine the impact of physical activity on cartilage thickness loss in knee osteoarthritis (OA).

Methods: A total of 689 participants with radiographic knee OA at baseline (Kellgren/Lawrence grade ≥2) from the Osteoarthritis Initiative completed the Physical Activity Scale for the Elderly (PASE) questionnaires at annual intervals over 4 years. Magnetic resonance imaging-based cartilage thickness change in the medial femorotibial compartment (MFTC) over 4 years was the main outcome. The impact of PASE tertiles (low, moderate, or high) on changes in MFTC cartilage thickness was estimated using a mixed-effects model adjusted for baseline characteristics. Furthermore, stratification by sex was performed for secondary analyses.

Results: Structural progression of MFTC cartilage loss of -0.20 mm (95% confidence interval [95% CI] -0.22, -0.17) was observed in the entire cohort, with no significant difference between physical activity levels after adjustment for baseline characteristics. An interaction between sex and physical activity was observed in the adjusted analysis (P = 0.02). Stratification by sex showed that women with low physical activity had a statistically greater cartilage loss than women with moderate physical activity (adjusted between-group difference -0.09 mm [95% CI -0.16, 0.02]), whereas no significant differences were observed in men.

Conclusion: While physical activity was not associated with cartilage thickness loss in the whole cohort, this relationship significantly differed between sexes. In women, but not in men, moderate physical activity may slow down structural disease progression compared to low physical activity levels. For both men and women, high physical activity levels do not appear to be more detrimental than lower physical activity levels for cartilage thickness loss.
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http://dx.doi.org/10.1002/acr.23791DOI Listing
February 2019

Sex-Specific Influence of Quadriceps Weakness on Worsening Patellofemoral and Tibiofemoral Cartilage Damage: A Prospective Cohort Study.

Arthritis Care Res (Hoboken) 2019 10 5;71(10):1360-1365. Epub 2019 Sep 5.

Boston University School of Medicine, Boston, Massachusetts, and University of Delaware, Newark.

Objective: Reports on quadriceps weakness as a risk factor for incident and progressive knee osteoarthritis are conflicting, potentially due to differing effects of muscle strength on patellofemoral and tibiofemoral compartments. This study aimed to examine the sex-specific relation of quadriceps strength to worsening patellofemoral and tibiofemoral cartilage damage over 84 months.

Methods: The Multicenter Osteoarthritis Study is a cohort study of individuals with or at risk for knee osteoarthritis. Maximal quadriceps strength was assessed at baseline. Cartilage damage was semiquantitatively assessed by magnetic resonance imaging at baseline and 84-month follow-up using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Worsening patellofemoral and tibiofemoral cartilage damage was defined as any WORMS score increase in each subregion within medial and lateral compartments separately. Logistic regression with generalized estimating equations was used to assess the sex-specific relation of quadriceps strength to worsening cartilage damage.

Results: A total of 1,018 participants (mean ± SD age 61 ± 8 years, and mean ± SD body mass index 29.3 ± 4.5 kg/m ; 64% female) were included. Quadriceps weakness increased the risk of worsening lateral patellofemoral cartilage damage in women (risk ratio for lowest versus highest quartile of strength 1.50 [95% confidence interval 1.03-2.20]; P = 0.007 for linear trend) but not in men. There was generally no association between quadriceps weakness and worsening cartilage damage in the medial or lateral tibiofemoral compartment for either women or men.

Conclusion: Low quadriceps strength increased the risk of worsening cartilage damage in the lateral patellofemoral joint of women, suggesting that optimizing quadriceps strength may help prevent worsening of structural damage in the patellofemoral joint in women.
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http://dx.doi.org/10.1002/acr.23773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453735PMC
October 2019

Greater knee flexion excursion/moment in hopping is associated with better knee function following anterior cruciate ligament reconstruction.

Knee Surg Sports Traumatol Arthrosc 2019 Feb 6;27(2):596-603. Epub 2018 Oct 6.

Melbourne School of Physiotherapy, The University of Melbourne, Melbourne, Australia.

Purpose: Individuals with impaired knee function after anterior cruciate ligament reconstruction (ACLR) may be at greater risk of developing knee osteoarthritis related to abnormal knee joint movement and loading. The aim of this study was to assess the association between knee biomechanics and knee laxity during hopping and clinically assessed knee function (i.e., patient-reported knee function and hop tests) following ACLR.

Methods: Sixty-six participants (23 women, mean age 28 ± 6 years, mean 18 ± 3 months following ACLR) completed a standardized single-leg hopping task. Three-dimensional movement analysis was used to assess knee flexion excursion and body weight/height normalized knee flexion moments during landing for the involved limb. Anterior-posterior knee laxity was assessed with a KT-1000 knee arthrometer. Participants then completed a patient-reported knee function questionnaire and three separate hop tests (% of uninvolved limb) and were divided into poor and satisfactory knee function groups (satisfactory: ≥85% patient-reported knee function and ≥ 85% hop test symmetry). Associations between knee function and hop biomechanics/knee laxity were assessed using logistic regression and interquartile range scaled odds ratios (OR).

Results: Greater knee flexion excursion (OR 2.9, 95%CI 1.1-7.8), greater knee flexion moment (OR 4.9, 95%CI 1.6-14.3) and lesser knee laxity (OR 4.7, 95%CI 1.5-14.9) were significantly associated with greater odds of having satisfactory knee function (≥ 85% patient-reported knee function and ≥ 85% hop test symmetry).

Conclusion: Greater knee flexion excursion/moment during hop-landing and lesser knee laxity is associated with better patient-reported knee function and single-leg hop test performance following ACLR. Patients with lower levels of knee function following ACLR demonstrated hop-landing biomechanics previously associated with early patellofemoral osteoarthritis. Therefore, interventions aimed at improving hop landing biomechanics in people with poor knee function are likely required.

Level Of Evidence: III, Cross-sectional study.
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http://dx.doi.org/10.1007/s00167-018-5197-7DOI Listing
February 2019

Worsening Knee Osteoarthritis Features on Magnetic Resonance Imaging 1 to 5 Years After Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2018 10 4;46(12):2873-2883. Epub 2018 Sep 4.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia.

Background: An anterior cruciate ligament (ACL) injury is a well-established risk factor for the long-term development of radiographic osteoarthritis (OA). However, little is known about the early degenerative changes (ie, <5 years after injury) of individual joint features (ie, cartilage, bone marrow), which may be reversible and responsive to interventions.

Purpose: To describe early degenerative changes between 1 and 5 years after ACL reconstruction (ACLR) on magnetic resonance imaging (MRI) and explore participant characteristics associated with these changes.

Study Design: Case-control study; Level of evidence, 3.

Methods: Seventy-eight participants (48 men; median age, 32 years; median body mass index [BMI], 26 kg/m) underwent 3.0-T MRI at 1 and 5 years after primary hamstring autograft ACLR. Early tibiofemoral and patellofemoral OA features were assessed with the MRI Osteoarthritis Knee Score. The primary outcome was worsening (ie, incident or progressive) cartilage defects, bone marrow lesions (BMLs), osteophytes, and meniscal lesions. Logistic regression with generalized estimating equations evaluated participant characteristics associated with worsening features.

Results: Worsening of cartilage defects in any compartment occurred in 40 (51%) participants. Specifically, worsening in the patellofemoral and medial and lateral tibiofemoral compartments was present in 34 (44%), 8 (10%), and 10 (13%) participants, respectively. Worsening patellofemoral and medial and lateral tibiofemoral BMLs (14 [18%], 5 [6%], and 10 [13%], respectively) and osteophytes (7 [9%], 8 [10%], and 6 [8%], respectively) were less prevalent, while 17 (22%) displayed deteriorating meniscal lesions. Worsening of at least 1 MRI-detected OA feature, in either the patellofemoral or tibiofemoral compartment, occurred in 53 (68%) participants. Radiographic OA in any compartment was evident in 5 (6%) and 16 (21%) participants at 1 and 5 years, respectively. A high BMI (>25 kg/m) was consistently associated with elevated odds (between 2- and 5-fold) of worsening patellofemoral and tibiofemoral OA features.

Conclusion: High rates of degenerative changes occur in the first 5 years after ACLR, particularly the development and progression of patellofemoral cartilage defects. Older patients with a higher BMI may be at particular risk and should be educated about this risk.
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http://dx.doi.org/10.1177/0363546518789685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379915PMC
October 2018

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

Br J Sports Med 2019 Oct 9;53(20):1268-1278. Epub 2018 Jun 9.

La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia.

Background: Knee MRI is increasingly used to inform clinical management. Features associated with osteoarthritis are often present in asymptomatic uninjured knees; however, the estimated prevalence varies substantially between studies. We performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees.

Methods: We searched six electronic databases for studies reporting MRI osteoarthritis feature prevalence (ie, cartilage defects, meniscal tears, bone marrow lesions and osteophytes) in asymptomatic uninjured knees. Summary estimates were calculated using random-effects meta-analysis (and stratified by mean age: <40 vs ≥40 years). Meta-regression explored heterogeneity.

Results: We included 63 studies (5397 knees of 4751 adults). The overall pooled prevalence of cartilage defects was 24% (95% CI 15% to 34%) and meniscal tears was 10% (7% to 13%), with significantly higher prevalence with age: cartilage defect <40 years 11% (6%to 17%) and ≥40 years 43% (29% to 57%); meniscal tear <40 years 4% (2% to 7%) and ≥40 years 19% (13% to 26%). The overall pooled estimate of bone marrow lesions and osteophytes was 18% (12% to 24%) and 25% (14% to 38%), respectively, with prevalence of osteophytes (but not bone marrow lesions) increasing with age. Significant associations were found between prevalence estimates and MRI sequences used, physical activity, radiographic osteoarthritis and risk of bias.

Conclusions: Summary estimates of MRI osteoarthritis feature prevalence among asymptomatic uninjured knees were 4%-14% in adults aged <40 years to 19%-43% in adults ≥40 years. These imaging findings should be interpreted in the context of clinical presentations and considered in clinical decision-making.
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http://dx.doi.org/10.1136/bjsports-2018-099257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837253PMC
October 2019

Knee extensor muscle weakness and radiographic knee osteoarthritis progression.

Acta Orthop 2018 08 1;89(4):406-411. Epub 2018 May 1.

b Institute of Anatomy , Paracelsus Medical University Salzburg and Nuremburg , Salzburg , Austria.

Background and purpose - Knee extensor (KE) muscle weakness is a modifiable feature commonly observed in individuals with knee osteoarthritis (KOA) and constitutes a potential target for patient-specific interventions. Therefore, in this study, we explored whether KE weakness is associated with radiographic (medial and/or lateral) KOA progression and how this relationship differs depending on frontal plane knee alignment and sex. Patients and methods - We studied 3,075 knees (1,961 participants, 58% female) from the Osteoarthritis Initiative with radiographic Kellgren-Lawrence grade 1-3. Peak KE torque (Nm/kg) was assessed at baseline, and progression defined as fixed-location joint space width loss (≥ 0.7mm) in medial and lateral tibiofemoral compartments from baseline to 4-year follow-up. Knee-based generalized estimating equations, stratified by alignment (malaligned vs. neutral), estimated the relative risk (RR) of progression for those in the lowest (and middle) vs. highest KE torque group (split by tertiles). Secondary analyses explored whether this relationship was compartmental- or sex-specific. Results - Being in the lowest (or middle) compared with the highest torque group increased the risk of progression in neutrally aligned knees (relative risk [RR] 1.2 [95% CI 1.0-1.4]; and 1.2 [CI 1.0-1.4], respectively), but not after adjusting for age, sex, BMI, pain, and radiographic severity. In secondary analyses, women with neutral alignment in the lowest compared with the highest torque group had significantly increased risk of lateral compartment progression independent of age, BMI, disease severity, and pain (RR 1.3 [CI 1.0-1.8]). No association was observed between KE torque and KOA progression in men, irrespective of alignment. Interpretation - These results identify a potentially important clinical phenotype: KE weakness may be a more important risk factor for radiographic KOA progression in women without knee malalignment.
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http://dx.doi.org/10.1080/17453674.2018.1464314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066769PMC
August 2018

ACL injuries: the secret probably lies in optimising rehabilitation.

Br J Sports Med 2018 Nov 16;52(22):1416-1418. Epub 2018 Mar 16.

La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1136/bjsports-2017-098872DOI Listing
November 2018

Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running.

Knee Surg Sports Traumatol Arthrosc 2018 Feb 28;26(2):391-398. Epub 2017 Nov 28.

Melbourne School of Physiotherapy, The University of Melbourne, Melbourne, Australia.

Purpose: Poor knee function after anterior cruciate ligament reconstruction (ACLR) may increase the risk of future knee symptoms and knee osteoarthritis via abnormal knee joint loading patterns, particularly during high-impact activity. This study aimed to assess the relationship between poor self-reported or clinically measured knee function and knee moments/vertical ground reaction force (vGRF) in individuals following ACLR.

Methods: 61 participants (mean 16.5 ± 3 months following ACLR, 23 women) completed a patient-reported knee function questionnaire and three hop tests (% of uninvolved limb). Participants were divided into satisfactory and poor knee function groups (poor < 85% patient-reported knee function and/or < 85% hop test symmetry). The knee biomechanics of both groups were assessed with three-dimensional motion analysis during the stance phase of overland running at self-selected speeds, and the association between knee function and knee moments was assessed using analysis of covariance with running speed as a covariate.

Results: Participants with poor knee function (n = 30) ran with significantly smaller peak knee flexion moments (moderate effect size 0.7, p = 0.03) and significantly smaller peak vGRFs (large effect size 1.0, p = 0.002) compared to those with satisfactory knee function (n = 31). No significant differences were observed for knee adduction and knee external rotation moments or knee kinematics.

Conclusion: Individuals following ACLR with poor self-reported knee function and/or hop test performance demonstrate knee moments during running that may be associated with lower knee joint contact forces. These findings provide greater understanding of the relationship between knee biomechanics during running and clinical assessments of knee function.

Level Of Evidence: III. Cross-sectional study.
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http://dx.doi.org/10.1007/s00167-017-4810-5DOI Listing
February 2018

University College Dublin: Integrating sports and exercise related sciences with physiotherapy in a Masters of Sports Physiotherapy (continuing professional development series).

Authors:
Adam G Culvenor

Br J Sports Med 2019 May 3;53(10):599-600. Epub 2017 Nov 3.

Institute of Anatomy, Paracelsus Medical University Salzburg and Nuremburg, Salzburg, Austria.

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http://dx.doi.org/10.1136/bjsports-2017-098678DOI Listing
May 2019

University of Birmingham: an innovative Masters of Exercise and Sports Medicine in partnership with the Football Association (Continuing Professional Development series).

Authors:
Adam G Culvenor

Br J Sports Med 2019 Aug 19;53(15):981-982. Epub 2017 Oct 19.

Institute of Anatomy Salzburg and Nuremberg, Paracelsus Medical University of Salzburg, Salzburg, Austria.

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http://dx.doi.org/10.1136/bjsports-2017-098432DOI Listing
August 2019

Do sports medicine clinicians have credible alternatives to knee arthroscopy for the degenerative knee?

Br J Sports Med 2018 Jul 19;52(14):884-885. Epub 2017 Oct 19.

Latrobe Sports Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.

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http://dx.doi.org/10.1136/bjsports-2017-098166DOI Listing
July 2018

Brief Report: Loss of Muscle Strength Prior to Knee Replacement: A Question of Anatomic Cross-Sectional Area or Specific Strength?

Arthritis Rheumatol 2018 02 20;70(2):222-229. Epub 2017 Dec 20.

Paracelsus Medical University, Salzburg, Austria, and Chondrometrics, Ainring, Germany.

Objective: To determine whether loss in thigh muscle strength prior to knee replacement is caused by reductions of muscle strength in the anatomic cross-sectional area or by reductions of specific strength.

Methods: All 100 of the participants in the Osteoarthritis Initiative who underwent knee replacement and whose medical records included data on thigh isometric muscle strength and magnetic resonance imaging (MRI) (58 women, and 42 men, mean ± SD age 65 ± 8 years, mean ± SD body mass index [BMI] 29 ± 5 kg/m ) were matched with a control (no knee replacement) for age, sex, height, BMI, and radiographic severity. Thigh muscle anatomic cross-sectional area was determined by MRI at the research visit before knee replacement (time 0) and 2 years before time 0 (time -2). Specific strength (strength/anatomic cross-sectional area) was calculated, and the measures were compared by conditional logistic regression (i.e., odds ratio [OR] per standard deviation). ORs adjusted for pain (OR ) and 95% confidence intervals (95% CIs) were also calculated.

Results: Knee replacement cases had significantly smaller extensor (but not flexor) anatomic cross-sectional areas than controls at time 0 (women, OR 1.89 [95% CI 1.05-3.90]; men, OR 2.22 [95% CI 1.04-4.76]), whereas no significant differences were found at time -2. Women who had knee replacement showed lower levels of extensor specific strength than controls at time 0 (OR 1.59 [95% CI 1.02-2.50]), although this difference was not observed in men and did not maintain significance after adjustment for pain (OR 1.22 [95% CI 0.71-2.08]). Female cases lost significantly more extensor specific strength between time -2 and time 0 than controls (OR 3.76 [95% CI 1.04-13.60]), whereas no significant differences were noted at time -2, or in men.

Conclusion: Prior to knee replacement, a significant reduction in knee extensor strength appears to occur in women through 2 mechanisms: one driven by pain (loss of specific strength) and one independent of pain (loss of muscle anatomic cross-sectional area). Men who underwent knee replacement showed significantly reduced levels of extensor anatomic cross-sectional area, but not significantly lower strength or specific strength.
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http://dx.doi.org/10.1002/art.40343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5788724PMC
February 2018