Publications by authors named "Harvi F Hart"

38 Publications

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

Medical Interventions for Patellofemoral Pain and Patellofemoral Osteoarthritis: A Systematic Review.

J Clin Med 2020 Oct 23;9(11). Epub 2020 Oct 23.

Department of General Practice, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

Patellofemoral pain (PFP) and patellofemoral osteoarthritis (PFOA) are common, persistent conditions that may lie along a pathological spectrum. While evidence supports exercise-therapy as a core treatment for PFP and PFOA, primary care physicians commonly prescribe medication, or refer for surgical consults in persistent cases. We conducted a systematic review of medical interventions (pharmaceutical, nutraceutical, and surgical) for PFP and PFOA to inform primary care decision making.

Methods: Following protocol registration, we searched seven databases for randomized clinical trials of our target interventions for PFP and PFOA. Our primary outcome was pain. We assessed risk of bias, calculated standardized mean differences (SMDs) and determined the level of evidence for each intervention.

Results: We included 14 publications investigating pharmaceutical or nutraceutical interventions, and eight publications investigating surgical interventions. Two randomized control trials (RCTs) provided moderate evidence of patellofemoral arthroplasty having similar pain outcomes compared to total knee arthroplasty in isolated PFOA, with SMDs ranging from -0.3 (95% CI -0.8, 0.2, Western Ontario McMaster Pain Subscale, 1 year post-surgery) to 0.3 (-0.1, 0.7, SF-36 Bodily Pain, 2 years post-surgery). Remaining studies provided, at most, limited evidence. No efficacy was demonstrated for oral nonsteroidal anti-inflammatories or arthroscopic surgery.

Conclusions: Pharmaceutical and nutraceutical prescriptions, and surgical referrals are currently being made with little supporting evidence, with some interventions showing limited efficacy. This should be considered within the broader context of evidence supporting exercise-therapy as a core treatment for PFP and PFOA.
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http://dx.doi.org/10.3390/jcm9113397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690719PMC
October 2020

Associations of foot and ankle characteristics with knee symptoms and function in individuals with patellofemoral osteoarthritis.

J Foot Ankle Res 2020 Sep 23;13(1):57. Epub 2020 Sep 23.

Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086, Australia.

Background: Foot and ankle characteristics are associated with patellofemoral pain (PFP) and may also relate to patellofemoral osteoarthritis (PFOA). A greater understanding of these characteristics and PFOA, could help to identify effective targeted treatments.

Objectives: To determine whether foot and ankle characteristics are associated with knee symptoms and function in individuals with PFOA.

Methods: For this cross-sectional study we measured weightbearing ankle dorsiflexion range of motion, foot posture (via the Foot Posture Index [FPI]), and midfoot mobility (via the Foot Measurement Platform), and obtained patient-reported outcomes for knee symptoms and function (100 mm visual analogue scales, Anterior Knee Pain Scale [AKPS], Knee injury and Osteoarthritis Outcome Score, repeated single step-ups and double-leg sit-to-stand to knee pain onset). Pearson's r with significance set at p < 0.05 was used to determine the association between foot and ankle charateristics, with knee symptoms and function, adjusting for age.

Results: 188 participants (126 [67%] women, mean [SD] age of 59.9 [7.1] years, BMI 29.3 [5.6] kg/m) with symptomatic PFOA were included in this study. Lower weightbearing ankle dorsiflexion range of motion had a small significant association with higher average knee pain (partial r = - 0.272, p < 0.001) and maximum knee pain during stair ambulation (partial r = - 0.164, p = 0.028), and lower scores on the AKPS (indicative of greater disability; partial r = 0.151, p = 0.042). Higher FPI scores (indicating a more pronated foot posture) and greater midfoot mobility (foot mobility magnitude) were significantly associated with fewer repeated single step-ups (partial r = - 0.181, p = 0.023 and partial r = - 0.197, p = 0.009, respectively) and double-leg sit-to-stands (partial r = - 0.202, p = 0.022 and partial r = - 0.169, p = 0.045, respectively) to knee pain onset, although the magnitude of these relationships was small. The amount of variance in knee pain and disability explained by the foot and ankle characteristics was small (R-squared 2 to 8%).

Conclusions: Lower weightbearing ankle dorsiflexion range of motion, a more pronated foot posture, and greater midfoot mobility demonstrated small associations with worse knee pain and greater disability in individuals with PFOA. Given the small magnitude of these relationships, it is unlikely that interventions aimed solely at addressing foot and ankle mobility will have substantial effects on knee symptoms and function in this population.

Trial Registration: The RCT was prospectively registered on 15 March 2017 with the Australia and New Zealand Clinical Trials Registry ( ANZCTRN12617000385347 ).
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http://dx.doi.org/10.1186/s13047-020-00426-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509922PMC
September 2020

Associations between cadence and knee loading in patients with knee osteoarthritis.

Arthritis Care Res (Hoboken) 2020 Aug 2. Epub 2020 Aug 2.

Wolf Orthopaedic Biomechanics Laboratory, Fowler Kennedy Sport Medicine Clinic, London, Canada, Ontario.

Objective: To test the hypothesis that higher walking cadence is associated with lower knee loading, while controlling for walking speed, in patients with medial compartment tibiofemoral osteoarthritis (OA).

Methods: 691 patients underwent quantitative gait analysis, including 3D knee moments and temporospatial parameters. Using multivariate linear regression, we tested the association of walking cadence with the knee adduction moment angular impulse (a surrogate measure of medial knee compartment load throughout stance), while controlling for walking speed. We repeated the analysis while also adjusting for sex, age, body mass index, radiographic OA, knee pain, lateral trunk lean, foot progression angle, and mechanical axis angle and while replacing the knee adduction moment angular impulse with other surrogate measures of knee loading.

Results: While controlling for walking speed, lower cadence was associated with higher knee adduction moment angular impulse (standardized beta = -0.396, p<0.001), suggesting a 0.02%BW.Ht.sec decrease in impulse for each step per minute increase in cadence (unstandardized beta [95% CI] = -0.020 %BW.Ht.sec [-0.027 to -0.015]), and remained consistent after adjusting for covariates. Lower cadence was also associated with higher first (standardized beta = -0.138, p=0.010) and second peak knee adduction moment (standardized beta = -0.132, p=0.018), higher peak knee flexion moment (standardized beta = -0.128, p=0.049) and vertical ground reaction force (standardized beta = -0.116, p=0.035) in the adjusted analyses.

Conclusion: When controlling for walking speed, lower cadence is associated with higher knee loading per step in patients with medial tibiofemoral OA. Future research should investigate the potential beneficial biomechanical and clinical effects of increasing walking cadence in patients with knee OA.
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http://dx.doi.org/10.1002/acr.24400DOI Listing
August 2020

Can radiographic patellofemoral osteoarthritis be diagnosed using clinical assessments?

Musculoskeletal Care 2020 12 30;18(4):467-476. Epub 2020 Jun 30.

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

Introduction: The aim of this study was to determine whether participant characteristics and clinical assessments could identify radiographic osteoarthritis (OA) in individuals with clinically diagnosed, symptomatic patellofemoral osteoarthritis (PFOA).

Methods: Participant characteristics and clinical assessments were obtained from 179 individuals aged 50 years and over with clinically diagnosed symptomatic PFOA, who were enrolled in a randomised trial. Anteroposterior, lateral, and skyline X-rays were taken of the symptomatic knee. The presence of radiographic PFOA was defined as "no or early PFOA" (Kellgren and Lawrence [KL] grade ≤1 in the PF compartment) or "definite PFOA" (KL grade ≥2). Diagnostic test statistics were applied to ascertain which participant characteristics and clinical assessments could identify the presence of definite radiographic PFOA.

Results: A total of 118 participants (66%) had definite radiographic PFOA. Univariate analysis identified that older age (>61 years), female sex, higher body mass index (BMI) (>29 kg/m ), longer pain duration (>2.75 years), higher maximum knee pain during stair ambulation (>47/100 mm), and fewer repeated single step-ups to pain onset (<21) were associated with the presence of definite radiographic PFOA. Multivariate logistic regression indicated that BMI, pain duration, and repeated single step-ups to pain onset were independently associated with radiographic PFOA and identified the presence of definite radiographic PFOA with an overall accuracy of 73%.

Conclusion: In individuals over 50 years of age with a clinical diagnosis of PFOA, higher BMI, longer pain duration, and fewer repeated single step-ups to pain onset increased the likelihood of radiographic PFOA. However, overall diagnostic accuracy was modest, suggesting that radiographic PFOA cannot be confidently identified using these tests.
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http://dx.doi.org/10.1002/msc.1490DOI Listing
December 2020

Mismatch between expectations and physical activity outcomes at six months following hip-arthroscopy: A qualitative study.

Phys Ther Sport 2020 Sep 13;45:14-22. Epub 2020 Jun 13.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Objective: To explore factors influencing participation in physical activity for young to middle-aged patients at six months post-hip arthroscopy.

Design: Qualitative study.

Setting: Three specialist surgical centres in Australia.

Participants: Seventeen adults aged 18-50 years.

Main Outcome Measures: Individual semi-structured interviews were undertaken and transcribed verbatum. Inductive analysis of the data was undertaken, with themes identified through an iterative coding process.

Results: Four key themes emerged from the analysis: 1) an evident mismatch between expectations and actual progress of physical activity during the first six months post-arthroscopy; 2) physical activity levels vary widely at six months post-operatively; 3) evidence of suboptimal psychological readiness to return to sport and an associated emotional toll; and 4) the influence of available support and information on post-operative physical activity.

Conclusions: This qualitative study has provided in-depth perspectives on recovery after hip arthroscopy. Clear opportunities exist to: 1) help patients develop realistic post-operative goals; 2) provide timely patient education and support; and 3) facilitate an effective transition to desired physical activity.
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http://dx.doi.org/10.1016/j.ptsp.2020.05.006DOI Listing
September 2020

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review.

Sports Med Open 2020 Jan 28;6(1). Epub 2020 Jan 28.

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

Background: Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods: A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results: Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. No studies reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] -1.35[-1.61 to -1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion: The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients' perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level Of Evidence: Level IV, systematic review of Level 2 through to Level 4 studies.
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http://dx.doi.org/10.1186/s40798-020-0234-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6987281PMC
January 2020

Immediate effects of foot orthoses on gait biomechanics in individuals with persistent patellofemoral pain.

Gait Posture 2020 03 7;77:20-28. Epub 2020 Jan 7.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia; Department of Mechanical Engineering, The University of Melbourne, Parkville, Victoria, Australia; School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia. Electronic address:

Background: The efficacy of foot orthoses in reducing patellofemoral pain (PFP) is well documented; however, the mechanisms by which foot orthoses modulate pain and function are poorly understood.

Research Question: This within-subject study investigated the immediate effects of foot orthoses on lower limb kinematics and angular impulses during level walking and stair ambulation in individuals with persistent PFP.

Methods: Forty-two participants with persistent PFP (≥3 months duration) underwent quantitative gait analysis during level walking, stair ascent and stair descent while using: (i) standard running sandals (control); and (ii) standard running sandals fitted with prefabricated foot orthoses. Hip, knee, and ankle joint kinematics and angular impulses were calculated and statistically analyzed using paired t-tests (p < 0.05).

Results: Relative to the control condition, foot orthoses use was associated with small but significant decreases in maximum ankle inversion angles during walking (mean difference [95% confidence interval]: -1.00° [-1.48 to -0.53]), stair ascent (-1.06° [-1.66 to -0.45]) and stair decent (-0.94° [-1.40 to -0.49]). Foot orthoses were also associated with decreased ankle eversion impulse during walking (-9.8Nms/kg [-12.7 to -6.8]), and decreased ankle dorsiflexion and eversion impulse during stair ascent (-67.6Nms/kg [-100.7 to -34.6] and -17.5Nms/kg [-23.6 to -11.4], respectively) and descent (-50.4Nms/kg [-77.2 to -23.6] and -11.6Nms/kg [-15.6 to -7.5], respectively). Ankle internal rotation impulse decreased when participants ascended stairs with foot orthoses (-3.3Nms/kg [-5.4 to -1.3]). Limited changes were observed at the knee and hip.

Significance: In individuals with persistent PFP, small immediate changes in kinematics and angular impulses - primarily at the ankle - were observed when foot orthoses were worn during walking or stair ambulation. The clinical implications of these small changes, as well as the longer-term effects of foot orthoses on lower limb biomechanics, are yet to be determined.
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http://dx.doi.org/10.1016/j.gaitpost.2019.12.012DOI Listing
March 2020

What are the Benefits and Risks Associated with Changing Foot Strike Pattern During Running? A Systematic Review and Meta-analysis of Injury, Running Economy, and Biomechanics.

Sports Med 2020 May;50(5):885-917

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

Background: Running participation continues to increase. The ideal strike pattern during running is a controversial topic. Many coaches and therapists promote non-rearfoot strike (NRFS) running with a belief that it can treat and prevent injury, and improve running economy.

Objective: The aims of this review were to synthesise the evidence comparing NRFS with rearfoot strike (RFS) running patterns in relation to injury and running economy (primary aim), and biomechanics (secondary aim).

Design: Systematic review and meta-analysis. Consideration was given to within participant, between participant, retrospective, and prospective study designs.

Data Sources: MEDLINE, EMBASE, CINAHL, and SPORTDiscus.

Results: Fifty-three studies were included. Limited evidence indicated that NRFS running is retrospectively associated with lower reported rates of mild (standard mean difference (SMD), 95% CI 3.25, 2.37-4.12), moderate (3.65, 2.71-4.59) and severe (0.93, 0.32-1.55) repetitive stress injury. Studies prospectively comparing injury risk between strike patterns are lacking. Limited evidence indicated that running economy did not differ between habitual RFS and habitual NRFS runners at slow (10.8-11.0 km/h), moderate (12.6-13.5 km/h), and fast (14.0-15.0 km/h) speeds, and was reduced in the immediate term when an NRFS-running pattern was imposed on habitual RFS runners at slow (10.8 km/h; SMD = - 1.67, - 2.82 to - 0.52) and moderate (12.6 km/h; - 1.26, - 2.42 to - 0.10) speeds. Key biomechanical findings, consistently including both comparison between habitual strike patterns and following immediate transition from RFS to NRFS running, indicated that NRFS running was associated with lower average and peak vertical loading rate (limited-moderate evidence; SMDs = 0.72-2.15); lower knee flexion range of motion (moderate-strong evidence; SMDs = 0.76-0.88); reduced patellofemoral joint stress (limited evidence; SMDs = 0.63-0.68); and greater peak internal ankle plantar flexor moment (limited evidence; SMDs = 0.73-1.33).

Conclusion: The relationship between strike pattern and injury risk could not be determined, as current evidence is limited to retrospective findings. Considering the lack of evidence to support any improvements in running economy, combined with the associated shift in loading profile (i.e., greater ankle and plantarflexor loading) found in this review, changing strike pattern cannot be recommended for an uninjured RFS runner.

Prospero Registration: CRD42015024523.
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http://dx.doi.org/10.1007/s40279-019-01238-yDOI Listing
May 2020

Psychometric Properties of the Hip-Return to Sport After Injury Scale (Short Form) for Evaluating Psychological Readiness to Return to Sports After Arthroscopic Hip Surgery.

Am J Sports Med 2020 02 4;48(2):376-384. Epub 2019 Dec 4.

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

Background: Successful return to sports activity after surgery requires both physical and psychological readiness. The Hip-Return to Sport After Injury (Short Form) has been developed to assess psychological readiness to return to sports after hip injury and hip surgery, including hip arthroscopy.

Purpose: To evaluate the reliability, validity, responsiveness, and interpretability of the scale for a cohort of patients after hip arthroscopy with a range of sports participation levels.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: Invitations to participate were sent to 145 patients from 3 specialist surgeons. The study included 77 participants 1 to 24 months after hip arthroscopy (mean ± SD age, 35 ± 9 years; 62% women) and 33 healthy age-matched controls (age, 37 ± 7 years; 52% women). The scale was administered electronically on 3 occasions to patients: baseline (≥1 month postarthroscopy), 1 week later, and 6 months later. In addition to the scale, participants were asked about sports participation status and their global rating of postsurgical change. The scale was administered to healthy controls on 1 occasion. The minimal detectable difference, discriminant validity, floor and ceiling effects, responsiveness, and interpretability (minimally important change) were determined for the scale.

Results: Among the postarthroscopy group, excellent test-retest reliability was found (intraclass correlation coefficient = 0.869; 95% CI, 0.756-0.932) with a minimal detectable difference of 26 points out of 100 at the individual level and 4 points out of 100 at the group level. At baseline discriminant validity was evident between those who had returned to sports (median = 69, n = 35) and those who had not returned to sports (median = 30, n = 42; Mann-Whitney score = 232.5, = -5.141, < .001) and between the returned-to-sports postarthroscopy group and healthy controls (median = 96, n = 33; Mann-Whitney score = 165.500, = 5.666, < .001). No floor or ceiling effects were evident. Responsiveness was demonstrated for the scale in relation to sports status. With sports status as an anchor, a minimally important change of 26 points was identified.

Conclusion: Assessment of the Hip-Return to Sport After Injury (Short Form) supports its use as a reliable and valid measure of psychological readiness to return to sports in patients after hip arthroscopy.
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http://dx.doi.org/10.1177/0363546519888644DOI Listing
February 2020

Immediate effects of foot orthoses on lower limb biomechanics, pain, and confidence in individuals with patellofemoral osteoarthritis.

Gait Posture 2020 02 24;76:51-57. Epub 2019 Oct 24.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, 3086, Australia; School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, 4072, Australia.

Background: Foot orthoses are a recommended treatment for patellofemoral (PF) pain and a number of lower limb osteoarthritic (OA) conditions. However, their mechanism of effect is poorly understood.

Research Question: To compare the immediate effects of foot orthoses and flat inserts on lower limb biomechanics, knee pain and confidence in individuals with PFOA.

Methods: Twenty-one participants (14 females; mean ± SD age 58 ± 8 years) with PFOA underwent three-dimensional motion analysis during level-walking, stair ascent, and stair descent under three footwear conditions: (i) their own shoes; (ii) prefabricated foot orthoses; and (iii) flat shoe inserts. Participants reported their average levels of knee pain and confidence after each task. Data were analysed with repeated-measures analysis of variance (ANOVA), effect sizes (partial eta squared), and Bonferroni post-hoc tests.

Results: During level-walking, there was a significant main effect of foot orthoses on peak ankle dorsiflexion angle (F = 0.773, p < 0.001, ƞ = 0.773) and peak ankle external dorsiflexion moment (F = 0.356, p = 0.046, ƞ = 0.356). Foot orthoses decreased the peak ankle dorsiflexion angle compared to the flat insert and shoe conditions, and decreased the peak ankle external dorsiflexion moment relative to flat inserts. During stair descent, there was a significant main effect of foot orthoses on peak ankle external dorsiflexion moment (F = 0.823, p = 0.006, ƞ = 0.738), with a trend towards lower peak dorsiflexion moment for foot orthoses compared to the flat insert and shoe conditions. No significant main effects were observed during stair ascent. No other lower limb biomechanical changes were observed across all three conditions. Knee pain and confidence scores were not significantly different across the three conditions.

Significance: Prefabricated foot orthoses altered sagittal plane biomechanics of the ankle during level-walking and stair descent in individuals with PFOA. Further research is required to determine whether these changes are clinically beneficial.
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http://dx.doi.org/10.1016/j.gaitpost.2019.10.019DOI Listing
February 2020

Obesity is related to incidence of patellofemoral osteoarthritis: the Cohort Hip and Cohort Knee (CHECK) study.

Rheumatol Int 2020 Feb 8;40(2):227-232. Epub 2019 Nov 8.

Erasmus MC, University Medical Center, Rotterdam, The Netherlands.

To determine the longitudinal association of baseline body mass index and change in body mass index over 8 years to incident of patellofemoral osteoarthritis at the 8-year follow-up. A sample of 528 women and men, aged 45-65 years, with knee complaints and without radiographic evidence of patellofemoral and tibiofemoral osteoarthritis at baseline, were selected from the Cohort Hip and Cohort Knee cohort. Incidence of patellofemoral osteoarthritis was defined as presence of radiographic patellofemoral osteoarthritis (with or without tibiofemoral osteoarthritis) at the 8-year follow-up. Baseline body mass index data were categorized into normal, overweight, and obese weight-categories. Logistic regression analyses, adjusted for age and sex, were conducted to determine the association of baseline body mass index and change in body mass index to patellofemoral osteoarthritis incidence 8 years later. Obesity was associated with greater odds of radiographic patellofemoral osteoarthritis incident (odds ratio: 1.8 [95% CI 1.1, 3.1]) 8 years later. There were no significant associations observed between body mass index change over 8 years and incidence of radiographic patellofemoral osteoarthritis in overweight and obese individuals. Obesity is associated with increased odds of developing radiographic patellofemoral osteoarthritis 8 years later.
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http://dx.doi.org/10.1007/s00296-019-04472-9DOI Listing
February 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

The efficacy of foot orthoses in individuals with patellofemoral osteoarthritis: a randomised feasibility trial.

Pilot Feasibility Stud 2019 11;5:90. Epub 2019 Jul 11.

2La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086 Australia.

Background: Foot orthoses have the potential to be an efficacious treatment for patellofemoral osteoarthritis (PFOA) but have not been evaluated in clinical trials in this population. This study aimed to determine the: (i) feasibility of conducting a randomised controlled trial (RCT) investigating the efficacy of foot orthoses in individuals with PFOA; and (ii) effects of foot orthoses versus flat shoe inserts on pain, function, and knee-related quality of life (QOL).

Methods: This 6-week, single-blinded pilot RCT randomly allocated participants with PFOA to receive foot orthoses or flat inserts. The primary outcome of feasibility was determined via the following parameters: one participant recruited per week, 20% (35 h/week) adherence to the intervention, 50% log book completion rate, and < 20% drop-out, with results reported using descriptive statistics. Secondary outcomes included average and maximum pain severity (100 mm visual analogue scale), Anterior Knee Pain Scale, and Knee injury and Osteoarthritis Outcome Score, analysed using analysis of covariance.

Results: Twenty-six participants (16 women; mean (SD) age of 60 (8) years) with PFOA were recruited. All feasibility parameters were exceeded, with three participants recruited per week, > 20% (37.2 [9.8] hours/week) adherence to the intervention, 69.2% (18/26) log-book completion, and 3.8% (1/26) drop-outs. The most common adverse events were arch irritation and shoe fit issues, which were more common in the foot orthoses group (67.9% 32.1%). There was a trend for the foot orthoses group to report larger improvements in average and maximum pain than the flat insert group, with the mean difference for maximum knee pain severity (21.9 mm, 95% CI - 2.1 to 46.0) exceeding the minimal clinically important difference (15 mm). The estimated sample size for a full-scale RCT is 160 participants. Suggestions to improve study design include a greater number of face-to-face follow-up appointments, a larger variety of foot orthoses to reduce rates of adverse events, and increasing follow-up time to determine long-term efficacy.

Conclusion: This study supports the feasibility of a full-scale RCT to determine the efficacy of foot orthoses flat inserts in individuals with PFOA.

Trial Registration: The trial protocol was retrospectively registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR number: 12616001287426).
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http://dx.doi.org/10.1186/s40814-019-0469-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625074PMC
July 2019

Influence of an unloader brace on lower limb electromyographic activity in individuals with predominant lateral osteoarthritis after anterior cruciate ligament reconstruction.

Braz J Phys Ther 2020 Jul - Aug;24(4):342-348. Epub 2019 Jun 1.

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

Objective: To determine the immediate effects of a varus unloader knee brace on lower-limb electromyographic activity in individuals with lateral knee osteoarthritis and valgus malalignment after anterior cruciate ligament reconstruction.

Methods: Electromyographic data were recorded in 19 individuals with lateral knee osteoarthritis and valgus malalignment after anterior cruciate ligament reconstruction during walking under three conditions: (i) no brace, (ii) unadjusted brace (no varus adjustment), and adjusted brace (varus adjustment). Variables of interest were statistically analyzed using repeated measures analysis of variance.

Results: There were no significant differences in muscle co-contraction between the three test conditions. The adjusted brace resulted in delayed offset of gluteus maximus (mean difference [95% CI]: 72ms [24, 119]), and earlier onset of gluteus medius (59ms [21, 97]) compared to no brace. The adjusted brace delayed onset of lateral gastrocnemius compared to no brace (53ms [28, 78]) and the unadjusted brace (39ms [7, 71]) and reduced average activation amplitude of gluteus maximus (-4mV [-6, -1]) and lateral gastrocnemius (-9mV [-16, -2]) compared to no brace.

Conclusions: The unloader brace did not produce significant changes in muscle co-contraction in individuals with lateral knee osteoarthritis and valgus malalignment after anterior cruciate ligament reconstruction. Significant changes in gluteal and gastrocnemius muscle activation timing and amplitude were observed, however, it is not clear whether these changes are of clinical importance.
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http://dx.doi.org/10.1016/j.bjpt.2019.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352036PMC
September 2020

The FOOTPATH study: protocol for a multicentre, participant- and assessor-blind, parallel group randomised clinical trial of foot orthoses for patellofemoral osteoarthritis.

BMJ Open 2019 04 20;9(4):e025315. Epub 2019 Apr 20.

La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.

Introduction: Patellofemoral (PF) osteoarthritis (OA) is a common and burdensome subgroup of knee OA, with very little evidence for effective treatments. Prefabricated foot orthoses are an affordable and accessible intervention that have been shown to reduce PF pain in younger adults. Similarities between PF pain and PFOA, as well as our pilot work, suggest that foot orthoses may also be an effective intervention for PFOA. The primary objective of this study is to compare the 3 month efficacy of prefabricated foot orthoses and flat shoe inserts in people with PFOA, on knee pain severity.

Methods And Analysis: The FOOTPATH Study (FOot OrThoses for PAtellofemoral osteoarTHritis) is a multicentre, randomised, participant- and assessor-blinded superiority trial with two parallel groups, a 3 month observation period (pre-randomisation) and 12 month follow-up. 160 participants with a clinical diagnosis of PFOA will be recruited from three sites in Australia, and randomised to one of two groups (prefabricated foot orthoses or flat shoe inserts). The primary outcome is worst knee pain severity during a self-nominated aggravating activity in the previous week (100 mm visual analogue scale) at 3 months, with a secondary endpoint at 12 months. Secondary outcomes include global rating of change, symptoms, function, health-related quality of life, kinesiophobia, self-efficacy and use of co-interventions for knee pain. Blinded, intention-to-treat analyses of primary and secondary patient-reported outcomes will be performed, as well as economic analyses.

Ethics And Dissemination: Ethical approval has been granted by La Trobe University's Human Ethics Committee and The University of Queensland's Medical Research Ethics Committee. Study outcomes will be disseminated via peer-reviewed journals, conference presentations targeting a range of healthcare disciplines and an open access website with clinician resources.

Trial Registration Number: ANZCTRN12617000385347; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2018-025315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500302PMC
April 2019

Step Rate and Worsening of Patellofemoral and Tibiofemoral Joint Osteoarthritis in Women and Men: The Multicenter Osteoarthritis Study.

Arthritis Care Res (Hoboken) 2020 01;72(1):107-113

Boston University and Northeastern University, Boston, Massachusetts.

Objective: To determine the association of self-selected walking step rate with worsening of cartilage damage in the patellofemoral (PF) joint and tibiofemoral (TF) joint compartments at a 2-year follow-up visit.

Methods: The Multicenter Osteoarthritis Study (MOST) is a prospective cohort of men and women with or at risk of knee osteoarthritis. Self-selected step rate was measured using an instrumented GAITRite walkway (CIR Systems) at the 60-month visit. Cartilage damage was semiquantitatively graded on magnetic resonance images at the 60- and 84-month visits in the medial and lateral PF and TF compartments. Step rate was divided into quartiles, and logistic regression was used to determine the association of step rate with the risk of worsening cartilage damage in men and women separately. Analyses were adjusted for age, body mass index, and knee injury/surgery.

Results: A total of 1,089 participants were included. Mean ± SD age was 66.9 ± 7.5 years, mean ± SD body mass index was 29.6 ± 4.7 kg/m , and 62.3% of the participants were women. Women with the lowest step rate had increased risk of lateral PF (risk ratio [RR] 2.1 [95% confidence interval (95% CI) 1.1-3.8]) and TF (RR 1.8 [95% CI 1.1-2.9]) cartilage damage worsening 2 years later compared to those with the highest step rate. Men with the lowest step rate had increased risk of medial TF cartilage damage worsening 2 years later (RR 2.1 [95% CI 1.1-3.9]).

Conclusion: Lower step rate was associated with increased risk of cartilage damage worsening in the lateral PF and TF compartments in women and worsening medial TF joint damage in men. Future research is necessary to understand the influence of step rate manipulation on joint biomechanics in women and men.
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http://dx.doi.org/10.1002/acr.23864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717684PMC
January 2020

Alignment differs between patellofemoral osteoarthritis cases and matched controls: An upright 3D MRI study.

J Orthop Res 2019 03 1;37(3):640-648. Epub 2019 Mar 1.

Centre for Hip Health and Mobility, Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada.

Patellofemoral (PF) osteoarthritis (OA) is a prevalent and clinically important knee OA subgroup. Malalignment may be an important risk factor for PF OA. However, little is known about alignment in PF OA, particularly in an upright, weightbearing environment. Using a vertically-oriented open-bore MR scanner, we evaluated 3D knee alignment in 15 PF OA cases and 15 individually matched asymptomatic controls. We imaged one knee per participant while they stood two-legged at four flexion angles (0°, 15°, 30°, 45°), and also while they stood one-legged at 30° knee flexion. We calculated 3D patellofemoral and tibiofemoral alignment. Using mixed effects models, four of the five patellofemoral measures differed by group. For key measures, PF OA patellae were 6.6° [95%CI 5.0, 8.2] more laterally tilted, 2.4 mm [1.3, 3.5] more laterally translated, and at least 3.7 mm [0.2, 7.2] more proximally translated compared to controls (more with knees flexed). Alignment did not differ between two-legged stance and one-legged stance in either group. Statement of Clinical Significance: Our study demonstrated significant and clinically relevant differences in alignment between PF OA cases and controls in upright standing and squatting positions. Our findings were similar to those in previous studies of PF OA using traditional MR scanners in supine positions, supporting the clinical usefulness of existing methods aimed at identifying individuals who may benefit from interventions designed to correct malalignment. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. 9999:1-9, 2019.
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http://dx.doi.org/10.1002/jor.24237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593798PMC
March 2019

Influence of kinesiophobia and pain catastrophism on objective function in women with patellofemoral pain.

Phys Ther Sport 2019 Jan 28;35:116-121. Epub 2018 Nov 28.

São Paulo State University (UNESP), School of Science and Technology, Laboratory of Biomechanics and Motor Control (LABCOM), Presidente Prudente, Brazil; La Trobe Sports and Exercise Medicine Research Centre (LASEM), School of Allied Health, La Trobe University, Bundoora, Victoria, Australia. Electronic address:

Objectives: (i) To compare kinesiophobia, pain catastrophism and objective function between women with patellofemoral pain (PFP) and pain-free; (ii) to investigate the association of kinesiophobia and pain catastrophism with objetive function in women with PFP.

Design: Case-control.

Setting: Laboratory-based.

Participants: Fifty-five women with PFP and forty pain-free women.

Main Outcome Measures: Kinesiophobia and pain catastrophism were assessed using the Tampa Scale of Kinesiophobia and Pain Catastrophizing Scale, respectively. Forward step-down, single leg hop, and modified star balance tests were used to assess objective function. Independent t-tests were used for between-groups comparisons and Pearson correlation coefficients were used to investigate the association between the outcomes.

Results: Women with PFP had significantly worse kinesiophobia (p < 0.001; Effect size (ES) = 1.16), pain catastrophism (p < 0.001; ES = 1.57), and poorer objective function (step-down, (p < 0.001; ES = 0.99); single-leg hop (p = 0.002; ES = 0.74); modified star balance (p < 0.001; ES = 0.66) than pain-free controls. Kinesiophobia and pain catastrophism were not correlated with objective function.

Conclusion: Greater kinesiophobia, pain catastrophism and poorer objective function is evident in women with PFP, compared to pain-free controls. Kinesiophobia and pain catastrophism were not associated with objective function in women with PFP. Future research is necessary to understand how other physical and psychological factors might affect objective function.
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http://dx.doi.org/10.1016/j.ptsp.2018.11.013DOI Listing
January 2019

Is Self-Reported Knee Stability Associated With Symptoms, Function, and Quality of Life in People With Knee Osteoarthritis After Anterior Cruciate Ligament Reconstruction?

Clin J Sport Med 2020 09;30(5):e134-e138

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

Objective: This study aimed to investigate the association of self-reported knee stability with symptoms, function, and quality of life in individuals with knee osteoarthritis after anterior cruciate ligament reconstruction (ACLR).

Setting: Cross-sectional.

Participants: Twenty-eight individuals with knee osteoarthritis, 5 to 12 years after ACLR.

Main Outcome Measures: Self-reported knee stability was assessed using visual analogue scales (VAS) during hop for distance (HD), side-to-side hop (SSH), and one-leg rise (OLR). Symptoms [Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, Anterior Knee Pain Scale (AKPS), and International Knee Documentation Committee form], self-reported function (KOOS-sport/rec), performance-based function (hopping and OLR), and quality of life (KOOS-QOL) were assessed. K-means clustering categorized individuals into low (n = 8) and high self-reported knee stability (n = 20) groups based on participants' VAS scores during functional tasks.

Results: The low self-reported knee stability group had worse knee symptoms than the high self-reported knee stability group [KOOS-pain: mean difference -17 (95% confidence interval, -28 to -5); AKPS: -10 (-20 to -1)], and worse self-reported function [KOOS-sport/rec: -33 (-48 to -18)] and performance-based function [HD: -28 (-53 to -3); SSH: -10 (-20 to -1), OLR: -18 (-32 to -50)].

Conclusion: Low self-reported stability is associated with worse symptoms, and worse self-reported and performance-based function. Further research is required to determine the causation relation of self-reported knee stability to knee symptoms and function in individuals with knee osteoarthritis after ACLR.
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http://dx.doi.org/10.1097/JSM.0000000000000674DOI Listing
September 2020

VALIDITY AND RELIABILITY OF THE FITBIT FLEX™ AND ACTIGRAPH GT3X+ AT JOGGING AND RUNNING SPEEDS.

Int J Sports Phys Ther 2018 Aug;13(5):860-870

La Trobe Sport and Exercise Medicine Research Centre (LASEM), School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.

Background: Monitoring levels of physical activity, as an outcome or in guiding rehabilitation, is challenging for clinicians. Personal activity monitors are increasing in popularity and provide potential to enhance rehabilitation protocols. However, research to support the validity and reliability of these devices at jogging and running speeds is limited.

Purpose: The purpose of this study was to evaluate the validity of the Fitbit Flex™ and ActiGraph GT3X + for measuring step count at jogging and running speeds. A secondary purpose was to examine inter-device reliability of the Fitbit Flex™.

Study Design: Cross-sectional study.

Methods: Thirty healthy participants aged between 19 and 50 years, completed a treadmill protocol at jogging and running speeds (8 km/h to 16 km/h). Treadmill speed was progressively increased by intervals of 2 km/h. Each interval was four minutes in duration with a two minute rest period between stages. Participants were encouraged to continue through the graded exercise test until they reached the maximum running speed that they felt they could maintain for four minutes. Step count data was collected for Fitbit Flex™ devices and the ActiGraph GT3X+. Video analysis of step count was used as the criterion measure.

Results: At speeds of 8 to 14 km/h Mean Absolute Percentage Errors were ≤1% for the Fitbit Flex™ and the ActiGraph GT3X + when compared to step count via video analysis. Standard Error of Measurement between the three Fitbit Flex™ devices was ≤ 7 steps for speeds of 8 to 14 km/h and varied between 9 to 19 steps at 16 km/h. Fitbit Flex™ devices showed good to excellent between device reliability at speeds of 8 to14 km/h (ICC 0.723 to 0.999; p ≤ 0.001). Greater variability was evident with the low participant numbers at 16 km/h (ICC 0.527 to 0.896; p ≥ 0.02).

Conclusion: Both the Fitbit Flex™ and the ActiGraph GT3X + provide a valid account of steps taken at jogging and running speeds up to 14 km/hr, attainable by non-elite runners on a treadmill. Fitbit Flex™ devices provide equivalent step count output to each other, enabling comparison between devices during treadmill jogging and running.

Level Of Evidence: 2b.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159488PMC
August 2018

Quality of life in individuals with patellofemoral pain: A systematic review including meta-analysis.

Phys Ther Sport 2018 Sep 28;33:96-108. Epub 2018 Jun 28.

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

Objective: The aim of this systematic review is to describe QoL in individuals with PFP, and determine the impact of PFP interventions on QoL.

Methods: Five databases were searched for studies reporting QoL in individuals with PFP, with mean age under 50 years. Data were pooled based on QoL tool (e.g. Knee Injury and Osteoarthritis Outcome Score [KOOS] QoL subscale, Short-Form 36 item health survey [SF-36]) using random-effects models, or through narrative synthesis where inadequate data were available.

Results: Individuals with PFP, had worse KOOS-QOL scores (pooled mean: 47[95% CI: 34 to 61] and health-related QoL (pooled SF-36 PCS and MCS: 47[95% CI: 41 to 53] and 54[95% CI: 47 to 62], respectively) compared with pain-free controls and population norms. Physical interventions were associated with improvements in knee- and health-related QoL in individuals with PFP in repeated measures studies. However, the effect of physical interventions compared to a control treatment was conflicting.

Conclusion: Individuals with PFP aged under 50 years, have markedly reduced knee- and health-related QoL compared to pain-free controls and population norms. Knee- and health-related QoL may improve following intervention, but it is unclear if these improvements are greater than that which occur in a control group.
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http://dx.doi.org/10.1016/j.ptsp.2018.06.006DOI Listing
September 2018

Is quality of life reduced in people with patellofemoral osteoarthritis and does it improve with treatment? A systematic review, meta-analysis and regression.

Disabil Rehabil 2019 12 10;41(25):2979-2993. Epub 2018 Jul 10.

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

To determine if quality of life is reduced in individuals with patellofemoral osteoarthritis, whether it can be improved with treatment, and potential factors associated with quality of life in individuals with patellofemoral osteoarthritis. Published articles were identified by using electronic and manual searches. Studies reporting quality of life in individuals with patellofemoral osteoarthritis relative to a comparator group (e.g., no osteoarthritis) and intervention studies reporting quality of life in patellofemoral osteoarthritis following treatment relative to baseline/control group were included. Seventeen studies (seven cross-sectional, 10 intervention) were included in this systematic review. Relative to those without osteoarthritis, individuals with patellofemoral osteoarthritis had worse knee-related quality of life (five studies) and health-related quality of life (two studies). Non-surgical treatments appear to improve knee-related quality of life compared to pre-treatment (three studies) but not control (three studies). Surgical-treatments also improved knee-related quality of life compared to pre-treatment (five studies). Worse knee-related quality of life was associated with younger age, worse pain, symptoms, function in activities of daily living, and function in sport and recreation. Individuals with patellofemoral osteoarthritis had worse knee-related and health-related quality of life compared to those without knee osteoarthritis. Non-surgical and surgical interventions may be effective in improving knee-related quality of life in individuals with patellofemoral osteoarthritis, but the intervention results are based on limited studies, and further research is needed to determine optimal strategies.Implications for rehabilitationClinicians and researchers should consider knee-related and health-related quality of life when developing treatment strategies for patellofemoral osteoarthritis.Researchers investigating the effectiveness of a treatment should compare intervention to a control group.Addressing knee pain and functional limitations may aid in improving knee-related quality of life in individuals with patellofemoral osteoarthritis.
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http://dx.doi.org/10.1080/09638288.2018.1482504DOI Listing
December 2019

2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017.

Br J Sports Med 2018 Sep 20;52(18):1170-1178. Epub 2018 Jun 20.

La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.

Patellofemoral pain affects a large proportion of the population, from adolescents to older adults, and carries a substantial personal and societal burden. An international group of scientists and clinicians meets biennially at the International Patellofemoral Research Retreat to share research findings related to patellofemoral pain conditions and develop consensus statements using best practice methods. This consensus statement, from the 5th International Patellofemoral Research Retreat held in Australia in July 2017, focuses on exercise therapy and physical interventions (eg, orthoses, taping and manual therapy) for patellofemoral pain. Literature searches were conducted to identify new systematic reviews and randomised controlled trials (RCTs) published since the 2016 Consensus Statement. The methodological quality of included systematic reviews and RCTs was graded using AMSTAR and PEDro, respectively. Evidence-based statements were developed from included papers and presented to a panel of 41 patellofemoral pain experts for consensus discussion and voting. Recommendations from the expert panel support the use of exercise therapy (especially the combination of hip-focused and knee-focused exercises), combined interventions and foot orthoses to improve pain and/or function in people with patellofemoral pain. The use of patellofemoral, knee or lumbar mobilisations in isolation, or electrophysical agents, is not recommended. There is uncertainty regarding the use of patellar taping/bracing, acupuncture/dry needling, manual soft tissue techniques, blood flow restriction training and gait retraining in patients with patellofemoral pain. In 2017, we launched the International Patellofemoral Research Network (www.ipfrn.org) to consolidate and grow our patellofemoral research community, facilitate collaboration and disseminate patellofemoral pain knowledge to clinicians and the general public. The 6th International Patellofemoral Research Retreat will be held in Milwaukee, Wisconsin, USA, in October 2019.
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http://dx.doi.org/10.1136/bjsports-2018-099397DOI Listing
September 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

Sub-elite Football Players With Hip-Related Groin Pain and a Positive Flexion, Adduction, and Internal Rotation Test Exhibit Distinct Biomechanical Differences Compared With the Asymptomatic Side.

J Orthop Sports Phys Ther 2018 07 8;48(7):584-593. Epub 2018 May 8.

Background Hip-related groin pain is common in sub-elite football players and may be associated with altered hip biomechanics. Objectives To compare the hip biomechanics, bony hip morphology associated with femoroacetabular impingement (FAI) syndrome, and hip strength and range of motion (ROM) between the symptomatic and asymptomatic limbs of sub-elite football players with unilateral hip-related groin pain and a positive flexion, adduction, and internal rotation (FADIR) test. Methods Fifteen sub-elite football (soccer) players with unilateral hip-related groin pain and a positive FADIR test were recruited for this observational cross-sectional study. Three-dimensional motion analysis and ground reaction force data were recorded for walking and a single-leg drop-jump (SLDJ) task. Participants also underwent a standard anterior-posterior hip radiograph and hip strength and ROM assessment. Between-limb differences were assessed using paired t tests or Wilcoxon signed-rank tests. Results The symptomatic limb displayed a smaller peak hip extension angle (P = .01) and a lower peak hip adduction moment (P = .03) compared with the asymptomatic limb during the stance phase of walking. Additionally, during the SLDJ, the symptomatic limb demonstrated less total sagittal plane ROM (P = .04). The symptomatic limb also demonstrated less external rotation ROM (P = .03). However, no differences were found between limbs for bony hip morphology associated with FAI syndrome or hip strength. Conclusion This study found between-limb asymmetries in low- and high-impact functional tasks, such as walking and an SLDJ, in football players with unilateral hip-related groin pain. Despite unilateral pain, bony morphology associated with FAI syndrome did not differ between limbs. J Orthop Sports Phys Ther 2018;48(7):584-593. Epub 8 May 2018. doi:10.2519/jospt.2018.7910.
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http://dx.doi.org/10.2519/jospt.2018.7910DOI Listing
July 2018

Gait patterns, symptoms, and function in patients with isolated tibiofemoral osteoarthritis and combined tibiofemoral and patellofemoral osteoarthritis.

J Orthop Res 2018 06 5;36(6):1666-1672. Epub 2017 Dec 5.

Department of Physical Therapy, University of British Columbia, 212-2177 Westbrook Mall, Vancouver, British Columbia, V6T 1Z3, Canada.

The purpose of this study was to compare hip and knee biomechanics during walking in individuals with isolated tibiofemoral osteoarthritis (TFOA), combined TFOA and patellofemoral osteoarthritis (PFOA), and those without knee osteoarthritis (OA), and to compare patient-reported symptoms and function in individuals with isolated TFOA and those with combined TFOA and PFOA. Participants with and without knee OA were assessed and categorized into (i) no OA, (ii) isolated TFOA, and (iii) combined TFOA and PFOA, based on Kellgren and Lawrence diagnostic criteria. Quantitative motion analyses were conducted during walking, and hip and knee kinematics, and external moments were calculated. Peak values in the sagittal and frontal planes during stance phase were computed. Patient-reported symptoms and function data were obtained using the Western Ontario McMaster Universities Arthritis Index. Multivariate analyses of variance were conducted to compare between-group differences in gait and patient-reported symptoms and function data. The results showed no statistically significant differences in hip and knee kinematics and external moments between the three groups. Relative to those with isolated TFOA, individuals with combined TFOA and PFOA had greater pain (mean difference [95%CI]: 1.5 [0.05-3.1]), stiffness (0.8 [0.02-1.5]), and poorer function (5.4 [0.2-10.7]). In conclusion, the combined TFOA and PFOA radiographic disease pattern is associated with worse pain and function compared to the isolated TFOA disease pattern. The results of the present study provide no indications that treatments designed to change walking biomechanics should differ between individuals with isolated TFOA and those with combined TFOA and PFOA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1666-1672, 2018.
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http://dx.doi.org/10.1002/jor.23805DOI Listing
June 2018

Patellofemoral and tibiofemoral alignment in a fully weight-bearing upright MR: Implementation and repeatability.

J Magn Reson Imaging 2018 03 21;47(3):841-847. Epub 2017 Aug 21.

Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada.

Purpose: To develop methods for evaluating 3D patellofemoral and tibiofemoral alignment in vertical open-bore magnetic resonance (MR) scanners, with participants upright and fully weight-bearing; and to evaluate the repeatability of these methods in individuals with patellofemoral osteoarthritis (OA) and in asymptomatic knees.

Materials And Methods: Our methods extend previously validated, reliable methods for evaluating alignment into an upright MR environment. In 10 participants with early patellofemoral OA and 10 with asymptomatic knees, we acquired sagittal T -weighted turbo spin echo images in a 3T scanner to create accurate participant-specific 3D anatomical surface models. In a vertical open-bore 0.5T MR scanner, we obtained lower-resolution sagittal gradient echo images to capture bony position and orientation data. Participants were scanned in a position of squatting with the knees flexed 30°, three separate times to evaluate repeatability. Bone segmentation was performed manually, surface models were registered to data from the 0.5T scanner, and 3D patellofemoral and tibiofemoral alignment was calculated in all six degrees of freedom (three rotations and three translations).

Results: Intraclass correlation coefficients (ICCs) were ≥0.94, with the exception of patellar spin (0.79). Standard errors of measure (SEM) were <2° rotation and <0.9 mm translation. Repeatability remained adequate when stratified by group, with the exception of patellar spin (ICC 0.57 for asymptomatic knees vs. 0.91 for OA knees).

Conclusion: We demonstrate methods for evaluating 3D alignment in upright fully weight-bearing participant positions in a vertical open-bore MR scanner. With the exception of patellar spin, repeatability was good to excellent.

Level Of Evidence: 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:841-847.
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http://dx.doi.org/10.1002/jmri.25823DOI Listing
March 2018

The prevalence of radiographic and MRI-defined patellofemoral osteoarthritis and structural pathology: a systematic review and meta-analysis.

Br J Sports Med 2017 Aug 29;51(16):1195-1208. Epub 2017 Apr 29.

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

Background: Patellofemoral osteoarthritis (PF OA) is more prevalent than previously thought and contributes to patient's suffering from knee OA. Synthesis of prevalence data can provide estimates of the burden of PF OA.

Objective: This study aims to conduct a systematic review and meta-analysis on the prevalence of PF OA and structural damage based on radiography and MRI studies in different populations.

Methods: We searched six electronic databases and reference lists of relevant cross-sectional and observational studies reporting the prevalence of PF OA. Two independent reviewers appraised methodological quality. Where possible, data were pooled using the following categories: radiography and MRI studies.

Results: Eighty-five studies that reported the prevalence of patellofemoral OA and structural damage were included in this systematic review. Meta-analysis revealed a high prevalence of radiographic PF OA in knee pain or symptomatic knee OA (43%), radiographic knee OA or at risk of developing OA (48%) and radiographic and symptomatic knee OA (57%) cohorts. The MRI-defined structural PF damage in knee pain or symptomatic population was 32% and 52% based on bone marrow lesion and cartilage defect, respectively.

Conclusion: One half of people with knee pain or radiographic OA have patellofemoral involvement. Prevalence of MRI findings was high in symptomatic and asymptomatic population. These pooled data and the variability found can provide evidence for future research addressing risk factors and treatments for PF OA.

Trial Registration Number: PROSPERO systematic review protocol (CRD42016035649).
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http://dx.doi.org/10.1136/bjsports-2017-097515DOI Listing
August 2017
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