Publications by authors named "Kay M Crossley"

224 Publications

Creating Prep to Play PRO for women playing elite Australian football: A how-to guide for developing injury prevention programs.

J Sport Health Sci 2021 Sep 18. Epub 2021 Sep 18.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, VIA 3086, Australia; Australian IOC Research Centre, La Trobe University, Melbourne, VIA 3086, Australia.

Background: Developing context-specific, evidence-informed, and implementable injury prevention programs is challenging. Women playing in the elite Australian Football League for Women (AFLW) are at high risk of serious knee injuries, and no AFLW-specific injury prevention program exists. The objective is to describe the collaborative process used to create a context-specific injury prevention program.

Methods: A previously used intervention development process was modified to incorporate a partnership with the sport's governing organization and focus on engaging program implementers. The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) Sports Setting Matrix guided program development and implementation strategies.

Results: The 7-step process, aligned with the RE-AIM Sports Setting Matrix, was applied to develop the injury prevention program titled "Prep to Play PRO". The steps were: (Step 1) gaining organizational support and establishing a project partnership; (Step 2) using research evidence and clinical and context experience; (Step 3) consulting content and context experts; (Step 4) engaging the organization, experts, program implementers, and end-users in co-creating the intervention and implementation strategies; (Step 5) testing the intervention acceptability and feasibility; (Step 6) evaluating the intervention and implementation strategies against theory; and (Step 7) obtaining feedback from early implementers and end-users.

Conclusion: Engaging critical stakeholders at multiple ecological levels (organization, team, athlete) throughout program development and implementation planning supported real-world use. The processes and activities described can guide future sports injury prevention program development and implementation.
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http://dx.doi.org/10.1016/j.jshs.2021.09.003DOI Listing
September 2021

Clinical findings in patellofemoral osteoarthritis compared to individually-matched controls: a pilot study.

BMJ Open Sport Exerc Med 2020 9;6(1):e000877. Epub 2020 Dec 9.

Department of Family Practice, The University of British Columbia, Vancouver, Canada.

Objective: To explore clinical characteristics in individuals with patellofemoral osteoarthritis (PFOA) compared to individually-matched asymptomatic controls. We also explored associations between functional performance and patient-reported symptoms with patellofemoral alignment.

Methods: We assessed 15 individuals with PFOA and 15 individually-matched asymptomatic controls. In addition to physical examination and patient-reported questionnaires, we evaluated functional performance, lower extremity strength and range of motion, and patellar alignment (using MRI). We analysed group differences with Wilcoxon's matched-pairs signed rank tests, and within-group associations with Spearman's rank correlations.

Results: We included 24 (80%) women with median (IQR) age of 56 (9) years and BMI of 22.8 (5.9) kg/m. Individuals with PFOA reported lower quality of life (8/100 points lower EQ-5D-5L, p=0.02), and performed worse on two functional tests: repeated one-leg rises (median 16 fewer rises, p=0.04) and timed stair climb (1.2 s slower, p=0.03). There were no differences in strength tests performed or range of motion. Patellar proximal translation correlated with worse functional performance and worse patient-reported pain, function and self-efficacy, while lateral translation and lateral tilt correlated with worse knee-related quality of life (Spearman's r ranging from 0.5 to 0.7).

Conclusion: Functional performance was worse in individuals with PFOA, despite those individuals having no significant differences on lower extremity strength testing. Patellofemoral alignment was associated with worse functional performance as well as worse patient-reported outcomes, and it may represent one mechanism underpinning PFOA-related symptoms.
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http://dx.doi.org/10.1136/bmjsem-2020-000877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323464PMC
December 2020

The Validity, Reliability, and Responsiveness of the International Hip Outcome Tool-33 (iHOT-33) in Patients With Hip and Groin Pain Treated Without Surgery.

Am J Sports Med 2021 08 15;49(10):2677-2688. Epub 2021 Jul 15.

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

Background: The International Hip Outcome Tool-33 (iHOT-33) was developed to evaluate patients seeking surgery for hip and/or groin (hip/groin) pain and may not be appropriate for those seeking nonsurgical treatment.

Purpose: To evaluate the psychometric properties of the iHOT-33 total (iHOT-Total) score and all subscale scores in adults with hip/groin pain who were not seeking surgery.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Patients with hip/groin pain who were not seeking surgery were recruited from 2 ongoing studies in Australia. Semistructured one-on-one interviews assessed content validity. Construct validity was assessed by testing hypothesized correlations between iHOT-33 and Copenhagen Hip and Groin Outcome Score (HAGOS) subscale scores. Test-retest reliability was assessed in patients not undertaking treatment and who reported "no change" in their Global Rating of Change (GROC) score at 6-month follow-up. Scores were reliable at group and individual levels if intraclass correlation coefficients (ICCs) were ≥0.80 and ≥0.90, respectively. Scores were responsive if Spearman rank correlations (ρ) between the change in the iHOT-33 score and the GROC score were ≥0.40.

Results: In total, 278 patients with hip/groin pain (93 women; mean age, 31 years) and 55 pain-free control participants (14 women; mean age, 29 years) were recruited. The iHOT-33 demonstrated acceptable content validity. Construct validity was acceptable, with all hypothesized strong positive correlations between iHOT-33 and HAGOS subscale scores confirmed ( range, 0.60-0.76; < .001), except for one correlation between the iHOT-Sport and HAGOS-Sport ( = .058; < .001). All scores were reliable at the group level, except for the iHOT-33 job subscale (iHOT-Job) (ICC range, 0.78-0.88 [95% CI, 0.60-0.93]). None of the subscales met the criteria for adequate reliability for use at the individual level (all ICCs <0.90). Minimal detectable change values (group level) ranged from 2.3 to 3.7 (95% CI, 1.7-5.0). All iHOT-33 subscale scores were responsive (ρ range, 0.40-0.58; ≤ .001), except for the iHOT-Job in patients not undertaking treatment (ρ = 0.27; = .001).

Conclusion: All iHOT-33 subscale scores were valid for use in patients with hip/groin pain who were not seeking surgery. Acceptable test-retest reliability was found for all subscale scores at the group level, except the iHOT-Job. All subscale scores, excluding the iHOT-Job, were responsive, regardless of undertaking physical therapist-led treatment or no treatment.
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http://dx.doi.org/10.1177/03635465211027180DOI Listing
August 2021

Patient education improves pain and function in people with knee osteoarthritis with better effects when combined with exercise therapy: a systematic review.

J Physiother 2021 Jul 20;67(3):177-189. Epub 2021 Jun 20.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia; Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia; Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia. Electronic address:

Question: Is patient education effective as a standalone intervention or combined with other interventions for people with knee osteoarthritis?

Design: Systematic review of randomised controlled trials. MEDLINE, EMBASE, SPORTDiscus, CINAHL and Web of Science were searched from inception to April 2020. The Cochrane Risk of Bias tool was used for included studies, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to interpret certainty of results.

Participants: People with knee osteoarthritis.

Intervention: Any patient education intervention compared with any non-pharmacological comparator.

Outcome Measures: Primary outcomes were self-reported pain and function.

Results: Twenty-nine trials involving 4,107 participants were included, informing low to very-low certainty evidence. Nineteen of 28 (68%) pooled comparisons were not statistically significant. Patient education was superior to usual care for pain (SMD -0.35, 95% CI -0.56 to -0.14) and function in the short term (-0.31, 95% CI -0.62 to 0.00), but inferior to exercise therapy for pain in the short term (0.77, 95% CI 0.07 to 1.47). Combining patient education with exercise therapy produced superior outcomes compared with patient education alone for pain in the short term (0.44, 95% CI 0.19 to 0.69) and function in the short (0.81, 95% CI 0.54 to 1.08) and medium term (0.39, 95% CI 0.15 to 0.62). When using the Western Ontario and McMaster Universities Osteoarthritis Index for these comparisons, clinically important differences indicated that patient education was inferior to exercise therapy for pain in the short term (MD 1.56, 95% CI 0.14 to 2.98) and the combination of patient education and exercise therapy for function in the short term (8.94, 95% CI 6.05 to 11.82).

Conclusion: Although patient education produced statistically superior short-term pain and function outcomes compared with usual care, differences were small and may not be clinically important. Patient education should not be provided as a standalone treatment and should be combined with exercise therapy to provide statistically superior and clinically important short-term improvements in function compared with education alone.

Registration: PROSPERO CRD42019122004.
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http://dx.doi.org/10.1016/j.jphys.2021.06.011DOI Listing
July 2021

REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies.

Br J Sports Med 2021 Jun 14. Epub 2021 Jun 14.

Sports and Exercise Medicine, Queen Mary University of London, London, UK.

Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.
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http://dx.doi.org/10.1136/bjsports-2020-103700DOI Listing
June 2021

Through the athlete lens: A novel study exploring the perspectives and experiences of injury prevention practices in women playing elite Australian Football.

Braz J Phys Ther 2021 May 24. Epub 2021 May 24.

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

Background: Efficacious injury prevention programs exist, yet translation to practice in real-world settings is poor. Little is known about how women playing elite team ball-sports perceive and experience injury prevention programs in practice. Understanding the end-user's (athlete's) perspective is essential to improve program uptake and adherence.

Objective: To explore the perspectives and experiences of injury prevention practices in athletes from the elite Australian Football League for Women (AFLW).

Methods: Convenience sample of 13 athletes from three AFLW clubs. Semi-structured interviews were audio-recorded and transcribed verbatim, analysed with a thematic analysis approach, and classified within the Socio-Ecological Model (SEM).

Results: Women playing elite Australian Football: (1) believe injury prevention programs have multiple aims and benefits, (2) perceive varying injury prevention practices between and within AFLW clubs, (3) believe injury prevention program adoption and implementation is complex and multi-factorial, and (4) think implementing injury prevention programs in the AFLW could be enhanced through education and resources. Mapping our results onto the SEM highlighted that athletes perceive multiple ecological levels (i.e. individual, interpersonal, community, and organizational) are involved in sports injury prevention.

Conclusions: Multi-level engagement strategies are required to enhance injury prevention program adoption and implementation and to maximise athlete adherence.
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http://dx.doi.org/10.1016/j.bjpt.2021.05.003DOI Listing
May 2021

Acute and sub-acute changes in dynamic postural control following hip arthroscopy and post-operative rehabilitation."

J Athl Train 2021 May 26. Epub 2021 May 26.

2School of Allied Health, College of Science, Health and Engineering, La Trobe University. AUSTRALIA.

Context: Hip pain is associated with impairments in postural control and balance. The Star Excursion Balance Test (SEBT) is a reliable and valid method to measure dynamic postural control.

Objective: Examine changes to dynamic postural control following hip arthroscopy and subsequent rehabilitation from pre-surgery to three and six months post arthroscopy.

Setting: Sixty-seven individuals (47 men) scheduled for hip arthroscopy to address chondrolabral pathology were matched with sixty-seven healthy controls. The hip pain group underwent post-operative rehabilitation including SEBT training.

Main Outcome Measures: SEBT reach normalized to limb length was collected pre-surgery and at three and six months post surgery, and compared with healthy matched controls. Repeated measure analysis of variance (ANOVA) evaluated whether SEBT reach differed between the three time points and t-tests were used to evaluate between-limb and between-group differences.

Results: Pre-surgical SEBT reach was significantly less than the control group in all directions (p<0.001). At three months post surgery, SEBT reach significantly increased in the posterior-lateral (PL) (p<0.001), anterior-lateral (AL) (p<0.001) and posterior-medial (PM) (p=0.006) directions from pre-surgery. At six months post surgery, all directions of reach had significantly increased (p<0.001) from baseline. Compared to the control group, AL (-2.5 %, p=0.038), anterior medial (AM) (-2.9%, p=0.019) and posterior-medial (PM) (-5.2%, p= 0.002) reach remained significantly less at six months post surgery. No significant difference existed between the control and surgical groups for reach in the PL (-3.6%, p=0.061) direction.

Conclusions: Pre-surgical dynamic balance control within a hip pain group was significantly poorer than matched controls as measured by the SEBT. At three months post hip arthroscopy, there were significant improvements in dynamic balance in the PM, PL and AL SEBT directions. By six months post surgery, all directions of SEBT reach had significantly improved but only PL reach improved to the level of healthy controls.
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http://dx.doi.org/10.4085/1062-6050-0709.20DOI Listing
May 2021

Knowledge, confidence and learning needs of physiotherapists treating persistent knee pain in Australia and Canada: a mixed-methods study.

Physiother Theory Pract 2021 Apr 19:1-13. Epub 2021 Apr 19.

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

: To determine the knowledge and confidence of physiotherapists in managing knee osteoarthritis (OA) and patellofemoral pain (PFP); and explore their learning behaviors and preferences related to the management of these knee conditions.: One hundred and sixteen Australian and Canadian Physiotherapists were recruited via social media, e-mail, and an online course. Part 1: Quantitative involved an online survey evaluating knowledge of evidence and confidence in providing treatments for knee OA and PFP. Part 2: Qualitative involved semi-structured interviews with 13 participants exploring current practice and learning needs, that were analyzed using an initial framework structured on interview questions, followed by inductive approach to identify additional themes.: Awareness regarding evidence supporting exercise for knee OA and PFP was good (89-96%), and qualitative themes indicated physiotherapists emphasized exercise-therapy and education. Perceived value of passive treatments and surgery varied. Preference for face-to-face workshops to address learning needs, alongside describing time and cost barriers to access them, emerged from qualitative findings. Online learning formats were viewed as convenient, but not as effective as face-to-face learning.: Knowledge and confidence related to interventions for knee OA and PFP of Australian and Canadian physiotherapist participants broadly aligns with guidelines. Knowledge translation strategies focused on face-to-face workshops, supported by online education may help to bridge evidence-to-practice gaps.
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http://dx.doi.org/10.1080/09593985.2021.1906805DOI Listing
April 2021

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

Physiotherapist-led treatment for femoroacetabular impingement syndrome (the PhysioFIRST study): a protocol for a participant and assessor-blinded randomised controlled trial.

BMJ Open 2021 04 7;11(4):e041742. Epub 2021 Apr 7.

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

Introduction: This double-blind, randomised controlled trial (RCT) aims to estimate the effect of a physiotherapist-led intervention with targeted strengthening compared with a physiotherapist-led intervention with standardised stretching, on hip-related quality of life (QOL) or perceived improvement at 6 months in people with femoroacetabular impingement (FAI) syndrome. We hypothesise that at 6 months, targeted strengthening physiotherapist-led treatment will be associated with greater improvements in hip-related QOL or greater patient-perceived global improvement when compared with standardised stretching physiotherapist-led treatment.

Methods And Analysis: We will recruit 164 participants with FAI syndrome who will be randomised into one of the two intervention groups, both receiving one-on-one treatment with the physiotherapist over 6 months. The targeted strengthening physiotherapist-led treatment group will receive a personalised exercise therapy and education programme. The standardised stretching physiotherapist-led treatment group will receive standardised stretching and personalised education programme. Primary outcomes are change in hip-related QOL using International Hip Outcome Tool-33 and patient-perceived global improvement. Secondary outcomes include cost-effectiveness, muscle strength, range of motion, functional task performance, biomechanics, hip cartilage structure and physical activity levels. Statistical analyses will make comparisons between both treatment groups by intention to treat, with all randomised participants included in analyses, regardless of protocol adherence. Linear mixed models (with baseline value as a covariate and treatment condition as a fixed factor) will be used to evaluate the treatment effect and 95% CI at primary end-point (6 months).

Ethics And Dissemination: The study protocol was approved (La Trobe University Human Ethics Committee (HEC17-080)) and prospectively registered with the Australian New Zealand Clinical Trials Registry. The findings of this RCT will be disseminated through peer reviewed scientific journals and conferences. Patients were involved in study development and will receive a short summary following the completion of the RCT.

Trial Registration Number: ACTRN12617001350314.
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http://dx.doi.org/10.1136/bmjopen-2020-041742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8031040PMC
April 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

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

Patellofemoral alignment, morphology and structural features are not related to sitting pain in individuals with patellofemoral pain.

Knee 2021 Jan 14;28:104-109. Epub 2020 Dec 14.

Department of General Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands.

Background: Sitting-related pain is a common feature of patellofemoral pain (PFP). However, little is known regarding features associated with sitting-related PFP. The aim of this study was to determine whether sitting-related PFP is associated with patellofemoral alignment, morphology and structural magnetic resonance imaging (MRI) features of the patellofemoral joint (cartilage lesions, bone marrow lesions, fat pad synovitis).

Methods: 133 individuals with PFP were included from two unique but similar cohorts. Participants were classified into one of three groups based on their response to item 8 of the Anterior Knee Pain Scale: (i) problems with sitting; (ii) sitting pain after exercise; and (iii) no difficulty with sitting. All participants underwent 3T Magnetic Resonance Imaging (MRI) to enable: (i) scoring of structural features of the patellofemoral joint with MRI Osteoarthritis Knee Score (MOAKS); and (ii) patellofemoral alignment and morphology measurements using standardised methods. The association of sitting pain to bony alignment, morphology and MOAKS features were evaluated using multinomial logistic regression (adjusted for age, sex, BMI; reference group = no difficulty with sitting).

Results: 82 (61.7%) participants reported problems with sitting, and 24 (18%) participants reported sitting pain after exercise. There were no significant associations between the presence of sitting pain and any morphology, alignment or structural characteristics.

Conclusions: Findings indicate that PFP related to sitting is not associated with patellofemoral alignment, morphology, or structural MRI features of the patellofemoral joint. Further research to determine mechanisms of sitting-related PFP, and inform targeted treatments, are required.
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http://dx.doi.org/10.1016/j.knee.2020.10.009DOI Listing
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

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

Lower-limb work during high- and low-impact activities in hip-related pain: Associations with sex and symptom severity.

Gait Posture 2021 01 29;83:1-8. Epub 2020 Sep 29.

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

Background: Hip-related pain (HRP) is described as a movement-related disorder. However, little attention is given to the way people with HRP move, especially in populations still participating in sport. Thus, limiting our understanding of movementbased impairments in HRP and their potential relationships with pain/symptoms.

Research Question: (1) What are the differences in absolute and relative amounts of positive and negative lower-limb joint work during walking and the single-leg drop jump (SLDJ) in football players with and without HRP? (2) What are the relationships between lower-limb joint work and HRP burden?

Methods: 88 football players with HRP and 30 control football players were recruited. Positive and negative work done by the hip, knee, and ankle (and each joint's relative contribution to total work done) were calculated. The effect of sex on the relationship between HRP and work done, as well as the association between work done and International Hip Outcome Tool (iHOT33) scores, were assessed using linear and beta regressions models.

Results: Walking: No joint work variables were significantly different between groups, nor were any relationships with iHOT33 scores evident. SLDJ: The knee's relative contribution to total lower-limb negative work done was 37.7 % and 42.4 % for women with and without HRP, respectively (P = 0.04). The iHOT33 was significantly associated with positive (P = 0.03 to <0.01) and negative (P = 0.02 to <0.01) work done by the hip as well as negative work done by the ankle (P = 0.03 to 0.01), independent of sex.

Significance: Only one significant between-group comparison was revealed, involving the knee in female football players. In addition, football players with a greater selfreported burden of HRP tended to display lower hip joint work during the SLDJ. Rehabilitation programs could be targeted to address these impairments and normalize work done during high impact tasks in the management of HRP.
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http://dx.doi.org/10.1016/j.gaitpost.2020.09.025DOI Listing
January 2021

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

Pericapsular hip muscle activity in people with and without femoroacetabular impingement. A comparison in dynamic tasks.

Phys Ther Sport 2020 Sep 25;45:135-144. Epub 2020 Jul 25.

The University of Queensland, School of Health & Rehabilitation Sciences, Brisbane, Queensland, 4072, Australia; La Trobe Sport and Exercise Medicine Research Centre (LASEM), College of Science, Health and Engineering, School of Allied Health, La Trobe University, Melbourne, Victoria, 3086, Australia. Electronic address: https://twitter.com/ASemciw.

Objectives: Compare anterior pericapsular muscle activity between individuals with and without femoroacetabular impingement syndrome (FAIS) during dynamic tasks, to investigate whether muscle activity is consistent with a role in retracting the capsule to prevent impingement and active restraint of the femoral head in walking.

Design: Cross-sectional.

Setting: University-laboratory.

Participants: Thirteen athletes with FAIS and 13 pain-free controls.

Main Outcome Measures: Muscle activity was recorded using fine-wire (Iliocapsularis, iliacus and anterior gluteus minimus) and surface (rectus femoris) electromyography (EMG), during three hip flexion tasks (active and assisted hip flexion; squatting) and four walking trials.

Results: Iliocapsularis EMG amplitude was no different between active and assisted hip flexion tasks around 90° of hip flexion in FAIS. There was no difference in EMG between groups in squatting. The pattern of burst activity preceding peak hip extension in iliacus, iliocapsularis, and anterior gluteus minimus was similar in both groups during walking.

Conclusion: In FAIS, similar activation of iliocapsularis during active and assisted hip flexion, despite reduced flexion torque demand in the latter, suggests a role in capsular retraction or enhanced hip joint protection. Pericapsular muscle activity in advance of peak hip extension during walking is consistent with a proposed contribution to femoral head control.
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http://dx.doi.org/10.1016/j.ptsp.2020.06.004DOI Listing
September 2020

HAPPi Kneecaps! Protocol for a participant- and assessor-blinded, randomised, parallel group feasibility trial of foot orthoses for adolescents with patellofemoral pain.

J Foot Ankle Res 2020 Aug 2;13(1):50. Epub 2020 Aug 2.

Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, 4072, Australia.

Background: Patellofemoral pain (PFP) is a common cause of knee pain in adolescents, but there are limited evidence-based treatment options for this population. Foot orthoses can improve pain and function in adults with PFP, and may be effective for adolescents. The primary aim of this study is to determine the feasibility of conducting a full-scale randomised controlled trial (RCT) evaluating the effects of contoured foot orthoses on knee pain severity and patient-perceived global change, compared to flat shoe insoles, in adolescents with PFP. The secondary aim is to provide an estimate of treatment effects for foot orthoses, compared to flat insoles, in adolescents with PFP.

Methods: This randomised, controlled, participant- and assessor-blinded, feasibility trial has two parallel groups. Forty adolescents (aged 12-18 years) with clinical symptoms of PFP will be recruited from Queensland, Australia. Participants will be randomised to receive either prefabricated contoured foot orthoses or flat shoe insoles. Both interventions will be fit by a physiotherapist, and worn for 3 months. Feasibility will be evaluated through assessing willingness of volunteers to enrol, number of eligible participants, recruitment rate, adherence with the study protocol, adverse effects, success of blinding, and drop-out rate. Secondary outcomes will evaluate knee-related pain, symptoms, function, quality of life, global rating of change, patient acceptable symptom state, and use of co-interventions, at 6 weeks and 3 months. Primary outcomes will be reported descriptively, while estimates of standard deviation and between-group differences (with 95% confidence intervals) will be reported for secondary outcomes.

Discussion: Findings of this study will inform the feasibility of a full-scale RCT investigating the efficacy of contoured foot orthoses in adolescents with PFP. This full-scale study is necessary to improve the evidence base for management of adolescent PFP, and enhance outcomes for this population.

Trial Registration: ACTRN12619000957190 .
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http://dx.doi.org/10.1186/s13047-020-00417-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397622PMC
August 2020

Novel Stepped Care Approach to Provide Education and Exercise Therapy for Patellofemoral Pain: Feasibility Study.

J Med Internet Res 2020 07 22;22(7):e18584. Epub 2020 Jul 22.

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

Background: Patellofemoral pain (PFP) impairs joint- and health-related quality of life and may be associated with knee osteoarthritis. We developed a novel, 2-phase, stepped-care approach for PFP, combining (1) self-directed web-based education and exercise therapy with (2) physiotherapist-supported education and exercise therapy. Physiotherapy sessions can be provided using 2 different modalities: face-to-face and telerehabilitation.

Objective: This study aims to (1) determine the feasibility of our stepped-care approach, (2) explore patient-reported outcomes following self-directed web-based education and exercise therapy in people with PFP (phase 1), and (3) estimate the differences in treatment effects between face-to-face and telerehabilitation to support further education and exercise therapy (phase 2) in those who had not completely recovered following self-directed care.

Methods: Phase 1 involved 6 weeks of self-directed web-based education and exercise therapy. Phase 2 involved random allocation to a further 12 weeks of physiotherapist-led (up to 8 sessions) education and exercise therapy delivered face-to-face or via telerehabilitation to participants who did not rate themselves as completely recovered following phase 1. Feasibility indicators of process, adherence, and participant retention were collected as primary outcomes alongside patient-reported outcomes on Global Rating of Change and knee pain, disability, knee-related quality of life, pain catastrophism, kinesiophobia, and knee self-efficacy. All participants were assessed at baseline, 6 weeks, and 18 weeks.

Results: A total of 71 participants were screened to identify 35 participants with PFP to enter the study. Overall, 100% (35/35) and 88% (31/35) of the participants were followed up with at 6 and 18 weeks, respectively. In phase 1 of the study, participants accessed the My Knee Cap website for an average of 6 (7.5) days and performed the exercises for an average of 2.5 (3.6) times per week. A total of 20% (7/35) of the participants reported that they had completely recovered at 6 weeks. Furthermore, 93% (26/28) of the participants who were followed up and had not completely recovered at 6 weeks agreed to be enrolled in phase 2. No statistically significant differences were found between the face-to-face and telerehabilitation groups for any outcome. The novel stepped-care approach was associated with marked improvement or complete recovery in 40% (14/35) of the participants following phase 1 and 71% (25/35) of the participants following phase 2.

Conclusions: Self-directed web-based education and exercise therapy for people with PFP is feasible, as noted by the high rate of participant retention and home exercise adherence achieved in this study. Furthermore, 20% (7/35) of people reported complete recovery at 6 weeks. Both face-to-face and telerehabilitation physiotherapy should be considered for those continuing to seek care, as there is no difference in outcomes between these delivery modes. Determining the efficacy of the stepped-care model may help guide more efficient health care for PFP.
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http://dx.doi.org/10.2196/18584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407256PMC
July 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

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

Improving function in people with hip-related pain: a systematic review and meta-analysis of physiotherapist-led interventions for hip-related pain.

Br J Sports Med 2020 Dec 6;54(23):1382-1394. Epub 2020 May 6.

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

Objective: To report the effectiveness of physiotherapist-led interventions in improving pain and function in young and middle-aged adults with hip-related pain.

Design: Systematic review and meta-analysis.

Data Sources: A comprehensive, reproducible search strategy was performed on five databases in May 2019. Reference lists and grey literature were also searched.

Eligibility Criteria For Selecting Studies: Population: people aged ≥18 years with hip-related pain (with or without a diagnosis of femoroacetabular impingement syndrome).

Intervention(s): physiotherapist-led interventions for hip pain. Comparators: sham treatment, no treatment or other treatment (eg, hip arthroscopic surgery).

Outcomes: primary outcomes included patient-reported hip pain and function. Secondary outcomes included physical function measures.

Results: 1722 papers were identified. After exclusion criteria were applied, 14 studies were included for analysis. They had varied risk of bias. There were no full-scale placebo-controlled randomised controlled trials (RCTs) of physiotherapist-led treatment. Pooled effects ranged from moderate effects (0.67 (95% CI 0.07 to 1.26)) favouring physiotherapist-led intervention over no treatment post-arthroscopy, to weak effects (-0.32 (95% CI 0.57 to 0.07)) favouring hip arthroscopy over physiotherapist-led treatment.

Conclusion: Physiotherapist-led interventions might improve pain and function in young and middle-aged adults with hip-related pain, however full-scale high-quality RCT studies are required.

Prospero Registration Number: CRD42018089088.
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http://dx.doi.org/10.1136/bjsports-2019-101690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677471PMC
December 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

Poor functional performance 1 year after ACL reconstruction increases the risk of early osteoarthritis progression.

Br J Sports Med 2020 May 10;54(9):546-553. Epub 2020 Apr 10.

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

Background: Not meeting functional performance criteria increases reinjury risk after ACL reconstruction (ACLR), but the implications for osteoarthritis are not well known.

Objective: To determine if poor functional performance post-ACLR is associated with risk of worsening early osteoarthritis features, knee symptoms, function and quality of life (QoL).

Methods: Seventy-eight participants (48 men) aged 28±15 years completed a functional performance test battery (three hop tests, one-leg-rise) 1 year post-ACLR. Poor functional performance was defined as <90% limb symmetry index (LSI) on each test. At 1 and 5 years, MRI, Knee injury Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective form were completed. Primary outcomes were: (i) worsening patellofemoral and tibiofemoral MRI-osteoarthritis features (cartilage, bone marrow lesions (BMLs) and meniscus) and (ii) change in KOOS and IKDC scores, between 1 and 5 years.

Results: Only 14 (18%) passed (≥90% LSI on all tests) the functional test battery. Poor functional performance on the battery (all four tests <90% LSI) 1 year post-ACLR was associated with 3.66 times (95% CI 1.12 to 12.01) greater risk of worsening patellofemoral BMLs. A triple-crossover hop <90% LSI was associated with 2.09 (95% CI 1.15 to 3.81) times greater risk of worsening patellofemoral cartilage. There was generally no association between functional performance and tibiofemoral MRI-osteoarthritis features, or KOOS/IKDC scores.

Conclusion: Only one in five participants met common functional performance criteria (≥90% LSI all four tests) 1 year post-ACLR. Poor function on all four tests was associated with a 3.66 times increased risk of worsening patellofemoral BMLs, and generally not associated with decline in self-reported outcomes.
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http://dx.doi.org/10.1136/bjsports-2019-101503DOI Listing
May 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

Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial.

Br J Sports Med 2020 Dec 26;54(23):1416-1422. Epub 2020 Mar 26.

University of Queensland, Brisbane, Queensland, Australia

Objectives: To test (i) if greater foot pronation (measured as midfoot width mobility) is associated with better outcomes with foot orthoses treatment, compared with hip exercises and (ii) if hip exercises are superior to foot orthoses, irrespective of midfoot width mobility.

Methods: A two-arm parallel, randomised superiority clinical trial was conducted in Australia and Denmark. Participants (18-40 years) were included who reported an insidious onset of knee pain (≥6 weeks duration); ≥3/10 numerical pain rating, that was aggravated by activities (eg, stairs, squatting, running). Participants were stratified by midfoot width mobility ( ≥11 mm change in midfoot width) and site, randomised to foot orthoses or hip exercises and blinded to objectives and stratification. Success was defined a priori as or on a patient-perceived 7-point scale at 12 weeks.

Results: Of 218 stratified and randomised participants, 192 completed 12-week follow-up. This study found no difference in success rates between foot orthoses versus hip exercises in those with (6/21 vs 9/20; 29% vs 45%, respectively) or (42/79 vs 37/72; 53% vs 51%) midfoot width mobility. There was no association between midfoot width mobility and treatment outcome (Interaction effect p=0.19). This study found no difference in success rate between foot orthoses versus hip exercises (48/100 vs 46/92; 48% vs 50%).

Conclusion: Midfoot width mobility should not be used to help clinicians decide which patient with patellofemoral pain might benefit most from foot orthoses. Clinicians and patients may consider either foot orthoses or hip exercises in managing patellofemoral pain.

Trial Registration Number: ACTRN12614000260628.
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http://dx.doi.org/10.1136/bjsports-2019-100935DOI Listing
December 2020
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