Publications by authors named "Rianne A van der Heijden"

19 Publications

  • Page 1 of 1

Quantitative volume and dynamic contrast-enhanced MRI derived perfusion of the infrapatellar fat pad in patellofemoral pain.

Quant Imaging Med Surg 2021 Jan;11(1):133-142

Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.

Background: Patellofemoral pain (PFP) is a common knee condition and possible precursor of knee osteoarthritis (OA). Inflammation, leading to an increased perfusion, or increased volume of the infrapatellar fat pad (IPFP) may induce knee pain. The aim of the study was to compare quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters, as imaging biomarkers of inflammation, and volume of the IPFP between patients with PFP and controls and between patients with and without IPFP edema or joint effusion.

Methods: Patients with PFP and healthy controls were included and underwent non-fat suppressed 3D fast-spoiled gradient-echo (FSPGR) and DCE-MRI. Image registration was applied to correct for motion. The IPFP was delineated on FSPGR using Horos software. Volume was calculated and quantitative perfusion parameters were extracted by fitting extended Tofts' pharmacokinetic model. Differences in volume and DCE-MRI parameters between patients and controls were tested by linear regression analyses. IPFP edema and effusion were analyzed identically.

Results: Forty-three controls and 35 PFP patients were included. Mean IPFP volume was 26.04 (4.18) mL in control subjects and 27.52 (5.37) mL in patients. Median K was 0.017 (0.016) min in control subjects and 0.016 (0.020) min in patients. None of the differences in volume and perfusion parameters were statistically significant. Knees with effusion showed a higher perfusion of the IPFP compared to knees without effusion in patients only.

Conclusions: The IPFP has been implicated as source of knee pain, but higher DCE-MR blood perfusion, an imaging biomarker of inflammation, and larger volume are not associated with PFP. Patient's knees with effusion showed a higher perfusion, pointing towards inflammation.
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http://dx.doi.org/10.21037/qims-20-441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719925PMC
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

Editorial for "Failed Total Hip Arthroplasty: Diagnostic Performance of Locoregional Lymphadenopathy at MRI to Identify Infected Implants".

J Magn Reson Imaging 2021 01 18;53(1):211-212. Epub 2020 Aug 18.

Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1002/jmri.27333DOI Listing
January 2021

Patellofemoral alignment and geometry and early signs of osteoarthritis are associated in patellofemoral pain population.

Scand J Med Sci Sports 2020 May 18;30(5):885-893. Epub 2020 Mar 18.

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

Background: Patellofemoral pain (PFP) patients show increased prevalence of patellar malalignment. Structural and alignment abnormalities of the patellofemoral joint (PFJ) may play a role in development of PFP and patellofemoral osteoarthritis (PFOA).

Objectives: Evaluating associations of patellofemoral alignment and femoral geometry with bony and cartilaginous abnormalities in PFP patients and healthy control subjects.

Methods: Data from a case-control study were used (64 PFP subjects, 70 control subjects, 57% female, age 23.2 (6.4)). Alignment and femoral geometry measures in the PFJ were determined using MRI. Structural abnormalities in the PFJ associated with OA (bone marrow lesions, osteophytes, minor cartilage defects and Hoffa-synovitis), quantified cartilage composition (T1ρ relaxation times) in the PFJ and perfusion within the patellar bone were examined using different MRI techniques. Associations were analyzed using regression analyses, adjusted for potential confounders.

Results: Lateral patellar tilt was negatively associated with presence of osteophytes on both patella (OR 0.91; 95% CI 0.84 to 0.98), anterior femur (OR 0.92; 95% CI 0.84 to 0.99) and minor cartilage defects on patella (OR 0.91; 95% CI 0.84 to 0.99). Patella alta was positively associated with the presence of bone marrow lesions in the patella and minor cartilage defects (OR 48.33; 95% CI 4.27 to 547.30 and OR 17.51; 95% CI 1.17 to 262.57, respectively). Patella alta and medial patellar translation were positively associated with T1ρ relaxation times within trochlear cartilage (β 5.2; 95% CI 0.77 to 9.58, and 0.36; 95% CI 0.08 to 0.64, respectively). None of the alignment and geometry measures were associated with bone perfusion.

Conclusion: Our study implies that associations between patellofemoral alignment and geometry and structural joint abnormalities linked to OA are already present in both PFP patients and healthy control subjects.
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http://dx.doi.org/10.1111/sms.13641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187437PMC
May 2020

Quantitative DCE-MRI demonstrates increased blood perfusion in Hoffa's fat pad signal abnormalities in knee osteoarthritis, but not in patellofemoral pain.

Eur Radiol 2020 Jun 17;30(6):3401-3408. Epub 2020 Feb 17.

Department of Radiology & Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.

Objective: Infrapatellar fat pad (IPFP) fat-suppressed T2 (T2) hyperintense regions on MRI are an important imaging feature of knee osteoarthritis (OA) and are thought to represent inflammation. These regions are also common in non-OA subjects, and may not always be linked to inflammation. Our aim was to evaluate quantitative blood perfusion parameters, as surrogate measure of inflammation, within T2-hyperintense regions in patients with OA, with patellofemoral pain (PFP) (supposed OA precursor), and control subjects.

Methods: Twenty-two knee OA patients, 35 PFP patients and 43 healthy controls were included and underwent MRI, comprising T2 and DCE-MRI sequences. T2-hyperintense IPFP regions were delineated and a reference region was drawn in adjacent IPFP tissue with normal signal intensity. After fitting the extended Tofts pharmacokinetic model, quantitative DCE-MRI perfusion parameters were compared between the two regions within subjects in each subgroup, using a paired Wilcoxon signed-rank test.

Results: T2-hyperintense IPFP regions were present in 16 of 22 (73%) OA patients, 13 of 35 (37%) PFP patients, and 14 of 43 (33%) controls. DCE-MRI perfusion parameters were significantly different between regions with and without a T2-hyperintense signal in OA patients, demonstrating higher Ktrans compared to normal IFPF tissue (0.039 min versus 0.025 min, p = 0.017) and higher Ve (0.157 versus 0.119, p = 0.010). For PFP patients and controls no significant differences were found.

Conclusions: IPFP T2-hyperintense regions are associated with higher perfusion in knee OA patients in contrast to identically appearing regions in PFP patients and controls, pointing towards an inflammatory pathogenesis in OA only.

Key Points: • Morphologically identical appearing T2-hyperintense infrapatellar fat pad regions show different perfusion in healthy subjects, subjects with patellofemoral pain, and subjects with knee osteoarthritis. • Elevated DCE-MRI perfusion parameters within T2-hyperintense infrapatellar fat pad regions in patients with osteoarthritis suggest an inflammatory pathogenesis in osteoarthritis, but not in patellofemoral pain and healthy subjects.
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http://dx.doi.org/10.1007/s00330-020-06671-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7248045PMC
June 2020

Quantitative subchondral bone perfusion imaging in knee osteoarthritis using dynamic contrast enhanced MRI.

Semin Arthritis Rheum 2020 Apr 1;50(2):177-182. Epub 2019 Aug 1.

Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands. Electronic address:

Objective: Subchondral bone changes, characterized by increased bone turnover and vascularity, are believed to stimulate progression and pain in knee osteoarthritis (OA). The objective of this study was to evaluate the bone perfusion in knee OA using quantitative dynamic contrast enhanced MRI (DCE-MRI).

Design: Unicompartmental knee OA patients were included and underwent 3 Tesla DCE-MRI and T2-weighted MRI. Quantitative DCE-MRI analysis of Ktrans and Kep, representing perfusion parameters, was performed to evaluate differences between the most and least affected knee compartment. First, DCE-MRI parameter differences between epimetaphyseal and subchondral bone in both femur and tibia were assessed. Second, DCE-MRI parameters in subchondral bone marrow lesions (BMLs) were compared to surrounding subchondral bone without BMLs.

Results: Twenty-three patients were analyzed. Median Ktrans and Kep in epimetaphyseal bone were significantly higher (p < 0.05) in the most affected (Ktrans: 0.014; Kep: 0.054 min) compared to least affected (Ktrans: 0.010; Kep: 0.016 min) compartment. For subchondral bone, DCE-MRI parameters were significantly higher (p < 0.05) in the most affected (Ktrans: 0.019; Kep: 0.091 min) compared to least affected (Ktrans: 0.014; Kep: 0.058 min) compartment as well. Subchondral BMLs detected on fat-saturated T2-weighted images were present in all patients. Median Ktrans (0.091 vs 0.000 min) and Kep (0.258 vs 0.000 min) were significantly higher within subchondral BMLs compared to surrounding subchondral bone without BMLs (p < 0.001).

Conclusions: Increased perfusion parameters in epimetaphyseal bone, subchondral bone and BMLs are observed in unicompartmental knee OA. BMLs likely account for most of the effect of the higher bone perfusion in knee OA.
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http://dx.doi.org/10.1016/j.semarthrit.2019.07.013DOI Listing
April 2020

Association Between Self-reported Measures, Physical Examination, and Early Magnetic Resonance Imaging Signs of Osteoarthritis in Patients With Patellofemoral Pain.

J Orthop Sports Phys Ther 2019 09 10;49(9):634-639. Epub 2019 Jul 10.

Background: Structural abnormalities associated with osteoarthritis (OA) are found in some patients with patellofemoral pain (PFP).

Objectives: To investigate the association between early signs of OA on magnetic resonance imaging (MRI) and characteristics from self-reported measures and physical examination in patients with PFP.

Methods: This exploratory study included data from patients with PFP from a previously published cross-sectional case-control study (n = 64; 55% female; mean ± SD age, 23.4 ± 7.0 years). Structural OA features (osteophytes, bone marrow lesions, cartilage defects, Hoffa synovitis, patellar tendon abnormalities) and quantitative T2 measurements of cartilage composition were extracted from MRI. Associations between characteristics from self-reported measures (pain at rest, pain during stair walking, knee function, duration of complaints, hours of sports participation each week), physical examination (crepitus, quadriceps strength), and early MRI signs of OA were assessed.

Results: Symptom duration was associated with bone marrow lesions in the patella (odds ratio [OR] = 1.1; 95% confidence interval [CI]: 1.0, 1.2). Sports participation (hours per week) was inversely associated with patellar tendon abnormalities on MRI (OR = 0.8; 95% CI: 0.6, 1.0). Crepitus and bilateral nature of the complaints were associated with minor patellar cartilage defects (OR = 12.0; 95% CI: 2.3, 63.6 and OR = 7.6; 95% CI: 1.1, 53.8, respectively). There were no significant associations between clinical characteristics and cartilage T2 relaxation time.

Conclusion: Presence of crepitus, bilateral complaints, a long PFP symptom duration, and reduced weekly sport participation were associated with early signs of OA in a young PFP population.

Level Of Evidence: Etiology, level 2c. .
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http://dx.doi.org/10.2519/jospt.2019.8889DOI Listing
September 2019

Are Patellofemoral Joint Alignment and Shape Associated With Structural Magnetic Resonance Imaging Abnormalities and Symptoms Among People With Patellofemoral Pain?

Am J Sports Med 2018 11 15;46(13):3217-3226. Epub 2018 Oct 15.

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

Background: Patellofemoral malalignment has been observed among people with patellofemoral pain (PFP) and may be associated with the presence of imaging features of osteoarthritis, symptoms, and function.

Purpose: To determine whether patellofemoral joint alignment and bony shape are associated with (1) cartilage, bone, and soft tissue morphological abnormalities defined on magnetic resonance imaging (MRI) and (2) reported symptoms and function among people with PFP.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Participants (mean ± SD age, 30.2 ± 9.5 years; range, 14-50 years; 78 females, 58.6%) completed questionnaires regarding demographics, pain, symptoms, and function and underwent a 3-T MRI scan of their more symptomatic eligible knee. Structural MRI abnormalities were scored with the MOAKS (Magnetic Resonance Imaging Osteoarthritis Knee Score), and MRI alignment and shape were measured with standardized methods. Associations among MOAKS features, PFP symptoms, and alignment and shape measures were evaluated with regression analyses (α = .05).

Results: Minor cartilage defects were present in 22 (16.5%) participants, patellar osteophytes in 83 (62.4%), anterior femur osteophytes in 29 (21.8%), Hoffa synovitis in 81 (60.9%), and prefemoral fat pad synovitis in 49 (36.8%). A larger Insall-Salvati ratio was significantly associated with the presence of patellar osteophytes (odds ratio [OR], 51.82; 95% CI, 4.20-640.01), Hoffa synovitis (OR, 60.37; 95% CI, 4.66-782.61), and prefemoral fat pad synovitis (OR, 43.31; 95% CI, 4.28-438.72) in the patellofemoral joint. A larger patellar tilt angle was significantly associated with the presence of minor cartilage defects (OR, 1.10; 95% CI, 1.00-1.20), the presence of patellar osteophytes (OR 1.12; 95%CI 1.02-1.22), and prefemoral fat pad synovitis (OR, 1.11; 95% CI, 1.03-1.20) in the patellofemoral joint. Finally, a larger bisect offset was significantly associated with the presence of minor cartilage defects (OR, 1.05; 95% CI, 1.00-1.11) and patellar osteophytes (OR, 1.07; 95% CI, 1.01-1.14) in the patellofemoral joint. The majority of patellofemoral alignment measures were not associated with symptoms or function.

Conclusion: For people with PFP, the presence of morphological abnormalities defined on MRI appears to be related to particular patellofemoral alignment measures, including higher Insall-Salvati ratio (indicating patella alta), larger patellar tilt angle (indicating greater lateral tilt), and larger bisect offset (indicating greater lateral displacement). Hardly any associations were found with symptoms or function. So there might be a distinct subgroup of PFP that is more prone to developing patellofemoral osteoarthritis later in life, as particular alignment measures seem to be associated with the presence of patellar osteophytes. Prospective studies are required to investigate the longitudinal relationship between alignment or bony shape and morphological abnormalities defined on MRI in this patient population.
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http://dx.doi.org/10.1177/0363546518801314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236631PMC
November 2018

Blood perfusion of patellar bone measured by dynamic contrast-enhanced MRI in patients with patellofemoral pain: A case-control study.

J Magn Reson Imaging 2018 11 7;48(5):1344-1350. Epub 2018 May 7.

Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.

Background: Altered perfusion might play an important role in the pathophysiology of patellofemoral pain (PFP), a common knee complaint with unclear pathophysiology.

Purpose: To investigate differences in dynamic contrast-enhanced (DCE)-MRI perfusion parameters between patients with PFP and healthy control subjects.

Population/subjects/phantom/specimen/animal Model: Thirty-five adult patients with PFP and 44 healthy adult control subjects.

Field Strength/sequence: 3T DCE-MRI consisting of a sagittal, anterior-posterior, frequency-encoded, fat-suppressed 3D spoiled gradient-echo sequence with intravenous contrast administration.

Assessment: Patellar bone volumes of interest (VOIs) were delineated by a blinded observer. Quantitative perfusion parameters (k and k ) were calculated from motion-compensated DCE-MRI data by fitting Tofts' model. Weighted mean and unweighted median values of k and k were computed within the patellar bone VOIs.

Statistical Tests: Differences in patellar bone perfusion parameters were compared between groups by linear regression analyses, adjusted for confounders.

Results: Mean differences of weighted mean and unweighted median were 0.0039 (95% confidence interval [CI] -0.0013; 0.0091) and 0.0052 (95% CI -0.0078; 0.018) for k , and 0.046 (95% CI -0.021; 0.11) and 0.069 (95% CI -0.017; 0.15) for k , respectively. All perfusion parameters were not significantly different between groups (P-values: 0.32; 0.47 for k , and 0.24; 0.15) for k . However, a significant difference in variance between populations was observed for k (P-value 0.007).

Data Conclusion: Higher patellar bone perfusion parameters were found in patients with PFP when compared to healthy control subjects, but these differences were not statistically significant. This result, and the observed significant difference in k variance, warrant further research.

Level Of Evidence: 1 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1344-1350.
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http://dx.doi.org/10.1002/jmri.26174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6221059PMC
November 2018

International patellofemoral osteoarthritis consortium: Consensus statement on the diagnosis, burden, outcome measures, prognosis, risk factors and treatment.

Semin Arthritis Rheum 2018 04 23;47(5):666-675. Epub 2017 Sep 23.

Department of General Practice, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; Department of Orthopaedic Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.

Objective: To present the current status of knowledge in the field of patellofemoral (PF) osteoarthritis (OA) and formulate a research agenda in order to guide future research on this topic.

Design: A 1-day meeting was organized with the aim to bring together international experts in the field to discuss the current state of knowledge on PF OA. Experts from multiple disciplines were invited based on their scientific publications in the field of PF OA and interest in the subject. Topics discussed include the diagnosis, impact, prognosis, and treatment of PF OA.

Methods: Following context-setting presentations, an interactive discussion was held in order to achieve consensus on the PF OA topics of interest: (1) diagnosis and definition; (2) burden; (3) outcome measures; (4) prognosis; (5) risk factors, and (6) treatment. Groups of meeting attendees reviewed the literature on these topics and narratively summarized the current state of knowledge, and each group formulated research agenda items relevant to the specific topics of interest. Each consortium member consequently ranked the importance of all items on a 0-10 Numerical Rating Scale (NRS) (10 = extremely important, to 0 = not at all important).

Results: After ranking all formulated items on importance, 6 of the 28 research agenda items formulated received an average of 7.5 points on the NRS. The most highly ranked items covered the fields of treatment, diagnosis, and definition of PF OA.

Conclusions: We recommend to develop clear clinical criteria for PF OA and to reach consensus on the definition of PF OA by both radiographs and MRI. Additionally, more understanding is necessary to be able to distinguish PF symptoms from those arising from the tibiofemoral joint. More insight is needed on effective treatment strategies for PF OA; specifically, tailoring nonpharmacological treatments to individuals with PF OA, and determining whether isolated PF OA requires different treatment strategies than combined PF and tibiofemoral OA.
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http://dx.doi.org/10.1016/j.semarthrit.2017.09.009DOI Listing
April 2018

Characteristics and Outcome of Patellofemoral Pain in Adolescents: Do They Differ From Adults?

J Orthop Sports Phys Ther 2017 Oct 4;47(10):801-805. Epub 2017 Sep 4.

Study Design Case series with 1-year follow-up. Background Most of the recommendations for the diagnosis, treatment, and prognosis of patellofemoral pain (PFP) are based on research performed in adults. The literature suggests that there are potential differences between adolescents and adults with PFP. Objectives To investigate differences in characteristics, symptoms, and prognosis at 1-year follow-up between adolescents and adults with PFP. Methods Data from 64 patients with PFP, assessed at baseline and 1-year follow-up, were used. At baseline, data on demographics, symptoms, and coping strategies were obtained by questionnaire. Physical examination included strength and flexibility measurements of the quadriceps and hamstrings. At 1-year follow-up, a questionnaire was used to collect data on pain, function, and recovery. Differences between adolescents (14-18 years) and adults (18-40 years) were analyzed using regression techniques, adjusted for sex, body mass index, and the presence of bilateral pain. Results Of the 64 patients with PFP included at baseline, 78.1% were available for follow-up. At baseline, adolescents with PFP had a significantly lower body mass index (20.7 versus 24.9 kg/m) and a greater percentage of bilateral pain (70% versus 43.2%) than adults with PFP. There were no differences in reported pain and symptoms between the 2 groups. In total, 25% of the adolescents regarded themselves as recovered after 1 year, compared to 22.7% of the adults (adjusted P = .725). Conclusion The sample size of the study, in relation to the number of statistical tests performed, urges caution in the interpretation of the results. In contrast to what has been suggested previously, only minor differences seem to exist between adolescents and adults with PFP. In both groups, PFP is clearly not a self-limiting disease, with nearly 75% of those in this study reporting persistent pain at 1-year follow-up. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2017;47(10):801-805. Epub 4 Sep 2017. doi:10.2519/jospt.2017.7326.
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http://dx.doi.org/10.2519/jospt.2017.7326DOI Listing
October 2017

Dynamic contrast-enhanced MRI of the patellar bone: How to quantify perfusion.

J Magn Reson Imaging 2018 03 14;47(3):848-858. Epub 2017 Jul 14.

Biomedical Imaging Group Rotterdam, Departments of Medical Informatics & Radiology, Erasmus MC, Rotterdam, The Netherlands.

Purpose: To identify the optimal combination of pharmacokinetic model and arterial input function (AIF) for quantitative analysis of blood perfusion in the patellar bone using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

Materials And Methods: This method design study used a random subset of five control subjects from an Institutional Review Board (IRB)-approved case-control study into patellofemoral pain, scanned on a 3T MR system with a contrast-enhanced time-resolved imaging of contrast kinetics (TRICKS) sequence. We systematically investigated the reproducibility of pharmacokinetic parameters for all combinations of Orton and Parker AIF models with Tofts, Extended Tofts (ETofts), and Brix pharmacokinetic models. Furthermore, we evaluated if the AIF should use literature parameters, be subject-specific, or group-specific. Model selection was based on the goodness-of-fit and the coefficient of variation of the pharmacokinetic parameters inside the patella. This extends previous studies that were not focused on the patella and did not evaluate as many combinations of arterial and pharmacokinetic models.

Results: The vascular component in the ETofts model could not reliably be recovered (coefficient of variation [CV] of v >50%) and the Brix model parameters showed high variability of up to 20% for k across good AIF models. Compared to group-specific AIF, the subject-specific AIF's mostly had higher residual. The best reproducibility and goodness-of-fit were obtained by combining Tofts' pharmacokinetic model with the group-specific Parker AIF.

Conclusion: We identified several good combinations of pharmacokinetic models and AIF for quantitative analysis of perfusion in the patellar bone. The recommended combination is Tofts pharmacokinetic model combined with a group-specific Parker AIF model.

Level Of Evidence: 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:848-858.
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http://dx.doi.org/10.1002/jmri.25817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836942PMC
March 2018

Lower Pressure Pain Thresholds in Patellofemoral Pain Patients, Especially in Female Patients: A Cross-Sectional Case-Control Study.

Pain Med 2018 01;19(1):184-192

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

Objective: It has been suggested that repeated overload might sensitize nociceptors, causing local hyperalgesia in patients with patellofemoral pain (PFP). This might also lead to generalized hyperalgesia, indicative of altered central pain processing. This study aimed to investigate differences in pressure pain threshold (PPT) as a measure of pressure hyperalgesia between patients with PFP and healthy controls and in predefined subgroups and to study associations between PPT and patient characteristics.

Design: Case-control study.

Setting: Physiotherapy, general practices, and sports medicine practices.

Subjects: Sixty-four patients with PFP and 70 healthy controls.

Methods: Demographics, pain (numerical rating score), and function (anterior knee pain score) were obtained by questionnaire. The PPT was measured with a handheld dynamometer with algometry tip at the most painful spot of the affected knee (medial facet in controls), the same spot at the contralateral knee, and at the contralateral forearm. Differences between groups were tested using analysis of variance techniques including the variables age, gender, body mass index, and sports participation.

Results: Patients had significantly lower PPTs compared with controls at all locations (affected knee: mean difference = -12.2, 95% confidence interval [CI] = -17.3 to -7.1; contralateral knee: mean difference = -4.7, 95% CI = -10.1 to 0.52; contralateral arm: mean difference = -5.7, 95% CI = -10.5 to -0.8). Both male and female patients demonstrated lower PPTs, though a significant subgroup effect was found for female gender (effect size ranging from 0.73 to 0.98).

Conclusions: Local and generalized pressure hyperalgesia, suggesting alterations in both peripheral and central pain processing, were present in patients with PFP, though females with PFP were most likely to suffer from generalized hyperalgesia.
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http://dx.doi.org/10.1093/pm/pnx059DOI Listing
January 2018

Pain During Prolonged Sitting Is a Common Problem in Persons With Patellofemoral Pain.

J Orthop Sports Phys Ther 2016 Aug 3;46(8):658-63. Epub 2016 Jul 3.

Study Design Retrospective cohort. Background Although persons with patellofemoral pain (PFP) often report pain with prolonged sitting, little is known about the prevalence and characteristics of sitting pain. Objectives To describe the proportion of persons with PFP who experience problems with prolonged sitting and to determine patient characteristics associated with sitting pain. Methods Four hundred fifty-eight participants with a diagnosis of PFP from 4 separate studies were included. Item 8 of the Anterior Knee Pain Scale was used to define the presence of problems with prolonged sitting with knee flexion, based on 3 categories: (1) "no difficulty," (2) "pain after exercise," or (3) "problems with prolonged sitting." Differences in demographic and clinical variables between categories were evaluated using Kruskal-Wallis tests (P<.05). Results Two hundred forty-nine (54.4% of the study sample) participants reported problems with prolonged sitting, and 121 (26.4%) reported sitting pain after exercise. Compared to those with no difficulty sitting (n = 88), participants classified as having problems with prolonged sitting were significantly younger (P = .038), more likely to be female (P = .033), had a lower body mass index (P = .027), reported higher pain severity (P<.001) and lower Anterior Knee Pain Scale scores (P<.001), and more frequently reported problems with squatting (P<.001). Conclusion Problems with prolonged sitting are evident in more than half of persons with PFP. Findings highlight the need to identify and adequately manage PFP associated with prolonged sitting. Further research should explore mechanisms of sitting pain and evaluate targeted interventions to reduce PFP with prolonged sitting. Level of Evidence Symptom prevalence study, level 2b. J Orthop Sports Phys Ther 2016;46(8):658-663. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6470.
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http://dx.doi.org/10.2519/jospt.2016.6470DOI Listing
August 2016

Structural Abnormalities on Magnetic Resonance Imaging in Patients With Patellofemoral Pain: A Cross-sectional Case-Control Study.

Am J Sports Med 2016 Sep 20;44(9):2339-46. Epub 2016 May 20.

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

Background: Structural abnormalities of the patellofemoral joint might play a role in the pathogenesis of patellofemoral pain (PFP), a common knee problem among young and physically active individuals. No previous study has investigated if PFP is associated with structural abnormalities of the patellofemoral joint using high-resolution magnetic resonance imaging (MRI).

Purpose: To investigate the presence of structural abnormalities of the patellofemoral joint on high-resolution MRI in patients with PFP compared with healthy control subjects.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Patients with PFP and healthy control subjects between 14 and 40 years of age underwent high-resolution 3-T MRI. All images were scored using the Magnetic Resonance Imaging Osteoarthritis Knee Score with the addition of specific patellofemoral features. Associations between PFP and the presence of structural abnormalities were analyzed using logistic regression analyses adjusted for age, body mass index (BMI), sex, and sports participation.

Results: A total of 64 patients and 70 control subjects were included in the study. Mean ± SD age was 23.2 ± 6.4 years, mean BMI ± SD was 22.9 ± 3.4 kg/m(2), and 56.7% were female. Full-thickness cartilage loss was not present. Minor patellar cartilage defects, patellar bone marrow lesions, and high signal intensity of the Hoffa fat pad were frequently seen in both patients (23%, 53%, and 58%, respectively) and control subjects (21%, 51%, and 51%, respectively). After adjustment for age, BMI, sex, and sports participation, none of the structural abnormalities were statistically significantly associated with PFP.

Conclusion: Structural abnormalities of the patellofemoral joint have been hypothesized as a factor in the pathogenesis of PFP, but the study findings suggest that structural abnormalities of the patellofemoral joint on MRI are not associated with PFP.
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http://dx.doi.org/10.1177/0363546516646107DOI Listing
September 2016

No Difference on Quantitative Magnetic Resonance Imaging in Patellofemoral Cartilage Composition Between Patients With Patellofemoral Pain and Healthy Controls.

Am J Sports Med 2016 May 7;44(5):1172-8. Epub 2016 Mar 7.

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

Background: Retropatellar cartilage damage has been suggested as an etiological factor for patellofemoral pain (PFP), a common knee condition among young and physically active individuals. To date, there is no conclusive evidence for an association between cartilage defects and PFP. Nowadays, advanced quantitative magnetic resonance imaging (MRI) techniques enable estimation of cartilage composition.

Purpose: To investigate differences in patellofemoral cartilage composition between patients with PFP and healthy control subjects using quantitative MRI.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Patients with PFP and healthy control subjects underwent 3.0-T MRI including delayed gadolinium-enhanced MRI of cartilage and T1ρ and T2 mapping. Differences in relaxation times of patellofemoral cartilage were compared between groups by linear regression analyses, adjusted for age, body mass index, sex, sports participation, and time of image acquisition.

Results: This case-control study included 64 patients and 70 controls. The mean (±SD) age was 23.2 ± 6.4 years and the mean body mass index was 22.9 ± 3.4 kg/m(2); 56.7% were female. For delayed gadolinium-enhanced MRI of cartilage, the mean T1GD relaxation times of patellar (657.8 vs 669.4 ms) and femoral cartilage (661.6 vs 659.8 ms) did not significantly differ between patients and controls. In addition, no significant difference was found in mean T1ρ relaxation times of patellar (46.9 vs 46.0 ms) and femoral cartilage (50.8 vs 50.2 ms) and mean T2 relaxation times of patellar (33.2 vs 32.9 ms) and femoral cartilage (36.7 vs 36.6 ms) between patients and controls. Analysis of prespecified medial and lateral subregions within the patellofemoral cartilage also revealed no significant differences.

Conclusion: There was no difference in composition of the patellofemoral cartilage, estimated with multiple quantitative MRI techniques, between patients with PFP and healthy control subjects. However, clinically relevant differences could not be ruled out for T1ρ in the adolescent population. Retropatellar cartilage damage has long been hypothesized as an important factor in the pathogenesis of PFP, but study findings suggest that diminished patellofemoral cartilage composition is not associated with PFP.
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http://dx.doi.org/10.1177/0363546516632507DOI Listing
May 2016

Exercise for treating patellofemoral pain syndrome: an abridged version of Cochrane systematic review.

Eur J Phys Rehabil Med 2016 Feb 9;52(1):110-33. Epub 2015 Jul 9.

Department of General Practice, Erasmu MC, University Medical Center Rotterdam, The Netherlands -

Background: Patellofemoral pain syndrome (PFPS) is a common knee problem characterised by retropatellar or peripatellar pain, which particularly affects adolescents and young adults. Exercise therapy is often prescribed.

Aim: To assess the effects of exercise therapy in people with PFPS.

Design: Systematic review.

Setting: All settings.

Population: Adolescents and adults with PFPS.

Methods: A search was performed in nine databases up to May 2014, including the Cochrane Register, MEDLINE and EMBASE. Randomised and quasi-randomised trials evaluating the effect of exercise therapy in adolescents and adults with PFPS were considered for inclusion. Two review authors independently selected trials, extracted data and assessed risk of bias.

Results: In total, 31 trials including 1690 participants were included in this review, of which most were at high risk of performance bias and detection bias due to lack of blinding. The included studies provided evidence for: exercise therapy versus control; exercise therapy versus other conservative interventions (e.g. taping); and different exercises or exercise programmes. Pooled data favoured exercise therapy over control for pain during activity (short term MD -1.46 [-2.39, -0.54]), usual pain (short term estimated MD -1.44 [-2.48,-0.39]), functional ability; (short term estimated MD 12.21 [6.44, 18.09] and long term recovery (RR 1.35 [0.99, 1.84]). Pooled data favoured hip and knee exercise over knee exercises alone for pain during activity (short-term MD -2.20 [3.80, -0.60]) and usual pain (short term MD-1.77 [-2.78,-0.76]).

Conclusion: This review found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone.

Clinical Rehabilitation Impact: Very low quality evidence but consistent evidence indicates that exercise therapy benefits patients with PFP. However, there is insufficient evidence to determine the best form of exercise therapy and it is unknown whether this result would apply to all people with PFPS.
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February 2016

Exercise for treating patellofemoral pain syndrome.

Cochrane Database Syst Rev 2015 Jan 20;1:CD010387. Epub 2015 Jan 20.

Department of General Practice, Erasmus Medical Center, Burg Jacobplein 51, Rotterdam, Netherlands, 3015CA.

Background: Patellofemoral pain syndrome (PFPS) is a common knee problem, which particularly affects adolescents and young adults. PFPS, which is characterised by retropatellar (behind the kneecap) or peripatellar (around the kneecap) pain, is often referred to as anterior knee pain. The pain mostly occurs when load is put on the knee extensor mechanism when climbing stairs, squatting, running, cycling or sitting with flexed knees. Exercise therapy is often prescribed for this condition.

Objectives: To assess the effects (benefits and harms) of exercise therapy aimed at reducing knee pain and improving knee function for people with patellofemoral pain syndrome.

Search Methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 4), MEDLINE (1946 to May 2014), EMBASE (1980 to 2014 Week 20), PEDro (to June 2014), CINAHL (1982 to May 2014) and AMED (1985 to May 2014), trial registers (to June 2014) and conference abstracts.

Selection Criteria: Randomised and quasi-randomised trials evaluating the effect of exercise therapy on pain, function and recovery in adolescents and adults with patellofemoral pain syndrome. We included comparisons of exercise therapy versus control (e.g. no treatment) or versus another non-surgical therapy; or of different exercises or exercise programmes.

Data Collection And Analysis: Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. Where appropriate, we pooled data using either fixed-effect or random-effects methods. We selected the following seven outcomes for summarising the available evidence: pain during activity (short-term: ≤ 3 months); usual pain (short-term); pain during activity (long-term: > 3 months); usual pain (long-term); functional ability (short-term); functional ability (long-term); and recovery (long-term).

Main Results: In total, 31 heterogeneous trials including 1690 participants with patellofemoral pain are included in this review. There was considerable between-study variation in patient characteristics (e.g. activity level) and diagnostic criteria for study inclusion (e.g. minimum duration of symptoms) and exercise therapy. Eight trials, six of which were quasi-randomised, were at high risk of selection bias. We assessed most trials as being at high risk of performance bias and detection bias, which resulted from lack of blinding.The included studies, some of which contributed to more than one comparison, provided evidence for the following comparisons: exercise therapy versus control (10 trials); exercise therapy versus other conservative interventions (e.g. taping; eight trials evaluating different interventions); and different exercises or exercise programmes. The latter group comprised: supervised versus home exercises (two trials); closed kinetic chain (KC) versus open KC exercises (four trials); variants of closed KC exercises (two trials making different comparisons); other comparisons of other types of KC or miscellaneous exercises (five trials evaluating different interventions); hip and knee versus knee exercises (seven trials); hip versus knee exercises (two studies); and high- versus low-intensity exercises (one study). There were no trials testing exercise medium (land versus water) or duration of exercises. Where available, the evidence for each of seven main outcomes for all comparisons was of very low quality, generally due to serious flaws in design and small numbers of participants. This means that we are very unsure about the estimates. The evidence for the two largest comparisons is summarised here. Exercise versus control. Pooled data from five studies (375 participants) for pain during activity (short-term) favoured exercise therapy: mean difference (MD) -1.46, 95% confidence interval (CI) -2.39 to -0.54. The CI included the minimal clinically important difference (MCID) of 1.3 (scale 0 to 10), indicating the possibility of a clinically important reduction in pain. The same finding applied for usual pain (short-term; two studies, 41 participants), pain during activity (long-term; two studies, 180 participants) and usual pain (long-term; one study, 94 participants). Pooled data from seven studies (483 participants) for functional ability (short-term) also favoured exercise therapy; standardised mean difference (SMD) 1.10, 95% CI 0.58 to 1.63. Re-expressed in terms of the Anterior Knee Pain Score (AKPS; 0 to 100), this result (estimated MD 12.21 higher, 95% CI 6.44 to 18.09 higher) included the MCID of 10.0, indicating the possibility of a clinically important improvement in function. The same finding applied for functional ability (long-term; three studies, 274 participants). Pooled data (two studies, 166 participants) indicated that, based on the 'recovery' of 250 per 1000 in the control group, 88 more (95% CI 2 fewer to 210 more) participants per 1000 recovered in the long term (12 months) as a result of exercise therapy. Hip plus knee versus knee exercises. Pooled data from three studies (104 participants) for pain during activity (short-term) favoured hip and knee exercise: MD -2.20, 95% CI -3.80 to -0.60; the CI included a clinically important effect. The same applied for usual pain (short-term; two studies, 46 participants). One study (49 participants) found a clinically important reduction in pain during activity (long-term) for hip and knee exercise. Although tending to favour hip and knee exercises, the evidence for functional ability (short-term; four studies, 174 participants; and long-term; two studies, 78 participants) and recovery (one study, 29 participants) did not show that either approach was superior.

Authors' Conclusions: This review has found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery. However, there is insufficient evidence to determine the best form of exercise therapy and it is unknown whether this result would apply to all people with PFPS. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone.Further randomised trials are warranted but in order to optimise research effort and engender the large multicentre randomised trials that are required to inform practice, these should be preceded by research that aims to identify priority questions and attain agreement and, where practical, standardisation regarding diagnostic criteria and measurement of outcome.
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http://dx.doi.org/10.1002/14651858.CD010387.pub2DOI Listing
January 2015

The development of Cam-type deformity in adolescent and young male soccer players.

Am J Sports Med 2012 May 13;40(5):1099-106. Epub 2012 Mar 13.

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

Background: Cam impingement is a well-recognized cause of hip pain and might cause osteoarthritis of the hip. Clinically, cam impingement is mostly observed in young, active male patients, but only a few studies have focused on the manifestation of cam-type deformities during skeletal development.

Purpose: To determine the age of onset and prevalence of cam-type deformities in young male soccer players versus controls.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: In this study, 89 elite preprofessional soccer players and 92 controls aged 12 to 19 years were included. In the soccer players, range of motion and impingement tests were performed. Both an anteroposterior (AP) pelvic radiograph and a frog-leg lateral radiograph of the hip were obtained according to a standardized protocol. Controls with both an AP pelvic and a frog-leg lateral radiograph and no hip disorders were obtained from radiology databases. The α angle was automatically determined in all radiographs, using a threshold value of 60° to define a cam-type deformity. Further, all radiographs were scored using a 3-point scoring system. The anterosuperior head-neck junction was classified as (1) normal, (2) flattened, or (3) having a prominence. Differences in prevalence were tested using logistic regression. Differences in range of motion were calculated using generalized estimating equations.

Results: An α angle >60° was already found at the age of 12 years in some soccer players and controls. A cam-type deformity defined by α angle tended to be more prevalent in soccer players (26%) than in controls (17%; P = .31). In 13% of soccer players, a prominence was visible on radiographs and was first seen at the age of 13 years. The anterosuperior flattening (56% vs 18%, P = .0001) and prominence (13% vs 0%, P < .03) were more prevalent in soccer players than in controls.

Conclusion: Cam-type deformities were recognizable and present from the age of 13 years and were more prevalent in soccer players than in their nonathletic peers. Cam-type deformity develops during adolescence and is likely to be influenced by high-impact sports practice.
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http://dx.doi.org/10.1177/0363546512438381DOI Listing
May 2012
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