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Background Previous investigations on valgus knee bracing have mostly used the external knee adduction moment. This is a critical limitation, as the external knee adduction moment does not account for muscle forces that contribute substantially to the medial tibiofemoral contact force (MTCF) during walking. The aims of this pilot study were to: 1) determine the effect of a valgus knee brace on MTCF; 2) determine whether the effect is more pronounced after 8 weeks of brace use; 3) assess the feasibility of an 8-week brace intervention. Methods Participants with medial radiographic knee OA and varus malalignment were fitted with an Össur Unloader One© brace. Participants were instructed to wear the brace for 8 weeks. The MTCF was estimated via an electromyogram-assisted neuromuscular model with and without the knee brace at week 0 and week 8. Feasibility outcomes included change in symptoms, quality of life, confidence, acceptability, adherence and adverse events. Results Of the 30 (60% male) participants enrolled, 28 (93%) completed 8-week outcome assessments. There was a main effect of the brace (p Conclusion Although significant, reductions in the peak MTCF and MTCF while wearing the knee brace were small. No effect of time on MTCF was observed. Although there were numerous minor adverse events, feasibility outcomes were generally favourable. Trial registration Australian and New Zealand Clinical Trials Registry (12619000622101).

Background There is paucity of data on the prevalence of ultrasound-detected synovial abnormalities in the general population, and the relationship between synovial changes and knee pain remains unclear. We examined the prevalence of synovial abnormalities on ultrasound and the relationship of these features with knee pain and radiographic osteoarthritis (ROA) in a community sample. Methods Participants aged 50 years or over were from the Xiangya Osteoarthritis Study, a community-based cohort study. Participants were questioned about chronic knee pain and underwent (1) ultrasonography of both knees to determine presence of synovial hypertrophy (≥ 4 mm), effusion (≥ 4 mm), and Power Doppler signal [PDS; yes/no]; and (2) standard radiographs of both knees (tibiofemoral and patellofemoral views) to determine ROA. Results There were 3755 participants (mean age 64.4 years; women 57.4%). The prevalence of synovial hypertrophy, effusion, and PDS were 18.1% (men 20.2%; women 16.5%), 46.6% (men 49.9%; women 44.2%), and 4.9% (men 4.9%; women 5.0%), respectively, and increased with age (P for trend P for interaction were 0.004 and 0.067, respectively. Conclusions Knee synovial hypertrophy and effusion are more common and increase with age, affecting men more than women. All three ultrasound-detected synovial abnormalities associate both with knee pain and ROA, and knee synovial hypertrophy or effusion and ROA may interact to increase the risk of knee pain.

PURPOSE: To examine the effects of increased cadence and minimalist footwear on lower-limb variability in runners with patellofemoral pain (PFP). METHODS: Fifteen (12 female, 3 male) runners with PFP ran on an instrumented treadmill with three-dimensional motion capture in three randomly ordered conditions: (i) standard shoe at preferred cadence, (ii) standard shoe +10% cadence, and (iii) minimalist shoe at preferred cadence. Vector coding was used to calculate coordination variability between strides for select lower-limb joint couplings. Approximate entropy was calculated to assess continuous variability for segment kinematic and kinetic data and compared between conditions using repeated-measures ANOVA. One-dimensional statistical parametric mapping repeated-measures ANOVA was performed on the coordination variability data. Cohen's d effect size was calculated for all comparisons. RESULTS: Larger approximate entropy values (i.e., greater variability) were observed for the standard shoe +10% cadence versus the standard shoe at preferred cadence for hip flexion/extension (P < 0.001; d = 1.12), hip adduction/abduction (P < 0.001; d = 0.99) and ankle dorsiflexion/plantarflexion (P < 0.001; d = 1.37) kinematics, and knee flexion/extension moments (P < 0.001; d = 0.93). Greater variability was also observed in the minimalist shoe versus the standard shoe at preferred cadence for hip internal/external rotation moments (P < 0.001; d = 0.76), knee adduction/abduction moments (P < 0.001; d = 0.51), and knee internal/external rotation moments (P < 0.001; d = 1.02). One-dimensional statistical parametric mapping repeated-measures ANOVA revealed no significant differences in coordination variability between running conditions. CONCLUSIONS: Greater hip and knee kinematic and kinetic variability observed with either increased cadence or minimalist footwear may be beneficial for those with PFP.

To determine the effect of a combination of a minimalist shoe and increased cadence on measures of patellofemoral joint loading during running in individuals with patellofemoral pain.Within-participant repeated measures with four conditions presented in random order: (1) control shoe at preferred cadence; (2) control shoe with +10% cadence; (3) minimalist shoe at preferred cadence; (4) minimalist shoe with +10% cadence.Fifteen recreational runners with patellofemoral pain ran on an instrumented treadmill while three-dimensional motion capture data were acquired. Peak patellofemoral joint stress, joint reaction force, knee extensor moment and knee joint angle during the stance phase of running were calculated. One-way repeated measures ANOVA was used to compare the control condition (1) to the three experimental conditions (2-4).Running in a minimalist shoe at an increased cadence reduced patellofemoral stress and joint reaction force on average by approximately 29% (p0.001) compared to the control condition. Running in a minimalist shoe at preferred cadence reduced patellofemoral joint stress by 15% and joint reaction force by 17% (p0.001), compared to the control condition. Running in control shoes at an increased cadence reduced patellofemoral joint stress and joint reaction force by 16% and 19% (p0.001), respectively, compared to the control condition.In individuals with patellofemoral pain, running in a minimalist shoe at an increased cadence had the greatest reduction in patellofemoral joint loading compared to a control shoe at preferred cadence. This may be an effective intervention to modulate biomechanical factors related to patellofemoral pain.

Objectives To determine the feasibility of a clinical trial that compares a 6-week, physiotherapist-guided gait retraining program with a foot orthoses intervention in runners with patellofemoral pain. Design Pilot randomised controlled trial. Methods Runners aged 18–40 years with clinically diagnosed patellofemoral pain were randomly allocated to either a 6-week gait retraining intervention of increasing cadence and use of a minimalist shoe or prefabricated foot orthoses. Outcomes at baseline and 12-weeks included recruitment, retention, adherence, adverse events, global improvement, anterior knee pain scale, worst and average pain on a 100 mm visual analogue scale. Results Of the 16 randomised participants, two withdrew prior to commencing treatment due to non-trial related matters (n = 1 from each group) and 14 completed the pilot trial. Minor calf muscle soreness was reported by 3 participants in the gait retraining group while no adverse events were reported in the foot orthoses group. There were no deviations from the treatment protocols. There was a large between-group difference favouring gait retraining at 12-weeks in the anterior knee pain scale and the worst pain in the past week, which was reflected in the number needed-to-treat of 2. Conclusions This study supports the feasibility of a trial comparing gait retraining with foot orthoses and provides point estimates of effect that informs the design and planning of a larger clinical trial. It appears that a 6-week gait retraining program has a clinically meaningful effect on runners with patellofemoral pain when compared to an evidence-based treatment of foot orthoses.

Summary Objective To determine if an increase in knee extensor strength mediates the effect of a 12-week knee extensor strength training program on pain and physical function improvement in people with knee osteoarthritis (OA). Design Secondary analysis from a randomised controlled trial comparing the effects of a 12-week knee extensor strengthening exercise program to a control group with no intervention. Methods Data from participants with complete data ( n = 97) enrolled in a previous clinical trial were analysed. Baseline and 12-week follow-up assessments included peak isometric knee extensor strength, pain and physical function. Peak knee extensor strength (Nm/kg) was assessed on an isokinetic dynamometer and subscales of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index were used to assess pain and physical function. Twelve-week change in pain and physical function were regressed separately, on 12-week change in knee extensor strength and group allocation. Covariates included baseline pain or physical function as appropriate, and baseline knee extensor strength, age, sex and knee alignment (stratification variable). Results Improved knee extensor strength mediated the effect of the strengthening program on both pain relief (mediated effect size = 0.69, 95% confidence intervals (CI) 0.05–1.33, P = 0.03), and improved physical function (mediated effect size = 1.86, 95% CI 0.08–3.64, P = 0.04), at 12 weeks. Conclusions Increased knee extensor strength partially mediates the effect of a knee extensor strength training program on pain and physical function improvement in people with knee OA.

To estimate the reliability and measurement error of performance-based tests of physical function recommended by the Osteoarthritis Research Society International (OARSI) in people with hip and/or knee osteoarthritis (OA).Prospective repeated measures between independent raters within a session and within-rater over a week interval. Relative reliability was estimated for 51 people with hip and/or knee OA (mean age 64.5 years, standard deviation (SD) 6.21 years; 47% females; 36 (70%) primary knee OA) on the 30s Chair Stand Test (30sCST), 40m Fast-Paced Walk Test (40mFPWT), 11-Stair Climb Test (11-step SCT), Timed Up and Go (TUG), Six-Minute Walk Test (6MWT), 10m Fast-Paced Walk Test (10mFPWT) and 20s Stair Climb Test (20sSCT) using intra-class correlation coefficients (ICC). Absolute reliability was calculated using standard error of measurement (SEM) and minimal detectable change (MDC).Measurement error was acceptable (SEM 10%) for all tests. Between-rater reliability was: optimal (ICC 0.9, lower 1-sided 95% CI 0.7) for the 40mFPWT, 6MWT and 10mFPWT; sufficient (ICC0.8, lower 1-sided 95% CI 0.7) for 30sCST, 20sSCT; unacceptable (lower 1-side 95% CI 0.7) for 11-step SCT and TUG. Within-rater reliability was optimal for 40mFPWT, and 6MWT; sufficient for 30sCST and 10mFPWT and unacceptable for 11-step SCT, TUG and 20sSCT.The 30sCST, 40mFPWT, 6MWT and 10mFPWT, demonstrated, at minimum, acceptable levels of both between and within-rater reliability and measurement error. All tests demonstrated sufficiently small measurement error indicating they are adequate for measuring change over time in individuals with knee/hip OA.

Introduction This study aimed to evaluate associations between strength of selected hip and knee muscles and self-reported physical function, and their clinical relevance, in men and women with hip osteoarthritis (OA). Methods Cross-sectional data from 195 participants with symptomatic hip OA were used. Peak isometric torque of hip extensors, flexors, and abductors, and knee extensors were measured, along with physical function using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Separate linear regressions in men and women were used to determine the association between strength and physical function accounting for age, pain, and radiographic disease severity. Subsequently, magnitudes of strength associated with estimates of minimal clinically important improvement (MCII) in physical function were estimated according to severity of difficulty with physical function. Results For men, greater strength of the hip extensors, hip flexors and knee extensors were each associated with better physical function. For women, greater muscle strength of all tested muscles were each associated with better physical function. For men and women, increases in muscle strength between 17–32%, 133–223%, and 151–284% may be associated with estimates of MCII in physical function for those with mild, moderate, and severe physical dysfunction, respectively. Conclusion Greater isometric strength of specific hip and thigh muscle groups may be associated with better self-reported physical function in men and women. In people with mild physical dysfunction, an estimate of MCII in physical function may be associated with attainable increases in strength. However, in patients with more severe dysfunction, greater and perhaps unattainable strength increases may be associated with an estimate of MCII in physical function. Longitudinal studies are required to validate these observations.

BACKGROUND: Arthroscopic partial meniscectomy may cause knee osteoarthritis, which may be related to altered joint loading. Previous research has failed to demonstrate that exercise can reduce medial compartment knee loads following meniscectomy but has not considered muscular loading in their estimates. RESEARCH QUESTION: What is the effect of exercise compared to no intervention on peak medial tibiofemoral joint contact force during walking using an electromyogram-driven neuromusculoskeletal model, following medial arthroscopic partial meniscectomy? METHODS: This is a secondary analysis of a randomized controlled trial (RCT). 41 participants aged between 30-50 years with medial arthroscopic partial meniscectomy within the past 3-12 months, were randomly allocated to either a 12-week, home-based, physiotherapist-guided exercise program or to no exercise (control group). Three-dimensional lower-body motion, ground reaction forces, and surface electromyograms from eight lower-limb muscles were acquired during self-selected normal- and fast-paced walking at baseline and follow-up. An electromyogram-driven neuromusculoskeletal model estimated medial compartment contact forces (body weight). Linear regression models evaluated between-group differences (mean difference (95% CI)). RESULTS: There were no significant between-group differences in the change (follow-up minus baseline) in first peak medial contact force during self-selected normal- or fast-paced walking (0.07 (-0.08 to 0.23), P = 0.34 and 0.01 (-0.19 to 0.22), P = 0.89 respectively). No significant between-group difference was found for change in second peak medial contact force during normal- or fast-paced walking (0.09 (-0.09 to 0.28), P = 0.31 and 0.02 (-0.17 to 0.22), P = 0.81 respectively). At the individual level, variability was observed for changes in first (range -26.2% to +31.7%) and second (range -46.5% to +59.9%) peak tibiofemoral contact force. SIGNIFICANCE: This is the first study to apply electromyogram-driven neuromusculoskeletal modelling to an exercise intervention in a RCT. While our results suggest that a 12-week exercise program does not alter peak medial knee loads after meniscectomy, within-participant variability suggests individual-specific muscle activation patterns that warrant further investigation.

Background Dynamic postural control during everyday tasks is poorly understood in people following anterior cruciate ligament reconstruction (ACLR). Understanding dynamic postural control can provide insight into potentially modifiable impairments in people following ACLR who are at increased risk for second ACL injury and/or knee osteoarthritis. Research question Determine whether measures indicative of dynamic postural control differ between individuals with and without ACLR during stair ascent and descent. Methods: Seventeen individuals with ACLR (>1 yr post-surgery) and 16 age and sex-matched healthy controls participated. Centre of pressure (COP) measures included: i) COP excursion, ii) COP velocity, and iii) dynamic time-toboundary (TTB). Mixed linear models were used to compare COP measures for the ACLR leg, non-ACLR leg, and healthy controls during stair ascent and stair descent. Results There were no statistically significant differences observed during stair ascent (all p > 0.05). Several statistical differences were found during stair descent for individual with ACLR, but not between those with ACLR and healthy controls. The ACLR leg had higher medial-lateral COP excursion (mean difference 1.06 cm, [95 %CI 0.08–2.06 cm], p = 0.036; effect size = 0.38) compared to the non-ACLR leg during stair descent. In addition, the ACLR leg had a lower medial-lateral TTB (mean difference −13 ms [95 %CI −38 to 2 ms], p = 0.005; effect size = 0.49) and medial-lateral TTB normalized to stance time (mean difference −5.8 % [95 %CI −10.3 to 1.3 %], p = 0.012; effect size = 0.80) compared to the non-ACLR leg during stair descent. No statistical differences were observed for anterior-posterior measures during stair descent (all p > 0.05). Significance: Taken together, findings indicate that there are small to large differences in medial-lateral postural control in the ACLR leg compared to the non-ACLR leg during stair descent. Further work is required to understand clinical implication of these novel observations.

Our primary objective was to examine external hip joint moments during walking in people with mild radiographic hip osteoarthritis (OA) with and without symptoms and disease-free controls. Three groups were compared (symptomatic with mild radiographic hip OA, n = 12; asymptomatic with mild radiographic hip OA, n = 13; OA-free controls, n = 20). Measures of the external moment (peak and impulse) in the sagittal, frontal and transverse plane during walking were determined. Variables were compared according to group allocation using mixed linear regression models that included individual gait trials, with group allocation as fixed effect and walking speed as a random effect. Participants with evidence of radiographic disease irrespective of symptoms walked 14-16% slower compared to disease-free controls (p = 0.002). Radiographic disease without symptoms was not associated with any altered measures of hip joint moment compared to asymptomatic OA-free controls once speed was taken into account (p ≥ 0.099). People with both mild radiographic disease and symptoms had lower external peak hip adduction moment (p = 0.005) and lower external peak internal rotation moment (p

Summary Objective To establish “normal” ranges for synovial thickness and effusion detected by ultrasound (US) and to determine cut-offs associated with knee pain (KP) and radiographic knee osteoarthritis (RKOA) in the community. Methods 147 women and 152 men ≥40 years old were randomly selected from the Nottingham KP and Related Health in the Community (KPIC) cohort (n = 9506). The “normal” range was established using the percentile method in 163 participants who had no KP and no RKOA. Optimal (maximum sensitivity and specificity) and high specificity (90%) cut-offs were established using receiver operating characteristic (ROC) curve analysis in a comparison between people with both KP and RKOA and normal controls. Results Effusion and synovial hypertrophy differed by gender but not by age or laterality, therefore gender-specific reference limits were estimated. However, the “normal” ranges between men and women were similar for effusion (0–10.3 mm vs 0–9.8 mm), but different for synovial hypertrophy (0–6.8 mm vs 0–5.4 mm). Power Doppler Signal (PDS) in the healthy controls was uncommon (1.2% in men and 0.0% in women). The optimal cut-off was 7.4 mm for men and 5.3 mm for women for effusion, and 3.7 and 1.6 for hypertrophy respectively. The high specificity cut-off was 8.9 for men and 7.8 for women for effusion, and 5.8 and 4.2 for hypertrophy respectively. Conclusions US effusion and synovial hypertrophy but not PDS are common, but differ by gender, in community-derived people without painful knee OA. Currently used cut-offs for abnormality need reappraisal.

Summary Objective To investigate relationships between external knee adduction moment parameters (KAM) and osteoarthritis (OA) symptoms according to disease severity. Design 164 participants with symptomatic medial knee OA were included. Radiographic severity was graded by (1) Kellgren & Lawrence (KL) scale (Grade 2, n = 49; Grade, n = 52; Grade 4, n = 63) and; (2) medial tibiofemoral joint space narrowing (JSN) (Grade 1, n = 47; Grade 2, n = 50; Grade 3, n = 67). KAM-related parameters (peak KAM, KAM impulse and cumulative load) were determined from three-dimensional gait analysis and pedometry. Cumulative load was determined by multiplying KAM impulse by the average number of steps/day recorded over at least 5 days. Symptoms were assessed via numeric rating scale ((NRS), pain) and Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (pain and physical function). Relationships between KAM parameters (independent variables) and symptoms (dependent variables) were evaluated by radiographic severity using linear models, adjusting for covariates. Results In mild disease (either KL Grade 2 or JSN Grade 1), there were no associations between KAM and symptoms. In moderate disease of KL Grade 3, higher KAM impulse was associated with greater WOMAC pain. In severe disease (KL Grade 4), higher KAM impulse was associated with less WOMAC pain (KL Grade 4), while higher peak KAM was associated with better function (KL Grade 4). Higher cumulative knee adduction load was associated with less pain on both NRS and WOMAC (JSN Grade 3) as well as better function (both JSN Grade 3 and KL Grade 4). Conclusions Relationships between KAM-related parameters and symptoms differ according to underlying radiographic OA severity.

Walking canes are a self-management strategy recommended for people with knee osteoarthritis (OA) by clinical practice guidelines. Ensuring that an adequate amount of body-weight support (%BWS) is taken through the walking cane is important as this reduces measures of knee joint loading.1) How much body weight support do people with knee OA place through a cane? 2) Do measures of body weight support increase following a brief simple training session?Seventeen individuals with knee pain who had not used a walking cane before were recruited. A standard-grip aluminum cane was then used for 1 week with limited manufacturer instructions. Following this, participants were evaluated using an instrumented force-measuring cane to assess body weight support (% total body weight) through the cane. Force data were recorded during a 430-metre walk undertaken twice; once before 10 min of cane training administered by a physiotherapist, and once immediately after training. Measures of BWS (peak force, average force, impulse equal to the average cane force times duration, and cane-ground contact duration) were extracted. Using bathroom scales, training aimed to take at least 10% body weight support through the cane.Before training, the average peak BWS was 7.2 ± 2.5% of total body weight. Following 10 min of training, there was a significant increase in average peak BWS by 28%, average BWS by 25%, and BWS impulse by 54% (p 0.05). However, individual BWS responses to training were variable. Duration of cane placement increased by 22% after training (p = 0.02). Timing of peak BWS through the cane occurred at 51% of contact phase before training, and at 53% after training (p = 0.05).A short training session can increase the transfer of body weight through a walking cane. However, more sophisticated feedback may be needed to achieve target levels of BWS.

Background Valgus knee braces have been reported to reduce the external knee adduction moment during walking. However, mechanistic investigations into the effects of valgus bracing on medial compartment contact forces using electromyogram-driven neuromusculoskeletal models are limited. Research question What are the immediate effects of valgus bracing on medial tibiofemoral contact forces and muscular loading of the tibiofemoral joint? Methods Sixteen (9 male) healthy adults (27.7 ± 4.4 years) performed 20 over-ground walking trials at self-selected speed both with and without an Ossur Unloader One® brace. Assessment order (i.e., with or without brace) was randomised and counterbalanced to prevent order effects. While walking, three-dimensional lower-body motion, ground reaction forces, and surface electromyograms from eight lower-limb muscles were acquired. These data were used to calibrate an electromyogram-driven neuromusculoskeletal model of muscle and tibiofemoral contact forces (N), from which muscle and external load contributions (%) to those contact forces were determined. Results Although walking with the brace resulted in no significant changes in peak tibiofemoral contact forces at the group-level, individual responses were variable and non-uniform. At the group-level, wearing the brace resulted in a 2.35% (95% CI 0.46-4.24; p = 0.02) greater relative contribution of muscle to lateral compartment contact loading (54.2 ± 11.1%) compared to not wearing the brace (51.8 ± 12.1%) (p

BACKGROUND: Hip osteoarthritis (OA) is a significant cause of disability, with hip pain and reduced external hip moments during walking being key features of the condition. The external hip adduction moment is greater in healthy women than men, however these between-sex differences are not evident in those with end-stage hip OA. Whether sex-specific hip kinetics are associated with early-midstage hip OA has not been investigated and may be a potential target for directed treatment. METHODS: Thirty-eight women and twenty-eight men with a diagnosis of symptomatic, unilateral, mild-to-moderate hip OA (Kellegren-Lawrence Grade 2 or 3) underwent three-dimensional gait analysis of normal walking gait using Vicon motion capture. Hip joint, trunk and pelvic angles and hip moments were calculated using the Plug-in-Gait model. The external peak flexion moment, and the first peak, second peak and mid-stance minimum of the hip adduction moment during the stance phase of walking as well as hip, trunk and pelvic kinematics occurring at the three moment time points were compared between groups using an analysis of covariance. RESULTS: Women with hip OA exhibited a greater external hip adduction moment (mean difference 0.8-1.3 N m/BW.Ht(%), P

Background Knee osteoarthritis is common in people who have undergone partial meniscectomy, and a higher external knee flexion moment during gait may be a potential contributor. Although the peak external knee flexion moment has been shown to increase from 3 months to 2 years following partial meniscectomy, mechanisms underpinning the increase in the peak knee flexion moment are unknown. Methods Sixty-six participants with partial meniscectomy completed three-dimensional gait (normal and fast pace) and quadriceps strength assessment at baseline (3 months following partial meniscectomy) and again 2 years later. Variables included external knee flexion moment, vertical ground reaction force, knee flexion kinematics, and quadriceps peak torque. Findings For normal pace walking, the main significant predictors of change in peak knee flexion moment were an increase in peak vertical ground reaction force (R2 = 0.55), mostly due to an increase in walking speed, and increase in peak knee flexion angle (R2 = 0.19). For fast pace walking, the main significant predictors of change in peak knee flexion moment were an in increase in peak vertical ground reaction force (R2 = 0.51) and increase in knee flexion angle at initial contact (R2 = 0.17). Change in peak vertical force was mostly due to an increase in walking speed. Interpretation Findings suggest that increases in vertical ground reaction force and peak knee flexion angle during stance are predominant contributors to the 2-year change in peak knee flexion moment. Future studies are necessary to refine our understanding of joint loading and its determinants following meniscectomy.

AB Purpose: This study aimed to evaluate the effects of a 12-wk, home-based, physiotherapist-guided neuromuscular exercise program on the knee adduction moment (an indicator of mediolateral knee load distribution) in people with a medial arthroscopic partial meniscectomy (APM) within the past 3-12 months. Methods: An assessor-blinded, randomized controlled trial including people age 30-50 yr with no to mild pain after medial APM was conducted. Participants were randomly allocated to either a 12-wk neuromuscular exercise program that targeted neutral lower limb alignment or a control group with no exercise. The exercise program included eight individual sessions with one of seven physiotherapists in private clinics, together with home exercises. Primary outcomes were the peak external knee adduction moment during normal-paced walking and during one-leg sit-to-stand. Secondary outcomes included additional measures of knee joint load distribution, patient-reported outcomes, maximal knee and hip muscle strength, and physical function measures. Results: Of 62 randomized participants, 60 (97%) completed the trial. There were no significant between-group differences in the change in peak knee adduction moment during normal-paced walking (mean difference (95% confidence interval), 0.22 (-0.11 to 0.55) N[middle dot]m/body weight x height %, P =0.19) or during one-leg sit-to-stand (-0.01 (-0.33 to 0.31) N[middle dot]m/body weight x height %, P = 0.95). There were also no significant between-group differences for any of the secondary outcomes. Conclusions: In patients 3-12 months after a medial APM, a neuromuscular exercise program did not alter the peak knee adduction moment, a key predictor of osteoarthritis structural disease progression. (Australia and New Zealand Clinical Trials Registry, #ACTRN12612000542897.)

Background:\ud Femoroacetabular impingement syndrome (FAI), a hip disorder affecting active young adults, is believed to be a leading cause of hip osteoarthritis (OA). Current management approaches for FAI include arthroscopic hip surgery and physiotherapy-led non-surgical care; however, there is a paucity of clinical trial evidence comparing these approaches. In particular, it is unknown whether these management approaches modify the future risk of developing hip OA. The primary objective of this randomised controlled trial is to determine if participants with FAI who undergo hip arthroscopy have greater improvements in hip cartilage health, as demonstrated by changes in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to those who undergo physiotherapy-led non-surgical management.\ud \ud Methods:\ud This is a pragmatic, multi-centre, two-arm superiority randomised controlled trial comparing hip arthroscopy to physiotherapy-led management for FAI. A total of 140 participants with FAI will be recruited from the clinics of participating orthopaedic surgeons, and randomly allocated to receive either surgery or physiotherapy-led non-surgical care. The surgical intervention involves arthroscopic FAI surgery from one of eight orthopaedic surgeons specialising in this field, located in three different Australian cities. The physiotherapy-led non-surgical management is an individualised physiotherapy program, named Personalised Hip Therapy (PHT), developed by a panel to represent the best non-operative care for FAI. It entails at least six individual physiotherapy sessions over 12 weeks, and up to ten sessions over six months, provided by experienced musculoskeletal physiotherapists trained to deliver the PHT program. The primary outcome measure is the change in dGEMRIC score of a ROI containing both acetabular and femoral head cartilages at the chondrolabral transitional zone of the mid-sagittal plane between baseline and 12 months. Secondary outcomes include patient-reported outcomes and several structural and biomechanical measures relevant to the pathogenesis of FAI and development of hip OA. Interventions will be compared by intention-to-treat analysis.\ud \ud Discussion:\ud The findings will help determine whether hip arthroscopy or an individualised physiotherapy program is superior for the management of FAI, including for the prevention of hip OA.\ud \ud Trial registration:\ud Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015 (retrospectively registered).

The incidence, progression and related risk factors for recent-onset knee pain (KP) remain uncertain. This study aims to examine the natural history of KP including incidence and progression and to identify possible phenotypes and their associated risk factors. A prospective community-based cohort of men and women aged 40 years or over within the East Midlands region (UK) will be recruited via a postal questionnaire from their general practices. The questionnaire will enquire about: presence and onset of KP; pain severity (0–10 numerical rating scale (NRS)); pain catastrophizing and neuropathic-like pain (NP) using the painDETECT questionnaires (definite NP scores ≥19–38); risk factors for KP and/or osteoarthritis (OA) (age, body mass index, constitutional knee alignment, nodal OA, index: ring finger length (2D4D) ratio); quality of life (SF12); and mental health (Hospital Anxiety and Depression Scale). Clinical assessments will be undertaken in a sample of 400 participants comprising three groups: early KP (≤3 year’s duration), established KP (>3 years) and no KP. Assessments will include knee radiographs (standing semi-flexed and 300 skyline views); knee ultrasound (synovial effusion, hypertrophy, and Doppler activity); quantitative sensory testing; muscle strength (quadriceps, hip abductor, and hand-grip); balance; gait analysis (GAITrite); and biomarker sampling. A repeat questionnaire will be sent to responders at years 1 and 3. The baseline early KP group will undergo repeat assessments at year 1 (apart from radiographs) and year 3 (with radiographs). Any incident KP individuals identified at year 1 or 3 questionnaires will have clinical and radiographic assessments at the respective time points. Baseline data will be used to examine risk factors for early onset KP and to identify KP phenotypes. Subsequent prospective data, at least to Year 3, will allow examination of the natural history of KP and risk factors for incidence and progression. The study was registered on the clinicaltrials.gov portal: NCT02098070 ) on the 14th of March 2014.

Background Femoroacetabular impingment (FAI) syndrome is common among young active adults and a proposed risk factor for the future development of hip osteoarthritis. Pain is dominant and drives clinical decision-making. Evidence for altered hip joint function in this patient population is inconsistent, making the identification of treatment targets challenging. A broader assessment, considering adjacent body segments (i.e. pelvis, trunk) and individual movement strategies, may better inform treatment programs. This exploratory study aimed to compare trunk, pelvis, and hip biomechanics during step ascent between individuals with and without FAI syndrome. Methods Fifteen participants diagnosed with symptomatic cam-type or combined (cam plus pincer) FAI who were scheduled for arthroscopic surgery, and 11 age-, and sex-comparable pain- and disease-free individuals, underwent three-dimensional motion analysis during a step ascent task. Trunk, pelvis and hip biomechanics were compared between groups. Results Participants with FAI syndrome exhibited altered ipsilateral trunk lean and pelvic rise towards the symptomatic side during single-leg support compared to controls. Alterations were not uniformly adopted across all individuals with FAI syndrome; those who exhibited more pronounced alterations to frontal plane pelvis control tended to report pain during the task. There were minimal between-group differences for hip biomechanics. Conclusion Exploratory data suggest biomechanics at the trunk and pelvis during step ascent differ between individuals with and without FAI syndrome. Those with FAI syndrome implement a range of proximal strategies for task completion, some of which may have relevance for rehabilitation. Longitudinal investigations of larger cohorts are required to evaluate hypothesized clinical and structural consequences.

Background Pain is a cardinal symptom of knee osteoarthritis (OA) and although conservative treatments such as exercise and diet related interventions can reduce pain, effects are modest and can be improved. Frontal plane knee joint motion has been associated with knee pain, and is suggested as a patient-specific characteristic on which to tailor interventions. Research question Does the association between baseline frontal plane knee joint kinematics and pain-relief differ among overweight and obese people with knee OA who underwent an intervention from the Intensive Diet and Exercise for Arthritis (IDEA) clinical trial: diet-only, exercise-only, and combined diet and exercise intervention? Methods 323 participants with knee OA were included in the analysis (77% females; 66 ± 6 years; 33.5 ± 3.7 kg/m 2 ). At baseline, frontal plane knee joint kinematics during walking were measured using 3-dimensional gait analysis and characterised as peak varus-valgus knee angle, peak varus-valgus excursion, and peak varus angular velocity. Pain was assessed at baseline and 18-month follow-up using the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale. Linear regressions were performed unadjusted and adjusted for covariates to determine if the associations between baseline frontal plane knee joint kinematics and 18-month change in pain differed according to intervention. Results The interaction terms between the intervention and measures of frontal plane knee joint kinematics were not statistically significant (all P ≥ 0.05). Significance We found no evidence to suggest that 18-months of either exercise, diet, or a combination of diet and exercise could be more effective than the other to improve pain based on frontal plane measures of knee kinematics.

Gluteal tendinopathy (GT) and hip osteoarthritis (OA) are the most common causes of hip pain and associated disability in older adults. Pain and altered walking biomechanics are common to both conditions. This study aimed to compare three-dimensional walking biomechanics between individuals with unilateral, symptomatic GT and HOA.Sixty individuals with symptomatic unilateral GT confirmed by magnetic-resonance-imaging and 73 individuals with symptomatic unilateral HOA (Kellgren-Lawrence Grade ≥ 2) underwent three-dimensional gait analysis. Maximum and minimum values of the external sagittal hip moment, the first peak, second peak and mid-stance minimum of the hip adduction moment (HAM), sagittal plane hip excursion and hip joint angles, pelvic obliquity and trunk lean, at the three HAM time points during stance phase of walking were compared between groups.Compared to individuals with HOA, those with GT exhibited a greater hip peak extension moment (P 0.001) and greater HAM throughout the stance phase of walking (P = 0.01-P 0.001), greater hip adduction (P 0.001) and internal rotation (P 0.01-P 0.001) angles and lower hip flexion angles and excursion (P = 0.02 - P 0.001). Individuals with HOA exhibited a greater forward trunk lean (P ≤ 0.001) throughout stance, and greater ipsilateral trunk lean in the frontal plane (P 0.001) than those with GT.Despite presence of pain in both conditions, hip kinematics and kinetics differ between individuals with symptomatic unilateral GT and those with symptomatic unilateral HOA. These condition-specific impairments may be targets for optimization of management of HOA and GT.

Poor knee function after anterior cruciate ligament reconstruction (ACLR) may increase the risk of future knee symptoms and knee osteoarthritis via abnormal knee joint loading patterns, particularly during high-impact activity. This study aimed to assess the relationship between poor self-reported or clinically measured knee function and knee moments/vertical ground reaction force (vGRF) in individuals following ACLR. 61 participants (mean 16.5 ± 3 months following ACLR, 23 women) completed a patient-reported knee function questionnaire and three hop tests (% of uninvolved limb). Participants were divided into satisfactory and poor knee function groups (poor

Background Clinical guidelines recommend knee muscle strengthening exercises to improve physical function. However, the amount of knee muscle strength increase needed for clinically relevant improvements in physical function is unclear. Understanding how much increase in knee muscle strength is associated with improved physical function could assist clinicians in providing appropriate strength gain targets for their patients in order to optimise outcomes from exercise. The aim of this study was to investigate whether an increase in knee muscle strength is associated with improved self-reported physical function following exercise; and whether the relationship differs according to physical function status at baseline. Methods Data from 100 participants with medial knee osteoarthritis enrolled in a 12-week randomised controlled trial comparing neuromuscular exercise to quadriceps strengthening exercise were pooled. Participants were categorised as having mild, moderate or severe physical dysfunction at baseline using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Associations between 12-week changes in physical function (dependent variable) and peak isometric knee extensor and flexor strength (independent variables) were evaluated with and without accounting for baseline physical function status and covariates using linear regression models. Results In covariate-adjusted models without accounting for baseline physical function, every 1-unit (Nm/kg) increase in knee extensor strength was associated with physical function improvement of 17 WOMAC units (95% confidence interval (CI) −29 to −5). When accounting for baseline severity of physical function, every 1-unit increase in knee extensor strength was associated with physical function improvement of 24 WOMAC units (95% CI −42 to −7) in participants with severe physical dysfunction. There were no associations between change in strength and change in physical function in participants with mild or moderate physical dysfunction at baseline. The association between change in knee flexor strength and change in physical function was not significant, irrespective of baseline function status. Conclusions In patients with severe physical dysfunction, an increase in knee extensor strength and improved physical function were associated. Trial registration ANZCTR 12610000660088. Registered 12 August 2010. Electronic supplementary material The online version of this article (10.1186/s13075-017-1477-8) contains supplementary material, which is available to authorized users.

The primary objective was to examine the hip adduction moment during walking in people with hip osteoarthritis (OA) according to pain severity. Sixty-eight participants with unilateral symptomatic hip OA were included. Pain during walking was assessed on a 5-point Likert item within the Western Ontario and McMaster Universities Index (no pain = 12; mild pain n = 37; moderate pain n = 19). Measures of the external hip adduction moment (peaks, Nm/BW × BH (%) and impulse, Nm.s/BW × BH (%)) were determined. Other measures included frontal plane hip, pelvis and trunk kinematics, walking speed and peak isometric hip abductor strength. Variables were compared according to pain severity using linear models and biomechanical variables were examined. Participants with moderate pain had a significantly higher second peak hip adduction moment and impulse compared to those with less pain. There was no difference in any measure of hip adduction moment between those with mild pain and no pain. There were no differences in kinematics across pain severity categories. Participants with moderate pain had a significantly slower walking speed compared to participants with mild and no pain. Participants with moderate pain had weaker peak isometric hip abductor strength compared to those with mild pain and no pain. The hip adduction moment during walking, hip abduction strength and walking speed differs according to pain severity during walking in people with hip OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1637-1644, 2018.

Objective: To investigate demographic, symptom-related, and cognitive determinants of cane use for knee osteoarthritis (OA) and prioritize the factors that could facilitate cane use in people with no previous cane use. Methods: A survey of people ages 45 years with a clinical diagnosis of knee OA was conducted. The survey consisted of the following two sections: 1) demographic and cognitive determinants of cane use assessed via subscales of the Cane Cognitive Mediator Scale, and 2) 19 statements, underpinned by the Behaviour Change Wheel theoretical framework, relating to factors that could facilitate regular cane use. Logistic regression was used to examine determinants of cane use, while a priority pairwise ranking activity (1000minds software) determined the rank order of the 19 statements that could facilitate cane use. Results: A total of 529 people completed Part 1 (80% females; 35% cane users) and 231 people completed Part 2. Age (odds ratio [OR] 1.06, 95% confidence interval [95% CI] 1.03- 1.09), body mass index (BMI) (OR 1.03, 95% CI 1.01-1.06), knee pain 3 years (OR 2.62, 95% CI 1.63-4.21) and numeric rating scale pain level while walking (OR 1.19, 95% CI 1.09-1.30) were significant independent determinants of cane use. In people who had never used a cane, statements relating to cane-use technique, fitting, knowledge of benefits, and motivation were ranked highest overall. Conclusion: Independent determinants of cane use include older age, higher BMI, greater pain duration, and greater severity of knee pain. Strategies targeting an individual's capability and motivation to use a cane may increase cane use among people with knee OA.

Background: Altered knee joint biomechanics is thought to play a role in the pathogenesis of knee osteoarthritis and has been reported in patients after arthroscopic partial meniscectomy (APM) while performing various activities. Longitudinally, understanding knee joint biomechanics during jogging may assist future studies to assess the implications of jogging on knee joint health in this population. Purpose: To investigate knee joint biomechanics during jogging in patients 3 months after APM and a healthy control group at baseline and 2 years later at follow-up. Study Design: Controlled laboratory study. Methods: Seventy-eight patients who underwent medial APM and 38 healthy controls underwent a 3-dimensional motion analysis during barefoot overground jogging at baseline. Sixty-four patients who underwent APM and 23 controls returned at follow-up. External peak moments (flexion and adduction) and the peak knee flexion angle during stance were evaluated for the APM leg, non-APM leg (nonoperated leg), and control leg. Results: At baseline, the peak knee flexion angle was 1.4° lower in the APM leg compared with the non-APM leg ( P = .03). No differences were found between the moments in the APM leg compared with the control leg (all P > .05). However, the normalized peak knee adduction moment was 35% higher in the non-APM leg compared with the control leg ( P = .008). In the non-APM leg, the normalized peak knee adduction and flexion moments were higher compared with the APM leg by 16% and 10%, respectively, at baseline ( P ≤ .004). Despite the increase in the peak knee flexion moment in the APM leg compared with the non-APM leg ( P < .001), there were no differences in the peak knee flexion moment or any other parameter assessed at 2-year follow-up between the legs ( P > .05). Conclusion: Comparing the APM leg and control leg, no differences in knee joint biomechanics during jogging for the variables assessed were observed. Higher knee moments in the non-APM leg may have clinical implications for the noninvolved leg. Kinematic differences were small (~1.4°) and therefore of questionable clinical relevance. Clinical Relevance: These results may facilitate future clinical research regarding the implications of jogging on knee joint health in middle-aged, overweight patients after APM.

Knee muscle weakness and a greater external knee adduction moment are suggested risk factors for medial tibiofemoral knee osteoarthritis. Knee muscle weakness and a greater knee adduction moment may be related to each other, are potentially modifiable, and have been observed after arthroscopic partial meniscectomy.The aim of this exploratory study was to determine if knee muscle weakness 3 months after arthroscopic partial meniscectomy (baseline) is associated with an increase in external knee adduction parameters during the subsequent 2 years.Eighty-two participants undergoing medial arthroscopic partial meniscectomy were assessed at baseline, and 66 participants who were reassessed 2 years later were included in our study. Isokinetic muscle strength and external adduction moment parameters (peak and impulse) during normal and fast walking were measured at baseline and followup. Multiple linear regression models were used to examine the association between baseline muscle strength and 2-year change in adduction moment parameters. A post hoc power calculation showed we had 80% power to detect a correlation of 0.31 between baseline muscle strength and change in the external knee adduction, with an alpha error of 0.05 and two-sided significance.Maximal isokinetic muscle strength 3 months after arthroscopic partial meniscectomy was not associated with change in adduction moment parameters (p value range from 0.12 to 0.96).No evidence was found to suggest that improving maximal knee muscle strength after a recent arthroscopic partial meniscectomy would reduce change in knee adduction moment observed during the subsequent 2 years. As muscle function is modifiable, future investigation of other aspects of muscle function that may relate to change in knee adduction moment is warranted.

People following arthroscopic partial medial meniscectomy (APM) are at increased risk of developing knee osteoarthritis. High impact loading and peak loading early in the stance phase of gait may play a role in the pathogenesis of knee osteoarthritis. This was a secondary analysis of longitudinal data to investigate loading-related indices at baseline in an APM group (3 months post-surgery) and a healthy control group, and again 2 years later (follow-up). At baseline, 82 participants with medial APM and 38 healthy controls were assessed, with 66 and 23 re-assessed at follow-up, respectively. Outcome measures included: (i) heel strike transient (HST) presence and magnitude, (ii) maximum loading rate, (iii) peak vertical force (Fz) during early stance. At baseline, maximum loading rate was lower in the operated leg (APM) and non-operated leg (non-APM leg) compared to controls (p ≤ 0.03) and peak Fz was lower in the APM leg compared to non-APM leg (p ≤ 0.01). Over 2 years, peak Fz increased in the APM leg compared to the non-APM leg and controls (p ≤ 0.01). Following recent APM, people may adapt their gait to protect the operated knee from excessive loads, as evidenced by a lower maximum loading rate in the APM leg compared to controls, and a reduced peak Fz in the APM leg compared to the non-APM leg. No differences at follow-up may suggest an eventual return to more typical gait. However, the increase in peak Fz in the APM leg may be of concern for long-term joint health given the compromised function of the meniscus.

Objectives Patients undergoing medial arthroscopic partial meniscectomy are at increased risk of developing and/or progressing knee osteoarthritis, with increased medial compartment load being a potential contributor. The aim of this study was to evaluate the immediate effect of a valgus unloader knee brace on knee joint moments in patients following medial arthroscopic partial meniscectomy. Design Within-participant design. Methods Twenty-two patients (age 35–55 years) who had undergone medial arthroscopic partial meniscectomy within the previous 8–15 months completed three-dimensional analysis of gait, forward lunge and one-leg rise during two conditions: with and without a valgus unloader knee brace. Outcome measures included the peak and impulse of the knee adduction moment and the peak knee flexion moment. Results The peak knee flexion moment increased during brace condition for forward lunge (mean difference [95% CI]) 0.54 [0.27–0.82] (Nm/(BW × HT)%), p

Objective: Evaluate general practitioner (GP) management of tennis elbow (TE) in Australia. Methods: Data about the management of TE by GPs from 2000 to 2015 were extracted from the Bettering the Evaluation of Care of Health program database. Patient and GP characteristics and encounter management data were classified by the International Classification of Primary Care, version 2, and reported using descriptive statistics with point estimates and 95% confidence intervals. Results: TE was managed by GPs 242,000 times per year on average. Patients were mainly female (52.3%), aged between 35 and 64 years (mean: 49.3 yrs), had higher relative risks of concomitant disorders (e.g. carpal tunnel syndrome and other tendonitis) and their TE was 10 times more likely to be work related than problems managed for patients who did not have TE. Use of diagnostic tests was low, implying a clinical examination based diagnosis of TE. Management was by procedural treatments (36 per 100 TE problems), advice, education or counselling (25 per 100), and referral to other health care providers (14 per 100, mainly to physiotherapy). The rate of local injection did not change over the 15 years and was performed at similar rates as physiotherapy referral. Conclusion: The high risk of comorbidities and work relatedness and no abatement in the reasonably high rate of local injections (which is contrary to the evidence from clinical trials) provides support for the development and dissemination of TE clinical guidelines for GPs.

Hip osteoarthritis (OA) is often associated with pain and impaired function. Understanding biomechanical alterations in patients with hip OA during challenging activities such as stair use is important to inform treatments. The aim of this study was to determine whether kinematics and kinetics during stair ambulation differed between people with hip OA and healthy controls. Fifteen participants with symptomatic and radiographic hip OA and 15 asymptomatic healthy controls underwent 3-D motion analysis during stair ascent and descent. Trunk, pelvis, and hip kinematics as well as hip kinetics were evaluated. Analyses were performed unadjusted and adjusted for speed and leg length. In both the unadjusted and adjusted analyses, participants with hip OA ascended stairs with less hip range of motion in all three planes and a lower peak external rotation moment compared to controls. In the unadjusted analysis, hip OA participants descended stairs with greater ipsilateral trunk lean, less sagittal plane range of motion, lower peak extension moment, lower peak external rotation moment, and greater hip adduction moment impulse compared to controls. In the adjusted results, peak internal rotation moment and hip adduction moment impulse were greater in hip OA participants compared to controls. Findings show that individuals with hip OA display limited range of hip joint movement, particularly during stair ascent, and overall indicate the use of strategies (e.g., trunk lean; lower peak external rotation moment; higher adduction moment impulse) that implicate altered hip abductor function. Future research is required to further understand the implications of these findings on hip OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1505-1514, 2017.

Background The purpose of this feasibility study was to begin to determine the efficacy of cylinder cast immobilisation compared to no form of immobilisation for patients following first-time patellar dislocation (FTPD). Materials and methods Participants were patients who attended a National Health Service Accident and Emergency department following a FTPD. Patients were randomised to receive immobilisation for four weeks in a cylinder cast followed by rehabilitation, versus no immobilisation and early rehabilitation. All patients were followed-up over a three month period, assessed using the Visual analogue scale for pain, Short Form-36, the Lysholm knee score and the Modified Functional Index. Results Forty-one patients were approached to participate. Eight satisfied the pre-defined eligibility criteria and were randomised between the two groups. Whilst the results indicated a trend for superior short-term functional outcomes for those patients not immobilised compared to those immobilised following a FTPD, the small sample and baseline imbalances between the groups may have had a substantial influence on the results. Conclusion This feasibility study has indicated that the outcome measurements adopted were appropriate to answer this research question, but the assessment of return to normal activity, recurrent instability and dislocation and cost-effectiveness over a longer follow-up period is recommended. Similarly, defining a more pragmatic eligibility criteria and recruiting from multiple centres would be recommended for the definitive trial requiring a sample of 348 patients to demonstrate a statistical significant treatment effect. Level of evidence Level 2b

Individuals with anterior cruciate ligament (ACL) reconstruction are at increased risk to develop knee osteoarthritis (OA). Gait analysis describing kinetics of the lower extremity during walking and stair use (stair ascent and stair descent) can provide insight to everyday dynamic knee joint loading. In this study, we compared lower extremity gait patterns of those with ACL reconstruction (>1 year) to a control group. Fifteen ACL reconstructed individuals and 17 healthy controls participated in this study. Knee extensor and flexor strength were assessed. Using inverse dynamics, lower extremity moments were calculated during the stance phase of walking and during two steps of stair ascent and descent. Univariate ANOVA was used to test for main effects between (1) injured leg and control group and (2) non-injured leg and control group. Student paired t-tests were used to determine differences between the injured and non-injured leg. Those with ACL reconstruction exhibited reduced initial knee flexion angles during stair descent, reduced knee extension moments during stair descent and stair ascent (second step), and increased hip extension moments during stair ascent (second step) and walking as compared to controls. Knee flexor strength was significantly reduced in the ACL group, but no differences were found in knee extensor strength. No kinematic or kinetic differences were observed between the injured and non-injured leg of the ACL group. Walking and stair ambulation highlight altered joint loading in those with ACL reconstruction surgery. Individuals appeared to compensate for lower knee extension moments by increasing hip extension moments. Furthermore, the load distribution on the articular cartilage is likely shifted as evidenced by reduced knee flexion angles in the ACL reconstructed leg.

Background: Understanding the biomechanics of the medial longitudinal arch (MLA) may provide insights into injury risk and prevention, as well as function of the arch-supporting structures. Our understanding of MLA deformation is currently limited to sit-to-stand, walking, and running. Material and Methods: Three-dimensional deformation of the MLA of the right foot was characterized in 17 healthy participants during several simulated activities of daily living. MLA deformation was quantified by both changes in arch length and navicular displacement during the stance phase of three motions: walking, stair ascent, and stair descent. Three levels of load were also evaluated: no load, a front load (13.6 kg), and a backpack load (13.6 kg). Force platforms and an eight-camera motion capture system were used to collect relevant lower extremity kinetic and kinematic data. Results: Motion type had a significant ( p < 0.05) effect on navicular displacement and arch length elongation with navicular displacement being greatest during stair descent, while the walking and stair descent conditions showed the greatest increase in arch length. External load did not significantly affect either of these two measures ( p > 0.05). Conclusion: Differences in the MLA deformation variables resulting from varied dynamic activities of daily living can be greater than those during walking and should be considered. Clinical Relevance: Detailing the mechanics of the MLA may aid in further understanding injuries associated with the MLA, and the results of the current study indicate that these mechanics change based on activity.

To track the clinical evolution of febrile urinary tract infection (UTI) diagnosed in 0- to 3-month-old infants and characterize uropathogen frequencies, antimicrobial resistance rates, renal abnormalities, and differences in the sexes in this age group.We observed prospectively 46 infants identified in a cohort of 209 children with first UTI diagnosed between July 2006 and July 2008 at the age of 0 to 3 months. Renal ultrasound scanning and voiding cystourethrography examinations were performed in all infants.Infants3 months old represented 21% of all children with first UTI. Of these children, 26% were female and 74% were male. Escherichia coli was isolated in 88% of cases and had a high rate of resistance to ampicillin (71%) and to trimethoprim/sulfamethoxazole (47%); 21% of children had vesicoureteral reflux, which was of low-grade in 67% of cases, with spontaneous resolution before 2 years in all cases. In infants with normal ultrasound scanning results, a low-grade vesicoureteral reflux was subsequently found in 10% of cases.Infants aged 0 to 3 months represent 21% of children treated for febrile UTI. Boys represent 74% of these cases. E coli is responsible for 88% of UTIs, with a high rate of resistance to antibiotics. When ultrasound scanning examination results are normal, the risk of missing a significant renal abnormality is expected to be extremely low.

This review highlights the changes that have occurred in the general approach to cystic renal diseases in children. For instance, genetic mutations at the level of the primary cilia are considered as the origin of many renal cystic diseases. Furthermore, these diseases are now included in the spectrum of the hepato-renal fibrocystic diseases. Imaging plays an important role as it helps to detect and characterize many of the cystic diseases based on a detailed sonographic analysis. The diagnosis can be achieved during fetal life or after birth. Hyperechoic kidneys and/or renal cysts are the main sonographic signs leading to such diagnosis. US is able to differentiate between recessive and dominant polycystic kidney diseases, hepatocyte nuclear factor 1 Beta mutation, glomerulocystic kidneys and nephronophtisis. MR imaging can, in selected cases, provide additional information including the progressive associated hepatic changes.

Peak expiratory flow (PEF) monitoring has long been a mainstay of asthma management, but controversy surrounds its efficacy in the pediatric population, and little published research exists on the subject. PEF is both effort and technique dependent and is not suitable for use in children under the age of 5 or with developmental disabilities. However, PEF is useful for monitoring airway changes if used properly, especially in that segment of the population labeled as "poor perceivers" of worsening symptoms. The authors review existing literature on the subject, including the newly revised National Heart, Lung, and Blood Institute (National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma-full report 2007. Retrieved June 17, 2008, from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm) evidence-based guidelines.

Individuals following anterior cruciate ligament reconstruction (ACLR) with concomitant meniscal pathology have a higher risk of developing knee osteoarthritis (OA) compared to those with isolated ACLR. Knee extensor weakness and altered dynamic knee joint biomechanics have been suggested to play a role in the development of knee OA following ACLR. This study investigated whether these factors differ in people following ACLR who have concomitant meniscal pathology compared to patients with isolated ACLR. Thirty-three patients with isolated ACLR and 34 patients with ACLR and meniscal pathology underwent strength and gait assessment 12–24 months post-operatively. Primary measures were peak isometric knee extensor torque and knee adduction moment (peak and impulse). Secondary measures included peak knee flexion moment and knee kinematics (sagittal and transverse). There were no between-group differences in knee extensor strength [mean difference (95 % CI) 0.09 (−0.23 to 0.42) Nm/kg, n.s.], peak knee adduction moment [−0.02 (−0.54 to 0.49) Nm/(BW × HT) %, n.s.] or knee adduction moment impulse [0.01 (−0.15 to 0.17) Nm/(BW × HT) %, p = n.s.]. No between-group differences were found for any secondary measures. No evidence was found to suggest that the higher prevalence of OA in patients with ACLR and meniscal pathology compared to patients with isolated ACLR is attributed to reduced knee muscle strength or altered knee joint biomechanics assessed 1–2 years post-surgery. Given that there is a higher incidence of knee OA in patients with concomitant meniscal pathology and ACLR, further investigation is needed so that population-specific rehabilitation protocols can be developed. III.

To investigate the relative impact of radiographic osteoarthritis (ROA) and current knee pain on lower limb physical function, quadriceps strength, knee joint proprioception, and postural sway.Using a 2x2 factorial design, 142 community derived subjects aged over 45 were divided into four subgroups based on the presence or absence of ROA (KellgrenLawrencegrade 2) and knee pain (as assessed by NHANES questions and a 100 mm visual analogue scale). Maximum isometric contraction of the quadriceps, knee joint proprioceptive acuity, static postural sway, and WOMAC index (both whole and function subscale) were assessed in all subjects.Compared with normal subjects, reported disability was greater for all other subgroups (p0.01). Subjects with both ROA and knee pain reported the greatest disability, and those with knee pain only had greater disability than those with ROA only. Quadriceps weakness was observed in all groups compared with normal subjects (p0.01), though they were no significant intergroup differences. Subjects with knee pain had a greater sway area than those without (p0.05) but the presence of ROA was not associated with increased postural sway. No differences in proprioceptive acuity were observed between groups.The presence of knee pain has a negative association with quadriceps strength, postural sway, and disability compared with ROA. However, the presence of pain-free ROA has a significant negative influence on relative quadriceps strength and reported disability.

Objectives To determine if two successive ultrasound examinations could rule out the presence of clinically significant contralateral anomalies in neonates with multicystic dysplastic kidney (MCDK), thereby avoiding unnecessary voiding cystourethrography (VCUG). Study design We followed 76 newborn infants with antenatally discovered MCDK. Two successive neonatal renal ultrasound examinations were performed, one within the first week and one at around 1 month of life. VCUG and isotopic studies were performed in all infants. Results Urologic anomalies of the contralateral kidney were present in 19 of 76 children (25%): vesicoureteral reflux (VUR) in 16 (21%), ureteropelvic junction obstruction in 2 (3%), and renal duplex kidney in 1 (1%). Sixty-one infants (80% of total) had normal contralateral urinary tract on the 2 successive neonatal renal ultrasound scans. Among them, 4 of 61 (7%) infants presented with low-grade VUR on VCUG that had resolved spontaneously before 2 years of age. The sensitivity, specificity, positive predictive value, and negative predictive value of two successive ultrasound scans in the neonatal period to predict contralateral urological anomalies on VCUG were 75%, 95%, 80%, and 93%, respectively. Conclusions In infants with antenatally diagnosed MCDK, two successive normal neonatal renal ultrasound scans will rule out clinically significant contralateral anomalies, thereby rendering the need for a neonatal VCUG unnecessary.

Our aim was to review the sonographic features of type I primary hyperoxaluria in children and to correlate the sonographic patterns with the clinical development of end-stage renal disease (ESRD).We performed a retrospective analysis of the clinical and imaging files of 13 patients with type I primary hyperoxaluria who were treated in one institution and of the sonographic patterns and the clinical follow-up reports.We encountered the following two sonographic patterns: medullary nephrocalcinosis in eight patients and cortical nephrocalcinosis in five patients. The sonographic appearance of cortical nephrocalcinosis is quite specific: a hyperechoic peripheral renal cortex with acoustic shadowing behind it. Medullary nephrocalcinosis is less specific because there are many other causes of hyperechoic pyramids. All patients with medullary nephrocalcinosis developed lithiasis during the course of the disease. All patients with cortical nephrocalcinosis but only two of eight with medullary nephrocalcinosis developed ESRD.Sonography can be used differentiate the two patterns of type 1 primary hyperoxaluria. The cortical nephrocalcinosis type carries a higher risk of developing ESRD.

OBJECTIVE: The purpose of this study was to determine the incidence of minor degrees of renal pelvis dilatation that-is detected by antenatal ultrasound scanning in an unselected population and its value in the prediction of significant uropathies. STUDY DESIGN: This prospective study was conducted over a 24-month period. Infants with an anteroposterior pelvic diameter of greater than or equal to4 mm in the second trimester and/or greater than or equal to7 mm but

Background Patients following meniscectomy are at increased risk of developing knee osteoarthritis in the tibiofemoral compartment and at the patellofemoral joint. As osteoarthritis is widely considered a mechanical disease, it is important to understand the potential effect of arthroscopic partial meniscectomy (APM) on knee joint mechanics. The purpose of this study was to evaluate changes in knee joint biomechanics during a forward lunge in patients with a suspected degenerative meniscal tear from before to three months after APM. Methods Twenty-two patients (35–55 years old) with a suspected degenerative medial meniscal tear participated in this study. Three dimensional knee biomechanics were assessed on the injured and contralateral leg before and three months after APM. The visual analogue scale was used to assess knee pain and the Knee Injury Osteoarthritis Outcome Score was used to assess sport/recreation function and knee-related confidence before and after APM. Results The external peak knee flexion moment reduced in the APM leg compared to the contralateral leg (mean difference (95% CI)) − 1.08 (− 1.80 to − 0.35) (Nm/(BW × HT)%), p = 0.004. Peak knee flexion angle also reduced in the APM leg compared to the contralateral leg − 3.94 (− 6.27 to − 1.60) degrees, p = 0.001. There was no change in knee pain between the APM leg and contralateral leg (p = 0.118). Self-reported sport/recreation function improved (p = 0.004). Conclusions Although patients self-reported less difficulty during strenuous tasks following APM, patients used less knee flexion, a strategy that may limit excessive patellar loads during forward lunge in the recently operated leg.

AB Purpose: Higher knee load and quadriceps weakness are potential factors involved in the pathogenesis of knee osteoarthritis after arthroscopic partial meniscectomy (APM). In people following APM, this study evaluated the association between external knee joint moments and quadriceps strength and 2-yr change in indices of cartilage integrity in the medial tibiofemoral compartment and patella. Methods: Seventy people with medial APM were assessed 3 months after APM (baseline) and reassessed 2 yr later (follow-up). At baseline, isokinetic quadriceps strength and the external knee adduction moment (peak and impulse) and knee flexion moment (peak) during walking were assessed. Magnetic resonance imaging was used to assess cartilage (cartilage volume and cartilage defects) in the medial tibial compartment and patella at baseline and follow-up. Results: Increased peak knee adduction moment during fast-pace walking at baseline was associated with onset or deterioration of medial tibiofemoral cartilage defects (OR, 2.06; 95% CI, 1.03-4.12; P = 0.042) over 2 yr. Increased peak knee flexion moment during normal-pace walking at baseline was associated with loss of patellar cartilage volume over 2 yr ([beta] = -0.24; 95% CI, -0.47 to -0.01; P = 0.04). No significant association was observed for quadriceps strength. Conclusion: In middle-age adults, a higher peak knee adduction moment and peak knee flexion moment at 3 months after medial APM may be associated with adverse structural changes at the medial tibia and patella over the subsequent 2 yr. These preliminary findings warrant further investigation as interventions aimed at reducing these moments may be designed if appropriate.

Summary Objective To [1] compare the frequency and severity of ultrasound (US) features in people with normal knees (controls), knee pain (KP), asymptomatic radiographic OA (ROA), and symptomatic OA (SROA), [2] examine relationships between US features, pain and radiographic severity, [3] explore the relationship between change in pain and US features over a 3-month period. Method Community participants were recruited into a multiple group case–control study. All underwent assessment for pain, knee radiographs and US examination for effusion, synovial hypertrophy, popliteal cysts and power Doppler (PD) signal within the synovium. A 3-month follow-up was undertaken in over half of control and SROA participants. Results 243 participants were recruited (90 controls; 59 KP; 32 ROA; 62 SROA). Effusion and synovial hypertrophy were more common in ROA and SROA participants. Severity of effusion and synovial hypertrophy were greater in SROA compared to ROA (P

The purpose of this study was to compare muscle activity amplitudes and co-contraction in those with anterior cruciate ligament (ACL) reconstruction to healthy controls during stair negotiation. Eighteen participants with unilateral ACL reconstruction and 17 healthy controls performed stair ascent and descent while surface electromyography was recorded from knee and hip musculature. During stair ascent, the ACL group displayed higher gluteus maximus activity (1-50% stance, p = 0.02), higher vastus lateralis:biceps femoris co-contraction (51-100% stance, p = 0.01), and higher vastus lateralis:vastus medialis co-contraction (51-100% stance, p = 0.05). During stair descent, the ACL group demonstrated higher gluteus maximus activity (1-50% stance, p = 0.01; 51-100% stance, p < 0.01), lower rectus femoris activity (1-50% stance, p = 0.04), higher semimembranosus activity (1-50% stance, p=0.01), higher gluteus medius activity (51-100% stance, p = 0.01), and higher vastus medialis:semimembranosus co-contraction (1-50% stance, p = 0.02). While the altered muscle activity strategies observed in the ACL group may act to increase joint stability, these strategies may alter joint loading and contribute to post-traumatic knee osteoarthritis often observed in this population. Our results warrant further investigation to determine the longterm effects of altered muscle activity on the knee joint following ACL reconstruction.

Background Spina bifida is a congenital defect of the neural tube resulting in motor and sensory disruption. Persons with spina bifida can also experience executive function impairments. Secondary conditions are physical, medical, cognitive, emotional, or psychosocial consequences to which persons with disabilities are more susceptible. Our experience suggested clinicians underappreciate the presence and impact of secondary conditions in adults with spina bifida because they do not specifically ask for this information. Objective Describe the presence and impact of secondary conditions on daily life, as perceived by adults with spina bifida. Methods A clinic-based sample was recruited from the active patient population of an adult specialty center for spina bifida-related care. All subjects were verbally administered a survey developed through literature review and clinical experience of the researchers. The survey measured the presence and perceived impact of secondary conditions. Recruitment and survey data collection occurred over a 6-month period to maximize age representation. Survey data were stratified by age, gender and lesion level for analysis. Results Seventy-two respondents completed the survey. Pain was commonly reported, along with pressure ulcers, bowel & bladder concerns, depression, sleep disturbance, and limited social and community participation. No significant relationships were found between the presence or perceived impact of secondary conditions and age, gender or level of lesion. Conclusions Secondary conditions in spina bifida are present by early adulthood. Identifying these conditions during clinical encounters requires specific rather than general questions. Future study should evaluate earlier initiation of preventative measures by pediatric providers.

Intra-articular injection (IAI) of steroid is a safe and effective treatment for painful knee osteoarthritis (OA).1 The mechanism of action is thought to be partly mediated by an anti-inflammatory effect on the synovium which may be detected by changes observed on ultrasound (US) examination.2 Placebo IAI of saline can also significantly reduce pain though the mechanisms are not generally thought to associate with a peripheral effect.3–5 This pilot study aimed to investigate whether improved knee pain correlated with improved US measures following IAI of a corticosteroid or a placebo in OA knees. Twenty-five participants with painful knee OA (Kellgren and Lawrence grade ≥2) were randomised to one of two treatment sequences (IAI of methylprednisolone (40 mg in 1 mL) followed by IAI of saline placebo (1 mL, 0.9%), or vice versa) to their most painful knee. Synovial fluid equal to volume injected …