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Idiopathic Normal Pressure Hydrocephalus (iNPH) is a progressive neurologic disorder (fluid build-up in the brain) that affects 0.2%-5% of the UK population aged over 65. Mobility problems, dementia and urinary incontinence are symptoms of iNPH but often these are not properly evaluated, and patients receive the wrong diagnosis. Here, we describe the development and testing of firmware embedded in a wearable device in conjunction with a user-based software system that records and analyses a patient's gait. The movement patterns, expressed as quantitative data, allow clinicians to improve the non-invasive assessment of iNPH as well as monitor the management of patients undergoing treatment. The wearable sensor system comprises a miniature electronic unit that attaches to one ankle of the patient via a simple Velcro strap which was designed for this application. The unit monitors acceleration along three axes with a sample rate of 60 Hz and transmits the data via a Bluetooth communication link to a tablet or smart phone running the Android and the iOS operating systems. The software package extracts statistics based on stride length, stride height, distance walked and speed. Analysis confirmed that the system achieved an average accuracy of at least 98% for gait tests conducted over distances 9 m. This device has been developed to assist in the management and treatment of older adults diagnosed with iNPH., (Creative Commons Attribution license.)

Aim: To determine the efficacy of transdermal anti-inflammatory patches in the treatment of acute and chronic musculoskeletal pain. Methods: A comprehensive search of: Cochrane Central register of controlled trials, EMBASE, MEDLINE, CINAHL and PubMed, for studies using transdermal anti-inflammatory patches vs placebo for management of musculoskeletal pain, e.g. soft tissue injuries or tendonitis (last search January 2024). Cochrane Risk of Bias Tools v1 was used for quality assessment and GRADE determined certainty of evidence. Meta-analysis was performed. Results: Twenty-three randomized placebo-controlled trials (n = 4729) were included. There was low-certainty evidence that transdermal patches provided statistically and clinically significant pain relief on movement at long-term follow-up for chronic musculoskeletal pain (effect size -2-69 (95% CI: -4.14, -1.24) and at short-term follow-up which was non-clinically significant, (-1.24: 95% CI: -1.78, -0.69). Conclusion: Several types of transdermal anti-inflammatory patches may offer short-term and long-term pain relief for acute and chronic musculoskeletal conditions. However, the clinical significance of this effect for the long-term pain relief was based on low-certainty evidence of transdermal anti-inflammatory patches versus placebo; for short-term pain there was an overall non-clinically significant improvement. Performing a meta-analysis for all outcomes was not possible due to insufficiency in the evidence-base. Protocol registration: www.crd.york.ac.uk/prospero identifier is CRD42020185944.

Background: Patients with painful ankle osteoarthritis (OA) have a mixed experience of non-surgical management which they may attribute to a lack of guidance for clinicians on usual care treatment. Therefore, the purpose of this study was to survey the current clinical practices of UK-based physiotherapists and podiatrists for the treatment of painful ankle osteoarthritis (OA)., Methods: UK-based physiotherapists and podiatrists who treat patients with ankle OA completed a self-administered online questionnaire about their professional and clinical service characteristics, diagnostic criteria, treatment aims, preferred treatment options, and treatment outcome measures. Data were collected anonymously and stored on JISC online survey. 'Usual care' was defined as a combination of 'Always', and 'Frequently', and 'Not usual care' was defined as 'Sometimes' 'Rarely,' 'Never', and 'not applicable' combined. Statistically significant differences in responses between the physiotherapists and podiatrists were analysed using X 2 tests for each treatment modality. Statistical significance was set at p < 0.05., Results: Between 1st June 2021 and 31st August 2021, 100 responses were received; 2 were invalid. Of the 98 valid responses, 63 were from physiotherapists and 35 from podiatrists. The most common treatment aims in both professions were to reduce pain (n = 87, 89%) and improve quality of life (n = 82, 84%). 50 respondents (51%) offered 3 or 4 treatment sessions and 53 respondents (54%) saw patients for 30-40 min at the first treatment session. The five most common modalities used by physiotherapists were patient education (n = 63, 100%), teaching self-management (n = 58, 92%), lifestyle modification (n = 54, 86%), ankle strengthening (n = 55, 87%), and proprioception exercises (n = 54, 86%). For podiatrists, these were patient education (n = 35, 100%), ankle strengthening (n = 31, 89%), activity pacing (n = 28, 80%), lifestyle modification (n = 27, 77%), and gait training (n = 27, 77%)., Conclusions: This first-ever survey revealed physiotherapists' and podiatrists' current practices to treat painful ankle OA. This study provides a better understanding of how ankle OA is treated in UK current clinical practice and can inform future clinical trials to compare current practice with new treatment modalities., (© 2023. The Author(s).)

Background: Data collected during initial primary care consultations could be a source of baseline prognostic factors associated with changes in outcome measures for patients with knee pain., Objectives: To identify, appraise and synthesize studies investigating prognostic factors associated with changes in outcome for people presenting with knee pain in primary care., Methods: EMBASE, CINAHL, AMED, MEDLINE and MedRxiv electronic databases were searched from inception to March 2021 and repeated in August 2022. Prospective cohort studies of adult participants with musculoskeletal knee pain assessing the association between putative prognostic factors and outcomes in primary care were included. The Quality in Prognostic Studies (QUIPS) tool and The Modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, specific to prognostic reviews were used to appraise and synthesize the evidence respectively., Results: Eight studies were included. Eight knee pain outcomes were identified. Methodological and statistical heterogeneity resulted in qualitative analysis. All evidence was judged to be of low to very low quality. Bilateral knee pain (multivariable odds ratio (OR) range 2.60-2.74; 95%CI range 0.90-8.10, p value = 0.09) and a lower educational level (multivariable (OR) range 1.74-5.6; 95%CI range 1.16-16.20, p value = <0.001) were synonymously associated with persisting knee pain at 12-month follow up. A total of 37 univariable and 63 multivariable prognostic factors were statistically associated with outcomes ( p  ≤ 0.05) in single studies., Conclusions: There was consensus from two independent studies that bilateral knee pain and lower educational level were associated with persistent knee pain. Many baseline factors were associated with outcome in individual studies but not consistently between studies. The current understanding, accuracy and reliability of the prognostic value of initial primary care consultation data for knee pain outcomes are limited. This review will provide an essential guide for candidate variable selection in future primary care prognostic confirmatory studies.Key messagesBilateral knee pain and lower educational level were associated with persistent knee pain.Many baseline factors were associated with outcome in individual studies but not consistently between studies.The current understanding, accuracy and reliability of the prognostic value of initial primary care consultation data for knee pain outcomes are limited.

The propose of this study was to systematically review the current literature and meta-analyse the effects of dietary nitrate (NO 3 - ) supplementation on the contractile properties of skeletal muscle. A literature search of three databases was conducted in June 2021, with 19 studies meeting the inclusion criteria. Studies were included if a placebo versus dietary NO 3 - -only supplementation protocol was used in healthy human, assessed muscle contraction or activities that was < 3 minutes in duration and focused on the lower-body. For the meta-analysis, a pooled standardised mean difference (SMD) was determined for maximum voluntary contraction (MVC) ( n  = 11), cycling, running and inertial load squad peak power output (PPO) ( n =  8), mean power output (MPO) ( n  = 6) and time to PPO ( n  = 4). NO 3 - supplementation demonstrated a small improvement in PPO (SMD = 0.25, P = 0.030) and MPO (SMD = 0.28, P = 0.030) when compared to the placebo. NO 3 - also resulted in an enhanced time to PPO (SMD = -0.78, P < 0.001). There was no clear effect of NO 3 - on isometric MVC (SMD = 0.03, P = 0.758). This review reports that NO 3 - supplementation may have potential to enhance PPO, MPO and time to PPO during dynamic exercise, which may transfer to brief explosive actions commonly observed in sporting activities. Due to the variability in studies, we encourage researchers to use this work to explore areas where evidence in lacking and standardize the study design and procedures.Key teaching pointsFindings from this meta-analysis highlight the potential positive ergogenic effect of dietary NO3-supplementation on PPO, MPO and time to PPO during short duration (<10 s) dynamic exercise.NO3- supplementation might be considered as an ergogenic aid when executing power-based actions (e.g., 100 m sprinter or weightlifter).This review highlights that further research is required to address some of the contrasting findings presented here using a standardised procedure to allow for improved synthesis.

Background: Lumbar disc disease is a leading cause of low back pain. Lumbar discectomy (LD) may be indicated if symptoms are not managed conservatively. Rehabilitation has traditionally been delivered postoperatively; however, there is increasing delivery preoperatively. There are few data concerning perceptions and experiences of preoperative rehabilitation. Exploring experiences of preoperative rehabilitation may help in the development and delivery of effective care for patients., Objectives: To develop an understanding of patient and healthcare provider (HCP) experiences, perspectives and preferences of preoperative LD rehabilitation, including why patients do not attend., Design: A qualitative interpretive approach using focus groups and individual interviews., Methods: Data were collected from; a) patients listed for surgery and attended the preoperative rehabilitation (October 2019 to March 2020), b) patients listed for surgery but did not attend rehabilitation, and c) HCPs involved in the delivery of rehabilitation. Data were transcribed verbatim and analysed using thematic analysis., Results/findings: Twenty participants were included, twelve patients and eight HCPs. The preoperative class was a valuable service for both patients and HCPs. It provided a solution to staffing and time pressures. It provided the required education and exercise content helping the patients along their surgery pathway. Travel distance, transportation links, parking difficulty and cost, lack of knowledge about the class aims, and previous negative experiences were barriers to patient attendance., Conclusions: For most patients and HCPs, the preoperative class was valuable. Addressing the challenges and barriers could improve attendance. Future research should focus on management of patient expectations and preferences preoperatively., Competing Interests: Declaration of competing interest None declared., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: In elite football, periodic health examination (PHE) may be useful for injury risk prediction., Objective: To explore whether PHE-derived variables are prognostic factors for indirect muscle injuries (IMIs) in elite players., Design: Retrospective cohort study., Setting: An English Premier League football club., Participants: 134 outfield elite male players, over 5 seasons (1 July 2013-19 May 2018)., Outcome and Analysis: The outcome was any time-loss, lower extremity index IMI (I-IMI). Prognostic associations were estimated using odds ratios (ORs) and corresponding statistical significance for 36 variables, derived from univariable and multivariable logistic regression models. Missing data were handled using multiple imputation. Non-linear associations were explored using fractional polynomials., Results: During 317 participant-seasons, 138 I-IMIs were recorded. Univariable associations were determined for previous calf IMI frequency (OR 1.80, 95% CI 1.09 to 2.97), hamstring IMI frequency (OR 1.56, 95% CI 1.17 to 2.09), if the most recent hamstring IMI occurred >12 months but <3 years prior to PHE (OR 2.95, 95% CI 1.51 to 5.73) and age (OR 1.12 per 1-year increase, 95% CI 1.06 to 1.18). Multivariable analyses showed that if a player's most recent previous hamstring IMI was >12 months but <3 years prior to PHE (OR 2.24, 95% CI 1.11 to 4.53), this was the only variable with added prognostic value over and above age, which was a confirmed prognostic factor (OR 1.12 per 1-year increase, 95% CI 1.05 to 1.18). Allowing non-linear associations conferred no advantage over linear associations., Conclusion: PHE has limited use for injury risk prediction. Most variables did not add prognostic value over and above age, other than if a player experienced a hamstring IMI >12 months but <3 years prior to PHE. However, the precision of this prognostic association should be confirmed in future., Trial Registration Number: NCT03782389., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Running is a popular sport with widely recognized health benefits. Given the high rates of knee injury in runners and the growing prevalence of knee osteoarthritis (KOA), it may be useful to assess perceptions about running and knee joint health., Purpose: The objectives of this study were to (1) explore and compare the perceptions of the general public (PUB) and health care professionals (HCPs) on the topic of running and knee health and (2) explore recommendations about running and knee health provided by HCPs., Study Design: Cross-sectional study., Methods: We conducted an online survey between June 18 and October 1, 2020. The questionnaire included questions on running and knee health, and HCPs were asked about their typical recommendations and level of confidence in providing recommendations on the topic. Perceptions (proportions) were compared between the PUB and HCPs using the chi-square test., Results: In total, 4521 responses (PUB, n = 2514; HCPs, n = 2007) were analyzed. A greater proportion of HCPs perceived regular running as healthy for knees (86% vs 68%; P < .001). More of the PUB than HCPs ( P < .001) believed that running frequently (29% vs 13%), long distances (54% vs 45%), and on hard surfaces (60% vs 36%) increased the risk of developing KOA. Running for those with KOA was perceived by the PUB as posing an increased risk of getting more knee pain (48%) and needing joint replacement surgery (38%), more so than by HCPs (26% and 17%, respectively). The majority of HCPs reported being relatively confident in providing evidence-based recommendations about running and knee health and mostly recommended that runners with KOA modify training parameters instead of quit., Conclusion: More HCPs perceived running as healthy for knees when compared with the PUB. Most HCPs felt confident in providing evidence-based recommendations about running and knee health., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Salary support was provided by the Canadian Institutes for Health Research to J.-F.E. and the Michael Smith Foundation for Health Research to M.A.H. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Nitrate (NO 3 - ) supplementation has been reported to lower motor unit (MU) firing rate (MUFR) during dynamic resistance exercise; however, its impact on MU activity during isometric and ischemic exercise is unknown., Purpose: To assess the effect of NO 3 - supplementation on knee extensor MU activities during brief isometric contractions and a 3 min sustained contraction with blood flow restriction (BFR)., Methods: Sixteen healthy active young adults (six females) completed two trials in a randomized, double-blind, crossover design. Trials were preceded by 5 days of either NO 3 - (NIT) or placebo (PLA) supplementation. Intramuscular electromyography was used to determine the M. vastus lateralis MU potential (MUP) size, MUFR and near fibre (NF) jiggle (a measure of neuromuscular stability) during brief (20 s) isometric contractions at 25% maximal strength and throughout a 3 min sustained BFR isometric contraction., Results: Plasma nitrite (NO 2 - ) concentration was elevated after NIT compared to PLA (475 ± 93 vs. 198 ± 46 nmol L -1 , p < 0.001). While changes in MUP area, NF jiggle and MUFR were similar between NIT and PLA trials (all p > 0.05), MUP duration was shorter with NIT compared to PLA during brief isometric contractions and the sustained ischemic contraction (p < 0.01). In addition, mean MUP duration, MUP area and NF jiggle increased, and MUFR decreased over the 3 min sustained BFR isometric contraction for both conditions (all p < 0.05)., Conclusions: These findings provide insight into the effect of NO 3 - supplementation on MUP properties and reveal faster MUP duration after short-term NO 3 - supplementation which may have positive implications for skeletal muscle contractile performance., (© 2022. The Author(s).)

Background: The type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers., Method: Physical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing (preop, postop), and rehabilitation content for patients undergoing lumbar discectomy., Results: Seventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription., Conclusions: Whilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery., (© 2022. The Author(s).)

When immobilisation after a cervical spine or head injury is required, the role of the rigid cervical collar is unclear and controversial. There is a need for further studies investigating the use of a rigid cervical collar when head and neck trauma occurs in sport. This study will compare present practice (immobilisation with a cervical collar) to the same procedure without a collar during a simulated spinal immobilisation and extraction scenario from the field of play to the side-line in football (soccer). It will use a prospective cohort within-subjects cross over randomised, controlled trial design. Healthy participants will assume the role of players with a head or neck injury. Clinical practitioners will perform the immobilisation and extrication procedure according to current clinical guidelines. Three dimensional linear and angular acceleration profiles of the head and torso will be measured and the time taken to complete the procedure. The interventions will be a 'cervical collar' or 'no collar' in random order. Data from the IMUs will be transferred wirelessly to a computer for analysis. Accordingly, within-subject differences between each condition (collar vs no collar) will be assessed with parametric or non-parametric inferential statistics. Statistical significance will be set at p<0.05. Trial registration number: ISRCTN16515969., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Patellofemoral pain (PFP) can cause significant pain leading to limitations in societal participation and physical activity. PFP is usually associated with athletes undergoing intensive physical training, or military recruits; but recent evidence shows that PFP is common in the general population. The relationship of PFP with physical activity is not entirely clear. Our aim is to provide a better estimate of the general population prevalence of PFP and to relate this to the level of physical activity, and demographic characteristics. The Survey instrument for Natural history, Aetiology and Prevalence of Patellofemoral pain Studies (SNAPPS) was developed as a PFP screening tool to be used in the community. The electronic version of the SNAPPS (eSNAPPS) has recently been validated and was used to survey attendees at mass-participation running events. We will use an electronic survey to collect data from a sample of 1100 Rugby League World Cup spectators. The survey will have four sections: i) general and demographic; ii) knee pain (eSNAPPS); iii) level of physical activity; and iv) quality of life in relation to knee pain. The primary analytic approach will be descriptive of PFP prevalence. Secondary analyses will explore the relationships of the presence of PFP and the other variables. We will disseminate this work by publication of peer-reviewed papers in scientific journals, presentations at scientific conferences, and on the dedicated SNAPPS website https://www.snappspfp.com/., Competing Interests: The authors have declared that no competing interests exist.

Background: Current clinical guidelines recommend conservative management including non-pharmacologic therapy prior to considering surgery for knee OA. There is a paucity of clinical trials investigating the use of biomechanical device therapies on those with patellofemoral joint osteoarthritis (PFJOA). The aim was to systematically review the effectiveness of biomechanical devices (bracing, taping, and footwear) in the management of symptomatic PFJOA., Method: The Cochrane, PEDro, MEDLINE, CINAHL, AMED and EMBASE electronic databases were search from inception to October 31, 2020. Included studies were randomised controlled or clinical trials studying any form of biomechanical device therapy in the management of PFJOA in the English language. Studies included in the search were quality-appraised using the PEDro scoring system., Result: Eleven studies were identified which included assessment of either patellar taping, or foot orthotics, knee bracing or combined physiotherapy treatments. Trial quality ranged from 'poor' through 'fair' to 'good'. For patellar bracing, pooled analysis of two good quality randomised controlled trials showed no overall significant improvement on a visual analogue scale (VAS) (random effects (RE) standardised mean difference (SMD) = -0.42 (95%CI -1.12 to +0.29). Pooled data from the same two studies showed a non-significant improvement in favour of bracing assessed by the KOOS/WOMAC (RE SMD = -0.18 (95%CI -0.66 to +0.31). Two studies of 'fair' and 'good' quality applying patellar tape showed a significant reduction in pain immediately after application and after 4 days. A randomised trial of a foot orthotic showed a non-significant improvement in pain after 6 weeks with a between groups adjusted mean difference for maximum VAS of 21.9 mm (95% CI - 2.1 to 46.0) and 8.1 (95% CI- 6.9 to 23.1) for KOOS pain. A multimodal physiotherapy intervention (which included taping in two studies) showed a pooled significant improvement in VAS (SMD = -0.4; (95% CI -0.71 to -0.09) at 3 months compared to controls., Conclusion: There is some good quality evidence that a combined physiotherapy approach significantly reduces short-term pain in those with PFJOA. Long-term effects of all interventions are still unknown, which indicates the need for further research to determine the longer term impact of all biomechanical devices on outcomes in symptomatic PFJOA.

Objectives: Osteoarthritis (OA) of the ankle joint is associated with life-long joint pain and disability if not appropriately managed. There is a dearth of research concerning ankle OA and the impact on those living with the condition., Aim: To explore the experiences of people living with painful OA ankle and their views about the non-surgical management of this condition., Design: Qualitative design, using semi-structured interviews., Participants: Nine participants, recruited from an orthopaedic clinic at a UK hospital and the general population. All had a clinical and radiographic diagnosis of OA ankle. Interviews were digitally recorded and transcribed verbatim. Thematic analysis was undertaken to identify emerging themes. Ethical approval was obtained., Results: Nine semi-structured interviews were undertaken. Eight participants were male, median age=55 years (IQR=42.5-64.5). Mechanism of onset was due to trauma (falls, repeated inversion injuries or road traffic collisions) (n=7), or the effects of haemophilia (n=2). The median duration of symptoms was 2 years (IQR=1.5-10). Data saturation was achieved. Four themes were identified: CONCLUSIONS: This is the first study to explore the experiences of people with symptomatic OA ankle. Our findings suggest that those with OA ankle suffer with severe pain, which has a substantial negative impact on a person's physical and mental wellbeing. The findings of this study may be used to inform future research., (Copyright © 2020 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Introduction: An increasing number of patients are attending the Emergency Department (ED) with back pain with or without sciatica. There is evidence to suggest that medical management is varied and inconsistent., Objective: The purpose of this study was to review the literature to determine the evidence base for the therapeutic management of adults presenting with back pain with or without sciatica in the ED., Methods: A systematic review of the literature included the therapeutic management of patients presenting in the ED. Articles published in peer review journals in English language up to August 2018 were searched for in the following data-bases: MEDLINE, EMBASE, SCOPUS, CINAHL, ZETOC, PubMed, The Cochrane Library (Cochrane Database of Systematic Reviews), Web of Science, Open Grey and ETHOS. A narrative synthesis approach was followed., Results: Twenty two studies, including 17 randomised control trials, one randomised control pilot study, two cohort studies, one cohort pilot study and one retrospective audit were included. The Downs and Black methodological quality scores ranged from 16 to 31 with a mean score of 24 out of a possible 32., Conclusion: Evidence suggests that Naproxen alone should be considered as first line management in cases of back pain without sciatica. Intra-venous corticosteroids should be considered in the management of cases of severe sciatica. More high quality trials are needed to determine an evidence-based management protocol for the treatment of acute low back pain in the ED, specifically focusing on non-pharmacological management and the first line management of patients presenting with LBP with sciatica. Systematic Review Registration Number PROSPERO CRD42016042087., (Copyright © 2020 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Background: In elite football (soccer), periodic health examination (PHE) could provide prognostic factors to predict injury risk., Objective: To develop and internally validate a prognostic model to predict individualised indirect (non-contact) muscle injury (IMI) risk during a season in elite footballers, only using PHE-derived candidate prognostic factors., Methods: Routinely collected preseason PHE and injury data were used from 152 players over 5 seasons (1st July 2013 to 19th May 2018). Ten candidate prognostic factors (12 parameters) were included in model development. Multiple imputation was used to handle missing values. The outcome was any time-loss, index indirect muscle injury (I-IMI) affecting the lower extremity. A full logistic regression model was fitted, and a parsimonious model developed using backward-selection to remove factors that exceeded a threshold that was equivalent to Akaike's Information Criterion (alpha 0.157). Predictive performance was assessed through calibration, discrimination and decision-curve analysis, averaged across all imputed datasets. The model was internally validated using bootstrapping and adjusted for overfitting., Results: During 317 participant-seasons, 138 I-IMIs were recorded. The parsimonious model included only age and frequency of previous IMIs; apparent calibration was perfect, but discrimination was modest (C-index = 0.641, 95% confidence interval (CI) = 0.580 to 0.703), with clinical utility evident between risk thresholds of 37-71%. After validation and overfitting adjustment, performance deteriorated (C-index = 0.589 (95% CI = 0.528 to 0.651); calibration-in-the-large = - 0.009 (95% CI = - 0.239 to 0.239); calibration slope = 0.718 (95% CI = 0.275 to 1.161))., Conclusion: The selected PHE data were insufficient prognostic factors from which to develop a useful model for predicting IMI risk in elite footballers. Further research should prioritise identifying novel prognostic factors to improve future risk prediction models in this field., Trial Registration: NCT03782389.

Objective: Trials testing promising interventions in knee osteoarthritis (OA) often fail to show pain reductions. This may be due to change in activity whereby a person's pain decreases, leading them to increase their activity levels, in turn increasing pain back to baseline levels. Using data from a trial of a beneficial treatment for knee pain, we explored whether activity changes might mask a treatment's effect on pain, by looking at whether activity levels increased with effective treatment and whether change in activity level related to change in pain., Design: During the InRespond trial (ISRCTN55059760) participants wore an accelerometer for 7 days before and during treatments. We assessed change in pain on treatment using scores for overall knee pain and pain in a nominated pain-aggravating activity both in the last week and evaluated change in different types of activity using accelerometer data. Principal components analysis tested whether change in activity and pain outcomes were correlated and created composites combining them. We then tested whether activity, pain or the composites showed a treatment effect, and examined their responsiveness., Results: In the 61 participants (mean age 64.5 years, 38% women, mean overall knee pain score 5.08 (0-10)), activity levels mostly decreased during the trial. Principal component analyses suggested that pain and activity did not correlate highly, loading on different components. Treatment that showed significant effects on pain did not show similar effects on either activity (e.g. the active treatment had a slightly greater reduction in total steps taken than the control treatment (difference 1942.6 steps/week, p = 0.42) nor on composites combining activity and pain. Pain outcomes were the most responsive; static loading (standing) outcomes were the most responsive activity outcome., Conclusion: We found no evidence to support the hypothesis that activity levels increase during effective OA treatment and might account for the negligible pain effects of OA treatments., (© 2020 The Authors.)

Background: Indirect muscle injuries (IMIs) are a considerable burden to elite football (soccer) teams, and prevention of these injuries offers many benefits. Preseason medical, musculoskeletal and performance screening (termed periodic health examination (PHE)) can be used to help determine players at risk of injuries such as IMIs, where identification of PHE-derived prognostic factors (PF) may inform IMI prevention strategies. Furthermore, using several PFs in combination within a multivariable prognostic model may allow individualised IMI risk estimation and specific targeting of prevention strategies, based upon an individual's PF profile. No such models have been developed in elite football and the current IMI prognostic factor evidence is limited. This study aims to (1) develop and internally validate a prognostic model for individualised IMI risk prediction within a season in elite footballers, using the extent of the prognostic evidence and clinical reasoning; and (2) explore potential PHE-derived PFs associated with IMI outcomes in elite footballers, using available PHE data from a professional team., Methods: This is a protocol for a retrospective cohort study. PHE and injury data were routinely collected over 5 seasons (1 July 2013 to 19 May 2018), from a population of elite male players aged 16-40 years old. Of 60 candidate PFs, 15 were excluded. Twelve variables (derived from 10 PFs) will be included in model development that were identified from a systematic review, missing data assessment, measurement reliability evaluation and clinical reasoning. A full multivariable logistic regression model will be fitted, to ensure adjustment before backward elimination. The performance and internal validation of the model will be assessed. The remaining 35 candidate PFs are eligible for further exploration, using univariable logistic regression to obtain unadjusted risk estimates. Exploratory PFs will also be incorporated into multivariable logistic regression models to determine risk estimates whilst adjusting for age, height and body weight., Discussion: This study will offer insights into clinical usefulness of a model to predict IMI risk in elite football and highlight the practicalities of model development in this setting. Further exploration may identify other relevant PFs for future confirmatory studies and model updating, or influence future injury prevention research., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

In elite football, measurement of running kinetics with inertial measurement units (IMUs) may be useful as a component of periodic health examination (PHE). This study determined the reliability of, and agreement between a research orientated IMU and clinically orientated IMU system for initial peak acceleration (IPA) and IPA symmetry index (SI) measurement during running in elite footballers. On consecutive days, 16 participants performed treadmill running at 14kmph and 18kmph. Both IMUs measured IPA and IPA SI concurrently. All measurements had good or excellent within-session reliability (intraclass correlation coefficient (ICC 2,1 ) range = 0.79-0.96, IPA standard error of measurement (SEM) range = 0.19-0.62 g, IPA SI SEM range = 2.50-8.05%). Only the research orientated IMU demonstrated acceptable minimal detectable changes (MDCs) for IPA at 14kmph (range = 7.46-9.80%) and IPA SI at both speeds (range = 6.92-9.21%). Considering both systems, between-session IPA reliability ranged from fair to good (ICC 2,1 range = 0.63-0.87, SEM range = 0.51-1.10 g) and poor to fair for IPA SI (ICC 2,1 range = 0.32-0.65, SEM range = 8.07-11.18%). All MDCs were >10%. For IPA and SI, the 95% levels of agreement indicated poor between system agreement. Therefore, the use of IMUs to evaluate treadmill running kinetics cannot be recommended in this population as a PHE test to identify prognostic factors for injuries or for rehabilitation purposes., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

During single leg squats (SLS), tibial angle (TA) quantification using inertial measurement units (IMU) may offer a practical alternative to frontal plane projection angle (FPPA) measurement using 2-dimensional (2D) video analysis. This study determined: (i) the reliability of IMUs and 2D video analysis for TA measurement, and 2D video analysis for FPPA measurement; (ii) the agreement between IMU TA and both 2D video TA and FPPA measurements during single leg squats in elite footballers. 18 players were tested on consecutive days. Absolute TA (ATA) and relative TA (RTA) were measured with IMUs. ATA and FPPA were measured concurrently using 2D video analysis. Within-session reliability for all measurements varied across days (intraclass correlation coefficient (ICC) range = 0.27-0.83, standard error of measurement (SEM) range = 2.12-6.23°, minimal detectable change (MDC) range = 5.87-17.26°). Between-sessions, ATA reliability was good for both systems (ICCs = 0.70-0.74, SEMs = 1.64-7.53°, MDCs = 4.55-7.01°), while IMU RTA and 2D FPPA reliability ranged from poor to good (ICCs = 0.39-0.72, SEMs = 2.60-5.99°, MDCs = 7.20-16.61°). All limits of agreement exceeded a 5° acceptability threshold. Both systems were reliable for between-session ATA, although agreement was poor. IMU RTA and 2D video FPPA reliability was variable. For SLS assessment, IMU derived TAs are not useful surrogates for 2D video FPPA measures in this population., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In professional soccer and other elite sports, medical and performance screening of athletes (also termed periodic health examination or PHE) is common practice. The purposes of this are: (1) to assist in identifying prevalent conditions that may be a threat to safe participation, (2) to assist in setting benchmark targets for rehabilitation or performance purposes and (3) to assist clinicians in determining which athletes may be at risk of future injury and selecting appropriate injury prevention strategies to reduce the perceived risk. However, when using PHE as an injury prevention tool, are clinicians seeking to identify potential causes of injury or to predict future injury? This Current Opinion aims to examine the conceptual differences between aetiology and prediction of injury while relating these areas to the capabilities of PHE in practice. We also introduce the concept of prognosis-a broader approach that is closely related to prediction-and why this may have greater applicability to PHE of professional athletes.

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Fracture and dislocation of the shoulder are usually identifiable through the use of plain radiographs in an emergency department. However, other significant soft tissue injuries can be missed at initial presentation. This study used contrast enhanced magnetic resonance arthrography (MRA) to determine the pattern of underlying soft tissue injuries in patients with traumatic shoulder injury, loss of active range of motion, and normal plain radiography., Methods: A prospective, observational cohort study. Twenty-six patients with acute shoulder trauma and no identifiable radiograph abnormality were screened for inclusion. Those unable to actively abduction their affected arm to 90° at initial presentation and at two week's clinical review were consented for MRA., Results: Twenty patients (Mean age 44 years, 4 females) proceeded to MRA. One patient had no abnormality, three patients showed minimal pathology. Four patients had an isolated bony/labral injury. Eight patients had injuries isolated to the rotator cuff. Four patients had a combination of bony and rotator cuff injury. Four patients were referred to a specialist shoulder surgeon following MRA and underwent surgery., Conclusions: Significant soft tissue pathology was common in our cohort of patients with acute shoulder trauma, despite the reassurance of normal plain radiography. These patients were unable to actively abduct to 90° both at initial presentation and at two week's post injury review. A more aggressive management and diagnostic strategy may identify those in need of early operative intervention and provide robust rehabilitation programmes.

Objective: The aim of this study was to compare the short-term effects of Mobilization with movement (MWM) and Kinesiotaping (KT) on patients with patellofemoral pain (PFP) respect to pain, function and balance., Methods: Thirty-five female patients diagnosed with unilateral PFP were assigned into 2 groups. The first group (n = 18) received two techniques of MWM intervention (Straight Leg-Raise with Traction and Tibial Gliding) while KT was applied to the other group (n = 17). Both groups received 4 sessions of treatment twice a week for a period of 2 weeks with a 6-week-home exercise program. Pain severity, knee range of motion, hamstring flexibility, and physical performance (10-step stair climbing test, timed up and go test), Kujala Patellofemoral Pain Scoring and Y-Balance test were assessed. These outcomes were evaluated before the treatment, 45 min after the initial treatment, at the end of the 4-session-treatment during 2-week period and 6 weeks later in both groups., Results: Both treatment groups had statistically significant improvements on pain, function and balance (p < 0.05). Pain at rest (p = 0.008) and the hamstring muscle flexibility (p = 0.027) were demonstrated significant improvements in favor of MWM group., Conclusions: Our results demonstrated similar results for both treatment techniques in terms of pain, function and balance. The MWM technique with exercise had a short-term favorable effect on pain at rest and hamstring muscle flexibility than the KT technique with exercise in patients with PFP., Level of Evidence: Level I, therapeutic study., (Copyright © 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Objective: The aim of this systematic review was to determine the validity and inter- and intra-observer reliability of the assessment of knee joint effusion in osteoarthritis (OA) of the knee., Methods: MEDLINE, Web of Knowledge, CINAHL, EMBASE, and AMED were searched from their inception to February 2015. Articles were included according to a priori defined criteria: samples containing participants with knee OA; prospective evaluation of clinical tests and assessments of knee effusion that included reliability, sensitivity, and specificity of these tests., Results: A total of 10 publications were reviewed. Eight of these considered reliability and four on validity of clinical assessments against ultrasound effusion. It was not possible to undertake a meta-analysis of reliability or validity because of differences in study designs and the clinical tests. Intra-observer kappa agreement for visible swelling ranged from 0.37 (suprapatellar) to 1.0 (prepatellar); for bulge sign 0.47 and balloon sign 0.37. Inter-observer kappa agreement for visible swelling ranged from -0.02 (prepatellar) to 0.65 (infrapatellar), the balloon sign -0.11 to 0.82, patellar tap -0.02 to 0.75 and bulge sign kappa -0.04 to 0.14 or reliability coefficient 0.97. Reliability and diagnostic accuracy tended to be better in experienced observers. Very few data looked at performance of individual clinical tests with sensitivity ranging 18.2-85.7% and specificity 35.3-93.3%, both higher with larger effusions., Conclusion: The majority of unstandardized clinical tests to assess joint effusion in knee OA had relatively low intra- and inter-observer reliability. There is some evidence experience improved reliability and diagnostic accuracy of tests. Currently there is insufficient evidence to recommend any particular test in clinical practice., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Patellofemoral pain refers to pain behind or around the patella (also known as patellofemoral pain syndrome, anterior knee pain, runner's knee, and, formerly, chondromalacia patellae). Patellofemoral pain is common, accounting for 11-17% of all knee pain presentations to general practice.(1 2) While it typically occurs in physically active people aged <40 years, it also affects people of all activity levels and ages.(1 2) Patellofemoral pain can be diagnosed in the clinic, and evidence based treatments can reduce pain and improve function, allowing patients to maintain a physically active lifestyle., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Study Design: Secondary analysis of a randomized controlled trial., Background: The use of external supports has been questioned because they may lead to weakness in the surrounding muscles. To our knowledge, there is no investigation into the effect of knee supports or braces on quadriceps muscle strength and quadriceps inhibition in individuals with patellofemoral joint (PFJ) osteoarthritis (OA)., Objectives: To investigate the effects of a flexible knee support on quadriceps maximum voluntary contraction (MVC) and arthrogenous muscle inhibition (AMI) in patients with PFJ OA., Methods: The study included 108 participants who had at least 3 months of patellofemoral pain and a Kellgren-Lawrence score of 2 or 3 for PFJ OA. The participants were randomized to a group that wore a flexible knee support (brace) or a group that did not wear a support (no brace) in a 6-week randomized controlled trial, followed by an open-label trial, in which all participants wore the brace for a total of 12 weeks. Quadriceps MVC, measured isometrically, and quadriceps AMI, measured by twitch interpolation, were assessed at the 6-week and 12-week time points., Results: After 6 weeks, MVC did not differ between the brace and no-brace groups (9.09 Nm; 95% confidence interval [CI]: -4.89, 23.07; P = .20). Arthrogenous muscle inhibition significantly decreased in the brace group (-8.62%; 95% CI: -13.90%, -3.33%; P = .002). After 12 weeks, in all of the participants who wore a flexible knee support, MVC increased by 7.98 Nm (95% CI: 2.52, 13.45; P = .004) and AMI decreased (-8.42%; 95% CI: -11.48%, -5.36%; P<.001). Although statistically significant, these results have doubtful clinical significance., Conclusion: A patellofemoral flexible knee support in participants with PFJ OA does not have an adverse effect on quadriceps MVC or AMI. Using a knee support should not be discouraged because of concerns about deleterious effects on quadriceps strength and inhibition., Level of Evidence: Therapy, level 1b.

Objective: Braces used to treat (PF) osteoarthritis (OA) may reduce contact stress across the PF joint. We hypothesised that in PF OA, braces would decrease knee pain and shrink PF bone marrow lesions (BMLs)., Methods: Eligible subjects had painful PF OA. Subjects were randomly allocated to brace or no brace for 6 weeks. Knee MRIs were acquired at baseline and 6 weeks. We measured BMLs on post-contrast fat suppressed sagittal and proton density weighted axial images. The primary symptom outcome was change in pain at 6 weeks during a preselected painful activity, and the primary structural outcome was BML volume change in the PF joint. Analyses used multiple linear regression., Results: We randomised 126 subjects aged 40-70 years (mean age 55.5  years; 72 females (57.1%)). Mean nominated visual analogue scale (0-10 cm) pain score at baseline was 6.5 cm. 94 knees (75%) had PF BMLs at baseline. Subjects wore the brace for a mean of 7.4 h/day. 6 subjects withdrew during the trial. After accounting for baseline values, the brace group had lower knee pain than the control group at 6 weeks (difference between groups -1.3 cm, 95% CI -2.0 to -0.7; p<0.001) and reduced PF BML volume (difference -490.6 mm(3), 95% CI -929.5 to -51.7; p=0.03) but not tibiofemoral volume (difference -53.9 mm(3), 95% CI -625.9 to 518.2; p=0.85)., Conclusions: A PF brace reduces BML volume in the targeted compartment of the knee, and relieves knee pain., Trial Registration Number: UK. ISRCTN50380458., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: The knee can be injected at different anatomic sites with or without image-guidance. We undertook a systematic review to determine the accuracy of intra-articular knee injection (IAKI) and whether this varied by site, use of image-guidance, and experience of injectors, and whether accuracy of injection, site, or use of image-guidance influenced outcomes following IAKIs., Methods: Medline, Embase, AMED, CINAHL, Web of Knowledge, Cochrane Central Registers for Controlled Trials up to Dec 2012 were searched for studies that evaluated either accuracy of IAKIs or outcomes related to accuracy, knee injection sites, or use of image-guidance. Within-study and between-study analyses were performed., Results: Data from 23 publications were included. Within-study analyses suggested IAKIs at the superomedial patellar, medial midpatellar (MMP), superolateral patellar (SLP) and lateral suprapatellar bursae sites were more accurate when using image-guidance than when blinded (ranges of pooled risk difference 0.09-0.19). Pooling data across studies suggested blinded IAKIs at the SLP site were most accurate (87%) while MMP (64%) and anterolateral joint line (ALJL) sites were (70%) least accurate. Overall about one in five blinded IAKIs were inaccurate. There was some evidence that experience of the injector was linked with improved accuracy for blinded though not image-guided injections. Based on a small number of studies, short but not longer-term outcomes for ultrasound-guided were found to be superior to blinded IAKIs., Conclusions: Image-guided IAKIs are modestly more accurate than blinded IAKIs especially at the MMP and ALJL sites. Blinded injections at SLP site had good accuracy especially if performed by experienced injectors. Further studies are required to address the question whether accurate localization is linked with an improved response., (© 2013 The Authors. Published by Elsevier HS Journals, Inc. All rights reserved.)

Purpose: To evaluate ankle function following endoscopically guided percutaneous Achilles tendon repair. The hypothesis of this study was that patients with percutaneous repair of the Achilles tendon would still display impaired involved side ankle proprioception., Methods: Nineteen male patients with percutaneous Achilles tendon surgery were tested for bilateral ankle active angle reproduction at 10° dorsiflexion and 15° plantar flexion, peak concentric isokinetic ankle dorsiflexor and plantar flexor torque, one-leg hop for distance, and single-leg vertical jump height. Dominant sides of age- and sex-matched 19 healthy controls were evaluated for ankle active angle reproduction at 10° dorsiflexion and 15° plantar flexion, peak concentric isokinetic ankle dorsiflexor and plantar flexor torque., Results: Peak isokinetic torque, one-leg hop for distance, single-leg vertical jump for height and ankle joint position sense at 10° dorsiflexion did not differ between the affected and unaffected side. Ankle joint position sense for active angle replication at 15° plantar flexion revealed a significant side-to-side difference. Joint position sense at 10° dorsiflexion and at 15° plantar flexion at affected side was poor in patients compared with the controls, while joint position sense at 10° dorsiflexion and at 15° plantar flexion at unaffected side was same in patients compared with the controls., Conclusions: It has revealed a significant difference in joint position sense at plantar flexion of the patients at least 1 year after percutaneous Achilles tendon surgery compared to their unaffected limb. Large prospective longitudinal studies are needed to evaluate therapeutic interventions designed to improve proprioception.

Background: There is limited information on the relationship between plantar foot pressure and patellofemoral pain syndrome (PFPS). In addition, there is not enough research on the effects of an infrapatellar strap on PFPS., Objective: The aim of this study was to evaluate the immediate effects of an infrapatellar strap on dynamic pedabarography in patients with unilateral PFPS., Methods: Clinical case control study design. 18 females subjects with unilateral PFPS were included in the study. Gait parameters were tested using pedabarography during barefoot walking with and without an infrapatellar strap., Results: There were no statistically significant differences in gait trials comparing infrapatellar strap to no strap (P>0.05). In addition, a significant difference (P=0.043) in the % forefoot surface on the involved side demonstrated that body weight is transferred to medial aspect of the foot., Discussion: Although our results show a difference between the forefoot surface % of the affected and unaffected sides of subjects with PFPS there was no indication that an infrapatellar strap had any immediate effect on this parameter., Conclusion: It is not clear whether PFPS is a cause or effect of abnormal gait. Further research is warranted to investigate the long-term effects of wearing an infrapatellar strap and associated altered foot biomechanics due to PFPS., (Crown Copyright © 2010. Published by Elsevier Ltd. All rights reserved.)

This study's aim was to determine the between days reliability of surface EMG recordings from the superficial quadriceps during a multi joint sub-maximal fatiguing protocol. Three subject groups (healthy n=29; patellofemoral pain syndrome n=74; knee osteoarthritis n=55) performed the task at 60 maximum voluntary isometric contraction on three separate days. Spectral and amplitude EMG parameters were recorded from vastus medialis oblique, vastus lateralis and rectus femoris and were analysed for between days reliability using intraclass correlation coefficient (ICC((2,1))), the standard errors of measure and smallest detectable differences. For frequency results, initial and final frequency values had 'good' or 'excellent' reliability in all groups for all muscles. ICCs for median frequency slopes for vastus medialis oblique, vastus lateralis, and rectus femoris respectively, in the osteoarthritis group were 0.04, 0.55, and 0.72; in the patellofemoral pain group were 0.41, 0.17, and 0.33; in the healthy group were 0.68, 0.64, and 0.31. The standard errors of measurement and smallest detectable differences for all groups and for all muscles were unacceptably high. For amplitude results, ICC root mean squared initial and final values were 'good' to 'excellent' for all groups and all muscles, albeit with high measurement error. The ICCs for root mean squared slopes in all tests were 'poor' with extremely high measurement error. The poor between days reliability and high measurement error suggests that surface EMG should not be adopted to assess fatigue during multi joint sub-maximal isometric quadriceps testing.