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Background Knee osteoarthritis is a major cause of pain and disability. Pain control is poor, with most patients remaining in moderate to severe pain. This may be because central causes of pain, a common contributor to knee pain, are not affected by current treatment strategies. Antidepressants, such as amitriptyline, have been used to treat chronic pain in other conditions. The aim of this randomised, double blind, controlled trial, is to determine whether low dose amitriptyline reduces pain in people with painful knee osteoarthritis over 3 months compared to benztropine, an active placebo. Methods/design One hundred and sixty people with painful radiographic knee osteoarthritis will be recruited via clinicians, local and social media advertising. Participants will be randomly allocated in a 1:1 ratio to receive either low dose amitriptyline (25 mg) or active placebo (benztropine mesylate, 1 mg) for 3 months. The primary outcome is change from baseline in knee pain (WOMAC pain subscale) at 12 weeks. Secondary outcomes include change in function (total WOMAC) and the proportion of individuals achieving a substantial response (≥ 50% reduction in pain intensity, measured by Visual Analog Scale, VAS, from no pain to worst pain imaginable, 0-100 mm) and moderate response (≥ 30% reduction in pain intensity, measured by VAS) at 12 weeks. Intention to treat analyses will be performed. Subgroup analyses will be done. Discussion This study will provide high level evidence regarding the effectiveness of low dose amitriptyline compared to benztropine in reducing pain and improving function in knee OA. This trial has the potential to provide an effective new therapeutic approach for pain management in knee osteoarthritis, with the potential of ready translation into clinical practice, as it is repurposing an old drug, which is familiar to clinicians and with a well described safety record. Trial registration Australian New Zealand Clinical Trials Registry prior to recruitment commencing (ACTRN12615000301561, March 31, 2015, amended 14 December 2018, February 2021). Additional amendment requested 18 July 2021.

OBJECTIVE To examine whether joint line tenderness and patellofemoral grind from physical examination were associated with cartilage volume loss, worsening of radiographic osteoarthritis, and the risk of total knee replacement. METHODS This study examined 4,353 Osteoarthritis Initiative participants. For each measurement of joint line tenderness and patellofemoral grind, the patterns were defined as no (none at baseline and at 1 year), fluctuating (present at either time point), and persistent (present at both time points). Cartilage volume loss and worsening of radiographic osteoarthritis over 4 years were assessed using magnetic resonance imaging and radiographs, and total knee replacement over 6 years was assessed. RESULTS A total of 35.0% of participants had joint line tenderness, and 15.8% had patellofemoral grind. Baseline patellofemoral grind, but not joint line tenderness, was associated with increased cartilage volume loss (1.08% per year versus 0.96% per year; P = 0.02) and an increased risk of total knee replacement (odds ratio [OR] 1.55 [95% confidence interval (95% CI) 1.11-2.17]; P = 0.01). While the patterns of joint line tenderness were not significantly associated with joint outcomes, participants with persistent patellofemoral grind had an increased rate of cartilage volume loss (1.30% per year versus 0.90% per year; P < 0.001) and an increased risk of total knee replacement (OR 2.10 [95% CI 1.30-3.38]; P = 0.002) compared with those participants without patellofemoral grind. CONCLUSION Patellofemoral grind, but not joint line tenderness, may represent a clinical marker associated with accelerated cartilage volume loss over 4 years and an increased risk of total knee replacement over 6 years. This simple clinical examination may provide clinicians with an inexpensive way to identify those at higher risk of disease progression who should be targeted for surveillance and management.

Background Hand osteoarthritis is a common and disabling problem without effective therapies. Accumulating evidence suggests the role of local inflammation in causing pain and structural progression in hand osteoarthritis, and hand osteoarthritis with synovitis is a commonly encountered clinical phenotype. Methotrexate is a well-established, low-cost, and effective treatment for inflammatory arthritis with a well-described safety profile. The aim of this multicentre, randomised, double-blind, placebo-controlled trial is to determine whether methotrexate reduces pain over 6 months in patients with hand osteoarthritis and synovitis. Methods Ninety-six participants with hand osteoarthritis and synovitis will be recruited through the Osteoarthritis Clinical Trial Network (Melbourne, Hobart, Adelaide, and Perth), and randomly allocated in a 1:1 ratio to receive either methotrexate 20 mg or identical placebo once weekly for 6 months. The primary outcome is pain reduction (assessed by 100 mm visual analogue scale) at 6 months. The secondary outcomes include changes in physical function and quality of life assessed using Functional Index for Hand Osteoarthritis, Australian Canadian Osteoarthritis Hand Index, Health Assessment Questionnaire, Michigan Hand Outcomes Questionnaire, Short-Form-36, tender and swollen joint count, and grip strength, and structural progression assessed using progression of synovitis and bone marrow lesions from magnetic resonance imaging and radiographic progression at 6 months. Adverse events will be recorded. The primary analysis will be by intention to treat, including all participants in their randomised groups. Discussion This study will provide high-quality evidence to address whether methotrexate has an effect on reducing pain over 6 months in patients with hand osteoarthritis and synovitis, with major clinical and public health importance. While a positive trial will inform international clinical practice guidelines for the management of hand osteoarthritis, a negative trial would be highly topical and change current trends in clinical practice. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12617000877381. Registered 15 June 2017, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373124

Resume Objectif Les lesions des plateaux vertebraux (Modic) suscitent un interet croissant et il est admis que divers phenotypes presentent des correlats cliniques et histologiques distincts. Neanmoins, l’histoire naturelle de ces lesions n’est pas parfaitement elucidee. Cette etude a examine l’histoire naturelle des lesions de type Modic. Methodes Soixante-douze adultes d’un meme groupe (frequentation d’un centre de lutte contre le surpoids) selectionne sans tenir compte des lombalgies ont eu une imagerie par resonance magnetique (IRM) du rachis lombaire a l’inclusion (2012), puis environ deux ans plus tard afin d’evaluer les lesions Modic. Cinquante-six patients ont participe a l’etude jusqu’a son terme. La discopathie a ete evaluee en se fondant sur la hauteur discale et la classification de Pfirrmann a l’inclusion. Resultats A l’inclusion, six lesions Modic de type 1 ont ete observees chez trois (4,2 %) participants. Lors du suivi, quatre lesions etaient toujours presentes, deux avaient evolue en lesions Modic de type 2 et quatre lesions incidentes ont ete retrouvees. Un seul participant (1,4 %) presentait a l’inclusion une lesion Modic de type 3, qui etait toujours presente au suivi, accompagnee d’une lesion incidente. Les lesions de type Modic 2 etaient les plus frequentes ( n = 47, 20 participants sur 72 [27,8 %]). Leur resolution a ete rare ( n = 1 et deux evolutions vers une lesion de type 1). Dix-huit lesions incidentes se sont produites chez sept (12,5 %) participants, la plupart concernant les deux cotes du disque intervertebral. Une diminution de la hauteur discale moyenne par rapport a l’inclusion a ete associee a un risque accru de lesions incidentes de type 2 (OR 1,9 ; IC 95 % 1,1 a 3,3 ; p = 0,03). Une degenerescence discale severe a l’inclusion aux niveaux L3/4, L4/5 et L5/S1 a egalement ete associee a un risque accru de lesions incidentes de type 2 (toutes les valeurs p ≤ 0,05). Conclusion Cette etude longitudinale a demontre que les lesions de type Modic 2 etaient les plus frequentes chez les adultes de ce groupe, que leur resolution etait rare et que des lesions incidentes apparaissaient des deux cotes du disque intervertebral dans le contexte d’une degenerescence discale severe. Ces resultats suggerent que les lesions de type Modic 2 sont une consequence de la degenerescence discale.

Whether meniscal extrusion and bone marrow lesions (BMLs) are independently associated with the risk of knee osteoarthritis (OA) is unknown.Data was extracted from the Osteoarthritis Initiative (OAI) cohort. Participants were grouped according to the absence (Kellgren-Lawrence (KL) grade ≤ 1, n = 2120) or presence (KL ≥ 2, n = 2249) of radiographic OA (ROA). Baseline meniscal extrusion and tibial BMLs were assessed. Tibial plateau cartilage volume was assessed at baseline and 72 months, while radiographic disease was assessed at baseline and 48 months. Total knee replacement (TKR) was assessed at 72 months.In those with ROA, the presence of a baseline meniscal extrusion (independent of BMLs) was associated with accelerated cartilage volume loss (medial tibia: -2.1%/annum vs -1.5%; lateral: -2.6%/annum vs -1.6%; both P 0.001), progressive ROA and TKR (Odds ratio (OR) range 1.4-1.8; 95% CI range 1.1-2.9). The presence of a baseline BML was associated with accelerated cartilage volume loss (medial tibia: -2.1%/annum vs -1.6%; lateral: -1.9%/annum vs -1.6%; P ≤ 0.02), progressive ROA and joint replacement (OR range 1.5-2.4; 95% CI range 1.1-3.4). In those with no ROA, a baseline medial meniscal extrusion was associated with accelerated cartilage volume loss (medial tibia: -2.1%/annum vs -1.2%, P 0.001), and a baseline medial BML with incident ROA (OR 1.7, 95% CI 1.1 to 2.9).The presence of baseline meniscal extrusion and BMLs are associated with incident and progressive knee of each other (OA) and represent important structural targets for the treatment and prevention of knee OA.

Introduction and objectives Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that affects the immunocompromised. Patients with systemic autoimmune rheumatic disease are increasingly recognised as an at-risk clinical population with a high mortality. This case-control study examined differences in the characteristics and peripheral blood parameters between patients with systemic autoimmune rheumatic disease who developed PJP and gender, age and disease-matched controls. Methods Historical data collected between 2002 and 2013 at the Royal Melbourne Hospital, Australia were reviewed. Cases were defined by having a systemic autoimmune rheumatic disease and a diagnosis of PJP (either a positive toluidine blue O stain or P. jirovecii PCR, with a concurrent respiratory illness that was clinically consistent with PJP). Controls were matched for age, gender and disease in a 4:1 ratio. Peripheral blood results were retrieved from an in-house pathology database. Clinical information including glucocorticoid exposure, PJP prophylaxis, comorbidities and month of admission were retrieved from medical notes. Results After adjustment for corticosteroid exposure and C-reactive protein, lymphocyte count on admission (0.4 vs. 1.3; p = 0.04) and at nadir (0.2 vs. 0.8 × 109/L; p = 0.05) was significantly lower in cases than in controls. Cases (n = 11) were more frequently Caucasian rather than non-Caucasian (81.8% vs. 65.9%; p = 0.04). In addition, cases more commonly presented in autumn (March to May) than in other seasons (OR = 7.3; 95% CI: 1.4-38.7; p = 0.02). Conclusion These data demonstrate that patients with systemic autoimmune rheumatic disease who develop PJP have significantly greater lymphopenia than age, gender and disease-matched controls, independent of corticosteroid exposure, as well as a potential ethnicity and seasonal predilection to PJP. This may help to inform prophylactic guidelines for PJP in these patients.

Objective To examine whether the presence of bulge sign or patellar tap was associated with frequent knee pain, progression of radiographic OA (ROA) and total knee replacement (TKR). Methods This study included 4344 Osteoarthritis Initiative participants examined at baseline for bulge sign and/or patellar tap. The clinical signs were categorized as no (none at baseline and 2 years), resolved (present at baseline only), developed (present at 2 years only) and persistent (present at both time points). Frequent knee pain and progression of ROA over 4 years and TKR over 6 years were assessed. Binary logistic regression was used to examine the associations. Results A total of 12.7% of participants had bulge sign only, 2.0% had patellar tap only and 3.3% had both. A positive baseline bulge sign was associated with an increased risk of frequent knee pain [OR 1.31 (95% CI 1.04, 1.64), P = 0.02] and TKR [OR 1.47 (95% CI 1.06, 2.05), P = 0.02]. Developed bulge sign was associated with an increased risk of frequent knee pain [OR 1.75 (95% CI 1.34, 2.29), P < 0.001] and progressive ROA [OR 1.67 (95% CI 1.11, 2.51), P = 0.01]. Persistent bulge sign was associated with an increased risk of frequent knee pain [OR 1.60 (95% CI 1.09, 2.35), P = 0.02], progressive ROA [OR 1.84 (95% CI 1.01, 3.33), P = 0.045] and TKR [OR 2.13 (95% CI 1.23, 3.68), P = 0.007]. Patellar tap was not examined for its association with joint outcomes due to its low prevalence. Conclusion The presence of bulge sign identifies individuals at increased risk of frequent knee pain, progression of ROA and TKR. This provides clinicians with a quick, simple, inexpensive method for identifying those at higher risk of progressive knee OA who should be targeted for therapy.

Objectives Low back pain is the largest contributor to disability worldwide. The role of body composition as a risk factor for back pain remains unclear. Our aim was to examine the relationship between fat mass and fat distribution on back pain intensity and disability using validated tools over 3 years. Methods Participants (aged 25–60 years) were assessed at baseline using dual-energy X-ray absorptiometry (DXA) to measure body composition. All participants completed the Chronic Pain Grade Scale at baseline and 3-year follow-up. Of the 150 participants, 123 (82%) completed the follow-up. Results Higher baseline body mass index (BMI) and fat mass (total, trunk, upper limb, lower limb, android, and gynoid) were all associated with high intensity back pain at either baseline and/or follow-up (total fat mass: multivariable OR 1.05, 95% CI 1.01–1.09, p

Objective.Although there is evidence for a beneficial effect of dietary antioxidants on knee joint health, the data are sparse for the hip. Our aim was to examine the relationship between dietary antioxidants and early hip structural abnormalities in community-based adults.Methods.The study included 214 participants without diagnosed hip osteoarthritis (OA) who underwent hip magnetic resonance imaging in 2009–2010. The prevalence of femoral head cartilage defects and bone marrow lesions (BML) was assessed. Intakes of antioxidant vitamins and their food sources were estimated from a food frequency questionnaire during 1990–1994.Results.Higher intakes of Vitamin E (OR 0.63, 95% CI 0.41–0.96), lutein/zeaxanthin (OR 0.58, 95% CI 0.34–0.99), and lycopene (OR 0.64, 95% CI 0.44–0.95) were associated with a reduced prevalence of femoral head cartilage defects. Higher intakes of α-carotene (OR 0.42, 95% CI 0.19–0.94), β-carotene (OR 0.31, 95% CI 0.13–0.78), and lutein/zeaxanthin (OR 0.42, 95% CI 0.18–0.98) were associated with a reduced prevalence of femoral head BML. Higher vegetable consumption was associated with a reduced prevalence of femoral head cartilage defects (OR 0.65, 95% CI 0.46–0.91) and BML (OR 0.60, 95% CI 0.37–0.97).Conclusion.Higher carotenoids intake and vegetable consumption were associated with reduced risk of hip cartilage defects and BML, and higher Vitamin E intake was associated with reduced risk of hip cartilage defects. These findings suggest a beneficial effect of dietary antioxidants on hip joint health. Although our findings need to be confirmed in other longitudinal studies, they suggest that the modification of dietary antioxidant intake may be a strategy for the prevention of hip OA.

BACKGROUND Although weight control is important in managing knee osteoarthritis (OA), it is difficult to achieve. Understanding beliefs regarding weight management in people with knee OA may improve weight control. AIMS To examine differences in bodyweight satisfaction, weight management strategies and weight-related health-beliefs in obese, overweight and normal weight people with knee OA. METHODS The beliefs and attitudes to weight in 102 people with symptomatic knee OA were ascertained. Participants were classified as being obese, overweight or of normal weight. RESULTS Although obese and overweight participants were less satisfied with their bodyweight, they were more likely to want to lose weight and to report dieting compared with normal weight participants(P

Background There is evidence that knee pain not only is a consequence of structural deterioration in osteoarthritis (OA) but also contributes to structural progression. Clarifying this is important because targeting the factors related to knee pain may offer a clinical approach for slowing the progression of knee OA. The aim of this study was to examine whether knee pain over 1 year predicted cartilage volume loss, incidence and progression of radiographic osteoarthritis (ROA) over 4 years. Methods Osteoarthritis Initiative participants with no ROA (Kellgren-Lawrence grade ≤ 1) (n = 2120) and with ROA (Kellgren-Lawrence grade > 2) (n = 2249) were examined. Knee pain was assessed at baseline and 1 year using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Knee pain patterns were categorised as no pain (WOMAC pain 5 at either time point) and persistent pain (WOMAC pain > 5 at both time points). Cartilage volume, incidence and progression of ROA were assessed using magnetic resonance imaging and x-rays at baseline and 4-years. Results In both non-ROA and ROA, greater baseline WOMAC knee pain score was associated with increased medial and lateral cartilage volume loss (p ≤ 0.001), incidence (OR 1.07, 95% CI 1.01–1.13) and progression (OR 1.07, 95% CI 1.03–1.10) of ROA. Non-ROA and ROA participants with fluctuating and persistent knee pain had increased cartilage volume loss compared with those with no pain (p for trend ≤ 0.01). Non-ROA participants with fluctuating knee pain had increased risk of incident ROA (OR 1.62, 95% CI 1.04–2.54), corresponding to a number needed to harm of 19.5. In ROA the risk of progressive ROA increased in participants with persistent knee pain (OR 1.82, 95% CI 1.28–2.60), corresponding to a number needed to harm of 9.6. Conclusions Knee pain over 1 year predicted accelerated cartilage volume loss and increased risk of incident and progressive ROA. Early management of knee pain and controlling knee pain over time by targeting the underlying mechanisms may be important for preserving knee structure and reducing the burden of knee OA. Electronic supplementary material The online version of this article (10.1186/s13075-018-1751-4) contains supplementary material, which is available to authorized users.

Objective: To examine whether baseline knee joint effusion volume and the change in effusion volume over 1 year are associated with cartilage volume loss, progression of radiographic OA (ROA) over 4 years and risk of total knee replacement over 6 years. Methods: This study included 4115 Osteoarthritis Initiative participants with knee joint effusion volume quantified by MRI at baseline. The change in effusion volume over 1 year was assessed. Cartilage volume loss and progression of ROA over 4 years were assessed using MRI and X-ray and total knee replacement over 6 years was assessed. Multiple linear regression and binary logistic regression were used for data analyses. Results: Baseline knee effusion volume (per 5 ml) was positively associated with a loss of medial and lateral cartilage volume [regression coefficient 0.13%/year (95% CI 0.10, 0.17) and 0.13%/year (95% CI 0.10, 0.16), respectively, both P < 0.001], progression of ROA [odds ratio (OR) 1.28 (95% CI 1.20, 1.37), P < 0.001], and risk of knee replacement [OR 1.12 (95% CI 1.05, 1.20), P = 0.001]. A 5 ml increase in knee effusion volume over 1 year was positively associated with medial cartilage volume loss [regression coefficient 0.09%/year (95% CI 0.04, 0.15), P = 0.001], progression of ROA [OR 1.21 (95% CI 1.11, 1.33), P < 0.001] and risk of knee replacement [OR 1.24 (95% CI 1.12, 1.37), P < 0.001]. Conclusions: Knee joint effusion volume assessed from MRI provides a continuous and sensitive measure that was associated with cartilage volume loss, progression of ROA and risk of total knee replacement. It may provide a method to identify individuals with an inflammatory OA phenotype who are at higher risk of disease progression.

Pneumocystis jirovecci pneumonia (PJP) is an opportunistic fungal infection occurring in immunocompromised patients, such as those with human immunodeficiency virus (HIV), organ transplantation, malignancies and connective tissue diseases (CTDs). Risk factors for PJP are not well characterised, leading to uncertainty regarding the indications for antimicrobial prophylaxis and monitoring. This study compared differences between patients with and without CTDs who developed PJP.Retrospective data was collected for all subjects with a positive toludine blue O stain or a positive P. jirovecci PCR and a concurrent respiratory illness that was clinically consistent with PJP between 2002 and 2013 at the Royal Melbourne Hospital, Australia. Sub-groups were assigned according to the underlying disease. Peripheral blood results were retrieved from an in-house pathology database.Eleven of 90 subjects (12.2%) diagnosed with PJP had underlying CTDs. The CTDs group was more likely to have been exposed to corticosteroids (100% versus 35.2%, p0.001) and other iatrogenic immunosuppression (90.9% versus 24.6%, p0.001). After adjusting for age and gender, the CTDs group had greater lymphopaenia (0.17 versus 0.58 × 10(9)/L; p = 0.034) and were older (69.6 versus 50.6 years; p0.001) than the non-CTD group. Excluding renal transplant recipients, people with CTDs also had lower eGFR than the non-CTD group (65 versus 80; p = 0.015).CTDs contributed to a significant proportion of total PJP diagnoses. Clinicians treating CTDs must be vigilant for PJP, particularly in older patients with exposure to corticosteroids or other iatrogenic immunosuppression, lymphopaenia and renal impairment; factors which may lower the clinical threshold for initiating prophylaxis.

Rheumatoid arthritis (RA) is a common and debilitating disease. Expanded therapeutic options, targeting pro-inflammatory cytokines such as tumour necrosis factor (TNF) and interleukin-6 (IL-6), have revolutionised RA treatment. To date, efficacy data shows superiority of IL-6 inhibition over placebo, conventional disease modifying anti-rheumatic drugs such as methotrexate, and TNF inhibition. Moreover, while demonstrating some key differences in the safety profile compared with TNF inhibition (e.g. hyperlipidemia and neutropenia), these safety concerns have not, at least to date, been found to cause clinically significant adverse outcomes. Other safety parameters, such as infection and malignancy rates have been found to be comparable between IL-6 and TNF inhibition. This review explores the biology and clinical applications of IL-6 inhibition in the management of RA.

Background Optimal management of osteoarthritis requires active patient participation. Understanding patients’ perceived health information needs is important in order to optimize health service delivery and health outcomes in osteoarthritis. We aimed to review the existing literature regarding patients’ perceived health information needs for OA. Methods A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990–2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients’ perceived needs of osteoarthritis health information were categorized. Results 30 studies from 2876 were included: 16 qualitative, 11 quantitative and 3 mixed-methods studies. Three areas of perceived need emerged: (1) Need for clear communication: terms used were misunderstood or had unintended connotations. Patients wanted clear explanations. (2) Need for information from various sources: patients wanted accessible health professionals with specialist knowledge of arthritis. The Internet, whilst a source of information, was acknowledged to have dubious reliability. Print media, television, support groups, family and friends were utilised to fulfil diverse information needs. (3) Needs of information content: patients desired more information about diagnosis, prognosis, management and prevention. Conclusions Patients desire more information regarding the diagnosis of osteoarthritis, its impact on daily life and its long-term prognosis. They want more information not only about pharmacological management options, but also non-pharmacological options to help them manage their symptoms. Also, patients wanted this information to be delivered in a clear manner from multiple sources of health information. To address these gaps, more effective communication strategies are required. The use of a variety of sources and modes of delivery may enable the provision of complementary material to provide information more successfully, resulting in better patient adherence to guidelines and improved health outcomes.

Objective To systematically review the literature to determine whether biomechanical factors, meniscal pathology, and physical activity are risk factors for bone marrow lesions (BMLs) at the knee identified from magnetic resonance imaging in pre-osteoarthritis and osteoarthritis populations. Methods Electronic searches of MEDLINE and EMBASE were performed from January 1, 1996 to October 31, 2012 using the keywords of bone marrow lesion(s), bone marrow (o)edema, osteoarthritis, and knee. Studies examining biomechanical factors, meniscal pathology, or physical activity in relation to the presence, incidence, or change in BMLs at the knee were included. Two independent reviewers extracted the data and assessed the methodological quality of selected studies. Due to the heterogeneity of the studies, we performed a best evidence synthesis. Results Fifteen studies were included in this review, of which 9 were considered high quality. The study populations were heterogeneous in terms of the symptoms and radiographic knee osteoarthritis. There was strong evidence for relationships of mechanical knee alignment and meniscal pathology with BMLs in osteoarthritis populations. There was a paucity of evidence for a relationship between physical activity and BMLs. Conclusion Despite the heterogeneity of included studies, these data suggest that mechanical knee alignment and meniscal pathology are risk factors for BMLs in knee osteoarthritis. It suggests that BMLs in individuals with osteoarthritis are more susceptible to mechanical knee alignment. Given the role of BMLs in the pathogenesis of knee osteoarthritis, identifying strategies to modify these risk factors will be important in slowing the progression and reducing the burden of knee osteoarthritis.

Background Osteoarthritis has a high prevalence in people with high bone mineral density (BMD). Nevertheless, whether high systemic BMD predates early structural features of knee osteoarthritis is unclear. This study examined the association between systemic BMD and knee cartilage defect progression and cartilage volume loss in middle-aged people without clinical knee disease. Methods Adults (n = 153) aged 25–60 years had total body, lumbar spine, and total hip BMD assessed by dual-energy X-ray absorptiometry at baseline (2005–2008), and tibial cartilage volume and tibiofemoral cartilage defects assessed by magnetic resonance imaging at baseline and follow up (2008–2010). Results Higher spine BMD was associated with increased risk for progression of medial (OR = 1.45, 95% CI 1.10, 1.91) and lateral (OR = 1.30, 95% CI 1.00, 1.67) tibiofemoral cartilage defects. Total hip BMD was also positively associated with the progression of medial (OR = 1.63, 95% CI 1.10, 2.41) and lateral (OR = 1.53, 95% CI 1.08, 2.18) tibiofemoral cartilage defects. Greater total body, spine, and total hip BMD were associated with increased rate of lateral tibial cartilage volume loss (for every 1 g/10 cm2 increase in total body BMD: B = 0.44%, 95% CI 0.17%, 0.71%; spine BMD: 0.17%, 95% CI 0.04%, 0.30%; total hip BMD: 0.29%, 95% CI 0.13%, 0.45%), with no significant associations for medial tibial cartilage volume loss. Conclusion In middle-aged people without clinical knee disease, higher systemic BMD was associated with increased early knee cartilage damage. Further work is needed to clarify the effect of systemic BMD at different stages of the pathway from health through to disease in knee osteoarthritis, as new therapies targeting bone are developed for the management of knee osteoarthritis.

Background Degenerative disc disease of the lumbar spine is common, with severe disease increasing the risk for chronic low back pain. This cross-sectional study examined whether disc degeneration is representative of a ‘whole-organ’ pathology, by examining its association with bone (vertebral endplate) and soft tissue (paraspinal muscle fat) abnormalities. Methods Seventy-two community-based individuals unselected for low back pain, had Magnetic Resonance Imaging (MRI). Lumbosacral disc degeneration was determined via the Pfirrmann grading system, a validated method to assess the intervertebral disc, distinguishing the nucleus and annulus, the signal intensity and the height of the intervertebral disc. Modic change and high paraspinal muscle fat content was also measured from MRI. Results Severe disc degeneration was associated, or tended to be associated with type 2 Modic change from L2 to L5 (OR range 3.5 to 25.3, p ≤ 0.06). Moreover, severe disc degeneration at all intervertebral levels was associated with or tended to be associated with high fat content of the paraspinal muscles (OR range 3.7 to 14.3, p ≤ 0.09). Conclusion These data demonstrate that disc degeneration of the lumbar spine is commonly accompanied by Modic change and high fat content of paraspinal muscles, thus representing a ‘whole-organ’ pathology. Longitudinal studies are required to determine the temporal relationship between these structural abnormalities. Understanding this may have the potential to identify novel targets for the treatment and prevention of lumbosacral disc degeneration.

Osteoarthritis (OA) is the most common joint disorder, is associated with an increasing socioeconomic impact owing to the ageing population and mainly affects the diarthrodial joints. Primary OA results from a combination of risk factors, with increasing age and obesity being the most prominent. The concept of the pathophysiology is still evolving, from being viewed as cartilage-limited to a multifactorial disease that affects the whole joint. An intricate relationship between local and systemic factors modulates its clinical and structural presentations, leading to a common final pathway of joint destruction. Pharmacological treatments are mostly related to relief of symptoms and there is no disease-modifying OA drug (that is, treatment that will reduce symptoms in addition to slowing or stopping the disease progression) yet approved by the regulatory agencies. Identifying phenotypes of patients will enable the detection of the disease in its early stages as well as distinguish individuals who are at higher risk of progression, which in turn could be used to guide clinical decision making and allow more effective and specific therapeutic interventions to be designed. This Primer is an update on the progress made in the field of OA epidemiology, quality of life, pathophysiological mechanisms, diagnosis, screening, prevention and disease management.

Summary Objective To identify and synthesise evidence regarding patients' perceived health service needs related to osteoarthritis (OA). Design A comprehensive systematic scoping review of MEDLINE, PsycINFO, EMBASE and CINAHL (1990–2016) was performed to capture information regarding patient perceived health service needs related to OA. Risk of bias and quality of included articles were assessed. Relevant data were extracted and collated to provide a systematic review of the existing literature. Results Of the 1384 identified manuscripts, 21 were relevant to areas of patient perceived need, including needs related to medical care, pharmacologic therapy, physiotherapy and exercise therapy and alternative medicine. Key findings included (1) Symptom control drove the need for both conventional and complementary services. (2) An individualized relationship was sought with a practitioner knowledgeable in OA care and who adopted a holistic approach, whether providing conventional or alternative therapies. (3) Medications were required to obtain symptomatic relief, with use tempered by recognition of potential side effects and financial cost. (4) The need for allied health services was recognised, although patient and system issues were barriers to uptake. (5) Patient's attitudes towards joint replacement, orthoses and physical aids were influenced by patient preferences and previous healthcare experiences. Conclusion Patient perceived needs are similar to those suggested by clinical guideline recommendations. Better aligning patient perceived needs with healthcare requirements may improve OA outcomes and optimise healthcare system utilisation.

Study Design: A cross-sectional, community-based study. Objective: The aim of this study was to investigate the relationship between structural features of the thoracolumbar fascia and low back pain and disability. Summary of Background Data: The thoracolumbar fascia plays a role in stabilization of the spine by transmitting tension from the spinal and abdominal musculature to the vertebrae. It has been hypothesized that the fascia is associated with low back pain through the development of increased pressure in the paraspinal compartment, which leads to muscle ischemia. Methods: Seventy-two participants from a community-based study of musculoskeletal health underwent Magnetic Resonance Imaging from the T12 vertebral body to the sacrum. The length of the paraspinal fascia and cross-sectional area of the paraspinal compartment were quantitatively measured from axial images at the level of the transverse processes and the Chronic Pain Grade Scale was used to assess low back pain intensity and disability. Results: A shorter length of fascia around the parapsinal compartment was significantly associated with high intensity low back pain and/or disability, after adjusting for age, gender, and body mass index [right odds ratio (OR) 1.9, 95% CI 0.99–3.8, P = 0.05; left OR 2.6, 95% CI 1.2 to 5.6, P = 0.01). Further adjustment for the cross-sectional area of the compartment strengthened the associations between fascial length and low back pain/or disability (right OR 8.9, 95% CI 1.9–40.9, P = 0.005; left OR 9.6, 95% CI 1.2–42.9, P = 0.003). Conclusion: This study has demonstrated that a shorter lumbar paraspinal fascia is associated with high intensity low back pain and/or disability among community-based adults. Although cohort studies are needed, these results suggest that structural features of the fascia may play a role in high levels of low back pain and disability.

Purpose: The bony articular surface contributes to a joint�s congruency, and it might be a determinant of structural change. The aim of this longitudinal study was to determine (i) whether the angle of the trochlear groove is associated with the rate of loss of patella cartilage volume for 2 yr and (ii) whether this association is influenced by particular modifiable and nonmodifiable factors. Methods: A total of 297 community-based adults with no history of knee pathologic disease were recruited at baseline (2003�2004), and 271 of these subjects were reexamined at follow-up (2006�2007). Magnetic resonance imaging was performed at baseline and follow-up to determine the change in patella cartilage volume, whereas baseline images were used to assess trochlear groove angles. A baseline questionnaire determined participation in vigorous physical activity. Results: For every 1° increase in the proximal trochlear groove angle at baseline, there was an associated 1.12-mm3 (95% confidence interval (CI) = 0.00�2.24 mm3) increase in the annual rate of patella cartilage volume loss. There was a trend for this effect to occur for males, as well as people participating in vigorous physical activity (all P = 0.07). Males who exercised vigorously were more adversely affected (5.0 mm3 per annum (95% CI = 0.5�9.4 mm3 per annum)) than males who did not exercise vigorously (0.6 mm3 per annum (95% CI = -2.1 to 3.3 mm3 per annum)). Conclusions: A more flattened proximal trochlear groove is associated with increased patella cartilage volume loss, particularly for physically active men. Our results suggest that lifestyle factors, such as physical activity, may modify the association between joint incongruity and cartilage loss and can be further affected by subjects� characteristics such as gender. Understanding these complex interactions will help optimize strategies to maintain patellofemoral joint health.

Objective.To estimate prospectively any association between measures of physical activity and the risk of either primary knee or hip replacement due to osteoarthritis (OA).Methods.Eligible subjects (n = 39,023) were selected from participants in a prospective cohort study recruited 1990–1994. Primary knee and hip replacement for OA during 2001–2005 was determined by linking the cohort records to the National Joint Replacement Registry. A total physical activity level was computed, incorporating both intensity and frequency for different forms of physical activity obtained by questionnaire at baseline attendance.Results.There was a dose-response relationship between total physical activity level and the risk of primary knee replacement [hazards ratio (HR) 1.04, 95% CI 1.01–1.07 for an increase of 1 level in total physical activity]. Although vigorous activity frequency was associated with an increased risk of primary knee replacement (HR 1.42, 95% CI 1.08–1.86) for 1–2 times/week and HR 1.24 (95% CI 0.90–1.71) for ≥ 3 times/week), the p for trend was marginal (continuous HR 1.08, 95% CI 1.00–1.16, p = 0.05). The frequency of less vigorous activity or walking was not associated with the risk of primary knee replacement, nor was any measure of physical activity associated with the risk of primary hip replacement.Conclusion.Increasing levels of total physical activity are positively associated with the risk of primary knee but not hip replacement due to OA. Physical activity might affect the knee and hip joints differently depending on the preexisting health status and anatomy of the joint, as well as the sort of physical activity performed.

Introduction Knee osteoarthritis (OA) is a major cause of pain and disability in women, becoming a major health problem in mid to later life. A better understanding of factors contributing to deleterious structural knee changes may be important for preventing OA. In men, occupations associated with frequent knee bending have been shown to be associated with damage to knee cartilage. This has not been examined in women. The aim of this study was to examine the effect of occupational specific knee activities on tibial and patella cartilage morphology among healthy females. Methods 96 females aged 26–62 years with no history of knee injury or symptoms were recruited as part of a study of community-based study of lifestyle factors on knee health. Occupational activity data examining the frequency of tasks such as heavy lifting, knee bending, stair climbing, walking and standing were obtained by questionnaire. Tibial and patella cartilage volumes and defects were measured from magnetic resonance imaging using validated methods. Results Heavy lifting/bending/squatting, knee bending, stair climbing and walking were all associated with an increased risk of patella, but not tibial, cartilage defects (odds ratio 1.8–2.9; p ≤ 0.05) after adjustment for potential confounders, including knee alignment and radiographic joint space narrowing. There was a trend towards knee bending being associated with a reduction in patella cartilage volume (p = 0.07). Conclusion Our results demonstrate that asymptomatic adult females with occupations requiring frequent knee bending have patella, but not tibial cartilage damage. These findings suggest that vocational tasks requiring knee bending are detrimental to the structure of cartilage in females and may be an area to consider in the prevention of knee OA.

Summary Objectives Identifying factors that influence the rate of cartilage loss at the knee may help to prevent or delay the progression of knee osteoarthritis (OA). Changes in knee alignment alter knee joint load and may affect the rate of cartilage loss. The aim of this study was to determine whether change in knee alignment between baseline and 2 years is associated with a change in knee cartilage volume in knee OA in the subsequent 2.5 years. Methods Seventy-eight adults with symptomatic knee OA were recruited using a combined strategy. Radiographs were performed at time 0 and 2 years to determine change in knee alignment, measured on a continuous scale. Magnetic Resonance Imaging was performed at 2 and 4.5 years to determine annual percentage change in medial and lateral tibial cartilage volumes. Results In multivariate analyses, for every 1° change toward genu valgum, there is an associated 0.44% reduction in the rate of annual medial tibial cartilage volume loss (95% CI: −0.85%, −0.04%, P =0.03). Similarly, because our measures of change in alignment and cartilage volume were continuous, these results also implied that for every 1° change toward genu varum, there was an associated 0.44% increase in the rate of annual medial tibial cartilage volume loss. Change in knee angle did not significantly affect the rate of loss of the lateral tibial cartilage volume ( P =0.95). Conclusion Our results have demonstrated that progressive change toward genu valgum reduced the annual rate of medial tibial cartilage volume loss in people with knee OA, without expediting the rate of lateral tibial cartilage volume loss. These findings suggest that methods to reduce varus alignment may delay the progression of medial tibiofemoral OA and warrant further investigation.

SummaryObjectivesAlthough vastus medialis and vastus lateralis are important muscular determinants of patellofemoral joint function, it is unclear how these muscles relate to the structure of the patellofemoral joint. The aim of this cross-sectional study was to determine the relationship between the vasti muscles and patella cartilage volume and defects and patella bone volume.MethodsOne hundred and seventy-five women, aged 40–67 years, with no knee pain or clinical lower-limb disease had magnetic resonance imaging (MRI) of their dominant knee. The cross-sectional areas of the distal vastus medialis and lateralis were measured 37.5mm superior to the quadriceps tendon insertion at the proximal pole of the patella. Patella cartilage volume and defects and patella bone volume were measured from these images using validated methods.ResultsThere was no significant association between the distal vastus medialis cross-sectional area and patella cartilage volume. For every 1mm2 increase in the distal vastus medialis cross-sectional area, there was an associated increased risk of patella cartilage defects [odds ratio (OR): 1.2; 95% confidence interval (CI) 1.004, 1.5; P=0.05], and an associated increase in patella bone volume (OR: 3.9; 95% CI 2.0, 5.8; P

Objectives: The aim of this study was to determine whether measures of obesity and adiposity are associated with the rate of patella cartilage volume loss in healthy adults. Methods: 297 community-based adults aged 50–79 years with no clinical knee osteoarthritis were recruited at baseline (2003–4). 271 (62% female) subjects were re-examined at follow-up (2006–7). Measures of obesity (body mass index (BMI) and weight) and adiposity (fat mass and percentage fat mass), as well as patella cartilage volume, were determined by established protocols. Results: Patella cartilage volume was lost at an annual rate of 1.8% (95% CI 1.4% to 2.1%). Increased baseline BMI, weight, fat mass and percentage fat mass were all associated with an increased rate of patella cartilage volume loss after adjustment for confounders (all p⩽0.04). The direction and magnitude of the effects were similar for both sexes but the number of men examined was considerably smaller and the associations were not statistically significant. There were no significant associations observed between change in any of the obesity and adiposity measures and the rate of patella cartilage volume loss. Conclusion: This study demonstrated that increased levels of obesity and adiposity are associated with an increased annual rate of patella cartilage volume loss in healthy adults. Weight-loss interventions that reduce body mass, or specifically target a reduction in fat mass, may help to reduce the rate at which patella cartilage volume is lost, and subsequently the risk of patellofemoral osteoarthritis.

Summary Objectives Varus–valgus alignment of the knee is increasingly becoming recognised as an important biomechanical variable in patellofemoral osteoarthritis (OA). The aim of this study was to determine the cross-sectional and longitudinal relationships between frontal plane knee alignment and patella cartilage volume in people with knee OA. Methods Ninety-nine adults with symptomatic knee OA were recruited using a combined strategy including referral from specialist centres, arthritis support groups and media advertising. Both baseline and follow-up X-rays and magnetic resonance imaging (MRI) were performed 2 years apart. Knee alignment and patella cartilage volume were determined from X-ray and MRI, respectively. Results Annual change in knee alignment was negatively associated with an annual change in the total patella cartilage volume before ( P =0.002) and after ( P =0.003) adjustment for potential confounders over an average of a 1.9-year period. For every 1° change towards valgus direction, there was a 23.4-mm 3 [95% confidence interval (CI) 8.1mm 3 –38.7mm 3 ] annual reduction in the total patella cartilage volume. Conclusion This study is the first to clearly demonstrate and quantitate the annual reduction in patella cartilage volume that occurs as knee alignment becomes increasingly valgus in an osteoarthritic cohort. Interventions that aim to minimise change towards valgus alignment may reduce the risk for the onset and progression of patellofemoral OA.

SummaryObjectivesCartilage defects are highly prevalent in subjects with knee osteoarthritis (OA). Although they are associated with increased cartilage loss and joint replacement, there is little data on the natural history of cartilage defects. The aim of this study was to examine the progression of cartilage defects over 2 years in people with knee OA and to identify factors associated with progression.MethodsOne hundred and seventeen subjects with OA underwent magnetic resonance imaging of their dominant knee at baseline and follow-up. Cartilage defects were scored (0–4) at four sites. Bone size of the medial and lateral tibial plateau was determined. Height, weight, body mass index and physical activity were measured by standard protocols.ResultsThe mean cartilage defect score increased significantly over the 2-year study period in all tibiofemoral compartments (all P

Vertebral endplate (Modic) abnormalities are important structural lesions in the spine, but their association with body composition and fat distribution have not been examined. Moreover, no study has examined whether Modic change are related to other structural features of low back pain, such as reduced intervertebral disc height. Seventy-two community-based individuals not selected for low back pain had lumbar vertebral Modic change and intervertebral disc height assessed from MRI. Dual energy x-ray absorptiometry measured body composition and fat distribution. The predominance of Modic change was type 2. Modic change was associated with an increased fat mass index (OR 1.20, 95 % CI 1.01 to 1.43), and tended to be associated with a reduced fat-free mass index (OR 0.62, 95 % CI 0.37 to 1.03, p = 0.07). While an increased percentage of gynoid fat was associated with a reduced risk (OR 0.62, 95 % CI 0.43 to 0.89), an increased percentage of android fat was associated with an increased risk of Modic change (OR 2.11, 95 % CI 1.18 to 3.76). Modic change was also associated with reduced intervertebral disc height at L2/3, L4/5 and L5/S1 (OR range 1.4 to 1.8; all p ≤ 0.03). Modic type 2 change is associated with reduced intervertebral disc height and an increased fat mass index. Whereas gynoid fat distribution protected against Modic type 2 change, an android pattern increased the risk of this lesion. Modic type 2 change, which histologically represent fat replacement, might have a metabolic component to its aetiology.

We welcome the comments from Emanuel et al. [1]. In a systematic review, Pfirrmann’s method [2] was endorsed as a valid and reliable ‘gold-standard’ for assessing intervertebral disc degeneration [3]. Nevertheless, the Pfirrmann system uses qualitative descriptors such as ‘disc height normal to slightly decreased’. This descriptor is highly subjective with confounding influences of gender, age and body habitus and the ambiguity of what represents a ‘normal’ disc height. There is no quantitative measure of disc height in the Pfirrmann grading system. This prompted us to validate disc height against the ‘gold-standard’. In our work [4], we validate that for every one-grade increase in the Pfirrmann score, there is a reduction in disc height. For example, there was a 1.60 mm reduction (95 % confidence interval –2.37 to –0.83 mm) in disc height for each Pfirrmann grade increase at the level of L3/4, independent of age, gender, body mass index and smoking history. While Emanuel et al. highlight that disc height has diurnal and joint loading variation [1], the Pfirrmann Score has the same inherent limitations [2]. Any extraneous variability from such measures would have served to cause misclassification and reduced our chances of demonstrating significant results in the current study. Moreover, contemporaneous assessment of disc height and the Pfirrmann grade was made, mitigating extraneous variability. While there was large variability around the estimated marginal means, this is probably a reflection of the modest sample size (n = 72) and is accounted for in regression analyses, with highly significant results (all p ≤ 0.009). In our study, we also demonstrated that disc height was smaller in people with high pain and/or disability, substantiating the clinical utility of the measure. While Emanuel et al. argue that factors such as high inter-subject and intra-subject variation limit the use of disc height as a clinical or epidemiological measure (e.g. from diurnal variation in water content of the disc or joint loading), this can be mitigated by standardising assessments to a particular time of the day (e.g. morning). While quantitative mapping shows promise, such techniques are highly sophisticated, expensive and not widely available. We contend that our data validate disc height as a readily available, simple and effective means of assessing intervertebral disc degeneration, but do acknowledge that disc height may not be the best singular measure for disc degeneration. We welcome further efforts to identify continuous measures that sensitively assess disc degeneration.

Summary Objectives Although the geometry of the trochlear groove is considered important in the pathogenesis of patellofemoral joint pathology it is unclear how the shape of the trochlear groove relates to patella morphology. This cross-sectional study investigated the relationship between the shape of the trochlear groove and patella cartilage and bone morphology in healthy adults. Methods Two hundred and ninety-seven healthy adults aged between 50 and 79 years with no clinical history of knee pain or pathology were examined using magnetic resonance imaging (MRI). From the magnetic resonance (MR) images, the bony angles formed at the distal and proximal trochlear groove were measured, together with patella cartilage and bone volumes and patella cartilage defects. Results After adjustment for potential confounders, there was an 8.70mm 3 (95% confidence interval (CI) 2.15, 15.26) increase in patella cartilage volume ( P =0.009), with no increased prevalence of cartilage defects (odds ratio=0.99 (95% CI 0.96, 1.02), P =0.35), for every 1° increase (i.e., as the angle became more flatter) at the distal trochlear groove. Moreover, there was a 53.86mm 3 (95% CI −90.26, −17.46) reduction in patella bone volume for every 1° that the angle at the distal trochlear groove became more flattened ( P =0.004). No significant association between the proximal trochlear groove angle and the patella cartilage or bone properties was observed. Conclusion A more flattened bony angle at the distal trochlear groove was associated with increased patella cartilage volume and reduced patella bone volume, but no increased prevalence of patella cartilage defects in adults with no history of knee pain or clinical disease. These cross-sectional findings suggest that a flattened distal trochlear groove may protect against degenerative patellofemoral conditions, such as osteoarthritis, but this will need to be confirmed in a longitudinal study.

Although patellofemoral osteoarthritis is common and a frequent cause of disability, its aetiology remains unknown. Biomechanical factors are believed to be important in the pathogenesis of the disease. Although the patellofemoral joint bears little axial load during normal walking, retropatellar load increases during knee flexion and can exceed three times body-weight during deep knee bends. The combination of large forces being transmitted to relatively incongruent articular surfaces during activities of daily living may explain why patellofemoral osteoarthritis is so common. Other patellofemoral pathologies considered to be biomechanically mediated, such as patellofemoral pain syndrome, may provide clues to helping understand the aetiology of patellofemoral osteoarthritis. For instance, patellofemoral pain syndrome is believed to be primarily due to abnormalities in bony geometry, neuromuscular patterns and tight fibromuscular support, which ultimately contribute toward lateral patella translation, maltracking and pain. Genu valgum has also been implicated as a factor that predates lateral patella pathologies, such as the progression of patellofemoral osteoarthritis. Nevertheless, it remains unclear whether common patellofemoral pathologies that occur in early life, such as subluxation/ dislocation and patellofemoral pain syndrome, are risk factors for degenerative changes, such as patellofemoral osteoarthritis, that occur in later life. This review examines the biomechanical factors associated with patellofemoral joint pathology, using patellofemoral osteoarthritis as a disease paradigm.

Knee osteoarthritis (OA) is characterized by joint changes, such as cartilage degradation, subchondral sclerosis and osteophyte formation around the margin of the articular surface. The knee joint has three compartments: the medial tibiofemoral, the lateral tibiofemoral and the patellofemoral. Although most epidemiological studies have predominantly examined risk factors for tibiofemoral rather than patellofemoral disease, pain associated with knee OA commonly emanates from the patellofemoral joint. Evaluating the patellofemoral joint using radiography is problematic, which may have led to the paucity of data on patellofemoral OA. However, the advent of magnetic resonance imaging has enabled direct visualization of the entire knee joint and has given new insights into the pathogenesis of joint pathologies, such as OA. This discussion aims to compare and contrast patellofemoral and tibiofemoral OA and, thus, highlight that they are independent entities and, as such, must be examined as separate pathologica...

Objective To evaluate the effects of age, physical activity, and body mass index (BMI) on patella cartilage volume and defects and bone volume in middle-aged women without knee pain. Methods Magnetic resonance imaging was performed in 176 healthy women, ages 40–67 years, without knee pain to measure patella cartilage and bone volume and patella cartilage defects. The effects of age, physical activity, BMI, smoking, and alcohol were analyzed to determine whether associations existed between these variables and patella cartilage and bone volume and cartilage defects. Results Patella cartilage volume decreased with age (P = 0.01) and BMI (P = 0.05) after adjusting for age and patella bone volume. Patella bone volume was positively associated with body height in both the univariate and multivariate models. Cartilage defects in the patellofemoral compartment were present in 36.4% of the study population. Age, weight, and BMI were positively associated with the presence of cartilage defects in the multivariate analysis. Conclusion This study demonstrated that although age is positively associated with both patella bone volume and cartilage defects, it is inversely associated with patella cartilage volume in healthy individuals. Moreover, BMI is inversely associated with both patella cartilage volume and patella bone volume in middle-aged women without knee osteoarthritis. Longitudinal studies will be required to determine whether avoiding a high BMI will reduce the risk of developing patellofemoral osteoarthritis.

Objective It is unclear whether physical activity that is beneficial for the cardiovascular system is detrimental to knee structures. We examined the association between intensity, frequency, and duration of physical activity and knee structures in a community-based population. Methods A total of 297 healthy adults ages 50–79 years with no history of knee injury or disease were recruited from an existing study on healthy aging. Each subject underwent knee magnetic resonance imaging (MRI) to measure tibial cartilage volume, tibiofemoral cartilage defects, and bone marrow lesions. Physical activity and anthropometric data were obtained via questionnaire during 1990–1994 and 2003–2004. Results Tibial cartilage volume increased with frequency (P = 0.01) and duration (P = 0.001) of vigorous activity (activity leading to diaphoresis or dyspnea) reported 10 years previously, as well as recent vigorous activity in the 7 days prior to MRI (P = 0.05). Recent weight-bearing vigorous activity increased with tibial cartilage volume (P = 0.02) and was inversely associated with cartilage defects (P = 0.02). A reduced risk of bone marrow lesions was associated with regular walking (P = 0.04). Conclusion Vigorous physical activity appears to have a beneficial effect on knee articular cartilage in healthy, community-based adults with no history of knee injury or disease. Regular walking reduces the risk of bone marrow lesions in the knee. This study provides further support for a beneficial effect of physical activity for diseases associated with aging and suggests that exercise that is good for the heart is also good for the knees.

Summary Objective The optimal therapy for femoroacetabular impingement (FAI) is unclear. The aim of this systematic review was to examine the evidence for surgical and non-surgical treatment of FAI on symptom and structural outcomes. Design MEDLINE and EMBASE were searched electronically. Surgical and non-surgical management strategies were searched with "FAI". Studies which included comparison groups and reported symptom or structural outcomes were included (Levels I–III evidence). A risk of bias assessment was performed. Results Eighteen studies comparing management strategies for FAI were identified. Most studies had high risk of bias. No study compared surgical and non-surgical treatment. When surgical approaches were compared there was evidence of superior symptom outcomes with arthroscopy compared to open surgery and with labral preservation. There was some evidence that surgical interventions are effective in reducing alpha angle (improved hip shape), but no data on whether this affects long-term outcomes. There was some weak evidence that surgery is associated with structural progression of hip osteoarthritis (OA). Conclusions Although evidence supports improvement in symptoms after surgery in FAI, no studies have compared surgical and non-surgical treatment. Therefore no conclusion regarding the relative efficacy of one approach over the other can be made. Surgery improves alpha angle but whether this alters the risk of development or progression of hip OA is unknown. This review highlights the lack of evidence for use of surgery in FAI. Given that hip geometry may be modified by non-surgical factors, clarifying the role of non-surgical approaches vs surgery for the management of FAI is warranted.

Introduction Varied definitions of disc pathology exist in the literature. Magnetic Resonance Imaging (MRI) classification systems incorporate several qualitative features including disc appearance, the distinction between the nucleus and the annulus, signal intensity and intervertebral disc height. The lack of a continuous measure has made it difficult to sensitively examine degenerative disc disease. This study sought to examine the relationship between disc degeneration and intervertebral disc height. Methods 72 community-based individuals not selected for low back pain had MRI from which the presence of lumbosacral disc degeneration was identified using the Pfirrmann grading system, and intervertebral disc height was measured. Results At each lumbosacral level, with higher grade of disc degeneration, intervertebral disc height was reduced (all p ≤ 0.003). Results remained unchanged when grade 5 disc degeneration, which necessitated a collapsed disc space, was excluded from analyses (all p ≤ 0.03). To quantify these associations, at each lumbosacral level, for every grade increase in disc degeneration, there was a reduction in intervertebral disc height, after adjusting for age, gender, Body mass index and smoking history (β range from −0.98 mm to −1.60 mm, 95 % CI range from −2.37 to −0.31, all p ≤ 0.005). Conclusion This study has demonstrated a negative dose–response relationship between increasing severity of disc degeneration with a reduction in intervertebral disc height. Although the assessment of disc degeneration incorporates a number of qualitative measures, these data substantiate the utility of intervertebral disc height as a quantitative and continuous outcome measure in epidemiological studies, and potentially clinical practice.

Introduction Bone marrow lesions (BMLs) are features detected on MRI that are important in the pathogenesis of knee osteoarthritis. Since BMLs reflect heterogeneous pathologies this prospective cohort study examined whether BMLs detected using different MRI sequences are associated with distinct structural and clinical endpoints. Methods A total of 297 community-based adults without knee pain were examined to identify BMLs visualised using three-dimensional T1-weighted gradient-echo fat-suppressed (T1-weighted sequences) fat-suppressed and fat-saturated FSE T2-weighted MRI sequences (T2-weighted sequences) at baseline. Cartilage volume was measured at baseline and follow-up, while incident knee pain was assessed at follow-up, an average of 2.3 years later. Results At baseline, 46 BMLs were visualised in 39 participants. Of the 45 BMLs visualised on T2-weighted sequences, 34 (74 %) were also seen on T1-weighted sequences. One BML was seen on only T1-weighted sequences. Knees with BMLs visualised on both T1- and T2-weighted sequences had significantly higher medial tibial cartilage volume loss (45 mm3/annum, standard error of the mean (SEM) 14) than those with BMLs identified on only T2-weighted sequences (−13 mm3/annum SEM 19), after adjustment for age, gender and body mass index (p = 0.01). Incident knee pain was more likely in individuals with BMLs in the medial compartment visualised on both T1- and T2-weighted (eight participants, 53 %) compared to those with BMLs on only T2-weighted sequences (0 %) or no BMLs (76 participants, 31 %, p = 0.02). Conclusions BMLs present on both T1- and T2-weighted MRI sequences were associated with increased medial tibial cartilage loss and incident knee pain compared with those BMLs seen only on T2-weighted sequences. This suggests that combining different MRI sequences may provide more informative targets in the prevention and treatment of knee osteoarthritis.

OBJECTIVES: Conflicting reports of the effect of physical activity on knee cartilage may be due to the heterogeneity of populations examined and, in particular, the underlying health of the knee joint. This study examined the influence of recreational and occupational physical activity on cartilage volume loss. METHODS: A total of 250 participants with no significant musculoskeletal disease were recruited. A gender-specific median cartilage volume split was used to define people in the lowest and highest 50% of baseline cartilage volume. Baseline recreational and occupational activity was examined by questionnaire, while cartilage volume was assessed by MRI at baseline and 2.4 : years later. RESULTS: Significant interactions were demonstrable between physical activity and cartilage volume loss based on stratification of baseline cartilage volume (all P ⩽ 0.03). There was a dose-response relationship between frequently performed baseline occupational activities and medial cartilage volume loss in both the low (B = 0.2% per annum, 95% CI: 0.0, 0.04% per annum) and high (B = -0.2% per annum, 95% CI: -0.4, 0.0% per annum) baseline cartilage volume groups (P = 0.001 for interaction). Individuals with low baseline cartilage volume who were active in their occupation and/or recreational activity had greater medial cartilage volume loss than their more inactive counterparts (2.4% per annumvs1.5% per annum, P = 0.02). CONCLUSION: Whereas people with less baseline cartilage volume are more at risk of structural knee damage with either heavy occupational or recreational workloads or both, individuals with high baseline cartilage volume may advantageously modify their risk for knee OA by participating in more frequent occupational physical activities.

Objectives To systematically review the evidence on whether statin therapy, commonly used in clinical practice to treat hypercholesterolaemia for primary and secondary prevention of cardiovascular disease, contributes to tendinopathy; and to examine causality according to the Bradford Hill criteria. Study design A systematic review of studies examining the relationship between statin therapy and tendinopathy. Included studies were rated based on their methodological quality. A best evidence synthesis was used to summarise the results, and Bradford Hill criteria were used to assess causation. Data sources Ovid MEDLINE, CINAHL Plus, PubMed and Embase databases. Study selection We included adult human studies published in the English language between January 1966 and October 2015. Study designs eligible for inclusion were randomised controlled trials and cross-sectional, cohort or case-control studies. Data synthesis Four studies (three cohort studies and one case-control study) were included, with a mean methodological quality score of 67%. Three studies were deemed high quality. Tendon rupture was the primary outcome in three studies, and rotator cuff disease in the other. All studies found no positive association between statin therapy and tendon rupture for the total study population. There was evidence that simvastatin reduces the risk of tendinopathy. Conclusion To date, there is a paucity of evidence to implicate statin therapy as a well established risk factor or causal mechanism for tendon rupture in the general population. There is strong evidence that simvastatin reduces the risk of tendinopathy.