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Abstract: Physiotherapists are critically positioned to integrate education into patient care, including pain science education (PSE) to enhance management and outcomes. Anecdotally, many physiotherapists report difficulty providing PSE in private practice settings. Here, we aimed to explore current PSE use, knowledge, and barriers to implementation. A nationwide online (Qualtrics) survey of PSE-trained Australian private practice physiotherapists assessed use, knowledge (revised Neurophysiology of Pain Questionnaire [rNPQ]), concept application, implementation barriers, and resource awareness/use/preferences, exploring associations with individual/clinic-level factors (clinical experience, PSE training, work location). A total of 278 physiotherapists (62.9% female, 39.4 [11.8] years, 15.2 [11.6] years of experience, 37.2% rural/remote) completed the survey. Pain science knowledge (rNPQ: mean 10.4 [2.2]/13) and perceived PSE competence was high, although 30% supported inaccurate PSE concepts. Pain science education training via professional development course was associated with higher knowledge relative to university training (multivariable; β = 1.337, P < 0.001). Physiotherapists reported providing PSE to 61% of patients, with patient-related barriers (expecting other treatments: 94%; previous negative/contradictory PSE experiences: 89%), clinic-level barriers (time constraints: 77%; insufficient billing schedules: 57%), and clinician-specific barriers (difficulties identifying/addressing patient maladaptive beliefs/behaviours: 53%; cultural/demographic translation challenges: 46%) reported. Fewer years of clinical experience was associated with heightened worry that providing PSE might go wrong (multivariable; β = -0.034, P = 0.010) and/or damage therapeutic relationships (multivariable; β = -0.049, P < 0.001). Physiotherapists were aware of over 100 PSE resources, with varying levels of perceived use/effectiveness, yet were largely unaware of educational strategies. Physiotherapists called for reduced complexity and greater ability to individualise PSE resources. Findings will guide improvements in PSE training/resources, to maximise physiotherapists' confidence and preparedness to effectively implement PSE., (Copyright © 2025 International Association for the Study of Pain.)

Abstract: This systematic review and meta-analysis critically examined the evidence for peer support interventions to reduce pain and improve health outcomes in community-dwelling adults with chronic musculoskeletal pain (PROSPERO CRD42022356850). A systematic search (inception-January 2023) of electronic databases and grey literature was undertaken to identify relevant randomised controlled trials, with risk of bias and GRADE assessments performed on included studies. Meta-analyses used a generic, inverse-variance, random-effects model, calculating mean difference (MD) or standardised mean difference (SMD). Of 16,445 records identified, 29 records reporting on 24 studies (n = 6202 participants) were included. All evidence had unclear/high risk of bias and low-very low certainty. Peer support interventions resulted in small improvements in pain (medium-term: MD -3.48, 95% CI -6.61, -0.35; long-term: MD -1.97, 95% CI -3.53, -0.42), self-efficacy (medium-term: SMD 0.26, 95% CI 0.16, 0.36; long-term: SMD 0.21, 95% CI 0.07, 0.36), and function (long-term: SMD -0.10, 95% CI -0.19, -0.00) relative to usual care and greater self-efficacy (medium-term: SMD 0.36, 95% CI 0.20, 0.51) relative to waitlist control. Peer support interventions resulted in similar improvement as active (health professional led) interventions bar long-term self-efficacy (MD -0.41, 95% CI -0.77, -0.05), which favoured active interventions. No point estimates reached minimal clinically important difference thresholds. Pooled health service utilisation outcomes showed unclear estimates. Self-management, quality of life, and social support outcomes had mixed evidence. Despite low-very low evidence certainty, peer support interventions demonstrated small improvements over usual care and waitlist controls for some clinical outcomes, suggesting that peer support may be useful as an adjunct to other treatments for musculoskeletal pain., (Copyright © 2024 International Association for the Study of Pain.)

Background: Midfoot pain is common but poorly understood, with radiographs often indicating no anomalies. This study aimed to describe bone, joint and soft tissue changes and to explore associations between MRI-detected abnormalities and clinical symptoms (pain and disability) in a group of adults with midfoot pain, but who were radiographically negative for osteoarthritis., Methods: Community-based participants with midfoot pain underwent an MRI scan of one foot and scored semi-quantitatively using the Foot OsteoArthritis MRI Score (FOAMRIS). Foot pain and disability were recorded using visual analog scales (VAS) and the Modified-Manchester Foot Pain Disability Index (MMFPDI). Associations were assessed for continuous data using Spearman's Rho, and for categorical data, a Wilcoxon signed rank test. Linear regression was used to explore the association between participant-reported measures and MRI abnormalities, adjusted for age, sex and BMI., Results: Sixty-one participants (70% female, mean age 48.5 years, median BMI 28.6 kg/m 2 ) were included. Median VAS pain was 31/100 mm (IQR 21-47) and median disability was 30/48 (IQR 26-36). There was a moderate association between midfoot pain severity and the number of joints exhibiting joint space narrowing; adjusted results suggested 31% (95% confidence interval 3%-68%) worse VAS pain with each additional affected joint. Greater numbers of joints with cysts were associated with worse VAS pain [14% (0%-31%)] and disability [1.1 units (0-2.2)]. Effusion/synovitis was associated with MMFPDI pain. No other MRI abnormalities were associated with sex, body mass and foot pain/disability measures. Bone marrow lesions, joint space narrowing, cysts and osteophytes occurred more frequently with age. MRI abnormalities were common, particularly in the talo-navicular joint, first and second cuneo-metatarsal joints. Those with dorsal foot pain had more multi-joint involvement, bone marrow lesions, joint space narrowing and cysts and for those with pain on midfoot movement, bone marrow lesions and cysts were reported., Conclusions: In people with midfoot pain, MRI-detected features of osteoarthritis and soft-tissue abnormalities were found, clustered in the medial and intermediate cuneiform joints. These features were more common with age but not associated with pain or disability measures. Younger people with dorsal midfoot pain exhibited early signs of bone and joint features of osteoarthritis and we recommend further imaging studies to determine the clinical and diagnostic significance., (© 2025 The Author(s). Journal of Foot and Ankle Research published by John Wiley & Sons Australia, Ltd on behalf of Australian Podiatry Association and The Royal College of Podiatry.)

Integrating running gait coordination assessment into athlete monitoring systems could provide unique insight into training tolerance and fatigue-related gait alterations. This study investigated the impact of an overload training intervention and recovery on running gait coordination assessed by field-based self-testing. Fifteen trained distance runners were recruited to perform 1-week of light training (baseline), 2 weeks of heavy training (high intensity, duration, and frequency) designed to overload participants, and a 10-day light taper to allow recovery and adaptation. Field-based running assessments using ankle accelerometry and online short recovery and stress scale (SRSS) surveys were completed daily. Running performance was assessed after each training phase using a maximal effort multi-stage running test-to-exhaustion (RTE). Gait coordination was assessed using detrended fluctuation analysis (DFA) of a stride interval time series. Two participants withdrew during baseline training due to changed personal circumstances. Four participants withdrew during heavy training due to injury. The remaining nine participants completed heavy training and were included in the final analysis. Heavy training reduced DFA values (standardised mean difference (SMD) = -1.44 ± 0.90; p = 0.004), recovery (SMD = -1.83 ± 0.82; p less than 0.001), performance (SMD = -0.36 ± 0.32; p = 0.03), and increased stress (SMD = 1.78 ± 0.94; p = 0.001) compared to baseline. DFA values ( p = 0.73), recovery ( p = 0.77), and stress ( p = 0.73) returned to baseline levels after tapering while performance trended towards improvement from baseline (SMD = 0.28 ± 0.37; p = 0.13). Reduced DFA values were associated with reduced performance (r 2 = 0.55) and recovery (r 2 = 0.55) and increased stress (r 2 = 0.62). Field-based testing of running gait coordination is a promising method of monitoring training tolerance in running athletes during overload training.

Importance: Recent guidelines call for better evidence on health outcomes after living kidney donation., Objective: To determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. Their rates of estimated glomerular filtration rate (eGFR) decline and risk of albuminuria were also compared., Design, Setting, and Participants: Prospective cohort study of 924 standard-criteria living kidney donors enrolled before surgery and a concurrent sample of 396 nondonors. Recruitment occurred from 2004 to 2014 from 17 transplant centers (12 in Canada and 5 in Australia); follow-up occurred until November 2021. Donors and nondonors had the same annual schedule of follow-up assessments. Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics., Exposure: Living kidney donation., Main Outcomes and Measures: Hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure [DBP] ≥90 mm Hg, or antihypertensive medication), annualized change in eGFR (starting 12 months after donation/simulated donation date in nondonors), and albuminuria (albumin to creatinine ratio ≥3 mg/mmol [≥30 mg/g])., Results: Among the 924 donors, 66% were female; they had a mean age of 47 years and a mean eGFR of 100 mL/min/1.73 m2. Donors were more likely than nondonors to have a family history of kidney failure (464/922 [50%] vs 89/394 [23%], respectively). After statistical weighting, the sample of nondonors increased to 928 and baseline characteristics were similar between the 2 groups. During a median follow-up of 7.3 years (IQR, 6.0-9.0), in weighted analysis, hypertension occurred in 161 of 924 donors (17%) and 158 of 928 nondonors (17%) (weighted hazard ratio, 1.11 [95% CI, 0.75-1.66]). The longitudinal change in mean blood pressure was similar in donors and nondonors. After the initial drop in donors' eGFR after nephrectomy (mean, 32 mL/min/1.73 m2), donors had a 1.4-mL/min/1.73 m2 (95% CI, 1.2-1.5) per year lesser decline in eGFR than nondonors. However, more donors than nondonors had an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up (438/924 [47%] vs 49/928 [5%]). Albuminuria occurred in 132 of 905 donors (15%) and 95 of 904 nondonors (11%) (weighted hazard ratio, 1.46 [95% CI, 0.97-2.21]); the weighted between-group difference in the albumin to creatinine ratio was 1.02 (95% CI, 0.88-1.19)., Conclusions and Relevance: In this cohort study of living kidney donors and nondonors with the same follow-up schedule, the risks of hypertension and albuminuria were not significantly different. After the initial drop in eGFR from nephrectomy, donors had a slower mean rate of eGFR decline than nondonors but were more likely to have an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up., Trial Registration: ClinicalTrials.gov Identifier: NCT00936078.

Running is a popular form of physical activity yet discontinuation is common. Interventions targeting physical activity adoption have shown modest effects, often with little translation into long-term participation, which may limit the health benefits available to the wider community. This paper details the development of a new online running intervention (Just Run) aimed at improving continuation of running activity in new runners through a motivational and psychological lens, including aspects of design, content, refinement, and usability testing. A six-step intervention mapping process was used to develop a theory-based online intervention using a mix of research designs. Key stakeholders including runners, coaches and relevant experts in physical activity and behavior change provided valuable insight, feedback and refinement of the education to be delivered. The final Just Run intervention included ten modules delivered online over twelve weeks to promote ongoing running participation through videos, testimonials, and activities. Key themes identified through the literature and stakeholder engagement process related to goal setting, self-efficacy, intrinsic motivation, social support and overcoming barriers to running participation. Usability testing confirmed the quality and suitability of the education to the target population. Just Run has been developed with a range of stakeholders to address an area of unmet need in the adoption and promotion of running. Just Run is a robust online intervention that has been designed and pre-tested with positive feedback and unique insights from key stakeholders. Further investigation is required to support its implementation to the wider community., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: There are important methodological considerations for translating wearable-based gait-monitoring data to field settings. This study investigated different devices' sampling rates, signal lengths, and testing frequencies for athlete monitoring using dynamical systems variables., Methods: Secondary analysis of previous wearables data (N = 10 runners) from a 5-week intensive training intervention investigated impacts of sampling rate (100-2000 Hz) and signal length (100-300 strides) on detection of gait changes caused by intensive training. Primary analysis of data from 13 separate runners during 1 week of field-based testing determined day-to-day stability of outcomes using single-session data and mean data from 2 sessions. Stride-interval long-range correlation coefficient α from detrended fluctuation analysis was the gait outcome variable., Results: Stride-interval α reduced at 100- and 200- versus 300- to 2000-Hz sampling rates (mean difference: -.02 to -.08; P ≤ .045) and at 100- compared to 200- to 300-stride signal lengths (mean difference: -.05 to -.07; P < .010). Effects of intensive training were detected at 100, 200, and 400 to 2000 Hz (P ≤ .043) but not 300 Hz (P = .069). Within-athlete α variability was lower using 2-session mean versus single-session data (smallest detectable change: .13 and .22, respectively)., Conclusions: Detecting altered gait following intensive training was possible using 200 to 300 strides and a 100-Hz sampling rate, although 100 and 200 Hz underestimated α compared to higher rates. Using 2-session mean data lowers smallest detectable change values by nearly half compared to single-session data. Coaches, runners, and researchers can use these findings to integrate wearable-device gait monitoring into practice using dynamic systems variables.

Objectives: Foot and ankle involvement is common in rheumatic and musculoskeletal diseases, yet high-quality evidence assessing the effectiveness of treatments for these disorders is lacking. The Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group is developing a core outcome set for use in clinical trials and longitudinal observational studies in this area., Methods: A scoping review was performed to identify outcome domains in the existing literature. Clinical trials and observational studies comparing pharmacological, conservative or surgical interventions involving adult participants with any foot or ankle disorder in the following rheumatic and musculoskeletal diseases (RMDs) were eligible for inclusion: rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathies, crystal arthropathies and connective tissue diseases. Outcome domains were categorised according to the OMERACT Filter 2.1., Results: Outcome domains were extracted from 150 eligible studies. Most studies included participants with foot/ankle OA (63% of studies) or foot/ankle involvement in RA (29% of studies). Foot/ankle pain was the outcome domain most commonly measured (78% of studies), being the most frequently specified outcome domain across all RMDs. There was considerable heterogeneity in the other outcome domains measured, across core areas of manifestations (signs, symptoms, biomarkers), life impact, and societal/resource use. The group's progress to date, including findings from the scoping review, was presented and discussed during a virtual OMERACT Special Interest Group (SIG) in October 2022. During this meeting, feedback was sought amongst delegates regarding the scope of the core outcome set, and feedback was received on the next steps of the project, including focus group and Delphi methods., Conclusion: Findings from the scoping review and feedback from the SIG will contribute to the development of a core outcome set for foot and ankle disorders in RMDs. The next steps are to determine which outcome domains are important to patients, followed by a Delphi exercise with key stakeholders to prioritise outcome domains., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The aim of this study was to determine the effect of surgical change to the acetabular offset and femoral offset on the abductor muscle and hip contact forces after primary total hip arthroplasty (THA) using computational methods. Thirty-five patients undergoing primary THA were recruited. Patients underwent a computed tomography scan of their pelvis and hip, and underwent gait analysis pre- and 6-months postoperatively. Surgically induced changes in acetabular and femoral offset were used to inform a musculoskeletal model to estimated abductor muscle and hip joint contact forces. Two experiments were performed: (1) influence of changes in hip geometry on hip biomechanics with preoperative kinematics; and (2) influence of changes in hip geometry on hip biomechanics with postoperative kinematics. Superior and medial placement of the hip centre of rotation during THA was most influential in reducing hip contact forces, predicting 63% of the variance (p < 0.001). When comparing the preoperative geometry and kinematics model, with postoperative geometry and kinematics, hip contact forces increased after surgery (0.68 BW, p = 0.001). Increasing the abductor lever arm reduced abductor muscle force by 28% (p < 0.001) and resultant hip contact force by 17% (0.6 BW, p = 0.003), with both preoperative and postoperative kinematics. Failure to increase abductor lever arm increased resultant hip contact force 11% (0.33 BW, p < 0.001). In conclusion, increasing the abductor lever arm provides a substantial biomechanical benefit to reduce hip abductor and resultant hip joint contact forces. The magnitude of this effect is equivalent to the average increase in hip contact force seen with improved gait from pre-to post-surgery., (© 2022 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals LLC on behalf of Orthopaedic Research Society.)

Objective: To compare magnetic resonance imaging (MRI)-detected structural abnormalities in patients with symptomatic midfoot osteoarthritis (OA), patients with persistent midfoot pain, and asymptomatic controls, and to explore the association between MRI features, pain, and foot-related disability., Methods: One hundred seven adults consisting of 50 patients with symptomatic and radiographically confirmed midfoot OA, 22 adults with persistent midfoot pain but absence of radiographic OA, and 35 asymptomatic adults underwent 3T MRI of the midfoot and clinical assessment. MRIs were read for the presence and severity of abnormalities (bone marrow lesions [BMLs], subchondral cysts, osteophytes, joint space narrowing [JSN], effusion-synovitis, tenosynovitis, and enthesopathy) using the Foot Osteoarthritis MRI Score. Pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index., Results: The severity sum score of BMLs in the midfoot was greater in patients with midfoot pain and no signs of OA on radiography compared to controls (P = 0.007), with a pattern of involvement in the cuneiform-metatarsal joints similar to that in patients with midfoot OA. In univariable models, BMLs (ρ = 0.307), JSN (ρ = 0.423), and subchondral cysts (ρ = 0.302) were positively associated with pain (P < 0.01). In multivariable models, MRI abnormalities were not associated with pain and disability when adjusted for covariates., Conclusion: In individuals with persistent midfoot pain but no signs of OA on radiography, MRI findings suggested an underrecognized prevalence of OA, particularly in the second and third cuneiform-metatarsal joints, where BML patterns were consistent with previously recognized sites of elevated mechanical loading. Joint abnormalities were not strongly associated with pain or foot-related disability., (© 2022 The Authors. Arthritis Care & Research published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Background: Foot and ankle involvement is common in rheumatic and musculoskeletal diseases (RMDs). High-quality evidence is lacking to determine the effectiveness of treatments for these disorders. Heterogeneity in the outcomes used across clinical trials and observational studies hinders the ability to compare findings, and some outcomes are not always meaningful to patients and end-users. The Core set of Outcome Measures for FOot and ankle disorders in RheumaTic and musculoskeletal diseases (COMFORT) study aims to develop a core outcome set (COS) for use in all trials of interventions for foot and ankle disorders in RMDs. This protocol addresses core outcome domains (what to measure) only. Future work will focus on core outcome measurement instruments (how to measure)., Methods: COMFORT: Core Domain Set is a mixed-methods study involving the following: (i) identification of important outcome domains through literature reviews, qualitative interviews and focus groups with patients and (ii) prioritisation of domains through an online, modified Delphi consensus study and subsequent consensus meeting with representation from all stakeholder groups. Findings will be disseminated widely to enhance uptake., Conclusions: This protocol details the development process and methodology to identify and prioritise domains for a COS in the novel area of foot and ankle disorders in RMDs. Future use of this standardised set of outcome domains, developed with all key stakeholders, will help address issues with outcome variability. This will facilitate comparing and combining study findings, thus improving the evidence base for treatments of these conditions. Future work will identify suitable outcome measurement instruments for each of the core domains., Trial Registration: This study is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, as of June 2022: https://www.comet-initiative.org/Studies/Details/2081., (© 2023. The Author(s).)

Background: To compare intrinsic foot muscle size between people with and without symptomatic midfoot osteoarthritis, and examine the association between muscle size and strength, pain and foot-related disability., Methods: Twenty-three participants with symptomatic midfoot osteoarthritis and 23 age, sex and BMI matched controls were included. Intrinsic foot muscle cross-sectional area was measured using MRI. Hand-held dynamometry was used to assess foot and ankle muscle strength, and foot-related pain and disability was measured using Manchester Foot Pain & Disability Index., Findings: Small and non-statistically significant differences were found in intrinsic foot muscle cross-sectional area between the two groups (effect sizes 0.15-0.26, p > 0.05). Muscle strength was reduced in the midfoot osteoarthritis group, with differences of 12-33% (effect sizes 0.47-1.2). In the control group, moderate positive associations) existed between foot muscle cross-sectional area and lesser digits flexor strength (r = 0.5 to 0.7, p < 0.05). Conversely, in the midfoot osteoarthritis group, negligible positive associations were found (r < 0.3, p > 0.05). Associations between foot muscle cross-sectional with and pain and disability scores in the midfoot osteoarthritis group were negligible (r < -0.3, p > 0.05)., Interpretation: Despite reductions in maximal isometric muscle strength, midfoot osteoarthritis does not appear to be associated with reduced intrinsic foot muscle cross-sectional area measured by MRI. Muscle compositional or neural factors may explain the reductions in muscle strength and variation in symptoms in people with midfoot osteoarthritis and should be investigated., Competing Interests: Declaration of Competing Interest The authors have no financial or other competing interests to declare., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Living kidney donation is considered generally safe in healthy individuals; however, there is a need to better understand the long-term effects of donation on blood pressure and kidney function., Objectives: To determine the risk of hypertension in healthy, normotensive adults who donate a kidney compared with healthy, normotensive non-donors with similar indicators of baseline health. We will also compare the 2 groups on the rate of decline in kidney function, the risk of albuminuria, and changes in health-related quality of life., Design Participants and Setting: Prospective cohort study of 1042 living kidney donors recruited before surgery from 17 transplant centers (12 in Canada and 5 in Australia) between 2004 and 2014. Non-donor participants (n = 396) included relatives or friends of the donor, or donor candidates who were ineligible to donate due to blood group or cross-match incompatibility. Follow-up will continue until 2021, and the main analysis will be performed in 2022. The anticipated median (25th, 75th percentile, maximum) follow-up time after donation is 7 years (6, 8, 15)., Measurements: Donors and non-donors completed the same schedule of measurements at baseline and follow-up (non-donors were assigned a simulated nephrectomy date). Annual measurements were obtained for blood pressure, estimated glomerular filtration rate (eGFR), albuminuria, patient-reported health-related quality of life, and general health., Outcomes: Incident hypertension (a systolic/diastolic blood pressure ≥ 140/90 mm Hg or receipt of anti-hypertensive medication) will be adjudicated by a physician blinded to the participant's donation status. We will assess the rate of change in eGFR starting from 12 months after the nephrectomy date and the proportion who develop an albumin-to-creatinine ratio ≥3 mg/mmol (≥30 mg/g) in follow-up. Health-related quality of life will be assessed using the 36-item RAND health survey and the Beck Anxiety and Depression inventories., Limitations: Donation-attributable hypertension may not manifest until decades after donation., Conclusion: This prospective cohort study will estimate the attributable risk of hypertension and other health outcomes after living kidney donation., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: During the study period, Dr Garg was supported by the Dr Adam Linton Chair in Kidney Health Analytics and a Clinician Investigator Salary Award from the CIHR, and he was the joint Ontario Renal Network-Trillium Gift of Life Network Provincial Medical Lead for Access to Kidney Transplantation. Dr Boudville was supported by grants from the National Health and Medical Research Council and the Raine Foundation; he also received unrestricted educational grants and consulting fees from Baxter, Amgen, Astra Zeneca, Otsuka, and Vifor. Dr Feldman was supported by a grant from Theator and received speaker fees from Abbott and Merck. Dr Gill was supported by a Foundation Award from the CIHR and he received grant support from Astellas Canada and Canadian Blood Services, and he served as a consultant for Veloxis, Takeda. Dr Klarenbach was supported by a Kidney Health Research Chair and the Division of Nephrology at the University of Alberta, and he was the Director of the Real World Evidence Consortium., (© The Author(s) 2022.)

Objective: To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research., Method: Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion., Results: Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment., Conclusions: Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition., (Copyright © 2022 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise, and synthesize the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions., Methods: Electronic databases were searched for studies presenting economic evaluations of nonsurgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness, and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35)., Results: Thirty-six studies were identified reporting nonsurgical interventions (n = 10), nonsurgical versus surgical interventions (n = 14), and surgical interventions (n = 12). The most common conditions were osteoarthritis, ankle fracture, and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the nonsurgical alternative., Conclusion: Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle symptoms to best inform future clinical practice guidelines., (© 2020 American College of Rheumatology.)

Coordinate system definition is a critical element of biomechanical modeling of the knee, and cases of skeletal trauma present major technical challenges. This paper presents a method to define a tibial coordinate system by fitting geometric primitives to surface anatomy requiring minimal user input. The method presented here utilizes a conical fit to both the tibial shaft and femoral condyles to generate independent axes forming the basis of a tibial coordinate system. Definition of the tibial axis showed high accuracy when shape fitting to ≥50 mm of shaft with <3° of angular variation from the axis obtained using the full tibia. Repeatability and reproducibility of the axis was compared using intraclass correlation coefficients which showed excellent intra- and inter-observer agreement across cases. Additionally, shape fitting to the distal femoral condyles showed high accuracy compared to the reference axis established automatically through identifying the medial and lateral epicondyles (<4°). Utilizing geometric primitives to estimate functional axes for the tibia and femur removes reliance on anatomical landmarks that can be displaced by fracture or inaccurately identified by observers. Furthermore, fitting of such primitives provides a more complete understanding of the true bony anatomy, which cannot be done through simple landmark identification.

Purpose: To determine the effect of manipulating foot longitudinal arch motion with different-stiffness foot orthoses on running economy (RE) in runners with flat-arched feet and if changes in arch deformation and recoil were associated with changes in RE., Methods: Twenty-three recreational distance runners performed 5-minute submaximal treadmill runs at 12 km·h-1, in the following 3 conditions in a randomized order: (1) footwear only, (2) flexible orthoses (reduced arch thickness), and (3) standard orthoses. The RE (submaximal steady-state oxygen consumption [VO2submax]) and sagittal arch range of motion were compared among conditions using a repeated-measures analysis of variance and effect sizes (Cohen d). Pearson correlation coefficients were used to determine the association between the change in the sagittal arch range of motion and VO2submax., Results: Compared with standard orthoses, the mean VO2submax was significantly lower in both the flexible orthoses (-0.8 mL·kg-1·min-1, P < .001, d = 0.35) and footwear-only conditions (-1.2 mL·kg-1·min-1, P < .001, d = 0.49). The change in VO2submax between the flexible orthoses and footwear-only conditions was significantly positively correlated with the change in sagittal arch range of motion (r = .591, P = .005)., Conclusion: Conventional foot orthoses were associated with poorer RE compared with flexible orthoses and footwear alone. Changes in arch deformation were positively correlated to changes in oxygen consumption, indicating that foot orthoses that limit arch deformation and recoil degrade RE. Foot orthoses that facilitate energy storage and release in the foot longitudinal arch may be advisable for athletes prescribed these devices for clinical purposes to maintain optimal running performance.

Background: Although living kidney donation is safe, some donors experience perioperative complications., Objective: This study explored how perioperative complications affected donor-reported health-related quality of life, depression, and anxiety., Design: This research was a conducted as a prospective cohort study., Setting: Twelve transplant centers across Canada., Patients: A total of 912 living kidney donors were included in this study., Measurements: Short Form 36 health survey, Beck Depression Inventory and Beck Anxiety Inventory., Methods: Living kidney donors were prospectively enrolled predonation between 2009 to 2014. Donor perioperative complications were graded using the Clavien-Dindo classification system. Mental and physical health-related quality of life was assessed with the 3 measurements; measurements were taken predonation and at 3- and 12-months postdonation., Results: Seventy-four donors (8%) experienced a perioperative complication; most were minor (n = 67 [91%]), and all minor complications resolved before hospital discharge. The presence (versus absence) of a perioperative complication was associated with lower mental health-related quality of life and higher depression symptoms 3-month postdonation; neither of these differences persisted at 12-month. Perioperative complications were not associated with any changes in physical health-related quality of life or anxiety 3-month postdonation., Limitations: Minor complications may have been missed and information on complications postdischarge were not collected. No minimal clinically significant change has been defined for kidney donors across the 3 measurements., Conclusions: These findings highlight a potential opportunity to better support the psychosocial needs of donors who experience perioperative complications in the months following donation., Trial Registration: NCT00319579 and NCT00936078., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A.X.G. received operating grant support from the CIHR, which included partnership funding from Astellas for data collection. L.S.F. received investigator-initiated research grants from Merck and Johnson & Johnson and an educational grant from Medtronic., (© The Author(s) 2021.)

Introduction: Numerous classifications have been developed to assess tibial plateau fractures (TPF). Of these, the Schatzker system is the most widely reported in the literature yet this system is limited in its characterisation of morphological fracture features underlying the fracture location. The purpose of this study was to compare 3D morphological features of TPFs across different Schatzker types., Methods: This study retrospectively analysed preoperative TPF imaging data to reconstruct 3D models of the fractures. Ninety-one fractures (29 female, 62 male) were analysed and classified using Schatzker. Fracture location across Schatzker types was compared based on division of the articular surface into six 'zones'. Additionally, morphological characteristics of the fractures were compared based on fracture type, including; the number, volume and shape of the fragments., Results: Schatzker II, IV and VI fractures were most common, making up 41%, 16% and 20%, respectively. Type II fractures commonly involved both the lateral and central aspect of the tibial plateau, similarly, type IV fractures incorporated the lateral condyle in most cases. Considering the morphological metrics, statistically significant differences were observed between Schatzker types for the number of; total, articular, cortical and volumetrically significant (all P < 0.001) fragments along with the volume of both primary (P < 0.001) and secondary (P = 0.02) fragments., Discussion: Assessment of underlying fracture characteristics in addition to fracture location can serve to provide greater detail relating to fracture morphology, which has the potential to assist with both surgical decision making and assessment of postoperative outcomes. Incorporating this information as part of a hierarchical or multifactorial framework for classifying fractures may help distinguish subtle differences between fracture types that are classifiable using the most current systems., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Despite marked improvements in self-reported pain, perceived functional ability, and gait function following primary total hip arthroplasty (THA), it remains unclear whether these improvements translate into improved physical activity and sleep behaviors. The aim of this study was to determine the change in 24-hour activity profile (waking activities and sleep) and laboratory-based gait function from preoperatively to 2 years following the THA., Methods: Fifty-one patients undergoing primary THA at a single public hospital were recruited. All THAs were performed using a posterior surgical approach with the same prosthesis type. A wrist-worn accelerometer was used to capture 24-hour activity profiles preoperatively and at 1 and 2 years postoperatively. Three-dimensional gait analysis was performed to determine changes in temporospatial and kinematic parameters of the hip and pelvis., Results: Patients showed improvements in all temporospatial and kinematic parameters with time. Preoperatively, patients were sedentary or asleep for a mean time (and standard deviation) of 19.5 ± 2.2 hours per day. This remained unchanged up to 2 years postoperatively (19.6 ± 1.3 hours per day). Sleep efficiency remained suboptimal (<85%) at all time points and was worse at 2 years (77% ± 10%) compared with preoperatively (84% ± 5%). More than one-quarter of the sample were sedentary for >11 hours per day at 1 year (32%) and 2 years (41%), which was greater than the preoperative percentage (21%). Patients accumulated their activity performing light activities; however, patients performed less light activity at 2 years compared with preoperative levels. No significant differences (p = 0.935) were observed for moderate or vigorous activity across time., Conclusions: Together with improvements in self-reported pain and perceived physical function, patients had significantly improved gait function postoperatively. However, despite the opportunity for patients to be more physically active postoperatively, patients were more sedentary, slept worse, and performed less physical activity at 2 years compared with preoperative levels., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This work received funding from the National Health and Medical Research Council (NHMRC) in Australia (ID: 1126229, 1120560) and Australian Government Research Training Program Scholarships. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G518)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: There is a common perception that poorly fitting footwear will negatively impact a child's foot, however, there is limited evidence to support this., Aim: To determine the effect of shoe size on foot motion, perceived footwear comfort and fit during walking, maximal vertical jump height and maximal standing broad jump distance in children aged 8-12 years., Methods: Fourteen participants completed 3D walking gait analysis and jumping tasks in three different sizes of school shoes (one size bigger, fitted for size, one size smaller). In-shoe motion of the hindfoot, midfoot and 1st metatarsophalangeal joint (1st MTPJ) were calculated using a multi-segment kinematic foot model. Physical performance measures were calculated via maximal vertical jump and maximal standing broad jump. Perceived footwear comfort and fit (heel, toes and overall) was assessed using a 100 mm visual analog scale (VAS). Differences were compared between shoe sizes using repeated measures ANOVA, post-hoc tests and effect sizes (Cohen's d)., Results: Compared to the fitted footwear, the smaller sizing restricted hindfoot eversion (-2.5°, p = 0.021, d = 0.82), 1st MTPJ dorsiflexion (-3.9°, p = 0.012, d = 0.54), and compared to the bigger footwear, smaller sizing restricted sagittal plane midfoot range-of-motion during walking (-2.5°, p = 0.047, d = 0.59). The fitted footwear was rated as more comfortable overall with the smaller size rated as too tight in both the heel (mean difference 11.5 mm, p = 0.042, d = 0.58) and toes (mean difference 12.1 mm, p = 0.022, d = 0.59), compared to the fitted size. Vertical and standing broad jump distance were not impacted by footwear size (p = 0.218-0.836)., Significance: Footwear that is too small restricts foot motion during walking in children aged 8-12 years. Jump performance was not affected. Children were able to recognise shoes that were not correctly matched to their foot length, reinforcing that comfort is an important part of the fitting process., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Living kidney donors incur donation-related expenses, but how these expenses impact postdonation mental health is unknown., Methods: In this prospective cohort study, the association between mental health and donor-incurred expenses (both out-of-pocket costs and lost wages) was examined in 821 people who donated a kidney at one of the 12 transplant centers in Canada between 2009 and 2014. Mental health was measured by the RAND Short Form-36 Health Survey along with Beck Anxiety Inventory and Beck Depression Inventory., Results: A total of 209 donors (25%) reported expenses of >5500 Canadian dollars. Compared with donors who incurred lower expenses, those who incurred higher expenses demonstrated significantly worse mental health-related quality of life 3 months after donation, with a trend towards worse anxiety and depression, after controlling for predonation mental health-related quality of life and other risk factors for psychological distress. Between-group differences for donors with lower and higher expenses on these measures were no longer significant 12 months after donation., Conclusions: Living kidney donor transplant programs should ensure that adequate psychosocial support is available to all donors who need it, based on known and unknown risk factors. Efforts to minimize donor-incurred expenses and to better support the mental well-being of donors need to continue. Further research is needed to investigate the effect of donor reimbursement programs, which mitigate donor expenses, on postdonation mental health., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare foot and leg muscle strength in people with symptomatic midfoot osteoarthritis (OA) with asymptomatic controls, and to determine the association between muscle strength, foot pain, and disability., Methods: Participants with symptomatic midfoot OA and asymptomatic controls were recruited for this cross-sectional study from general practices and community health clinics. The maximum isometric muscle strength of the ankle plantarflexors, dorsiflexors, invertors and evertors, and the hallux and lesser toe plantarflexors was measured using hand-held dynamometry. Self-reported foot pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index. Differences in muscle strength were compared between groups. Multivariable regression was used to determine the association between muscle strength, foot pain, and disability after adjusting for covariates., Results: People with midfoot OA (n = 52) exhibited strength deficits in all muscle groups, ranging from 19% (dorsiflexors) to 30% (invertors) relative to the control group (n = 36), with effect sizes of 0.6-1.1 (P < 0.001). In those with midfoot OA, ankle invertor muscle strength was negatively and independently associated with foot pain (β = -0.026 [95% confidence interval (95% CI) -0.051, -0.001]; P = 0.045). Invertor muscle strength was negatively associated with foot-related disability, although not after adjustment for depressive symptoms (β = -0.023 [95% CI -0.063, 0.017]; P = 0.250)., Conclusion: People with symptomatic midfoot OA demonstrate weakness in the foot and leg muscles compared to asymptomatic controls. Preliminary indications from this study suggest that strengthening of the foot and leg muscles may offer potential to reduce pain and improve function in people with midfoot OA., (© 2020 The Authors. Arthritis Care & Research published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Background: The goal of postoperative tibial plateau fracture (TPF) management is to ensure surgical fixation is maintained while returning patients to normal function as soon as possible, allowing patients to resume their normal activities of daily living. The aim of this study was to investigate longitudinal changes in lower limb joint kinematics following TPF and determine how these kinematics relate to self-reported function., Methods: Patients presenting with a TPF were recruited (n = 18) and undertook gait analysis at six postoperative time points (two weeks, six weeks, three months, six months, one and two years). Lower limb joint kinematics were assessed at each time point based on gait data. Statistical parametric mapping (SPM) was undertaken to investigate the change in joint kinematic traces with time. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was assessed at each time point to obtain self-reported outcomes. A healthy reference was also analyzed and used for qualitative comparison of joint kinematics., Results and Significance: Knee kinematics showed improvements with time, however only minor changes were noted after six weeks at the hip, and six months at the knee and ankle relative to two weeks postoperative. SPM identified significant improvements with time in hip (p < 0.001) and knee (p = 0.003) flexion. No significant changes were observed with time at the ankle however, when compared to the healthy reference, participants showed reduced plantarflexion at two years. Lower limb joint ROM showed significant weak to moderate correlation with the ADL sub-scale of the KOOS (hip r = 0.442, knee r = 0.303, ankle r = 0.367). The lack of significant changes with time and overall reduced plantarflexion at the ankle potentially reduces propulsive capacity during gait up to two years postoperative. In this study, we see a deficiency in joint kinematics in TPF patients up to two years when compared to a healthy reference, especially at the ankle., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To determine how foot structure and lower limb function differ between individuals with and without midfoot osteoarthritis (OA)., Design: Electronic databases were searched from inception until May 2020. To be eligible, studies needed to (1) include participants with radiographically confirmed midfoot OA, with or without midfoot symptoms, (2) include a control group of participants without radiographic midfoot OA or without midfoot symptoms, and (3) report outcomes of foot structure, alignment, range of motion or any measures of lower limb function during walking. Screening and data extraction were performed by two independent assessors, with disagreements resolved by a third independent assessor. The methodological quality of included studies was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies., Results: A total of 1,550 records were screened by title and abstract and 11 met the inclusion criteria. Quantitative synthesis indicated that individuals who had midfoot OA had a more pronated foot posture, greater first ray mobility, less range of motion in the subtalar joint and first metatarsophalangeal joints, longer central metatarsals and increased peak plantar pressures, pressure time integrals and contact times in the heel and midfoot during walking. Meta-analysis could not be performed as the data were not sufficiently homogenous., Conclusions: There are several differences in foot structure and lower limb function between individuals with and without midfoot OA. Future research with more consistent case definitions and detailed biomechanical models would further our understanding of potential mechanisms underlying the development of midfoot OA., (Copyright © 2020 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Comfort is important for running shoe prescription in athletes to enhance performance and potentially decrease injury risk. A three-stage process was used to develop a new running footwear comfort assessment tool (RUN-CAT): (i) a survey of 282 runners to identify meaningful items of comfort, (ii-a) field testing of 100 runners who assessed the comfort of different shoes, (ii-b) item reduction using bootstrap aggregation and weightings using multiple regressions to identify a final set of items, and (iii) defining test-retest reliability, standard error of measurement (SEM), minimal detectable difference (MDD 90 ) and minimal important difference (MID) values for the final tool. Of the 19 initial items, after item reduction, four were included in the final tool: heel cushioning, shoe stability, forefoot cushioning and forefoot flexibility. Reliability of the overall comfort score was good to excellent (within-day ICC 0.88, between-day 0.70) with all four components displaying good reliability (ICC >0.70). The SEM of the comfort score was 2.8 points and the MDD 90 was 6.5 mm. Subject nominated MID values ranged from 9.3 to 9.9 mm. The RUN-CAT demonstrates excellent reliability, acceptable measurement error and can discriminate between footwear models. Clinicians and researchers can incorporate the RUN-CAT to optimise running shoe comfort in athletes.

Previous studies have established that up to 1 year post total hip arthroplasty (THA), patients do not recover normal function and the magnitude of hip joint loading remains reduced compared to healthy individuals. However, the temporal nature of the loading profile has not been considered to identify individuals who are at a greater risk of poor functional outcomes following THA. This study aimed to determine changes to the profile and magnitude of the resultant hip joint reaction force before and up to 6 months post-primary THA, and factors associated with atypical loading profiles. Hip joint loading was computed using a personalized lower-limb musculoskeletal model in 43 participants awaiting primary THA for osteoarthritis (mean age: SD = 65, 14 years; body mass index: SD = 30, 5 kg/m 2 ) before and up to 6 months after THA. Atypical, single-peak loading profiles were observed for 11 patients before surgery, where four showed a single peak at 6 months. Patients displaying a single-peak profile walked slower (mean difference: -0.4 m/s) compared to individuals displaying double-peak profile (P = <.001) and had significantly reduced sagittal plane hip range of motion during gait (mean difference -9.6°, P = <.001). Self-reported pain, function, and stiffness did not differentiate between patients with a single or double-peak loading profile. Individuals with a single-peak force profile did not meet the minimal clinically important hip range of motion during gait and would be classified as low-functioning THA patients. Clinical Relevance: The temporal nature of the force profile may help to identify individuals who are at the greatest risk of poor functional outcomes after THA., (© 2020 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Background: Tibial plateau fractures are one of the most common intra-articular fractures resulting from high or low energy impact trauma. Few studies have assessed postoperative outcomes of these fractures with respect to changes in knee joint loading post-surgery. This gait analysis study compared lower limb joint loading up to two years post-surgery., Methods: Twenty patients (range 27-67 years; 9:11(male:female)) were treated with open reduction internal fixation and instructed to weight bear as tolerated immediately following surgery. Joint loading at the hip, knee and ankle were assessed at six time points post-operatively up to two years. Gait analyses were performed at each time point and a musculoskeletal model was used to compute external joint moments for the lower limb., Results: Hip flexion and extension (P = <0.001, P = <0.001), knee flexion (P = 0.014) and ankle plantarflexion moments (P = <0.001) showed significant increases with time. The hip flexion moment increased between six months and one year (mean difference = 0.16 Nm/kg) but did not increase thereafter (mean difference = 0.01 Nm/kg). Knee flexion and extension, and ankle plantarflexion moments increased up to six months (mean difference = 0.22 Nm/kg, 0.14 Nm/kg, 0.80 Nm/kg, respectively), but no further differences were seen with time from six months postoperative., Discussion: The greatest changes in joint loads were observed at the hip and ankle within the first six months, likely a result of mechanical adaptations attempting to account for limited motion at the knee. Knee joint loading plateaued beyond six months suggesting functional outcomes are largely reliant on postoperative management within the initial three months while the bone is healing., Competing Interests: Declaration of Competing Interest All authors have read and approved the final submitted manuscript., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Foot orthoses and insoles are prescribed to runners, however their impact on running economy and performance is uncertain. The aim of this systematic review and meta-analysis was to determine the effect of foot orthoses and insoles on running economy and performance in distance runners. Seven electronic databases were searched from inception until June 2018. Eligible studies investigated the effect of foot orthoses or insoles on running economy (using indirect calorimetry) or running performance. Standardised mean differences (SMDs) were computed and meta-analyses were conducted using random effects models. Methodological quality was assessed using the Quality Index. Nine studies met the criteria and were included: five studies investigated the effect of foot orthoses on running economy and four investigated insoles. Foot orthoses were associated with small negative effects on running economy compared to no orthoses (SMD 0.42 [95% CI 0.17,0.72] p = 0.007). Shock absorbing insoles were also associated with negative effects on running economy, but an imprecise estimate (SMD 0.26 [95% CI -0.33,0.84] p = 0.83). Quality Index scores ranged from 4 to 15 out of 17. Foot orthoses and shock absorbing insoles may adversely affect running economy in distance runners. Future research should consider their potential effects on running performance.

Aims: The purpose of this exploratory study was to investigate if the 24-hour activity profile (i.e. waking activities and sleep) objectively measured using wrist-worn accelerometry of patients scheduled for total hip arthroplasty (THA) improves postoperatively., Patients and Methods: A total of 51 THA patients with a mean age of 64 years (24 to 87) were recruited from a single public hospital. All patients underwent THA using the same surgical approach with the same prosthesis type. The 24-hour activity profiles were captured using wrist-worn accelerometers preoperatively and at 2, 6, 12, and 26 weeks postoperatively. Patient-reported outcomes (Hip Disability and Osteoarthritis Outcome Score (HOOS)) were collected at all timepoints except two weeks postoperatively. Accelerometry data were used to quantify the intensity (sedentary, light, moderate, and vigorous activities) and frequency (bouts) of activity during the day and sleep efficiency. The analysis investigated changes with time and differences between Charnley class., Results: Patients slept or were sedentary for a mean of 19.5 hours/day preoperatively and the 24-hour activity pattern did not improve significantly postoperatively. Outside of sleep, the patients spent their time in sedentary activities for a mean of 620 minutes/day (sd 143) preoperatively and 641 minutes/day (sd 133) six months postoperatively. No significant improvements were observed for light, moderate, and vigorous intensity activities (p = 0.140, p = 0.531, and p = 0.407, respectively). Sleep efficiency was poor (< 85%) at all timepoints. There was no postoperative improvement in sleep efficiency when adjusted for medications (p > 0.05). Patient-reported outcome measures showed a significant improvement with time in all domains when compared with preoperative levels. There were no differences with Charnley class at six months postoperatively. However, Charnley class C patients were more sedentary at two weeks postoperatively when compared with Charnley class A patients (p < 0.05). There were no further differences between Charnley classifications., Conclusion: This study describes the 24-hour activity profile of THA patients for the first time. Prior to THA, patients in this cohort were inactive and slept poorly. This cohort shows no improvement in 24-hour activity profiles at six months postoperative. Cite this article: Bone Joint J 2019;101-B:415-425.

Background: Foot and ankle pain is common in the Australian adult population. People with musculoskeletal foot and ankle conditions are often referred for surgical opinion, yet how patients are managed prior to referral is largely unknown. The aim of this study was to determine the characteristics and management of patients with musculoskeletal foot and ankle complaints prior to public-sector orthopaedic referral in South Australia., Methods: People with non-urgent foot or ankle complaints were recruited over a 12-month period from the waiting-lists of three tertiary hospitals in Adelaide, Australia. Participants completed a questionnaire on their medical history, duration and location of their foot or ankle complaint, diagnosis of their condition, previous treatment and medical imaging. The Manchester-Oxford Foot and Ankle Questionnaire, and the EuroQol-5D-5 L measured foot/ankle pain severity and health-related-quality-of-life (HRQoL). Descriptive statistics were generated for sample demographics, medical history and foot/ankle symptoms. Multivariable regressions were used to explore factors associated with foot/ankle pain severity and whether participants considered an operation necessary., Results: Two hundred and thirty-three adults returned questionnaires, with a survey response rate of 38.4% (66.1% female, median age 57.7 years IQR 18.5, BMI 29.3 kg/m 2 IQR 8.7). Half of the participants had seen a podiatrist (52.8%), and 36.5% did not see any other health professional prior to orthopaedic referral. Sixty-five (27.9%) had not yet been given a diagnosis. BMI was positively associated with foot/ankle pain severity (β 0.48, 95% CI 0.05, 0.92), while HRQoL had a negative association (β - 0.31, 95% CI -0.45, - 0.18). Participants told by their GP that they may need an operation were significantly more likely to consider surgery necessary (OR 31.41, 95% CI 11.30, 87.35), while older people were less likely (OR 0.94, 95% CI 0.90, 0.98)., Conclusions: More than one-third of the participants had not accessed allied-health care prior to specialist orthopaedic referral. Participants may consider their GPs opinion on the necessity of surgery compelling, and most expected to undergo surgery, but many couldn't report their diagnosis. The discordance between the expectation of surgery and historically low surgical conversion rates suggests more work is necessary to improve the management of this group., Competing Interests: This study was approved by the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Marker-based dynamic functional or regression methods are used to compute joint centre locations that can be used to improve linear scaling of the pelvis in musculoskeletal models, although large errors have been reported using these methods. This study aimed to investigate if statistical shape models could improve prediction of the hip joint centre (HJC) location. The inclusion of complete pelvis imaging data from computed tomography (CT) was also explored to determine if free-form deformation techniques could further improve HJC estimates. Mean Euclidean distance errors were calculated between HJC from CT and estimates from shape modelling methods, and functional- and regression-based linear scaling approaches. The HJC of a generic musculoskeletal model was also perturbed to compute the root-mean squared error (RMSE) of the hip muscle moment arms between the reference HJC obtained from CT and the different scaling methods. Shape modelling without medical imaging data significantly reduced HJC location error estimates (11.4 ± 3.3 mm) compared to functional (36.9 ± 17.5 mm, p = <0.001) and regression (31.2 ± 15 mm, p = <0.001) methods. The addition of complete pelvis imaging data to the shape modelling workflow further reduced HJC error estimates compared to no imaging (6.6 ± 3.1 mm, p = 0.002). Average RMSE were greatest for the hip flexor and extensor muscle groups using the functional (16.71 mm and 8.87 mm respectively) and regression methods (16.15 mm and 9.97 mm respectively). The effects on moment-arms were less substantial for the shape modelling methods, ranging from 0.05 to 3.2 mm. Shape modelling methods improved HJC location and muscle moment-arm estimates compared to linear scaling of musculoskeletal models in patients with hip osteoarthritis., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: To investigate whether functional overreaching affects locomotor system behaviour when running at fixed relative intensities and if any effects were associated with changes in running performance., Design: Prospective intervention study., Methods: Ten trained male runners completed three training blocks in a fixed order. Training consisted of one week of light training (baseline), two weeks of heavy training designed to induce functional overreaching, and ten days of light taper training designed to allow athletes to recover from, and adapt to, the heavy training. Locomotor behaviour, 5-km time trial performance, and subjective reports of training status (Daily Analysis of Life Demands for Athletes (DALDA) questionnaire) were assessed at the completion of each training block. Locomotor behaviour was assessed using detrended fluctuation analysis of stride intervals during running at speeds corresponding to 65% and 85% of maximum heart rate (HR max ) at baseline., Results: Time trial performance (effect size ±95% confidence interval (ES): 0.16±0.06; p<0.001), locomotor behaviour at 65% HR max (ES: -1.12±0.95; p=0.026), and DALDA (ES: 2.55±0.80; p<0.001) were all detrimentally affected by the heavy training. Time trial performance improved relative to baseline after the taper (ES: -0.16±0.10; p=0.003) but locomotor behaviour at 65% HR max (ES: -1.18±1.17; p=0.048) and DALDA (ES: 0.92±0.90; p=0.045) remained impaired., Conclusions: Locomotor behaviour during running at 65% HR max was impaired by functional overreaching and remained impaired after a 10-day taper, despite improved running performance. Locomotor changes may increase injury risk and should be considered within athlete monitoring programs independently of performance changes., (Copyright © 2018 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: Approximately 40% of the kidneys for transplant worldwide come from living donors. Despite advantages of living donor transplants, rates have stagnated in recent years. One possible barrier may be costs related to the transplant process that potential willing donors may incur for travel, parking, accommodation, and lost productivity., Methods: To better understand and quantify the financial costs incurred by living kidney donors, we conducted a prospective cohort study, recruiting 912 living kidney donors from 12 transplant centers across Canada between 2009 and 2014; 821 of them completed all or a portion of the costing survey. We report microcosted total, out-of-pocket, and lost productivity costs (in 2016 Canadian dollars) for living kidney donors from donor evaluation start to 3 months after donation. We examined costs according to ( 1 ) the donor's relationship with their recipient, including spousal (donation to a partner), emotionally related nonspousal (friend, step-parent, in law), or genetically related; and ( 2 ) donation type (directed, paired kidney, or nondirected)., Results: Living kidney donors incurred a median (75th percentile) of $1254 ($2589) in out-of-pocket costs and $0 ($1908) in lost productivity costs. On average, total costs were $2226 higher in spousal compared with emotionally related nonspousal donors ( P =0.02) and $1664 higher in directed donors compared with nondirected donors ( P <0.001). Total costs (out-of-pocket and lost productivity) exceeded $5500 for 205 (25%) donors., Conclusions: Our results can be used to inform strategies to minimize the financial burden of living donation, which may help improve the donation experience and increase the number of living donor kidney transplants., (Copyright © 2018 by the American Society of Nephrology.)

Objective: Barefoot impressions collected from crime scenes can be used in forensic analysis. The reliability of the measurement method employed during comparison of these foot impressions is paramount to prevent incorrect conclusions being made. A number of methods of obtaining measurements from barefoot impressions have been described in the research literature; however there has been no comprehensive review of their reliability. Therefore, the aim of this systematic review was to determine the reliability of measurements used to describe footprint morphology obtained from static and dynamic barefoot impressions., Methods: Four electronic databases were searched from inception to 23 November 2017. Eligible studies were required to report either the test-retest, intra or inter-rater reliability of measurements taken from barefoot impressions for the purposes of identification or classification of foot morphology. Methodological quality was assessed using the COSMIN checklist., Results: Eleven studies were identified that reported the reliability of 10 measurements (Reel method, arch index, Chippaux-Smirak index, footprint angle, Staheli index, contact area, Martirosov's K index, toe score and metatarsal ridge-to-toe measurement). High intra-rater reliability has been established for the Reel method (ICC=0.98-0.99), arch index (ICC=0.96-0.99), Chippaux-Smirak index (ICC=0.98-0.99), footprint angle (ICC=0.97-0.98), Staheli index (ICC=0.98-0.99) and footprint index (ICC=0.96-0.97). High inter-rater reliability has been established for the Reel method (ICC=0.99) and footprint angle (ICC=0.99). Overall methodological quality was rated as 'Poor' to 'Fair'., Conclusion: The measurement developed by Reel et al. has both its intra- and inter-rater reliability established to be high. However, the findings of this review were unable to inform a recommendation of one specific technique based on reliability data due to a small body of research at this time. Furthermore, there is a lack of data on the reliability of footprint measurement and comparison techniques in real-world scenarios. Overall, the findings regarding reliability of the techniques covered in this systematic review are to be interpreted with caution due to the methodological quality of reliability testing conducted within the included studies., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Obesity and musculoskeletal pain are strongly related, but there is emerging evidence that body fat, not body weight, may be a better indicator of risk. There is, therefore, a need to determine if body fat is associated with musculoskeletal pain as it may improve management strategies. The aim of this systematic review was to investigate the association between body fat and musculoskeletal pain., Methods: Seven electronic databases were searched from inception to 8th January 2018. Cross-sectional and longitudinal studies investigating the association between measures of body fat and musculoskeletal pain were included. All included articles were assessed for methodological rigour using the Epidemiology Appraisal Instrument. Standardised mean differences (SMDs) and effect estimates were pooled for meta-analysis., Results: A total of 10,221 citations were identified through the database searching, which after abstract and full-text review, yielded 28 unique articles. Fourteen studies were included in the meta-analyses, which found significant cross-sectional associations between total body fat mass and widespread pain (SMD 0.49, 95% CI 0.37-0.61, p < 0.001). Individuals with low-back pain and knee pain had a higher body fat percentage than asymptomatic controls (SMD 0.34, 95% CI 0.17-0.52, p < 0.001 and SMD 0.18, 95% CI 0.05-0.32, p = 0.009, respectively). Fat mass index was significantly, albeit weakly, associated with foot pain (SMD 0.05, 95% CI 0.03-0.06, p < 0.001). Longitudinal studies (n = 8) were unsuitable for meta-analysis, but were largely indicative of elevated body fat increasing the risk of incident and worsening joint pain. There was conflicting evidence for an association between body fat percentage and incident low-back pain (3 studies, follow-up 4-20 years). Increasing knee pain (1 study) and incident foot pain (2 studies) were positively associated with body fat percentage and fat mass index. The percentage of items in the EAI graded as 'yes' for each study ranged from 23 to 85%, indicating variable methodological quality of the included studies., Conclusions: This systematic review and meta-analysis identified positive cross-sectional associations between increased body fat and widespread and single-site joint pain in the low-back, knee and foot. Longitudinal studies suggest elevated body fat may infer increased risk of incident and worsening joint pain, although further high-quality studies are required.

Objective: To determine the potential presence and characteristics of biomechanical responders to customized foot orthoses during walking in adults with flat-arched feet., Design: Experimental, repeated-measures., Setting: University clinic and laboratory., Participants: Eighteen symptom-free adults with flat-arched feet., Interventions: Customized foot orthoses., Main Outcome Measures: In-shoe foot biomechanics were measured during walking with and without customized foot orthoses using 3D analysis. Selected kinematic and kinetic variables during baseline walking were compared between subgroups who displayed reductions in calcaneal eversion with foot orthoses to those with no change or increases., Results: Biomechanical responders displayed significantly greater peak calcaneal eversion (+2.2 degrees, P = 0.009). Time to peak calcaneal eversion (-11%, P = 0.006), peak dorsiflexion of the hallux (-6 degrees, P = 0.001), and medial-lateral excursion of the center of pressure during loading response were all reduced in the responder subgroup (-2 mm, P ≤ 0.001). Variables significantly different between subgroups were moderately associated with the response to foot orthoses (canonical correlation = 0.687, effect size = 0.47, P = 0.063)., Conclusions: Individuals with increased dynamic foot pronation were more likely to show a favorable biomechanical response to customized foot orthoses, providing preliminary evidence to support the stratified use of foot orthoses to optimize their effectiveness.

Background: Bariatric surgery candidates have a high prevalence of foot pain, depression and elevated plantar pressures. There is, however, limited research into how these factors interact pre- and post-surgery. The aims of this study were therefore to investigate the mechanical and non-mechanical factors associated with foot pain severity before, and the change after, surgery., Methods: Bariatric surgery candidates underwent baseline and six-month follow-up measures. Foot pain was measured with the Manchester-Oxford Foot Questionnaire. Mechanical measures included body mass index (BMI), dynamic plantar pressures, radiographic foot posture, and hindfoot range of motion. Depressive symptoms, the non-mechanical measure, were assessed by questionnaire. Multivariable linear regression was used to determine which variables were associated with foot pain at baseline and at follow-up. Multilevel repeated models assessed the associations between foot pain and plantar pressure, adjusting for the interaction between group and follow-up time., Results: Forty-five participants (84% female), with mean (SD) age of 45.7 (9.4) years were recruited. Twenty-nine participants had bariatric surgery and 16 participants remained on the waiting list (controls). Following bariatric surgery, foot pain reduced significantly by - 35.7 points (95% CI -42.2 to - 28.8), while depressive symptoms and whole foot peak pressures had a significant mean change of - 5.9 points (95% CI -10.3 to - 1.5) and - 36 kPa (95% CI -50 to - 22), respectively. In multivariable analysis, depressive symptoms were associated with foot pain at baseline β = 0.7 (95% CI 0.2 to 1.2) after controlling for age, gender, BMI, foot posture and plantar pressure. Depressive symptoms were also associated with foot pain at follow-up in those undergoing bariatric surgery, β = 1.2 (95% CI 0.8 to 1.7). Foot posture and hindfoot range of motion did not change following surgery and a change in plantar pressures was not associated with a change in foot pain., Conclusions: Foot pain severity in bariatric surgery candidates was associated with depressive symptoms at baseline. Reduced foot pain following bariatric surgery was associated with an improvement in depressive symptoms, without a significant change in foot posture or foot function. Foot pain severity in bariatric candidates may be mediated by non-mechanical or non-local factors before and following surgery., Competing Interests: The study was approved by the Southern Adelaide Clinical Human Research Ethics Committee, project number 211.14. All participants provided informed consent.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction: Classification systems such as the Schatzker and AO/OTA have been proposed for standardised assessment of tibial plateau fractures and to guide clinical decision making. However, there has been no comprehensive literature review of all classification systems for tibial plateau fractures, including assessment of their reliability. The aim of this systematic review was to identify and appraise previously established classification systems for tibial plateau fractures and determine their reliability for fracture classification., Methods: Six databases were searched from inception until October 2016. Classification systems for tibial plateau fractures were identified. No restriction was placed on imaging modality (plain film X-ray, CT, MRI). Data synthesis was performed to identify common features of the systems, their prevalence within the literature and studies of intra and inter-rater reliability of fracture classification using Kappa coefficient (κ)., Results: Thirty-eight classification systems were identified, five of which were a sub-classification of a single fracture type from a previous tool. The Schatzker and AO/OTA classification systems were the most commonly reported. Of the tools identified only five have been tested for inter and intra-observer reliability (Schatzker, AO/OTA, Duparc, Hohl and Luo). Reliability of more simplistic classification systems, such as that by Luo et al. (three-column) was typically high (intra-κ = 0.67-0.81, inter-κ = 0.71-0.87), but with the disadvantage of providing less information on fracture patterns and morphology. Intra and inter-observer reliability using plain film X-ray was frequently moderate (κ = 0.40-0.60), with 2D and 3D CT typically improving reliability of classification. Only 11 of the 32 complete classification systems identified association of fracture classification with clinical outcome., Discussion: Frequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability. More sophisticated imaging modalities such as 2D and 3D CT typically improve reliability estimates. Using fracture classification based on imaging findings to predict clinical outcome was not a commonly reported goal of newly developed systems. More detailed assessment of fracture patterns and morphology, in conjunction with information on surgical fixation, may be desirable for predicting outcomes and to guide clinical decision making., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To identify foot pain clusters according to pain location in a community-based sample of the general population., Methods: This study analyzed data from the North West Adelaide Health Study. Data were obtained between 2004 and 2006, using computer-assisted telephone interviewing, clinical assessment, and self-completed questionnaire. The location of foot pain was assessed using a diagram during the clinical assessment. Hierarchical cluster analysis was undertaken to identify foot pain location clusters, which were then compared in relation to demographics, comorbidities, and podiatry services utilization., Results: There were 558 participants with foot pain (mean age 54.4 years, 57.5% female). Five clusters were identified: 1 with predominantly arch and ball pain (26.8%), 1 with rearfoot pain (20.9%), 1 with heel pain (13.3%), and 2 with predominantly forefoot, toe, and nail pain (28.3% and 10.7%). Each cluster was distinct in age, sex, and comorbidity profile. Of the two clusters with predominantly forefoot, toe, and nail pain, one of them had a higher proportion of men and those classified as obese, had diabetes mellitus, and used podiatry services (30%), while the other was comprised of a higher proportion of women who were overweight and reported less use of podiatry services (17.5%)., Conclusion: Five clusters of foot pain according to pain location were identified, all with distinct age, sex, and comorbidity profiles. These findings may assist in the identification of individuals at risk for developing foot pain and in the development of targeted preventive strategies and treatments., (© 2017, American College of Rheumatology.)

Objective: To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research., Methods: Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications)., Results: 124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union., Conclusions: Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: In 3D gait analysis, kinematics of the foot joints are usually reported via isolated time histories of joint rotations and no information is provided on the relationship between rotations at different joints. The aim of this study was to identify movement coordination patterns in the foot during walking by expanding an existing vector coding technique according to an established multi-segment foot and ankle model. A graphical representation is also described to summarise the coordination patterns of joint rotations across multiple patients., Methods: Three-dimensional multi-segment foot kinematics were recorded in 13 adults during walking. A modified vector coding technique was used to identify coordination patterns between foot joints involving calcaneus, midfoot, metatarsus and hallux segments. According to the type and direction of joints rotations, these were classified as in-phase (same direction), anti-phase (opposite directions), proximal or distal joint dominant., Results: In early stance, 51 to 75% of walking trials showed proximal-phase coordination between foot joints comprising the calcaneus, midfoot and metatarsus. In-phase coordination was more prominent in late stance, reflecting synergy in the simultaneous inversion occurring at multiple foot joints. Conversely, a distal-phase coordination pattern was identified for sagittal plane motion of the ankle relative to the midtarsal joint, highlighting the critical role of arch shortening to locomotor function in push-off., Conclusions: This study has identified coordination patterns between movement of the calcaneus, midfoot, metatarsus and hallux by expanding an existing vector cording technique for assessing and classifying coordination patterns of foot joints rotations during walking. This approach provides a different perspective in the analysis of multi-segment foot kinematics, and may be used for the objective quantification of the alterations in foot joint coordination patterns due to lower limb pathologies or following injuries.