Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation.

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

An exercise and patient education intervention to reduce pain and physical limitations in adults with acetabular dysplasia: study protocol for a process evaluation integrated within a randomised controlled trial (the MovetheHip trial).

BACKGROUND: The Movethehip trial investigates the effectiveness of an exercise and patient education intervention for adults with acetabular dysplasia. The intervention involves eight tailored one-to-one sessions with trained providers who employ supportive feedback tools. The present protocol reports a planned process evaluation, which aims to determine how the intervention functions by examining the implementation of the intervention (process, dose and reach), its acceptability, mechanisms of change and the influence of contextual factors. METHODS: Two hundred trial participants aged 18-50 years will be recruited from a University Hospital in Denmark and randomised to the intervention or control group. Approximately ten providers will deliver the intervention. The process evaluation adopts a concurrent mixed-methods design. The implementation will be assessed using self-report questionnaires (at baseline and 6-month follow-up), training records and semi-structured focus group interviews with intervention providers (n = 10) and healthcare managers (n = 4-6). The mechanisms of change will be explored through semi-structured one-to-one interviews (at baseline and 6-month follow-up) with 15-20 purposefully sampled participants and by measuring changes in health outcomes (self-reported pain, physical functioning and quality of life completed at baseline and at 3- and 6-month follow-up). Additionally, change will be measured through an explorative examination of associations between dose and change in health outcomes, applying simple linear regression models. The acceptability of the intervention and the influence of contextual factors will be explored through one-to-one participant interviews and focus group interviews with 4-6 healthcare managers. The interviews will focus on expectations, experiences, events, personal understandings and interaction with interpersonal and organisational aspects. Interview data will be analysed using theoretical thematic analyses, and findings will be merged with quantitative data and reported jointly on a theme-by-theme basis. DISCUSSION: The process evaluation conducted as part of the MovetheHip trial will illuminate how the intervention functions, and if the intervention is proven effective, the findings of the evaluation will contribute to pinpoint how the intervention may be optimised to facilitate future up-scaling and implementation. TRIAL REGISTRATION: The MovetheHip protocol was approved by the Committee on Health Research Ethics in the Central Denmark Region. ClinicalTrials, NCT04795843. Registered on 20 March 2021.

Association of 5-Year Hip Arthroscopy Outcomes with Hip Morphology and Cartilage Status at Time of Surgery: A National Registry Study With HAGOS Outcomes in 281 Patients With Femoroacetabular Impingement Syndrome.

Background: The effects of specific bony hip morphologies, cam and dysplasia, and cartilage damage on mid- and long-term (≥5 years) patient-reported outcomes (PROs) are understudied. Purpose: To investigate if changes in PROs from preoperatively to 5 years after hip arthroscopy are associated with preoperative bony hip morphology and cartilage status in patients with femoroacetabular impingement syndrome. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were identified in the Danish Hip Arthroscopy Registry. Hip and groin function was assessed from preoperatively to 5 years postoperatively with the Copenhagen Hip and Groin Outcome Score (HAGOS) Activities of Daily Living (ADL) and Sports and Recreation (Sport) subscales. Morphology was defined using the anterior alpha angle (AA) and lateral center-edge angle (LCEA) as follows: mild to moderate cam (55°≤ AA < 78°), severe cam (AA ≥ 78°), pincer (LCEA > 39°), and borderline dysplasia (20°≤ LCEA < 25°). Joint space width (JSW) was defined as slightly reduced (3.1 mm ≤ JSW ≤ 4 mm) or severely reduced (2.1 mm ≤ JSW ≤ 3 mm). Acetabular cartilage status was defined by modified Beck grades 0 to 4 and femoral head cartilage status by International Cartilage Regeneration & Joint Preservation Society grades 0 to 4. Acetabular and femoral cartilage injury areas were categorized as <1, 1 to 2, or >2 cm2. Multiple regression analyses assessed adjusted associations between hip morphology and cartilage injuries with improvement in HAGOS-ADL and HAGOS-Sport. Results: The study included 281 patients (age, 35 ± 10 years; 52.3% female). No cam and mild-to-moderate cam were associated with greater improvement in HAGOS-ADL (16 points [P = .002] and 7 points [P = .038], respectively) compared with severe cam. Normal JSW was associated with greater improvement in HAGOS-ADL (21 points; P = .026) compared with severely reduced JSW. Femoral head cartilage injury area <1 cm2 was associated with greater improvements in HAGOS-ADL (17 points; P = .03) and HAGOS-Sport (21 points; P = .035) compared with femoral cartilage injury area >2 cm2. Conclusion: Patients having no-to-moderate cam morphology, normal JSW, or femoral head cartilage injury area <1 cm2 had greater improvement in PROs 5 years after hip arthroscopy compared with patients having severe cam morphology, severely reduced JSW, or femoral cartilage injury area >2 cm2.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study.

BACKGROUND: Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes. PURPOSE: To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS. RESULTS: Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245). CONCLUSION: A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

Stratified care in hip arthroscopy: can we predict successful and unsuccessful outcomes? Development and external temporal validation of multivariable prediction models.

OBJECTIVE: Although hip arthroscopy is a widely adopted treatment option for hip-related pain, it is unknown whether preoperative clinical information can be used to assist surgical decision-making to avoid offering surgery to patients with limited potential for a successful outcome. We aimed to develop and validate clinical prediction models to identify patients more likely to have an unsuccessful or successful outcome 1 year post hip arthroscopy based on the patient acceptable symptom state. METHODS: Patient records were extracted from the Danish Hip Arthroscopy Registry (DHAR). A priori, 26 common clinical variables from DHAR were selected as prognostic factors, including demographics, radiographic parameters of hip morphology and self-reported measures. We used 1082 hip arthroscopy patients (surgery performed 25 April 2012 to 4 October 2017) to develop the clinical prediction models based on logistic regression analyses. The development models were internally validated using bootstrapping and shrinkage before temporal external validation was performed using 464 hip arthroscopy patients (surgery performed 5 October 2017 to 13 May 2019). RESULTS: The prediction model for unsuccessful outcomes showed best and acceptable predictive performance on the external validation dataset for all multiple imputations (Nagelkerke R2 range: 0.25-0.26) and calibration (intercept range: -0.10 to -0.11; slope range: 1.06-1.09), and acceptable discrimination (area under the curve range: 0.76-0.77). The prediction model for successful outcomes did not calibrate well, while also showing poor discrimination. CONCLUSION: Common clinical variables including demographics, radiographic parameters of hip morphology and self-reported measures were able to predict the probability of having an unsuccessful outcome 1 year after hip arthroscopy, while the model for successful outcome showed unacceptable accuracy. The externally validated prediction model can be used to support clinical evaluation and shared decision making by informing the orthopaedic surgeon and patient about the risk of an unsuccessful outcome, and thus when surgery may not be appropriate.

Are Exercise Therapy Protocols For The Treatment of Hip-Related Pain Adequately Described? A Systematic Review of Intervention Descriptions.

Background: Hip-related pain is an umbrella term encompassing pain from non-arthritic hip joint pathologies, such as femoroacetabular impingement syndrome, hip dysplasia, and labral tears. Exercise therapy is commonly recommended for these conditions, but the reporting completeness of these interventions is currently unclear. Purpose: The aim of this systematic review was to assess the reporting completeness of exercise therapy protocols for people with hip-related pain. Study design: Systematic review according to PRISMA guidelines. Materials and Methods: A systematic search was conducted, searching the MEDLINE, CINAHL, and Cochrane databases. The search results were independently screened by two researchers. Inclusion criteria were studies using exercise therapy in people with non-arthritic hip-related pain. Two independent researchers used the Cochrane risk of bias tool version 2 to analyze risk of bias, and the Consensus on Exercise Reporting Template (CERT) checklist and score (1-19) to synthesize reporting completeness. Results: Fifty-two studies used exercise therapy for hip-related pain, but only 23 were included in the synthesis as 29 studies had no description of the intervention. CERT scores ranged from 1 to 17 (median 12, IQR 5-15). The most well-described items were tailoring (87%), and the least well-described items were motivation strategies (9%) and starting level (13%). Studies used exercise therapy alone (n=13), or in combination with hip arthroscopy (n=10). Conclusion: Only 23 of 52 eligible studies reported sufficient details to be included in the CERT synthesis. The median CERT score was 12 (IQR 5-15), with no study reaching the maximum score of 19. Lack of reporting makes it difficult to replicate interventions in future research, and to draw conclusions on efficacy and dose-response to exercise therapy for hip-related pain. Level of evidence: Level 1, systematic review.

Blood flow restriction added to usual care exercise in patients with early weight bearing restrictions after cartilage or meniscus repair in the knee joint: a feasibility study.

PURPOSE: Blood flow restriction - low load strength training (BFR-LLST) is theoretically superior to traditional heavy strength training when rehabilitating patients who cannot heavily load tissues following surgery. The main purpose of this study was to examine the feasibility of BFR-LLST added to usual care exercise early after cartilage or meniscus repair in the knee joint. METHODS: We included 42 patients with cartilage (n = 21) or meniscus repair (n = 21) of the knee joint. They attended 9 weeks of BFR-LLST added to a usual care exercise program at an outpatient rehabilitation center. Outcome measures were assessed at different time points from four (baseline) to 26 weeks postoperatively and included adherence, harms, knee joint and thigh pain, perceived exertion, thigh circumference (muscle size proxy), isometric knee-extension strength, self-reported disability and quality of life. RESULTS: On average, patients with cartilage or meniscus repair completed > 84% of the total BFR-LLST supervised sessions. Thirty-eight patients reported 146 adverse events of which none were considered serious. No decrease in thigh circumference or exacerbation of knee joint or quadriceps muscle pain of the operated leg was found in either group during the intervention period. CONCLUSIONS: BFR-LLST added to usual care exercise initiated early after cartilage or meniscus repair seems feasible and may prevent disuse thigh muscle atrophy during a period of weight bearing restrictions. Harms were reported, but no serious adverse events were found. Our findings are promising but need replication using a RCT-design. TRIAL REGISTRATION: NCT03371901 , preprint (open access):  https://www.medrxiv.org/content/10.1101/2022.03.31.22272398v1.

Comparing exercise and patient education with usual care in the treatment of hip dysplasia: a protocol for a randomised controlled trial with 6-month follow-up (MovetheHip trial).

INTRODUCTION: Surgery is not a viable treatment for all patients with hip dysplasia. Currently, usual care for these patients is limited to a consultation on self-management. We have shown that an exercise and patient education intervention is a feasible and acceptable intervention for patients not receiving surgery. Therefore, we aim to investigate whether patients with hip dysplasia randomised to exercise and patient education have a different mean change in self-reported pain compared with those randomised to usual care over 6 months. Furthermore, we aim to evaluate the cost-effectiveness and perform a process evaluation. METHODS AND ANALYSIS: In a randomised controlled trial, 200 young and middle-aged patients will be randomised to either exercise and patient education or usual care at a 1:1 ratio through permuted block randomisation. The intervention group will receive exercise instruction and patient education over 6 months. The usual care group will receive one consultation on self-management of hip symptoms. The primary outcome is the self-reported mean change in the pain subscale of the Copenhagen Hip and Groin Outcome Score (HAGOS). Secondary outcomes include mean changes in the other HAGOS subscales, in the Short Version of the International Hip Outcome Tool, in performance, balance and maximal hip muscle strength. Between-group comparison from baseline to 6-month follow-up will be made with intention-to-treat analyses with a mixed-effects model. Cost-effectiveness will be evaluated by relating quality-adjusted life years and differences in HAGOS pain to differences in costs over 12 months. The functioning of the intervention will be evaluated as implementation, mechanisms of change and contextual factors. ETHICS AND DISSEMINATION: The study protocol was approved by the Committee on Health Research Ethics in the Central Denmark Region and registered at ClinicalTrials. Positive, negative and inconclusive findings will be disseminated through international peer-reviewed scientific journals and international conferences. TRIAL REGISTRATION NUMBER: NCT04795843.

Feasibility and acceptability of a six-month exercise and patient education intervention for patients with hip dysplasia: A mixed methods study.

BACKGROUND AND OBJECTIVES: To evaluate the feasibility and acceptability of exercise and patient education for patients with hip dysplasia not receiving surgery. DESIGN: Feasibility study. METHODS: The participants received exercise instruction and patient education over six months. Feasibility covered recruitment, retention, and mechanisms of change (MC). MC were measured with Hip and Groin Outcome Score (HAGOS), muscle strength tests, Y-balance test, and hop for distance test (HDT) over six months. Acceptability covered adherence, expectations, perceptions, benefits, and harms. RESULTS: Thirty of 32 were recruited (median age: 30 years); six were lost to follow-up. Twenty-four participants improved by a mean of 11 (95%CI: 5-17) HAGOS pain points, improvements in all subscales were 1-11 points. Mean hip abduction strength improved 0.2 (95%CI: 0.04-0.4) Nm/kg, similar to flexion and extension. Median Y-balance test improvements: anterior: 70 (IQR: 64-74) to 75 (IQR: 72-80) centimetres; posteromedial: 104 (IQR: 94-112) to 119 (IQR: 112-122) centimetres and posterolateral: 98 (IQR: 89-109) to 116 (IQR: 108-121) centimetres (p < .001). Median improvement in HDT was: 37 (IQR: 30-44) to 52 (IQR: 45-58) centimetres (p < .001). Participants adhered to 84% of scheduled sessions (1,581:1,872), expectations were met, and perceptions were characterized by high self-efficacy for exercise. Benefits were reported with no serious harms. CONCLUSION: Patients with hip dysplasia are willing to be recruited for exercise and patient education, with acceptable retention. MC were observed through improvements in pain, strength and function with high acceptance of the exercise and patient education intervention. Thus, it seems feasible to conduct a full-scale randomised controlled trial.

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

Maximal hip muscle strength and rate of torque development 6-30 months after hip arthroscopy for femoroacetabular impingement syndrome: A cross-sectional study.

OBJECTIVES: Reduced sports function is often observed after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Impaired muscle strength could be reasons for this. We aimed to investigate hip muscle strength after hip arthroscopy for FAIS and its association with sports function and participation. DESIGN: Cross-sectional study. METHODS: We included 45 patients (34 males; mean age: 30.6 ±â€¯5.9 years) after unilateral hip arthroscopy for FAIS (mean follow-up [range]: 19.3 [9.8-28.4] months). Maximal isometric hip muscle strength (Nm/kg) including early- (0-100 ms) and late-phase (0-200 ms) rate of torque development (Nm∗kg-1∗s-1) for adduction, abduction, flexion, and extension was measured with an externally fixated handheld dynamometer and compared between operated and non-operated hip. Associations between muscle strength and self-reported sports function and return to sport were investigated. RESULTS: For maximal hip muscle strength, no between-hip differences were observed for adduction, abduction, flexion, and extension (p ≥ 0.102). For rate of torque development, significantly lower values were observed for the operated hip in flexion at both 0-100 ms (mean difference: 1.58 Nm∗kg-1∗s-1, 95% CI [0.39; 2.77], p = 0.01) and 0-200 ms (mean difference: 0.72 Nm∗kg-1∗s-1, 95% CI [0.09; 1.35], p = 0.027). Higher maximal hip extension strength was significantly associated with greater ability to participate fully in preinjury sport at preinjury level (odds ratio: 17.71 95% CI [1.77; 177.60]). CONCLUSIONS: After hip arthroscopy for FAIS subjects show limited impairments in maximal and explosive hip muscle strength between operated and non-operated hip. Higher muscle strength was positively associated with higher sports function and ability to participate in sport.

Evaluating lower limb tendinopathy with Victorian Institute of Sport Assessment (VISA) questionnaires: a systematic review shows very-low-quality evidence for their content and structural validity-part I.

PURPOSE: The Victorian Institute of Sport Assessment (Achilles tendon-VISA-A, greater trochanteric pain syndrome-VISA-G, proximal hamstring tendinopathy-VISA-H, patellar tendon-VISA-P) questionnaires are widely used in research and clinical practice; however, no systematic reviews have formally evaluated their content, structural, and cross-cultural validity evidence. The measurement properties referring to content, structural and cross-cultural validity of the VISA questionnaires were appraised and synthesized. METHODS: The systematic review was conducted according to Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology. PubMed, Cochrane, CINAHL, EMBASE, Web of Science, SportsDiscus, grey literature, and reference lists were searched. Development studies and cross-cultural adaptations (12 languages) assessing content or structural validity of the VISA questionnaires were included and two reviewers assessed their methodological quality. Evidence for content (relevance, comprehensiveness, and comprehensibility), structural, and cross-cultural validity was synthesized. A modified Grading of Recommendations Assessment Development and Evaluation (GRADE) approach was applied to evidence synthesis. RESULTS: The VISA-A presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility. VISA-G displayed moderate-quality evidence for sufficient comprehensibility and very-low-quality evidence of sufficient relevance and comprehensiveness. The VISA-P presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility, while VISA-H presented very-low evidence of insufficient content validity. VISA-A displayed low-quality evidence for structural validity concerning unidimensionality and internal structure, while VISA-H presented low-quality evidence of insufficient unidimensionality. The structural validity of VISA-G and VISA-P were indeterminate and inconsistent, respectively. Internal consistency for VISA-G, VISA-H, and VISA-P was indeterminate. No studies evaluated cross-cultural validity, while measurement invariance across sexes was assessed in one study. CONCLUSIONS: Only very-low-quality evidence exists for the content and structural validity of VISA questionnaires when assessing the severity of symptoms and disability in patients with lower limb tendinopathies. LEVEL OF EVIDENCE: IV. REGISTRATION: PROSPERO reference-CRD42019126595.

Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement: A Pragmatic, Double-Blind Randomized Controlled Trial (SExSI Trial).

BACKGROUND: A strong recommendation against subacromial decompression surgery was issued in 2019. This leaves nonoperative care as the only treatment option, but recent studies suggest that the dose of strengthening exercise is not sufficient in current nonoperative care. At this point, it is unknown if adding more strengthening to current nonoperative care is of clinical value. PURPOSE: To assess the effectiveness of adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement compared with usual care alone. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In this double-blinded, pragmatic randomized controlled trial, we randomly allocated 200 consecutive patients referred to orthopaedic shoulder specialist care for long-standing shoulder pain (>3 months), aged 18 to 65 years and diagnosed with subacromial impingement using validated criteria, to the intervention group (IG) or control group (CG). Outcome assessors were blinded, and participants were blinded to the study hypothesis as well as to the treatment method in the other group. The CG received usual nonoperative care; the IG underwent the same plus an add-on intervention designed to at least double the total dose of shoulder strengthening. The primary outcome was the Shoulder Pain and Disability Index (SPADI; 0-100) at 4-month follow-up, with 10 points defined as the minimal clinically important difference. Secondary outcomes included shoulder strength, range of motion, health-related quality of life, and the Patient Acceptable Symptom State (PASS). RESULTS: Intention-to-treat and per-protocol analyses showed no significant or clinically relevant between-group differences for any outcome. From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, -22.1 points; CG, -22.7 points; between-group mean difference, 0.6 points [95% CI, -5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and 48% of the CG (P = .4127) reached the PASS. No serious adverse events were reported. CONCLUSION: Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. Moreover, approximately half of all randomized patients did not achieve the PASS after 4 months of nonoperative care, leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem. REGISTRATION: NCT02747251 (ClinicalTrials.gov identifier).

A systematic review evaluating the clinimetric properties of the Victorian Institute of Sport Assessment (VISA) questionnaires for lower limb tendinopathy shows moderate to high-quality evidence for sufficient reliability, validity and responsiveness-part II.

PURPOSE: The evaluation of measurement properties such as reliability, measurement error, construct validity, and responsiveness provides information on the quality of the scale as a whole, rather than on an item level. We aimed to synthesize the measurement properties referring to reliability, measurement error, construct validity, and responsiveness of the Victorian Institute of Sport Assessment questionnaires (Achilles tendon-VISA-A, greater trochanteric pain syndrome-VISA-G, proximal hamstring tendinopathy-VISA-H, patellar tendon-VISA-P). METHODS: A systematic review was conducted according to Consensus-based Standards for the Selection of Health Measurement Instruments methodology (COSMIN). PubMed, Cochrane, CINAHL, EMBASE, Web of Science, SportsDiscus, grey literature, and reference lists were searched. Studies assessing the measurement properties concerning reliability, validity, and responsiveness of the VISA questionnaires in patients with lower limb tendinopathies were included. Two reviewers assessed the methodological quality of studies assessing reliability, validity, and responsiveness using the COSMIN guidelines and the evidence for these measurement properties. A modified Grading of Recommendations Assessment Development and Evaluation (GRADE) approach was applied to the evidence synthesis. RESULTS: There is moderate-quality evidence for sufficient VISA-A, VISA-G, and VISA-P reliability. There is moderate-quality evidence for sufficient VISA-G and VISA-P measurement error, and high-quality evidence for sufficient construct validity for all the VISA questionnaires. Furthermore, high-quality evidence exists with regard to VISA-A for sufficient responsiveness in patients with insertional Achilles tendinopathy following conservative interventions. CONCLUSIONS: Sufficient reliability, measurement error, construct validity and responsiveness were found for the VISA questionnaires with variable quality of evidence except for VISA-A which displayed insufficient measurement error. LEVEL OF EVIDENCE: IV. REGISTRATION DETAILS: Prospero (CRD42018107671); PROSPERO reference-CRD42019126595.

How Many Patients Achieve an Acceptable Symptom State After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A Cross-sectional Study Including PASS Cutoff Values for the HAGOS and iHOT-33.

BACKGROUND: Hip arthroscopy is a viable treatment for femoroacetabular impingement syndrome (FAIS). Clinically relevant improvements in hip function and pain after surgery are often reported, but it is less clear how many patients achieve an acceptable symptom state (Patient Acceptable Symptom State [PASS]). PURPOSE: To investigate the proportion of patients who achieved a PASS 12 to 24 months after hip arthroscopy and to determine the cutoff scores of the 2 recommended and valid patient-reported outcome measures (the subscales of the Copenhagen Hip and Groin Outcome Score [HAGOS] and the International Hip Outcome Tool-33 [iHOT-33]) for which patients are most likely to achieve PASS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Eligible study patients were identified in the Danish Hip Arthroscopy Registry. An electronic questionnaire was used to collect data on PASS, HAGOS, and iHOT-33 12 to 24 months after surgery. PASS was measured using an anchor question. Receiver operating characteristic curve analyses were applied to identify the PASS cutoff values of HAGOS and iHOT-33 scores. RESULTS: A total of 137 individuals (mean age at surgery, 35.4 ± 9.4 years) were included in the study at a mean follow-up of 18.5 ± 3.2 months after surgery. At follow-up, 64 individuals (46.7%; 95% CI, 38.6-55.1) reported PASS. Higher HAGOS and iHOT-33 values were observed for participants who reported PASS compared with those who did not report PASS (Cohen d ≥ 1.06; P < .001). Cutoff scores for HAGOS subscales (42.5-82.5) and iHOT-33 (67.00) showed excellent to outstanding discriminative ability in predicting PASS (area under the curve, 0.82-0.92). CONCLUSION: In total, 46% of individuals having hip arthroscopy for FAIS achieved PASS at 12 to 24 months of follow-up. Patients who achieved PASS had statistically significant and substantially better self-reported hip function compared with those who did not achieve PASS. Cutoff values at HAGOS subscales and iHOT-33 showed excellent to outstanding discriminative ability in predicting patients with PASS.