Structural Foot Characteristics in People With Midfoot Osteoarthritis: Cross-Sectional Findings From the Clinical Assessment Study of the Foot.

OBJECTIVE: This study compared radiographic measures of foot structure between people with and without symptomatic radiographic midfoot osteoarthritis (OA). METHODS: This was a cross-sectional study of adults aged 50 years and older registered with four UK general practices who reported foot pain in the past year. Bilateral weightbearing dorsoplantar and lateral radiographs were obtained. Symptomatic radiographic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more midfoot joints (first cuneometatarsal, second cuneometatarsal, navicular-first cuneiform, and talonavicular). Midfoot OA cases were matched 1:1 for sex and age to controls with a 5-year age tolerance. Eleven radiographic measures were extracted and compared between the groups using independent sample t-tests and effect sizes (Cohen's d). RESULTS: We identified 63 midfoot OA cases (mean ± SD age was 66.8 ± 8.0 years, with 32 male and 31 female participants) and matched these to 63 controls (mean ± SD age was 65.9 ± 7.8 years). There were no differences in metatarsal lengths between the groups. However, those with midfoot OA had a higher calcaneal-first metatarsal angle (d = 0.43, small effect size, P = 0.018) and lower calcaneal inclination angle (d = 0.46, small effect size, P = 0.011) compared with controls. CONCLUSIONS: People with midfoot OA have a flatter foot posture compared with controls. Although caution is required when inferring causation from cross-sectional data, these findings are consistent with a pathomechanical pathway linking foot structure to the development of midfoot OA. Prospective studies are required to determine the temporal relationships between foot structure, function, and the development of this common and disabling condition.

Plantar pressures in people with midfoot osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot.

BACKGROUND: Midfoot osteoarthritis (OA) is a common condition, however its aetiology is not well understood. Understanding how plantar pressures differ between people with and without midfoot OA may provide insight into the aetiology and how best to manage this condition. RESEARCH QUESTION: To compare plantar pressures between people with and without symptomatic radiographic midfoot OA. METHODS: This was a cross-sectional study of adults aged ≥ 50 years registered with four UK general practices who reported foot pain in the past year. Symptomatic radiographic midfoot OA was defined as midfoot pain in the last four weeks, combined with radiographic OA in one or more midfoot joints. Cases were matched 1:1 for sex and age ( ± 5 years) to controls. Peak plantar pressure and maximum force in 10 regions of the foot were determined using a pressure platform (RSscan International, Olen, Belgium) and compared between the groups using independent samples t-tests and effect sizes (Cohen's d). RESULTS: We included 61 midfoot OA cases (mean age 67.0, SD 8.1, 31 males, 30 females) and matched these to 61 controls (mean age 66.0, SD 7.9). Midfoot OA cases displayed greater force (d=0.79, medium effect size, p = <0.001) and pressure at the midfoot (d=0.70, medium effect size, p = <0.001), greater force at the fourth metatarsophalangeal (MTP) joint (d=0.28, small effect size, p = 0.13), and fifth MTP joint (d=0.37, small effect size, p = 0.10) and greater pressure at the fifth MTP joint (d=0.34, small effect size, p = 0.13). They also displayed lower force (d=0.40, small effect size, p = 0.02) and pressure at the hallux (d=0.50, medium effect size, p = <0.001) and lower force (d=0.54, medium effect size, p = <0.001) and pressure at the lesser toes (d=0.48, small effect size, p = <0.001) compared with controls. SIGNIFICANCE: Midfoot OA appears to be associated with lowering of the medial longitudinal arch, greater lateral push off and less propulsion at toe off. Longitudinal studies are needed to establish causal relationships.

Estimating the direct healthcare utilization and cost of musculoskeletal pain among people with comorbidity: a retrospective electronic health record study.

OBJECTIVE: To investigate the impact of pre-existing painful musculoskeletal conditions on healthcare utilization and costs among patients with five common conditions: acute coronary syndrome (ACS), stroke, cancer, dementia and pneumonia. METHODS: Using primary and secondary care services data from electronic health records, a negative binomial regression model was used to compare resource use while a two-part model was used to compare costs across the five conditions, between those with and without a pre-existing musculoskeletal pain. RESULTS: The study included 760,792 patients (144,870 with ACS, 121,208 with stroke, 231,702 with cancer, 134,638 with dementia, and 128,374 with pneumonia) in the complete case analysis. Pre-existing musculoskeletal pain had an incident rate ratio of above one for most healthcare resources over the follow-up period and an adjusted additional mean cumulative total healthcare costs per patient of £674.59 (95%CI 570.30 to 778.87) for ACS; £613.34 (95%CI 496.87 to 729.82) for stroke; £459.26 (95%CI 376.60 to 541.91) for cancer; and £766.23 (95%CI 655.06 to 877.39) for dementia over five years after diagnosis; and £200.85 (95%CI 104.16 to 297.55) for pneumonia over one year after diagnosis compared to those without musculoskeletal pain. CONCLUSION: This study highlights that individuals with painful musculoskeletal conditions have higher healthcare utiliszation and costs than those without painful musculoskeletal conditions. Given the high occurrence of musculoskeletal pain in patients with other conditions, effective management strategies are needed to reduce the burden on healthcare resources.

Clinical and cost-effectiveness of bracing in symptomatic knee osteoarthritis management: protocol for a multicentre, primary care, randomised, parallel-group, superiority trial.

BACKGROUND: Brace effectiveness for knee osteoarthritis (OA) remains unclear and international guidelines offer conflicting recommendations. Our trial will determine the clinical and cost-effectiveness of adding knee bracing (matched to patients' clinical and radiographic presentation and with adherence support) to a package of advice, written information and exercise instruction delivered by physiotherapists. METHODS AND ANALYSIS: A multicentre, pragmatic, two-parallel group, single-blind, superiority, randomised controlled trial with internal pilot and nested qualitative study. 434 eligible participants with symptomatic knee OA identified from general practice, physiotherapy referrals and self-referral will be randomised 1:1 to advice, written information and exercise instruction and knee brace versus advice, written information and exercise instruction alone. The primary analysis will be intention-to-treat comparing treatment arms on the primary outcome (Knee Osteoarthritis Outcomes Score (KOOS)-5) (composite knee score) at the primary endpoint (6 months) adjusted for prespecified covariates. Secondary analysis of KOOS subscales (pain, other symptoms, activities of daily living, function in sport and recreation, knee-related quality of life), self-reported pain, instability (buckling), treatment response, physical activity, social participation, self-efficacy and treatment acceptability will occur at 3, 6, and 12 months postrandomisation. Analysis of covariance and logistic regression will model continuous and dichotomous outcomes, respectively. Treatment effect estimates will be presented as mean differences or ORs with 95% CIs. Economic evaluation will estimate cost-effectiveness. Semistructured interviews to explore acceptability and experiences of trial interventions will be conducted with participants and physiotherapists delivering interventions. ETHICS AND DISSEMINATION: North West Preston Research Ethics Committee, the Health Research Authority and Health and Care Research in Wales approved the study (REC Reference: 19/NW/0183; IRAS Reference: 247370). This protocol has been coproduced with stakeholders including patients and public. Findings will be disseminated to patients and a range of stakeholders. TRIAL REGISTRATION NUMBER: ISRCTN28555470.

Identification of patterns of foot and ankle pain in the community: Cross-sectional findings from the clinical assessment study of the foot.

OBJECTIVES: To investigate patterns of foot and ankle pain locations and symptoms, socio-demographic and comorbid characteristics to examine whether there are distinct foot and ankle pain phenotypes. METHODS: Adults aged ≥50 years registered with four general practices in North Staffordshire were mailed a Health Survey questionnaire. Participants reporting foot pain in the last month indicated foot pain location on a foot manikin. Foot and ankle pain patterns were investigated by latent class analysis. Associations between the classes with foot pain symptoms, socio-demographic and comorbid characteristics were assessed. RESULTS: Four thousand four hundred fifty-five participants with complete foot pain and manikin data were included in this analysis (mean age 65 years [SD 9.8], 49% male). Of those with foot and ankle pain (n = 1356), 90% had pain in more than one region. Six distinct classes of foot and ankle pain were identified: no pain (71%), bilateral forefoot/midfoot pain (4%), bilateral hindfoot pain (5%), left forefoot/midfoot pain (8%), right forefoot/midfoot pain (5%) and bilateral widespread foot and ankle pain (6%). People with bilateral widespread foot and ankle pain were more likely to be female, obese, depressed, anxious, have/had a manual occupation, have comorbidities, lower SF-12 scores and greater foot-specific disability. Age did not differ between classes. CONCLUSIONS: Six distinct classes of foot and ankle pain locations were identified, and those with bilateral widespread foot and ankle pain had distinct characteristics. Further investigation of these individuals is required to determine if they have poorer outcomes over time and whether they would benefit from earlier identification and treatment.

Position of the Academy of Nutrition and Dietetics: Food Insecurity in the United States.

It is the position of the Academy of Nutrition and Dietetics that systematic and sustained action is needed to achieve food and nutrition security in the United States. To achieve food security, effective interventions are needed, along with adequate funding for, and increased utilization of, food and nutrition assistance programs; inclusion of nutrition education in such programs; strategies to support individual and household economic stability; and research to measure impact on food insecurity- and health-related outcomes. Millions of individuals living in the United States experience food insecurity. Negative nutritional and non-nutritional outcomes are associated with food insecurity across the lifespan, including substandard academic achievement, inadequate intake of key nutrients, increased risk for chronic disease, and poor psychological and cognitive functioning. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, play key roles in addressing food insecurity and are uniquely positioned to make valuable contributions through competent and collaborative practice, provision of comprehensive food and nutrition education and training, innovative research related to all aspects of food insecurity, and advocacy efforts at the local, state, regional, and national levels.

Food insecurity and diabetes self-management among food pantry clients.

OBJECTIVE: To examine the association between level of food security and diabetes self-management among food pantry clients, which is largely not possible using clinic-based sampling methods. DESIGN: Cross-sectional descriptive study. SETTING: Community-based food pantries in California, Ohio and Texas, USA, from March 2012 through March 2014. SUBJECTS: Convenience sample of adults with diabetes queuing at pantries (n 1237; 83 % response). Sampled adults were stratified as food secure, low food secure or very low food secure. We used point-of-care glycated Hb (HbA1c) testing to determine glycaemic control and captured diabetes self-management using validated survey items. RESULTS: The sample was 70 % female, 55 % Latino/Hispanic, 25 % white and 10 % black/African American, with a mean age of 56 years. Eighty-four per cent were food insecure, one-half of whom had very low food security. Mean HbA1c was 8·1 % and did not vary significantly by food security status. In adjusted models, very-low-food-secure participants, compared with both low-food-secure and food-secure participants, had poorer diabetes self-efficacy, greater diabetes distress, greater medication non-adherence, higher prevalence of severe hypoglycaemic episodes, higher prevalence of depressive symptoms, more medication affordability challenges, and more food and medicine or health supply trade-offs. CONCLUSIONS: Few studies of the health impact of food security have been able to examine very low food security. In a food pantry sample with high rates of food insecurity, we found that diabetes self-management becomes increasingly difficult as food security worsens. The efficacy of interventions to improve diabetes self-management may increase if food security is simultaneously addressed.

Investigations of Potential Phenotypes of Foot Osteoarthritis: Cross-Sectional Analysis From the Clinical Assessment Study of the Foot.

OBJECTIVE: To investigate the existence of distinct foot osteoarthritis (OA) phenotypes based on pattern of joint involvement and comparative symptom and risk profiles. METHODS: Participants ages ≥50 years reporting foot pain in the previous year were drawn from a population-based cohort. Radiographs were scored for OA in the first metatarsophalangeal (MTP) joint, first and second cuneometatarsal, navicular first cuneiform, and talonavicular joints according to a published atlas. Chi-square tests established clustering, and odds ratios (ORs) examined symmetry and pairwise associations of radiographic OA in the feet. Distinct underlying classes of foot OA were investigated by latent class analysis (LCA) and their association with symptoms and risk factors was assessed. RESULTS: In 533 participants (mean age 64.9 years, 55.9% female) radiographic OA clustered across both feet (P < 0.001) and was highly symmetrical (adjusted OR 3.0, 95% confidence interval 2.1, 4.2). LCA identified 3 distinct classes of foot OA: no or minimal foot OA (64%), isolated first MTP joint OA (22%), and polyarticular foot OA (15%). After adjustment for age and sex, polyarticular foot OA was associated with nodal OA, increased body mass index, and more pain and functional limitation compared to the other classes. CONCLUSION: Patterning of radiographic foot OA has provided insight into the existence of 2 forms of foot OA: isolated first MTP joint OA and polyarticular foot OA. The symptom and risk factor profiles in individuals with polyarticular foot OA indicate a possible distinctive phenotype of foot OA, but further research is needed to explore the characteristics of isolated first MTP joint and polyarticular foot OA.

A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic Control Among Clients In Three States.

Food insecurity--defined as not having adequate quantity and quality of food at all times for all household members to have an active, healthy life--is a risk factor for poor diabetes control, yet few diabetes interventions address this important factor. Food pantries, which receive food from food banks and distribute it to clients in need, may be ideal sites for diabetes self-management support because they can provide free diabetes-appropriate food to people in low-income communities. Between February 2012 and March 2014, we enrolled 687 food pantry clients with diabetes in three states in a six-month pilot intervention that provided them with diabetes-appropriate food, blood sugar monitoring, primary care referral, and self-management support. Improvements were seen in pre-post analyses of glycemic control (hemoglobin A1c decreased from 8.11 percent to 7.96 percent), fruit and vegetable intake (which increased from 2.8 to 3.1 servings per day), self-efficacy, and medication adherence. Among participants with elevated HbA1c (at least 7.5 percent) at baseline, HbA1c improved from 9.52 percent to 9.04 percent. Although food pantries are nontraditional settings for diabetes support, this pilot study suggests a promising health promotion model for vulnerable populations. Policies supporting such interventions may be particularly effective because of food pantries' food access and distribution capacity.

The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot.

INTRODUCTION: The foot is largely overlooked in calls for better characterisation of clinical phenotypes in osteoarthritis (OA). Yet the midfoot complex in particular has the potential to provide important insights into OA pathogenesis given its central role in lower limb load transmission and alignment. Its recent inclusion in radiographic atlases has paved the way for international studies. In this UK study, we provide the first comprehensive account of the descriptive epidemiology of symptomatic midfoot OA. METHODS: Participants aged ≥50 years registered with four general practices were recruited via a mailed health survey (n = 5109 responders) and research clinic (n = 560 responders). Symptomatic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more joints (1st and 2nd cuneometatarsal, navicular first cuneiform and talonavicular joints) graded from weight-bearing dorso-plantar and lateral radiographs using a validated atlas. Prevalence estimates, overall and stratified by age, gender, and socio-economic class, were derived using multiple imputation and weighted logistic regression. Associations between symptomatic midfoot OA and current body mass index, previous injury, history of high-heeled footwear, nodal interphalangeal joint OA and patterns of comorbidity were estimated using binary logistic regression. Healthcare use was summarised. RESULTS: Symptomatic midfoot OA was present in 12.0% (95 % CI: 10.9, 13.2) of the population aged over 50 years. Higher occurrence was observed in females, adults aged over 75 years, and those in intermediate/routine occupational classes. Obesity, previous foot/ankle injury, and pain in other weight-loaded joints, but not high-heeled footwear or nodal interphalangeal joint OA, were associated with increased risk of symptomatic midfoot OA. Persons with symptomatic midfoot OA were also more likely to report multiple non-musculoskeletal comorbidities, including diabetes. In the previous 12 months, the proportions consulting a general practitioner, physiotherapist or podiatrist/chiropodist about foot pain were 46.2%, 18.5% and 47.9% respectively. A total of 64.7% had used oral analgesia in the past month for foot pain (36.1% paracetamol, 31.9% mild/moderate opioids, 27.7% NSAIDs). CONCLUSIONS: Our study confirms that symptomatic OA frequently affects the midfoot. The patterns of associations are interpreted as being largely consistent with the role of mechanical factors in its pathogenesis.

The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot.

OBJECTIVES: To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) affecting the 1st metatarsophalangeal joint (MTPJ), 1st and 2nd cuneometatarsal joints (CMJs), navicular first cuneiform joint (NCJ) and talonavicular joint (TNJ) in community-dwelling older adults. METHODS: 9334 adults aged ≥50 years registered with four general practices were mailed a health survey. Responders reporting foot pain within the last 12 months were invited to undergo weight-bearing dorso-plantar and lateral radiographs of both feet. OA at the 1st MTPJ, 1st and 2nd CMJs, NCJ and TNJ was graded using a validated atlas. Population prevalence estimates for symptomatic radiographic foot OA overall and for each joint were calculated using multiple imputation and weighted logistic regression modelling to account for missing data and non-response. RESULTS: 5109 health surveys were received (adjusted response 56%). Radiographs were obtained on 557 participants. Overall population prevalence of symptomatic radiographic OA was 16.7% (95% CI 15.3% to 18.0%), 1st MTPJ 7.8% (6.7% to 8.9%), 1st CMJ 3.9% (2.9% to 4.9%), 2nd CMJ 6.8% (5.7% to 7.8%), NCJ 5.2% (4.0% to 6.4%) and TNJ 5.8% (4.8% to 6.9%). With the exception of the 1st CMJ, prevalence was greater in females than males, increased with age and was higher in lower socioeconomic classes. Three-quarters of those with symptomatic radiographic OA reported disabling foot symptoms. CONCLUSIONS: While cautious interpretation due to non-response is warranted, our study suggests that symptomatic radiographic foot OA affects one in six older adults and the majority report associated disability. Clinicians should consider OA as a possible cause of chronic foot pain in older people.

Radiographic assessment of umbilical venous and arterial catheter tip location.

Umbilical venous and arterial catheters are routinely used in the care of critically ill patients in neonatal intensive care settings. Providers caring for these vulnerable patients have a role in ensuring that catheter tips remain in an appropriate position. The ideal anatomic tip location for both types of umbilical catheters is reviewed, and the evaluation of this position via radiographic study is discussed. Umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) have their own different complications. Complications of a malpositioned catheter of either type can be life threatening; therefore, evaluation of catheter tip location is an important skill in the provision of neonatal intensive care.

Comparison of clinical burden between patients with erosive hand osteoarthritis and inflammatory arthritis in symptomatic community-dwelling adults: the Keele clinical assessment studies.

OBJECTIVE: To investigate in the general population the clinical impact of erosive OA in interphalangeal joints (IPJs) compared with symptomatic radiographic hand OA and inflammatory arthritis. METHODS: Standardized assessments with hand radiographs were performed in participants of two population-based cohorts in North Staffordshire with hand symptoms lasting ≥1 day in the past month. Erosive OA was defined as the presence of an eroded or remodelled phase in ≥1 IPJ using the Verbruggen-Veys method. Radiographic hand OA was defined as the presence of ≥1 IPJ/first carpometacarpal joint with a Kellgren-Lawrence score of ≥2. Diagnoses of inflammatory arthritis were based on medical records. Hand pain and disability were assessed with the Australian/Canadian Hand Osteoarthritis Index (AUSCAN). Linear regression analyses were used to compare clinical determinants between groups and calculate mean differences with 95% CIs, adjusted for age and sex. RESULTS: Of 1076 participants with hand symptoms [60% women, mean age 64.8 years (s.d. 8.3 years)]; 80 persons (7.4%) had erosive OA. The population prevalence of erosive OA in ≥1 IPJ was 2.4% (95% CI 1.8, 3.0). Persons with erosive OA reported more pain and disability than persons with symptomatic radiographic hand OA [adjusted mean difference 1.3 (95% CI 0.3, 2.3) and 2.3 (95% CI 0.4, 4.2), respectively]. Individuals with inflammatory arthritis (n = 44) reported more pain and disability than those with erosive OA [adjusted mean difference 1.7 (95% CI 0.05, 3.4) and 6.3 (95% CI 2.8, 9.9), respectively]. CONCLUSION: While erosive OA has a greater impact than symptomatic radiographic hand OA in the general population, it is not as severe in terms of hand pain and disability as inflammatory RA.

The clinical assessment study of the foot (CASF): study protocol for a prospective observational study of foot pain and foot osteoarthritis in the general population.

BACKGROUND: Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 years. The foot joint complex is commonly affected by OA, yet there is relatively little research into OA of the foot, compared with other frequently affected sites such as the knee and hand. Existing epidemiological studies of foot OA have focussed predominantly on the first metatarsophalangeal joint at the expense of other joints. This three-year prospective population-based observational cohort study will describe the prevalence of symptomatic radiographic foot OA, relate its occurrence to symptoms, examination findings and life-style-factors, describe the natural history of foot OA, and examine how it presents to, and is diagnosed and managed in primary care. METHODS: All adults aged 50 years and over registered with four general practices in North Staffordshire, UK, will be invited to participate in a postal Health Survey questionnaire. Respondents to the questionnaire who indicate that they have experienced foot pain in the preceding twelve months will be invited to attend a research clinic for a detailed clinical assessment. This assessment will consist of: clinical interview; physical examination; digital photography of both feet and ankles; plain x-rays of both feet, ankles and hands; ultrasound examination of the plantar fascia; anthropometric measurement; and a further self-complete questionnaire. Follow-up will be undertaken in consenting participants by postal questionnaire at 18 months (clinic attenders only) and three years (clinic attenders and survey participants), and also by review of medical records. DISCUSSION: This three-year prospective epidemiological study will combine survey data, comprehensive clinical, x-ray and ultrasound assessment, and review of primary care records to identify radiographic phenotypes of foot OA in a population of community-dwelling older adults, and describe their impact on symptoms, function and clinical examination findings, and their presentation, diagnosis and management in primary care.

Radiographic thumb osteoarthritis: frequency, patterns and associations with pain and clinical assessment findings in a community-dwelling population.

OBJECTIVES: The aim of this study was to investigate: (i) the frequency and patterns of radiographic OA (ROA) in the thumb joints; and (ii) associations between thumb ROA and the clinical characteristics of thumb OA in older adults with hand pain or problems. METHODS: Participants were 592 community-dwelling older adults with hand pain or hand problems who attended a research clinic. Hand X-rays were taken and 32 joints were scored for the presence of ROA. The occurrence and pattern of ROA in the hand were examined. Univariable and multivariable associations of thumb pain and clinical assessments (nodes, deformity, enlargement, thenar muscle wasting, grind test, Kapandji index, Finkelstein's test and thumb extension) with ROA were investigated. RESULTS: The first CMC and thumb IP joints were the hand joints most frequently affected with ROA. The thumb (thumb IP, first MCP, first CMC, trapezioscaphoid) was the most commonly affected joint group (n = 412). Isolated thumb ROA occurred more frequently than in any other isolated joint group. Multivariable analyses showed that older age, thumb pain, thenar muscle wasting and presence of nodes, deformity or enlargement best determined the presence of thumb ROA. CONCLUSION: The first CMC and thumb IP joints were frequently affected with ROA. Prevalence estimates of ROA would be underestimated if these were not scored. One-third of the individuals with thumb ROA did not have involvement of the first CMC joint. The presence of thumb ROA was strongly associated with a combination of older age, thumb pain and clinical features of OA.

The Clinical Assessment Study of the Hand (CAS-HA): a prospective study of musculoskeletal hand problems in the general population.

BACKGROUND: Pain in the hand affects an estimated 12-21% of the population, and at older ages the hand is one of the most common sites of pain and osteoarthritis. The association between symptomatic hand osteoarthritis and disability in everyday life has not been studied in detail, although there is evidence that older people with hand problems suffer significant pain and disability. Despite the high prevalence of hand problems and the limitations they cause in older adults, little attention has been paid to the hand by health planners and policy makers. We plan to conduct a prospective, population-based, observational cohort study designed in parallel with our previously reported cohort study of knee pain, to describe the course of musculoskeletal hand problems in older adults and investigate the relative merits of different approaches to classification and defining prognosis. METHODS/DESIGN: All adults aged 50 years and over registered with two general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to the survey who indicate that they have experienced hand pain or problems within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, hand assessment, screening test of lower limb function, digital photography, plain x-rays, anthropometric measurement and brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months, and (iii) repeat postal questionnaire at 3 years. DISCUSSION: This paper describes the protocol for the Clinical Assessment Study of the Hand (CAS-HA), a prospective, population-based, observational cohort study of community-dwelling older adults with hand pain and hand problems based in North Staffordshire.