Harmonising measures of knee and hip osteoarthritis in population-based cohort studies: an international study.

OBJECTIVE: Population-based osteoarthritis (OA) cohorts provide vital data on risk factors and outcomes of OA, however the methods to define OA vary between cohorts. We aimed to provide recommendations for combining knee and hip OA data in extant and future population cohort studies, in order to facilitate informative individual participant level analyses. METHOD: International OA experts met to make recommendations on: 1) defining OA by X-ray and/or pain; 2) compare The National Health and Nutrition Examination Survey (NHANES)-type OA pain questions; 3) the comparability of the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) scale to NHANES-type OA pain questions; 4) the best radiographic scoring method; 5) the usefulness of other OA outcome measures. Key issues were explored using new analyses in two population-based OA cohorts (Multicenter Osteoarthritis Study; MOST and Osteoarthritis Initiative OAI). RESULTS: OA should be defined by both symptoms and radiographs, with symptoms alone as a secondary definition. Kellgren and Lawrence (K/L) grade ≥2 should be used to define radiographic OA (ROA). The variable wording of pain questions can result in varying prevalence between 41.0% and 75.4%, however questions where the time anchor is similar have high sensitivity and specificity (91.2% and 89.9% respectively). A threshold of 3 on a 0-20 scale (95% CI 2.1, 3.9) in the WOMAC pain subscale demonstrated equivalence with the preferred NHANES-type question. CONCLUSION: This research provides recommendations, based on expert agreement, for harmonising and combining OA data in existing and future population-based cohorts.

Physical activity and osteoarthritis: a consensus study to harmonise self-reporting methods of physical activity across international cohorts.

Physical activity (PA) is increasingly recognised as an important factor within studies of osteoarthritis (OA). However, subjective methods used to assess PA are highly variable and have not been developed for use within studies of OA, which creates difficulties when comparing and interpreting PA data in OA research. The aim of this study was, therefore, to gain expert agreement on the appropriate methods to harmonise PA data among existing population cohorts to enable the investigation of the association of PA and OA. The definition of PA in an OA context and methods of harmonization were established via an international expert consensus meeting and modified Delphi exercise using a geographically diverse committee selected on the basis of individual expertise in physical activity, exercise medicine, and OA. Agreement was met for all aims of study: (1) The use of Metabolic Equivalent of Task (MET) minutes per week (MET-min/week) as a method for harmonising PA variables among cohorts; (2) The determination of methods for treating missing components of MET-min/week calculation; a value will be produced from comparable activities within a representative cohort; (3) Exclusion of the domain of occupation from total MET-min/week; (4) The need for a specific measure of joint loading of an activity in addition to intensity and time, in studies of diseases, such as OA. This study has developed a systematic method to classify and harmonise PA in existing OA cohorts. It also provides minimum requirements for future studies intending to include subjective PA measures.

Tennis injury data from The Championships, Wimbledon, from 2003 to 2012.

OBJECTIVE: The primary aims of this retrospective study were to describe the burden of injury presenting to the medical team and the changes in injury profile over 10 years (2003-2012) at The Championships, Wimbledon. Secondary aims included description of gender difference in rates, distribution and pathology of injuries. DESIGN: Retrospective observational cohort of player injury presentations over 10 years (2003-2012) at The Championships, Wimbledon. RESULTS: The overall rate of presentation of injury for all players over the 10-year period was 20.7 per 1000 sets played. Injury rates were lower for male players (17.7 injuries per 1000 sets played) than female players (23.4 injuries per 1000 sets played). There was variability in the numbers of injuries reported by men and women players over the 10-year period. CONCLUSIONS: The rates of presentation of injury at this Grand Slam tennis tournament varied between male and female players, and between years. More robust systems of data collection are required in professional tennis to enable more sophisticated injury data analysis between sexes, years and different playing surfaces.

Physical activity interventions in the workplace: the rationale and future direction for workplace wellness.

The developing and developed worlds are both facing an obesity epidemic with their workers getting bigger, or to be more specific, fatter. As demonstrated elsewhere in this issue, the individual and societal health and economic costs of obesity and physical inactivity are enormous. There is thus a need for regional, national and global action to combat the issues, with programmes broadly divisible into children and adolescents, the workforce, active aging, healthy aging and a broad cross-cutting agenda that focuses on the built environment.

Selecting outcome measures in sports medicine: a guide for practitioners using the example of anterior cruciate ligament rehabilitation.

Using examples from the field of anterior cruciate ligament rehabilitation, this review provides sports and health practitioners with a comprehensive, user-friendly, guide to selecting outcome measures for use with active populations. A series of questions are presented for consideration when selecting a measure: is the measure appropriate for the intended use? (appropriateness); is the measure acceptable to patients? (acceptability); is it feasible to use the measure? (feasibility); does the measure provide meaningful results? (interpretability); does the measure provide reproducible values? (reliability); does the measure assess what it is supposed to assess? (validity); can the measure detect change? (responsiveness); do substantial proportions of patients achieve the worst or best scores? (floor and ceiling effects); is the measure structured and scored correctly? (dimensionality and internal consistency); has the measure been tested with the types of patients with whom it will be used? (sample characteristics). Evaluation of the measure using these questions will assist practitioners in making their judgements.

Consensus statement on epidemiological studies of medical conditions in tennis, April 2009.

BACKGROUND: The reported incidence, severity and nature of injuries sustained in tennis vary considerably between studies. While some of these variations can be explained by differences in sample populations and conditions, the main reasons are related to differences in definitions and methodologies employed in the studies. OBJECTIVE: This statement aims to review existing consensus statements for injury surveillance in other sports in order to establish definitions, methods and reporting procedures that are applicable to the specific requirements of tennis. DESIGN: The International Tennis Federation facilitated a meeting of 11 experts from seven countries representing a range of tennis stakeholders. Using a mixed methods consensus approach, key issues related to definitions, methodology and implementation were discussed and voted on by the group during a structured 1-day meeting. Following this meeting, two members of the group collaborated to produce a draft statement, based on the group discussions and voting outcomes. Three revisions were prepared and circulated for comment before the final consensus statement was produced. RESULTS: A definition of medical conditions (injuries and illnesses) that should be recorded in tennis epidemiological studies and criteria for recording the severity and nature of these conditions are proposed. Suggestions are made for recording players' baseline information together with recommendations on how medical conditions sustained during match play and training should be reported. CONCLUSIONS: The definitions and methodology proposed for recording injuries and illnesses sustained during tennis activities will lead to more consistent and comparable data being collected. The surveillance procedures presented here may also be applicable to other racket sports.

Metatarsal fractures and sports.

OBJECTIVES: Metatarsal fractures are commonly sustained during sport but little is written about metatarsal fractures in the athletic population. Demographics and definitive treatment in patients who sustained metatarsal fractures through sport were compared with an overall metatarsal fracture population. MATERIALS AND METHODS: We used a prospective cohort study from a teaching hospital fracture clinic. Eighteen months of data were coded from presentation with a metatarsal fracture. Demographics, metatarsal fracture, participating sport and treatment were recorded and analysed. RESULTS: 791 patients presented with metatarsal fractures in an 18 month period with 74 metatarsal fractures sustained through sport. In the overall cohort group, there were 443 females and 348 males with a mean age of 44 (age range 15-91) and in the athletic population there were 6 females and 68 males with a mean age of 26 (age range 15-62). The majority of the metatarsal fractures sustained from sport were from soccer (73%), with the fifth metatarsal being the most commonly fractured. The definitive treatment in both groups appears to be similar, where the mainstay of treatment is conservative with the use of cast or early mobilisation with an elasticated support stocking. CONCLUSION: In this cohort approximately 9% of metatarsal fractures were sustained through sport, with soccer being the most common sport. Following high profile injuries to metatarsals in soccer players, it has been suggested that the incidence of these fractures is rising. Thus, it is recommended that a detailed prospective study be undertaken to specifically study the incidence, aetiology and morbidity of metatarsal fractures in the athletic population.

Magnetic resonance imaging of the lumbar spine in asymptomatic professional fast bowlers in cricket.

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.

Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review.

A literature search was performed to determine whether non-steroidal anti-inflammatory drugs (NSAIDs) adversely affect the healing of stress fractures. Evidence exists from laboratory studies and animal subjects that NSAIDs can affect fracture healing. This link has not been proved or disproved in human subjects, particularly for stress fractures. In view of the high usage of NSAIDs in treating musculoskeletal disorders, research is required to investigate whether the healing of stress fractures is affected by these drugs.

Assessing risk factors for early hip osteoarthritis in activity-related hip pain: a Delphi study.

OBJECTIVE: Hip pain and injury as a result of activity can lead to the development of early hip osteoarthritis (OA) in susceptible individuals. Our understanding of the factors that increase susceptibility continues to evolve. The ability to clearly identify individuals (and cohorts) with activity-related hip pain who are at risk of early hip OA is currently lacking. The purpose of this study was to gain expert consensus on which key clinical measures might help predict the risk of early hip OA in individuals presenting with activity-related hip pain. The agreed measures would constitute a standardised approach to initial clinical assessment to help identify these individuals. METHODS: This Dephi study used online surveys to gain concordance of expert opinion in a structured process of 'rounds'. In this study, we asked 'What outcome measures are useful in predicting hip OA in activity-related hip pain?' The Delphi panel consisted of experts from sport and exercise medicine, orthopaedics, rheumatology, physiotherapy and OA research. RESULTS: The study identified key clinical measures in the history, examination and investigations (plain anteroposterior radiograph and femoroacetabular impingement views) that the panel agreed would be useful in predicting future risk of hip OA when assessing activity-related hip pain. The panel also agreed that certain investigations and tests (eg, MR angiography) did not currently have a role in routine assessment. There was a lack of consensus regarding the role of MRI, patient-reported outcome measures (PROMs) and certain biomechanical and functional assessments. CONCLUSIONS: We provide a standardised approach to the clinical assessment of patients with activity-related hip pain. Assessment measures rejected by the Delphi panel were newer, more expensive investigations that currently lack evidence. Assessment measures that did not reach consensus include MRI and PROMs. Their role remains ambiguous and would benefit from further research.

Golfing injuries. An overview.

Golf is becoming an increasingly available and popular sport. It is played by people of all ages and abilities, which accounts for a wide spectrum of injury. Few reports of injuries exist, but increasing media attention of the golfing injuries of professional players has raised the profile of these medical conditions. Numerically, the vast majority of problems occur from soft tissue musculoskeletal injuries rising principally from overuse. The injury pattern seen is influenced by the age, ability and amount of play. Anatomically, most injuries are localised to the back, wrist, elbow and shoulder. In addition to causing new injuries the game may cause recrudescence of old injuries and exacerbate pre-existing degenerative disease. A different injury pattern is seen among elite players compared with recreational players, and this relates to skill and amount of practice. Appropriate conditioning and attention to technique may help to reduce the incidence of injury. There are no injuries exclusive to golf, however fracture of the hamate bone is an uncommon injury seen in sports involving the use of a club or bat. The high number of childhood golf-related head injuries is disturbing. Most of these arise from blows to the head from a golf club and highlight the need for early tuition in the safety aspects of the game.

Biomechanical analysis of the effect of orthotic shoe inserts: a review of the literature.

Physical activity is increasingly recognised as an important component of primary disease prevention. Overuse injuries are common sequelae of exercise and sporting activities in general, and of running in particular, frequently resulting in cessation of activity. It has been proposed that there is a link between foot shape, foot function and the occurrence of injury. As a means of treatment and prevention of further injury, orthoses and shoe inserts are widely prescribed in the belief that they can alter the pattern of lower extremity joints' alignment and movement. Although this is an assumption widely made in the treatment of many joint conditions, the manner through which this treatment could be effective is not clear. This article aims to examine the literature to gain an improved understanding of the present state of knowledge regarding the effect of foot shape and orthotic use on foot kinematic and plantar pressure characteristics. The effects of foot type on the occurrence of lower limb injury during sporting activities and different aspects of biomechanics are reviewed, and the effects of applying orthoses on injury treatment and prevention and on various aspects of biomechanics of the lower limb joints are discussed. Further research is required, firstly to establish the casual effect of foot type and function on the risk of lower extremity overuse injury, and secondly to document the specific effect of orthotic therapy on injury treatment and prevention. Specifically, more prospective studies are necessary to investigate the long term effect of orthotic intervention.

Common hip injuries in sport.

As a major weight-bearing joint, normal hip function is fundamental to successful sporting participation. Not only is it important in running-, jumping- and kicking-based activities, it also contributes to the generation and transference of forces in upper limb-dominated activities. Injuries to the hip do not account for a large proportion of the sports physician's workload, but may result in significant morbidity. The wide variety of acute, subacute and chronic injuries, affecting both the joint and surrounding soft tissues, can prove a diagnostic dilemma. The predisposition and the types of injuries around the hip vary with the age of the athlete. The young child rarely sustains a significant injury but one should be aware of orthopaedic conditions common in this age group that may manifest themselves through exercise. The immature skeleton of the adolescent is relatively injury prone and the demands of sport often exceed the capacity of the growing musculoskeletal system. In adults and older athletes, a further spectrum of injury exists, along with the effects of aging tissues and the concerns of degenerative joint disease. Rational treatment is based on a clear diagnosis developed through sound knowledge and a thorough history and examination. For the sports physician, treatments are typically early physical therapy and structured, progressive rehabilitation programmes which are individualised to the needs of the athlete. The spectrum of hip injuries is reviewed with current recommended diagnoses and management.

Osteitis pubis in collegiate football players.

Osteitis pubis in athletes is an inflammatory condition of the pubic symphysis and surrounding muscular insertions. It is of uncertain etiology, however, and is seen particularly in those sports requiring sprinting and sudden changes of direction. There is a paucity of literature of this condition occurring in players of American football. This report presents two such cases and details proposed etiology and a specific management protocol.

A prospective controlled study of diagnostic imaging for acute shin splints.

OBJECTIVE: The purpose of this prospective, observational study was to examine the relationship of clinical examination, plain radiograph (XR), triple-phase bone scan (TPBS), and magnetic resonance imaging (MRI) in the investigation of patients presenting with acute shin splints. METHODS: 23 subjects with exercise induced lower leg pain and diffuse tibial tenderness of less than 3 months' duration were recruited. Subjects were excluded if there was clinical evidence of compartment syndrome, muscle hernia, or stress fracture. Each subject underwent XR, TPBS, and MRI within 2 wk of physical examination. Four asymptomatic controls underwent TPBS and MRI. Clinical findings, XR, TPBS, and MRI findings were independently recorded using a consistent template and subsequently analyzed. A single consensus lesion was chosen that provided the greatest overlap and highest grade to allow comparison of clinical and imaging findings. Sensitivity and specificity were calculated from data relating to clinical findings and diagnostic imaging. RESULTS: Eighteen subjects had bilateral symptoms and five unilateral with a mean duration of symptom of 5.4 wk (+/- 3.5). Of 41 symptomatic lower legs, there were TPBS abnormalities in 36 and MRI findings in 34. Analysis of clinical findings to TPBS and MRI demonstrated a sensitivity and specificity of 84%, 33% and 79%, 33%, respectively. Assuming TPBS as the "gold-standard," MRI findings demonstrated a sensitivity of 95% and specificity of 67%. There was poor agreement between the grading of TPBS and MRI (k = 0.3). In the 5/46 asymptomatic limbs, 3/5 demonstrated uptake on bone scan and 4/5 signal change with MRI. Imaging abnormalities were similarly seen in the four control patients. CONCLUSIONS: MRI may be used rather than TPBS and radiographs for evaluating acute tibial pain in athletes where avoidance of radiation exposure is desirable. Similar sensitivity and specificity may be expected from both investigations; however, in the light of abnormal TPBS and MRI findings in control and asymptomatic limbs, we recommend further studies be performed to define the extent of nonpathological TPBS and MRI changes.

Surface effects on ground reaction forces and lower extremity kinematics in running.

INTRODUCTION: Although running surface stiffness has been associated with overuse injuries, all evidence to support this suggestion has been circumstantial. In the present study, the biomechanical response of heel-toe runners to changes in running surface has been investigated. METHODS: Six heel-toe runners performed shod running trials over three surfaces: a conventional asphalt surface, a new rubber-modified asphalt surface, and an acrylic sports surface. The surfaces were categorised according to impact absorbing ability using standard impact test procedures (BS 7044). RESULTS: The rubber-modified asphalt was found to exhibit the greatest amount of mechanical impact absorption, and the conventional asphalt the least. The comparison of peak impact force values across surfaces for the group of subjects demonstrated no significant differences in magnitude of force. However, a significant reduction in loading rate of peak impact force was detected for the rubber-modified surface compared with conventional asphalt (P < 0.1). Although analysis of group data revealed no significant differences in kinematic variables when running on the different surfaces, a varied response to surface manipulation among runners was demonstrated, with marked differences in initial joint angles, peak joint angles, and peak joint angular velocities being observed. DISCUSSION: For some subjects, the maintenance of similar peak impact forces for different running surfaces was explained by observed kinematic adjustments. For example, when running on the surface providing the least impact absorption, an increased initial knee flexion was observed for some subjects, suggesting an increased lower extremity compliance. However, for some subjects, sagittal plane kinematic data were not sufficient for the explanation of peak impact force results. It appears that the mechanism of adaptation varies among runners, highlighting the requirement of individual subject analyses.

Comparing spondylolysis in cricketers and soccer players.

OBJECTIVE: To determine whether the location of spondylolysis in the lumbar spine of athletes differs with biomechanical factors. METHODS: Single photon emission computerised tomography and reverse gantry computerised tomography were used to investigate 42 cricketers and 28 soccer players with activity related low back pain. Sites of increased scintigraphic uptake in the posterior elements of the lumbar spine and complete or incomplete fracture in the pars interarticularis were compared for these two sports. RESULTS: Thirty seven (90.4%) cricketers and 23 (82.1%) soccer players studied had sites of increased uptake. In cricketers, these sites were on the left of the neural arch of 49 lumbar vertebrae and on the right of 33 vertebrae. In soccer players there was a significantly different proportion, with 17 sites on the left and 28 on the right (difference of 22.0%; 95% confidence interval (CI) 0.04 to 0.38). Lower lumbar levels showed increased scintigraphic uptake more frequently than did higher levels, although the trend was reversed at L3 and L4 in soccer. Forty spondylolyses were identified in the lumbar vertebrae of the cricketers and 35 spondylolyses in the soccer players. These comprised 26 complete and 14 incomplete fractures in the cricketers, and 25 complete and 10 incomplete fractures in the soccer players. Similar numbers of incomplete fractures were found either side of the neural arch in soccer players, but there were more incomplete fractures in the left pars (14) than in the right (2) in cricketers. The proportion of incomplete fractures either side of the neural arch was significantly different between cricket players and soccer players (difference of 37.5%; 95% CI 0.02 to 0.65). Most complete fractures were at L5 (66.7%) and more were found at L3 (15.7%) than L4 (6.9%). However, incomplete fractures were more evenly spread though the lower three lumbar levels with 41.7% at L5, 37.5% at L4, and 20.8% at L3. CONCLUSIONS: Fast bowling in cricket is associated with pars interarticularis bone stress response and with development of incomplete stress fractures that occur more frequently on the left than the right. Playing soccer is associated with a more symmetrical distribution of bone stress response, including stress fracturing. Within cricketers, unilateral spondylolyses tend to arise on the contralateral side to the bowling arm.

The 'sports hernia': a common cause of groin pain.

Athletes who participate in sports that require repetitive twisting and turning at speed, such as soccer or ice hockey, may be at risk of developing a 'sports hernia'-disruption of the inguinal canal without a clinically detectable hernia. Insidious onset of unilateral groin pain is the most common symptom. Concurrent pathologies, such as osteitis pubis and adductor tenoperiostitis, may complicate diagnosis. Plain radiographs and a bone scan can aid differential diagnosis, but herniography is not recommended. Surgery is the preferred treatment. Structured rehabilitation should enable athletes to return to sports activity 6 to 8 weeks after surgery.