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Patellar cartilage status in people after ACL reconstruction: Influence of timing of return to sports and infrapatellar fat pad morphology
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Abstracts / Journal of Science and Medicine in Sport 20S (2017) e2–e31
Methods: Male Australian football players either with (HISTORY; n = 7) or without (CONTROL; n = 10) a history of groin pain performed 10 successful trials of an unanticipated change-ofdirection task with a defensive opponent and 5 maximal isokinetic hip abduction-adduction contractions. Three-dimensional ground reaction forces (GRF) and kinematics were recorded during the change-of-direction task. The weight acceptance phase was defined from initial contact (IC) when the vertical GRF exceeded 10 N, to the first local minimum (FWA ) after peak vertical GRF (FV ). Any between-group differences were determined using independentsamples t-tests and a Bayesian approach (precision of estimation and magnitude-based inferences). Moderate or large effect sizes (d) were defined as substantial changes to enable a more informative inferential assertions regarding magnitude. Results: There were substantial between-group differences for majority of the variables including HISTORY group displaying decreased knee flexion (d: IC 0.91, FV 0.61, FWA 0.78) and hip internal rotation (d: IC 0.74, FV 0.87, FWA 0.94), increased knee internal rotation (d: IC 0.86, FV 0.75, FWA −0.95) and T12-L1 right rotation (d: IC 1.17, FV 0.99, FWA 0.78), and higher GRFs (d: FV 0.52, FWA 0.82, FPOST 0.50), and decreased right adductor/abductor muscle strength ratio (d: 0.78). Discussion: Weak hip adductor muscular strength may have served as a precursor for the impaired ability of the HISTORY group to control lower limb function and alignment while executing the change-of-direction task. They also utilised decreased hip internal rotation, which is associated with groin injury and increased demands on the pubic symphysis. This provides evidence to support current rehabilitation methods of improving hip adduction-abduction muscular imbalances, and suggests the inclusion of lower limb alignment and control during a change-ofdirection task within rehabilitation. http://dx.doi.org/10.1016/j.jsams.2016.12.066 63 The joint health of recreational runners – An analysis of symptoms, injury history and osteoarthritis R. Leech 1,∗ , K. Flatters 1 , M. Batt 2 , K. Edwards 1 1
University of Nottingham, Arthritis Research UK Nottingham University Hospitals, Arthritis Research UK 2
Introduction: Running is becoming increasingly popular. Over 3 million individuals in England participate in athletics on a monthly basis whilst an equivalent percentage of the Australian population (7.4%) run or jog regularly. The importance of emphasising and encouraging an active lifestyle is critical within the wider societal context. Thus, the effect of running – one of the most easily accessible sporting pastimes – on musculoskeletal health must be understood. The Health of Adults’ Longitudinal Observational (HALO) study aims to explore the association between physical activity (including running) and other lifestyle factors on health and chronic disease, such as osteoarthritis (OA). This paper aims to examine the associations between running behaviour, prevalence and severity of joint symptoms and injury history. Methods: As part of the HALO study, recreational runners from across the United Kingdom and Australia have been recruited (n = 1345 runners, male = 563, female = 782, mean age = 47.3 years (range 18–81). Participants completed a questionnaire providing detail on demographics, health and wellbeing, occupational and recreational physical activity, injury, joint symptoms and OA. Differences between running groups were assessed using c2 test.
Results: The majority of participants considered themselves to be road runners (n = 970; 72.1%). Across all runners (road, trail, track, adventure racer, other) history of running ranged from 1 month – 67 years. 57.5% reported a history of injury (55.2% road; 60.9% trail; p = 0.12) and 13.2% have undergone joint surgery (12.9% road; 13.6% trail; p = 0.78). Overall, 17.5% had a clinical diagnosis of OA (15.2% road; 23.0% trail; p = 0.14), with the knee the most commonly affected joint. 30.4% reported a history of knee joint pain (28.6% road; 35.0% trail; p = 0.05), 12.9% morning stiffness (12.2% road; 14.4% trail; p = 0.38) and 29.9% joint crepitus (29.4% road; 32.5% trail; p = 0.35) persisting for one month or more. Discussion: Evidence supports the overall beneficial health effects of running, whilst greater joint loading has been hypothesised as a risk factor for OA onset and progression. Anecdotally, many believe that running on hard surfaces, such as tarmac, will be detrimental to the joints. Findings from the present study suggest that running on different terrain provides no significant effect on the incidence of knee symptoms. In contrast to much of the previous data in this area, this cohort includes many younger runners therefore the relatively high prevalence of knee pain and OA is of significant interest. http://dx.doi.org/10.1016/j.jsams.2016.12.067 64 Patellar cartilage status in people after ACL reconstruction: Influence of timing of return to sports and infrapatellar fat pad morphology A. Van Ginckel Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Australia Introduction: People after ACL reconstruction (ACLR) are at higher risk of knee osteoarthritis (OA). We showed that knee cartilage at 6 months post-ACLR has low in vivo resiliency when compared to controls, which may render the cartilage more vulnerable to dissipate repetitive high impact loads typically occurring during sports. Previous reports, however, have largely focussed on the tibiofemoral joint despite growing evidence indicating that the patellofemoral joint (PFJ) may also be a pertinent source of pathology and symptoms. Additionally, the infrapatellar fat pad (IPFP) is closely aligned to the PFJ and may show a variety of abnormalities following ACLR including oedema and scarring, all of which may affect the proper function of the knee. The purpose of this study was: (1) to compare patellar cartilage morphology and resiliency between ACLR patients and matched controls, (2) to explore associations between patellar cartilage status and timing of return to sports as well as IPFP morphology. Methods: Fifteen patients at 6 months from isolated ACL reconstruction were compared with 15 matched controls. A 3 T MRI evaluation was performed entailing morphological characteristics of cartilage and IPFP (3D volume/thickness, presence of scarring/oedema) and cartilage resiliency (after a 30-min run: in vivo deformation including recovery up to 54 min following exercise). Timing of return to sports was queried using researcher-designed questionnaires. Results: No significant differences existed between groups for patellar cartilage volume (p = 0.25) and thickness (p = 0.63). Similarly, patellar cartilage deformational behaviour and extent of recovery following the 30-min run appeared similar between groups (p = 0.52). Return at 5 months or sooner was associated with less recovery of patellar cartilage volumes following the exercise (at 30 min after exercise: rs = 0.79, p = 0.02). In patients, but not in controls, larger normalised IPFP volumes were associated with greater
Abstracts / Journal of Science and Medicine in Sport 20S (2017) e2–e31
patellar cartilage volumes (rs = 0.65, p = 0.01). Presence of oedema (2/15 patients) was also related to less recovery of patellar cartilage volumes at 30 min (rs = 0.59, p = 0.02) and 45 min (rs = 0.55, p = 0.04) after exercise cessation. Discussion: At 6 months from ACLR, patellar cartilage quality may not be diminished as is tibiofemoral cartilage. Its relationship to timing of return to sports, however, suggests that accelerated post-surgical rehabilitation, rather than the initial trauma from injury or surgery, may account for the relatively high prevalence of MRI-detected PFJOA seen as early as 1 year post-surgery. Longitudinal studies are warranted, especially to further understand the role of the IPFP in knee joint health after ACLR. http://dx.doi.org/10.1016/j.jsams.2016.12.068 65 A randomised trial investigating an accelerated weight bearing program after autologous chondrocyte implantation: 2-year outcomes J. Ebert 1,∗ , P. Edwards 1 , M. Fallon 2 , T. Ackland 1 , D. Wood 3 1 School of Sport Science, Exercise & Health, The University of Western Australia, Australia 2 Perth Radiological Clinic, Australia 3 School of Surgery (Orthopaedics), The University of Western Australia, Australia
Introduction: Matrix-induced autologous chondrocyte implantation (MACI) is a surgical treatment option for symptomatic knee cartilage defects. While encouraging results are reported, outcomes remain limited by a lack of knowledge on how to progress post-operative weight bearing (WB) and exercise. Rehabilitation protocols remain conservative and information for the therapist is notably deficient. This study sought to investigate patient and graft outcome after an accelerated WB return after MACI. Methods: After MACI, 37 patients were prospectively randomized to either an accelerated (AR, 6 weeks, n = 18) or conservative (CR, 8 weeks, n = 19) return to full WB gait. Clinical outcomes were assessed at 3, 6, 12 and 24 months post-surgery, including knee range of motion, the six-minute walk test, maximal isokinetic knee flexor and extensor strength, the Knee Injury and Osteoarthritis Outcome Score and the Short Form Health Survey. High resolution magnetic resonance imaging (MRI) was undertaken to assess eight pertinent parameters of graft repair, as well as a combined MRI composite score. Repeated measures ANOVA was employed to investigate clinical and MRI scores over time, between the AR and CR groups. Results: A significant time effect (p < 0.001) existed for all clinical scores demonstrating improvement to 24 months in both groups. No group differences (p > 0.05) were observed. At 24 months post-surgery, a mean Limb Symmetry Index (LSI) for maximal knee extension strength was calculated for the AR (88.5%) and CR (86.9%) groups, comparing the operated and non-operated limbs. The LSI for maximal knee flexor strength was 101.0% and 102.2% for the AR and CR groups, respectively. There were no significant differences (p > 0.05) in the MRI-based scores between the two groups. There was no incidence of graft de-lamination in the AR group, with 94% (17/18) of patients satisfied with MACI for relieving their knee pain. This was compared to 2 patients in the CR group who demonstrated a graft area devoid of graft material, though with 95% (18/19) of patients still satisfied with MACI for relieving their knee pain. Discussion: Reported results after MACI are encouraging, though patient outcomes remain limited by a lack of knowledge
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on best-practice rehabilitation, with current programs based on expert opinion, animal studies and basic science. In this study, the AR group that reduced the length of time spent ambulating on crutches produced comparable outcomes to the traditionally conservative regimen, without compromising graft integrity. This AR protocol appears safe, accelerating the patient’s return to full WB and normal daily activities. http://dx.doi.org/10.1016/j.jsams.2016.12.069 66 Functional limitations in individuals with symptomatic and radiographic mild-to-moderate hip osteoarthritis: A case–control study M. Constantinou 1,2,∗ , P. Mills 1,2 , A. Loureiro 1,2 , R. Barrett 1,2 1 School of Allied Health Sciences, Menzies Health Institute Qld, Griffith University, Australia 2 School of Physiotherapy, Australian Catholic University, Australia
Background: It is well established that individuals with advanced stage hip OA exhibit functional limitations, while findings in those with mild-to-moderate hip OA are inconsistent. The aim of this study was to compare physical function in those with symptomatic and radiographic mild-to-moderate hip osteoarthritis (OA) and healthy controls and to determine the extent to which patient-reported outcomes can be predicted by physical function in those with mild-to-moderate hip OA. Methods: Participants with symptomatic and radiographic mild-to-moderate hip OA and healthy controls were recruited for this study. Eligible participants completed the Hip Disability and Osteoarthritis Outcome Score (HOOS) and the modified Harris Hip Score (HHS) questionnaires and underwent a battery of physical function tests consisting of gait-related performance tests (selfselected walking speed, timed-up-and-go test, timed stair test), physical examination tests (lower limb muscle strength and hip range of motion) and physical activity over 10 days as measured by accelerometry. Results: Twenty-seven individuals with mild-to-moderate hip OA (mean age 63.2 ± 7.6 years) and 26 healthy controls (mean age 59.3 ± 7.6 years) participated in the study. Compared to healthy controls, individuals with mild-to-moderate hip OA reported significantly lower scores on HOOS and HHS, demonstrated 13% slower self-selected walking speed, 38% and 36% slower times for timed-up-and-go and timed stair tests respectively, were weaker in hip flexor and abductor, knee flexor and extensor, ankle dorsiand plantar-flexor muscle strength by 20–48%, had less hip range of motion but demonstrated no difference in physical activity as measured by accelerometry compared to healthy controls. Stepwise linear regression revealed that hip flexor and knee extensor muscle strength were the most consistent uni-variate predictors of HOOS and its corresponding sub-scores (R2 = 0.30-0.39) whereas the timed-stair-test was the best predictor of the modified HHS (R2 = 0.31) and its corresponding Function score (R2 = 0.39). Discussion: Individuals with symptomatic and radiographic mild-to-moderate hip OA exhibit lower physical function than healthy controls. Patient-reported outcomes reflect different aspects of function than physical measures in mild-to-moderate hip OA and a combination of both appear necessary to comprehensively assess dysfunction. http://dx.doi.org/10.1016/j.jsams.2016.12.070
Abstracts / Journal of Science and Medicine in Sport 20S (2017) e2–e31
Methods: Male Australian football players either with (HISTORY; n = 7) or without (CONTROL; n = 10) a history of groin pain performed 10 successful trials of an unanticipated change-ofdirection task with a defensive opponent and 5 maximal isokinetic hip abduction-adduction contractions. Three-dimensional ground reaction forces (GRF) and kinematics were recorded during the change-of-direction task. The weight acceptance phase was defined from initial contact (IC) when the vertical GRF exceeded 10 N, to the first local minimum (FWA ) after peak vertical GRF (FV ). Any between-group differences were determined using independentsamples t-tests and a Bayesian approach (precision of estimation and magnitude-based inferences). Moderate or large effect sizes (d) were defined as substantial changes to enable a more informative inferential assertions regarding magnitude. Results: There were substantial between-group differences for majority of the variables including HISTORY group displaying decreased knee flexion (d: IC 0.91, FV 0.61, FWA 0.78) and hip internal rotation (d: IC 0.74, FV 0.87, FWA 0.94), increased knee internal rotation (d: IC 0.86, FV 0.75, FWA −0.95) and T12-L1 right rotation (d: IC 1.17, FV 0.99, FWA 0.78), and higher GRFs (d: FV 0.52, FWA 0.82, FPOST 0.50), and decreased right adductor/abductor muscle strength ratio (d: 0.78). Discussion: Weak hip adductor muscular strength may have served as a precursor for the impaired ability of the HISTORY group to control lower limb function and alignment while executing the change-of-direction task. They also utilised decreased hip internal rotation, which is associated with groin injury and increased demands on the pubic symphysis. This provides evidence to support current rehabilitation methods of improving hip adduction-abduction muscular imbalances, and suggests the inclusion of lower limb alignment and control during a change-ofdirection task within rehabilitation. http://dx.doi.org/10.1016/j.jsams.2016.12.066 63 The joint health of recreational runners – An analysis of symptoms, injury history and osteoarthritis R. Leech 1,∗ , K. Flatters 1 , M. Batt 2 , K. Edwards 1 1
University of Nottingham, Arthritis Research UK Nottingham University Hospitals, Arthritis Research UK 2
Introduction: Running is becoming increasingly popular. Over 3 million individuals in England participate in athletics on a monthly basis whilst an equivalent percentage of the Australian population (7.4%) run or jog regularly. The importance of emphasising and encouraging an active lifestyle is critical within the wider societal context. Thus, the effect of running – one of the most easily accessible sporting pastimes – on musculoskeletal health must be understood. The Health of Adults’ Longitudinal Observational (HALO) study aims to explore the association between physical activity (including running) and other lifestyle factors on health and chronic disease, such as osteoarthritis (OA). This paper aims to examine the associations between running behaviour, prevalence and severity of joint symptoms and injury history. Methods: As part of the HALO study, recreational runners from across the United Kingdom and Australia have been recruited (n = 1345 runners, male = 563, female = 782, mean age = 47.3 years (range 18–81). Participants completed a questionnaire providing detail on demographics, health and wellbeing, occupational and recreational physical activity, injury, joint symptoms and OA. Differences between running groups were assessed using c2 test.
Results: The majority of participants considered themselves to be road runners (n = 970; 72.1%). Across all runners (road, trail, track, adventure racer, other) history of running ranged from 1 month – 67 years. 57.5% reported a history of injury (55.2% road; 60.9% trail; p = 0.12) and 13.2% have undergone joint surgery (12.9% road; 13.6% trail; p = 0.78). Overall, 17.5% had a clinical diagnosis of OA (15.2% road; 23.0% trail; p = 0.14), with the knee the most commonly affected joint. 30.4% reported a history of knee joint pain (28.6% road; 35.0% trail; p = 0.05), 12.9% morning stiffness (12.2% road; 14.4% trail; p = 0.38) and 29.9% joint crepitus (29.4% road; 32.5% trail; p = 0.35) persisting for one month or more. Discussion: Evidence supports the overall beneficial health effects of running, whilst greater joint loading has been hypothesised as a risk factor for OA onset and progression. Anecdotally, many believe that running on hard surfaces, such as tarmac, will be detrimental to the joints. Findings from the present study suggest that running on different terrain provides no significant effect on the incidence of knee symptoms. In contrast to much of the previous data in this area, this cohort includes many younger runners therefore the relatively high prevalence of knee pain and OA is of significant interest. http://dx.doi.org/10.1016/j.jsams.2016.12.067 64 Patellar cartilage status in people after ACL reconstruction: Influence of timing of return to sports and infrapatellar fat pad morphology A. Van Ginckel Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Australia Introduction: People after ACL reconstruction (ACLR) are at higher risk of knee osteoarthritis (OA). We showed that knee cartilage at 6 months post-ACLR has low in vivo resiliency when compared to controls, which may render the cartilage more vulnerable to dissipate repetitive high impact loads typically occurring during sports. Previous reports, however, have largely focussed on the tibiofemoral joint despite growing evidence indicating that the patellofemoral joint (PFJ) may also be a pertinent source of pathology and symptoms. Additionally, the infrapatellar fat pad (IPFP) is closely aligned to the PFJ and may show a variety of abnormalities following ACLR including oedema and scarring, all of which may affect the proper function of the knee. The purpose of this study was: (1) to compare patellar cartilage morphology and resiliency between ACLR patients and matched controls, (2) to explore associations between patellar cartilage status and timing of return to sports as well as IPFP morphology. Methods: Fifteen patients at 6 months from isolated ACL reconstruction were compared with 15 matched controls. A 3 T MRI evaluation was performed entailing morphological characteristics of cartilage and IPFP (3D volume/thickness, presence of scarring/oedema) and cartilage resiliency (after a 30-min run: in vivo deformation including recovery up to 54 min following exercise). Timing of return to sports was queried using researcher-designed questionnaires. Results: No significant differences existed between groups for patellar cartilage volume (p = 0.25) and thickness (p = 0.63). Similarly, patellar cartilage deformational behaviour and extent of recovery following the 30-min run appeared similar between groups (p = 0.52). Return at 5 months or sooner was associated with less recovery of patellar cartilage volumes following the exercise (at 30 min after exercise: rs = 0.79, p = 0.02). In patients, but not in controls, larger normalised IPFP volumes were associated with greater
Abstracts / Journal of Science and Medicine in Sport 20S (2017) e2–e31
patellar cartilage volumes (rs = 0.65, p = 0.01). Presence of oedema (2/15 patients) was also related to less recovery of patellar cartilage volumes at 30 min (rs = 0.59, p = 0.02) and 45 min (rs = 0.55, p = 0.04) after exercise cessation. Discussion: At 6 months from ACLR, patellar cartilage quality may not be diminished as is tibiofemoral cartilage. Its relationship to timing of return to sports, however, suggests that accelerated post-surgical rehabilitation, rather than the initial trauma from injury or surgery, may account for the relatively high prevalence of MRI-detected PFJOA seen as early as 1 year post-surgery. Longitudinal studies are warranted, especially to further understand the role of the IPFP in knee joint health after ACLR. http://dx.doi.org/10.1016/j.jsams.2016.12.068 65 A randomised trial investigating an accelerated weight bearing program after autologous chondrocyte implantation: 2-year outcomes J. Ebert 1,∗ , P. Edwards 1 , M. Fallon 2 , T. Ackland 1 , D. Wood 3 1 School of Sport Science, Exercise & Health, The University of Western Australia, Australia 2 Perth Radiological Clinic, Australia 3 School of Surgery (Orthopaedics), The University of Western Australia, Australia
Introduction: Matrix-induced autologous chondrocyte implantation (MACI) is a surgical treatment option for symptomatic knee cartilage defects. While encouraging results are reported, outcomes remain limited by a lack of knowledge on how to progress post-operative weight bearing (WB) and exercise. Rehabilitation protocols remain conservative and information for the therapist is notably deficient. This study sought to investigate patient and graft outcome after an accelerated WB return after MACI. Methods: After MACI, 37 patients were prospectively randomized to either an accelerated (AR, 6 weeks, n = 18) or conservative (CR, 8 weeks, n = 19) return to full WB gait. Clinical outcomes were assessed at 3, 6, 12 and 24 months post-surgery, including knee range of motion, the six-minute walk test, maximal isokinetic knee flexor and extensor strength, the Knee Injury and Osteoarthritis Outcome Score and the Short Form Health Survey. High resolution magnetic resonance imaging (MRI) was undertaken to assess eight pertinent parameters of graft repair, as well as a combined MRI composite score. Repeated measures ANOVA was employed to investigate clinical and MRI scores over time, between the AR and CR groups. Results: A significant time effect (p < 0.001) existed for all clinical scores demonstrating improvement to 24 months in both groups. No group differences (p > 0.05) were observed. At 24 months post-surgery, a mean Limb Symmetry Index (LSI) for maximal knee extension strength was calculated for the AR (88.5%) and CR (86.9%) groups, comparing the operated and non-operated limbs. The LSI for maximal knee flexor strength was 101.0% and 102.2% for the AR and CR groups, respectively. There were no significant differences (p > 0.05) in the MRI-based scores between the two groups. There was no incidence of graft de-lamination in the AR group, with 94% (17/18) of patients satisfied with MACI for relieving their knee pain. This was compared to 2 patients in the CR group who demonstrated a graft area devoid of graft material, though with 95% (18/19) of patients still satisfied with MACI for relieving their knee pain. Discussion: Reported results after MACI are encouraging, though patient outcomes remain limited by a lack of knowledge
e29
on best-practice rehabilitation, with current programs based on expert opinion, animal studies and basic science. In this study, the AR group that reduced the length of time spent ambulating on crutches produced comparable outcomes to the traditionally conservative regimen, without compromising graft integrity. This AR protocol appears safe, accelerating the patient’s return to full WB and normal daily activities. http://dx.doi.org/10.1016/j.jsams.2016.12.069 66 Functional limitations in individuals with symptomatic and radiographic mild-to-moderate hip osteoarthritis: A case–control study M. Constantinou 1,2,∗ , P. Mills 1,2 , A. Loureiro 1,2 , R. Barrett 1,2 1 School of Allied Health Sciences, Menzies Health Institute Qld, Griffith University, Australia 2 School of Physiotherapy, Australian Catholic University, Australia
Background: It is well established that individuals with advanced stage hip OA exhibit functional limitations, while findings in those with mild-to-moderate hip OA are inconsistent. The aim of this study was to compare physical function in those with symptomatic and radiographic mild-to-moderate hip osteoarthritis (OA) and healthy controls and to determine the extent to which patient-reported outcomes can be predicted by physical function in those with mild-to-moderate hip OA. Methods: Participants with symptomatic and radiographic mild-to-moderate hip OA and healthy controls were recruited for this study. Eligible participants completed the Hip Disability and Osteoarthritis Outcome Score (HOOS) and the modified Harris Hip Score (HHS) questionnaires and underwent a battery of physical function tests consisting of gait-related performance tests (selfselected walking speed, timed-up-and-go test, timed stair test), physical examination tests (lower limb muscle strength and hip range of motion) and physical activity over 10 days as measured by accelerometry. Results: Twenty-seven individuals with mild-to-moderate hip OA (mean age 63.2 ± 7.6 years) and 26 healthy controls (mean age 59.3 ± 7.6 years) participated in the study. Compared to healthy controls, individuals with mild-to-moderate hip OA reported significantly lower scores on HOOS and HHS, demonstrated 13% slower self-selected walking speed, 38% and 36% slower times for timed-up-and-go and timed stair tests respectively, were weaker in hip flexor and abductor, knee flexor and extensor, ankle dorsiand plantar-flexor muscle strength by 20–48%, had less hip range of motion but demonstrated no difference in physical activity as measured by accelerometry compared to healthy controls. Stepwise linear regression revealed that hip flexor and knee extensor muscle strength were the most consistent uni-variate predictors of HOOS and its corresponding sub-scores (R2 = 0.30-0.39) whereas the timed-stair-test was the best predictor of the modified HHS (R2 = 0.31) and its corresponding Function score (R2 = 0.39). Discussion: Individuals with symptomatic and radiographic mild-to-moderate hip OA exhibit lower physical function than healthy controls. Patient-reported outcomes reflect different aspects of function than physical measures in mild-to-moderate hip OA and a combination of both appear necessary to comprehensively assess dysfunction. http://dx.doi.org/10.1016/j.jsams.2016.12.070