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1.  Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis 
Hip and groin injuries are common in many sports. Understanding the factors differentiating athletes with hip/groin pain from those without these injuries could facilitate management and prevention.
Conduct a systematic review and meta-analysis of the literature on factors differentiating athletes with and without hip/groin pain.
The review was registered as PROSPERO CRD42014007416 and a comprehensive, systematic search was conducted in June 2014. Inclusion criteria were: cross-sectional, cohort or case–control study designs of n>10 that examined outcome measures differentiating athletes with and without hip/groin pain. Two authors independently screened search results, assessed study quality, and performed data extraction. Methodological heterogeneity was determined and data pooled for meta-analysis when appropriate. A best evidence synthesis was performed on the remaining outcome measures.
Of 2251 titles identified, 17 articles were included of which 10 were high quality. Sixty two different outcome measures were examined, 8 underwent meta-analysis. Pooled data showed strong evidence that athletes with hip/groin pain demonstrated: pain and lower strength on the adductor squeeze test, reduced range of motion in hip internal rotation and bent knee fall out; however, hip external rotation range was equivalent to controls. Strong evidence was found that lower patient-reported outcome (PRO) scores, altered trunk muscle function, and moderate evidence of bone oedema and secondary cleft sign were associated with hip/groin pain.
PROs, pain and reduced strength on the adductor squeeze test, reduced range of motion in internal rotation and bent knee fall out are the outcome measures that best differentiate athletes with hip/groin pain from those without this pain.
PMCID: PMC4484362  PMID: 26031646
Athlete; Injuries; Groin; Hip; Sports
2.  Measures of Knee Function 
Arthritis care & research  2011;63(0 11):S208-S228.
PMCID: PMC4336550  PMID: 22588746
3.  A phase II trial for the efficacy of physiotherapy intervention for early-onset hip osteoarthritis: study protocol for a randomised controlled trial 
Trials  2015;16:26.
Early-onset hip osteoarthritis is commonly seen in people undergoing hip arthroscopy and is associated with increased pain, reduced ability to participate in physical activity, reduced quality of life and reduced range of motion and muscle strength. Despite this, the efficacy of non-surgical interventions such as exercise therapies remains unknown. The primary aim is to establish the feasibility of a phase III randomised controlled trial investigating a targeted physiotherapy intervention for people with early-onset hip osteoarthritis. The secondary aims are to determine the size of treatment effects of a physiotherapy intervention, targeted to improve hip joint range and hip-related symptoms in early-onset hip osteoarthritis following hip arthroscopy, compared to a health-education control.
This protocol describes a randomised, assessor- and participant-blind, controlled clinical trial. We will include 20 participants who are (i) aged between 18 and 50 years; (ii) have undergone hip arthroscopy during the past six to 12 months; (iii) have early-onset hip osteoarthritis (defined as chondrolabral pathology) at the time of hip arthroscopy; and (iv) experience hip-related pain during activities. Primary outcome will be the feasibility of a phase III clinical trial. Secondary outcomes will be (i) perceived global change score; (ii) hip-related symptoms (measured using the Hip disability and Osteoarthritis Outcome Score (HOOS) pain subscale, activity subscale, and sport and recreation subscale); (iii) hip quality of life (measured using the HOOS quality of life subscale and International Hip Outcome tool; (iv) hip muscle strength and (v) hip range of motion. The physiotherapy intervention is semi-standardised, including joint and soft tissue mobilisation and stretching, hip and trunk muscle retraining and functional and activity-specific retraining and education. The control intervention encompasses individualised health education, with the same frequency and duration as the intervention. The trial primary end-point is the conclusion of the 12-week intervention, and follow-up measures will be collected at the 12-week post-baseline assessment.
The findings of this study will provide guidance regarding the feasibility of a full-scale phase III randomised controlled trial, prior to its undertaking.
Trial registration
The trial protocol was registered with the Australian Clinical Trials Registry (number: 12614000426684) on 17 April 2014.
Electronic supplementary material
The online version of this article (doi:10.1186/s13063-014-0543-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4318367  PMID: 25622524
Osteoarthritis; Hip joint; Hip arthroscopy; Randomised controlled trial; Physiotherapy
4.  Stress fracture risk factors in female football players and their clinical implications 
British Journal of Sports Medicine  2007;41(Suppl 1):i38-i43.
A stress fracture represents the inability of the skeleton to withstand repetitive bouts of mechanical loading, which results in structural fatigue, and resultant signs and symptoms of localised pain and tenderness. Reports of stress fractures in female football players are not prevalent; however, they are probably under‐reported and their importance lies in the morbidity that they cause in terms of time lost from participation. By considering risk factors for stress fractures in female football players it may be possible to reduce the impact of these troublesome injuries. Risk factors for stress fractures in female football players include intrinsic risk factors such as gender, endocrine, nutritional, physical fitness and neuromusculoskeletal factors, as well as extrinsic risk factors such as training programme, equipment and environmental factors. This paper discusses these risk factors and their implications in terms of developing prevention and management strategies for stress fractures in female football players.
PMCID: PMC2465247  PMID: 17584950
5.  Predictors of symptomatic response to glucosamine in knee osteoarthritis: an exploratory study 
To evaluate whether patient characteristics and/or radiographic disease patterns predict symptomatic response to treatment with glucosamine in osteoarthritis (OA) of the knee.
Exploratory prospective correlational study.
39 participants with chronic knee pain from the local community.
Glucosamine sulphate (1.5 g/day) for 12 weeks.
Main outcome measures
Pain and physical function were assessed with visual analogue scales (VASs) and participant‐perceived global change scores (GCSs). Regression modelling evaluated the relationship between treatment outcome and age, body mass index (BMI), pain and function self‐efficacy and presence/absence of osteophytes in the medial and lateral tibiofemoral joint (TFJ) and patellofemoral joint (PFJ) compartments.
13 (33%) participants were men. The mean (SD) age and BMI were 53.6 (13.1) years and 27.9 (4.6) kg/m2, respectively. 13 (33%), 19 (49%) and 24 (62%) participants had medial TFJ, lateral TFJ and PFJ osteophytes, respectively. Glucosamine significantly improved pain (mean change on VAS =  −1.4, 95% CI −0.6 to −2.2; p = 0.002) and activity restriction (−1.9, 95% CI −1.0 to −2.8; p<0.001). At 12 weeks, 30 (77%) and 27 (69%) participants reported improvement in pain and physical function, respectively. Regression modelling showed that no evaluated variables predicted change in pain on VAS. Decreased function self‐efficacy, presence of PFJ osteophytes and absence of medial TFJ osteophytes predicted functional improvement on VAS. BMI, pain self‐efficacy and function self‐efficacy predicted improvement in pain by GCS.
Although glucosamine significantly improved symptoms, most of the variance in outcome at 12 weeks was unexplained by the predictors evaluated. However, glucosamine may be more effective at improving symptoms in patients with knee OA who have a lower BMI, PFJ osteophytes and lower functional self‐efficacy.
PMCID: PMC2465359  PMID: 17261554
6.  Efficacy of acupuncture for chronic knee pain: protocol for a randomised controlled trial using a Zelen design 
Chronic knee pain is a common and disabling condition in people over 50 years of age, with knee joint osteoarthritis being a major cause. Acupuncture is a popular form of complementary and alternative medicine for treating pain and dysfunction associated with musculoskeletal conditions. This pragmatic Zelen-design randomised controlled trial is investigating the efficacy and cost-effectiveness of needle and laser acupuncture, administered by medical practitioners, in people with chronic knee pain.
Two hundred and eighty two people aged over 50 years with chronic knee pain have been recruited from metropolitan Melbourne and regional Victoria, Australia. Participants originally consented to participate in a longitudinal natural history study but were then covertly randomised into one of four treatment groups. One group continued as originally consented (ie natural history group) and received no acupuncture treatment. The other three were treatment groups: i) laser acupuncture, ii) sham laser or, iii) needle acupuncture. Acupuncture treatments used a combined Western and Traditional Chinese Medicine style, were delivered by general practitioners and comprised 8–12 visits over 12 weeks. Follow-up is currently ongoing. The primary outcomes are pain measured by an 11-point numeric rating scale (NRS) and self-reported physical function measured by the Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Index subscale at the completion of treatment at 12 weeks. Secondary outcomes include quality of life, global rating of change scores and additional measures of pain (other NRS and WOMAC subscale) and physical function (NRS). Additional parameters include a range of psychosocial measures in order to evaluate potential relationships with acupuncture treatment outcomes. Relative cost-effectiveness will be determined from health service usage and outcome data. Follow-up assessments will also occur at 12 months.
The findings from this study will help determine whether laser and/or needle acupuncture is efficacious, and cost-effective, in the management of chronic knee pain in older people.
Trial registration
Australian New Zealand Clinical Trials Registry reference: ACTRN12609001001280
PMCID: PMC3493360  PMID: 22992309
7.  Physical therapies for Achilles tendinopathy: systematic review and meta-analysis 
Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management.
A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively.
Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference −0.59, 95% confidence interval −1.11 to −0.07), as well as no differences in effect between eccentric exercise and shock wave therapy at 16 weeks (VISA-A:–0.55,–2.21 to 1.11). Pooled data did not support the addition of night splints to eccentric exercise at 12 weeks (VISA-A:–0.35,–1.44 to 0.74). Limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention.
Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate. Shock wave therapy may represent an effective alternative. High-quality RCTs following CONSORT guidelines are required to further evaluate the efficacy of physical therapies and determine optimal clinical pathways for AT.
PMCID: PMC3537637  PMID: 22747701
Achilles tendon; Tendinopathy; Physical therapy modalities
8.  Gait Retraining to Reduce the Knee Adduction Moment Through Real-Time Visual Feedback of Dynamic Knee Alignment 
Journal of biomechanics  2010;43(11):2208-2213.
Varus knee alignment is a risk factor for medial knee osteoarthritis and is associated with high knee adduction moments. Therefore, reducing the knee adduction moment in varus-aligned individuals with otherwise healthy knees may reduce their risk for developing osteoarthritis. A gait modification that improves dynamic knee alignment may reduce the adduction moment, and systematic training may lead to more natural-feeling and less effortful execution of this pattern. To test these hypotheses, eight healthy, varus-aligned individuals underwent a gait modification protocol. Real-time feedback of dynamic knee alignment was provided over eight training sessions, using a fading paradigm. Natural and modified gait were assessed post-training and after 1 month, and compared to pre-training natural gait. The knee adduction moment, as well as hip adduction, hip internal rotation and knee adduction angles were evaluated. At each training session, subjects rated how effortful and natural-feeling the modified pattern was to execute. Post-training, the modified pattern demonstrated an 8° increase in hip internal rotation and 3° increase in hip adduction. Knee adduction decreased 2°, and the knee adduction moment decreased 19%. Natural gait did not differ between the three visits, nor did the modified gait pattern between the post-training and 1 month visits. The modified pattern felt more natural and required less effort after training. Based on these results, gait retraining to improve dynamic knee alignment resulted in significant reductions in the knee adduction moment, primarily though hip internal rotation. Further, systematic training led to more natural-feeling and less effortful execution of the gait pattern.
PMCID: PMC2914211  PMID: 20452595
gait retraining; adduction moment; alignment; real-time feedback; varus
12.  Relationships between the Foot Posture Index and foot kinematics during gait in individuals with and without patellofemoral pain syndrome 
Foot posture assessment is commonly undertaken in clinical practice for the evaluation of individuals with patellofemoral pain syndrome (PFPS), particularly when considering prescription of foot orthoses. However, the validity of static assessment to provide insight into dynamic function in individuals with PFPS is unclear. This study was designed to evaluate the extent to which a static foot posture measurement tool (the Foot Posture Index - FPI) can provide insight into kinematic variables associated with foot pronation during level walking in individuals with PFPS and asymptomatic controls.
Twenty-six individuals (5 males, 21 females) with PFPS aged 25.1 ± 4.6 years and 20 control participants (4 males, 16 females) aged 23.4 ± 2.3 years were recruited into the study. Each participant underwent clinical evaluation of the FPI and kinematic analysis of the rearfoot and forefoot during walking using a three-dimensional motion analysis system. The association of the FPI score with rearfoot eversion, forefoot dorsiflexion, and forefoot abduction kinematic variables (magnitude, timing of peak and range of motion) were evaluated using partial correlation coefficient statistics with gait velocity entered as a covariate.
A more pronated foot type as measured by the FPI was associated with greater peak forefoot abduction (r = 0.502, p = 0.013) and earlier peak rearfoot eversion relative to the laboratory (r = -0.440, p = 0.031) in the PFPS group, and greater rearfoot eversion range of motion relative to the laboratory (r = 0.614, p = 0.009) in the control group.
In both individuals with and without PFPS, there was fair to moderate association between the FPI and some parameters of dynamic foot function. Inconsistent findings between the PFPS and control groups indicate that pathology may play a role in the relationship between static foot posture and dynamic function. The fair association between pronated foot posture as indicated by the FPI and earlier peak rearfoot eversion relative to the laboratory observed exclusively in those with PFPS is consistent with the biomechanical model of PFPS development. However, prospective studies are required to determine whether this relationship is causal.
PMCID: PMC3064639  PMID: 21401957
13.  Predictors of short and long term outcome in patellofemoral pain syndrome: a prospective longitudinal study 
Patellofemoral pain syndrome (PFP) is a common musculoskeletal condition that has a tendency to become chronic and problematic in a proportion of affected individuals. The objective of this study was to identify prognostic factors that may have clinical utility in predicting poor outcome on measures of pain and function in individuals with PFP.
A prospective follow-up study was conducted of 179 participants in a randomised clinical trial. Nine baseline factors (age, gender, body mass index, arch height, duration of knee pain, worst pain visual analogue scale, Kujala Patellofemoral Score (KPS), functional index questionnaire (FIQ), step down repetitions) were investigated for their prognostic ability on outcome assessed at six, 12 and 52 weeks (worst pain, KPS and FIQ). Factors with significant univariate associations were entered into multivariate linear regression models to identify a group of factors independently associated with poor outcome.
Long symptom duration was the most consistent predictor of poor outcome over 52 weeks rated on the KPS and the FIQ (β-0.07, 95% confidence interval -0.1 to -0.03, p < 0.000; and -0.02, -0.03 to -0.01, p < 0.000, respectively). Worse KPS at baseline was predictive of outcome at six, 12 and 52 weeks. Gender, body mass index and arch height were generally not associated with outcome (univariate analysis), while age, worst pain, FIQ and step downs were excluded during multivariate analyses.
Patients presenting with PFP of long duration who score worse on the KPS have a poorer prognosis, irrespective of age, gender and morphometry. These results suggest that strategies aimed at preventing chronicity of more severe PFP may optimise prognosis.
PMCID: PMC2823664  PMID: 20082723
14.  Targeted physiotherapy for patellofemoral joint osteoarthritis: A protocol for a randomised, single-blind controlled trial 
The patellofemoral joint (PFJ) is one compartment of the knee that is frequently affected by osteoarthritis (OA) and is a potent source of OA symptoms. However, there is a dearth of evidence for compartment-specific treatments for PFJ OA. Therefore, this project aims to evaluate whether a physiotherapy treatment, targeted to the PFJ, results in greater improvements in pain and physical function than a physiotherapy education intervention in people with symptomatic and radiographic PFJ OA.
90 people with PFJ OA (PFJ-specific history, signs and symptoms and radiographic evidence of PFJ OA) will be recruited from the community and randomly allocated into one of two treatments. A randomised controlled trial adhering to CONSORT guidelines will evaluate the efficacy of physiotherapy (8 individual sessions over 12 weeks, as well as a home exercise program 4 times/week) compared to a physiotherapist-delivered OA education control treatment (8 individual sessions over 12 weeks). Physiotherapy treatment will consist of (i) quadriceps muscle retraining; (ii) quadriceps and hip muscle strengthening; (iii) patellar taping; (iv) manual PFJ and soft tissue mobilisation; and (v) OA education. Resistance and dosage of exercises will be tailored to the participant's functional level and clinical state. Primary outcomes will be evaluated by a blinded examiner at baseline, 12 weeks and 9 months using validated and reliable pain, physical function and perceived global effect scales. All analyses will be conducted on an intention-to-treat basis using linear mixed regression models, including respective baseline scores as a covariate, subjects as a random effect, treatment condition as a fixed factor and the covariate by treatment interaction.
This RCT is targeting PFJ OA, an important sub-group of knee OA patients, with a specifically designed conservative intervention. The project's outcome will influence PFJ OA rehabilitation, with the potential to reduce the personal and societal burden of this increasing public health problem.
Trial Registration
Australia New Zealand Clinical Trials Registry ACTRN12608000288325
PMCID: PMC2556332  PMID: 18793446
15.  Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial 
BMJ : British Medical Journal  2003;327(7407):135.
Objectives To test the hypotheses that therapeutic taping of the knee improves pain and disability in patients with osteoarthritis of the knee and that benefits remain after stopping treatment.
Design Randomised single blind controlled trial with three intervention arms (therapeutic tape, control tape, and no tape) of three weeks' duration and three week follow up.
Setting Outcome assessment was performed in a university based laboratory. Taping interventions were applied by eight physiotherapists in metropolitan private practice.
Participants 87 patients with symptoms of knee osteoarthritis as defined by the American College of Rheumatology.
Main outcome measures Primary outcome measure was pain as measured by visual analogue scale and participant perceived rating of change. Secondary measures of pain and disability included the Western Ontario and MacMaster Universities osteoarthritis index, knee pain scale, and the SF-36.
Results The therapeutic tape group reported a greater reduction in pain on all primary outcomes than either of the other two groups. A significant association was evident between intervention and change in pain at three weeks (P=0.000), with 73% (21/29) of the therapeutic tape group reporting improvement compared with 49% (14/29) of the control tape group and 10% (3/29) of the no tape group. Significantly greater improvement in pain and disability was observed on most secondary outcomes in the therapeutic tape group compared with the no tape group. Benefits of therapeutic tape were maintained three weeks after stopping treatment.
Conclusions Therapeutic knee taping is an efficacious treatment for the management of pain and disability in patients with knee osteoarthritis.
PMCID: PMC165705  PMID: 12869456

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