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Knee pain and osteoarthritis (Knee OA) treatment research
Professor Shaw-Ruey Lyu from the School of Medicine, Tzu-Chi University, discusses Knee Pain and Osteoarthritis (Knee OA) Treatment Research, in particular Knee Health Promotion Option (KHPO). Starting from 2002, I conducted a series of studies(1-3,5,6,8,9) to investigate medial abrasion phenomenon (MAP) as a cause of knee OA. I found a high correlation between medial plica-related MAP and knee OA. MAP would elicit lifelong interplay between a pathologic medial plica and the facing medial femoral condyle, and therefore plays a role in the pathogenesis of knee OA both physically and chemically.(10,11,13) Consequently, I have developed the procedures of arthroscopic medial release (AMR)(4) and the concept of arthroscopic cartilage regeneration facilitating procedure (ACRFP)(7,15) for the treatment of knee OA.

Ylipaino altistaa nuoren miehen polvivammalle Väitöskirjatutkimus selvittää polvivammojen yleisyyttä, riskitekijöitä ja diagnostiikkaa Polvivammat ovat yleisiä erityisesti alle 30-vuotiailla miehillä, mutta sairaalahoitoa vaativien polvivammojen ilmaantuvuudesta ja riskitekijöistä ei ole esitetty tarkkaa tietoa. Väitöskirjatutkimus selvitti aihetta suomalaisilla 18 30-vuotiailla miehillä varusmiespalveluksen aikana (n=128 584). Tulokset osoittivat, että sairaalahoitoon johtaneiden polvivammojen ilmaantuvuus oli 11 potilasta 1000 henkilövuotta kohden [95 % luottamusväli (CI): 10,4 11,7] tarkoittaen sitä, että joka vuosi noin yksi sadasta varusmiehestä joutuu sairaalahoitoon polvivamman vuoksi. Merkittävimmät riskitekijät polvivammoille olivat korkeampi ikä, jonka ristitulosuhde oli 1,7-kertainen yli 20-vuotiailla, sekä ylipaino, jonka ristitulosuhde oli 1,6-kertainen verrattuna niihin, joilla ylipainoa ei ollut. Kirurginen toimenpide tehtiin kahdelle kolmasosalle kaikista sairaalassa hoidetuista potilaista ja pidempiaikainen haitta (palveluskelpoisuusluokan muutos) jäi yhdelle kolmasosalle potilaista. Tiedot sairaalahoitoon johtaneista polvivammoista ja kirurgisista toimenpiteistä saatiin selvitettyä kansallisen hoitoilmoitusrekisterin avulla. Tiedot palveluskelpoisuusluokan muutoksista ja mahdollisesti polvivammoihin yhteydessä olevista riskitekijöistä saatiin puolustusvoimien Vartti- ja palveluskelpoisuusluokanmuutosrekistereistä. Palveluskelpoisuusluokan muutosta käytettiin tutkimuksessa kuvaamaan pidempiaikaista haittaa. Polvivammojen riskitekijöitä analysoitiin logistisella regressiolla. Väitöskirjatutkimus paneutui myös polvivammojen ja polven etuosan kiputilan magneettikuvauspainotteiseen diagnostiikkaan suomalaisilla varusmiehillä. Magneettikuvausta pidetään yleisesti herkkänä ja tarkkana polvivammojen tutkimisvälineenä, mutta polven etuosan kiputilassa, tuoreissa rustovaurioissa ja vanhoissa nivelkierukkarepeämissä sen merkitys on epäselvempi. Tutkimustulokset osoittivat, että lähes puolet syvistä, tuoreista polven rustovaurioista jäi diagnosoimatta normaalin kliinisen työn yhteydessä suoritetussa 1.0 Teslan magneettikuvauksessa. Huolimatta normaalista magneettikuvauslöydöksestä saattaa polvinivelen tähystystutkimus paljastaa korjaustoimenpiteisiin soveltuvia syviä rustovaurioita. Magneettitutkimuksen diagnostisessa validiteetissa nivelkierukkarepeämän diagnostiikassa ei todettu eroa akuutissa polvivammassa ja kroonisissa, yli 6 kk kestäneissä polvioireissa. Polven etuosan kipua käsittelevässä aineistossa yleisimmät löydökset olivat polvilumpion rustovaurio (45 % polvista) ja nivelkalvon poimu (45 %). Oireiden, löydösten ja polvilumpion rustovaurion asteen välillä ei todettu selkeää yhteyttä (p = 0,83). Tulokset tukevat aiempia havaintoja siitä, että polvilumpion rustovaurioita ei voida luotettavasti diagnosoida polven etuosan kiputilaan liittyvien oireiden ja statuslöydösten perusteella. Tässä aineistossa 1.0 Teslan magneettikuvauksessa käytettiin erityisesti polvilumpion ruston arvioimiseen sopivaa kuvausleikettä (aksiaalinen 3D T1 FS SPGR). Herkkyys oli alhainen pinnallisille polvilumpion rustovaurioille (13 %), mutta selkeästi parempi syvemmille rustovaurioille (83 %). Magneettikuvausta tällä menetelmällä voidaankin käyttää diagnostisena apuvälineenä polvilumpion syvempien, mahdollisesti operatiivista hoitoa tarvitsevien rustovaurioiden diagnostiikassa. Tuoreita rustovaurioita käsittelevässä retrospektiivisessa aineistossa oli 32 potilasta, joilla oli todettu artroskopiassa tuore traumaattinen rustovaurio. Tuoreiden ja vanhojen nivelkierukkarepeämien magneettikuvausdiagnostiikkaa vertailevien aineistojen mukaanottokriteerit täytti 82 potilaista, joilla oli tuore polvivamma, ja 40 potilasta, joilla oli pidempikestoinen polviongelma. Pitkäaikaiseen polven etuosan kiputilaan liittyvien oireiden ja löydösten yhteyttä tähystystutkimuksen tuloksiin tutkittiin prospektiivisesti 56 potilaan aineistossa. Kaikissa diagnostiikkaa käsittelevissä osatutkimuksissa magneettikuvauksen tuloksia verrattiin polvinivelen tähystystutkimuksen tuloksiin. Tutkimukset suoritettiin keskussotilassairaalassa Helsingissä. Tutkimuspotilaat olivat varusmiehiä, joiden ikä oli tutkimushetkellä 18 25-vuotta. ; Knee injuries and anterior knee pain are frequently encountered and treated by orthopaedic surgeons and general practitioners in daily clinical practice. Knee injuries are most common in those under 30 years of age and especially in males. Accurate incidence rates of knee injuries requiring hospitalisation (i.e. inpatient care admission) in this high-risk subgroup, however, are not known. Also unclear are the roles of intrinsic modifiable factors, such as body mass index (BMI), weight, aerobic fitness, and muscular strength, as risk factors for knee injuries. The epidemiologic section of this dissertation is based on population-based data among Finnish young adult male conscripts. Our aim was to determine the incidence and possible risk factors for knee injuries requiring inpatient care. Moreover, knee injuries were analysed by specified diagnosis (cruciate and collateral ligament tears, meniscal tears, traumatic chondral lesions, and patellar dislocations). The total number of Finnish male conscripts performing their compulsory military service during the study period was 128,584 and total exposure time was 97,503 person-years. Risk factor analyses were performed by logistic regression. The person-based incidence of inpatient care admissions for knee injury in general was 11 cases per 1000 person-years (95% confidence interval [CI]: 10.4 11.7). The most important risk factors were higher age (odds ratio [OR] 1.7; 95% CI: 1.3 2.2) and obesity (OR 1.6; 95% CI: 1.03 2.5). Two-thirds of all subjects admitted to inpatient care for knee injuries had surgery, and one-third had long-term notable disability. The diagnostic section of this dissertation addresses three diagnostic challenges: fresh traumatic chondral lesions, fresh meniscal tears, and anterior knee pain (AKP). Study populations were based on conscripts treated at the Central Military Hospital in Helsinki, Finland. Arthroscopic results served as the gold standard for calculating the sensitivity, specificity, and accuracy of magnetic resonance imaging (MRI) findings. The validity of MRI for fresh traumatic chondral lesions and for fresh vs. old meniscal tears was studied retrospectively. Study populations comprised young adult conscripts in whom both knee MRI and arthroscopy were performed at the Central Military Hospital. In the first sample, 32 patients, ranging in age from 19 to 21 years (median, 19 years), with arthroscopically proven fresh traumatic chondral lesions of the knee met the inclusion criteria. In the samples used for comparing MRI validity in fresh traumatic and old meniscal tears, 82 patients, ranging in age from 18 to 25 (median, 20 years) met the inclusion criteria with acute knee trauma (MRI within 30 days from trauma) and 40 patients with chronic knee symptoms (symptoms lasting over 6 months before MRI). Diagnostic studies revealed that routine clinical use of 1.0 Tesla (T) MRI has poor sensitivity (36%) for detecting fresh traumatic articular cartilage lesions. Sensitivity was associated with the lesion grade and was only 17% for superficial lesions and moderately better, 57%, for full-thickness lesions. Thus, almost half of the full-thickness cartilage lesions remained undiagnosed following preoperative MRI. Despite negative MRI findings, arthroscopy may reveal lesions amenable to cartilage repair procedures.The diagnostic validity of MRI for meniscal tears in acute knee trauma and in knee symptoms lasting over 6 months in young adults was similar. This study also suggests that effusion and haemarthrosis are not associated with the diagnostic validity of MRI for meniscal tears. The association between the clinical symptoms and arthroscopic findings, and the role of MRI in AKP were studied prospectively. Fifty-six young adult conscripts (median age, 19.5 years) with AKP were prospectively selected for the study and MRI of the knee followed by arthroscopy was performed at the Central Military Hospital in Finland. Arthroscopy con?rmed the presence of patellar chondral lesions in 25 (45%) of 56 knees of patients with AKP. Synovial plicae were as common a finding as patellar chondral lesions and was present in 25 knees. Normal anatomy was observed in only six knees. The presence of retropatellar crepitus or pain on manipulation of the patella was not associated with a higher proportion of patellar chondral lesions in patients with typical clinical AKP symptoms. The severity of patellar chondral lesions observed at arthroscopy was not associated with clinical symptoms of AKP syndrome (p = 0.83). This data supports earlier reports that patellar chondral lesions cannot be distinguished from other causes of AKP based on clinical symptoms and physical examination signs. The routine MRI protocol used for patients with AKP showed a sensitivity of only 13% for superficial patellar chondral lesions. For more severe lesions, the sensitivity was substantially higher, 83%, and 1.0T MRI may be considered a sensitive diagnostic tool in these cases.

This study explored participants' experiences of randomized controlled trial (RCT) participation to examine their understanding of the trial design and whether their consent was indeed informed. A nested qualitative interview study was conducted with 38 participants from a sample of 282 who participated in a complex RCT evaluating the effectiveness of laser compared with needle acupuncture for chronic knee pain. Overall participants had a good understanding of the RCT, and concepts such as randomization and placebo. Their experiences of being in the trial were largely positive, even if they did not experience any knee pain improvement. Their responses to unblinding at the end of the study were accepting. Participants had a good functional understanding of the RCT, sufficient for valid informed consent.

Background: Cooled Radiofrequency ablation is a newer technique for management of chronic knee pain in osteoarthritis. The aim of the study is to evaluate the clinical outcomes in patients with chronic osteoarthritis in terms of pain scores for first six months of cooled radiofrequency ablation using ultrasound guidance. Methods: A cross-sectional study with retrospective review of database was evaluated to analyze the change in the Numerical Rating Scale from baseline scores at 1 day, 1 month and 6 months after the Cooled Radiofrequency ablation of genicular nerves around knee in patients with chronic knee osteoarthritis. Results: Median age was 71 years [ 61-73 years (IQR: 25-75)] with more female preponderance. Numerical Rating Scale (Mean ± S.D.) was significantly less at 1 day (1.87 ± 1.22), 1 month (3.03 ± 0.99) and 6 months (3.37 ± 1.098) from baseline values (6.77 ± 1.00). No soreness and numbness were noted.Conclusions: Cooled Radiofrequency using Ultrasound guidance for management of knee pain in chronic osteoarthritis is promising and reduces Numerical Rating Score significantly from baseline at 1 month and 6 months respectively.Keywords: Cooled radiofrequency ablation; genicular nerve; numeric rating scale

BACKGROUND: The aim of this study was to investigate the frequency of chondromalacia patella (CMP) and to evaluate its relation with trochlear morphometric and patellofemoral alignment measurements as well as with edema in superolateral region of Hoffa's fat pad (SHFP) in military recruits with anterior knee pain (AKP). MATERIALS AND METHODS: Knee magnetic resonance imaging examinations of 288 military recruits with AKP were retrospectively evaluated. Patellar cartilage lesions were graded using modified Noyes system. Quantitative measurements of trochlear morphology (sulcus angle, trochlear sulcus depth, and lateral trochlear inclination [LTI]) and patellofemoral alignment (patellar translation [PT], lateral patellofemoral angle (LPA), Insall-Salvati index, and tibial tuberosity-trochlear groove distance) were made. The SHFP region was assessed for the presence of edema. Mean values of measurements in knees with and without CMP and in knees with early and advanced stage CMP were compared. RESULTS: We found CMP in 169 (58.7%) patients. Patients with CMP demonstrated a significantly greater sulcus angle (P = 0.012), smaller LTI (P = 0.004), greater PT (P = 0.01), smaller LPA (P = 0.036), greater Insall-Salvati ratio (P = 0.034), and higher incidence of SHFP edema (P = 0.001) compared to those without CMP. While none of the measurements were associated with the severity of cartilage damage, the incidence of SHFP edema was significantly correlated with the severity of CMP (P = 0.001). CONCLUSION: CMP is a common disorder among military recruits with AKP. Patellofemoral malalignment is an important contributory factor in the development of CMP, and the presence of edema in SHFP may be a strong indicator of underlying severe CMP in this population.

David E Jamison,1,2 Steven P Cohen1–6 1Department of Anesthesiology, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, USA; 2Department of Anesthesiology, Uniformed Services University of Health Sciences (USUHS), Bethesda, MD, USA; 3Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; 4Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA; 5Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA; 6Department of Physical Medicine and Rehabilitation, USUHS, Bethesda, MD, USA Background: The use of radiofrequency ablation (RFA) procedures to treat chronic knee pain has surged in the past decade, though many questions remain regarding anatomical targets, selection criteria, and evidence for effectiveness. Methods: A comprehensive literature review was performed on anatomy, selection criteria, technical parameters, results of clinical studies, and complications. Databases searched included MEDLINE and Google Scholar, with all types of clinical and preclinical studies considered. Results: We identified nine relevant clinical trials, which included 592 patients, evaluating knee RFA for osteoarthritis and persistent postsurgical pain. These included one randomized, placebo-controlled trial, one randomized controlled trial evaluating RFA as add-on therapy, four comparative-effectiveness studies, two randomized trials comparing different techniques and treatment paradigms, and one non-randomized, controlled trial. The results of these studies demonstrate significant benefit for both reduction and functional improvement lasting between 3 and 12 months, with questionable utility for prognostic blocks. There was considerable variation in the described neuroanatomy, neural targets, radiofrequency technique, and selection criteria. Conclusion: RFA of the knee appears to be a viable and effective treatment option, providing significant benefit to well-selected patients lasting at least 3 months. More research is needed to better identify neural targets, refine selection criteria to include the use of prognostic blocks, optimize treatment parameters, and better elucidate relative effectiveness compared to other treatments. Keywords: Knee pain, osteoarthritis, radiofrequency, ablation, denervation, genicular nerve

Purpose
The known advantage of exercise for older adults who had knee pain is limited by low adherence to an exercise program. This study aims to determine the effect of the LINE application on action and coping plans on exercise adherence, self-efficacy for exercise, specific self-efficacy (task, maintenance and recovery), functional performance (knee range of motion, time up and go, 30-s chair stand and knee outcome for activities of daily living) and knee pain scale among older adults with knee pain in suburban Bangkok, Thailand.


Design/methodology/approach
A total of 86 participants aged between 50 and 65 years old were divided into two groups for a period of 14 weeks: intervention (received action and coping plans via the LINE application) and control group (received usual care). All outcomes were measured at baseline and posttest except exercise adherence, which was collected postintervention.


Findings
A significant difference between intervention and control groups across all outcomes. Within group comparisons before and after, the intervention indicates that participants of the intervention group significantly improved posttest. In conclusion, using mobile health technology in combination with action and coping plans was found to enhance older adults' exercise adherence and motivation, thus, decreasing knee pain while increasing functionality.


Originality/value
This study provides new insight into the combination of action and coping plans implementing with instant messaging through the LINE application which had a positive impact on enhance exercise adherence and knee functional performance of Thai elderly with knee pain.

Abstract Background Musculoskeletal disorders affect all racial and ethnic groups, including Hispanics. Because these disorders are not life-threatening, decision-making is generally preference-based. Little is known about whether Hispanics in the U.S. differ from non-Hispanic Whites with respect to key decision making preferences. Methods We assembled six focus groups of Hispanic and non-Hispanic White patients with chronic back or knee pain at an urban medical center to discuss management of their conditions and the roles they preferred in medical decision-making. Hispanic groups were further stratified by socioeconomic status, using neighborhood characteristics as proxy measures. Discussions were led by a moderator, taped, transcribed and analyzed using a grounded theory approach. Results The analysis revealed ethnic differences in several areas pertinent to medical decision-making. Specifically, Hispanic participants were more likely to permit their physician to take the predominant role in making health decisions. Also, Hispanics of lower socioeconomic status generally preferred to use non-internet sources of health information to make medical decisions and to rely on advice obtained by word of mouth. Hispanics emphasized the role of faith and religion in coping with musculoskeletal disability. The analysis also revealed broad areas of concordance across ethnic strata including the primary role that pain and achieving pain relief play in patients' experiences and decisions. Conclusions These findings suggest differences between Hispanics and non-Hispanic Whites in preferred information sources and decision-making roles. These findings are hypothesis-generating. If confirmed in further research, they may inform the development of interventions to enhance preference-based decision-making among Hispanics.

OBJECTIVES: Due to their potentially deleterious effects, minimizing the use of opioids for musculoskeletal pain is a priority for healthcare systems. The objective of this study was to examine the risk of future opioid prescription use based on prior opioid use within a non-surgical cohort with musculoskeletal knee pain. We also examined the risk of pre-existing comorbidities on future opioid use, and the risk of prior opioid use on future comorbidities (sleep, mental health, cardiometabolic disorders). METHODS: Data came from the Military Health System Data Repository for 80 290 consecutive beneficiaries with an initial episode of care for patellofemoral pain from January 1, 2010 through December 31, 2011. Risk was calculated using 2 × 2 tables based on pre- and post-opioid utilization and comorbid diagnosis. Risk ratios, relative and absolute risk increases, and numbers needed to harm were calculated, all with 95% confidence intervals. RESULTS: Prior opioid use resulted in a risk ratio of 18.0 (95 CI 17.1, 19.0) and an absolute risk increase of 61.6% for future opioid use (numbers needed to harm = 2). The presence of all comorbidities (except cardiometabolic syndrome) were associated with a significant relative risk for future opioid use (RR range 1.2-1.5), but the absolute risk increase was trivial (range 0.7%-2.2%). The relative risk for a chronic pain diagnosis, traumatic brain injury/concussion, insomnia, depression, and PTSD were all significantly higher in those with prior opioid use (1.3-1.6), but absolute risk increase was minimal (1.1%-6.5%). DISCUSSION: Prior opioid use was a strong risk factor for future opioid use in non-surgical patients with knee pain. These findings show that history of prior opioid use is important when assessing the risk of future opioid use, whereas prior comorbidities may not be as important. Opioid history assessment should be standard practice for all patients with patellofemoral pain in whom an opioid prescription is considered.

Background: Adolescents frequently self-report pain, according to epidemiological research. The knee is one of the sites wherein pain is most commonly reported. Musculoskeletal disorders play a significant role in the prolonged disability experienced by individuals, leading to substantial global personal, societal, and economic burdens. Patellofemoral pain (PFP) is a clinical knee pain commonly affecting adolescents. This study aimed to estimate the frequency of knee pain in Saudi adolescents. Methods: This cross-sectional survey was conducted from June to November 2022 and included 676 adolescents aged 10 to 18 years. The participants were questioned regarding their demographics, school habits, and the impact of these factors on back pain, musculoskeletal pain in the past 12 months, as well as quality-of-life scale and knee pain symptoms. The data were analyzed using descriptive statistics, with frequencies and percentages presented for categorical variables. Analysis of variance (ANOVA) was performed to compare means between groups, while the chi-squared test was used to compare categorical variables. Statistical significance was set at p < 0.05. Results: A total of 676 adolescents participated in the study, with 57.5% females and 42.5% males. Among the participants, 68.8% were aged between 15 and 18 years. The prevalence of knee pain was notably higher among females (26%) compared to males (19.2%). Age and BMI were identified as significant predictors of knee pain. A significant association was also found between BMI classification and knee stiffness (p-value = 0.008). Furthermore, a significant difference was observed between adolescents who engaged in physical activities during leisure time and those who experienced difficulty bending (p-value = 0.03). Conclusions: Our study highlights a high prevalence of knee pain among Saudi adolescents, emphasizing the need for increased awareness about its risk factors. Preventive measures, including conservative approaches and lifestyle/activity modifications, can effectively mitigate adolescent knee pain.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a painful musculoskeletal condition, which is characterised by knee pain located in the anterior aspect (front) and retropatellar region (behind) of the knee joint. Various non‐operative interventions are suggested for the treatment of this condition. Knee orthoses (knee braces, sleeves, straps or bandages) are worn over the knee and are thought to help reduce knee pain. They can be used in isolation or in addition to other treatments such as exercise or non‐steroidal anti‐inflammatory medications. OBJECTIVES: To assess the effects (benefits and harms) of knee orthoses (knee braces, sleeves, straps or bandages) for treating PFPS. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (11 May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015 Issue 5), MEDLINE (1946 to 8 May 2015), EMBASE (1980 to 2015 Week 18), SPORTDiscus (1985 to 11 May 2015), AMED (1985 to 8 May 2015), CINAHL (1937 to 11 May 2015), PEDro (1929 to June 2015), trial registries and conference proceedings. SELECTION CRITERIA: Randomised and quasi‐randomised controlled clinical trials evaluating knee orthoses for treating people with PFPS. Our primary outcomes were pain and function. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for eligibility, assessed study risk of bias and extracted data. We calculated mean differences (MD) or, where pooling data from different scales, standardised mean differences (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CIs for binary outcomes. We pooled data using the fixed‐effect model. MAIN RESULTS: We included five trials (one of which was quasi‐randomised) that reported results for 368 people who had PFPS. Participants were recruited from health clinics in three trials and were military recruits undergoing training in the other two trials. Although no trials recruited participants who were ...