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Background Tendinopathies of the lower extremity (e.g. Achilles, patellar, and plantar heel pain) are common in both general and sporting populations. However, the prevalence and incidence in Danish general practice is unknown. The aim was to determine the prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice. Methods In this registry-based study, we extracted data from the electronic patient files of all patients in a single Danish general practice. The practice included 8836 patients. We searched ICPC-2 codes to identify patients with either of the following lower-extremity tendinopathies: plantar heel pain; Achilles tendinopathy; patellar tendinopathy; greater trochanteric pain syndrome or adductor tendinopathy. We defined an incident and prevalent case as a patient with a consultation because of tendinopathy in 2016 only. A prevalent, but not incident case was a patient with consultations in both 2015 and 2016. Incidence and prevalence were expressed as the number of patients with a tendinopathy per 1000 registered patients. Results The prevalence and incidence rate were 16.6 and 7.9 per 1000 registered patients, respectively. Plantar heel pain was the most prevalent tendinopathy and accounted for 39% of lower-extremity tendinopathies. Patients with tendinopathies were significantly older than all registered patients (46.0 years (95%CI: 43.3;48.7) versus 38.8 years (95%CI: 38.4;39.3), respectively). Conclusions Lower-extremity tendinopathies, especially plantar heel pain, had a high prevalence and incidence rate in a Danish general practice. In a typical general practice with 5000 patients, general practitioners should expect to see more than 80 patients with a lower-extremity tendinopathy every year.

Background Despite the established relevance of ultrasonography and assessment of pressure pain thresholds in patients with plantar fasciopathy, patient and probe positioning has been mostly ignored and are not necessarily reported in research. The primary aim of this study was to compare plantar fascia thickness in stretched and relaxed positions in patients with plantar fasciopathy. The secondary aim was to compare plantar heel pressure pain thresholds in these positions. Methods In this cross-sectional study, we measured the plantar fascia thickness with ultrasonography, and localised pressure pain thresholds using pressure algometry of 20 patients with plantar fasciopathy. These were assessed bilaterally, with the plantar fascia in both a stretched and relaxed position. In the stretched position, toes were maximally dorsiflexed, while in the relaxed position participants’ feet were hanging freely over the end of the table. Results The plantar fascia of the most symptomatic foot was significantly thicker when stretched compared with the relaxed position (sagittal: mean difference 0.2 mm, 95%CI: 0.1–0.4, P  = 0.013; frontal: mean difference − 0.27, 95%CI: − 0.49 to − 0.06, P  = 0.014). The plantar fascia was significantly thinner in the frontal plane compared with the sagittal plane in both positions (stretched: mean difference − 0.2 mm, 95%CI: − 0.42 to − 0.03, P  = 0.025; relaxed: mean difference − 0.3 mm, 95%CI:-0.49 to − 0.08, P  = 0.008). There was no difference between pressure pain thresholds in stretched or relaxed positions in either foot ( P  > 0.4). Conclusions The plantar fascia was significantly thicker in a stretched compared with a relaxed position and in the sagittal compared with the frontal plane, but differences were smaller than the standard deviation. Pressure pain thresholds were not different between the positions. These results highlight the importance of how ultrasonography is performed and reported in research to allow for replication. Trial registration The study was pre-registered September 25th, 2017 on ClinicalTrials.gov ( NCT03291665 ).

Background Plantar fasciopathy is the most common reason for complaints of plantar heel pain and one of the most prevalent musculoskeletal conditions with a reported lifetime incidence of 10%. The condition is normally considered self-limiting with persistent symptoms that often last for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. Heavy-slow resistance training and radiofrequency microtenotomy for the treatment of plantar fasciopathy have shown potentially positive effects on short- and long-term outcomes (> 3 months). However, the effect of heavy-slow resistance training compared with a radiofrequency microtenotomy treatment is currently unknown. This trial compares the efficacy of heavy-slow resistance training and radiofrequency microtenotomy treatment with supplemental standardized patient education and heel inserts in improving the Foot Health Status Questionnaire pain score after 6 months in patients with plantar fasciopathy. Methods In this randomized superiority trial, we will recruit 70 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of two groups: (1) heavy-slow resistance training, patient education and a heel insert ( n = 35), and (2) radiofrequency microtenotomy treatment, patient education and a heel insert ( n = 35). All participants will be followed for 1 year, with the 6-month follow-up considered the primary endpoint. The primary outcome is the Foot Health Status Questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a Global Perceived Effect scale, the physical activity level, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Discussion By comparing the two treatment options, we should be able to answer if radiofrequency microtenotomy compared with heavy-slow resistance training is superior in patients with plantar fasciopathy. Trial registration ClinicalTrials.gov NCT03854682. Prospectively registered on February 26, 2019.

IntroductionShort-term self-reported changes may be more strongly associated with long-term prognosis as they describe a disease trajectory and not a state. This study aimed to investigate the association between Global Rating of Change (GROC) after 4 weeks and the outcome after 12 months among adolescents with non-traumatic knee pain (Patellofemoral Pain (PFP) or Osgood-Schlatter (OSD)).Material and MethodsWe included data from two prospective clinical trials including adolescents (aged 10–14 years) with PFP (N=151) or OSD (N=51) who underwent a self-management rehabilitation programme including education and exercise. Primary outcome was a 7-point GROC ranging from “much improved” to “much worse”. Adolescents were considered to have a successful outcome if they reported being “much improved” or “improved”. Outcomes were collected after 4 weeks and 12 months.ResultsAmong adolescents with an unsuccessful outcome after 4 weeks (58% of all adolescents), 78% had a successful outcome after 12 months. Among those with a successful outcome after 4 weeks (42% of all adolescents), 94% had a successful outcome after 12 months. Having a successful outcome after 4 weeks increased the relative risk of a successful outcome after 12 months (relative risk 1.21 (95%CI: 1.07–1.38) and absolute risk difference: 16%.ConclusionSelf-reported improvement after 4-weeks of treatment is associated with better outcomes after 12 months. Importantly, despite no improvement after 4 weeks, a large proportion of adolescents between 10 and 14 years of age will report improvement after 12 months. This highlights the importance of following the rehabilitation programme irrespective of short-term improvements.

IntroductionHeel fat pad syndrome (HFPS) is the second leading cause of plantar heel pain. Clinical practice guidelines recommend conservative treatments for HFPS (activity modification, arch taping, and viscoelastic heel-cups). Alarmingly, the evidence for managing HFPS is scant and no well-executed randomised trials exist to support specific treatments. We aim to examine the effect of a novel heel fat pad loop taping on pain and function for HFPS.Materials and MethodsIn this two-arm crossover, participant-blinded RCT, participants with HFPS are block-randomized into either AB or BA interventions (A=loop taping that encircles/bunches the fat pad to centralize it and enhance its fullness and resilience to compression, B=control taping that mimic the loop taping without any force/pressure or attempt to bunch/centralize the fat pad) with a 4-to-7-day between-intervention washout period. The primary outcome is pain during the most pain-aggravating activity selected by participants (30-sec single-leg standing or 20-meter barefoot walking). Secondary outcomes are worst pain in the past 24 hours, foot health/function using the Foot Health Status Questionnaire, and global rating of change. We also assessed mechanistic outcomes of ultrasound-measured heel fat pad thickness and pressure-algometer-measured pressure pain thresholds.ResultsThis pre-registered RCT will be completed in December 2022. 19 participates are needed to detect a 2-point greater pain reduction for loop vs. control taping. We have eligibility-screened 17 participants, enrolled and completed data collection in 2.ConclusionFindings of this first RCT examining clinical and mechanistic effects of loop taping will provide much-needed evidence on effective non-pharmacological managements of HFPS.

IntroductionPerceived diagnostic uncertainty emerges during consultations because of miscommunication, potentially leaving adolescents confused and unable to understand ‘what’s wrong with me’. Repeated interviews are a valuable method to facilitate a high-quality, in-depth time-exploration of participants’ experiences and knowledge regarding complex topics. This study aims to explore how adolescents with non-traumatic knee pain experience changes, needs, and understanding of their knee pain over time following a consultation in an orthopaedic department through a series of repeated interviews.Materials and MethodsAdolescents aged 10-19 years with non-traumatic knee pain were eligible. We did semi-structured interviews online. The first interview was conducted 1-3 days after the consultation, followed by a second interview 11-17 days after the consultation. Data were analysed using an inductive reflexive thematic analysis by Braun and Clarke, separately in two sprints (timing of interviews). Both time points were synthesized within a matrix, thus completing the final analysis.ResultsWe included ten adolescents with non-traumatic knee pain. The adolescents emphasized the importance of validating their experiences and the significance of social acceptance regarding the existence of ‘knee pain’. Adolescents who were referred for further examinations (e.g., imaging) described a feeling of complete halt in activities and a need to wait for clarification. Lastly, adolescents mentioned experiencing difficulties remembering what was said during the consultation.ConclusionCommunication is crucial for maintaining trust and reducing diagnostic uncertainty in adolescents. This underscores the necessity for personalised approaches in medical consultations, considering the unique experiences and understanding of each adolescent.

IntroductionPatient decision aids can support patient-clinician shared decision-making, yet little is known about the underlying change-mechanisms which facilitates patient-clinician collaboration in clinical settings. The MAP-Knee Tool was developed with GPs and adolescents with non-traumatic knee pain. It incorporated different components (diagnosis tool, credible explanations, prognostic factors, and an option grid) to support the consultation process and enhance patient-clinician collaboration. Our study was a Realist Evaluation of the effectiveness of the MAP-Knee Tool tested in a stepped-wedge randomised cluster trial in hospital settings.Methods and MaterialsThe Realist Evaluation investigates how, why, for whom and under which circumstances adolescents with knee pain and clinicians (GPs, physiotherapists, surgeons) benefitted from the MAP-Knee Tool though a theory-gleaning process. Data comprised intervention documents, survey data and qualitative realist interviews with researchers, adolescents, and clinicians. Thematic Realist Analysis of the qualitative data was applied, and findings were integrated with quantitative findings to establish an initial program theory and identify context-mechanism-outcome configurations.ResultsData indicated that absence of observable symptoms in adolescents increased the complexity of treatment situations, heightened diagnostic uncertainty, and complicated shared decision-making. However, clinicians employed various strategies to mitigate this complexity. Five context-mechanism-outcome configurations were identified, relating to clinicians’ confidence, recognizing patients pain experience, diagnostic uncertainty, credible explanations, defensive actions, and systemic barriers.ConclusionTheory-gleaning indicated that the MAP-Knee tool likely facilitates shared decision-making by reducing the complexity within the treatment situation. However, additional data is needed to refine and expand the identified change-mechanisms, providing a more comprehensive understanding of their impact.

Introduction Variable eligibility criteria across studies on plantar heel pain may result in compromising the generalisability of meta-analyses when heterogeneity is not accounted for. We aimed to explore: (i) heterogeneity of participant eligibility criteria in studies that have investigated plantar heel pain, and (ii) associations between key eligibility criteria and the characteristics of the participants included in the study. Methods In this systematic review with narrative synthesis, we extracted participant eligibility criteria, and participants’ age, body mass index (BMI), symptom duration and pain level from published studies on plantar heel pain. We performed a content analysis of criteria and aligned overarching criteria to the International Classification of Functioning, Disability and Health (ICF). We pooled studies that used the same thresholds for participant eligibility criteria into sub-groups. We also pooled and reported studies that did not have any eligibility criteria for the quantitative characteristics to use their data for reference values and pooled studies that did not have any eligibility criteria for the characteristics as reference. Results Two hundred and fourteen articles were included. The most reported participant eligibility criteria (as aligned to the ICF) related to body structures/function and personal factors. Age, BMI, symptom duration and pain level were used with various ranges and/or thresholds across studies (age was reported in 23 different ways across 97 studies; BMI 7/13; symptom duration 14/100; and pain level 8/31). When eligibility criteria included thresholds close to the reference value of a participant characteristic, characteristics were associated with criteria (e.g., younger participants when an upper age threshold was used). Conclusion Participant eligibility criteria in studies on plantar heel pain vary widely; studies differed substantially in their use of quantitative thresholds. Participant characteristics of samples in studies were associated with the criteria used. This study emphasises a need for adjusting for participant heterogeneity in systematic reviews to improve their validity.

Background Plantar fasciopathy has a lifetime prevalence of 10%. Patients experience sharp pain under the heel, often for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. A corticosteroid injection offers short-term pain relief but is no better than placebo in the longer term (> 8 weeks). Heavy-slow resistance training has shown potentially positive effects on long-term outcomes (> 3 months), and combining exercises with an injection may prove to be superior to exercises alone. However, the effect of heavy-slow resistance training compared with a simpler approach of patient advice (e.g., load management) and insoles is currently unknown. This trial compares the efficacy of patient advice with patient advice plus heavy-slow resistance training and with patient advice plus heavy-slow resistance training plus a corticosteroid injection in improving the Foot Health Status Questionnaire pain score after 12 weeks in patients with plantar fasciopathy. Methods In this randomised superiority trial, we will recruit 180 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of three groups: (1) patient advice and an insole ( n  = 60); (2) patient advice, an insole, and self-dosed heavy-slow resistance training consisting of heel raises ( n  = 60); or (3) patient advice, an insole, heavy-slow resistance training, and an ultrasound-guided corticosteroid injection ( n  = 60). All participants will be followed for 1 year, with the 12-week follow-up considered the primary endpoint. The primary outcome is the Foot Health Status questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a 7-point Global Rating of Change, the Pain Self-Efficacy Questionnaire, physical activity level, health-related quality of life measured by the EQ-5D-5L, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Additionally, a health economic evaluation of the treatments will be carried out. Discussion This trial will test if adding heavy-slow resistance training to fundamental patient advice and an insole improves outcomes and if a corticosteroid injection adds even further to that effect in patients with plantar fasciopathy. Trial registration ClinicalTrials.gov, NCT03804008 . Prospectively registered on January 15, 2019.

Introduction Plantar fasciopathy, characterised by plantar heel pain, affects one in ten in a lifetime. Heavy-slow resistance training (HSR) is an emerging treatment, but it often takes considerable time before the effect starts to manifest. Combining HSR with a corticosteroid injection (known for its short-term pain relief) could potentially improve outcomes in both short and long term. As this combination is yet to be investigated, we aimed to evaluate the feasibility of combining HSR with a corticosteroid injection for individuals with plantar fasciopathy before investigating the efficacy in a clinical trial. Materials and methods We recruited 20 participants with plantar fasciopathy for this prospectively registered feasibility study ( ClinicalTrials.gov : NCT03535896). Participants received an ultrasound-guided injection and performed heel raises on a step every second day for 8 weeks. To assess participant acceptability of the combined interventions and exercise compliance, we used a 7-point Likert scale dichotomised to “unacceptable” (categories 1–2) or “acceptable” (categories 3–7) and training diaries. Greater than or equal to 10/20 had to rate the combination “acceptable”, ≥ 15/20 had to perform ≥ 20 training sessions, and ≥ 15/20 had to start exercising ≤ 7 days after injection to confirm feasibility. Results Eighteen out of 20 rated the combination acceptable. Five training diaries could not be retrieved. Ten out of 15 participants performed ≥ 20 training sessions, and 15/15 started exercising ≤ 7 days after injection. Conclusions Based on participant acceptability and time to exercise start, combining HSR with corticosteroid injection is feasible and the efficacy should be investigated in a future trial. Due to loss of 5/20 training diaries, firm conclusions regarding exercise compliance could not be drawn. Trial registration ClinicalTrials.gov , NCT03535896