Association Between Physical Tests and Patients-Reported Outcomes in Athletes Performing Exercise Therapy for Patellar Tendinopathy: A Secondary Analysis of the JUMPER Study.

BACKGROUND: Physical tests are commonly used in patellar tendinopathy to aid the clinical diagnosis, assess the prognosis, and monitor treatment. However, it is still unknown whether these physical measures are associated with patient-reported outcomes after exercise therapy. PURPOSE: To identify the prognostic value of baseline physical test results and to determine the association between physical response after exercise therapy and clinical improvement over 24 weeks. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study recruited 76 consecutive athletes with patellar tendinopathy who were randomized to 2 different programs of exercise therapy for 24 weeks. Athletes underwent a range of physical tests before and during exercise therapy (12 and 24 weeks), including isometric muscle strength (quadriceps and hip abductors), muscle flexibility (quadriceps, hamstrings, soleus, and gastrocnemius), vertical jump height, and visual analog scale (VAS) scores by palpation, after 3 jump trials, and after single-leg squat (VAS-SLS). The Victorian Institute of Sports Assessment-Patella (VISA-P) questionnaire was used as the primary patient-reported outcome. Linear mixed-effect models were used to assess the prognostic value of baseline physical tests. The change in VISA-P score was further dichotomized into clinical responsiveness (≥14 points) and nonresponsiveness (<14 points). Multiple linear and logistic regression models were performed to evaluate associations between physical response and clinical improvement. RESULTS: Of the 76 included patients, 67 (88%) had complete follow-ups. The estimated mean VISA-P score increased by 23 points (95% CI, 19-28 points) after 24 weeks. No association was found between any baseline physical test results and a 24-week change in VISA-P score (all Pinteraction > .2, using the likelihood ratio test). Improvement in VAS-SLS after exercise therapy was not associated with VISA-P improvement after adjustment (ß = -1.76; P = .01; Bonferroni-corrected P = .10; R2 = 36.3%). No associations were found between changes in other physical test results and clinical improvement (all P > .05). CONCLUSION: In patients with patellar tendinopathy, physical test results including strength and flexibility in the lower limb, jump performance, and pain levels during pain-provoking tests were not identified as prognostic factors for patient-reported outcomes after exercise therapy. Similarly, changes in physical test results were not associated with changes in patient-reported outcomes after adjustments. These results do not support using physical test results to estimate prognosis or monitor treatment response. REGISTRATION: NCT02938143 (ClinicalTrials.gov identifier).

Decreasing patellar tendon stiffness during exercise therapy for patellar tendinopathy is associated with better outcome.

OBJECTIVES: To assess the associations between: 1) baseline patellar tendon stiffness and clinical outcome after exercise therapy in athletes with patellar tendinopathy and 2) the change in patellar tendon stiffness and clinical outcome during progressive tendon-loading exercise therapy and eccentric exercise therapy. DESIGN: Randomized controlled trial. METHODS: Athletes with patellar tendinopathy aged 18-35 years, playing tendon-loading sports at least 3 times per week were randomized in a 1:1 ratio between progressive tendon-loading exercise therapy and eccentric exercise therapy for 24 weeks. Patellar tendinopathy was diagnosed clinically, and confirmed by ultrasound. Patellar tendon stiffness (kilopascal, kPa) was assessed using shear-wave elastography. Clinical outcome was assessed using the validated Victorian Institute of Sports Assessment (VISA-P; range 0-100) questionnaire. Both were assessed at baseline, 12 and 24 week follow-up. Adjusted general linear, mixed-linear models and Generalized Estimating Equations were used. RESULTS: We included 76 athletes (58 men, mean age 24 ±â€¯4 years). No association was found between baseline stiffness and VISA-P after 24 weeks (p = 0.52). Decreased stiffness (adjusted mean difference = 10 kPa (95% CI: 4-15) was significantly associated with improved clinical outcome at 12 weeks in all athletes (p = 0.02), and at both 12 and 24 weeks (p = 0.01) in athletes allocated to progressive tendon-loading exercise therapy. CONCLUSIONS: Patellar tendon stiffness, assessed with shear-wave elastography, is unsuitable to use as a single predictive measurement for clinical outcome. Decreasing stiffness during the course of exercise therapy is associated with improved clinical outcome in athletes recovering from patellar tendinopathy.

Association Between T2* Relaxation Times Derived From Ultrashort Echo Time MRI and Symptoms During Exercise Therapy for Patellar Tendinopathy: A Large Prospective Study.

BACKGROUND: Exercise therapy is considered preferential treatment for patellar tendinopathy (PT). However, there is conflicting evidence for structural patellar tendon adaptation in response to exercise therapy and its association with symptoms is weak. PURPOSE: To assess the association between 1) T2* relaxation times and symptom severity; 2) baseline T2* and clinical outcome; and 3) longitudinal T2* changes and clinical outcome in athletes with PT performing exercise therapy. STUDY TYPE: Randomized controlled clinical trial. SUBJECTS: Seventy-six athletes (18-35 years) with clinically diagnosed and ultrasound-confirmed PT. FIELD STRENGTH/SEQUENCE: 3D gradient echo sequence (3.0 T). ASSESSMENT: Patients were enrolled in a randomized trial of progressive tendon-loading exercises (PTLE) versus eccentric exercise therapy (EET). Symptoms were assessed using the Victorian Institute of Sports Assessment (VISA-P) questionnaire. 3D-Ultrashort echo time (UTE)-MRI was acquired at baseline, 12 and 24 weeks. Voxel-wise T2* relaxation times were quantified using mono-exponential and bi-exponential models. T2* analysis was performed in three patellar tendon tissue compartments representing: aligned collagen, degenerative tissue, and interface. STATISTICAL TESTS: Adjusted general linear, mixed-linear models, and generalized estimating equations. RESULTS: We included 76 patients with PT (58 men, mean age 24 ± 4 years); 38 in the PTLE-group and 38 in the EET-group, of which 57 subjects remained eligible for analysis. T2* relaxation times were significantly associated with VISA-P in degenerative and interface tissues of the patellar tendon. No association was found between baseline T2* and VISA-P after 24 weeks (P > 0.29). The estimated mean T2* in degenerative tissue decreased from 14 msec (95%CI: 12-16) at baseline to 13 msec (95%CI: 11-15) at 12 weeks and to 13 msec (95%CI: 10-15) at 24 weeks. The significant decrease in T2* from baseline to 24 weeks was associated with improved clinical outcome. DATA CONCLUSION: Tissue-specific T2* relaxation times, identified with 3D-UTE-MRI, decreased significantly in athletes with patellar tendinopathy performing exercise therapy and this decrease was associated with improved clinical outcome. EVIDENCE LEVEL: 1 TECHNICAL EFFICACY: Stage 4.

Detection of knee synovitis using non-contrast-enhanced qDESS compared with contrast-enhanced MRI.

BACKGROUND: To assess diagnostic accuracy of quantitative double-echo in steady-state (qDESS) MRI for detecting synovitis in knee osteoarthritis (OA). METHODS: Patients with different degrees of radiographic knee OA were included prospectively. All underwent MRI with both qDESS and contrast-enhanced T1-weighted magnetic resonance imaging (CE-MRI). A linear combination of the two qDESS images can be used to create an image that displays contrast between synovium and the synovial fluid. Synovitis on both qDESS and CE-MRI was assessed semi-quantitatively, using a whole-knee synovitis sum score, indicating no/equivocal, mild, moderate, and severe synovitis. The correlation between sum scores of qDESS and CE-MRI (reference standard) was determined using Spearman's rank correlation coefficient and intraclass correlation coefficient for absolute agreement. Receiver operating characteristic analysis was performed to assess the diagnostic performance of qDESS for detecting different degrees of synovitis, with CE-MRI as reference standard. RESULTS: In the 31 patients included, very strong correlation was found between synovitis sum scores on qDESS and CE-MRI (ρ = 0.96, p < 0.001), with high absolute agreement (0.84 (95%CI 0.14-0.95)). Mean sum score (SD) values on qDESS 5.16 (3.75) were lower than on CE-MRI 7.13 (4.66), indicating systematically underestimated synovitis severity on qDESS. For detecting mild synovitis or higher, high sensitivity and specificity were found for qDESS (1.00 (95%CI 0.80-1.00) and 0.909 (0.571-1.00), respectively). For detecting moderate synovitis or higher, sensitivity and specificity were good (0.727 (95%CI 0.393-0.927) and 1.00 (0.800-1.00), respectively). CONCLUSION: qDESS MRI is able to, however with an underestimation, detect synovitis in patients with knee OA.

Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial.

OBJECTIVE: To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT). METHODS: In a stratified, investigator-blinded, block-randomised trial, 76 patients with clinically diagnosed and ultrasound-confirmed PT were randomly assigned in a 1:1 ratio to receive either PTLE or EET. The primary end point was clinical outcome after 24 weeks following an intention-to-treat analysis, as assessed with the validated Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire measuring pain, function and ability to play sports. Secondary outcomes included the return to sports rate, subjective patient satisfaction and exercise adherence. RESULTS: Patients were randomised between January 2017 and July 2019. The intention-to-treat population (mean age, 24 years, SD 4); 58 (76%) male) consisted of patients with mostly chronic PT (median symptom duration 2 years). Most patients (82%) underwent prior treatment for PT but failed to recover fully. 38 patients were randomised to the PTLE group and 38 patients to the EET group. The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 vs 18 points, adjusted mean between-group difference, 9 (95% CI 1 to 16); p=0.023). There was a trend towards a higher return to sports rate in the PTLE group (43% vs 27%, p=0.13). No significant between-group difference was found for subjective patient satisfaction (81% vs 83%, p=0.54) and exercise adherence between the PTLE group and EET group after 24 weeks (40% vs 49%, p=0.33). CONCLUSIONS: In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT.

Diagnostic accuracy of grayscale, power Doppler and contrast-enhanced ultrasound compared with contrast-enhanced MRI in the visualization of synovitis in knee osteoarthritis.

PURPOSE: To assess the diagnostic accuracy of grayscale (GSUS), power Doppler (PDUS) and contrast-enhanced ultrasound (CEUS) for detecting synovitis in knee osteoarthritis (OA). METHOD: Patients with different degrees of radiographic knee OA were included prospectively. All underwent GSUS, PDUS, CEUS, and contrast-enhanced magnetic resonance imaging (CE-MRI), on which synovitis was assessed semi-quantitatively. Correlations of synovitis severity on ultrasound based techniques with CE-MRI were determined. Receiver operating characteristic (ROC) analysis was performed to assess diagnostic performance of GSUS, PDUS, and CEUS, for detecting synovitis, using CE-MRI as reference-standard. RESULTS: In the 31 patients included, synovitis scoring on GSUS and CEUS was significantly correlated (ρ = 0.608, p < 0.001 and ρ = 0.391, p = 0.033) with CE-MRI. For detecting mild synovitis, the area under the curve (AUC) was 0.781 (95 %CI 0.609-0.953) for GSUS, 0.788 (0.622-0.954) for PDUS, and 0.653 (0.452-0.853) for CEUS. Sensitivity and specificity were 0.667 (0.431-0.845) and 0.700 (0.354-0.919) for GSUS, 0.905 (0.682-0.983) and 0.500 (0.201-0.799) for PDUS, and 0.550 (0.320-0.762) and 0.700 (0.354-0.919) for CEUS, respectively. The AUC of GSUS increased to 0.862 (0.735-0.989), 0.823 (0.666-0.979), and 0.885 (0.767-1.000), when combined with PDUS, CEUS, or both, respectively. For detecting moderate synovitis, the AUC of GSUS was higher (0.882 (0.750-1.000)) and no added value of PDUS and CEUS was observed. CONCLUSIONS: GSUS has limited overall accuracy for detecting synovitis in knee OA. When GSUS is combined with PDUS or CEUS, overall diagnostic performance improves for detecting mild synovitis, but not for moderate synovitis.

The association between patellar tendon stiffness measured with shear-wave elastography and patellar tendinopathy-a case-control study.

OBJECTIVES: (1) To determine the association between patellar tendon stiffness and the presence of patellar tendinopathy (PT). (2) To evaluate the reliability of shear-wave elastography (SWE). METHODS: Participants were consecutively enrolled between January 2017 and June 2019. PT was diagnosed clinically and confirmed by either grayscale US or power Doppler US, or both. Controls had no history of anterior knee pain and no clinical signs of PT. Patellar tendon stiffness (kilopascal, kPa) was assessed using SWE. Logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Reliability analyses included coefficients-of-variation (CV), coefficients-of-repeatability (CR), intraclass correlation coefficient (ICC) for intraobserver and interobserver reliability, and Bland-Altman analysis. RESULTS: In total, 76 participants with PT (58 men, mean age 24.4 ± 3.8 years) and 35 asymptomatic controls (16 men, mean age 21.5 ± 3.8 years) were included. Univariate analyses (OR 1.094, 95% CI 1.061-1.128, p < .001) and adjusted multivariate analyses (OR 1.294, 95% CI 1.044-1.605, p = .018) showed that athletes with PT had significantly increased patellar tendon stiffness. ICC for intraobserver reliability was 0.95 (95% CI 0.92-0.97), CR (CV) 12 kPa (10%) and 0.79 (95% CI 0.65-0.88), CR (CV) 18 kPa (21%) for interobserver reliability. Mean differences from Bland-Altman analysis were 5.6 kPa (95% CI 3.1-8.1, p < .001) for intraobserver reliability and 4.6 kPa (95% CI 1.9-7.2, p < .001) for interobserver reliability. CONCLUSIONS: PT is associated with significantly higher patellar tendon stiffness. SWE measurements demonstrate excellent intraobserver reliability and good interobserver reliability. Therefore, SWE is a promising tool to implement in longitudinal studies and future studies should evaluate its prognostic value and utility as a monitoring tool in athletes with PT. KEY POINTS: • Patellar tendon stiffness measured with shear-wave elastography (SWE) is higher in athletes with patellar tendinopathy than in healthy controls, also after adjusting for potential confounders. • Excellent intraobserver reliability and good interobserver reliability were found for the quantitative assessment of patellar tendon stiffness using SWE.

Tissue-Specific T2 * Biomarkers in Patellar Tendinopathy by Subregional Quantification Using 3D Ultrashort Echo Time MRI.

BACKGROUND: Quantitative MRI of patellar tendinopathy (PT) can be challenging due to spatial variation of T2 * relaxation times. PURPOSE: 1) To compare T2 * quantification using a standard approach with analysis in specific tissue compartments of the patellar tendon. 2) To evaluate test-retest reliability of different methods for fitting ultrashort echo time (UTE)-relaxometry data. STUDY TYPE: Prospective. SUBJECTS: Sixty-five athletes with PT. FIELD STRENGTH/SEQUENCE: 3D UTE scans covering the patellar tendon were acquired using a 3.0T scanner and a 16-channel surface coil. ASSESSMENT: Voxelwise median T2 * was quantified with monoexponential, fractional-order, and biexponential fitting. We applied two methods for T2 * analysis: first, a standard approach by analyzing all voxels covering the proximal patellar tendon. Second, within subregions of the patellar tendon, by using thresholds on biexponential fitting parameter percentage short T2 * (0-30% for mostly long T2 *, 30-60% for mixed T2 *, and 60-100% for mostly short T2 *). STATISTICAL TESTS: Average test-retest reliability was assessed in three athletes using coefficients-of-variation (CV) and coefficients-of-repeatability (CR). RESULTS: With standard image analysis, we found a median [interquartile range, IQR] monoexponential T2 * of 6.43 msec [4.32-8.55] and fractional order T2 * 4.39 msec [3.06-5.78]. The percentage of short T2 * components was 52.9% [35.5-69.6]. Subregional monoexponential T2 * was 13.78 msec [12.11-16.46], 7.65 msec [6.49-8.61], and 3.05 msec [2.52-3.60] and fractional order T2 * 11.82 msec [10.09-14.44], 5.14 msec [4.25-5.96], and 2.19 msec [1.82-2.64] for 0-30%, 30-60%, and 60-100% short T2 *, respectively. Biexponential component short T2 * was 1.693 msec [1.417-2.003] for tissue with mostly short T2 * and long T2 * of 15.79 msec [13.47-18.61] for mostly long T2 *. The average CR (CV) was 2 msec (15%), 2 msec (19%) and 10% (22%) for monoexponential, fractional order and percentage short T2 *, respectively. DATA CONCLUSION: Patellar tendinopathy is characterized by regional variability in binding states of water. Quantitative multicompartment T2 * analysis in PT can be facilitated using a voxel selection method based on using biexponential fitting parameters. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 1 J. Magn. Reson. Imaging 2020;52:420-430.

Clinical risk factors for Achilles tendinopathy: a systematic review.

BACKGROUND: Achilles tendinopathy is a common problem, but its exact aetiology remains unclear. OBJECTIVE: To evaluate the association between potential clinical risk factors and Achilles tendinopathy. DESIGN: Systematic review. DATA SOURCES: The databases Embase, MEDLINE Ovid, Web of Science, Cochrane Library and Google Scholar were searched up to February 2018. ELIGIBILITY CRITERIA: To answer our research question, cohort studies investigating risk factors for Achilles tendinopathy in humans were included. We restricted our search to potential clinical risk factors (imaging studies were excluded). RESULTS: We included 10 cohort studies, all with a high risk of bias, from 5111 publications identified. There is limited evidence for nine risk factors: (1) prior lower limb tendinopathy or fracture, (2) use of ofloxacin (quinolone) antibiotics, (3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, (4) moderate alcohol use, (5) training during cold weather, (6) decreased isokinetic plantar flexor strength, (7) abnormal gait pattern with decreased forward progression of propulsion, (8) more lateral foot roll-over at the forefoot flat phase and (9) creatinine clearance of <60 mL/min in heart transplant patients. Twenty-six other putative risk factors were not associated with Achilles tendinopathy, including being overweight, static foot posture and physical activity level. CONCLUSION: From an ocean of studies with high levels of bias, we extracted nine clinical risk factors that may increase a person's risk of Achilles tendinopathy. Clinicians may consider ofloxacin use, alcohol consumption and a reduced plantar flexor strength as modifiable risk factors when treating patients with Achilles tendinopathy. TRIAL REGISTRATION NUMBER: CRD42017053258.

Osteoporotic Vertebral Fracture Prevalence Varies Widely Between Qualitative and Quantitative Radiological Assessment Methods: The Rotterdam Study.

Accurate diagnosis of vertebral osteoporotic fractures is crucial for the identification of individuals at high risk of future fractures. Different methods for radiological assessment of vertebral fractures exist, but a gold standard is lacking. The aim of our study was to estimate statistical measures of agreement and prevalence of osteoporotic vertebral fractures in the population-based Rotterdam Study, across two assessment methods. The quantitative morphometry assisted by SpineAnalyzer® (QM SA) method evaluates vertebral height loss that affects vertebral shape whereas the algorithm-based qualitative (ABQ) method judges endplate integrity and includes guidelines for the differentiation of vertebral fracture and nonfracture deformities. Cross-sectional radiographs were assessed for 7582 participants aged 45 to 95 years. With QM SA, the prevalence was 14.2% (95% CI, 13.4% to 15.0%), compared to 4.0% (95% CI, 3.6% to 4.5%) with ABQ. Inter-method agreement according to kappa (κ) was 0.24. The highest agreement between methods was among females (κ = 0.31), participants age >80 years (κ = 0.40), and at the L1 level (κ = 0.40). With ABQ, most fractures were found at the thoracolumbar junction (T12 -L1 ) followed by the T7 -T8 level, whereas with QM SA, most deformities were in the mid thoracic (T7 -T8 ) and lower thoracic spine (T11 -T12 ), with similar number of fractures in both peaks. Excluding mild QM SA deformities (grade 1 with QM) from the analysis increased, the agreement between the methods from κ = 0.24 to 0.40, whereas reexamining mild deformities based on endplate depression increased agreement from κ = 0.24 to 0.50 (p <0.001). Vertebral fracture prevalence differs significantly between QM SA and ABQ; reexamining QM mild deformities based on endplate depression would increase the agreement between methods. More widespread and consistent application of an optimal method may improve clinical care. © 2017 American Society for Bone and Mineral Research.

[Osteoporotic vertebral fractures or Scheuermann's disease?]. / Osteoporotische wervelfracturen of ziekte van Scheuermann?

A 56-year-old man was treated with bisphosphonates following incidental findings of vertebral deformities on a chest radiograph taken for cough. After re-evaluation with DEXA and spinal radiographs he was diagnosed with Scheuermann's disease, not osteoporosis. His gastrointestinal symptoms resolved after bisphosphonates were stopped. A 42-year-old man with limb-girdle muscular dystrophy and complaining of back pain underwent investigations. Radiographs showed loss of height in multiple thoracic vertebrae, yet DEXA bone mineral density was high-normal and an MRI scan suggested Scheuermann's disease. Recent osteoporotic vertebral fractures are an indication for anti-osteoporotic treatment, because they are highly predictive of future fracture risk. There are a number of differential diagnoses that should be considered in individuals with vertebral deformities, including Scheuermann's disease, especially if the clinical picture is not typically osteoporotic. This is important in order to avoid unnecessary medical treatment, which should be reserved for patients with osteoporosis. Refining vertebral fracture definitions may help to improve diagnostic accuracy.

Review of radiological scoring methods of osteoporotic vertebral fractures for clinical and research settings.

BACKGROUND: Osteoporosis is the most common metabolic bone disease; vertebral fractures are the most common osteoporotic fractures. METHODS: Several radiological scoring methods using different criteria for osteoporotic vertebral fractures exist. Quantitative morphometry (QM) uses ratios derived from direct vertebral body height measurements to define fractures. Semi-quantitative (SQ) visual grading is performed according to height and area reduction. The algorithm-based qualitative (ABQ) method introduced a scheme to systematically rule out non-fracture deformities and diagnoses osteoporotic vertebral fractures based on endplate depression. The concordance across methods is currently a matter of debate. RESULTS: This article reviews the most commonly applied standardised radiographic scoring methods for osteoporotic vertebral fractures, attaining an impartial perspective of benefits and limitations. It provides image examples and discusses aspects that facilitate large-scale application, such as automated image analysis software and different imaging investigations. It also reviews the implications of different fracture definitions for scientific research and clinical practice. CONCLUSION: Accurate standardised scoring methods for assessing osteoporotic vertebral fractures are crucial, considering that differences in definition will have implications for patient care and scientific research. Evaluation of the feasibility and concordance among methods will allow establishing their benefits and limitations, and most importantly, optimise their effectiveness for widespread application.

Scheuermann disease: evaluation of radiological criteria and population prevalence.

STUDY DESIGN: Observational population-based study. OBJECTIVE: To determine the prevalence of radiographical Scheuermann disease in a Dutch population and evaluate the consistency of diagnostic criteria. SUMMARY OF BACKGROUND DATA: Scheuermann disease is a form of osteochondrosis characterized by increased posterior rounding of the thoracic spine with structural vertebral deformity. Different expert opinion-based radiological criteria exist, yet these have not been validated. The prevalence in the general population reported ranged from 1% to 10%. METHODS: Lateral spine radiographs of 2753 Rotterdam Study participants (aged 45-89 yr) were assessed for Scheuermann disease using Sørensen and Sachs' radiographical criteria in 2 phases. Cohen κ statistics were calculated for interrater agreement. Prevalence estimates were calculated and sex differences were tested with Pearson χ test. We evaluated whether varying the kyphosis angle criterion would change the prevalence estimate. RESULTS: A total of 677 (24.6%) individuals had endplate irregularities and 140 (5.1%) individuals had vertebral wedging. Abnormalities were significantly more prevalent among males (P < 0.05). The interrater agreement κ statistics were 78.8% for vertebral wedging and 79.4% for endplate irregularity. A total of 127 individuals had both criteria, of which 111 had a kyphosis angle greater than 45°, resulting in a prevalence of 4.0% (95% confidence interval [CI]: 3.3%-4.7%). The disease prevalence was 4.5% in males versus 3.6% in females, yet this difference was not statistically significant (P = 0.23). Adjustment of the kyphosis angle criterion from 45° to 40° or 35° increased the number of cases marginally, corresponding to prevalence estimates not significantly different from the estimates using original criteria (4.2% [95% CI: 3.3%-4.7%] and 4.4% [95% CI: 3.6%-5.2%]). CONCLUSION: Our results revealed a prevalence of 4.0% of radiographical Scheuermann disease in Dutch individuals aged 45 years and older. Although there is no current "gold standard" for the radiographical definition, standardized scoring of independent features resulted in substantial interobserver agreement, and different applications of diagnostic criteria did not significantly alter the classification.