Early Surgery Versus Exercise Therapy and Patient Education for Traumatic and Nontraumatic Meniscal Tears in Young Adults-An Exploratory Analysis From the DREAM Trial.

OBJECTIVE: To compare the effect of early meniscal surgery versus exercise and education with the option of later surgery on pain, function, and quality of life in young patients with a meniscal tear, taking symptom onset into account. DESIGN: Randomized controlled trial. METHODS: In a randomized controlled trial (the "Danish RCT on Exercise versus Arthroscopic Meniscal surgery for young adults" [DREAM] trial), 121 patients aged 18-40 years with a magnetic resonance imaging-verified meniscal tear were randomized to surgery or 12 weeks of supervised exercise and patient education. For this exploratory study, the analyses were stratified by symptom onset (traumatic/nontraumatic). The main outcome was the difference in change after 12 months in the mean score of 4 Knee injury and Osteoarthritis Outcome Score subscales (KOOS4) covering pain, symptoms, function in sport and recreation, and quality of life. RESULTS: Forty-two patients (69%) in the exercise therapy group and 47 (78%) in the surgery group were categorized as having a traumatic tear. We observed no difference in change in the KOOS4 after 12 months between the 2 treatment groups for either traumatic tears (18.8 versus 16.0 in the surgery versus exercise therapy groups; adjusted mean difference, 4.8 [95% confidence interval, -1.7 to 11.2]) or nontraumatic tears (20.6 versus 17.3 in the surgery versus exercise therapy groups; adjusted mean difference, 7.0 [95% confidence interval, -3.7 to 17.7]). CONCLUSION: In patients with traumatic and nontraumatic meniscus tears, early meniscal surgery did not appear superior to exercise and education in improving pain, function, and quality of life after 12 months. Further research is needed to confirm the clinical applicability of these findings. J Orthop Sports Phys Ther 2024;54(5):1-10. Epub 22 February 2024. doi:10.2519/jospt.2024.12245.

Two-year MRI-defined structural damage and patient-reported outcomes following surgery or exercise for meniscal tears in young adults.

OBJECTIVE: To investigate potential differences in structural knee joint damage assessed by MRI and patient-reported outcomes (PROMs) at 2-year follow-up between young adults randomised to early surgery or exercise and education with optional delayed surgery for a meniscal tear. METHODS: A secondary analysis of a multicentre randomised controlled trial including 121 patients (18-40 years) with an MRI-verified meniscal tear. For this study, only patients with 2-year follow-up were included. The main outcomes were the difference in worsening of structural knee damage, assessed by MRI using the Anterior Cruciate Ligament OsteoArthrits Score, and the difference in change in the mean score of four Knee Injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sport and recreation, and quality of life, from baseline to 2 years. RESULTS: In total, 82/121 (68%) patients completed the 2-year follow-up (39 from the surgical group and 43 from the exercise group). MRI-defined cartilage damage had developed or progressed in seven (9.1%) patients and osteophytes developed in two (2.6%) patients. The worsening of structural damage from baseline to 2-year follow-up was similar between groups. The mean (95% CI) adjusted differences in change in KOOS4 between intervention groups from baseline to 2 years was -1.4 (-9.1, 6.2) points. The mean improvement in KOOS4 was 16.4 (10.4, 22.4) in the surgical group and 21.5 (15.0, 28.0) in the exercise group. No between group differences in improvement were found in the KOOS subscales. CONCLUSIONS: The 2-year worsening of MRI-defined structural damage was limited and similar in young adult patients with a meniscal tear treated with surgery or exercise with optional delayed surgery. Both groups had similar clinically relevant improvements in KOOS4, suggesting the choice of treatment strategy does not impact 2-year structural knee damage or PROMs. TRIAL REGISTRATION NUMBER: NCT02995551.

Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis.

BACKGROUND: Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear. OBJECTIVE: This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions. METHODS: We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up. CONCLUSIONS: Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention. TRIAL REGISTRATION: PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189028.

Effect of exercise therapy versus surgery on mechanical symptoms in young patients with a meniscal tear: a secondary analysis of the DREAM trial.

OBJECTIVE: To compare the effect of early surgery versus exercise and education on mechanical symptoms and other patient-reported outcomes in patients aged 18-40 years with a meniscal tear and self-reported mechanical knee symptoms. METHODS: In a randomised controlled trial, 121 patients aged 18-40 years with a MRI-verified meniscal tear were randomised to surgery or 12-week supervised exercise and education. For this study, 63 patients (33 and 30 patients in the surgery and in the exercise group, respectively) reporting baseline mechanical symptoms were included. The main outcome was self-reported mechanical symptoms (yes/no) at 3, 6 and 12 months assessed using a single item from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes were KOOS4 and the 5 KOOS-subscales and the Western Ontario Meniscal Evaluation Tool (WOMET). RESULTS: In total, 55/63 patients completed the 12-month follow-up. At 12 months, 9/26 (35%) in the surgery group and 20/29 (69%) in the exercise group reported mechanical symptoms. The risk difference and relative risk at any time point was 28.7% (95% CI 8.6% to 48.8%) and 1.83 (95% CI 0.98 to 2.70) of reporting mechanical symptoms in the exercise group compared with the surgery group. We did not detect any between-group differences in the secondary outcomes. CONCLUSION: The results from this secondary analysis suggest that early surgery is more effective than exercise and education for relieving self-reported mechanical knee symptoms, but not for improving pain, function and quality of life in young patients with a meniscal tear and mechanical symptoms. TRIAL REGISTRATION NUMBER: NCT02995551.

Randomised controlled trials (RCTs) in sports injury research: authors-please report the compliance with the intervention.

BACKGROUND: In randomised controlled trials (RCTs) of interventions that aim to prevent sports injuries, the intention-to-treat principle is a recommended analysis method and one emphasised in the Consolidated Standards of Reporting Trials (CONSORT) statement that guides quality reporting of such trials. However, an important element of injury prevention trials-compliance with the intervention-is not always well-reported. The purpose of the present educational review was to describe the compliance during follow-up in eight large-scale sports injury trials and address compliance issues that surfaced. Then, we discuss how readers and researchers might consider interpreting results from intention-to-treat analyses depending on the observed compliance with the intervention. METHODS: Data from seven different randomised trials and one experimental study were included in the present educational review. In the trials that used training programme as an intervention, we defined full compliance as having completed the programme within ±10% of the prescribed running distance (ProjectRun21 (PR21), RUNCLEVER, Start 2 Run) or time-spent-running in minutes (Groningen Novice Running (GRONORUN)) for each planned training session. In the trials using running shoes as the intervention, full compliance was defined as wearing the prescribed running shoe in all running sessions the participants completed during follow-up. RESULTS: In the trials that used a running programme intervention, the number of participants who had been fully compliant was 0 of 839 (0%) at 24-week follow-up in RUNCLEVER, 0 of 612 (0%) at 14-week follow-up in PR21, 12 of 56 (21%) at 4-week follow-up in Start 2 Run and 8 of 532 (1%) at 8-week follow-up in GRONORUN. In the trials using a shoe-related intervention, the numbers of participants who had been fully compliant at the end of follow-up were 207 of 304 (68%) in the 21 week trial, and 322 of 423 (76%), 521 of 577 (90%), 753 of 874 (86%) after 24-week follow-up in the other three trials, respectively. CONCLUSION: The proportion of runners compliant at the end of follow-up ranged from 0% to 21% in the trials using running programme as intervention and from 68% to 90% in the trials using running shoes as intervention. We encourage sports injury researchers to carefully assess and report the compliance with intervention in their articles, use appropriate analytical approaches and take compliance into account when drawing study conclusions. In studies with low compliance, G-estimation may be a useful analytical tool provided certain assumptions are met.

The Garmin-RUNSAFE Running Health Study on the aetiology of running-related injuries: rationale and design of an 18-month prospective cohort study including runners worldwide.

INTRODUCTION: Running injuries affect millions of persons every year and have become a substantial public health issue owing to the popularity of running. To ensure adherence to running, it is important to prevent injuries and to have an in-depth understanding of the aetiology of running injuries. The main purpose of the present paper was to describe the design of a future prospective cohort study exploring if a dose-response relationship exists between changes in training load and running injury occurrence, and how this association is modified by other variables. METHODS AND ANALYSIS: In this protocol, the design of an 18-month observational prospective cohort study is described that will include a minimum of 20 000 consenting runners who upload their running data to Garmin Connect and volunteer to be a part of the study. The primary outcome is running-related injuries categorised into the following states: (1) no injury; (2) a problem; and (3) injury. The primary exposure is change in training load (eg, running distance and the cumulative training load based on the number of strides, ground contact time, vertical oscillation and body weight). The change in training load is a time-dependent exposure in the sense that progression or regression can change many times during follow-up. Effect-measure modifiers include, but is not limited to, other types of sports activity, activity of daily living and demographics, and are assessed through questionnaires and/or by Garmin devices. ETHICS AND DISSEMINATION: The study design, procedures and informed consent have been evaluated by the Ethics Committee of the Central Denmark Region (Request number: 227/2016 - Record number: 1-10-72-189-16).

ProjectRun21: Do running experience and running pace influence the risk of running injury-A 14-week prospective cohort study.

OBJECTIVES: The health benefits from participation in half-marathon is challenged by a yearly running-related injury (RRI) incidence proportion exceeding 30%. Research in injury etiology is needed to successfully prevent injuries. The body's load capacity is believed to play an essential role for injury development. Therefore, the purpose of ProjectRun21 was to investigate the association between load capacity defined as running experience and running pace, and RRI when following a specific half-marathon running schedule. DESIGN: A 14-week prospective cohort study. METHODS: A cohort of 784 healthy runners followed a specific half-marathon running schedule. Data on running activity was collected objectively using a Global-Positioning-System watch or smartphone. RRI were collected using e-mail-based weekly questionnaires. Primary exposures were running experience and running pace, dichotomized into a high and a low group for runners running less or more than 15km/week and faster or slower than 6min/km, respectively. Data was analyses through time-to-event models with cumulative risk difference (RD) as measure of association. RESULTS: A total of 136 participants sustained a RRI during follow-up. Although not statistically significant, all estimates indicate a tendency toward fewer injuries amongst runners categorized as having high experience (RD=-11.3% (-27.2% to 4.6%)) or high pace (RD=-17.4% (-39.0% to 4.5%)), and a combination of both high experience and high pace (RD=-8.1% (-22.3% to 6.1%)) compared with their counterpart peers. CONCLUSIONS: Runners covering less than 15km per week, and/or runs slower than 6min/km, may sustain more RRI than their counterpart runners.

The Association Between Changes in Weekly Running Distance and Running-Related Injury: Preparing for a Half Marathon.

BACKGROUND: Sudden changes in training load may play a key role in the development of running-related injury (RRI). Because the injury mechanism depends on the runner's musculoskeletal load capacity, the running schedule followed prior to sudden change in training load may influence the amount of change that a runner can tolerate before the runner is at a higher risk of RRI. OBJECTIVES: To investigate the association between change in weekly running distance and RRI, and to examine whether the association may be modified by the running schedule the runner follows. METHODS: Two hundred sixty-one healthy (noninjured) runners were included in this prospective cohort study over a period of 14 weeks. Data on running activity were collected daily and objectively, using a global positioning system watch or smartphone. Instances of RRIs were collected using weekly e-mailed questionnaires. Primary exposure was defined as changes in weekly running distance. Data were analyzed with time-to-event models that produced cumulative risk difference as the measure of association. RESULTS: A total of 56 participants (21.5%) sustained an RRI during the 14-week study period. Twenty-one days into the study period, significantly more runners were injured when they increased their weekly running distance by 20% to 60% compared with those who increased their distance by less than 20% (risk difference, 22.6%; 95% confidence interval: 0.9%, 44.3%; P = .041). No significant difference was found after 56 and 98 days. No significant effect-measure modification by running schedule was found. CONCLUSION: Significantly more runners were injured 21 days into the study period when they increased their weekly running distances by 20% to 60% compared with those who increased their distances by less than 20%. LEVEL OF EVIDENCE: Prognosis, level 1b. J Orthop Sports Phys Ther 2019;49(4):230-238. Epub 7 Dec 2018. doi:10.2519/jospt.2019.8541.

IS THERE EVIDENCE FOR AN ASSOCIATION BETWEEN CHANGES IN TRAINING LOAD AND RUNNING-RELATED INJURIES? A SYSTEMATIC REVIEW.

BACKGROUND: Sudden changes (increases and decreases) in training load have been suggested to play a key role in the development of running-related injuries. However, the compiled evidence for an association between change in training load and running-related injury does not exist. PURPOSE: The purpose of the present systematic review was to compile the evidence from original articles examining the association between changes in training load and running-related injuries. STUDY DESIGN: Systematic review. METHODS: Four databases (Pubmed/Medline, SPORTDiscus, Embase, and Scopus) were systematically searched. Two reviewers screened titles, abstracts, and full-text articles independently. Articles were included if i) the study design was a randomized trial, a prospective cohort study, a cross-sectional study or a case-control study, ii) participants were runners between 18-65 years, and iii) specific information on changes in training load was provided. Methodological quality of included articles was assessed using the Newcastle Ottawa Scale and the PEDro rating scale. RESULTS: Four articles fulfilled the eligibility criteria of which three found an association between increases in training load and an increased risk of running-related injuries: This association was shown by an increased injury risk amongst runners: i) if they recently had performed one or more changes in either velocity and/or distance and/or frequency compared with the non-injured runners (p = 0.037), ii) increasing their average weekly running distance by more than 30% compared to an increase less than 10% (Hazard Ratio = 1.59 (95% Confidence Interval: 0.96; 2.66)), iii) increasing their total running distance significantly more the week before the injury origin compared with other weeks (mean difference: 86%; 95% Confidence Interval: 12%; 159%, p = 0.026). However, no difference was found between a 10% and a 24% average increase in weekly volume (HR = 0.8, 95% CI: 0.6; 1.3). CONCLUSION: Very limited evidence exists supporting that a sudden change in training load is associated with increased risk of running-related injury. LEVEL OF EVIDENCE: 2.

Design of ProjectRun21: a 14-week prospective cohort study of the influence of running experience and running pace on running-related injury in half-marathoners.

BACKGROUND: Participation in half-marathon has been steeply increasing during the past decade. In line, a vast number of half-marathon running schedules has surfaced. Unfortunately, the injury incidence proportion for half-marathoners has been found to exceed 30% during 1-year follow-up. The majority of running-related injuries are suggested to develop as overuse injuries, which leads to injury if the cumulative training load over one or more training sessions exceeds the runners' load capacity for adaptive tissue repair. Owing to an increase of load capacity along with adaptive running training, the runners' running experience and pace abilities can be used as estimates for load capacity. Since no evidence-based knowledge exist of how to plan appropriate half-marathon running schedules considering the level of running experience and running pace, the aim of ProjectRun21 is to investigate the association between running experience or running pace and the risk of running-related injury. METHODS: Healthy runners using Global Positioning System (GPS) watch between 18 and 65 years will be invited to participate in this 14-week prospective cohort study. Runners will be allowed to self-select one of three half-marathon running schedules developed for the study. Running data will be collected objectively by GPS. Injury will be based on the consensus-based time loss definition by Yamato et al.: "Running-related (training or competition) musculoskeletal pain in the lower limbs that causes a restriction on or stoppage of running (distance, speed, duration, or training) for at least 7 days or 3 consecutive scheduled training sessions, or that requires the runner to consult a physician or other health professional". Running experience and running pace will be included as primary exposures, while the exposure to running is pre-fixed in the running schedules and thereby conditioned by design. Time-to-event models will be used for analytical purposes. DISCUSSION: ProjectRun21 will examine if particular subgroups of runners with certain running experiences and running paces seem to sustain more running-related injuries compared with other subgroups of runners. This will enable sport coaches, physiotherapists as well as the runners to evaluate their injury risk of taking up a 14-week running schedule for half-marathon.

RUNNING INJURY DEVELOPMENT: THE ATTITUDES OF MIDDLE- AND LONG-DISTANCE RUNNERS AND THEIR COACHES.

BACKGROUND: Behavioral science methods have rarely been used in running injury research. Therefore, the attitudes amongst runners and their coaches regarding factors leading to running injuries warrants formal investigation. PURPOSE: To investigate the attitudes of middle- and long-distance runners able to compete in national championships and their coaches about factors associated with running injury development. METHODS: A link to an online survey was distributed to middle- and long-distance runners and their coaches across 25 Danish Athletics Clubs. The main research question was: "Which factors do you believe influence the risk of running injuries?". In response to this question, the athletes and coaches had to click "Yes" or "No" to 19 predefined factors. In addition, they had the possibility to submit a free-text response. RESULTS: A total of 68 athletes and 19 coaches were included in the study. A majority of the athletes (76% [95%CI: 66%; 86%]) and coaches (79% [95%CI: 61%; 97%]) reported "Ignoring pain" as a risk factor for running injury. A majority of the coaches reported "Reduced muscle strength" (79% [95%CI: 61%; 97%]) and "high running distance" (74% [95%CI: 54%; 94%]) to be associated with injury, while half of the runners found "insufficient recovery between running sessions" (53% [95%CI: 47%; 71%]) important. CONCLUSION: Runners and their coaches emphasize ignoring pain as a factor associated with injury development. The question remains how much running, if any at all, runners having slight symptoms or mild pain, are able to tolerate before these symptoms develop into a running-related injury. LEVEL OF EVIDENCE: 3b.

Reliability of video-based quantification of the knee- and hip angle at foot strike during running.

INTRODUCTION: In clinical practice, joint kinematics during running are primarily quantified by two-dimensional (2D) video recordings and motion-analysis software. The applicability of this approach depends on the clinicians' ability to quantify kinematics in a reliable manner. The reliability of quantifying knee- and hip angles at foot strike is uninvestigated. OBJECTIVE: To investigate the intra- and inter-rater reliability within and between days of clinicians' ability to quantify the knee- and hip angles at foot strike during running. METHODS: Eighteen recreational runners were recorded twice using a clinical 2D video setup during treadmill running. Two blinded raters quantified joint angles on each video twice with freeware motion analysis software (Kinovea 0.8.15). RESULTS: The range from the lower prediction limit to the upper prediction limit of the 95% prediction interval varied three to eight degrees (within day) and nine to 14 degrees (between day) for the knee angles. Similarly, the hip angles varied three to seven degrees (within day) and nine to 11 degrees (between day). CONCLUSION: The intra- and inter rater reliability of within and between day quantifications of the knee- and hip angle based on a clinical 2D video setup is sufficient to encourage clinicians to keep using 2D motion analysis techniques in clinical practice to quantify the knee- and hip angles in healthy runners. However, the interpretation should include critical evaluation of the physical set-up of the 2D motion analysis system prior to the recordings and conclusions should take measurement variations (3-8 degrees and 9-14 degrees for within and between day, respectively) into account. LEVEL OF EVIDENCE: 3.