Dr. Armaghan Mahmoudian

OBJECTIVE: To synthesize the literature and generate evidence and gap maps examining randomized controlled trial interventions and outcome measures for patellofemoral pain (PFP). DESIGN: A systematic evidence and gap map. LITERATURE SEARCH: PubMed, CINAHL Complete via EBSCO, PEDro, Scopus, SPORTDiscus (EBSCO), Embase via Ovid, Cochrane Database of Systematic Reviews via Ovid, Web of Science, and CENTRAL. STUDY SELECTION CRITERIA: Peer-reviewed randomized controlled trials (RCTs), pilot RCTs, and pilot feasibility RCTs evaluating interventions for PFP. DATA SYNTHESIS: Interventions were mapped against outcomes. The Cochrane Risk of Bias tool was used to assess risk of bias, and the PFP diagnosis checklist was used to assess the criteria used in each study to confirm a diagnosis of PFP. RESULTS: 307 studies were included. The most frequently included intervention was physical intervention, particularly therapeutic exercises (n=281, 82%), 59 studies (19%) included non-physical interventions. Pain outcomes were included in 274 studies (89%), and patient-reported physical function in 216 (70%). Other outcomes, such as activity or movement-related psychological factors, quality of life, and sleep, were infrequently assessed (each <10%). 207 studies (67%) were at high risk of bias, and 45 studies (15%) met the recommended PFP diagnostic criteria checklist. CONCLUSION: Among 307 RCTs, with approximately three-quarters published in the past 10 years, there was an uneven focus on physical interventions and pain and physical function outcomes.

Classification criteria for early-stage symptomatic knee osteoarthritis (EsSKOA) should discriminate individuals with EsSKOA from those with other causes of knee symptoms. We sought to identify conditions in the differential diagnosis of EsSKOA in adults with knee symptoms.
We conducted an online survey of clinicians. Those consulting monthly on at least five people with undiagnosed knee symptoms were eligible. From qualitative work and clinical experience, we developed three case scenarios representing possible EsSKOA: 1. 40-year-old with 1-month of knee stiffness and swelling; 2. 50-year-old with 8-months of knee discomfort while walking; and 3. 60-year-old with intense knee discomfort getting out of a car 1 week ago. For each scenario, participants indicated conditions on a pre-defined list that they would consider in the differential diagnosis, and the top three diagnoses based on clinical experience. The proportions that considered each condition and among the top three diagnoses for each scenario were summarized overall and by clinical discipline.
127 clinicians responded (43% female, 48% in practice ≤15 years, 50% university-affiliated practice, 7 clinical disciplines). Knee OA and meniscal injuries were among the top three conditions in the differential diagnosis for all three scenarios, followed by immune-mediated and crystal-induced inflammatory arthritis (scenario 1), patellofemoral pain syndrome (scenario 2), and collateral ligament injuries (scenario 3).
The differential diagnosis for EsSKOA in adults presenting with undiagnosed knee symptoms includes symptomatic established radiographic knee OA, patellofemoral pain syndrome, meniscal and collateral ligament injuries, and immune-mediated and crystal-induced inflammatory arthritis.

Objectives
Within the first phase of developing classification criteria for Early-stage Symptomatic Knee Osteoarthritis (EsSKOA), among individuals with knee osteoarthritis (OA) we explored: 1) symptoms within the first year of noticing their knee(s); 2) features that indicated OA was the cause; and 3) timing and reasons that initially prompted seeking healthcare.
Design
We conducted a cross-sectional online survey of individuals with knee OA recruited from Australia, Canada, the Netherlands, and the USA. Only individuals who indicated they recalled their first symptoms were eligible. Using free-text, participants described changes in how their knee looked, felt, moved, their overall state within the first year of noticing their knee(s), features perceived to indicate knee OA was the cause, and reasons for initially seeking healthcare. We assessed timing of seeking care by an ordinal scale. Data were analyzed using descriptive statistics and summative content analysis.
Results
We included 92 participants (median age 67 years [IQR 59,75], 69% women, median BMI 26 kg/m2 [IQR 24,30]). Within the first year from onset, frequently reported symptoms were knee pain (70%), swelling (58%), crepitus (42%), stiffness (29%), and instability (24%). While few could provide specific clinical features, approximately half (53%) perceived medical imaging as important to indicate OA. Only 35% sought healthcare within the first year of experiencing symptoms.
Conclusions
Individuals with knee OA recalled varied knee symptoms within the first year and few sought healthcare. We were unable to ascertain, from the perspective of patients, specific clinical features that indicated they had OA and not another condition.

Objectives The objectives were to determine the prevalence of meeting criteria for symptoms suggestive of early osteoarthritis (OA) following anterior cruciate ligament reconstruction (ACLR) and to characterize the longitudinal changes in these symptoms during the first two years post‐ACLR. Methods We analyzed data from 10231 patients aged 14‐40 years in the New Zealand ACL Registry who completed the Knee injury and Osteoarthritis Outcome Score (KOOS) at 6, 12, and 24 months post‐ACLR. Symptoms suggestive of early OA were defined as scoring ≤85% on at least 2 of 4 KOOS subscales. Longitudinal patterns of change were categorized as persistent, resolution, new, inconsistent, or no symptoms across the three visits. Prevalence and odds ratios (ORs) of symptoms were compared across visits, sex, and age groups using generalized estimating equations, and longitudinal patterns of symptom change were analyzed using multinomial logistic regression. Results Prevalence of meeting criteria of symptoms suggestive of early OA was 68% at 6 months, 54% at 12 months, and 46% at 24 months post‐ACLR. Longitudinally, 33% had persistent symptoms, 23% had no symptoms, 29% showed symptom resolution, 6% developed new symptoms, and 9% had inconsistent symptoms. Females consistently showed higher odds of symptoms (OR range:1.17‐1.52). Older age groups demonstrated higher odds of symptoms, particularly at 6 months (OR range:1.64‐2.45). Conclusion Symptoms suggestive of early OA are highly prevalent within two years post‐ACLR, with one‐third of patients experiencing persistent symptoms. These findings indicate that symptoms are more likely to persist rather than newly develop, emphasizing the importance of early identification and targeted interventions. image

To generate a list of candidate items potentially useful for discriminating individuals with Early-stage Symptomatic Knee Osteoarthritis (EsSKOA) from those with other conditions and from established osteoarthritis (OA), and to reduce this list based on expert consensus.
We conducted a three-round online international modified Delphi exercise with OA clinicians and researchers (“OA experts”). In Round 1, participants reviewed 84 candidate items and nominated additional item(s) potentially useful for EsSKOA classification; those nominated by ≥3 participants were added. In Round 2, participants rated perceived usefulness of 108 items (1 [not at all useful] to 9 [extremely useful]). In Round 3, participants could revise their ratings after reviewing Round 2 group median and quartiles. Following Round 3, we retained items with a median usefulness score >5 and ≥33.3% of participants categorised the item as useful (7 to 9), overall and in subgroup analysis by clinician field.
There were 128 participants in Round 1 and 113 (88%) completed all rounds. We retained 77 items that spanned multiple domains (demographics, symptoms, physical exam, performance-based measures, imaging, laboratory investigations, and gross inspection/arthroscopy). Highly rated items included (median usefulness score): prior knee joint injury (8), diagnosis of OA in a different joint (7), and activity-related knee pain (7). The interquartile range was most often 3.
We identified 77 items that OA experts consider potentially useful for EsSKOA classification. The results highlight experts’ uncertainty around item usefulness. Next, candidate items will be further assessed and reduced using data-driven and multicriteria decision analysis methods.

Objective: To investigate changes in socioeconomic inequalities in patient-related outcomes and pain medication use, following participation in a digital self-management intervention for osteoarthritis (OA) in Sweden.
Method: Participants with hip/knee OA enrolled in the digital intervention were included. Self-reported outcomes collected were the numerical rating scale (NRS) pain, activity impairment, general health, Knee/Hip injury and Osteoarthritis Outcome Score (KOOS-12, HOOS-12) Pain, Function, and Quality of Life subscales, 5-level EuroQol 5 Dimensions (EQ-5D-5L), Patient Acceptable Symptom State (PASS) for function, walking difficulties, fear of movement, wish for surgery, pain medication use, physical function measured by the 30s chair-stand test, and level of physical activity. Educational attainment was used as a socioeconomic measure and the concentration index was used to assess the magnitude of inequalities at baseline and 3 month follow-up.
Results: The study included 21,688 participants (mean ± sd age 64.1 ± 9.1 years, 74.4% females). All outcomes except for PASS demonstrated inequalities in favour of highly educated participants at both time-points, with highly educated participants reporting better outcomes. At 3 month follow-up, the magnitude of inequality widened for activity impairment, but narrowed for NRS pain, EQ-5D-5L, KOOS-12/HOOS-12 Pain and Function, physical function, and wish for surgery. There were no statistically conclusive changes in the magnitude of inequalities for the remaining outcomes.
Conclusions: There were inequalities in patient-related outcomes in favour of those with higher education among participants of a digital self-management intervention for OA, although the magnitude of these pre-existing inequalities generally narrowed after the 3 month intervention

Objective: To investigate changes in analgesic use before and after participation in a digital first-line treatment program (exercise and patient education) in persons with knee or hip OA and to explore associations between these changes in medication use and participant-reported pain and function.
Design: Retrospective cohort study with pre-post measures.
Setting: Community setting, Sweden.
Participants: Individuals (n=4100, mean [SD] age 64.5 [9.3], 73.3% females) participating in the digital program.
Interventions: A digital supervised education and exercise therapy.
Main Outcome Measures: Self-reported analgesic use for knee/hip pain during the past month at baseline and 12-week follow-up, knee/hip NRS pain (0-10, a higher value indicating more pain), and KOOS-12 or HOOS-12 Function subscale (0-100, higher values indicating better function). McNemar test, multivariable logistic regression and linear random intercept model were used for statistical analyses.
Results: Among participants, 61.4% and 49.4% were analgesic users at baseline and 12-week follow up, respectively, (absolute reduction 12.0%, 95%CI 10.5, 13.5). Being female, having hip OA, lower education, higher body mass index, living outside large metropolitan cities, co-existing rheumatoid arthritis, and walking difficulties were associated with higher odds of analgesic use at baseline. At both time points, persons not using analgesics at the time reported better outcomes. All groups but “new users” experienced improvements in their pain and function following participation in digital program with the greatest improvements observed among “quitters”.
Conclusion: Engaging in a digital exercise and patient education program as a primary treatment for knee or hip osteoarthritis was associated with a reduction in the use of analgesics. The greatest improvements were seen for those who stopped analgesic use. These results highlight the importance of providing effective first-line treatment to people with knee or hip OA.

Background: Sudden cardiac death in young athletes is a rare and tragic occurrence. A pre-participation physical examination (PPE) is widely used to identify athletes who might be at risk of sudden cardiac death. High school athletes in Escambia, Okaloosa, Santa Rosa, and Walton counties in Florida undergo annual sports physicals through a local sports medicine outreach program. A resting electrocardiogram (ECG) was implemented during the 2022 PPE. The aim of this study was to document the efficacy of implementing ECGs and to highlight the cardiac abnormalities identified in young athletes as part of a 1-d PPE.
Methods: In total, 1,357 high school athletes (males = 879 and females = 478; age, 15.1 ± 1.3 years) completed a resting 12-lead ECG. These were interpreted by cardiologists using the International Criteria, with abnormal results being further investigated before final sports clearance. Descriptive statistics regarding ECG findings were analyzed.
Results: Twenty-three ECGs (1.7%) were classified as “abnormal” and were referred for further testing. Of these, 14 athletes were cleared to participate in sports, and 6 declined further evaluation. Three athletes, all males, were not cleared for sports participation. Of these, 2 athletes presented with Wolf-Parkinson-White syndrome (0.15%), and 1 athlete (0.10%) presented with dilated cardiomyopathy.
Conclusion: Adding ECG screening as part of a single-day PPE can be used as a tool in identifying cardiac abnormalities among young athletes. To our knowledge, this is the highest number of athletes screened during a PPE in 1 d nationwide.

More than three decades ago, the American College of Rheumatology introduced the first widely accepted classification criteria for knee osteoarthritis (OA). These criteria provided a standardized framework for identifying OA in research settings1. Since then, OA clinical trials have recruited participants based on these criteria, but have failed to identify disease-modifying interventions, raising the possibility that the ACR criteria do not capture patients early enough for interventions to restore joint homeostasis and slow or arrest the OA disease process2, 3. While there have been efforts to define symptomatic early-stage knee OA4, 5, 6, widely accepted and validated criteria do not exist.