Most groin pain results from musculotendinous injuries, but not all groin pain signifies simply a pulled muscle. The pain can stem from one or more musculoskeletal or nonmusculoskeletal origins, such as avulsion fracture, osteitis pubis, or hernia. While acute causes are often readily identified, chronic groin pain can present a diagnostic challenge. Paying close attention to the history can help identify acute causes such as strains and avulsion fractures; determining the location and nature of the pain can also help with diagnosis. Conservative treatment is often effective for treatment of acute injuries such as strains and avulsion fractures.

Background:Osteoarthritis is most prevalent in the knee and drives the growing incidence of total knee arthroplasty. There is a need to explore non-surgical treatment options to increase the portfolio of alternatives available. The study aimed to determine the clinical response to an autologous bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) intra-articular injection compared to an active comparator. Methods:The study was a prospective, single-blinded, randomized controlled pilot study. Participants with diagnosed knee osteoarthritis were allocated to one of two treatment groups to receive a BMAC injection immediately followed by a PRP injection or a single injection of Gel-One ® crosslinked hyaluronate (HA). Outcomes were assessed at 3, 6, and 12 months post-treatment. Results:Significant improvements were observed in both treatment groups for all Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales with the exception of the symptoms assessment at 12 months in the HA group. BMAC KOOS scores peaked at 12 months, while HA KOOS scores generally peaked at 6 months. The gap in mean scores at 12 months in favor of the BMAC group did not reach statistical significance. Secondary outcomes included a greater reduction in pain at 12 months in the BMAC group (-3.13 points; 95% CI: -3.96, -3.29) compared to the HA group (-1.56 points; 95% CI: -2.59, -0.53; p= 0.02) via the numeric pain rating scale. Conclusions:Results demonstrate that both treatment groups experienced clinically and statistically significant improvement across the KOOS subscales. While BMAC has shown promise in the treatment of knee OA, there is a need for multi-center investigations with larger sample sizes, an extended follow-up, and placebo-based control. ClinicalTrials.gov Identifier: NCT02958267 progressing to a surgical intervention in cases where non-surgical treatment fails to relieve the underlying symptoms [7][8][9] . The accepted option for knee OA when non-surgical options fail is total knee arthroplasty (TKA). The prevalence of knee arthroplasty increased 300% in the United States from 1990 to 2010 [10] . Considering the aging demographic in the United States, the demand for primary TKA is expected to increase by another twoto seven-folds by 2030 with associated costs increasing exponentially [11,12] . The growing costs [13] , added to the risk of complications associated with TKA [14] , demonstrates the importance of evaluating lower risk and lower cost options to manage the condition with intent to delay the need for surgical intervention or avoid surgical intervention in a subset of the population.Conservative treatment options such as physical exercise and weight loss are recommended as an initial option to OA. [7][8][9] Pain associated with knee OA is often treated with non-steroidal

This panel discussion and report was facilitated by Magellan Rx Manage-ment and funded by Sanofi. Bert and Ruane report fees from Sanofi outside of this project. Sgaglione reports royalty payments from Zimmer Biomet and Wolters Kluwer. Dasa has received fees from Bioventus and Myoscience. All the authors received an honorarium for work on this project. Lopes is employed by Magellan Rx Management.

IntroductionOsteoarthritis (OA) is common and its prevalence is increased in military service members. In a phase 3 randomized controlled trial (NCT02357459), a single intra-articular injection of an extended-release formulation of triamcinolone acetonide (TA-ER) in participants with unilateral or bilateral knee OA demonstrated substantial improvement in pain and symptoms. Bilateral knee pain has emerged as a confounding factor in clinical trials when evaluating the effect of a single intra-articular injection. Furthermore, unilateral disease is frequently first to emerge in active military personnel secondary to prior traumatic joint injury. In this post hoc analysis, we assessed efficacy and safety of TA-ER in a subgroup of participants with unilateral knee OA.MethodsParticipants ≥ 40 years of age with symptomatic knee OA were randomized to a single intra-articular injection of TA-ER 32 mg, TA crystalline suspension (TAcs) 40 mg, or saline-placebo. Average daily pain (ADP)-intensity and rescue medication use were collected at each of weeks 1–24 postinjection; Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-A (pain), WOMAC-B (stiffness), WOMAC-C (function), and Knee Injury and Osteoarthritis Outcome Score Quality of Life (KOOS-QoL) were collected at weeks 4, 8, 12, 16, 20, and 24 postinjection. Adverse events (AEs) were assessed throughout the study. Participants with unilateral knee OA were selected for this analysis.ResultsOf 170 participants with unilateral OA (TA-ER, N = 51; saline-placebo, N = 60; TAcs, N = 59), 42% were male and 89% were white. TA-ER significantly (p < 0.05) improved ADP-intensity vs. saline-placebo (weeks 1–24) and TAcs (weeks 4–21). TA-ER significantly (p < 0.05) improved WOMAC-A vs. saline-placebo (all time points) and TAcs (weeks 4, 8, 12, 24). Consistent outcomes were observed for rescue medication, WOMAC-B, WOMAC-C, and KOOS-QoL. AEs were similar in frequency/type across treatments.ConclusionTA-ER provided 5–6 months’ pain relief that consistently exceeded saline-placebo and TAcs, suggesting that TA-ER injected intra-articularly into the affected knee may be an effective non-opioid treatment option. Although the participants included in this analysis did not fully represent the diverse demographics of active service members, the substantial unmet medical need in the military population suggests that TA-ER may be an important treatment option; additional studies of TA-ER in active military patients are needed.Trial RegistrationClinicalTrials.gov NCT02357459.FundingFlexion Therapeutics, Inc.Plain Language SummaryPlain language summary available for this article.

Musculoskeletal and physical therapy intervention directed at decreasing musculoskeletal pain in obese individuals prior to participation in a WM program reduces reported musculoskeletal pain for those participants completing the program but does not significantly improve weight loss over 6 months, compared with individuals with comparable musculoskeletal pain who enter directly into a WM program.