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Population & Epidemiology

Global prevalence and incidence of musculoskeletal and spinal disorders, focusing on demographic drivers and regional variations in disability burden.

Overview

Life course epidemiology concepts facilitate the study of back pain [1]. Substantial differences exist in reported prevalence rates of upper-extremity musculoskeletal disorders, mainly due to the absence of a universally accepted way of labelling or defining them [9]. The North Staffordshire Osteoarthritis Project (NorStOP) is a three-year prospective cohort study designed to determine the course, prognosis, and impact of clinical osteoarthritis on participation and health care use in a general population of older adults [6].

The study provides the first comprehensive North American population-based incidence of elbow dislocations, highlighting clinical burden and raising questions about outcomes [3]. It provides prevalence and incidence estimates for doctor-diagnosed Dupuytren’s disease useful for healthcare planning and resource allocation [7]. Older age is associated with poor overall survival in pleomorphic liposarcoma but not disease-specific survival [2]. Longer survival after treatment of metastatic bone disease is likely attributable to improvements in medical and surgical treatments [5].

Contemporary randomized controlled trials in spine surgery in the United States show a surprising absence of sociodemographic patient data, which potentially biases the generalizability of outcome data despite evidence of the importance of sociodemographic factors on surgical outcomes [24]. Studies need to include an equal number of male and female patients and be sufficiently powered to answer research questions for both sexes separately, with all raw data published disaggregated for sex and gender to improve the reporting of outcomes [46]. Congressionally directed research funding is believed to be constructive in the short term by emphasizing projects using relevant populations and approaches that benefit patients soon, defining best practice guidelines, and fielding new therapies to reduce complications and improve outcomes [12]. The AAOS developed Appropriate Use Criteria to guide clinicians in determining the appropriateness of prophylactic antibiotics for 64 patient scenarios based on evidence and expert opinion [19].

Anatomy & Pathophysiology

Osseous and Alignment

Osteophyte development follows a fairly constant pattern characteristic of each spinal region, with anterior osteophytes being more frequent and developed than posterior ones [32]. In asymptomatic populations, there is a decline in cervical lordosis curvature [68]. Chronic low back pain in males is associated with some lumbar vertebral bone mineral density (BMD) measures [67]. There is a relationship between sagittal spinal alignment and low back pain, which could allow for prospective identification of subjects prone to developing low back pain [76].

Soft Tissue and Degeneration

Immobilization induces intervertebral disc degeneration involving changes at the macroscale, microscale, and nanoscale, suggesting it may predispose to symptomatic spine development [41]. Few MRI findings showed large magnitude associations with symptom outcomes such as chronic low back pain or radicular symptoms, even when applying more specific definitions for spine-related symptom outcomes [8].

Biopsychosocial and Clinical Perspectives

Thoracic spine pain is associated with numerous risk factors across biopsychosocial categories, including concurrent musculoskeletal pain, psychological factors, and specific postural or lifestyle factors, though many associations were weak or inconsistent across studies [51]. Most people with persistent or recurrent low back pain adhere to the traditional biomedical perspective of anatomical/biomechanical causes for their pain, despite attempts to shift beliefs toward complex biopsychosocial factors [54].

Classification

Life Course Epidemiology: This conceptual framework can be adopted to facilitate the study of back pain [1].

Anatomic Variants: The study provides information to determine the prevalence of anatomic variants associated with femoroacetabular impingement in the general population [4].

Dupuytren’s Disease: Prevalence and incidence estimates for doctor-diagnosed Dupuytren’s disease are useful for healthcare planning and resource allocation [7].

Upper-Extremity Musculoskeletal Disorders: There are substantial differences in reported prevalence rates of upper-extremity musculoskeletal disorders, mainly due to the absence of a universally accepted way of labelling or defining them [9].

Low Back Pain: The prevalence rates of low back pain were constant over time at a group level, but did not necessarily involve the same individuals [18]. The correlation between scores on screening tools for low back pain was good, while the classification agreement between the screening instruments was low [62].

Ossification of the Spinal Ligaments: The prevalence of ossification of the spinal ligaments in the Chinese population was revealed [25].

Fracture Epidemiology: Differences in bone mineral density could potentially explain part of the urban-rural difference in fracture incidence [28].

Hamstring Injuries: Projections based on current trends estimate that the annual incidence of hamstring injuries will continue to rise through 2030 [31].

Scoliosis: The epidemiology of scoliosis has regional variation, and genetic differences may contribute to such differences [57].

Knee Osteoarthritis: The incidence of knee osteoarthritis is significantly different with regions, age, and sex [61].

HLA-B27: The prevalence of HLA-B27 in the normal population is significantly lower in Middle Eastern and Arab countries than in Western countries [64].

Other Considerations: The study provides the first comprehensive North American population-based incidence of elbow dislocations [3]. A considerable difference exists in both the number of surgeons and the proportion of total knee arthroplasties conducted across various settlement types, with only 0.6% of billed total knee arthroplasties occurring in rural areas despite 20% of the population living there [63].

Clinical Presentation

Demographics and Disease Burden

Age and Survival: Older age is associated with poor overall survival but not disease-specific survival in pleomorphic liposarcoma [2]. Incidence Trends: The incidence of concussion diagnosed in the general US population is increasing, driven largely by a substantial rise in the adolescent age group [14]. Prevalence Estimates: Morphological variations associated with femoroacetabular impingement have defined prevalence rates in the general population of nonprofessional athletes [4]. Prevalence and incidence estimates for doctor-diagnosed Dupuytren’s disease are available for healthcare planning and resource allocation [7]. The incidence of elbow dislocations in a Canadian metropolitan health region was comprehensively established as a population-based incidence study [3].

Chronic Pain and Prognostic Indicators

Low Back Pain: Prevalence rates of low back pain were constant over time at a group level, but did not necessarily involve the same individuals [18]. Few MRI findings showed large magnitude associations with chronic low back pain or radicular symptom outcomes [8]. The presence of comorbidities is associated with poorer care for low back pain [37]. Pelvic Girdle Pain: Persistency and/or duration of pain symptoms, as well as widespread pain, are the strongest predictors of poor long-term outcome in pelvic girdle pain 12 years postpartum [10]. Fibromyalgia: Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia [36]. Spondyloarthritis: Age, gender, and symptom duration do not have an impact on the longitudinal relationship between serum uric acid and patients' global assessment of disease activity in male patients with axial spondyloarthritis [17].

Triage, Screening, and Identification

Risk Stratification Tools: The StarT back screening tool and a pain mannequin improve triage in individuals with low back pain at risk of a worse prognosis [33]. Both the StarT back screening tool and a pain mannequin identified individuals at risk, but they captured different aspects and different numbers of individuals at high risk of a worse prognosis [33]. Clinical Challenges: Identifying the subset of osteoporotic patients with low BMD who require treatment is a major clinical challenge [15]. Primary Care Guidance: Guidelines for chronic low back pain should emphasize early identification of yellow flags in primary care [16]. Follow-up Engagement: One-year response rates for web-based follow-up are significantly associated with demographic characteristics, health status, and individualized attention via additional testing [11].

Injury Patterns and Mechanisms

Sports Injuries: Sex- and age-related differences exist among diagnoses and injury mechanisms involving emergency department visits for ankle-related basketball injuries [34].

Investigations

Plain radiography: Morphological variations associated with femoroacetabular impingement have a defined prevalence in the general population, as determined by a study of 1878 asymptomatic hips in nonprofessional athletes [4]. The natural history of progression patterns for vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals has been clarified [13]. Bilateral knee osteoarthritis is very common with time, as the majority of sufferers will eventually develop radiographic disease in both knees [50]. Female gender, radiographic knee osteoarthritis, and low back pain at baseline are risk factors for lumbar disc height narrowing [52].

MRI: Few MRI findings show large magnitude associations with chronic low back pain or radicular symptom outcomes [8]. SpineNet offers potential to grade lumbar spinal stenosis in large-scale epidemiological studies involving high volumes of MRI spine data with a high level of consistency and objectivity [21].

CT: Opportunistic CT screening for osteoporosis should not be considered a substitute for the accepted standard diagnostic method of dual x-ray absorptiometry (DXA) [60].

Other Considerations: The incidence of diagnosed concussion in the general US population is increasing, driven largely by a substantial rise in the adolescent age group [14]. Identifying the subset of osteoporotic patients with low bone mineral density (BMD) who require treatment remains a major clinical challenge [15]. Substantial heterogeneity across musculoskeletal cohorts suggests that patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes [22]. The prevalence of ossification of the spinal ligaments (OSL) has been revealed in the Chinese population through a cross-sectional study of 2000 consecutive individuals [25]. Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives because the musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends [26]. Urbanization influences bone mineral density, which could potentially explain part of the urban-rural difference in fracture incidence [28]. The incidence of anterior cruciate ligament reconstruction (ACLR) is increasing, especially among females and among younger cohorts under 20 years of age [29]. The overall incidence rate of severe low back pain in young male military recruits is 0.05%, reflecting that severe occurrences are not common in this age group [30]. Surgical incidence after knee MRI is likely appropriately lower for older patients [35]. Early detection and treatment reduced the risk of scoliotic curves progressing to 40 degrees or more by at least 63 per cent [59].

Treatment

Non-Operative

Successful management of femoroacetabular impingement with return to play was achieved by both nonoperative and operative treatment methods [83]. Most cases of pediatric tibial spine fractures are treated nonoperatively [65]. Guidelines for chronic low back pain should emphasize early identification of yellow flags in primary care [16]. Future studies on chronic low back pain in primary care should focus on identifying specific patient groups to achieve effective treatment allocation [39]. Adoption of concepts and methods from life course epidemiology could facilitate the study of back pain [1].

Operative

Indications: Surgical management is indicated for progressive, painful, unilateral coxa vara deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery [70]. The AAOS developed Appropriate Use Criteria to guide clinicians in determining the appropriateness of prophylactic antibiotics for 64 patient scenarios based on evidence and expert opinion [19].

Other Considerations: Patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes due to substantial heterogeneity across musculoskeletal cohorts [22]. The role of the team physician requires a balance between surgical and nonoperative management amidst external pressures [71]. Longer survival after treatment of metastatic bone disease is likely attributable to improvements in both medical and surgical treatments [5]. Older age is associated with poor overall survival but not disease-specific survival in pleomorphic liposarcoma [2].

Complications

Other Considerations: Pleomorphic liposarcoma: Older age is associated with poor overall survival in patients with pleomorphic liposarcoma [2]. Pelvic girdle pain: Persistency and/or duration of pain symptoms appear to be the strongest predictors of poor long-term outcome in pelvic girdle pain [10]. Widespread pain appears to be the strongest predictor of poor long-term outcome in pelvic girdle pain [10]. Chronic low back pain: Depression and anxiety at baseline are associated with greater disability at long-term follow-up in chronic low back pain patients compared to insomnia [27]. Arena football players: Years of experience is the only factor associated with severe injuries in arena football players [72].

Recovery

The natural history of musculoskeletal conditions varies significantly by pathology and demographic factors. In elderly individuals, the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures has been clarified [13]. For pleomorphic liposarcoma, older age is associated with poor overall survival but not disease-specific survival [2]. Conversely, longer survival after treatment of metastatic bone disease is likely attributable to improvements in both medical and surgical treatments [5]. In geriatric hip fracture, mortality is independently associated with DNA methylation age, which was approximately 17 years greater than chronological age in the mortality cohort [85].

Long-term outcomes and recovery trajectories are influenced by specific clinical predictors and interventions. For pelvic girdle pain, persistency and/or duration of pain symptoms as well as widespread pain appear to be the strongest predictors of poor long-term outcome 12 years postpartum [10]. Among individuals with long-lasting low back pain, high expectancies of returning to work were strongly associated with successful return to work [56]. Associations of depression and anxiety at baseline with disability at a five-year follow-up point among outpatients with chronic low back pain might be greater than that of insomnia at baseline [27]. Functional ability and health-related quality of life improved after rehabilitation in a structured national rehabilitation program in patients with musculoskeletal disorders [48].

Specific procedural and demographic factors also impact recovery metrics. One-year response rate for web-based follow-up is significantly associated with demographic characteristics, health status, and individualized attention via additional testing [11]. Age, gender, and symptom duration do not have an impact on the longitudinal relationship between serum uric acid and patients' global assessment of disease activity in male patients with axial spondyloarthritis [17]. Improvements in orthopaedic surgery residents’ ability to objectively measure intracompartmental pressures in a compartment syndrome model were maintained at the nine-month follow-up [58].

Further research is required to define long-term structural integrity and natural history for certain conditions. Further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time after Autologous Matrix-Induced Chondrogenesis for treatment of focal cartilage defects in the knee [43]. The natural history of idiopathic scoliosis in children six to fourteen years old may be becoming more benign spontaneously [23]. Adoption of concepts and methods from life course epidemiology could facilitate the study of back pain [1]. The North Staffordshire Osteoarthritis Project (NorStOP) is a three-year prospective cohort study designed to determine the course, prognosis, and impact of clinical osteoarthritis on participation and health care use in a general population of older adults [6].

Key Evidence

  • [L5] Adoption of concepts and methods from life course epidemiology could facilitate this. (10.1186/1471-2474-11-23)
  • [L3] Older age is associated with poor overall survival but not disease-specific survival. (10.1186/s13018-021-02327-3)
  • [L4] The study provides the first comprehensive North American population-based incidence of elbow dislocations, highlighting the clinical burden and raising questions about outcomes. (10.1111/j.1758-5740.2010.00084.x)
  • [L3] This study provides information to determine the prevalence of these anatomic variants in the general population. (10.1177/2325967120977892)
  • [L4] Longer survival is likely attributable to improvements in both medical and surgical treatments. (10.5435/jaaos-d-23-00332)
  • [L4] This study protocol describes a three-year prospective cohort study designed to determine the course, prognosis, and impact of clinical osteoarthritis on participation and health care use in a general population of older adults. (10.1186/1471-2474-5-2)
  • [L3] The study provides prevalence and incidence estimates useful for healthcare planning and resource allocation. (10.1177/1753193416687914)
  • [L2] Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. (10.1186/1471-2474-15-152)
  • [L1] There are substantial differences in reported prevalence rates on UEDs, mainly due to the absence of a universally accepted way of labelling or defining UEDs. (10.1186/1471-2474-7-7)
  • [L2] Persistency and/or duration of pain symptoms as well as widespread pain appear to be the strongest predictors of poor long-term outcome. (10.1186/s12891-017-1760-5)
  • [L2] One year response rate was significantly associated with demographic characteristics, health status, and individualized attention via additional testing. (10.1186/1471-2474-12-132)
  • [L5] The authors believe that congressionally directed research funding will be constructive in the short term by emphasizing projects using relevant populations and approaches that benefit patients soon, defining best practice guidelines and fielding new therapies to reduce complications and improve outcomes. (10.5435/00124635-201102001-00009)
  • [L2] This study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals. (10.1186/s12891-024-07254-y)
  • [L4] The incidence of concussion diagnosed in the general US population is increasing, driven largely by a substantial rise in the adolescent age group. (10.1177/2325967116662458)
  • [L5] A major clinical challenge is identifying the subset of osteoporotic patients with low BMD who require treatment. (10.1002/jor.22626)
  • [L4] Guidelines should emphasize early identification of these yellow flags in primary care. (10.1186/s12891-022-05397-4)
  • [L2] Age, gender and symptom duration do not have an impact on the relationships. (10.1186/s12891-022-05657-3)
  • [L2] The prevalence rates of LBP, when defined in a number of ways, were constant over time at a group level, but did not necessarily involve the same individuals. (10.1186/s12891-016-1377-0)
  • [L5] The AAOS developed Appropriate Use Criteria to guide clinicians in determining the appropriateness of prophylactic antibiotics for 64 patient scenarios based on evidence and expert opinion. (10.5435/jaaos-d-17-00006)
  • [L3] Thus SpineNet offers potential to grade LSS in large-scale epidemiological studies involving a high volume of MRI spine data with a high level of consistency and objectivity. (10.1186/s12891-020-3164-1)
  • [L4] The substantial heterogeneity across musculoskeletal cohorts suggests that patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes. (10.1186/1471-2474-14-83)
  • [L4] The results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously. (10.2106/00004623-199609000-00006)
  • [L2] Despite evidence of the importance of sociodemographic factors on surgical outcomes, this study identifies a surprising absence of sociodemographic data within contemporary RCTs in spine surgery, which potentially biases the generalizability of outcome data. (10.5435/jaaos-d-22-00838)
  • [L4] The prevalence of OSL in the Chinese was revealed. (10.1186/s12891-019-2569-1)
  • [L5] Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives, as the musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends. (10.2106/jbjs.22.01155)
  • [L2] The associations of depression and anxiety at baseline with disability at the long-term follow-up point might be greater than that of insomnia at baseline. (10.1186/s12891-023-06682-6)
  • [L4] This difference could potentially explain part of the urban-rural difference in fracture incidence. (10.1186/1471-2474-6-5)
  • [L3] The incidence of ACLR is increasing in Alberta, especially among females and among younger cohorts under 20 years of age. (10.1007/s00167-022-07093-1)
  • [L3] The lower than expected overall incidence rate of 0.05% reflects that severe LBP occurrences are not common in this age group. (10.1186/s12891-016-1136-2)
  • [L5] Projections based on current trends estimate that the annual incidence of these injuries will continue to rise. (10.1016/j.asmr.2025.101295)
  • [L3] Both screening tools identified individuals at risk, but they captured different aspects and different numbers of individuals at high risk of a worse prognosis. (10.1186/s12891-019-2836-1)
  • [L4] Sex- and age-related differences exist among diagnoses and injury mechanisms that involved ED visits. (10.1177/23259671251399846)
  • [L3] Surgical incidence after MRI was likely appropriately lower for older patients. (10.1177/23259671211052560)
  • [L3] Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. (10.1371/journal.pone.0138024)
  • [L3] The presence of comorbidities is associated with poorer care for low back pain. (10.1186/s12891-018-2316-z)
  • [L4] Future studies should focus on identifying this group to achieve effective treatment allocation. (10.1186/1471-2474-14-294)
  • [L5] The degeneration involved changes at the macroscale, microscale, and nanoscale, suggesting immobilization is not an innocuous strategy and may predispose to symptomatic spine development. (10.1186/s12891-018-2235-z)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L5] Studies need to include an equal number of male and female patients and be sufficiently powered to answer research questions for both sexes separately, with all raw data published disaggregated for sex and gender to improve the reporting of outcomes. (10.1302/0301-620x.106b7.bjj-2024-0594)
  • [L3] Functional ability and health related quality of life improved after rehabilitation. (10.1186/1471-2474-14-57)
  • [L2] Bilateral knee osteoarthritis is very common with time, as the majority of sufferers will eventually develop radiographic disease in both knees. (10.1186/1471-2474-13-153)
  • [L2] The review identified numerous associated and risk factors for thoracic spine pain across biopsychosocial categories, including concurrent musculoskeletal pain, psychological factors, and specific postural or lifestyle factors, though many associations were weak or inconsistent across studies. (10.1186/1471-2474-10-77)
  • [L2] This population-based cohort study quantitatively evaluated lumbar disc height using radiographic measurements and identified female gender, radiographic knee osteoarthritis, and low back pain at baseline as risk factors for disc height narrowing. (10.1186/s12891-015-0798-5)
  • [L4] Despite continuing attempts to shift pain beliefs to more complex biopsychosocial factors, most people with LBP adhere to the traditional biomedical perspective of anatomical/biomechanical causes. (10.1186/s12891-017-1831-7)
  • [L2] Among individuals with long lasting low back pain high expectancies of returning to work were strongly associated with successful return to work. (10.1186/s12891-016-1314-2)
  • [L4] This study indicates that epidemiology of scoliosis has regional variation, and genetic differences may contribute such difference. (10.1186/s12891-016-1140-6)
  • [L4] These improvements were maintained at the nine-month follow-up. (10.2106/jbjs.m.00582)
  • [L3] Early detection and treatment reduced the risk of scoliotic curves progressing to 40 degrees or more by at least 63 per cent. (10.2106/00004623-198163030-00002)
  • [L5] However, opportunistic CT screening should not be considered a substitute for the accepted standard diagnostic method of dual x-ray absorptiometry (DXA). (10.2106/jbjs.17.01376)
  • [L5] The incidence of knee osteoarthritis is significantly different with regions, age and sex. (10.1186/s12891-024-07191-w)
  • [L4] The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. (10.1186/s12891-018-2082-y)
  • [L3] A considerable difference exists in both the number of surgeons and the proportion of TKAs conducted across various settlement types, with only 0.6% of billed TKAs occurring in rural areas despite 20% of the population living there, indicating a gap in orthopaedic care access. (10.5435/jaaos-d-24-00391)
  • [L1] The prevalence of HLA-B27 in the normal population is significantly lower in the Middle Eastern and Arab countries than in Western Countries. (10.1186/s12891-017-1639-5)
  • [L3] Most cases in this study were treated nonoperatively. (10.1016/j.asmr.2021.12.005)
  • [L3] CLBP in males is associated with some lumbar vertebral BMD measures, raising important questions about the mechanism and potential clinical impact of this association. (10.1186/1471-2474-13-49)
  • [L4] The findings of this study indicate a decline in cervical lordosis curvature over the past eight years. (10.1186/s12891-026-09510-9)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L5] The author emphasizes that the role of the team physician is evolving, requiring availability, trust, and the ability to navigate complex return-to-play decisions amidst external pressures, while advocating for a balance between surgical and nonoperative management. (10.1177/0363546512468428)
  • [L2] Years of experience was the only factor that was associated with severe injuries. (10.1177/2325967118780040)
  • [L4] This study shows a relationship between sagittal spinal alignment and LBP in Tanzania, which could allow for prospective identification of subjects prone to developing LBP in the future. (10.1186/s12891-019-2953-x)
  • [L3] The successful management of FAI with return to play was achieved by both nonoperative and operative treatment methods. (10.1177/23259671221084979)
  • [L2] Mortality was independently associated with the DNA methylation age, and that age was approximately 17 years greater than chronological age in the mortality cohort. (10.2106/jbjs.23.01468)

See Also

References

[1] Extending conceptual frameworks: life course epidemiology for the study of back pain. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-23

[2] Survivorship and prognostic factors for pleomorphic liposarcoma: a population-based study. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02327-3

[3] Elbow Dislocations in a Canadian Metropolitan Health Region: A 3-Year Population-Based Incidence Study. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00084.x

[4] Prevalence of Morphological Variations Associated With Femoroacetabular Impingement According to Age and Sex: A Study of 1878 Asymptomatic Hips in Nonprofessional Athletes. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967120977892

[5] Life Expectancy After Treatment of Metastatic Bone Disease: An International Trend Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00332

[6] The North Staffordshire Osteoarthritis Project – NorStOP: Prospective, 3-year study of the epidemiology and management of clinical osteoarthritis in a general population of older adults. BMC Musculoskeletal Disorders. 2004. DOI: 10.1186/1471-2474-5-2

[7] Prevalence and incidence of doctor-diagnosed Dupuytren’s disease: a population-based study. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193416687914

[8] Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-152

[9] Incidence and prevalence of upper-extremity musculoskeletal disorders. A systematic appraisal of the literature. BMC Musculoskeletal Disorders. 2006. DOI: 10.1186/1471-2474-7-7

[10] Prevalence and predictors of persistent pelvic girdle pain 12 years postpartum. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1760-5

[11] Predictors of web-based follow-up response in the Prevention of Low Back Pain in the Military Trial (POLM). BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-132

[12] Congressionally Directed Research Will Improve Outcomes Through Funding Opportunities for Orthopaedics. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201102001-00009

[13] Progression of vertebral deformity of prevalent vertebral fractures in the elderly: a population-based study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07254-y

[14] The Rise of Concussions in the Adolescent Population. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116662458

[15] Research perspectives: The 2013 AAOS/ORS research symposium on Bone Quality and Fracture Prevention. Journal of Orthopaedic Research. 2014. DOI: 10.1002/jor.22626

[16] A cross-sectional hospital-based study of correlates of disability in patients with chronic low back pain in KwaZulu-Natal, South Africa. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05397-4

[17] The serum uric acid is longitudinally related to patients global assessment of disease activity in male patients with axial spondyloarthritis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05657-3

[18] Individual courses of low back pain in adult Danes: a cohort study with 4-year and 8-year follow-up. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-016-1377-0

[19] Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-17-00006

[21] Could automated machine-learned MRI grading aid epidemiological studies of lumbar spinal stenosis? Validation within the Wakayama spine study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3164-1

[22] Heterogeneity in health status and the influence of patient characteristics across patients seeking musculoskeletal orthopaedic care – a cross-sectional study. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-83

[23] Late-Onset Idiopathic Scoliosis in Children Six to Fourteen Years Old. A Cross-Sectional Prevalence Study. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199609000-00006

[24] Few Randomized Controlled Trials in Spine Surgery in the United States Include Sociodemographic Patient Data: A Systematic Review. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00838

[25] Epidemiology of ossification of the spinal ligaments and associated factors in the Chinese population: a cross-sectional study of 2000 consecutive individuals. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2569-1

[26] Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.22.01155

[27] The associations of depression, anxiety, and insomnia at baseline with disability at a five-year follow-up point among outpatients with chronic low back pain: a prospective cohort study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06682-6

[28] Effect of urbanization on bone mineral density: A Thai epidemiological study. BMC Musculoskeletal Disorders. 2005. DOI: 10.1186/1471-2474-6-5

[29] Increasing incidence of anterior cruciate ligament reconstruction: a 17‐year population‐based study. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07093-1

[30] The incidence and worsening of newly diagnosed low back pain in a population of young male military recruits. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1136-2

[31] Increased Incidence of Hamstring Injuries in the United States From 2015 to 2024 and Projected Growth Through 2030. Arthroscopy, Sports Medicine, and Rehabilitation. 2025. DOI: 10.1016/j.asmr.2025.101295

[32] Osteophytes of the Vertebral Column: An Anatomical Study of Their Development According to Age, Race, and Sex with Considerations as to Their Etiology and Significance.. The Journal of Bone and Joint Surgery. American Volume. 1962.

[33] The StarT back screening tool and a pain mannequin improve triage in individuals with low back pain at risk of a worse prognosis – a population based cohort study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2836-1

[34] Epidemiology of Ankle-Related Basketball Injuries Treated in Emergency Departments During 2014-2023. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251399846

[35] Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient’s Age and Sex. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211052560

[36] The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey. PLOS ONE. 2015. DOI: 10.1371/journal.pone.0138024

[37] What is the association between the presence of comorbidities and the appropriateness of care for low back pain? A population-based medical record review study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2316-z

[39] Chronic low back pain patient groups in primary care – A cross sectional cluster analysis. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-294

[41] Intervertebral disc degeneration induced by long-segment in-situ immobilization: a macro, micro, and nanoscale analysis. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2235-z

[43] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[46] Sex and gender in orthopaedic research. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b7.bjj-2024-0594

[48] Promoting work ability in a structured national rehabilitation program in patients with musculoskeletal disorders: outcomes and predictors in a prospective cohort study. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-57

[50] Is knee osteoarthritis a symmetrical disease? Analysis of a 12 year prospective cohort study. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-153

[51] Thoracic spine pain in the general population: Prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-77

[52] Risk factors for lumbar intervertebral disc height narrowing: a population-based longitudinal study in the elderly. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0798-5

[54] Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1831-7

[56] Do expectancies of return to work and Job satisfaction predict actual return to work in workers with long lasting LBP?. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1314-2

[57] Scoliosis epidemiology is not similar all over the world: a study from a scoliosis school screening on Chongming Island (China). BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1140-6

[58] The Effect of Focused Instruction on Orthopaedic Surgery Residents’ Ability to Objectively Measure Intracompartmental Pressures in a Compartment Syndrome Model. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00582

[59] The changing pattern of scoliosis treatment due to effective screening.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163030-00002

[60] Clinical Use of Opportunistic Computed Tomography Screening for Osteoporosis. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01376

[61] Regional disparities, age-related changes and sex-related differences in knee osteoarthritis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07191-w

[62] Risk classification of patients referred to secondary care for low back pain. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2082-y

[63] Utilization of Total Knee Arthroplasty in the United States by Settlement Type: Is There Equity of Access?. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00391

[64] HLA B27 antigen in Middle Eastern and Arab countries: systematic review of the strength of association with axial spondyloarthritis and methodological gaps. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1639-5

[65] The Incidence of Pediatric Tibial Spine Fractures Is Greater and Peaks Later in Male Patients. Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2021.12.005

[67] Chronic low back pain is associated with reduced vertebral bone mineral measures in community-dwelling adults. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-49

[68] A cervical lordosis curvature decline in Chinese asymptomatic populations from 2016 to 2024: a comparative analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09510-9

[70] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[71] Presidential Address of the American Orthopaedic Society for Sports Medicine. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512468428

[72] Injuries in the Chinese Arena Football League: American Versus Chinese Players. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118780040

[76] Risk factors of low back pain and the relationship with sagittal vertebral alignment in Tanzania. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2953-x

[83] Incidence of Symptomatic Femoroacetabular Impingement: A 4-Year Study at a National Collegiate Athletic Association Division I Institution. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221084979

[85] Blood and Bone-Derived DNA Methylation Ages Predict Mortality After Geriatric Hip Fracture. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.01468

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