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Athletes with Osteoarthritis With emphasis on Runners.

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Loeser, Rheum Dis Clin North America, Aug 2000. Hyaluronic Acid ... Lievense AM et al. Arthritis Rheum 2003. Soccer & Ballet: conflicting evidence for Hip OA ... – PowerPoint PPT presentation

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Title: Athletes with Osteoarthritis With emphasis on Runners.


1
Athletes with OsteoarthritisWith emphasis on
Runners.
  • Kevin deWeber, MD, FAAFP
  • Director, Primary Care Sports Medicine Fellowship
  • Uniformed Services University
  • Bethesda, MD

2
Objectives to discuss
  • Diagnosis of Osteoarthritis
  • Risk factors for Osteoarthritis
  • Treating athletes with Osteoarthritis

3
(No Transcript)
4
Definition of OA
  • Disease of the joints characterized by
  • Progressive articular cartilage loss
  • New subchondral bone formation
  • New bone and cartilage formation at joint margins
  • Low level synovitis

PAIN!
5
Clinical Diagnosis
  • Joint Pain
  • Typical Pain Pattern
  • Xray Findings
  • Standing films
  • AP with 30 deg flexion
  • No Sign of Zebras

6
Pathogenesis of OsteoarthritisAn Interplay of
Factors
Dieppe, American Academy of Orthopaedic
Surgeons, 1995
7
Articular Cartilage Where the rubber meets the
road
  • The Living Sponge
  • Shock Absorption Water Content Proteoglycan
    Synthesis
  • Limited Supply!! One Time Offer!!
  • Sure Bets Death, Taxes, Cartilage Fibrillation

8
Articular Cartilage
Glycosaminoglycan
9
Articular Cartilage
  • The Living Sponge
  • Shock Absorption Water Content
    Glycosaminoglycan
  • Limited Supply!! One Time Offer!!

10
Pathogenesis in OA
  • Decreases in
  • Water content
  • Proteoglycan synthesis
  • Collagen x-linking
  • Size of Aggrecan, GAG Hyaluronic acid
  • Traumatic damage

11
Epidemiology of OA
  • In U.S. by age 60
  • 100 histologic evidence of OA
  • 80 radiographic evidence of OA
  • 40 report pain c/w OA
  • 10 report activity limitation from OA
  • In U.S. by age 30
  • 3 symptomatic OA

Felson, Annals Int Med, Oct 2000 Loeser, Rheum
Dis Clin North America, Aug 2000
12
Cartilage Proteoglycan
13
Pathogenesis of Osteoarthritis Structure of
Cartilage Proteoglycan
Decreased Synthesis
14
Pathogenesis of OsteoarthritisAge Related
Changes to Cartilage
  • Intrinsic Factors
  • Water content
  • Proteoglycan content
  • Matrix integrity
  • Age Related Change
  • Decreases in
  • Water content
  • Proteoglycan synthesis
  • Collagen x-linking
  • Size of Aggrecan, GAG Hyaluronic acid
  • Increases in
  • Crystals/Calcification

Loeser, Rheum Dis Clin North America, Aug 2000
15
Case 1
  • 40 yo male club runner
  • My girlfriends cousin said running can cause
    arthritis. Is that true?

16
Does Running Cause Osteoarthritis?
We dont know conclusively!
(but there are some associations)
17
  • Influence of sporting activities on the
    development of OA of the hip a systematic
    review.
  • Arthritis Rheum 2003 Apr49(2)228-36
  • Lievense AM et al
  • Running 10 studies reviewed
  • Moderate evidence of positive association
    between running and hip OA
  • gt3 high-quality case-control studies w/
    consistent findings
  • Odds Ratio 1.7 12.4

18
  • Is Excessive Running Predictive of Degenerative
    Hip Disease?
  • British Medical Journal 1989
  • Marti B at al
  • Elite distance runners, bobsledders, controls
  • Increased hip OA in runners xrays
  • O.R. 12.4
  • Age, mileage, running pace predictive of OA
  • Signif. more OA in those running gt60 mi/week

19
  • Risk of OA associated with long-term
    weight-bearing sports a radiologic survey of the
    hips and knees in female ex-athletes and
    population controls.
  • Arthritis Rheum 1996
  • Spector TD et al
  • Elite female runners (n67) and tennis (n14)
  • Age 40-65, ? mileage
  • Age matched controls
  • Radiographs
  • Results O.R. 2-3 for knee and hip OA

20
  • OA of weight bearing joints of lower limbs in
    former elite male athletes.
  • BMJ 1994
  • Kujala et al
  • Elite male endurance athletes (runners
    x-country skiers) vs age-matched military
    recruits
  • O.R. 1.7 for OA of hip, knee

21
  • Sports and osteoarthrosis of the hip an
    epidemiologic study.
  • Am J Sports Med 1993
  • Vingard E, Alfredsson L et al
  • Long distance male runners vs controls
  • O.R. 2.1 for hip OA

22
Physical activity and self-reported,
physician-diagnosed osteoarthritis is physical
activity a risk factor.J Clin Epidemiol
2000Cheng Y et al.
  • 10-year survey of 17,000 Cooper Clinic pts
  • Self-report of physician diagnosis of OA
  • gt20 miles/wk walking or running signif. increased
    risk of OA (H.R. 2.4)
  • only men age 20-49

23
  • Long distance running and knee OA A Prospective
    Study
  • J Preventive Med 2008
  • Chakravarty et al

neg
  • 45 long-distance runners, 53 controls
  • Middle aged adults, ave. 58
  • Running minutes/wk 214 vs 28
  • Followed for 18 years (xrays, pain)
  • No difference in joint space, pain score, or
    incidence/severity of OA

24
Knee Osteoarthritis in former Runners, Soccer
players, Weight lifters, and Shooters Arthritis
Rheumatology 1995Kujala UM et al
neg
  • 117 Finnish world-class athletes
  • 28 were runners
  • Knee OA significantly associated with
  • Prior knee injury
  • (O.R. 4.73)
  • Increased BMI
  • (O.R. 1.76)

25
  • The Effect of Running on the Pathogenesis of
    Osteoarthritis in the Hips and Knees
  • Clinical Orthopaedics 1985
  • Sohn R, Micheli L

neg
  • 504 former collegiate swimmers runners
  • Runners averaged 25 miles/week
  • Followed for 25 years
  • No difference in severe knee pain (2)

26
neg
  • Is Running Associated with Degenerative Joint
    Disease?
  • JAMA 1986
  • Panush R et al
  • All subjects male, age 50
  • 17 runners (28 miles/week for 12 yrs)
  • 18 non-runners
  • No difference in clinical exams or x-rays

27
The relationship of running to osteoarthritis of
the knee and hip and bone mineral density of the
lumbar spine a 9 year longitudinal study.J
Rheumatol 1998Lane N et al
neg
  • 33 runners 33 matched non-runners
  • 9 year study, annual exams and radiographs
  • No difference in OA incidence
  • similar increase in symptoms x-rays in both
    groups

28
Running and the development of disability with
age.Ann Internal Med 1994Fries JF et al
neg
  • Followed 451 club runners and 330 non-runners
  • Ages 50-72
  • 8 year duration
  • Runners ave. 26 miles/week
  • Results runners had LOWER incidence of MSk
    disability and mortality
  • Didnt look specifically at OA

29
Strong Risk Factor for OA Obesity
  • 10 lb increase in weight 40 increase in knee
    osteoarthritis
  • Larger effect in women
  • (Felson et. al.
  • Ann Int Med 1992, Framingham Heart Cohort data)

30
Strong Risk Factor for OA Joint Trauma
31
(No Transcript)
32
Moderate Risk Factor for OA Certain Vocational
Activities
  • Jobs requiring repetitive knee bending/moderate
    activity predict higher rates of osteoarthritis
  • Felson et al
  • Annals of Int Med 1992

33
What other activities increase risk of HIP OA?
  • Heavy lifting
  • 10-20 kg x 10-20 years
  • Jensen LK. Occup Envir Med 2008
  • Farming (as above)
  • Sporting Activities carries OR of 2.0
  • Lievense AM et al. Arthritis Rheum 2003
  • Soccer Ballet conflicting evidence for Hip OA

34
What sports increase risk of Shoulder
Osteoarthritis?
  • Increased risk of glenohumeral OA in elite tennis
    players in one small study
  • Maquirriain J et al. Brit J Sports Med 2006

35
Questions to ask your patients who want to run
  • Are your joints currently normal?
  • What other risk factors do you have for OA?

36
What to tell your patients who want to run
  • Running has significant benefits
  • Less obesity
  • Less diabetes
  • Less heart disease
  • Less depression
  • Better bone density
  • Moderate running on normal joints is healthy

37
What To Tell Your Patients
  • High risk of OA
  • Obesity
  • Traumatic joint injury
  • Moderate risk of OA
  • High impact sports
  • Heavy labor
  • Running gt 60 mi/wk
  • ? Competitive weight lifting
  • Possible risk
  • Running gt 25 mi/wk

38
Patients needing caution when considering running
  • Prior LE fracture, dislocation, major ligament or
    meniscal injury
  • Higher risk of OA
  • Advise low-impact exercise
  • If run, lt25 mi/wk
  • Obese patients
  • Lose weight however you can!
  • Joint instability, incongruity, loss of
    innervation
  • Advise low-impact exercise

39
Case 2
History
  • 32 yo male stock broker training for Boston
    marathon
  • R knee pain for 9 mos
  • h/o old football injury
  • Swells after playing softball
  • No locking or giving way
  • Neg PMHx/PSHx
  • No fevers, rash, other joint pain

40
Case 2 (cont)
Exam
  • Full ROM
  • Mild effusion
  • Mild medial joint line TTP
  • Neg McMurray
  • No ligamentous laxity

41
Xrays
42
Treating Active Patients Osteoarthritis
43
Treatment of Osteoarthritis Overview
  • Nonpharmocologic Measures
  • Education, Weight loss, Exercise, Bracing
  • Pharmacologic Measures
  • Analgesics, Glucosamine, Injectables
  • Alternative Therapies
  • Accupuncture, Dietary Supplementation
  • Surgery

44
Zhang W et al. Osteoarthritis Research Society
International recommendations for the management
of hip and knee OA, Pt II OARSI evidence-based,
expert consensus guidelines. Osteoarth and
Cartilage 2008 16137-62.
45
Educate Your Athletes(LOE 1a)
  • Objectives of treatment
  • Changes in lifestyle
  • Importance of exercise
  • Pacing yourself
  • Weight reduction if needed
  • Unloading of joints

46
Lose Weight if Overweight/Obese(LOE 1a)
  • 10 lb / 40 rule
  • Break that vicious cycle
  • Team approach is critical

47
Exercise is EXCELLENT Treatment for OA
48
Evidence for Exercisein Treating OA
  • Regular aerobic walking for knee OA
  • LOE 1a for knee OA
  • LOE IV for hip OA
  • Home-based quad strength exercises
  • LOE 1a for knee OA
  • LOE IV for hip OA
  • Water-based exercise for hip OA
  • LOE 1b

49
What Kinds of Exercise are OK?
  • Little evidence-based recommendations
  • Common sense advice
  • Avoid further trauma
  • Wise to avoid high-risk activities
  • Listen to your joints

X
50
Knee Bracing(LOE 1a)
  • Medial or lateral unloading

51
Lateral Wedge Insoles(LOE 1a for knee)
  • Medial tibio-femoral OA

52
Other Effective Therapies
  • TENS effective in some with knee or hip OA
  • LOE 1a
  • Short-term, 2-4 weeks
  • Acupuncture relieves pain (no effect on function)
  • LOE 1a
  • Magnetic therapy
  • Cochrane review slightly better than placebo

53
Oral Therapy
No disease modifying drug for OA (yet)
  • Tylenol, max 4 gm/day
  • analgesic of choice
  • LOE 1a, but modest pain relief if OA mild/mod
  • NSAIDsLOE 1a
  • Tramadol LOE 1a in short-term trials
  • No long-term trials
  • More side-effects than Tylenol
  • Glucosamine

54
A Few Words about NSAIDS
  • Only slightly more effective than Tylenol
  • Much more frequent/serious side effects
  • Reserve for inflammatory flare-ups
  • Use lowest effective dose
  • Avoid long-term use protect GI tract if must
  • Non-selective vs COX-2 no big differences

55
Glucosamine Mechanism of Action
  • Small anti-inflammatory effect
  • Stimulates chondroitin synthesis

56
Glucosamine in Knee OA
  • LOE 1a for modest pain reduction
  • Significant differences in results between
    preparations (G. sulfate more effective)
  • LOE 1a for preservation of joint space
  • 1500 mg/day

57
Chondroitin in Knee OA
  • Safe efficacy as placebo for pain in most recent
    systematic reviews
  • LOE 1a for preservation of joint space
  • 800 mg/day

58
Glucosamine ChondroitinMy Take
  • I recommend in all patients with knee and hip OA
  • Research lag in hip OA
  • 4 week trial of daily dosing
  • Evaluate efficacy continue if helping
  • Consider indefinite use even if no pain relief
    for joint space preservation

59
Topical TreatmentsUseful as Adjuncts
  • Topical NSAIDs
  • LOE 1a for pain, stiffness, function
  • Side effects placebo
  • Onset slightly slower than oral
  • Only 1-2 week study durations
  • Capsaicin
  • LOE 1b for pain
  • 40 have stinging, burning, erythema

60
Intra-articular Treatments
  • Considerations before treatment
  • Surgical candidate vs not surgical candidate?
  • Previous injections effective or not effective?

61
Intra-articular Treatments
Corticosteroids Knee LOE 1a Hip LOE 1b
Hyaluronans Knee Hip 1a
  • Limitations
  • Steroids short duration effect 2-4 weeks
  • Hyaluronans delayed effect, duration up to 6
    months
  • Weekly injections, 3-5x

62
Surgery
  • Arthroscopy
  • Joint replacement
  • Cartilage transplantation

63
Arthroscopy with Lavage and Debridement
  • LOE III in knee (poor)
  • Huge placebo effect
  • Blinded study comparing sham surgery to
    lavage/debridement
  • No differences in outcome!
  • Moseley JB et al. A controlled trial of
    arthroscopic surgery for osteoarthritis of the
    knee. N Engl J Med 2002 Jul 11 347(2)81-8.

64
Knee Joint Replacement
  • LOE III, but universally recommended to improved
    pain, function, QOL
  • Unicompartmental
  • Total joint replacement

65
Other Knee Surgeries
  • Osteo-Articular Transplant (OATs) procedures
  • Autologous Chondrocyte Transplantation (ACT)

66
Summary and Review
  • Running in moderation does not cause OA in normal
    knees
  • Some sports are a/w OA
  • Soccer, football, risk of trauma
  • Running gt60mi/wk
  • Low-impact exercise treats OA
  • Athletes with OA need to stay active but minimize
    loading
  • Consider use of multiple treatments simultaneously

67
Questions
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