Athletes with Osteoarthritis With emphasis on Runners.

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Athletes with OsteoarthritisWith emphasis on
Runners.

• Kevin deWeber, MD, FAAFP
• Director, Primary Care Sports Medicine Fellowship
• Uniformed Services University
• Bethesda, MD

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Objectives to discuss

• Diagnosis of Osteoarthritis
• Risk factors for Osteoarthritis
• Treating athletes with Osteoarthritis

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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!
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Clinical Diagnosis

• Joint Pain
• Typical Pain Pattern
• Xray Findings
• Standing films
• AP with 30 deg flexion

• No Sign of Zebras

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Pathogenesis of OsteoarthritisAn Interplay of
Factors
Dieppe, American Academy of Orthopaedic
Surgeons, 1995
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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

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Articular Cartilage
Glycosaminoglycan
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Articular Cartilage

• The Living Sponge
• Shock Absorption Water Content
  Glycosaminoglycan
• Limited Supply!! One Time Offer!!

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Pathogenesis in OA

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

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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
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Cartilage Proteoglycan
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Pathogenesis of Osteoarthritis Structure of
Cartilage Proteoglycan
Decreased Synthesis
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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
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Case 1

• 40 yo male club runner
• My girlfriends cousin said running can cause
  arthritis. Is that true?

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Does Running Cause Osteoarthritis?
We dont know conclusively!
(but there are some associations)
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• 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

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• 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

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• 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

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• 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

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• 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

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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

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• 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

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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)

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• 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)

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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

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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

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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

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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)

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Strong Risk Factor for OA Joint Trauma
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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

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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

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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

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Questions to ask your patients who want to run

• Are your joints currently normal?
• What other risk factors do you have for OA?

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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

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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

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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

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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

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Case 2 (cont)
Exam

• Full ROM
• Mild effusion
• Mild medial joint line TTP
• Neg McMurray
• No ligamentous laxity

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Xrays
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Treating Active Patients Osteoarthritis
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Treatment of Osteoarthritis Overview

• Nonpharmocologic Measures
• Education, Weight loss, Exercise, Bracing
• Pharmacologic Measures
• Analgesics, Glucosamine, Injectables
• Alternative Therapies
• Accupuncture, Dietary Supplementation
• Surgery

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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.
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Educate Your Athletes(LOE 1a)

• Objectives of treatment
• Changes in lifestyle
• Importance of exercise
• Pacing yourself
• Weight reduction if needed
• Unloading of joints

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Lose Weight if Overweight/Obese(LOE 1a)

• 10 lb / 40 rule
• Break that vicious cycle
• Team approach is critical

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Exercise is EXCELLENT Treatment for OA
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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

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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
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Knee Bracing(LOE 1a)

• Medial or lateral unloading

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Lateral Wedge Insoles(LOE 1a for knee)

• Medial tibio-femoral OA

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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

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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

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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

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Glucosamine Mechanism of Action

• Small anti-inflammatory effect
• Stimulates chondroitin synthesis

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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

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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

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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

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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

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Intra-articular Treatments

• Considerations before treatment
• Surgical candidate vs not surgical candidate?
• Previous injections effective or not effective?

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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

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Surgery

• Arthroscopy
• Joint replacement
• Cartilage transplantation

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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.

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Knee Joint Replacement

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

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Other Knee Surgeries

• Osteo-Articular Transplant (OATs) procedures
• Autologous Chondrocyte Transplantation (ACT)

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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

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Questions