Driban JB, Hootman JM, Sitler MR, Harris KP, Cattano NM. Is participation in certain sports associated with knee osteoarthritis? A systematic review. J Athl Train. 2017;52:497–506.
What is the role of athletic trainers in preventing osteoarthritis and posttraumatic osteoarthritis in elite and non-elite level athletes?
Original research included in this systematic review was identified by searching PubMed, Journals@Ovid, MEDLINE, American College of Physicians Journal Club, Cochrane, and Ovid Health-star electronic databases. Key search terms used to locate applicable original research included: osteoarthritis, degenerative joint disease, knee, patellar, tibiofemoral, epidemiology, incidence, prevalence, and specific sport and activities such as football or weight lifting.
Articles included in this systematic review met the following inclusionary criteria: (1) showed a relationship between sport participation and osteoarthritis; (2) the research outcome measure included: radiographic/clinical knee osteoarthritis, total knee replacement, self-reported diagnosis of knee osteoarthritis, or placement on a waiting list for total knee replacement; (3) the research study design was either case–control or retrospective cohort; and (4) articles were published in the English language. Articles were excluded if underlying medical conditions were present, a patient's diagnosis was limited to only patellofemoral osteoarthritis or progression of knee tibiofemoral osteoarthritis, or if the data points were reported as number of knees as opposed to number of participants.
Two independent raters assessed the quality of the research studies using the Newcastle-Ottawa Scale (NOS), which has criteria for both case–control and retrospective cohort studies. The NOS is a 0 to 9 point scale, with a higher score indicating a better quality of research study. The authors assessed studies in three areas: selection, comparability, and exposure for case–control studies or outcome for retrospective cohort studies. At the conclusion of data extraction, pertinent information from each case–control and retrospective cohort study was recorded.
The authors of this systematic review initially identified 1,217 articles in their electronic database search. Seventeen articles, with a NOS score ranging from 3 to 7, were found to meet appropriate criteria to be included in this systematic review: 6 were classified as case–control studies and 11 were classified as retrospective cohort studies. Osteoarthritis data that included participation in sport or activity were stratified into low, medium, and high risk categories based on the following criteria: (1) intensity of activity; (2) rate of knee injury in participants; and (3) amount of impact and torsional loading. Participation in elite and non-elite soccer, elite long-distance running, competitive weight lifting, or wrestling was associated with a three to seven times higher prevalence of knee osteoarthritis when compared to a non-exposed control population.
Although the systematic review identified participation in elite and non-elite level soccer, elite long-distance running, competitive weight lifting, and wrestling as having a high risk of developing osteoarthritis, current literature is still unclear as to which individual components of each sport cause the increase in risk.1 Despite this ambiguity, research has identified a strong link between traumatic knee injuries, such as anterior cruciate ligament (ACL) injuries and meniscal tears, with a higher lifetime risk of developing osteoarthritis.2
In a study by Suter et al.,2 concurrent ACL and meniscal tear injuries were estimated to increase the likelihood of systematic osteoarthritis in patients by 34% (95% confidence interval: 26.8 to 41.7) when compared to a control group with no history of a traumatic knee injury. The importance of this metric is underscored by ACL injury rates experienced by elite athletes in the collegiate setting. In their analysis of the National Collegiate Athletic Association Injury Surveillance System, Agel et al.3 reported that, even when controlling for injury exposures, overall ACL injury rates significantly increased in men's and women's basketball, ice hockey, field hockey, football, and volleyball for the academic years 2004 to 2013.
Understanding knee joint biomechanics is of utmost importance to identify poor lower extremity mechanics that may lead to ACL injury. The purpose of a retrospective cohort study by Hewett et al.4 was to collect lower limb jump-landing biomechanics data from women prior to participation in basketball, soccer, and volleyball seasons and monitored them throughout the season to identify athletes who went on to suffer a non-contact ACL injury. Women who sustained non-contact ACL injuries had a significantly increased knee abduction angle and moment, an increase in ground reaction force, a significant decrease of 10.5° in peak knee flexion angle, and a 16% shorter stance time when landing from a jump-landing task.4 Clinicians can discriminate elite and non-elite level athletes who are at a greater risk of ACL injury from those who exhibit an increase in knee valgus alignment and joint moments while landing with a straighter leg occurring over a shorter amount of time during jump-landing tasks. These characteristics place a high amount of stress and excess torque on the ACL and increase the risk of ACL rupture.4 They concluded that increased knee abduction angle and moment were significant predictors of ACL injury in these female athletes.
The relationship between acute knee injury and early onset of osteoarthritis is referred to as post-traumatic osteoarthritis and well established in the research literature.2 Clinicians, especially athletic trainers providing care to elite and non-elite level athletes who experience knee joint trauma, are in an opportune position to prioritize and manage long-term patient outcomes associated with posttraumatic osteoarthritis. However, a study conducted by Pietrosimone et al.5 on athletic trainers' knowledge and perceptions of posttraumatic osteoarthritis reported that, although athletic trainers have an intimate knowledge that ACL and meniscal tear injuries increased the risk for developing knee osteoarthritis, 40% were not familiar with the etiology of posttraumatic osteoarthritis. These findings suggest that despite athletic trainers' familiarity with osteoarthritis, there might be confusion regarding the connection between knee joint trauma and the development of posttraumatic osteoarthritis. The importance of increasing athletic trainers' knowledge of posttraumatic osteoarthritis and subsequent inclusion of posttraumatic osteoarthritis prophylactic programs and patient education should be emphasized as a necessary step to bridging the gap between athletic trainers and the prevention of posttraumatic osteoarthritis.
Although it would be exceedingly difficult to develop a comprehensive prophylactic protocol for all elite and non-elite level athletes given the multidimensional nature of athletic activity and its link to osteoarthritis, clinicians can still focus on the prevention of traumatic knee injuries such as ACL tears that are prevalent in all levels of sport and have a strong connection to the development of posttraumatic osteoarthritis.1–3 In a position statement published by the National Athletic Trainers' Association in 2018, the efficacy of various ACL prevention techniques is evaluated for strength of evidence and incorporation into clinical practice.6 They recommended a multicomponent training program that incorporates strength, plyometrics, agility, balance, and flexibility in addition to biomechanical feedback on jump-landing tasks for prevention of ACL injuries in populations participating in high risk sports. Although the prevention techniques proposed by Padua et al.6 are specific to reducing the incidence of ACL injuries, athletic trainers can use the recommendations outlined in the position statement to simultaneously develop a prophylactic ACL protocol and address risk factors associated with the development of posttraumatic osteoarthritis.2,4,6
More longitudinal research is needed to fully understand the connection between participation in elite and non-elite level athletic activities and its connection with the development of osteoarthritis and posttraumatic osteoarthritis. Due to the high prevalence of osteoarthritis and posttraumatic osteoarthritis in those who have participated in elite and non-elite level athletic activities, development and implementation of injury prevention programs should be strongly considered for inclusion in athletic trainers' clinical practice. In addition, inclusion of patient-rated outcome measures when relevant in clinical practice such as the Knee Injury and Osteoarthritis Outcome Score7 and the Cincinnati Knee Score8 can not only increase patient-centered care through collection of subjective information, but also add to the growing body of knowledge regarding development of osteoarthritis and posttraumatic osteoarthritis after participation in sports. In clinical practice, athletic trainers should emphasize that the inclusion of tracking and reporting data from injury prevention programs and patient-rated outcome measures through practice-based research will serve to increase efficacy of future interventions to reduce the prevalence of osteoarthritis and posttraumatic osteoarthritis. The aforementioned strategies outline pertinent ways that athletic trainers can have a prominent role in the prevention, recognition, and treatment of osteoarthritis and posttraumatic osteoarthritis in those individuals who have participated in elite and non-elite level athletic activity.
- Driban JB, Hootman JM, Sitler MR, Harris KP, Cattano NM. Is participation in certain sports associated with knee osteoarthritis? A systematic review. J Athl Train. 2017;52:497–506. doi:10.4085/1062-6050-50.2.08 [CrossRef]
- Suter LG, Smith SR, Katz JN, et al. Projecting lifetime risk of symptomatic knee osteoarthritis and total knee replacement in individuals sustaining a complete anterior cruciate ligament tear in early adulthood. Arthritis Care Res. 2017;69:201–208. doi:10.1002/acr.22940 [CrossRef]
- Agel J, Rockwood T, Klossner D. Collegiate ACL injury rates across 15 sports: National Collegiate Athletic Association Injury Surveillance System data update (2004–2005 Through 2012–2013). Clin J Sport Med. 2016;26:518–523. doi:10.1097/JSM.0000000000000290 [CrossRef]
- Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33:492–501. doi:10.1177/0363546504269591 [CrossRef]
- Pietrosimone B, Blackburn JT, Golightly YM, et al. Certified athletic trainers' knowledge and perceptions of posttraumatic osteoarthritis after knee injury. J Athl Train. 2017;52:541–559. doi:10.4085/1062-6050-51.2.13 [CrossRef]
- Padua DA, DiStefano LJ, Hewett TE, et al. National Athletic Trainers' Association Position Statement: prevention of anterior cruciate ligament injury. J Athl Train. 2018;53:5–19. doi:10.4085/1062-6050-99-16 [CrossRef]
- Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS)–validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes. 2003;1:17. doi:10.1186/1477-7525-1-17 [CrossRef]
- Barber-Westin SD, Noyes FR, McCloskey JW. Rigorous statistical reliability, validity, and responsiveness testing of the Cincinnati knee rating system in 350 subjects with uninjured, injured, or anterior cruciate ligament-reconstructed knees. Am J Sports Med. 1999;27:402–416. doi:10.1177/03635465990270040201 [CrossRef]