Posted October 18, 2016
By Jeffrey B. Driban, PhD, ATC, CSCS
How many Athletic Trainers (ATs) can remember a patient who tore an anterior cruciate ligament (ACL), returned to visit a few years later and described chronic knee pain and limitations with their favorite activities?
The Bone and Joint Health National Awareness Week is a great time to focus on injury/illness prevention and wellness protection strategies that can help preserve long-term health. This is particularly relevant if we consider that 37 percent of ATs think osteoarthritis – a chronic painful and disabling condition – is not a major health concern.1 Furthermore, only approximately 70 percent of ATs discuss with a patient their risk for osteoarthritis and strategies to mitigate this risk.
In contrast, over 80 percent of adults after an ACL injury believe that knee osteoarthritis would be a major health concern and only 27 percent recalled having a conversation with their health professional about osteoarthritis risks associated with their knee injury.2 While many patients focus on short- and medium-term goals like return to play, it is vital that ATs provide patients with information about what they can expect after an injury. Let us consider some key questions.
What is osteoarthritis?
Osteoarthritis – the most common form of arthritis – is a progressive disease that affects all the tissues in a synovial joint. Osteoarthritis reflects a failed attempt to repair joint damage that is caused by stress on a joint. Osteoarthritis can be thought of as a disease, which is defined by the structural changes in a joint like bone spur formation or cartilage damage. It can also be thought of as an illness, which is defined by a patient’s reported experience like joint pain or other symptoms.3
Is osteoarthritis a major health concern?
Over 30.8 million million adults in the United States have osteoarthritis.4 Osteoarthritis is among the top 15 causes of disability.5 Osteoarthritis causes over $10 billion in annual absenteeism6 and more than $185 billion/year in healthcare expenditures.7 Unfortunately, a patient is at risk for early-onset osteoarthritis after a joint injury. This is troubling because adults 20 to 55 years of age with hip or knee osteoarthritis are 4 times more likely to be psychologically distressed compared with their peers. Furthermore, 67 percent of these patients report osteoarthritis-related work disability and approximately 40 percent report reduction in quality of life.8
Which physically active individuals are at risk for osteoarthritis?
Most adults who take part in physical activity and sports are safe and possibly even protected against osteoarthritis.9 However, men in soccer and certain elite-level sports may be at greater risk for hip or knee osteoarthritis.10,11 It remains unknown if these specific sports cause osteoarthritis or if other factors are the culprits (for example, the amount of training the athlete performs, the types of injuries that occur or how we manage an injury). Among our patients, one of the strongest risk factors for osteoarthritis is joint trauma. Individuals with a history of knee injury are 3 to 6 times more likely to develop osteoarthritis.12 Within the first decade after a knee injury, 1 in 3 patients develop osteoarthritis.13,14 Hence, a 20-year-old athlete who tears her ACL is at elevated risk for osteoarthritis by 30 years of age, which could lead to knee symptoms and then have a major impact on her work and quality of life for decades.
What can we do to prevent osteoarthritis?
An injury prevention program can reduce the risk of injury by 35 to 68 percent.15,16 Furthermore, lower limb injury prevention programs can improve performance, keep athletes on the field and be easily implemented in a team warm-up. Recently, the Osteoarthritis Action Alliance, of which the NATA is a member organization, released a Consensus Opinion on the Best Practice Features of Lower Limb Injury Prevention Programs (Executive Summary). The task force identified 6 core components that should be included as part of a training program for prevention of major joint injury among youth athletes:
1. lower extremity and core muscle strength training
2. plyometric - jump training
3. balance training (as part of a program)
4. continual feedback on proper technique
5. sufficient dosing and compliance
6. minimal to no extra equipment
Unfortunately, we are unable to prevent every injury. Hence, we need to educate our patients about their risk for osteoarthritis and secondary prevention strategies that could help delay or prevent the onset of osteoarthritis. Secondary prevention strategies include regular exercise and weight management. These concepts will be expanded upon in the Athletic Trainers’ Osteoarthritis Consortium’s review and recommendations on the role of ATs in preventing and managing post-traumatic osteoarthritis in physically active individuals. The article will published by the Journal of Athletic Training in Spring 2017.
It is important to recognize that ATs are in a key position to help prevent this chronic disabling disorder and have a lasting effect on a patient’s long-term health and wellness. So next time you treat an injury, think long-term and talk with your patient about their future risk of osteoarthritis and how they can help reduce their chances of getting it.
1. Pietrosimone BG, Blackburn JT, Golightly YM, et al. Certified Athletic Trainers' Knowledge and Perceptions of Posttraumatic Osteoarthritis After Knee Injury. Journal of athletic training. 2016.
2. Bennell KL, van Ginckel A, Kean CO, et al. Patient Knowledge and Beliefs About Knee Osteoarthritis After Anterior Cruciate Ligament Injury and Reconstruction. Arthritis Care Res (Hoboken). 2016; 68(8):1180-1185.
3. Lane NE, Brandt K, Hawker G, et al. OARSI-FDA initiative: defining the disease state of osteoarthritis. Osteoarthritis Cartilage. 2011; 19(5):478-482.
4. Cisternas MG, Murphy L, Sacks JJ, et al. Alternative Methods for Defining Osteoarthritis and the Impact on Estimating Prevalence in a US Population-Based Survey. Arthritis Care Res (Hoboken). 2016; 68(5):574-580.
5. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013; 380(9859):2163-2196.
6. Kotlarz H, Gunnarsson CL, Fang H, Rizzo JA. Osteoarthritis and absenteeism costs: evidence from US National Survey Data. J Occup Environ Med. 2010; 52(3):263-268.
7. Kotlarz H, Gunnarsson CL, Fang H, Rizzo JA. Insurer and out-of-pocket costs of osteoarthritis in the US: evidence from national survey data. Arthritis Rheum. 2009; 60(12):3546-3553.
8. Ackerman IN, Bucknill A, Page RS, et al. The substantial personal burden experienced by younger people with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2015; 23(8):1276-1284.
9. Urquhart DM, Tobing JF, Hanna FS, et al. What is the effect of physical activity on the knee joint? A systematic review. Med Sci Sports Exerc. 2011; 43(3):432-442.
10. Driban JB, Hootman JM, Sitler MR, Harris K, Cattano NM. Participation in certain sports is associated with knee osteoarthritis: a systematic review. Journal of athletic training. In Press.
11. Michaelsson K, Byberg L, Ahlbom A, Melhus H, Farahmand BY. Risk of severe knee and hip osteoarthritis in relation to level of physical exercise: a prospective cohort study of long-distance skiers in Sweden. PLoS One. 2011; 6(3):e18339.
12. Muthuri SG, McWilliams DF, Doherty M, Zhang W. History of knee injuries and knee osteoarthritis: a meta-analysis of observational studies. Osteoarthritis Cartilage. 2011; 19(11):1286-1293.
13. Harris K, Driban JB, Sitler MR, Cattano NM, Balasubramanian E. Tibiofemoral Osteoarthritis After Surgical or Nonsurgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review. Journal of athletic training. 2015; In Press.
14. Luc B, Gribble PA, Pietrosimone BG. Osteoarthritis Prevalence Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Numbers-Needed-to-Treat Analysis. Journal of athletic training. 2014; 49(6):806-819.
15. Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis. Br J Sports Med. 2014.
16. Emery CA, Roy TO, Whittaker JL, Nettel-Aguirre A, van Mechelen W. Neuromuscular training injury prevention strategies in youth sport: a systematic review and meta-analysis. Br J Sports Med. 2015; 49(13):865-870.
About the Author
Jeffrey B. Driban, PhD, ATC, CSCS is an Assistant Professor in the Division of Rheumatology at Tufts University School of Medicine and Tufts Medical Center. The goal of his research is to explore novel biochemical and imaging markers to gain a better understanding of osteoarthritis and potential disease phenotypes. Dr. Driban received his Bachelors of Science in Athletic Training from the University of Delaware. He received a Masters of Education and Doctor of Philosophy in Kinesiology with an Emphasis in Athletic Training from Temple University. He completed a post-doctoral research fellowship in the Division of Rheumatology at Tufts Medical Center where he continued his osteoarthritis focus. Dr. Driban also aims to raise awareness about osteoarthritis and promote primary and secondary prevention strategies for physically active individuals as the Chair of the Athletic Trainers’ Osteoarthritis Consortium and by serving as a National Athletic Trainers’ Association’s representative in the Osteoarthritis Action Alliance and Chair of the Alliance’s Osteoarthritis Prevention Work Group. Dr. Driban is also co-founder of Sports Medicine Research Company, which provides a blog and podcast focused bridging the gap between research and clinical practice related to sports medicine.