Osteoarthritis in young, active, and athletic individuals

Osteoarthritis in Young,
Active, and Athletic
Individuals
Bahaa' Ali Kornah
• Professor of Orthopedic Surgery
• Faculty of Medicine
• Al Azhar university
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Bahaa Kornah- AlAzhar UN.- Cairo EGYPT aging spine 2017
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
Bahaa Kornah. Al-Azhar Un. Cairo EGYPT
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

▪ People also ask
▪ Can young adults get osteoarthritis?
▪ Can you play sports with osteoarthritis?
▪ Do athletes get osteoarthritis?
▪ Can an 20 year old have osteoarthritis?

Objectives
▪ When is it not “Just a pain”

Definition of OA
▪ “OA (OA) is a degenerative joint disease, occurring
primarily in older persons, characterized by erosion of
the articular cartilage, hypertrophy of bone at the
margins (i.e., osteophytes), subchondral sclerosis, and
a range of biochemical and morphologic alterations of
the synovial membrane and joint capsule.
▪ Pathologic changes in the late stages of OA include
softening, ulceration, and focal disintegration of the
articular cartilage; synovial inflammation also can
occur.”
Harris: Kelley's Textbook of Rheumatology, 7th ed.
“Despite its prevalence, the precise etiology,
pathogenesis, and progression of OA remain
beyond our understanding…”
Bahaa Kornah , Cairo- Egypt

OA is usually thought to be a progressive disease
of the adult and elderly. However, there are
several risk factors apart from age that
predispose an individual to OA, such as
➢ Genetics,
➢ Obesity,
➢ Joint injury,
➢ Occupational or
➢ Recreational activities,
➢ Gender, and
➢ Race

Abnormal
Stress
Obesity,
Developmental and
Anatomical abnormalities
Bony remodeling
& Microfractures
Loss of joint
stability
Trauma
Abnormal
Cartilage
Aging
Genetic and
Metabolic diseases
Inflammation
Administration
of toxins
Immune responses
(Normal
Cartilage)
(Normal
Stresses)
(Theory A)
•Biomaterial failure
•Collagen network
Fracture
Cartilage Breakdown
(Theory B)
•Cell injury
•Increase of degradative
responses
•Increased Proteolytic enzymes
•Reduced Inhibitors
•Destruction of proteoglycan
collagen and other proteins
•+
•or
Abnormal
Stress

Is Osteoarthritis
a Bone Disease,
5/4/2020

a Little Bit of Everything?
Or

▪ Obesity and joint injury have been found to
be strongly associated with OA. In addition, a
higher prevalence of knee OA has been found
in African-Americans compared to
Caucasians.
▪ In young and athletic individuals, the more
time they spend engaging in occupational
and recreational activities, their higher
predisposition to injuries contribute to their
higher likelihood of developing OA.
Abnormal
Stress

▪ in a 2011 study
▪ The effect of occupational and recreational
activities on the development of OA was
evident, where active duty military personnel
were found to have significantly higher rates
of OA compared to the same age group in the
general population.
▪ The general view is that OA is the result of
“wear and tear”; because athletes and young
individuals use their joints more and the risk
is higher.

▪ it is important that the mechanism
and physiology of OA are
understood.
▪ The normal joint consists of
articular cartilage, macromolecular
framework, matrix water, and cells .
Plus 80% water, 20% collagens +
proteins
▪ All parts of the cartilage play
different roles in the stabilization
and protection of the joint.
Alterations in the structure of the
articular cartilage lead to injury and
degeneration.

▪ It is important to mention that while
OA involves the bone, synovium, and
joint capsule, the changes in the
articular cartilage are the most
critical.
▪ Joint degeneration occurs in athletes
and young individuals through
damage to the articular cartilage
caused by repetitive impact and
loading.
Abnormal
Stress

▪ Sports that cause direct blunt
trauma to joints (such as football,
soccer, hockey, lacrosse,
and rugby) account for the most impact damage.
▪ 80% of American football players with a history
of knee injury had evidence of OA 10 to 30 years
after competing.
▪ Similar results were found in soccer players when
compared with age-matched controls.

▪ The prevalence of OA of knee and hips are higher
in former athletes compared with non-athletes
(odds ratio of 1.9).
▪ Studies have shown that for contact stressors to
cause disruption to normal articular cartilage, a
force of 25 Mpa(Megapascal Pressure Unit) or
more is required.
▪ Activities such as running and jumping, which
put mechanical stress on joints, produce force
<25 Mpa, and therefore, are less likely to cause
any disruption to the cartilage.

▪ Without injury high load
▪ With injury to articular and
▪ intra articular injury

▪ In an athlete,
▪ the higher rate of loading and frequency of
impact increases the amount of disruption
and damage to joint cartilage.When the
articular surface is loaded, fluid moves in the
cartilage and effectively distributes loads
within the cartilage.
▪ Slow loading allow enough time for fluid
distribution, causing a decrease in the force
applied to the matrix framework; on the
other hand, fast loading does not, and
therefore, put a lot of stress on the matrix.

▪ Athletes are more likely to sustain joint injuries
compared with the average individual. Such joint
injuries may cause
▪ joint instability and
▪ degeneration of the articular cartilage, even with
normal use.
Ligament injuries and meniscal tears are
examples. It is estimated that 50% of individuals
diagnosed with any of these injuries will have OA
10 to 20 years later, with pain and functional
impairment.

Post trumatic OA

Articular Cartilage -
Unique
➢ No blood supply,
➢ No lymphatic drainage,
➢ No neural elements,
➢ Chondrocytes are shielded from immunological
recognition.
➢ 60 – 80% of human cartilage is water.
➢Avascular
➢Alymphatic
➢Aneural
➢Active
➢Complex

▪ The lack of innervation of cartilage
prevents pain sensation when cartilage is
damaged; as a result, many injuries go
unnoticed, predisposing the athlete to OA
with repetitive exposure to high levels of
impact and loading. This also gives
credence to the observation that OA pain
is not just from a cartilage problem.

▪ Within the athletic population, factors such
as
1. body mass,
2. muscle strength, and
3. genetics also contribute to the
susceptibility of joints to injuries.

Associated Risk Factors
▪ Risk Factors and Possible
Causes:
 Age
 Female versus Male sex
 Obesity
 Osteoporosis
 Occupation
 SportsActivities
 Prior injury
 Muscle weakness
 Propioceptive deficits
 Acromegaly
 Calcium crystal deposition disease
Bahaa kornah , cairo- Egypt

▪ There is good evidence to
correlate high body mass
indices and OA.
▪ Sumo wrestlers and
American football
linemen, who are
significantly heavier and
have high body mass
indices, are prone to OA.

Clinical Presentation
▪ No symptom
▪ Pain
▪ Stiffness
▪ When present, the main presenting symptom
of OA is pain; however, this is not always the
case.

▪ Pain
▪ There are varying degrees of pain
depending on the individual. Some people
tolerate high levels of pain, while others do
not.
▪ Pain tolerance decreases with age. This
implies that some people may have a
delayed diagnosis because they tend to
complain later, due to their higher
tolerance for pain.

▪ Pain
▪ In athletes and young individuals, diagnosis may
become a challenge because aches and pains are
regarded as a part of playing sports. Subtle pains
coupled with an athlete’s desire to return to play
may prevent him or her from admitting to or
complaining of pain.
▪ In addition, a truly objective way of assessing
musculoskeletal pain still eludes the medical
world.

▪ Stiffness
▪ Stiffness of the joints, with a predilection for the
fingers, knees, hips, and spine, especially in the
morning, is another common symptom of OA.
▪ Morning stiffness associated with OA usually
resolves within 30 minutes to an hour of waking
up.
▪ Stiffness can recur with inactivity.

▪ Stiffness
▪ The more the disease progresses, the
more evident the stiffness will be.
▪ Stiffness is one of the symptoms that
might prompt an athlete or a young
individual to seek help.
▪ Stiffness impairs daily function and is
commonly confined to the affected joint.

▪ Other symptoms include
▪ crackling or
▪ grating sensations, secondary to the
roughness of the surfaces in the joint.

Diagnosis
The diagnosis of OA
▪ History + physical examination findings,
▪ diagnostic imaging, and
▪ laboratory tests.
▪ There have been several proposed systems for
diagnosing OA, but these proposals have limitations
because it is often difficult to determine the
underlying cause of OA.This is particularly important
in athletes and young individuals, where it could be
one cause, such as a previous injury, or a combination
of etiologies.

Criteria for Classification of
Idiopathic OA of the Knee
R. Altman, E. Asch, D. Bloch, G. Bole, D. Borenstein, K.
Brandt, et al.The AmericanCollege of Rheumatology criteria
for the classification and reporting of OA of the knee.
Arthritis Rheum 1986;29:1039--1049.
Clinical and Laboratory
+ at least 5 of 9
- age >50
- stiffness <30 minutes
- crepitus
- bony tenderness
- bony enlargement
- no palpable warmth
- ESR <40 mm/hr
- RF <1:40
- SF OA
Up-to-date 2005
Diagnosing OA
Bahaa kornah , cairo- Egypt

Diagnosis
On physical examination,
▪ crepitus is commonly found in addition to
▪ tenderness of the involved joints.
▪ Joint effusion may also be present.
▪ Plain radiography is usually the initial diagnostic image
of choice, although sensitivity is poor, especially in the
early stages of OA.
▪ Radiographic features of OA include osteophytes, joint
space narrowing, subchondral sclerosis, and cysts.

Diagnosis
a role for ultrasonography in the diagnosis of OA.
▪ low cost,
▪ easy accessibility of equipment, and
▪ safety compared to X-ray, CT, or MRI.
▪ ability to perform multiregional joint evaluation in a
scanning session
Pitfalls
length of time it takes to acquire the skills for the use of the
equipment.
the quality of the images and interpretation depend on the
technician.

Asymmetrical joint space narrowing from loss
of articular cartilage
The medial compartment of the knee is most commonly affected by
osteoarthritis.
OA – Radiographic Diagnosis

Treatment of Osteoarthritis
The two goals of OA therapy should be:
1) To decrease the symptoms of the disease
pain and improve functionality.
2) To control the progression of the disease
process.
Brandt K, Slowman-Kovacs S. Nonsteroidal anti-inflammatory drugs in treatment of
osteoarthritis. Clin Orthop. 1985;213:84-91.

OARSI
Management
Goals
Maintain,
improve
mobility
Reduce
pain &
stiffness
Improve
QOL
Limit
Damage
Progres
s
Educate
Patients
Reduce
Physical
Disability
Zhang W et al. OARSI recommendations for the diagnosis of knee osteoarthritis. Part II: OARSI evidence based, expert consensus guidelines. Osteoarthritis &
cartilage. 2008;16(2):137-162

1
• Non pharmacological
management
2
• pharmacological management
3
• Surgical

Non-pharmacological
49
Patient
educatio
n
Psychologica
l support
Weight
loss
PT
Exercise

Treatment
▪ For years, exercise has been recommended as the
non-pharmacological treatment for OA.
▪ The main expected outcome of exercise is the
reduction of pain and disability.The long-term
benefits of exercise have been questioned in the
past.
▪ However, a recent meta-analysis supported
previous evidence of the benefits of exercise in
managing OA.
▪ increase strength, flexibility, and aerobic capacity

Treatment
▪ In this algorithm, patient education >>>>> followed by
patient-specific regimens at home
▪ In an athlete or younger individual, to use recommendations
effectively, as different exercises affect different aspects of the
disease process.
▪ An active athlete >>> muscle-strengthening exercises, because
they reduce pain, which will allow him or her to return to play.
▪ tailor exercise regimens to the individual.

Exercises – 4 Ds
▪ Golden rules:
❖Do it
❖Do it regularly
❖Do it correctly
❖Do not over do it

Treatment
▪ Bracing >>> change in the alignment and biomechanical
forces in the joint .
▪ The braces help joint stability
▪ In the athlete, bracing >>> decrease the amount of time
necessary to return to play.
▪ However, compliance with brace wearing for the duration needed
to affect change is poor in the general population.
▪ There are many types of braces on the market, but as with
exercise, the specific type of brace an individual needs depends
on the goals and expectations of that individual.

Treatment
▪ Bracing >>>
▪ Can used for prevention of trauma
▪ As a treatment

Braces
▪ Instability / lack of
confidence,
▪ Insecurity / apprehension
▪ Meniscus tear
▪ Ligamentous laxity
▪ Unicompartmental
disease

▪ Unilateral joint
unloading braces
are not
recommended for
general use.They
are commonly
prescribed for uni-
compartmental
disease of the
knee.

Varus (bowlegged) vs.Valgus (knock-kneed)
G2 Unloaded Brace
Bahaa Kornah , cairo- Egypt

PHARMACOLOGICAL MANAGEMENT
OF OSTEOARTHRITIS

Treatment Strategies for
Pain
Choosing an analgesic treatment will largely
depend on
– The cause and intensity of pain and
– Other individual patient factors:
– The presence of comorbidities
– Drug–drug interactions
– Drug–disease interactions
– Adherence to therapy
– cost
American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:
1331–46.

Classification of drugs for treatment in OA
classic, rapid acting drugs
(NSAIDs, Steroids)
»SADOA«
(Slow Acting Drugs in OA)
Symptom modifying drugs » Structure modifying
drugs
These act on symptoms (e.g.
pain, functional disability) with
no detectable effect on the
structural changes of the
disease.
have an effect on the progression
of the pathological changes in
OA. These drugs may or may not
have an independent effect on
symptoms:
1.
2.
SMD
relieving
drugs
SMD
with
no direct
effect on
symptoms

Pharmacologic treatment for OA
▪ Pain Relief :
 Analgesics (acetaminophen)
 NSAIDs, and COXIBS
 Acupuncture, Lidocaine patches
▪ IA injections
▪ Chondroprotectives:
 Glucosamine, Chondroitin & MSM
 Hyaluronic acid injections.
▪ Interleukin inhibitors
62

Treatment
▪ intra-articular injection with corticosteroids and
viscosupplementation with hyaluronic acid.
▪ As such, corticosteroid injections are only recommended
for short-term relief of pain.

Treatment
▪ Hyaluronic acid has anti-inflammatory and
analgesic effects, in addition to its viscoelastic
properties, making it beneficial in the
treatment of OA.

ORTHOPEDIC SURGERY
▪ Tidal irrigation of the knee
▪ Arthroscopic debridement and lavage
▪ Osteotomy can eliminate concentration of peak
dynamic loads and provides pain relief
▪ Joint replacement for advanced OA
▪ Joint arthroplasty may relieve pain and increase
mobility
▪ Cartilage regeneration

Treatment
▪ . Arthroscopy is the first surgical procedure considered
in OA.
▪ arthroscopy is still commonly performed. In athletes and
young individuals,
▪ the use of surgical debridement
▪ meniscal tears,
▪ ACL reconstruction ,
▪ hip impangment , etc

Treatment
▪ high tibial osteotomy (HTO)
▪ total knee arthroplasty (TKA) include and
unicondylar or
▪ partial knee arthroplasty (UKA).

◆Cartilage Repair andTransplantation:
⧫Experimental procedures used to promote cartilage
repair include,
 Penetration of subchondral bone.
 Osteotomy.
 Joint distraction.
 Soft-tissue graft of periosteum or perichondrium.
 Cell transplantation.
 Use of growth factors.
◆GeneTherapy:
⧫Gene for IL-1 receptor antagonist is being used in
animal OA with success.
Bahaa Kornah , cairo- Egypt

▪ Conclusion
▪ OA do occur inYoung
▪ OA leads to pain and functional impairment.
▪ There are several risk factors associated with
OA.
▪ In the athlete or young individual, injury,
occupational activities, and obesity are the
main factors that contribute to OA.

▪ Assessment of OA in younger people should
focus on a patient-centered history,
comprehensive physical examination,
performance-based measures, and patient-
reported outcome measures to enable
monitoring of symptoms and function over time.
▪ Referral for imaging should be reserved for
people presenting with atypical signs or
symptoms that may indicate diagnoses other
than OA

‫ا‬.‫د‬.‫قرنة‬ ‫بهاء‬
‫د‬/‫قرنة‬ ‫بهاء‬

‫قرنة‬ ‫بهاء‬
Bahaa Kornah
bkornah@hotmail.com
▪.
Bahaa kornah- AlAzhar UN.- Cairo EGYPT aging spine 2017

Osteoarthritis in young, active, and athletic individuals

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