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Exercise and Osteoarthritis: The Effect of Running with Aging in the Masters-Level Athlete

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Endurance Sports Medicine

Abstract

Participation in long-distance running has increased significantly over the past decades. Despite the systemic and bone health benefits of high-impact aerobic exercise, persistent dogma exists that running is associated with increased risk of osteoarthritis (OA). This chapter focuses on the development and progression of OA in aging athletes, proper evaluation, and treatment paradigms for an aging runner with OA-associated knee pain and other running maladies are presented. Recommendations regarding runner activity, cross-training principles, and adequate nutrition associated with prolonged running health are presented. This text presents the best current evidence for OA progression and treatment in an active population and addresses the subtleties of evaluating and treating an aging athlete population. This chapter concludes that a balance of running, cross-training, and healthy dietary principles will increase the ability of an aging runner to participate at a high level of function. Clinicians should encourage continued participation in running for the health benefits and to preserve function in the presence of early OA of the knee, with exploring other recommended activity options in patients with severe OA.

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References

  1. Running USA. 2014 Running USA annual marathon report. 2015. runningusa.org

  2. World Association of Masters Athletes, International Association of Athletics Federation (IAAF). 2015. www.world-masters-athletics.org

  3. Wright VJ. Masterful care of the aging triathlete. Sports Med Arthrosc. 2012;20(4):231–6.

    Article  PubMed  Google Scholar 

  4. Foster C, Wright G, Battista RA, Porcari JP. Training in the aging athlete. Curr Sports Med Rep. 2007;6(3):200–6.

    PubMed  Google Scholar 

  5. Leigey D, Irrgang J, Francis K, Cohen P, Wright V. Participation in high-impact sports predicts bone mineral density in senior Olympic athletes. Sports Health. 2009;1(6):508–13.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, et al. National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008;58(1):15–25.

    Article  PubMed  Google Scholar 

  7. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197–223.

    Article  PubMed  Google Scholar 

  8. Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA, et al. National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26–35.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Dieppe PA, Lohmander LS. Pathogenesis and management of pain in osteoarthritis. Lancet. 2005;365(9463):965–73.

    Article  CAS  PubMed  Google Scholar 

  10. Goldring MB, Goldring SR. Osteoarthritis. J Cell Physiol. 2007;213(3):626–34.

    Article  CAS  PubMed  Google Scholar 

  11. Buckwalter JA, Mow VC, Ratcliffe A. Restoration of injured or degenerated articular cartilage. J Am Acad Orthop Surg. 1994;2(4):192–201.

    Article  CAS  PubMed  Google Scholar 

  12. Buckwalter JA, Brown TD. Joint injury, repair, and remodeling: roles in post-traumatic osteoarthritis. Clin Orthop Relat Res. 2004;423:7–16.

    Article  Google Scholar 

  13. Cole BJ, Harner CD. Degenerative arthritis of the knee in active patients: evaluation and management. J Am Acad Orthop Surg. 1999;7(6):389–402.

    Article  CAS  PubMed  Google Scholar 

  14. Amoako AO, Pujalte GG. Osteoarthritis in young, active, and athletic individuals. Clin Med Insights Arthritis Musculoskelet Disord. 2014;7:27–32.

    PubMed  PubMed Central  Google Scholar 

  15. Hunter DJ. Osteoarthritis. Best Pract Res Clin Rheumatol. 2011;25(6):801–14.

    Article  PubMed  Google Scholar 

  16. Kirkendall DT, Garrett Jr WE. Management of the retired athlete with osteoarthritis of the knee. Cartilage. 2012;3 Suppl 1:69S–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Neogi T, Zhang Y. Epidemiology of osteoarthritis. Rheum Dis Clin North Am. 2013;39(1):1–19.

    Article  PubMed  Google Scholar 

  18. Huleatt JB, Campbell KJ, Laprade RF. Nonoperative treatment approach to knee osteoarthritis in the master athlete. Sports Health. 2014;6(1):56–62.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Buckwalter JA. Sports, joint injury, and posttraumatic osteoarthritis. J Orthop Sports Phys Ther. 2003;33(10):578–88.

    Article  PubMed  Google Scholar 

  20. Buckwalter JA. The role of mechanical forces in the initiation and progression of osteoarthritis. HSS J. 2012;8(1):37–8.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Anderson DD, Chubinskaya S, Guilak F, Martin JA, Oegema TR, Olson SA, et al. Post-traumatic osteoarthritis: improved understanding and opportunities for early intervention. J Orthop Res. 2011;29:802–9.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006;20(10):739–44.

    Article  PubMed  Google Scholar 

  23. Arokoski JP, Jurvelin JS, Väätäinen U, Helminen HJ. Normal and pathological adaptations of articular cartilage to joint loading. Scand J Med Sci Sports. 2000;10(4):186–98.

    Article  CAS  PubMed  Google Scholar 

  24. Griffin TM, Guilak F. The role of mechanical loading in the onset and progression of osteoarthritis. Exerc Sport Sci Rev. 2005;33(4):195–200.

    Article  PubMed  Google Scholar 

  25. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Felson DT. Does excess weight cause osteoarthritis, and if so, why? Ann Rheum Dis. 1996;55(9):668–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Messier SP, Pater M, Beavers DP, Legault C, Loeser RF, Hunter DJ, et al. Influences of alignment and obesity on knee joint loading in osteoarthritic gait. Osteoarthritis Cartilage. 2014;22(7):912–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Issa RI, Griffin TM. Pathobiology of obesity and osteoarthritis: integrating biomechanics and inflammation. Pathobiol Aging Age Relat Dis. 2012;2(2012). pii: 17470.

    Google Scholar 

  29. Griffin TM, Fermor B, Huebner JL, et al. Diet-induced obesity differentially regulates behavioral, biomechanical, and molecular risk factors for osteoarthritis in mice. Arthritis Res Ther. 2010;12(4):R130.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Henriksen M, Christensen R, Danneskiold-Samsøe B, Bliddal H. Changes in lower extremity muscle mass and muscle strength after weight loss in obese patients with knee osteoarthritis: a prospective cohort study. Arthritis Rheum. 2012;64(2):438–42.

    Article  PubMed  Google Scholar 

  31. Gleeson M, Bishop NC, Stensel DJ, Lindley MR, Mastana SS, Nimmo MA. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nat Rev Immunol. 2011;11(9):607–15.

    Article  CAS  PubMed  Google Scholar 

  32. Petersen AM, Pedersen BK. The anti-inflammatory effect of exercise. J Appl Physiol. 2005;98(4):1154–62. Review.

    Article  CAS  PubMed  Google Scholar 

  33. Mathur N, Pedersen BK. Exercise as a mean to control low-grade systemic inflammation. Mediators Inflamm. 2008;2008:109502. doi:10.1155/2008/109502. Epub 11 Jan 2009.

    Article  PubMed  Google Scholar 

  34. Flynn MG, McFarlin BK. Toll-like receptor 4: link to the anti-inflammatory effects of exercise? Exerc Sport Sci Rev. 2006;34(4):176–81.

    Article  PubMed  Google Scholar 

  35. Bennell K, Hinman R. Exercise as a treatment for osteoarthritis. Curr Opin Rheumatol. 2005;17(5):634–40.

    Article  PubMed  Google Scholar 

  36. van Baar ME, Dekker J, Oostendorp RA, Bijl D, Voorn TB, Bijlsma JW. Effectiveness of exercise in patients with osteoarthritis of hip or knee: nine months’ follow up. Ann Rheum Dis. 2001;60(12):1123–30.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Pelland L, Brosseau L, Wells G. Efficacy of strengthening exercises for osteoarthritis (part I): a meta-analysis. Phys Ther Rev. 2004;9:77–108.

    Article  Google Scholar 

  38. Brosseau L, Pelland L, Wells G. Efficacy of aerobic exercises for osteoarthritis (part II): a meta-analysis. Phys Ther Rev. 2004;9:125–45.

    Article  Google Scholar 

  39. Stahl R, Luke A, Ma CB, Krug R, Steinbach L, Majumdar S, et al. Prevalence of pathologic findings in asymptomatic knees of marathon runners before and after a competition in comparison with physically active subjects-a 3.0 T magnetic resonance imaging study. Skeletal Radiol. 2008;37(7):627–38.

    Article  PubMed  Google Scholar 

  40. Schueller-Weidekamm C, Schueller G, Uffmann M, Bader T. Incidence of chronic knee lesions in long-distance runners based on training level: findings at MRI. Eur J Radiol. 2006;58(2):286–93.

    Article  PubMed  Google Scholar 

  41. Kornaat PR, Van de Velde SK. Bone marrow edema lesions in the professional runner. Am J Sports Med. 2014;42(5):1242–6.

    Article  PubMed  Google Scholar 

  42. Neuman P, Englund M, Kostogiannis I, Fridén T, Roos H, Dahlberg LE. Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study. Am J Sports Med. 2008;36(9):1717–25.

    Article  PubMed  Google Scholar 

  43. Magnussen RA, Duthon V, Servien E, Neyret P. Anterior cruciate ligament reconstruction and osteoarthritis: evidence from long-term follow-up and potential solutions. Cartilage. 2013;4 Suppl 3:22S–6.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Ajuied A, Wong F, Smith C, Norris M, Earnshaw P, Back D, et al. Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med. 2014;42(9):2242–52.

    Article  PubMed  Google Scholar 

  45. Saragiotto BT, Yamato TP, Hespanhol Jr LC, Rainbow MJ, Davis IS, Lopes AD. What are the main risk factors for running-related injuries? Sports Med. 2014;44(8):1153–63.

    Article  PubMed  Google Scholar 

  46. Wen DY. Risk factors for overuse injuries in runners. Curr Sports Med Rep. 2007;6(5):307–13.

    PubMed  Google Scholar 

  47. Buckwalter JA, Lane NE. Athletics and osteoarthritis. Am J Sports Med. 1997;25(6):873–81.

    Article  CAS  PubMed  Google Scholar 

  48. Chakravarty EF, Hubert HB, Lingala VB, Zatarain E, Fries JF. Long distance running and knee osteoarthritis. A prospective study. Am J Prev Med. 2008;35(2):133–8.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Willick SE, Hansen PA. Running and osteoarthritis. Clin Sports Med. 2010;29(3):417–28.

    Article  PubMed  Google Scholar 

  50. Wang BW, Ramey DR, Schettler JD, Hubert HB, Fries JF. Postponed development of disability in elderly runners: a 13-year longitudinal study. Arch Intern Med. 2002;162(20):2285–94.

    Article  PubMed  Google Scholar 

  51. Miller RH, Edwards WB, Brandon SC, Morton AM, Deluzio KJ. Why don’t most runners get knee osteoarthritis? A case for per-unit-distance loads. Med Sci Sports Exerc. 2014;46(3):572–9.

    Article  PubMed  Google Scholar 

  52. Schubert AG, Kempf J, Heiderscheit BC. Influence of stride frequency and length on running mechanics: a systematic review. Sports Health. 2014;6(3):210–7.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Videbæk S, Bueno AM, Nielsen RO, Rasmussen S. Incidence of running-related injuries per 1000 h of running in different types of runners: a systematic review and meta-analysis. Sports Med. 2015;45(7):1017–26.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Rosenberg TD, Paulos LE, Parker RD, Coward DB, Scott SM. The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70(10):1479–83.

    Article  CAS  PubMed  Google Scholar 

  55. Wen DY, Puffer JC, Schmalzried TP. Lower extremity alignment and risk of overuse injuries in runners. Med Sci Sports Exerc. 1997;29(10):1291–8.

    Article  CAS  PubMed  Google Scholar 

  56. Wen DY, Puffer JC, Schmalzried TP. Injuries in runners: a prospective study of alignment. Clin J Sport Med. 1998;8(3):187–94.

    Article  CAS  PubMed  Google Scholar 

  57. Tayrose GA, Beutel BG, Cardone DA, Sherman OH. The masters athlete: a review of current exercise and treatment recommendations. Sports Health. 2015;7(3):270–6.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Wolfstadt JI, Cole BJ, Ogilvie-Harris DJ, Viswanathan S, Chahal J. Current concepts: the role of mesenchymal stem cells in the management of knee osteoarthritis. Sports Health. 2015;7(1):38–44.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Watson M, Brookes ST, Faulkner A, Kirwan J. WITHDRAWN: non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2007;1, CD000142.

    Google Scholar 

  60. Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb soft-tissue running injuries. Cochrane Database Syst Rev. 2011;(7):CD001256.

    Google Scholar 

  61. Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg. 2010;18(7):406–16.

    Article  PubMed  Google Scholar 

  62. Krohn K. Footwear alterations and bracing as treatments for knee osteoarthritis. Curr Opin Rheumatol. 2005;17(5):653–6.

    Article  PubMed  Google Scholar 

  63. Sanders JO, Murray J, Gross L. Non-arthroplasty treatment of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):256–60.

    Article  PubMed  Google Scholar 

  64. Balazs EA, Watson D, Duff IF, Roseman S. Hyaluronic acid in synovial fluid. I. Molecular parameters of hyaluronic acid in normal and arthritis human fluids. Arthritis Rheum. 1967;10(4):357–76.

    Article  CAS  PubMed  Google Scholar 

  65. Hunter DJ. Viscosupplementation for osteoarthritis of the knee. N Engl J Med. 2015;372(11):1040–7.

    Article  CAS  PubMed  Google Scholar 

  66. Conrozier T, Chevalier X. Long-term experience with hylan GF-20 in the treatment of knee osteoarthritis. Expert Opin Pharmacother. 2008;9(10):1797–804.

    Article  CAS  PubMed  Google Scholar 

  67. Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the treatment of osteoarthritis. J Rheumatol Suppl. 1993;39:3–9.

    CAS  PubMed  Google Scholar 

  68. Hepper CT, Halvorson JJ, Duncan ST, Gregory AJ, Dunn WR, Spindler KP. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies. J Am Acad Orthop Surg. 2009;17(10):638–46.

    Article  PubMed  Google Scholar 

  69. Caborn D, Rush J, Lanzer W, Parenti D, Murray C. A randomized, single-blind comparison of the efficacy and tolerability of hylan G-F 20 and triamcinolone hexacetonide in patients with osteoarthritis of the knee. J Rheumatol. 2004;31(2):333–43.

    CAS  PubMed  Google Scholar 

  70. Bodick N, Lufkin J, Willwerth C, Kumar A, Bolognese J, Schoonmaker C, et al. An intra-articular, extended-release formulation of triamcinolone acetonide prolongs and amplifies analgesic effect in patients with osteoarthritis of the knee: a randomized clinical trial. J Bone Joint Surg Am. 2015;97(11):877–88.

    Article  PubMed  Google Scholar 

  71. Everts PA, Brown Mahoney C, Hoffmann JJ, Schönberger JP, Box HA, van Zundert A, et al. Platelet-rich plasma preparation using three devices: implications for platelet activation and platelet growth factor release. Growth Factors. 2006;24(3):165–71.

    Article  CAS  PubMed  Google Scholar 

  72. Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior Outcomes Compared With Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015;31(11):2213–21.

    Google Scholar 

  73. Filardo G, Di Matteo B, Di Martino A, Merli ML, Cenacchi A, Fornasari P, et al. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med. 2015;43(7):1575–82.

    Article  PubMed  Google Scholar 

  74. Mokbel AN, El Tookhy OS, Shamaa AA, Rashed LA, Sabry D, El Sayed AM. Homing and reparative effect of intra-articular injection of autologus mesenchymal stem cells in osteoarthritic animal model. BMC Musculoskelet Disord. 2011;12:259.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. Counsel PD, Bates D, Boyd R, Connell DA. Cell therapy in joint disorders. Sports Health. 2015;7(1):27–37.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Luyten FP, Denti M, Filardo G, Kon E, Engebretsen L. Definition and classification of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2012;20(3):401–6.

    Article  PubMed  Google Scholar 

  77. Dervin GF, Stiell IG, Rody K, Grabowski J. Effect of arthroscopic débridement for osteoarthritis of the knee on health-related quality of life. J Bone Joint Surg Am. 2003;85-A(1):10–9.

    Article  PubMed  Google Scholar 

  78. Day B. The indications for arthroscopic debridement for osteoarthritis of the knee. Orthop Clin North Am. 2005;36(4):413–7.

    Article  PubMed  Google Scholar 

  79. Aaron RK, Skolnick AH, Reinert SE, Ciombor DM. Arthroscopic débridement for osteoarthritis of the knee. J Bone Joint Surg Am. 2006;88(5):936–43.

    PubMed  Google Scholar 

  80. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359(11):1097–107.

    Article  CAS  PubMed  Google Scholar 

  81. Howell SM. The role of arthroscopy in treating osteoarthritis of the knee in the older patient. Orthopedics. 2010;33(9):652.

    PubMed  Google Scholar 

  82. Omori G, Koga Y, Miyao M, Takemae T, Sato T, Yamagiwa H. High tibial osteotomy using two threaded pins and figure-of-eight wiring fixation for medial knee osteoarthritis: 14 to 24 years follow-up results. J Orthop Sci. 2008;13(1):39–45.

    Article  PubMed  Google Scholar 

  83. Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H. The long-term outcome of high tibial osteotomy: a ten to 20-year follow-up. J Bone Joint Surg Br. 2008;90(5):592–6.

    Article  CAS  PubMed  Google Scholar 

  84. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am. 2003;85-A(10):1968–73.

    Article  PubMed  Google Scholar 

  85. Spahn G, Mückley T, Kahl E, Hofmann GO. Factors affecting the outcome of arthroscopy in medial-compartment osteoarthritis of the knee. Arthroscopy. 2006;22(11):1233–40.

    Article  PubMed  Google Scholar 

  86. Dalury DF, Ewald FC, Christie MJ, Scott RD. Total knee arthroplasty in a group of patients less than 45 years of age. J Arthroplasty. 1995;10(5):598–602.

    Article  CAS  PubMed  Google Scholar 

  87. Vincent HK, Herman DC, Lear-Barnes L, Barnes R, Chen C, Greenberg S, et al. Setting standards for medically-based running analysis. Curr Sports Med Rep. 2014;13(4):275–83.

    Article  PubMed  PubMed Central  Google Scholar 

  88. Perkins KP, Hanney WJ, Rothschild CE. The risks and benefits of running barefoot or in minimalist shoes: a systematic review. Sports Health. 2014;6(6):475–80.

    Article  PubMed  PubMed Central  Google Scholar 

  89. Boyer ER, Derrick TR. Select injury-related variables are affected by stride length and foot strike style during running. Am J Sports Med. 2015;43(9):2310–7.

    Google Scholar 

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  1. Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1010, Kaufmann Medical Building, Pittsburgh, PA, 15213, USA

    Jason P. Zlotnicki, Aaron Mares & Volker Musahl

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  1. Department of Orthopaedic Surgery, Ohio State University Wexner Medical Center, Gahanna, Ohio, USA

    Timothy L Miller

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Zlotnicki, J.P., Mares, A., Musahl, V. (2016). Exercise and Osteoarthritis: The Effect of Running with Aging in the Masters-Level Athlete. In: Miller, T. (eds) Endurance Sports Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-32982-6_14

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