Risk Factors for Knee Osteoarthritis in Retired Professional Footballers: A Cross-Sectional Study

Knee osteoarthritis in the former elite football players and the ordinary population: a comparative cross-sectional study

A cross-sectional case-control study compared subjective knee function, quality of life and radiographic knee osteoarthritis (OA) between 45 former elite football players and an age-matched general male population. Participants completed the Knee OA Outcome Score (KOOS), a quality-of-life assessment (EQ-5D-3 L) and standing knee radiographs. Among the players, 24 (53%) sustained at least one moderate or severe knee injury, while 21 (47%) did not recall any injury. Players with previous knee injuries reported significantly lower knee-specific and general quality-of-life scores (KOOS 69; EQ-5D-3 L 0.69 (0.2)) compared to the non-injured players (KOOS 92; EQ-5D-3 L 0.81 (0.2)) or the control population (KOOS 90; EQ-5D-3 L 0.83 (0.2)). The injured knees had higher radiographic OA Kellgren-Lawrence (KL) scale grades 1.7 (1.3) than the knees of the non-injured players 0.8 (1.0) or the control knees 0.8 (1.0)Former elite football players who had previously sustained a moderate or severe knee injury reported inferior knee function and lower quality of life. Injured knees had higher levels of radiographic OA. Non-injured players reported similar knee and general function and their knees had similar grades of OA to those in the control group. The defining moment for long-term knee preservation in football should be injury prevention protocols.

Does Playing Football (Soccer) Really Increase the Risk of Knee Osteoarthritis? A Systematic Review and Meta-analysis

OBJECTIVE: To evaluate the relationship between football (soccer) participation and tibiofemoral knee osteoarthritis (OA), considering the influence of competitive level and previous knee injuries. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: PubMed, Embase, AMED, and Cochrane were searched for relevant publications. STUDY SELECTION CRITERIA: Studies of football players that included a control group consisting of mainly sedentary nonfootball players, and the relationship of knee OA, were considered. The studies had to report radiographically verified knee OA and specify football activity. DATA SYNTHESIS: Eleven studies, involving 1805 football players and 4022 control individuals were included. Subgroups consisting of data regarding level of play and previous injuries were also synthesized. RESULTS: The overall prevalence of knee OA among football players was increased among professional and recreational players, compared with controls. When knee injuries were excluded, there was no difference in knee OA between football players and controls (OR = 1.25; 95% CI: 0.61, 2.54). Football players with a previous knee injury had a greater risk of knee OA when compared with football players with no history of previous knee injury (OR = 4.16; 95% CI: 1.97, 8.77). CONCLUSION: Football players were at increased risk of knee OA. However, after excluding participants with a history of previous knee injury, there were no differences in knee OA between football players and controls. Previous knee injury was important for developing knee OA. Playing football, in the absence of major knee injuries, did not increase the risk of knee OA. J Orthop Sports Phys Ther 2024;54(5):1-12. Epub 26 February 2024. doi:10.2519/jospt.2024.12029.

Determination of the Prevalence of Knee and Hip Clinical Osteoarthritis in the Active Professional Male Footballer and Its Association with Pain, Function, Injury and Surgery

OBJECTIVE

To comment on and explore (1) the prevalence of clinical knee and hip osteoarthritis (OA); (2) the association between pain or function and clinical knee or hip OA; (3) the association between injury or surgery and clinical knee or hip OA.

METHODS

Participants were recruited from FIFPRO members. A total of 101 footballers consented to answer (1) a developed questionnaire, (2) patient-reported outcome measures, and (3) be evaluated by their team physician for clinical knee or hip OA.

RESULTS

Of the 53% evaluated for clinical knee and hip OA, a prevalence of 9.43% and 7.55% of knee and hip OA, respectively, was found. There was a significant and strong association between knee (p = 0.033; Cramers v Value = 0.523) and hip pain (p = 0.005; Cramers v Value = 0.602) and clinical OA. A significant association existed between Hip dysfunction and Osteoarthritis Outcome short form Scores and clinical OA of the hip (p = 0.036). The odds of clinical knee OA were 1.5 and 4.5 times more after one or more injuries or surgeries, respectively. There was no association between playing position and clinical OA.

CONCLUSION

There is a low prevalence of a clinical knee or hip OA in the active professional male footballer. Pain may be a valid symptom to predict or monitor knee or hip OA. Validated assessment tools should be utilised to identify a negative effect on function. The odds of developing clinical OA in the knee with the number of injuries or surgeries. The hip presents with earlier clinical signs of OA compared to the knee.

Mechanism of immune infiltration in synovial tissue of osteoarthritis: a gene expression-based study

BACKGROUND

Osteoarthritis is a chronic degenerative joint disease, and increasing evidences suggest that the pathogenic mechanism involves immune system and inflammation.

AIMS

The aim of current study was to uncover hub genes linked to immune infiltration in osteoarthritis synovial tissue using comprehensive bioinformatics analysis and experimental confirmation.

METHODS

Multiple microarray datasets (GSE55457, GSE55235, GSE12021 and GSE1919) for osteoarthritis in Gene Expression Omnibus database were downloaded for analysis. Differentially expressed genes (DEGs) were identified using Limma package in R software, and immune infiltration was evaluated by CIBERSORT algorithm. Then weighted gene co-expression network analysis (WGCNA) was performed to uncover immune infiltration-associated gene modules. Protein-protein interaction (PPI) network was constructed to select the hub genes, and the tissue distribution of these genes was analyzed using BioGPS database. Finally, the expression pattern of these genes was confirmed by RT-qPCR using clinical samples.

RESULTS

Totally 181 DEGs between osteoarthritis and normal control were screened. Macrophages, mast cells, memory CD4 T cells and B cells accounted for the majority of immune cell composition in synovial tissue. Osteoarthritis synovial showed high abundance of infiltrating resting mast cells, B cells memory and plasma cells. WGCNA screened 93 DEGs related to osteoarthritis immune infiltration. These genes were involved in TNF signaling pathway, IL-17 signaling pathway, response to steroid hormone, glucocorticoid and corticosteroid. Ten hub genes including MYC, JUN, DUSP1, NFKBIA, VEGFA, ATF3, IL-6, PTGS2, IL1B and SOCS3 were selected by using PPI network. Among them, four genes (MYC, JUN, DUSP1 and NFKBIA) specifically expressed in immune system were identified and clinical samples revealed consistent change of these four genes in synovial tissue retrieved from patients with osteoarthritis.

CONCLUSION

A 4-gene-based diagnostic model was developed, which had well predictive performance in osteoarthritis. MYC, JUN, DUSP1 and NFKBIA might be biomarkers and potential therapeutic targets in osteoarthritis.

Prevalence of and factors associated with osteoarthritis and pain in retired Olympians compared with the general population: part 2 - the spine and upper limb

OBJECTIVES

(1) To determine the prevalence of spine and upper limb osteoarthritis (OA) and pain in retired Olympians; (2) identify risk factors associated with their occurrence and (3) compare with a sample of the general population.

METHODS

3357 retired Olympians (44.7 years) and 1735 general population controls (40.5 years) completed a cross-sectional survey. The survey captured demographics, general health, self-reported physician-diagnosed OA, current joint/region pain and significant injury (lasting ≥1 month). Adjusted ORs (aORs) compared retired Olympians and the general population.

RESULTS

Overall, 40% of retired Olympians reported experiencing current joint pain. The prevalence of lumbar spine pain was 19.3% and shoulder pain 7.4%, with lumbar spine and shoulder OA 5.7% and 2.4%, respectively. Injury was associated with increased odds (aOR, 95% CI) of OA and pain at the lumbar spine (OA=5.59, 4.01 to 7.78; pain=4.90, 3.97 to 6.05), cervical spine (OA=17.83, 1.02 to 31.14; pain=9.41, 6.32 to 14.01) and shoulder (OA=4.91, 3.03 to 7.96; pain=6.04, 4.55 to 8.03) in retired Olympians. While the odds of OA did not differ between Olympians and the general population, the odds of lumbar spine pain (1.44, 1.20 to 1.73), the odds of shoulder OA after prior shoulder injury (2.64, 1.01 to 6.90) and the odds of cervical spine OA in female Olympians (2.02, 1.06 to 3.87) were all higher for Olympians compared with controls.

CONCLUSIONS

One in five retired Olympians reported experiencing current lumbar spine pain. Injury was associated with lumbar spine, cervical spine and shoulder OA and pain for Olympians. Although overall OA odds did not differ, after adjustment for recognised risk factors, Olympians were more likely to have lumbar spine pain and shoulder OA after shoulder injury, than the general population.

Prevalence of and factors associated with osteoarthritis and pain in retired Olympians, with comparison to the general population: part 1 – the lower limb

Objectives

This study aims (1) to determine the prevalence of lower limb osteoarthritis (OA) and pain in retired Olympians; (2) to identify factors associated with their occurrence and (3) to compare with a sample of the general population.

Methods

3357 retired Olympians (median 44.7 years) and 1735 general population controls (40.5 years) completed a cross-sectional survey. The survey captured demographics, general health, self-reported physician-diagnosed OA, current joint/region pain and injury history (lasting >1 month). Adjusted OR (aOR) compared retired Olympians with the general population.

Results

The prevalence of (any joint) OA in retired Olympians was 23.2% with the knee most affected (7.4%). Injury was associated with increased odds (aOR, 95% CI) of OA and pain in retired Olympians at the knee (OA=9.40, 6.90 to 12.79; pain=7.32, 5.77 to 9.28), hip (OA=14.30, 8.25 to 24.79; pain=9.76, 6.39 to 14.93) and ankle (OA=9.90, 5.05 to 19.41; pain=5.99, 3.84 to 9.34). Increasing age and obesity were also associated with knee OA and pain. While the odds of OA did not differ between Olympians and the general population, Olympians with prior knee and prior hip injury were more likely than controls with prior injury to experience knee (1.51, 1.03 to 2.21 (Olympians 22.0% vs controls 14.5%)) and hip OA (4.03, 1.10 to 14.85 (Olympians 19.1% vs Controls 11.5%)), respectively.

Conclusions

One in four retired Olympians reported physician-diagnosed OA, with injury associated with knee, hip and ankle OA and pain. Although overall OA odds did not differ, after adjustment for recognised risk factors Olympians were more likely to have knee and hip OA after injury than the general population, suggesting injury is an occupational risk factor for retired Olympians.

Health conditions among retired professional footballers: a scoping review

Objective

To conduct a scoping review providing an overview of the health conditions occuring in retired male and female professional footballers, with an emphasis on musculoskeletal, mental, neurocognitive, cardiovascular and reproductive health conditions.

Methods

In January 2022, a comprehensive systematic literature search in three databases (MEDLINE via PubMed, SPORTDiscus via EBSCOhost and EMBASE) was conducted for common health conditions among retired male and female professional footballers. Primary research studies (full text available online) which described the incidence or prevalence of a health condition (musculoskeletal, mental, neurocognitive, cardiovascular, reproductive) among retired male and female professional footballers were included for review. Case reports, qualitative research and grey literature were omitted.

Results

In total, 917 eligible articles were identified from the databases, with 41 meeting the eligibility criteria. Osteoarthritis of the hip, knee and ankle were found to be common among retired professional footballers. Mental health symptoms (eg, anxiety, depression) are experienced by retired male and female professional footballers. The incidence of neurocognitive disease appears to be higher among retired male professional footballers than among matched controls. There is very limited evidence examining the presence of health conditions in retired female professional footballers.

Conclusion

Osteoarthritis of the lower limb, musculoskeletal pain and mental health symptoms are common among retired professional footballers. Knowledge about the occurrence and timing of musculoskeletal, mental health and neurocognitive conditions among retired professional footballers can be used by a wide range of stakeholders to proactively intervene during and after a player's career to mitigate risk.

Foot and ankle Osteoarthritis and Cognitive impairment in retired UK Soccer players (FOCUS): protocol for a cross-sectional comparative study with general population controls

INTRODUCTION

Professional footballers commonly experience sports-related injury and repetitive microtrauma to the foot and ankle, placing them at risk of subsequent chronic pain and osteoarthritis (OA) of the foot and ankle. Similarly, repeated heading of the ball, head/neck injuries and concussion have been implicated in later development of neurodegenerative diseases such as dementia. A recent retrospective study found that death from neurodegenerative diseases was higher among former professional soccer players compared with age matched controls. However, well-designed lifetime studies are still needed to provide evidence regarding the prevalence of these conditions and their associated risk factors in retired professional football players compared with the general male population.

OBJECTIVES

To determine whether former professional male footballers have a higher prevalence than the general male population of: (1) foot/ankle pain and radiographic OA; and (2) cognitive and motor impairments associated with dementia and Parkinson's disease. Secondary objectives are to identify specific football-related risk factors such as head impact/concussion for neurodegenerative conditions and foot/ankle injuries for chronic foot/ankle pain and OA.

METHODS AND ANALYSIS

This is a cross-sectional, comparative study involving a questionnaire survey with subsamples of responders being assessed for cognitive function by telephone assessment, and foot/ankle OA by radiographic examination. A sample of 900 adult, male, ex professional footballers will be recruited and compared with a control group of 1100 age-matched general population men between 40 and 100 years old. Prevalence will be estimated per group. Poisson regression will be performed to determine prevalence ratio between the populations and logistic regression will be used to examine risk factors associated with each condition in footballers.

ETHICS AND DISSEMINATION

This study was approved by the East Midlands-Leicester Central Research Ethics Committee on 23 January 2020 (REC ref: 19/EM/0354). The study results will be disseminated at national and international meetings and submitted for peer-review publication.

Safety of Total Knee Arthroplasty in the Treatment of Knee Osteoarthritis and Its Effect on Postoperative Pain and Quality of Life of Patients

Objective

To explore the safety of total knee arthroplasty (TKA) in the treatment of knee osteoarthritis (KOA) and its impact on patients' postoperative pain and quality of life.

Methods

A total of 60 KOA patients admitted to our hospital from January 2019 to January 2020 were selected as the research objects. The knee joint scores (HSS) before and after TKA were compared, and the patients' quality of life was evaluated using the Osteoarthritis Index of Western Ontario and McMaster University (WOMAC). At the same time, the number of patients with complications was recorded, and the efficacy of TKA was comprehensively analyzed.

Results

The postoperative HSS score was significantly higher than the preoperative score (P < 0.05), the postoperative pain score increased with time, and the pain gradually decreased. The postoperative WOMAC score was significantly lower than the preoperative score (P < 0.001), and the score at 6 months after surgery was significantly lower than that at 3 months after surgery (P < 0.001). There were no complications such as severe prosthesis fracture, secondary sepsis, and patellar tendon rupture, and the total incidence of complications was 11.7%. The effective rate of treatment at 6 months after operation was 98.3%, which was significantly higher than that at 3 months after operation (P < 0.05).

Conclusion

Total knee arthroplasty can improve the knee joint function of patients with knee osteoarthritis, with low postoperative pain, low complication rate, and good quality of life for patients. It is worthy of promotion and application.

A Cross-Sectional Study of Retired Great British Olympians (Berlin 1936-Sochi 2014): Olympic Career Injuries, Joint Health in Later Life, and Reasons for Retirement from Olympic Sport

Background

The relationship between Olympic career sport injury and the long-term musculoskeletal health of the elite athlete remains unclear. This study describes the lifetime prevalence of medical attention injuries that occurred during training and/or competition as part of the athlete’s Olympic career, reasons for retirement from Olympic sport, and the point prevalence of pain and osteoarthritis (OA) among retired Great Britain’s (GB) Olympians.

Methods

This cross-sectional study involved distributing a questionnaire to retired GB Olympians who had competed at 36 Olympic Games between Berlin 1936 and Sochi 2014. The questionnaire captured Olympic career injury history (lasting ≥ 1 month), sport exposure, musculoskeletal pain (last 4 weeks), physician-diagnosed OA, and joint replacement. Injury prevalence was calculated for sports with a minimal of 15 respondents. Adjusted odds ratios (aOR) were estimated in logistic regression for pain, OA, and joint replacement. Models were adjusted for age, sex, BMI, and career duration.

Results

Six hundred fifty (57.8% male; 42.2% female) retired athletes representing 40 sports (29 summer; 11 winter), aged 60.5 years (range 23–97), completed the questionnaire. Overall, 721 injuries (368 athletes) were self-reported equating to a lifetime Olympic career injury prevalence of 56.6%. Injury prevalence was highest in field athletics (81.0%), gymnastics (75.0%), and track athletics (67.7%). Injuries most frequently occurred at the knee (19.0%), lower back (15.4%), and shoulder (11.5%). Of those injured, 19.5% retired from sport due to injury. Pain was most prevalent at the lumbar spine (32.8%), knee (25.3%), and hip (22.5%), and OA at the knee (13.4%), hip (10.4%), and lumbar spine (4.6%). Injury was associated with pain at the hip (aOR 4.88; 95% CI, 1.87–12.72, p = 0.001), knee (aOR 2.35; 95% CI, 1.45–3.81, p = 0.001), and lumbar spine (aOR 2.53; 95% CI, 1.63–3.92, p < 0.001); OA at the hip (aOR 5.97; 95% CI, 1.59–22.47, p = 0.008) and knee (aOR 3.91; 95% CI, 2.21–6.94, p < 0.001); and joint replacement at the hip (aOR 8.71; 95% CI, 2.13–35.63, p = 0.003) and knee (aOR 5.29; 95% CI, 2.39–11.74, p < 0.001).

Conclusion

The lifetime prevalence of Olympic career injury was 56.6%, with those injured more likely to self-report current pain and/or OA at the hip, knee, and lumbar spine and joint replacement at the hip and knee.

Intra-articular Injection Administration in UK Ex-professional Footballers During Their Playing Careers and the Association with Post-career Knee Osteoarthritis

Background

The long-term risk from knee intra-articular (KIA) injections in professional athletes such as ex-footballers remains unknown. The use of KIA injections is controversial and remains anecdotally prolific as it is perceived as being safe/beneficial. The aim of this study was to determine the number, type and frequency KIA injections administered to retired professional footballers during their playing careers and the associations with post-career knee osteoarthritis (KOA).

Methods

This is a cross-sectional study involving a postal questionnaire (n = 1207) and subsequent knee radiographs in a random sample of questionnaire responders (n = 470). Footballers self-reported in the questionnaire whether they had received KIA injections and the estimated total number over the course of their playing career. Participant characteristics and football career-related details were also recorded. KOA was measured as self-reported knee pain (KP), total knee replacement (TKR) and radiographic KOA (RKOA).

Results

44.5% of footballers had received at least one KIA injection (mean: 7.5; SD ± 11.2) during their professional career. 71% of knee injections were cortisone/corticosteroid based. Multivariate logistic regression, adjusting for age, body mass index (BMI) and significant knee injury identified that footballers with injections were two times more likely to have KP (OR 1.81, 95% CI 1.40–2.34) and TKR (OR 2.21, 95% CI 1.43–3.42) than those without injections. However, there was no association with RKOA (OR 1.30, 95% CI 0.85–2.01). Given, the association with KP and TKR, we found a significant dose–response relationship as the more injections a player received (by dose–response groups), the greater the risk of KP and TKR outcomes after adjustment for knee injury and other confounders (p for trend < 0.01).

Conclusion

On average, 8 KIA injections were given to the ex-footballers during their professional career. The most commonly administered injections were cortisone based. These injections associated with KP and TKR after they retired. The associations are independent of knee injuries and are dose dependent. The study suggests that there may have been excessive use of KIA injections to expedite return to play and this contributed to detrimental long-term outcomes such as KP and TKR post-retirement from professional football.

The Risk of Knee Osteoarthritis in Professional Soccer Players—a Systematic Review With Meta-Analyses

BACKGROUND

We address the question whether professional soccer players with and without macroinjury of the knee joint are at an elevated risk for knee osteoarthritis.

METHODS

A systematic review with meta-analyses was conducted. The study protocol was prospectively registered (registration number CRD42019137139). The MEDLINE, EMBASE, and Web of Science databases were searched for relevant publications; in addition, forward searching was performed, and the listed references were considered. All steps of the process were undertaken independently by two reviewers, and any discordances were resolved by consensus. For all publications whose full text was included, the methods used were critically evaluated. The quality of the evidence was judged using the GRADE criteria.

RESULTS

The pooled odds ratio for objectively ascertained osteoarthrosis of the knee was 2.25 (95% confidence interval [1.41-3.61], I2 = 71%). When only radiologically ascertained knee osteoarthrosis was considered, the odds ratio was 3.98 [1.34; 11.83], I2 = 58%). The pooled risk estimator in studies in which knee joint macroinjury was excluded was 2.81 ([1.25; 6.32], I2 = 71%).

CONCLUSION

A marked association was found between soccer playing and knee osteoarthritis in male professional soccer players. For female professional soccer players, the risk of knee osteoarthritis could not be assessed because of the lack of data. Knee injuries seem to play an important role in the development of knee osteoarthritis in professional soccer players.

Association between hyperuricemia, gout, urate lowering therapy, and osteoarthritis: A protocol for a systematic review and meta-analysis

INTRODUCTION

Osteoarthritis (OA), a chronic and degenerative joint disease characterized by articular cartilage degeneration, sclerosis of subchondral bone, and osteophyte formation, is deemed a leading cause of activity limitation and disability among the elderly people. Serum uric acid (UA) is a terminal metabolite of purine compound, while hyperuricemia (HU) and UA crystals are recognized causes of gout. Several studies have investigated the correlations between HU, gout and OA, but the findings are inconclusive. We are also concerned whether the urate lowering therapy (ULT) can become a potential treatment for OA and intend to undertake this meta-analysis to clarify the related hypotheses.

METHODS

Systematic literature search will be conducted on PubMed, Embase, and Web of Science to identify relevant studies up to February 2020 using appropriate search strategies. All citations and abstracts retrieved from literature search will be assessed by two reviewers independently. The Newcastle-Ottawa Scale or the Cochrane risk of bias assessment tool will be used as appropriate to assess the quality and the risk of bias of the included studies. The heterogeneity and the publication bias of the studies will be investigated accordingly.

RESULTS

We propose to undertake this meta-analysis as a feasible approach to clarify the associations between HU, gout or ULT, and OA.

DISCUSSIONS

This meta-analysis will help to strengthen our knowledge of the pathogenesis of OA and promote the development of preventive or treatment strategies.

REGISTRATION

PROSPERO registration number CRD42020168769.