When a physically active person like me injures a joint, especially one as crucial as a knee or ankle, one of the first thoughts, if not the first thought, is likely to be “How fast can I get back to my usual activities?”
That kind of thinking, however, could set the stage for a painful chronic problem years later: post-traumatic osteoarthritis.
In the rush to get back in the game, whether as part of a team or elite sport or simply a cherished recreational activity like jogging or tennis, it is tempting to short-circuit the rehabilitation needed to allow the joint to heal fully. But adequate recovery, including rehab measures aimed at strengthening structures that support the injured joint, is critical to maximize its stability, reduce the risk of reinjury and head off irreparable joint damage.
And you don’t have to be a senior citizen to pay the price of failing to build up the tissues that help protect that joint. Studies have shown that when an adolescent or young adult sustains a knee injury, for example, X-ray evidence of arthritis is often apparent within a decade.
As a team of orthopedists and rehabilitation specialists from the University of Iowa explained, “Recent research suggests that acute joint damage that occurs at the time of an injury initiates a sequence of events that can lead to progressive articular surface damage.” That means deterioration of the surface of the bone itself and the connecting tissues that cushion and stabilize bones of a joint like the knee, which is what arthritis is all about.
Osteoarthritis afflicts some 27 million Americans, and that number will certainly grow with the increase in obesity, the current emphasis on lifelong physical activity and the aging of the population. It is a degenerative joint disease that occurs when the protective cartilage on the ends of bones and often the surface of the bones themselves wear down, causing pain, stiffness, instability and disability that can interfere with work and mobility and diminish quality of life.
The Iowa team noted that arthritis will eventually develop in more than 40 percent of people who seriously injure the ligaments (the stabilizing bands that connect bones to one another); the meniscus (the crescent-shaped cartilage that cushions the knee and certain other joints), or the articular surface of a joint. People with a history of trauma to the knee, for example, are three to six times more likely to develop arthritis in that knee. Even without an acute injury, highly repetitive impact on a joint can damage the articular cartilage.
This may help to explain why I ended up with bone-on-bone arthritis and had to replace both knees at age 63. I’d sustained three ligament injuries (while skiing) and after years of running and singles tennis, the meniscus in both knees had shredded. Although I did the recommended physical therapy after each injury, I now know that I was not sufficiently diligent about maintaining the strength and flexibility of the supporting muscles and other tissues that might have better protected my knees for years longer.
Recognizing how common a scenario this is, a prestigious group of athletic trainers has issued a call for a more aggressive approach to both preventing and managing post-traumatic arthritis among physically active people. Although athletic trainers most often treat team players and elite athletes, they also work at physical therapy and rehab clinics where they often see joint damage among recreational athletes like me.
They pointed out in a consensus statement in the Journal of Athletic Training that arthritis should no longer be considered a disease that affects only the elderly.
“Increasing evidence demonstrates that young and middle-aged adults are suffering from osteoarthritis as well,” the statement said. “More than half of adults with symptomatic knee osteoarthritis are younger than 65.”
In fact, as Joseph M. Hart, an athletic trainer who conducts clinical research at the University of Virginia, and his colleagues wrote in the journal, “A 17-year-old athlete who tears her anterior cruciate ligament could develop osteoarthritis before she turns 30, potentially leading to chronic pain and disability.” Damage to this ligament, in the center of the knee, is the most common injury among young athletes, especially girls, they wrote.
Jeffrey B. Driban, an athletic trainer at Tufts Medical Center in Boston, said that one person in three who injures the anterior cruciate ligament “will have X-ray evidence of osteoarthritis within 10 years” whether or not the injury is repaired surgically.
Dr. Driban and co-authors pointed out that some sports – soccer, elite-level long-distance running, competitive weight lifting and wrestling – are associated with a higher risk of knee injuries.
A person’s risk of injury can be reduced by having deficits in muscle strength, balance and stability evaluated and treated, Dr. Hart said in an interview. However, he added, “not all injuries can be prevented, and unless the initial injury is properly treated, it can lead to additional injuries to the same joint or other joints,” increasing the chance that arthritis will develop early in life.
Dr. Driban said in an interview that sports participants who sustain a knee injury can minimize the risk of reinjury and arthritis by “not rushing back into activity or trying to play through pain. They must strengthen the muscles that support the joint – the quads, hamstrings and hip muscles. It’s important to think about the entire lower extremity, not just the knee.”
Following an injury, an athletic trainer, rehabilitation specialist or physical therapist who specializes in orthopedics can evaluate a person’s muscle strength, endurance, balance and movement quality, then guide recovery with a structured rehab program that is maintained for six to nine months, Dr. Hart said.
It is also important to continue to pursue an active lifestyle, said Abby C. Thomas of the University of North Carolina at Charlotte. “You may have to modify the activities you do, but you have to stay active to maintain strength and cardiovascular fitness without putting repetitive stress on a joint that’s already injured. If your knee hurts and you can’t run, maybe get on a bike or swim,” activities that place less stress on the knees.
“Don’t sit around on the couch because running hurts,” Dr. Thomas said. “Try walking, or something different, but don’t give up on physical activity.”
Lifelong activity is also important to prevent weight gain, since every extra pound places disproportionate stress on the knees. All the authors emphasized that pursuing a healthy lifestyle is crucial for everyone, not just elite athletes and those who play on school teams.