October, 2013

Does Running Cause Arthritis?

October 27, 2013

Does Running Cause Arthritis? Not Quite. Every so often when someone is getting to know me they eventually discover my daily running routine. Depending on what I’m trying to accomplish that morning and where I am in my training cycle, it ranges from 3-12 miles of varying intensity. The most common questions that arise immediately after are, “What is your mile time? Have you ever run a marathon before?” And finally there’s, “Isn’t that bad for your knees and hips?” I don’t really dwell much on the first two inquires, but I sometimes get irked by the last one because I know how wrong it is. It’s easy to assume that a repetitive weight-bearing activity like running will cause wear and tear on joint cartilage over time but that’s all it is, an assumption. This theory does not explain why an individual that runs 10 miles a week can have degeneration in their knee while a professional marathoner can have healthy joints well into their geriatric years. Fortunately researchers have published papers in the last several decades looking into the epidemiology and physiology of knee osteoarthritis comparing runners with less impacting physical activities. If you do a literature search on the topic you will discover that the debate is nothing new. Back in 1985, Sohn and Micheli compared knee data on 504 former collegiate cross country runners and 287 former collegiate swimmers. They saw that 15.5% of the runners experienced knee pain while 19.5% of the swimmers had these same symptoms. The incidence of surgery for osteoarthritis was 0.8% in those runners and 2.1% in the former swimmers.
Photo by Jeffrey Chan

Photo by Jeffrey Chan

Panush et al. looked into the differences between runners and non-runners evaluating knee radiographs. The mean age was 56 and the runners averaged 28 miles per week over a 12 year period. They found no difference in pain, swelling, x-ray or any other musculoskeletal complaint. Kujala et al. found that soccer players and weightlifters had a two fold increase in knee arthritis than runners. Paul Williams published a landmark study this year with overwhelming data showing that there’s no correlation between running and arthritis to the lower extremity when compared to walkers. What makes his paper stand out is the amount of subjects and volume of statistics he was able to collect. More than 89,000 participants were recruited (many as far back as the early 90’s) and responded to follow-up questionnaires concerning whether they were diagnosed with a degenerative arthritic condition. “Contrary to many previous reports, we find no evidence that running increases the risk of OA and, in fact, subjects that ran were at significantly lower risk for both OA and hip replacement.” He also took in account those who ran longer distances. “Our data even showed that marathon frequency, marathon intensity, and 10-km intensity did not predict any risk increase for OA or hip replacement, in contrast to the report of Michaelsson (et al.) that skiers who repeatedly participated in a 90-km ski race increased OA risk in proportion to the number of races run and performance (speed).” Not only do I think of this information as reassuring for myself as a track athlete but for my patients as well. I’m fortunate to be treating a demographic that I relate to, runners, that have pretty lofty goals. Many patients in my clinic strive to be at the top of their age group, hope to qualify for Boston or want to make their state cross country team. As much as I preach the importance of cross training, you can’t substitute a tempo run with cycling on a routine basis. You need to replicate the conditions of race day as much as possible. A training run is as important for working on your stride as it is developing your aerobic system. With all that has been published, my patients can focus on the next interval rather than worrying about the latest developments in knee replacement procedures. Despite all these papers refuting the causal relationship of running on arthritis, we still haven’t addressed those that are severely obese. You may be thinking, “A 300lb. male must be at high risk regardless and should avoid a running routine to save his knees.” This theory does have some substance to it. It would be too simple to say that the excessive load of their body weight, faulty biomechanics, and repetitive stress would lead to joint degeneration in their hips and knees…and it does. Ryan Koonce and Jonathan Bravman published a study in March highlighting what we are beginning to understand as the effect of adipose tissue on inflammation. What was once thought to be as energy storage and unsightly space filler, fatty tissue also acts as an endocrine organ when there is an excess amount. It essentially has a mind of its own and it’s not kind to the body. White fatty tissue produces pro-inflammatory proteins (cytokines like interleukin-6) that can initiate or further advance osteoarthritis as areas such as bone and cartilage are often targeted. They believe that it acts by way of oxidative stress and general cell dysfunction contributing to osteoarthritis. They conclude that, “The connection between obesity and OA cannot be explained by biomechanical factors or systemic inflammation alone; it is likely the result of a combination of the two. Just as OA is no longer thought of as just wear-and-tear arthritis, adipose tissue is no longer considered to be an energy depot.” With all this data it doesn’t mean that you don’t have to worry about getting cartilage degeneration in your knees. It does however show that what many think running of as an obvious contributor to arthritis is not so. You also have to take into account previous injury, genetics and so forth. What I’d take from it as well is that it reinforces the little things that we neglect to do such as stretching, foam rolling, slowly building up our mileage and cleaning up our diet. Control what you can control and leave everything up to luck. Dr. Jeffrey A Chan, DC, CSCS, ART

References

Chakravarty EF, Hubert HB, Lingala VB, et al. Long distance running and knee osteoarthritis. A prospective study. Am J Prev Med 2008;35(2):133–8 Hootman JM, Macera CA, Helmick CG, et al. Influence of physical activity-related joint stress on the risk of self-reported hip/knee osteoarthritis: a new method to quantify physical activity. Prev Med 2003;36(5):636–44. Lane NE, Bloch DA, Jones HH, et al. Long-distance running, bone density, and osteoarthritis. JAMA 1986;255:1141–51. Lane NE, Oehlert JW, Bloch DA, et al. The relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: a 9 year longitudinal study. J Rheumatol 1998;25:334–41. Koonce RC, Bravman JT. Obesity and osteoarthritis: more than just wear and tear. J Am Acad Orthop Surg. 2013 Mar;21(3):161-9 Krampla WW, Newrkla SP, Kroener AH, et al. Changes on magnetic resonance tomography in the knee joints of marathon runners: a 10-year longitudinal study. Skeletal Radiol 2008;37(7):619–26 Kujala UM, Kettunen J, Paananen H, et al. Knee osteoarthritis in former runners, soccer players, weight lifters, and shooters. Arthritis Rheum 1995;38:539–46. Panush RS, Schmidt C, Caldwell JR, et al. Is running associated with degenerative joint disease? JAMA 1986;255(14):1152–4. Sohn RS, Micheli LJ. The effect of running on the pathogenesis of osteoarthritis of the hips and knees. Clin Orthop Relat Res 1985;198:106–9. Thelin N, Holmberg S, Thelin A. Knee injuries account for the sports-related increased risk of knee osteoarthritis. Scand J Med Sci Sports 2006;16(5): 329–33. Williams, PT. Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk. Medicine and Science in Sport and Exercise 2013 Jul;45(7):1292-1297 Willick S. Running and osteoarthritis. In: O’Connor F, Wilder R, editors. Textbook of running medicine. New York: McGraw-Hill; 2001. p. 387–94.
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