Does long-distance running cause osteoarthritis?

Abstract

There is a dose-response relationship between physical activity and the reduced risk of some diseases (eg, cardiovascular disease, diabetes mellitus). At a certain "dose," however, the reduced risk of some diseases may be offset by an increased risk of injury and osteoarthritis. Osteoarthritis can be caused by trauma to, or overuse of, the joints. Sports injuries often occur as a result of dysfunctions in balance or the musculoskeletal system operating in nonneutral mechanics. It is unclear if long-distance running causes the knee and hip joints to deteriorate. The results of animal studies reveal a pattern of increased incidence of arthritis in these joints when there is a history of injury or use in atypical environments (eg, laboratory settings). Human studies show an increase in radiographic evidence of osteoarthritis in endurance sports athletes, but no related increase in symptoms reported. Although there are not currently enough data to give clear recommendations to long-distance runners, it appears that long-distance running does not increase the risk of osteoarthritis of the knees and hips for healthy people who have no other counterindications for this kind of physical activity. Long-distance running might even have a protective effect against joint degeneration. The authors recommend further study.

Full text

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Does Long-Distance Running Cause
Osteoarthritis?
Tyler Childs Cymet, DO
Vladimir Sinkov, MD
Exercise is thought to enhance our health. There is a dose-
response relationship between physical activity and the reduced
risk of some diseases (eg, cardiovascular disease, dia-
betes). At a certain çdose,å however, the reduced risk of
some diseases may be offset by an increased risk of injury
and osteoarthritis. Osteoarthritis can be caused by trauma
to, or overuse of, the joints. Sports injuries often occur as
a result of dysfunctions in balance or the musculoskeletal
system operating in nonneutral mechanics. It is unclear if
long-distance running causes the knee and hip joints to
deteriorate. The results of animal studies reveal a pattern
of increased incidence of arthritis in these joints when
there is a history of injury or use in atypical environ-
ments (eg, laboratory settings). Human studies show an
increase in radiographic evidence of osteoarthritis in
endurance sports athletes, but no related increase in prob-
lems reported[AQ 1: Please specify what you mean by
“problems reported.” Pain? Disability? Please indicate.
Thank you. —RJF]. Although there are not currently enough
data to give clear recommendations to long-distance runners,
it appears that long-distance running does not increase the
risk of osteoarthritis of the knees and hips for healthy people
who have no other counterindications for this kind of phys-
ical activity. Long-distance running might even have a pro-
tective effect against joint degeneration. The authors rec-
ommend further study.
P
hysical activity is important in maintaining health. Long-
distance and marathon running are relatively safe sports.1
Anecdotally, however, it is felt that “Today’s runners are
tomorrow’s cyclists”—not because of a “natural progres-
sion” from one sport to the other, but as a result of joint
injury.
Is there a causal relationship between running and
osteoarthritis? The current data are based on small studies,
and their results are often unclear. People engaged in sports
or other physically demanding activities are known to be at
an increased risk of osteoarthritis in the joints they use most
(eg, knees and hips in soccer players, hands in boxers, lower
backs in construction workers). Part of this seeming corre-
lation can be explained by increased risk of joint injury.2It
would also seem logical that these groups would be pre-
disposed to osteoarthritis from overuse injuries, and not
necessarily from trauma.
Osteoarthritis is generally divided into primary
osteoarthritis, related to age and genetics, and secondary
osteoarthritis, which is associated with a history of any kind

of joint injury (eg, trauma, infection, surgery, mineral depo-
sition, autoimmune disorders). Joint trauma can be acute or
chronic, and pain intensity can be severe or mild. The trauma
may be ligamentous, meniscal, or muscular in origin. Because
of nonpathogenic but highly repetitive loading, overuse
injuries may be considered a mild, chronic joint trauma.
Such use is thought, with time, to deplete the joint of the
lubricating glycoproteins, disrupt the collagen network,
slowly wear away the cartilage, and cause numerous
microfractures in the underlying bones[AQ 2: Please provide
references in support of this statement. Thank you. —RJF].
Animal Studies
Researchers conducting animal studies have attempted to
simulate long-term stress on weight-bearing joints to determine
how such activities might damage the joint. In sheep studies,
Radin and colleagues3have shown that 4 hours of walking on
a concrete surface resulted in signs of osteoarthritis.
More recent canine studies by Kiviranta et al4,5 demon-
strated that moderate running improved the joint condition
in terms of cartilage thickness and glycosaminoglycan content,
whereas more strenuous running reversed those benefits and
was detrimental to joint health. The latter finding was further
supported in a study of laboratory rats by Pap and colleagues,6
in which the animals were subjected to “strenuous running”
(30 km within 6 weeks). Researchers found histologic evi-
dence of osteoarthritis in all of the exercised group and none
in the resting controls.6
The findings of Lapvetelainen et al7differed from those
in the previously noted studies, however.3–6 Researchers cre-
ated mice with heterozygous inactivation of gene coding for
type 2 procollagen and subjected them and controls to lifelong
voluntary wheel-running exercise. As expected, the exercised
knockout mice had more knee osteoarthritis than resting con-
trols[AQ 3: I am not familiar with the term “knockout” in this
context. Is this standard technical terminology? (It sounds
“jargony.”) Please advise. —RJF]. However, running
knockout mice had less knee osteoarthritis than sedentary
mice. There was no difference in prevalence rates for
osteoarthritis between exercised mice and sedentary controls,
but increased prevalence of knee osteoarthritis was seen in
exercised and control mice with high body weight. Lapvete-
lainen et al7demonstrated that physical activity does not pre-
dispose normal mice to osteoarthritis and might, in fact, pro-
tect injured mice from the disease.
Although the results of more recent studies conflict with
their predecessors, there seems to be a pattern: intrinsic injury
or excessive exercise seems to lead to a higher incidence of
osteoarthritis, whereas moderate exercise was either non-
contributory in joint degeneration or it was found to be ben-
eficial in decreasing the risk of osteoarthritis in animals.8[AQ 4:
Edits okay? Original read: “Intrinsic injury or excessive
exercise seem to lead to more OA, whereas moderate exer-
cise was either beneficial or noncontributory in decreasing
the risk of OA in animals.” Please advise: Y/N. —RJF]
There are many limitations, however, to making such a
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general statement or applying this principle to humans. The
animals studied varied greatly among these experiments; the
anatomy, biomechanics of joint loading, muscle strength, and
ability to recover from minor joint injuries varies greatly from
sheep and dogs to mice and rats. Furthermore, though some
animals were subjected to the same joint loads as they would
experience in nature (eg, running), some experimental animals
were required to exercise in a laboratory environment to
which they were not adapted (eg, walking on concrete).3
Finally, the measurements of osteoarthritis varied from gross,
to histologic, to biochemical[AQ 5: Please put reference num-
bers 2-6 next to each measurement type (eg, gross,3histo-
logic,4-5, to biochemical6,7). Thank you. —RJF]. Even if all of
these confounding factors were controlled for, it is still ques-
tionable whether the results would be generalizable to
humans.
Human Studies
Numerous studies have investigated the association of pro-
longed running and osteoarthritis of the knee and hip. Unfor-
tunately, the evidence from these studies is conflicting, with
some researchers saying that running is not associated with
increased prevalence of osteoarthritis,9–16 while others indicate
that running can increase the risk of knee and hip
osteoarthritis.17–19 All of the studies, however, are retrospective;
many have few subjects, fail to separate runners from other
athletes14,18; or neglect to stratify the subjects by the amount
of running or history of injuries to the lower extremities; and
many study either professional athletes or amateurs[AQ 6: As
in AQ #5, please put reference numbers next to each item in
this list. —RJF]. In addition, some studies were done in other
countries, making it hard to generalize their results to the
population in the United States.14–15,20 Finally, researchers have
used different diagnostic criteria to evaluate the extent of
osteoarthritis in subjects.
In a 1973 study, Marti and colleagues17 conducted a ret-
rospective review of male subjects who were former athletes
(long-distance runners, n=27; bobsleigh riders, n=9) or normal,
healthy nonathlete controls (n=23). Subjects were then reex-
amined 15 years later. Researchers17 found that high-intensity
running (ie, 97 km per week) was associated with a signifi-
cantly higher incidence of radiographic evidence of
osteoarthritis of the hip. The limitations of the study included
atypically high intensity of running, small sample size, lack of
correlation with history of injury to the hip joint, and use of
radiographic evidence as the sole measure of osteoarthritis.
A study by Spector and colleagues18 in the United
Kingdom investigated osteoarthritis in women who were
former elite long-distance runners and tennis players. Spector
et al18 found a two- to threefold increase in the incidence of
radiographic osteoarthritis in the study group even when
subjects were controlled for age. The authors18 found similar
rates of reported knee pain between the former athletes and
controls subjects, however. This study also had a low number
of athletic participants (n=81), combined runners and tennis
players into one group, and looked at women only. In addi-
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tion, the study methods assumed that athletes and nonathletes
would report pain similarly.
The most recent study implicating running as a cause of
osteoarthritis was conducted by Cheng et al.19 The study
involved nearly 17,000 patients seen at the Cooper Clinic in
Dallas, Tex, from 1970 to 1995. All patients were later con-
tacted by mail and asked to report on physician-diagnosed ill-
nesses and conditions by return survey. Researchers19 found
significantly higher incidence of osteoarthritis in men (aged
20–49 years) who were involved in high levels of physical
activity (ie, walking or running more than 20 miles per week).
Although this 10-year study had a very large sample size
with subjects from a variety of age groups (range 20 to 87
years), the study was limited in that the population was demo-
graphically uniform (ie, well-educated, non-Hispanic white
men of high socioeconomic status) and did not gather data on
subjects’ occupational activities (eg, kneeling, squatting, car-
rying heavy loads) or history of physical trauma, and relied
solely on self-reported data during follow up.
In another longitudinal study, Sohn and colleagues9com-
pared 504 former college varsity cross-country runners with
a control group of 284 former college swimmers. Subjects
were observed for an average period of 25 years. In particular,
researchers9noted reports of pain in the hips and knees as well
as any history of surgical procedures for relief of that pain
(ie, evidence of the presence of osteoarthritis). In the group of
college swimmers, no data were gathered on the swimming
strokes subjects most commonly used in competition. Sohn et
al9found that moderate long-distance running (25.4 miles
per week on average) was not associated with higher incidence
of osteoarthritis of the hip or knee. In addition, there was also
no evidence to suggest that higher weekly averages for dis-
tance or more total years running were associated with a
higher incidence of osteoarthritis. The study9had a large
sample size, a long average follow-up time, and good mea-
sures for incidence of osteoarthritis.
Kujala and colleagues14–15 have conducted many studies
on the effects of running on the human musculoskeletal
system. In one of their articles, Kujala et al14 described the
incidence of knee osteoarthritis in former athletes in various
sports. Runners were not found to have an increased inci-
dence of knee osteoarthritis. However, the study14 had few par-
ticipants (N=117; long-distance runners, n=28) and included
only professional male athletes from Finland.
In another study, Kujala et al15 compared men who were
master orienteering runners with matched nonsmoking con-
trol subjects. Even though researchers found a higher inci-
dence of knee osteoarthritis in the runners (17% vs 10.6%,
P=.025), they attributed this difference to a higher likelihood
of knee injuries in the athletes and to referral bias.
One of the most well-known American studies on run-
ning and osteoarthritis was published by Lane et al12 in 1993.
These researchers looked at a large population of members of
the 50-Plus Runners’ Association and, after a careful selec-
tion process, narrowed down their sample to 33 matched
pairs of long-term long-distance runners and non-running
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controls living in Stanford, Calif. All 66 subjects underwent a
rheumatologic examination, completed annual questionnaires,
and received radiographs of their joints during the 5-year
study period. The study12 showed no difference in the inci-
dence of osteoarthritis in runners and nonrunners. The limi-
tations of this study included a small sample size and a lim-
ited follow-up time. However, in a subsequent study, Lane and
colleagues16 reported that at 9-year follow-up, the results were
the same; there was no difference in the incidence and pro-
gression of knee and hip osteoarthritis in runners and non-
runners.
Fries and colleagues13 studied 451 members of a run-
ners’ club and 330 community controls aged 50 to 72 years,
observing these 781 subjects during an 8-year study period.
The runners had lower mortality rates and a lower incidence
of musculoskeletal disabilities and osteoarthritis. The study,13
however, looked at overall disability rather than osteoarthritis
in particular.
Advising Patients
Most acute injuries in runners are from overuse.[AQ 7: Please
insert reference. —RJF] In addition, running while injured
seems to promote poor body mechanics, functioning as a
major contributor to chronic injuries.21
A 1 mile run may require anywhere from 1000 to 1500
strides from the runner. In long-term, repetitive strain, the
body responds by increasing water and proteoglycan con-
tent in the joint fluid while periarticular ligaments and sup-
porting muscles undergo adaptive hypertrophy.
In properly trained athletes, who have increased exercise
intensity and duration slowly, localized pain or problems
with performing to their regular expectations often precede
injury to a specific joint. Medical advice to a runner should take
into account the individual’s running style and ability, as well
as body size. The greater the body mass index, often the
greater the radiographic evidence of osteoarthritis noted in the
joints.22
Apophyseal injuries are a greater risk for athletes aged
between 16 and 25 years.23 Physicians should carefully con-
sider patient age, size, and biomechanics when providing
advice to long-distance runners.
The rate-limiting step in long-distance running is more
energy related, with amounts of glycogen in the muscle avail-
able for breakdown necessary for sustained exercise, and not
swelling, or bone and joint dysfunction.24
Conclusion
Although the existing evidence on whether long-term long-
distance running causes osteoarthritis is currently insufficient
for researchers to draw unequivocal conclusions, the pre-
ponderance of data seems to indicate that moderate levels of
running do not increase the risk of osteoarthritis of the knees
and hips for healthy people and that this activity might even
have a protective effect. A history of injury–from overuse or
acute trauma as a result of running, excessive running, intrinsic
anatomical instability in the joints, or a high body mass
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index–can accelerate the onset of osteoarthritis and cause dis-
ability, however. It is important that people considering a
new exercise regimen seek a physical evaluation by a sports
medicine physician and that they learn proper training
methods so that they may prevent joint injury.
The risks of running as noted should be weighed against
the tremendous benefits of this activity to the other body sys-
tems. Running has been shown to decrease the risk of car-
diovascular disease, diabetes, and depression[AQ 8: As with
AQ #5, please insert reference numbers after each item in this
list of benefits. Thank you. —RJF]. This kind of physical
activity has also been shown to help with weight control, to
improve bone density, and to decrease mortality[AQ 9: Please
continue inserting references as requested in AQ #5. —
RJF].20,25–27
To better understand the effects of running on the human
musculoskeletal system, more studies are needed. Such studies
would ideally follow cohorts of runners and controls prospec-
tively using validated diagnostic criteria28 and would use a
large sample size[AQ 10: Source added. Okay to include?
Please advise: Y/N. Also, did you have other references in
mind? Thank you. —RJF]. Subjects at various levels of run-
ning should be included, with controls for confounding fac-
tors such as sex, body weight, history of injury to the lower
extremities, family history of osteoarthritis, and occupational
risks.29
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From the Johns Hopkins School of Medicine (Cymet) and Union Memorial Hos-
pital (Sinkov), both in Baltimore, Md.
Address correspondence to: Tyler Cymet, DO, 6 Tyler Falls Ct, Apt A, Bal-
timore, MD 21209-5227.
E-mail: tcymet@lifebridgehealth.org
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