6

Exercise and the musculoskeletal system

R. S. P A N U S H
N. E. L A N E

There is growing interest in the relationships between exercise and health.

Studies have shown that increased physical activity decreases the risk of
cardiovascular disease, improves blood pressure, assists in weight reduc-
tion, improves mood, and enhances emotional well-being (Paffenbarger et
al, 1986; Haskell, 1988). In part, because of these findings, there has been a
dramatic increase in the popularity of recreational exercise. Millions of
people in many countries regularly swim, jog, do aerobics, cycle, play
racquet sports, and participate in other recreational and competitive sports
(Koplan et al, 1982, 1985). Physicians have been justifiably concerned that
these activities could have adverse long-term consequences on the musculo-
skeletal system. Might certain exercise(s) accelerate the development of
osteoarthritis (OA) in weight-bearing joints? Might certain exercise(s) lead
to chronic soft tissue (non-articular) injuries? Should patients with arthritis
exercise, and if so what type of exercise and how much?
This presentation will discuss the pathogenesis of OA and how repetitive
joint loading may influence joint degeneration, review the data available
regarding the effects of exercise on the development of degenerative joint
disease, and provide clinicians with answers to questions that their exer-
cising patients may ask (Lane, 1987, 1992; Land and Buckwalter, in press;
Lane et al, 1986, 1987, 1990, in press; Panush 1985, 1989, 1990, in press;
Panush and Brown, 1987a-c; Panush and Holtz, in press; Panush and
Panush, in press; Panush et al, 1986, in press a, in press b).
Exercise and non-articular soft tissue injury is addressed separately in this
volume (see Chapter 8).

JOINTS

Joints are formed as a connection between any two bones. There are three
types of joints found in the human body. They vary by the amount of relative
motion allowed. Diarthrodial or synovial-lined joints are characterized by
large amounts of motion, synarthroses or fibrous joints allow relative
motion, and amphiarthroses or cartilagenous joints provide for little or no
relative motion (Goss, 1972). The primary function of diarthrodial joints,
Bailli~re's Clinical Rheumatology-- 79
Vol. 8, No. 1, February 1994 Copyright 9 1994, by Bailli~re Tindall
ISBN 0-7020-1822-8 All rights of reproduction in any form reserved
80 R.S. PANUSH AND N. E. LANE

such as the hip and knee, is to facilitate the movement of body segments and
locomotion. Every movement by the human body involves diarthrodial
joints. Under normal conditions, the synovial joint is an efficient bearing
system, with excellent friction, lubrication and wear properties, that under-
goes little or no deterioration for the life of the individual (Dowson, 1981;
Mow and Mak, 1981). It must be able to withstand loads of up to six times
body weight on a repetitive basis, for up to one million cycles per year,
depending on the specific joint and function. Wear and tear breakdown of
these diarthrodial joints may lead to DJD (Mankin, 1974; Howell et al,
1976, 1979, 1983; Lynch et al, 1983; Lane and Buckwalter, in press).
Although individual anatomical forms and material properties vary, syn-
ovial fluid and soft connective tissues are common to all joints. Structures
that are formed by connective tissue include articular cartilage, capsule,
meniscus and ligament (Goss, 1972). Abnormalities in any of these struc-
tures of the joint can lead to significant pain and loss of function (Mankin,
1974; Howell et al, 1976, 1979, 1983; Lynch et al, 1983; Lane and Buck-
walter, in press).
Articular cartilage covers the ends of the bones and provides the primary
load-bearing functions in the joint, with excellent frictional characteristics
(Dowson, 1981; Mow and Mak, 1981). It also provides a highly wear-
resistant surface that allows one end of the joint to move efficiently over the
other with little or no attrition (Lipshitz and Glimcher, 1979). Most arthritic
changes begin with focal lesions on the cartilage surface, eventually leading
to the entire wearing away of the tissue and resultant OA. Because this
tissue plays a unique role in the function of the diarthrodial joint, much
research has attempted to understand its biology, molecular structure,
biochemistry, and biomaterial properties (Howell et al, 1976, 1979;
Dowson, 1981; Howell et al, 1983; Buckwalter, 1990; Lane and Buckwalter,
in press).

OSTEOARTHRITIS

Definition
Osteoarthritis is the most common type of arthritis. This syndrome has also
been termed degenerative joint disease, or 'osteoarthrosis'. It is very preva-
lent among the elderly, ultimately affecting the entire ageing population, at
least to some degree (Panush and Brown, 1987a-c; Hochberg, 1988;
Panush, 1989, 1990, in press).
Osteoarthritis is a clinical syndrome reflecting different aetiologies and
pathogenetic pathways, occurring in different sites, often with varying
clinical manifestations. Recently an American College of Rheumatology
subcommittee developed the following definition--'A heterogeneous group
of conditions that lead to joint symptoms and signs which are associated with
defective integrity of articular cartilage, in addition to related changes in the
underlying bone and at the joint margins' (Altman et al, 1986, 1987, 1990,
1991). This reflects the concept that OA may be the result of several
different processes which lead to symptomatic articular diseases.
EXERCISE AND THE MUSCULOSKELETAL SYSTEM 81

Specific criteria for the diagnosis of OA of the hip, knee, and hand have
been derived. They included:
1. History: pain, age greater than 50 years, decreased function, joint
swelling, stiffness lasting less than 30 min.
2. Physical examination: joint crepitus, bony enlargement, limitation of
motion, instability, joint tenderness.
3. Laboratory studies: normal erythrocyte sedimentation rate, negative
rheumatoid factor test, non-inflammatory synovial fluid.
4. Radiographic evaluation: osteophytes, narrowing, sclerosis, cysts, varus
deformity, chondrocalcinosis.
Osteoarthritis may be primary (also termed idiopathic) or secondary. The
idiopathic form of OA may be localized (such as to hands, feet, knees, hips,
spine, or to other articular sites) or generalized (with three or more areas
involved). The secondary form of OA may reflect trauma, congenital or
developmental disease, calcium deposition disease, other bone and joint
disorder, metabolic or endocrine disease, endemic conditions, or other
miscellaneous disorders (Kellgren and Lawrence, 1958; Kirk et al, 1967;
Koplan et al, 1985; Altman et al, 1986, 1987, 1990, 1991; Panush and Brown,
1987a-c; Hochberg, 1988; Panush, 1989, 1990, in press; Lane, 1992; Lane
and Buckwalter, in press).

Epidemiology
Osteoarthritis is quite common, particularly among ageing populations.
One survey estimated radiological evidence of OA in as many as 40 million
Americans, some of whom were not symptomatic. Of a population between
70 and 79 years of age, as many as 85% had OA by some estimates (National
Center for Health Statistics, 1966; Gordon, 1968). Surprisingly little
information exists about the natural history of OA. Certain data suggest that
the syndrome may be considerably less progressive than previously thought.
For example, a study suggested that OA in the elderly was a relatively
non-progressive disorder; prevalence of OA of the knees was 28% in
individuals aged 55-64 years and 39% in those aged 65-74 years and preva-
lence of OA of the hips was 23% for both age groups (Forman et al, 1983).

Clinical features
Osteoarthritis is typically a disease of the elderly, although it can affect
individuals at all ages. It occurs in many clinical patterns. The most
commonly affected joints include the distal interphalangeal (Heberden's
nodes), proximal interphalangeal (Bouchard's nodes), metacarpo-
phalangeal, metacarpal, hip and knee joints, and the joints of the cervical
and lumbar spine and the feet. Disease may be generalized or localized, and
may be non-inflammatory or inflammatory (sometimes termed 'erosive').
Patients frequently have pain at rest and nocturnal pain. Patients also
awaken stiff, although this stiffness is usually of much shorter duration than
that of inflammatory arthritis, usually lasting not more than 30min.
82 R.S. P A N U S H A N D N . E. L A N E

Radiographic findings are those noted previously. Laboratory studies are

generally normal in patients with OA. Synovial fluid examination charac-
teristically indicates non-inflammatory fluid (Altman et al, 1986, 1987, 1990,
1991; Panush and Brown, 1987a-c; Lane, 1987, 1992; Hochberg, 1988;
Panush, 1989, 1990, in press; Lane and Buckwalter, in press).

Aetiology and pathogenesis of osteoarthritis

The aetiology and pathogenesis of OA are not well understood. It is perhaps
best considered a syndrome reflecting the final common pathway of several
different but possibly interacting aetiological factors. These factors may
include: inflammatory disease, joint incongruence, developmental defects,
physical and mechanical stress, chondrocyte injury, release of degradative
enzymes, and matrix degeneration (Lane, 1987, 1992; Lane and Buck-
walter, in press; Land et al, 1987, 1990, in press; Panush, 1989, 1990, in
press; Panush and Brown, 1987a-c).

Management of osteoarthritis
Management of OA includes two approaches:
1. Pharmacological: non-steroidal anti-inflammatory drugs (NSAIDs),
analgesics, intra-articular corticosteroids.
2. Nonpharmacological: weight loss, exercise and rest, activity modifi-
cation, surgery.
Most rheumatologists agree on the approach to care of patients with OA.
Therapeutic programmes usually emphasize drug treatments, often initiated
with analgesics and/or salicylates or NSAIDs; several or all agents in this
class are used until one is found to be clinically effective. Analgesics may
include drugs such as acetaminophen, dextropropoxyphene (propoxy-
phene), or mild narcotic-containing analgesics. In addition, most rheuma-
tologists urge obese patients to reduce their weight, counsel patients
regarding appropriate limitation and modification of activities, and recom-
mend adjunctive programmes of physical and occupational therapies.
Occasionally, symptomatic joints that appear to have an inflammatory
component are injected with intra-articular corticosteroids. Patients who
cannot be managed successfully on a medical programme, and whose
radiographic evaluation shows sufficient damage, are offered reconstructive
or ameliorative surgery, sometimes with dramatic success (Moskowitz,
1981; Panush and Brown, 1987a-c; Panush, 1989, 1990, in press).

RELATIONSHIP OF PHYSICAL ACTIVITY TO OSTEOARTHRITIS

Factors important in the pathogenesis

Ligamentous instability, abnormal joint motion and prior injury too may be
important in the premature development of OA associated with regular
EXERCISE AND THE MUSCULOSKELETAL SYSTEM 83

exercise. Studies of individuals with cruciate, collateral ligament and

meniscal injuries have supported the concept that unstable or damaged
knees are associated with development of premature OA (Charnley, 1948;
Fairbank, 1948; Ottani and Betti, 1953; Carter and Wilkinson, 1964; Brown
and Rose, 1966; Gear, 1967; Jackson, 1968; Tapper and Hooever, 1969;
Appel, 1970; Aichroth, 1971; O'Donoghue et al, 1971; Goss, 1972; Dandy
and Jackson, 1975; Jones et al, 1978; Palmoski et al, 1980; Palmoski and
Brandt, 1981, 1982b; Fahmy et al, 1983; Funk, 1983; Noyes et al, 1983).
Warren and Marshall (1978) reviewed 86 patients most of whom (81%)
had sports injuries (downhill skiing and football) to the anterior cruciate and
medial collateral ligaments at an average of 4.5 years after operation; they
found that 42% had chondromalacia patellae and 20-52% had radiological
abnormalities (Warren and Marshal, 1978). A retrospective study, made at
10 and 14-year follow-up periods, of patients with untreated anterior
cruciate ruptures found that almost all of these injuries had occurred during
sports participation and 86% of the patients had undergone removal of one
or both menisci (McDermott and Freyne, 1983). Of these patients, 75 % had
continued at the same level of sports participation without a change in their
symptoms. Through radiographs, one-third of the knees demonstrated
articular joint-space narrowing or evidence of arthritic changes. It was
concluded that development of arthritis may be associated with varus
deformity, previous meniscectomy and relative body weight (McDonald
and Dameron, 1983).
Correlations of simultaneous meniscal injury and anterior collateral liga-
mentous reconstructive surgery by the iliotibial band procedure has been
studied (Funk, 1983). A 42% incidence of meniscal tears were detected at
initial evaluation. If the patient deferred reconstructive surgery during the
first year and continued to participate in sports, the incidence of meniscal
tears doubled. Both partial and total meniscectomies were associated with
degenerative changes. It was concluded that early joint stabilization and
direct meniscus-repair surgery may decrease the incidence of premature
OA. Damage to the menisci has been proved in an experimental animal, and
clinical studies have confirmed that the human knee is affected similarly
(Funk, 1983). Menisci are cartilagenous structures that perform the role of
shock absorbers during weight-bearing, and also help to stabilize the knee
joint. The harmful effect of meniscectomy can be ascribed to a two- and
three-fold increase in the stress that is transmitted across the joint with
loading, associated instability and high local surface stresses (Appel, 1970).
A 10% incidence of OA of the knee during long-term follow up of 440
patients who underwent meniscectomies was noted. These observations
support the concept that abnormal biomechanical forces, either congenital
or secondary to joint injury are important factors in the development of
exercise-related OA.
Immobilization may hasten articular degeneration. The biochemical
factors important in OA are under investigation (Enneking and Horowitz,
1972; Warren and Marshall, 1978; Palmoski et al, 1979; Palmoski and
Brandt, 1982a). The effects of chronic exercise on joint lubrication, local
inflammation, microfractures and ageing of cartilage are unknown.
84 R.S. P A N U S H A N D N . E. L A N E

Other factors considered important in the development of sports-related

OA include certain physical characteristics of the participant,
biomechanical and biochemical factors, age, gender, hormonal influences,
nutrition, characteristics of the playing surface, unique features of particular
sports, and duration and intensity of exercise participation, as has been
reviewed extensively elsewhere (Panush and Brown, 1987a-c; Panush,
1989, 1990, in press). Increasingly it is recognized that biomechanical factors
have an important role in the pathogenesis of OA.

Occupational observations
Is OA caused in part by mechanical stress? One analytical approach to
determining a possible relationship between exercise and joint disease is to
consider the epidemiological evidence that degenerative arthritis may fol-
low repetitive trauma, such as might occur with certain occupations. This is
reviewed in greater detail elsewhere in this volume (see Chapter 5). Most
discussions of the pathogenesis of OA include a role for 'stress' (Radin et al,
1972, 1991; Howell et al, 1976, 1979, 1983; Jurmain, 1977; Peyron, 1979;
Cooke et al, 1983; Lyngberg et al, 1988). Stamm wrote that 'osteoarthritic
changes in a joint are always and only of mechanical origin' (Stamm, 1939).
Several studies have suggested an increased prevalence of OA of elbows and
knees in miners (Kellgren and Lawrence, 1958; Lawrence, 1955), of
shoulders and elbows in pneumatic drill operators (Burke et al, 1977;
Jurmain, 1977), of intervertebral discs in dock workers (Kellgren and Law-
rence, 1958), and of hands in cotton workers (Lawrence, 1961), diamond
cutters (Tempelaar and Van Breeman, 1932; Kellgren and Lawrence, 1958)
and seamstresses (Tempelaar and Van Breeman, 1932), and of hand joints
in textile workers (Hadler, 1977; Hadler et al, 1978) (Table 1). Studies of
skeletons of several populations have suggested that 'age of onset, fre-
quency and location of degenerative changes are directly related to the
nature and degree of environmentally associated stress' (Jurmain, 1977),
which is consistent with previous observations associating hand OA and
usage patterns (Acheson et al, 1970).
However, not all of these studies were carried out to contemporary
standards, nor have they been confirmed. A more recent report for
example, failed to find an increased incidence of OA in pneumatic drill users
(Burke et al, 1977). Burke et al (1977) criticized inadequate sample sizes,
lack of statistical analyses and omission of appropriate control populations
in previous reports. They further commented that earlier work was 'fre-
quently misinterpreted' and that studies from their group suggested that
'impact, without injury or preceding abnormality of either joint contour or
ligaments, is unlikely to produce osteoarthritis' (Burke et al, 1977). 'Wear
and tear' may indeed predispose to OA, but this notion should be con-
sidered as tentative and not accepted uncritically (Hadler, 1977; Hadler et
al, 1978; Felson et al, 1988, 1990, 1991, 1992).

Epidemiological observations
Do epidemiological studies of OA implicate physical or mechanical factors
EXERCISE A N D THE M U S C U L O S K E L E T A L SYSTEM 85

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86 R. S. P A N U S H A N D N . E. L A N E

pertaining to predisposition or development of disease? The first national

Health and Nutrition Examination Survey of 1971-1975 (HANES 1) and the
Framingham studies explored cross-sectional associations between radio-
logical OA of the knee and possible risk factors (National Center for Health
Statistics, 1966; Anderson and Felson, 1988; Felson et al, 198& 1990, 1991,
1992). Strong associations were noted between knee OA and obesity and
those occupations involving stress of knee bending in these and some other
recent studies (Pellissier et al, 1952; Pellegrini et al, 1964; Hannan et al,
1991; Panush, in press), but not all habitual physical activities and leisure-
time physical activity (running, walking, team sports, racquet sports and
others) were linked with knee OA (Radin et al, 1972; Lindberg and Mont-
gomery, 1987; Hochberg, 1988; Kohutson and Schurman, 1990; Croft et al,
1991; Salaff et al, 1991) (Table 2).

Clinical observations
Is regular participation in physical activity associated with degenerative
arthritis? Several animal studies have suggested, but not proved, a possible
relationship between exercise and OA (Bollet, 1969; Howell et al, 1976,
1983; Peyron, 1979; Radin et al, 1979; Videman, 1982; Williams and Brandt,
1984). There are some, but not many, pertinent observations in human
studies (Lane, 1987, 1992; Panush and Brown, 1987a-c; Panush, 1989, 1990,
in press; Lane and Buckwalter, in press) (Table 2). Wrestlers were reported
to have an increased incidence of osteoarticular lesions of the spine
(Rubens-Duval et al, 1960), cervical spine, knees and elbows (Layani et al,
1960); boxers of the carpometacarpal joints (Iselin, 1960); baseball pitchers
of shoulders and elbows (Bennett, 1941; Adams, 1965; Dively Meyer,
1969); parachutists of knees, ankles and spine (Murray-Leslie et al, 1977b);
cyclists of the patella (Bagneres, 1967); cricketers of fingers (Vere Hodge,
1971); and gymnasts of shoulders, elbows and wrists (Bozdech, 1971;
Adams, 1976). Most of these reports are largely anecdotal, and not all reflect
confirmed associations. Studies of ballet dancers have noted OA of talar
joints as well as other chronic lower-extremity problems (Brodelius, 1961;
Ambre and Nilson, 1978; Greer and Panush, 1988); criteria for OA were not
specified.
Talar joint 'osteoarthritis' was also reported in 33 of 34 soccer players
(Brodelius, 1961). The clinical and radiological findings in knees and hips of
57 retired soccer players were compared with those in controls, and a
significant increase in OA of the hip was found (49%, compared with 25 % in
controls) (Klunder et al, 1980). These conclusions are in contrast with others,
which have found frequent OA of knees (28%) and ankles (92%), but not of
hips (0%), in amateur soccer players (Bourel et al, 1960; Solonen, 1966).
Frequent ankle (astragalotibial) abnormalities were suggested among
association soccer players. Another careful examination of knees of 51
association football players found osteoarthritis in only 7 individuals (Adams,
1976). Degenerative changes of the cervical spine were noted in former
national team association football players in Norway; the onset of changes
preceded those of a control population by 10-20 years (Sortland et al, 1982).
EXERCISE A N D T H E M U S C U L O S K E L E T A L SYSTEM 87

Few studies of American football players have been reported. Three

hundred and fifty former University of Missouri players were questioned
10-30 years after participation, and radiographs of knees were reviewed.
Among the 44 respondents, 83% had radiological evidence of OA (Rail et
al, 1964). A study comparing 23 American high school football players 20
years after high school graduation with 11 age-matched controls found no
significant increase in OA, radiographically, subjectively or objectively.
However, a significant increase in knee joint OA was found in the subgroup
of football players who had sustained a knee injury while playing football,
Of football players (average age 23 years) competing for a place on a
professional team, 90% had radiological abnormalities of the foot or ankle,
compared with 4% of an age-matched control population; linemen had
more changes than ball-carriers or linebackers, who, in turn, had more
changes than flankers or defensive backs. All those who had played football
for 9 years or longer had abnormal findings on radiography (Vincelette et al,
1972). Eighty-six patients were reviewed, most of whom (81%) had sports
injuries (skiing 28%, football 20%) to the anterior cruciate and medial
collateral ligaments. At an average of 4.5 years after operation, 42% had
chondromalacia patellae and 20-52% radiological abnormalities (Warren
and Marshall, 1978).
Most of these studies, which are few in number, suffer in several respects.
Criteria for OA (or 'osteoarthrosis' or 'degenerative joint disease' or
'abnormality') were not always clear, specified or consistent; duration of
follow up was often not indicated or was inadequate to determine the risk of
musculoskeletal problems at a later age; intensity and duration of physical
activity was variable and difficult to quantify; selection bias towards indi-
viduals exercising or not exercising was not weighted; other possible risk
factors and predisposition to musculoskeletal disorders were rarely con-
sidered; studies were not always properly controlled and examinations not
always 'blind'; little information regarding the non-professional, recre-
ational athlete was available; and little clinical information about functional
status was provided.
Medical problems of performing artists and dancers have recently been
recognized. As for athletes, these are frequent and may have long-term
consequences for joints and soft tissues, such as the development of OA
(Ottani and Betti, 1953; Coste et al, 1960; Brodelius, 1961; Tapper and
Hooever, 1969; Miller et al, 1975; Nikolaev and Najdenov, 1980; Ende and
Wickstrom, 1982; Lane, 1987; Greer and Panush, 1988; Hoppmann and
Patrone, 1989; Lockwood, 1989), and are discussed separately in this
volume (see Chapter 7).

Clinical studies o f r u n n e r s
Several studies, including our own (Lane et al, 1986; Panush et al, 1986),
which were published together, have now examined a possible relationship
between running and OA. Uncontrolled observations generally suggested
that runners without underlying biomechanical problems of the lower
extremity joints did not appear to develop arthritis at a rate different from
88 R.S. PANUSH A N D N. E. LANE

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EXERCISE A N D THE M U S C U L O S K E L E T A L SYSTEM 89

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90 R.S. P A N U S H A N D N. E. L A N E

non-runner, normal populations. However, those individuals who had

underlying articular biomechanical abnormalities did appear to be at greater
risk of subsequent development of OA, and these observations seemed to be
valid for other sports activities as well (Lane, 1989, 1992; Lane and
Buckwalter, in press; Panush and Brown, 1987a-c; Panush, 1989, 1990, in
press). We examined groups of long-duration, high-mileage runners and
non-running controls. We found a comparable (and low) prevalence of OA
in both runners and non-runners and concluded that running need not lead
inevitably to OA (Lane et al, 1986, 1987, 1990, in press; Panush et al, 1986).
These observations have, in general, now been confirmed by others (Murray
and Duncan, 1971; Puranen et al, 1975; de Carvalho and Long Feldt, 1977;
McDermott and Freyne, 1983; Sohn and Micheli, 1985; Marti et al, 1989,
1990; Konradsen et al, 1990) (Table 3).
One of our initial studies compared 17 male runners (average age 56
years) with age-matched and weight-matched sedentary controls. Running
subjects (53% were marathon runners) ran a mean of 28 miles/week for 12
years. We did not find an increased prevalence of OA among runners
(Panush et al, 1986). Our observations suggested, within the limits of the
study, that long-duration, high-mileage running need not be associated with
premature degenerative joint disease in the lower extremities. Preliminary
8-year follow-up observations are encouraging, with 73% of original runners
still running, with a prevalence of destructive joint disease that is compar-
able with that of controls (Panush et al, in press a,b).
Our other study was begun in 1984 to examine the association of running
with the development of OA and musculoskeletal disability in a group of
long-term runners (Lane et al, 1986). We compared the runners (who had a
mean duration of running of 9 years) with 41 control subjects matched for
age, sex, years of education and occupation. We scored the radiographs for
the individual radiographic features that comprise OA and included osteo-
phytes (scored 0-3 for increasing severity), joint-space narrowing (0-3) and
subchondral sclerosis (0-3). The results of our initial cross-sectional study
were that women runners with a mean age 59 years and an average of 9 years
running at over 200 min/week, had more sclerosis and spur formation in the
knees than matched controls, but no increase in clinical OA. Male runners
had no increased radiographic or clinical OA of the knees or lumbar spine
compared with the matched controls, and the runners, both men and
women, had significantly higher bone mineral density in the lumbar verte-
brae. At the 5-year follow-up of these study subjects, we found that at a
mean age of 65 years they continue to run approximately 180 rain/week
(Lane et al, in press). Both groups have had significant radiographic pro-
gression of the individual radiographic features of OA, and 5 controls and 4
runners (9%) have OA of the knee by the American College of Rheuma-
tology (ACR) criteria, 4 runners and 6 controls (13%/) have OA of the hand
by A C R criteria (Lane et al, in press). Although OA has developed in these
subjects, running does not appear to have accelerated the development of
OA in this population.
Unfortunately, we did not have the information in 1986 to evaluate
whether clinical OA was present in 1986, because the criteria were not
EXERCISE A N D THE MUSCULOSKELETAL SYSTEM 91

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92 R.S. P A N U S H A N D N . E. L A N E

developed. Therefore, we can only report the prevalence of OA of the

knee and hand from the 5-year follow-up data. The prevalence noted for
OA of the hand and knee is lower than has been reported in other
populations, but we are using different criteria for classification of OA, so it
is difficult to compare with other studies. Also, at 5-year follow up, the
lumbar bone density of the running subjects remains significantly greater
than the controls, but has declined notably in those runners who have
decreased time running per week or have stopped running (Michel et al,
1992). We will need to continue to follow these patients to evaluate further
the changes in OA, musculoskeletal disability and bone density as they
continue to age.
Former college varsity long-distance runners were compared with former
college swimmers in another study (Sohn and Micheli, 1985). Question-
naires were sent to 1153 former athletes. Respondents included 504 runners
and 287 swimmers, average age 57 years. Swimmers had a 2.4% incidence of
severe pain of the hips or knees and a 19.5% incidence of moderate pain,
compared with a 2% incidence of severe pain in the hips and knees and
15.5% incidence of moderate pain for runners. Eventually, 2.1% of the
swimmers and 1% of the runners underwent surgery (the difference was not
statistically significant). Runners averaged 25 miles/week for 12 years.
There was no correlation between the onset of pain and the number of miles
run per week or the number of years running. The authors concluded that
there was no association between moderate levels of running or number of
years running and the development of symptomatic OA. Twenty middle-
aged long-distance runners complained of knee pain. Six of the 20 had
clinical and radiographic evidence of osteoarthritis; 4 had a history of knee
trauma and all 6 had anatomical variances. This group had run an average of
62 miles/week for 20 years while unaffected runners average 41 miles/week
for 12 years. The authors concluded that running alone did not cause OA,
but rather prior injuries and anatomical variances were directly responsible
for some of the changes (McDermott and Freyne, 1983). Several additional
reports have found that runners are not at risk of developing premature OA
of knees or ankles (de Carvalho and Long Feldt, 1977; Sohn and Micheli,
1985; Konradsen et al, 1990).
We are aware of two studies that examined degenerative hip diseases in
former athletes (Puranen et al, 1975; Marti et al, 1989). Puranen et al (1975)
found that former champion distance runners had no more clinical or
radiographic OA than non-runners. However, a study by Marti et al (1989)
found more radiographic changes due to degenerative hip disease in former
national team long-distance runners than in bob-sled competitors and con-
trois. In all subjects studied, age and mileage run in 1973 were strong
predictors of radiographic hip OA. For runners, running pace in 1973 was
the strongest predictor of subsequent radiographic hip OA in 1988. These
authors concluded that high-intensity, high-mileage running should not be
dismissed as a risk factor for premature OA of the hip.
Cross-sectional studies on the effect of weight-bearing exercise on the
development of OA of the hip, knee or ankle and foot must be interpreted
with caution. The radiographic scoring methods that each group of investi-
EXERCISE A N D T H E M U S C U L O S K E L E T A L SYSTEM 93

gators has used are not the same. For example, while some investigators use
Kellgren and Lawrence global grading to evaluate the severity of OA of each
joint, other investigators have used grading of individual radiographic
features. Also, the reliability of the different grading methods used in most
studies has not been adequately tested. This information is important when
the major endpoints in the studies are radiographic features of OA. When
critically evaluating the literature of the effect of exercise on the develop-
ment of OA, the reader should decide whether radiographic scoring
methods were used to evaluate the radiographs, whether one observer or
multiple observers scored the radiographs, and what criteria for OA were
used. As more research is done in the development of methods to evaluate
the presence, severity and the progression of radiographic and clinical OA,
we will be better able to evaluate the effect of exercise on the development
of OA in normal populations (Lane and Buckwalter, in press).
Although a moderate amount of running does not appear to accelerate the
development of OA in lower-extremity joints for most people, the effect of
running on subjects who have experienced prior trauma or have joints with
significant anatomical variances seems different. In summary, runners who
had sustained injuries or had anatomical variances and continued to run,
had accelerated development of OA in the affected joints.

Are there benefits to the musculoskeletal system from exercise?

Are there any potential long-term benefits of physical activity to the
musculoskeletal system? Prolonged exercise increases bone density (Nilson
and Westlin, 1971; Huddleston et al, 1980; Lane et al, 1986; Michel et al,
1992). Increased bone density has been found not only in athletes of highest
international class, but also in 'ordinary' athletes and exercising controls, in
all of whom did bone density exceed that of sedentary individuals. Among
athletes, average bone density is highest in weight lifters, and progressively
lower in throwers, runners, soccer players and swimmers (Nilson and
Westlin, 1971).
Are there other factors pertaining to the musculoskeletal consequences of
regular exercise? It is now appreciated that physical conditioning induces
secretion of endorphins--endogenous opioid peptides with diverse func-
tions, including effects on energy balance, appetite, lipolysis, reproduction,
thermoregulation and psychological well-being (Appenzeller, 1981; Carr et
al, 1981). It is also known that psychological and/or environmental stress can
influence immunological responsiveness (Kusnecov, 1983) as well as mani-
festations of musculoskeletal disease (Trentham, 1982) addressed elsewhere
in this volume (see Chapters 4 and 9). Also, several studies have shown
alterations in immunological homeostasis in conditioned athletes or follow-
ing stress (Green et al, 1981; Hanson and Flaherty, 1981). It is therefore
possible, although still highly speculative, that physical conditioning, endor-
phin elaboration and immune responsiveness--and perhaps other
pathways--may interrelate to affect the development of musculoskeletal
disease, either adversely or favourably, through as yet uncertain mechan-
isms.
94 R. S. P A N U S H A N D N . E. L A N E

EXERCISE T H E R A P Y FOR ARTHRITIS

There is little documentation of clinical benefit from traditional exercise and

physical therapy programmes for patients with arthritis (Basmrajian, 1987).
Some long-held concepts relating to exercise and arthritis are now being
challenged. Several groups, including our own, have begun to study the
therapeutic effects of aerobic exercise programmes for patients with arthritis
(Gerber, 1990). Most of these observations remain quite preliminary;
however, there are reports that patients with inflammatory (rheumatoid)
arthritis (RA) have improved (by subjective and objective criteria) with
aerobic dance programmes (Perlman et al, 1987, 1990). Patients with both
R A and OA have benefited in a similar fashion from treadmill exercise
programmes (Walton, 1974; Gerber, 1990). Another group of investigators
has documented improvement of patients with R A from a stationary cycling
exercise programme (Harkcom et al, 1985; Nath et al, 1987; Minor et al,
1989). We found beneficial effects of Nautilus training for selected patients
with inflammatory and degenerative arthritis. Osteoarthritis patients have
benefited from walking. Although it is possible that the attention afforded
patients in unblinded exercise programmes, rather than the exercise itself,
may lead to clinical improvement, these studies do show that supervised
fitness programmes can be safe and beneficial (Ekbloom et al, 1975; Nord-
emar et al, 1981; Perlman et al, 1987, 1990; Nath et al, 1987; Labowitz et al,
1988; Lyngberg et al, 1988; Tork and Douglas, 1989; Ekdahl et al, 1990;
Kirsteins et al, 1991). Although these observations are of considerable
interest, they are limited; it would be premature to attempt to generalize
therapeutic aerobic exercise recommendations for arthritis patients.

IS EXERCISE GOOD OR BAD FOR ARTHRITIS PATIENTS?

Osteoarthritis is common. Its aetiology is multifactorial. Earlier theories

that OA was a necessary consequence of wear and tear on joints were naive.
Exercise is but one of many factors that may lead to, or exacerbate, OA
under certain circumstances. Underlying anatomical abnormalities or
activities that place abnormal biomechanical stress on joints may lead to
degenerative arthritis; much evidence suggests that merely putting a normal
joint through a normal range of motion need not inevitably lead to OA nor
exacerbate inflammatory arthritis. Traditional management programmes
for patients with arthritis are not always satisfactory. Many concepts relating
to the role of exercise--not only as a causal factor but also as an adjunctive
therapeutic modality--are changing. Indeed it appears that for certain
patients with degenerative or inflammatory arthritis, carefully supervised
aerobic exercise programmes may be clinically useful. In the words of Cicero
'Potest igitur exercitatio et temperantia etiam in senectute conservare
aliquid pristini ruboris. [Exercise and temperance can preserve something of
our early vigour even in old age.]'
EXERCISE AND THE MUSCULOSKELETALSYSTEM 95

SUMMARY

1. Normal joints in individuals of all ages may tolerate prolonged and

vigorous exercise without adverse consequences or accelerated
development of OA.
2. Individuals who have underlying muscle weakness or imbalance, neuro-
logical abnormalities, anatomical variances, and who engage in signifi-
cant amounts of exercise that stress the lower extremities, may
accelerate the development of OA.
3. Individuals who have suffered injuries to supporting structures may also
be susceptible to accelerated development of O A in weight-bearing
joints, even without increased stress to the joint from exercise.
4. Certain individuals with established degenerative or inflammatory
arthritis may benefit from supervised exercise programmes.
5. Still more information is needed so that physicians can identify subjects
at risk for the development of OA, advise the millions of participants
about the beneficial and deleterious effects of regular exercise and
sports participation, and develop successful rehabilitation programmes
for injured joints.

CONCLUSIONS

'Reasonable' exercise by individuals with normal (and perhaps certain

abnormal) joints need not be harmful. Risk of developing destructive joint
disease from recreational activities seems low; risk of developing chronic,
soft tissue, non-articular musculoskeletal injury from recreational activities
has not yet been adequately assessed. Inflammatory arthritis need not be
exacerbated by activity if patients and exercises are carefully selected. There
are probably combinations of factors (genetic background, physical
features, physical activity and effort, biomechanical factors, and others)
which, if/when clarified, could predict long-term effects of physical activity
on the individual musculoskeletal system.

Acknowledgements
The authors appreciate the skilled assistance of Pat Palma in preparing the manuscript and the
partial support from the Saint Barnabus Medical Center Research Foundation for this work.

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