Journal of Athletic Training 2016;51(11):952–961

doi: 10.4085/1062-6050-51.5.03
Ó by the National Athletic Trainers’ Association, Inc systematic review
www.natajournals.org

Osteoarthritis and the Tactical Athlete:

A Systematic Review
Kenneth L. Cameron, PhD, MPH, ATC*; Jeffrey B. Driban, PhD, ATC, CSCS†;
Steven J. Svoboda, MD*
*Keller Army Hospital, West Point, NY; †Tufts Medical Center, Boston, MA

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Objective: Although tactical athletes (eg, military service measures of disease burden, source of nonexposed con-
members, law enforcement personnel, fire fighters) are exposed trols).
to several known risk factors, it remains unclear if they are at Data Synthesis: Twelve articles met the inclusion criteria
increased risk for osteoarthritis (OA). The purpose of this and described retrospective cohort studies. Firefighters, active-
systematic review was to investigate the association between duty military service members, and veteran military parachutists
serving as a tactical athlete and the incidence and prevalence of consistently had a higher incidence or prevalence of knee, hip,
OA. or any OA diagnosis (4 studies). Active-duty pilots and veteran
Data Sources: We completed a comprehensive systematic military parachutists may have a higher prevalence of spine OA,
literature search in November 2014 using 12 bibliographic but this was not statistically significant (2 studies). Occupational
databases (eg, PubMed, Ovid, SportDiscus) supplemented with risk factors for OA among tactical athletes include rank and
manual searches of reference lists. branch of military service. The risk of OA among individuals who
Study Selection: Studies were included if they met the completed mandatory national military service remains unclear
following criteria: (1) an aim of the study was to investigate an (6 studies).
association between tactical athletes and OA; (2) the outcome Conclusions: The incidence of OA among tactical athletes
measure was radiographic OA, clinical OA, total joint replace- appears to be significantly higher when compared with
ment, self-reported diagnosis of OA, or placement on a waiting nonexposed controls. Further research is needed to specifically
list for a total joint replacement; (3) the study design was a identify modifiable risk factors within this high-risk population to
cohort study; and (4) the study was written in English. develop and implement effective risk-reduction strategies.
Data Extraction: One investigator extracted data from Key Words: epidemiology, military, fire fighters, police, law
articles that met all inclusion criteria (eg, group descriptions, enforcement, first responders

Key Points
 Active-duty military service members were significantly more likely to experience knee osteoarthritis (OA), hip OA,
and any OA diagnosis, regardless of site, when compared with nonexposed controls.
 The disparity between military service members and nonexposed controls appeared to exist regardless of age or sex
and increased with advancing age.
 Military rank and branch of military service appeared to be occupational risk factors associated with OA incidence.
 Fire fighters were at increased risk for both knee and hip OA, with adjusted risk ratios of 2.93 and 2.52, respectively.

O
steoarthritis (OA) is a chronic degenerative disease comorbidities (eg, obesity, cardiovascular disease, type 2
that involve the articular cartilage, bone, and diabetes), and OA negatively affects activities of daily
surrounding soft tissues in the affected joint. It is living and quality of life and can contribute to occupational
estimated that more than 27 million adults in the United disability.14
States are affected by this debilitating condition.1 Known Tactical athlete is a term that has been used to describe
risk factors for OA include female sex, obesity, history of individuals in service professions (eg, the military, fire
joint injury, and engaging in occupations that require a fighters, law enforcement, first responders) that have
significant amount of repetitive bending, squatting, kneel- significant physical fitness and physical performance
ing, and lifting.2–12 Although OA is typically thought to be requirements associated with their work. Tactical athletes
a disease that affects individuals later in life, studies5,13 are regularly exposed to many of the known risk factors for
suggest that OA can affect individuals in their third and OA described earlier. Because of the physical training
fourth decades of life, particularly in the presence of these requirements and the nature of their work, tactical athletes
known risk factors. As a result, some individuals may live are at increased risk for acute traumatic joint injury.15–19
more than half their lives with a chronic disease that limits Furthermore, the physical training and occupational
their function and diminishes their quality of life. demands placed upon most tactical athletes require a
Specifically, OA has been associated with an increased significant amount of repetitive bending, squatting, kneel-
risk for several other chronic health conditions and ing, and lifting. Finally, even though most tactical athletes

952 Volume 51  Number 11  November 2016

are not obese, many are required to endure heavy available in the literature. Articles were excluded if the
equipment loads during training and the performance of authors reported incidence or prevalence of arthritis instead
their occupational tasks. This may produce joint damage of specifically OA. If the primary reviewer (K.L.C.) was
due to excessive loading that is similar to that observed in unsure if a study met the inclusion and exclusion criteria,
obese individuals. Despite their being regularly exposed to the other 2 authors (J.B.D., S.J.S.) reviewed the article and
several known risk factors for OA, based on the available reached a consensus.
evidence, it remains unclear if tactical athletes are at The Figure provides an overview of the selection of
increased risk for OA. studies. Initially, we performed electronic and manual
The purpose of our study was to conduct a systematic searches of reference lists. Articles clearly not meeting the
review of the literature to investigate the association inclusion or meeting the exclusion criteria were eliminated;
between working as a tactical athlete and the incidence if insufficient information was available in the abstract to
and prevalence of OA. A secondary objective was to assess inclusion and exclusion criteria, then we obtained the
identify gaps in the existing literature with regard to OA full-text article. After the initial screening process, full-text
risk among tactical athletes. articles were retrieved and subsequently rescreened and
independently assessed for meeting the inclusion and

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METHODS exclusion criteria by 2 authors (K.L.C., J.B.D.).

Data Sources and Searches Data Extraction and Quality Assessment

A comprehensive literature search was conducted by 1 The quality of the included studies was assessed by 2
investigator (K.L.C.) between November 5 and 9, 2014. raters (K.L.C., J.B.D.) using the Newcastle-Ottawa Scale
The 12 primary databases searched were (1) PubMed, (2) (NOS). We chose this scale because of its ease of use and
Ovid: MEDLINE, (3) Ovid: MEDLINE Daily Updates, (4) applicability for assessing cohort study designs.20 It
Ovid OLDMEDLINE, (5) Your Journals@Ovid, (6) Ovid: assesses studies in 3 areas: selection (4 items), compara-
MEDLINE In-Process and Other Nonindexed Citations, (7) bility (1 item), and outcome of cohort studies (3 items). The
Ovid Healthstar, (8) Cochrane Database of Systematic maximum score is 9 points, with higher scores indicating
Reviews, (9) American College of Physicians Journal Club, better quality.20 Coding rules and procedures were clarified
(10) Database of Abstracts of Reviews of Effects, (11) as necessary between the 2 raters before their independent
Global Health, and (12) SPORTDiscus. Studies were assessments. Specifically, comparability was scored based
identified using predetermined search criteria: (osteoarthri- on a study’s controlling for sex and age, and outcome was
tis OR degenerative joint disease) AND (prevalence OR scored based on follow-up for 10 years or greater in 80% or
incidence OR epidemiology OR odds ratio) AND (military more of the cohort. Authors (K.L.C., J.B.D.) independently
OR army OR navy OR naval OR air force OR special rated each study in random order using the NOS instrument,
forces OR paratroopers OR servicemen OR servicewomen and a third author (S.J.S.) provided consensus as needed.
OR soldier OR officers OR occupation OR firefighters OR Consensus scores were determined using the following
firemen OR first responders OR police OR detective OR process. If the scores of authors 1 and 2 agreed, then that
law enforcement OR paramedics) AND (case control OR score was used as the consensus score. If the scores of
cross section* OR cohort OR surveillance system). The authors 1 and 2 differed by 1 point (ie, 4 articles), the
reference lists of full-text articles were also manually authors agreed on a consensus score through discussion. If
searched to identify potential additional articles not indexed the scores of authors 1 and 2 varied by 2 or more points or
by electronic databases. We also screened our personal consensus could not be reached, author 3 scored the article,
libraries to ensure we had identified all relevant articles. and all authors participated in discussion and reached a final
Because all of the included articles were from journals consensus score. During this quality-assessment process,
listed on PubMed, only PubMed was monitored for updates we excluded 1 article because of an inappropriate study
through March 13, 2015. This systematic review had no design (ie, case control). This left 12 articles that had
external funding source. sufficient information and an appropriate study design to be
included in the quantitative synthesis (Figure).
Study Selection A data-extraction spreadsheet was generated and re-
We included studies if they met the following 4 criteria: viewed by 2 of the authors (K.L.C., J.B.D.). One author
(1) an aim of the study was to investigate an association (K.L.C.) collected key information from each article: (1)
between tactical athletes and OA (see search criteria noted publication data: first author, publication year, journal,
earlier); (2) the outcome measure was radiographic OA, country, study design, and quality-assessment score; (2) OA
clinical OA, total joint replacement, self-reported diagnosis (outcome) details: definition of OA and time of follow up;
of OA, or placement on a waiting list for a total joint (3) group descriptions: source of nonexposed cohort, source
replacement; (3) the design was a cohort study; and (4) the of exposed cohort, matching variables, sex, percentage lost
study was written in English. A cohort study design was to follow up, sample size, participant age; and (4) outcome
defined as a study that compared the incidence or measures. The outcome measures were studied joints;
prevalence of OA among groups of people according to incidence or prevalence of OA; crude odds ratios, risk
whether they had a history of working as a tactical athlete ratios, or rate ratios; adjusted odds ratios, risk ratios, or rate
or not (exposure). We also included articles that examined ratios; confounding variables; and associated 95% confi-
OA incidence or prevalence in tactical athletes without a dence intervals (CIs). A second author (J.B.D.) then
control group if comparable reference values (eg, OA compared the extracted data with the original articles to
incidence or prevalence) for the general population were assess the accuracy of the extracted data.

Journal of Athletic Training 953

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Figure. Overview of the study identification, screening, and review process.

Data Synthesis and Analysis extensive screening (Figure), we extracted data from 12
We extracted OA incidence or prevalence; risk, rate, or articles (Table 2), all of which were classified as
odds ratios; and 95% CIs. If only incidence or prevalence retrospective cohort studies. Quality-assessment (NOS)
scores ranged from 3 to 7, with higher scores representing
data were reported, then we calculated risk, rate, or odds
higher-quality studies (Table 2). Various OA outcomes
ratios and 95% CIs (Table 1). All calculations were
were examined across studies (Table 1). One group
performed using STATA (version 10.1; Stata Corp, College examined the cumulative incidence of knee and hip OA
Station, TX). Significant odds ratios were defined as 95% in Swedish firefighters compared with the general popula-
CIs that did not encompass 1.00. To assess the association tion in low-exposure occupations.21 The remaining re-
between a history of being a tactical athlete and OA, we searchers either examined the incidence or prevalence of
classified occupations into 1 of 3 categories: (1) significant OA in active-duty or veteran military populations22–26 or
association with OA, (2) unclear but possible association examined the prevalence of OA in European countries
with OA, and (3) unclear but unlikely association with OA. where national military service is mandatory.27–32 Two
Unclear but possible association with OA was defined as an studies examined OA incidence rates in active-duty military
odds ratio that was not statistically significant but was populations22,23 and compared them with published refer-
,0.70 or an odds ratio .1.50. Unclear but unlikely ence rates in the general population.3,35,36 No studies were
association with OA was defined as an odds ratio between identified that examined OA incidence or prevalence in
0.70 and 1.50. These cut points were based on odds ratios other tactical athlete populations (eg, law enforcement, first
that correspond to a small standardized effect size (d ¼ responders). The heterogeneity among the studies regarding
0.20).33 These cut points are the same as those used by the type of OA and study outcome (ie, prevalence,
authors of another systematic review34 that evaluated the incidence, cumulative incidence) prohibited us from
association between sport participation and knee OA. conducting a meta-analysis as part of this review.

RESULTS Osteoarthritis in Firefighters, Active-Duty, and

Veteran Populations
Study Characteristics
In the single study21 that examined OA incidence in
We identified a total of 492 potential articles using the firefighters, the results suggested that firefighters were at
electronic search and additional search strategies. After increased risk for both knee and hip OA, with adjusted risk

954 Volume 51  Number 11  November 2016

ratios of 2.93 and 2.52, respectively (Table 1). Active-duty in the current systematic review appeared to be higher than
military service members appeared to be at significantly in nonexposed controls in the general population. This was
greater risk for any OA diagnosis22 and for hip OA,23 particularly evident when we reviewed studies that
regardless of sex or age, in comparison with reference rates specifically examined these OA outcomes in tactical athlete
in the general population. Furthermore, the disparity populations (Table 1).21–26 Active-duty military service
between active-duty military service members and nonex- members were significantly more likely to experience knee
posed controls increased with advancing age.22,23 OA,24 hip OA,23 and any OA diagnosis regardless of site22
Military rank and branch of military service also seem to when compared with nonexposed controls. The disparity
be associated with the incidence rate of OA in active-duty between military service members and nonexposed controls
military service members (Tables 3 and 4).22,23 After was present regardless of sex or age and increased with
controlling for the influence of sex, age, branch of military advancing age (Table 1). Though the prevalences of lumbar
service, and race, those in the junior enlisted ranks had the and cervical OA were 49% to 76% higher in specific
highest incidence rates for both any OA diagnosis and hip military populations,24–26 the observed differences were not
OA, followed by senior enlisted personnel and senior statistically significant. However, the magnitude of the
officers (Table 3). Service in the Army was also associated observed odds ratios suggests an unclear but possible

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with the highest incidence rate of any OA diagnosis and of association with OA. Finally, based on the findings of a
hip OA after controlling for sex, age, race, and military single study,21 the incidences of hip and knee OA appear to
rank (Table 4). Veteran military parachutists appeared to be be 2.52 to 2.93 times higher, respectively, among
significantly more likely to experience knee OA than sport firefighters than in nonexposed controls (Table 1). Despite
parachutists.24 Although the odds ratios for lumbar and the increased incidence and prevalence of OA observed
cervical OA in active-duty military pilots26 and veteran among tactical-athlete populations, it remains unclear
parachutists25 suggested a higher prevalence compared with which specific risk factors or occupational exposures are
controls, the observed differences failed to reach statistical contributing to the observed disparities between tactical
significance. Regardless of significance, the incidence or athletes and nonexposed controls in the general population.
prevalence of OA among firefighters, active-duty military Further study is needed to identify important modifiable
service members, and veterans appeared to be consistently and nonmodifiable risk factors for OA within this unique
higher than in controls. high-risk population in order to develop and implement
effective primary and secondary risk-reduction strategies.
Mandatory National Military Service and OA Military service members experience incidence rates for
acute traumatic joint injuries that are an order of
When we compared the prevalence of OA among those
magnitude higher than rates observed in the general
who had engaged in mandatory national military service
population,15–17,19,39 and acute traumatic joint injury has
with controls (elite-level male orienteering or track-and-
been identified as an important risk factor for OA.4,5,40,41
field athletes), the results were inconclusive (Table 1). In 3
Although estimates are that posttraumatic OA accounts for
studies,27,28,31 the prevalence of OA was lower in those with
12% of all OA cases in the general population,42 the
mandatory national military service requirements than in
prevalence of posttraumatic OA in tactical athletes remains
controls; however, the prevalence of OA was significantly
lower in only 1 of these studies.31 Conversely, investigators unclear and is probably much higher. Joint trauma in
in 5 studies27–30,32 reported a higher prevalence of OA in military populations has been associated with high rates of
those with mandatory national military service require- disability and medical discharge from service38,43–46 and
ments compared with controls, but again, the prevalence of likely contributes to the high rates of disability discharge
OA was significantly higher in only 1 of these studies.30 associated with OA observed in this population.37,47,48
Authors of 2 studies37,28 found a higher prevalence for some Limited data are available on acute traumatic joint injuries
OA outcomes and a lower prevalence for others. in other tactical athlete populations, but they are also
probably at increased risk for these injuries. Based on the
available data, it is unclear how many of the OA cases in
DISCUSSION our systematic review were associated with acute traumatic
Military service members and other tactical athletes joint injury; however, given the observed disparities in the
likely share similar occupational exposures and risk factors incidence and prevalence of OA and the high rates of joint
for OA. These include an increased risk for joint injury; trauma among tactical athletes, it is likely that posttrau-
occupational and physical training demands that require matic OA is contributing to these differences.22 A possible
frequent and repetitive kneeling, squatting, bending, and association is also suggested by the highest rates of acute
lifting; and wearing and carrying heavy equipment loads. traumatic joint injury and OA, which are both seen within
Therefore, we hypothesized that tactical athletes would the junior enlisted ranks.15 As a result, in future studies, it
have a higher prevalence or incidence (or both) of OA when is critical to accurately account for the number of OA cases
compared with nonexposed controls in the general among tactical athletes that may be related to a history of
population. The findings of our systematic review seem to acute traumatic joint injury. Military service members
support this hypothesis. offer a unique opportunity to study the progression of
Osteoarthritis has consistently been a leading cause of posttraumatic OA from the preinjury state due to the closed
disability discharge from the military for more than a Military Health System and the available surveillance
decade, regardless of whether the estimates are from resources in this population.22,49 It is also critical to
peacetime or periods of active combat.37,38 As a result, it develop and implement primary prevention strategies to
is not surprising that the incidence and prevalence of OA limit the effects of acute traumatic joint injuries in tactical-
among military service members and other tactical athletes athlete populations. Emerging evidence suggests that

Journal of Athletic Training 955

Table 1. Incidence and Prevalence of Osteoarthritis Among 12 Retrospective Cohort Studies Extended on Next Page
Tactical Athletes
Age Range, Type of No Incidence/
Study (Year) Sex(es) y Osteoarthritis Outcome Osteoarthritis Osteoarthritis Total Prevalence
Firefighters
Vingard et al21 (1991) Male 38–78 Knee Cumulative index 8 1232 1240 0.65%
Male 38–78 Hip Cumulative index 11 1229 1240 0.89%
Active-duty US military
Cameron et al22 (2011) Both 20–24 Any Incidence rate 12 859 4 549 717 4 562 576 2.82a
Both 25–29 Any Incidence rate 14 260 2 855 135 2 869 395 4.97a
Both 30–34 Any Incidence rate 15 446 1 995 313 2 010 759 7.68a
Both 35–39 Any Incidence rate 25 721 1 784 737 1 810 458 14.21a
Both 40 Any Incidence rate 37 950 1 372 453 1 410 403 26.91a
Scher et al23 (2009) Male 20–29 Hip Incidence rate 713 5 425 162 5 425 875 13.14b

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Male 30–39 Hip Incidence rate 1129 3 021 556 3 022 685 37.35b
Male 40–49 Hip Incidence rate 1425 1 074 946 1 076 371 132.39b
Male 20–49 Hip Incidence rate 3267 9 521 664 9 524 931 34.30b
Female 20–29 Hip Incidence rate 302 1 015 238 1 015 540 29.73b
Female 30–39 Hip Incidence rate 299 406 951 407 250 73.42b
Female 40–49 Hip Incidence rate 296 151 358 151 654 195.18b
Female 20–49 Hip Incidence rate 897 1 573 547 1 574 444 56.97b
Veteran military parachutists
Murray-Leslie et al24 (1977) Male 23–70 Knee Prevalence 19 27 46 41.30%
Murray-Leslie et al25 (1977) Male 23–70 Lumbar Prevalence 39 7 46 84.80%
Active-duty military pilots
Aydog et al26 (2004) Male 31–35 Cervical Prevalence 31 219 250 12.40%
Male 31–35 Lumbar Prevalence 18 232 250 7.20%
Mandatory national military
service
Kujala et al27 (1994) Male 21–85 Knee Prevalence 18 1385 1403 1.30%
Male 21–85 Hip Prevalence 20 1383 1403 1.40%
Male 21–85 Ankle Prevalence 0 1403 1403 0.00%
Kujala et al28 (1999) Male 47–71 Hip Prevalence 13 166 179 7.30%
Male 47–71 Knee Prevalence 19 160 179 10.60%
Kettunen et al29 (2006) Male 38–86 Knee Prevalence 119 388 507 23.50%
Male 38–86 Hip Prevalence 80 400 480 16.67%
Kettunen et al30 (2001) Male 47–99 Hip Prevalence 81 400 481 16.80%
Male 47–99 Knee Prevalence 120 388 508 23.60%
Sarna et al31 (1997) Male NA Ankle, knee, Prevalence 36 1676 1712 2.10%
and hip
Iosifidis et al32 (2015) Male 50–51 Ankle, knee, Prevalence 39 124 163 23.90%
and hip
Abbreviation: NA, not able to calculate due to lack of observed cases.
a
Incidence rate per 1000 person-years.
b
Incidence rate per 100 000 person-years.

injury-prevention programs targeting high-risk biomechan- ated with knee6,9,53–57 and hip56–59 OA. In the current
ical movement patterns may be effective in the primary systematic review, we observed that military rank and
prevention of acute traumatic knee-joint injury,50,51 and branch of military service were associated with the
these programs may be applicable to military training incidence of OA. Specifically, those serving in the Army
populations.52 Information on effective acute traumatic and the junior enlisted ranks experienced the highest rates
injury-prevention strategies for other joints is currently of OA after potentially important confounding variables,
limited in the literature. including sex and age, were controlled. These occupation-
In addition to high rates of acute traumatic joint injury, related factors may be surrogate measures for engaging in
tactical athletes also routinely engage in occupational and the high-risk occupational demands noted earlier; however,
physical training activities that require frequent and further research and analysis by specific Department of
repetitive bending, squatting, kneeling, and lifting. A Defense occupational groups (eg, Military Occupational
substantial amount of evidence in the literature suggests Specialty codes [MOS], Air Force Specialty Codes [AFSC],
that high-level occupation-related physical demands, par- Navy Enlisted Classification system [NEC]) are warranted
ticularly those that involve frequent and repetitive bending, to determine which occupational codes are associated with
squatting, kneeling, lifting, and climbing, may be associ- the highest incidence of OA.22

956 Volume 51  Number 11  November 2016

Table 1. Extended From Previous Page
Nonexposed Athletes
No Incidence/ Ratio
Osteoarthritis Osteoarthritis Total Prevalence Estimate (95% Confidence Interval)

200 90 857 91 057 0.22% Risk ratio 2.93 (1.32, 5.46)

320 90 737 91 057 0.35% Risk ratio 2.52 (1.38, 4.64)

576 257 285 257 861 2.23a Risk ratio 1.26 (1.16, 1.37)
833 264 586 265 419 3.14a Risk ratio 1.58 (1.48, 1.70)
1336 288 908 290 244 4.60a Risk ratio 1.67 (1.58, 1.77)
2319 325 155 327 474 7.08a Risk ratio 2.01 (1.92, 2.09)
7486 596 057 603 543 12.40a Risk ratio 2.17 (2.12, 2.22)
0 20 669 20 669 0b Risk ratio NA

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2 25 461 25 463 7.85b Risk ratio 4.76 (1.31, 39.31)
4 19 039 19 043 21.01b Risk ratio 6.30 (2.46, 23.16)
6 65 169 65 175 9.21b Risk ratio 3.72 (1.71, 10.16)
0 21 888 21 888 0b Risk ratio NA
1 24 948 24 949 4.01b Risk ratio 18.32 (3.26, 725.89)
0 18 812 18 812 0b Risk ratio NA
1 65 648 65 649 1.52b Risk ratio 37.40 (6.70, 1478.92)

6 52 58 10.40% Odds ratio 6.10 (2.00, 20.56)

120 34 154 77.90% Odds ratio 1.57 (0.62, 4.55)

6 52 58 10.40% Odds ratio 6.10 (2.00, 20.56)

120 34 154 77.90% Odds ratio 1.57 (0.62, 4.55)

10 488 498 2.00% Odds ratio 0.63 (0.28, 1.55)

10 488 498 2.00% Odds ratio 0.71 (0.31, 1.70)
1 497 498 0.20% Odds ratio NA
14 250 264 5.30% Odds ratio 1.40 (0.59, 3.30)
45 219 264 17.00% Odds ratio 0.58 (0.31, 1.05)
17 67 84 20.20% Odds ratio 1.21 (0.67, 2.28)
9 69 78 11.53% Odds ratio 1.53 (0.72, 3.64)
21 182 203 10.30% Odds ratio 1.76 (1.04, 3.08)
49 163 212 23.10% Odds ratio 1.03 (0.69, 1.54)
120 2561 2681 4.50% Odds ratio 0.46 (0.31, 0.67)

2 9 11 18.20% Odds ratio 1.42 (0.28, 13.98)

Military service members are required to meet minimum been estimated to weigh between 45 lb (20 kg) and 75 lb (34
height and weight standards, which limits the number of kg). For law enforcement officers, this may include personal
military personnel who are overweight and obese (a known protective equipment and clothing, shields, helmets, bullet-
risk factor for OA); however, a modern combat load can proof vests, and other tactical gear. Further research is
range from 52 lb (24 kg) to well over 100 lb (45 kg).60 needed to better understand the association between
Routinely carrying a load of this nature during extended exposure to these loads during the execution of occupational
military training or deployments may result in the same tasks and joint loading in relation to the initiation and
overloading of joints in tactical athletes that is typically seen progression of OA over time in tactical-athlete populations.
in obese individuals in the general population. This excessive Although active-duty military service was consistently
loading combined with repetitive physical activity (eg, associated with OA, findings were inconsistent among the 5
marching, running) or joint injury (or both) may increase studies that included individuals who participated in
joint vulnerability and the risk of OA, even in young and mandatory national military service in Finland or Greece.
physically fit tactical athletes.11 Excessive occupational loads Each nation requires less than 1 year of active service.61 In
are not limited to military personnel, as firefighters and law a previous systematic review,34 individuals who participat-
enforcement officers may also have to carry or bear heavy ed in national military service were more likely to develop
equipment in the execution of their duties. For firefighters, knee OA than were former athletes, including the reference
this equipment may include personal protective clothing, groups selected for this systematic review (eg, former elite
breathing equipment, hoses, ladders, and axes, which have track-and-field athletes, former elite athletes, orienteering

Journal of Athletic Training 957

 Newcastle-Ottawa
athletes). In our review, we failed to confirm that
individuals with a history of mandatory national military
Scaleb service were at higher risk for OA. Unfortunately, the small
6.0
7.0

7.0
5.0

4.0
6.0

5.0

5.0

6.0
4.0

3.0
3.0
number of studies and variations in the study designs,
outcomes, ages, joint(s) of interest, and reference groups
prevented us from pursuing a meta-analysis to further
explore the association between mandatory national
Range, y

31–35d
50–51d
military service and OA. Future researchers should
21–85
17–62

17–62
38–78

38–86

47–71
47–99

23–70
23–70
Age

NA
prospectively follow individuals in nations with various
lengths of mandatory military service to determine its effect
Self-reported diagnosis on OA. This is an interesting question because mandatory
Self-reported physician

Self-reported physician
Physician diagnosedc
Physician diagnosedc

Physician diagnosedc
Physician diagnosedc

Physician diagnosedc
national military service may expose untrained individuals
to episodes of overloading or increase their risk of injury,
Definition

which could increase their risk of OA. Conversely,

Radiographs
Radiographs

Radiographs
Radiographs
diagnosed

diagnosed
mandatory national military service may teach young

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adults the importance of a physically active and healthy
Osteoarthritis

lifestyle, which could reduce their risk for symptomatic

OA, particularly if the required terms of service are of short
duration. Finally, mandatory national military service may
Knee, hip, or ankle

Knee, hip, or ankle

Knee, hip, or ankle

Cervical or lumbar

Cervical or lumbar

spread a relatively short-duration occupational exposure to

Any osteoarthritis

Knee and ankle

OA over the entire population in comparison with an all-

Outcome

Knee and hip

Knee and hip

Knee and hip

diagnosis

Knee or hip

volunteer force, in which multiyear and career service

commitments are common among a narrower portion of the
national population.
Hip

Despite the findings of the current systematic review,

notable gaps remain in our understanding of OA in tactical-
Veteran military parachutists
Veteran military parachutists

athlete populations. Foremost, we were unable to find any

data on the incidence or prevalence of OA in tactical
National military service

National military service

National military service
National military service

National military service

National military service

Active-duty US military

Active-duty US military

athletes other than military service members and firefight-

Exposed

ers, and even the data in these populations are limited. No

Based on International Classification of Diseases codes or a national hospital discharge registry.

information seemed to be available on the incidence or

Military pilots

prevalence of OA in law enforcement, first responder, or

Firefighters

other tactical-athlete populations. Furthermore, outside the

military, limited information exists on occupational dis-
ability due to OA in tactical athletes. As noted previously,
the role of acute traumatic joint injury in the initiation and
Source

Former elite track-and-field athletes

Former elite track-and-field athletes
Worcester County, MA, population

progression of OA in tactical-athlete populations is still

Orienteering endurance athletes

poorly understood; however, examining the factors that

Master track-and-field athletes
(low-exposure occupations)
Canadian general population

contribute to the initiation and progression of posttraumatic

Elite track-and-field athletes

Swedish general population

Scores range from 0 to 9, with a higher score indicating higher quality.

OA in this population appears be warranted.22 Furthermore,

Nonexposed

OA studies in tactical athletes have primarily focused on

Former elite athletes

the knee, hip, and spine, but few data are available on OA
Sport parachutists
Sport parachutists
Table 2. Descriptive Characteristics of the Included Studiesa

Office personnel

incidence or prevalence in other joints. This is an important

gap, particularly when considering the high rates of joint
injury to the ankle16 and shoulder18 observed in tactical-
athlete populations. We know that acute traumatic joint
Only range of average ages could be extracted.

injury—repetitive bending, squatting, kneeling, and lift-

All studies had a retrospective cohort design.

ing—and excessive joint loading are risk factors for OA

United Kingdom
United Kingdom

and that tactical athletes are regularly exposed to these risk

United States

United States

factors, but we still have a poor understanding of how these

Country

factors interact in relation to the initiation and progression

Abbreviation: NA, no data to extract.
Sweden
Finland

Greece
Finland
Finland

Finland

Finland
Turkey

of OA in tactical athletes.
Important limitations related to the interpretation of
findings from this systematic review should be noted. None
Murray-Leslie et al24 (1977)
Murray-Leslie et al25 (1977)

of the studies that we reviewed were conducted prospec-

tively, and quality scores for all studies reviewed ranged
Cameron et al22 (2011)

Kettunen et al30 (2001)

Kettunen et al29 (2006)
Vingard et al21 (1991)

Iosifidis et al32 (2015)

from a low of 3 to a high of 7 on the 9-point NOS. High-

Aydog et al26 (2004)
Kujula et al27 (1994)

Kujula et al28 (1999)

Sarna et al31 (1997)
Scher et al23 (2009)

quality prospective cohort studies are the best way to

identify risk factors for OA within tactical-athlete popula-
Study (Year)

tions. These studies are needed to better understand the

modifiable and nonmodifiable risk factors for OA in tactical
athletes so that effective prevention strategies can be
developed and implemented. Despite this limitation,
a
b

d
c

958 Volume 51  Number 11  November 2016

Table 3. Incidence Rate Ratios by Rank in Active-Duty US Military
Age Type of Unadjusted Adjusted Rate Ratioa
Study (Year) Sex(es) Range, y Osteoarthritis Rank Incidence Rate (95% Confidence Interval)
Cameron et al22 (2011)b Both 18–62 Any Junior enlisted 3.57 1.67 (1.63, 1.72)
Senior enlisted 11.61 1.49 (1.46, 1.53)
Junior officers 5.74 1.00
Senior officers 17.45 1.12 (1.09, 1.15)
Scher et al23 (2009)c Both 18–62 Hip Junior enlisted 16.60 1.90 (1.63, 2.22)
Senior enlisted 24.80 1.31 (1.16, 1.48)
Junior officers 46.40 1.00
Senior officers 112.00 1.50 (1.31, 1.73)
a
Adjusted for sex, age, branch of military service, and race.
b
Incidence rate per 1000 person-years.
c
Incidence rate per 100 000 person-years.

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authors of some of the studies we reviewed were able to factors within this high-risk population in order to develop
assess the incidence of OA as an outcome in comparison and implement effective risk-reduction strategies.
with a previous review in athletes from which only
prevalence data were available.34 Tactical athletes may be REFERENCES
more physically active than the general population, and this 1. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the
may influence OA risk for some activities, which could not prevalence of arthritis and other rheumatic conditions in the United
be controlled in the current review.34 Finally, despite the States: part II. Arthritis Rheum. 2008;58(1):26–35.
observed differences in OA incidence and prevalence 2. Richmond SA, Fukuchi RK, Ezzat A, Schneider K, Schneider G,
between tactical athletes and nonexposed controls from Emery CA. Are joint injury, sport activity, physical activity, obesity,
the general population, we still do not know which specific or occupational activities predictors for osteoarthritis? A systematic
occupational factors or combination of factors are contrib- review. J Orthop Sports Phys Ther. 2013;43(8):515–B19.
uting to the observed disparity. 3. Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence
Even with these limitations in the literature, we of symptomatic hand, hip, and knee osteoarthritis among patients in a
health maintenance organization. Arthritis Rheum. 1995;38(8):1134–
consistently observed that specific subgroups of tactical
1141.
athletes (eg, firefighters, active-duty military, veteran 4. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term
parachutists) were at elevated risk for various types of consequence of anterior cruciate ligament and meniscus injuries:
OA. However, important gaps still exist in our understand- osteoarthritis. Am J Sports Med. 2007;35(10):1756–1769.
ing of the risk factors that contribute to the increased OA 5. Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence
risk among tactical athletes. Furthermore, data on the of knee osteoarthritis, pain, and functional limitations in female
incidence and prevalence of OA in some tactical-athlete soccer players twelve years after anterior cruciate ligament injury.
populations (eg, law enforcement, first responders) are not Arthritis Rheum. 2004;50(10):3145–3152.
currently available. Research examining the risk of OA in 6. Seidler A, Bolm-Audorff U, Abolmaali N, Elsner G. The role of
these tactical-athlete populations is needed. The influence cumulative physical work load in symptomatic knee osteoarthritis—a
case-control study in Germany. J Occup Med Toxicol. 2008;3:14.
of mandatory national military service on the prevalence of
7. Felson DT. Obesity and vocational and avocational overload of the
OA also remains unclear. It is important to appreciate that joint as risk factors for osteoarthritis. J Rheumatol Suppl. 2004;70:2–
tactical-athlete populations are at high risk for OA, which is 5.
a chronic disease that can impair physical function, lead to 8. Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new
occupational disability and early retirement, and reduce insights. Part 1: the disease and its risk factors. Ann Intern Med.
quality of life. It is also critical to identify modifiable risk 2000;133(8):635–646.

Table 4. Incidence Rate Ratios by Branch of Service in Active-Duty US Military

Age Type of Unadjusted Adjusted Rate Ratioa
Study (Year) Sex(es) Range, y Osteoarthritis Service Incidence Rate (95% Confidence Interval)
Cameron et al22 (2011)b Both 18–62 Any Army 9.70 1.49 (1.47, 1.52)
Air Force 8.06 1.08 (1.06, 1.10)
Navy 6.72 1.00
Marines 4.71 1.07 (1.05, 1.10)
Scher et al23 (2009)c Both 18–62 Hip Army 43.30 1.90 (1.75, 2.07)
Marines 37.00 1.85 (1.64, 2.09)
Navy 26.80 1.63 (1.49, 1.78)
Air Force 26.30 1.00
a
Adjusted for sex, age, military rank, and race.
b
Incidence rate per 1000 person-years.
c
Incidence rate per 100 000 person-years.

Journal of Athletic Training 959

 9. Felson DT, Hannan MT, Naimark A, et al. Occupational physical 31. Sarna S, Kaprio J, Kujala UM, Koskenvuo M. Health status of former
demands, knee bending, and knee osteoarthritis: results from the elite athletes. The Finnish experience. Aging (Milano). 1997;9(1–2):
Framingham Study. J Rheumatol. 1991;18(10):1587–1592. 35–41.
10. Felson DT, Zhang Y. An update on the epidemiology of knee and hip 32. Iosifidis MI, Tsarouhas A, Fylaktou A. Lower limb clinical and
osteoarthritis with a view to prevention. Arthritis Rheum. 1998;41(8): radiographic osteoarthritis in former elite male athletes. Knee Surg
1343–1355. Sports Traumatol Arthrosc. 2015;23(9):2528–2535.
11. Felson DT. Risk factors for osteoarthritis: understanding joint 33. Chinn S. A simple method for converting an odds ratio to effect size
vulnerability. Clin Orthop Relat Res. 2004;suppl 427:S16–S21. for use in meta-analysis. Stat Med. 2000;19(22):3127–3131.
12. Issa SN, Sharma L. Epidemiology of osteoarthritis: an update. Curr 34. Driban JB, Hootman JM, Sitler MR, Harris K, Cattano NM. Is
Rheumatol Rep. 2006;8(1):7–15. participation in certain sports associated with knee osteoarthritis? A
13. Englund M, Lohmander LS. Risk factors for symptomatic knee systematic review. J Athl Train. 2016. In press.
osteoarthritis fifteen to twenty-two years after meniscectomy. 35. Kopec JA, Rahman MM, Berthelot JM, et al. Descriptive
Arthritis Rheum. 2004;50(9):2811–2819. epidemiology of osteoarthritis in British Columbia, Canada. J
14. Vos T, Flaxman AD, Naghavi ML, et al. Years lived with disability Rheumatol. 2007;34(2):386–393.
(YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a 36. Kopec JA, Rahman MM, Sayre EC, et al. Trends in physician-
systematic analysis for the Global Burden of Disease Study 2010. diagnosed osteoarthritis incidence in an administrative database in

Downloaded from http://meridian.allenpress.com/jat/article-pdf/51/11/952/1457649/1062-6050-51_5_03.pdf by Vietnam user on 31 October 2024

Lancet. 2012;380(9859):2163–2196. British Columbia, Canada, 1996–1997 through 2003–2004. Arthritis
15. Cameron KL, Owens BD. The burden and management of sports- Rheum. 2008;59(7):929–934.
related musculoskeletal injuries and conditions within the US 37. Patzkowski JC, Rivera JC, Ficke JR, Wenke JC. The changing face
military. Clin Sports Med. 2014;33(4):573–589. of disability in the US Army: the Operation Enduring Freedom and
16. Cameron KL, Owens BD, DeBerardino TM. Incidence of ankle Operation Iraqi Freedom effect. J Am Acad Orthop Surg. 2012;
sprains among active-duty members of the United States Armed 20(suppl 1):S23–S30.
Services from 1998 through 2006. J Athl Train. 2010;45(1):29–38. 38. Amoroso PJ, Canham ML. Chapter 4. Disabilities related to the
17. Jones JC, Burks R, Owens BD, et al. Incidence and risk factors musculoskeletal system: Physical Evaluation Board data. Mil Med.
associated with meniscal injuries among active-duty US military 1999;164(suppl 8):1–73.
service members. J Athl Train. 2012;47(1):67–73. 39. Hsiao M, Owens BD, Burks R, Sturdivant RX, Cameron KL.
18. Owens BD, Dawson L, Burks R, Cameron KL. Incidence of shoulder Incidence of acute traumatic patellar dislocation among active-duty
dislocation in the United States military: demographic considerations United States military service members. Am J Sports Med. 2010;
from a high-risk population. J Bone Joint Surg Am. 2009;91(4):791–796.
38(10):1997–2004.
19. Owens BD, Mountcastle SB, Dunn WR, DeBerardino TM, Taylor
40. Roos H, Adalberth T, Dahlberg L, Lohmander LS. Osteoarthritis of
DC. Incidence of anterior cruciate ligament injury among active duty
the knee after injury to the anterior cruciate ligament or meniscus: the
U.S. military servicemen and servicewomen. Mil Med. 2007;172(1):
influence of time and age. Osteoarthritis Cartilage. 1995;3(4):261–
90–91.
267.
20. Hootman JM, Driban JB, Sitler MR, Harris KA, Cattano NM.
41. Wilder FV, Hall BJ, Barrett JP Jr, Lemrow NB. History of acute knee
Reliability and validity of three quality rating instruments for
injury and osteoarthritis of the knee: a prospective epidemiological
systematic reviews of observational studies. Res Synth Methods.
assessment. The Clearwater Osteoarthritis Study. Osteoarthritis
2011;2(2):110–118.
Cartilage. 2002;10(8):611–616.
21. Vingard E, Alfredsson L, Goldie I, Hogstedt C. Occupation and
42. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA.
osteoarthrosis of the hip and knee: a register-based cohort study. Int J
Posttraumatic osteoarthritis: a first estimate of incidence, prevalence,
Epidemiol. 1991;20(4):1025–1031.
22. Cameron KL, Hsiao MS, Owens BD, Burks R, Svoboda SJ. and burden of disease. J Orthop Trauma. 2006;20(10):739–744.
Incidence of physician diagnosed osteoarthritis among active duty 43. Songer TJ, LaPorte RE. Disabilities due to injury in the military. Am
United States military service members. Arthritis Rheum. 2011; J Prev Med. 2000;18(suppl 3):33–40.
63(10):2974–2982. 44. Dunn WR, Lincoln AE, Hinton RY, Smith GS, Amoroso PJ.
23. Scher DL, Belmont PJ Jr, Mountcastle S, Owens BD. The incidence Occupational disability after hospitalization for the treatment of an
of primary hip osteoarthritis in active duty US military service injury of the anterior cruciate ligament. J Bone Joint Surg Am. 2003;
members. Arthritis Rheum. 2009;61(4):468–475. 85(9):1656–1666.
24. Murray-Leslie CF, Lintott DJ, Wright V. The knee and ankles in 45. Sulsky SI, Mundt KA, Bigelow C, Amoroso PJ. Case-control study
sport and veteran military parachutists. Ann Rheum Dis. 1977;36(4): of discharge from the US Army for disabling occupational knee
327–331. injury: the role of gender, race/ethnicity, and age. Am J Prev Med.
25. Murray-Leslie CF, Lintott DJ, Wright V. The spine in sport and 2000;18(suppl 3):103–111.
veteran military parachutists. Ann Rheum Dis. 1977;36(4):332–342. 46. Sulsky SI, Mundt KA, Bigelow C, Amoroso PJ. Risk factors for
26. Aydog ST, Turbedar E, Demirel AH, Tetik O, Akin A, Doral MN. occupational knee related disability among enlisted women in the US
Cervical and lumbar spinal changes diagnosed in four-view Army. Occup Environ Med. 2002;59(9):601–607.
radiographs of 732 military pilots. Aviat Space Environ Med. 2004; 47. Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. Battlefield
75(2):154–157. orthopaedic injuries cause the majority of long-term disabilities. J
27. Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints Am Acad Orthop Surg. 2011;19(suppl 1):S1–S7.
of lower limbs in former elite male athletes. BMJ. 1994;308(6923): 48. Rivera JC, Wenke JC, Buckwalter JA, Ficke JR, Johnson AE.
231–234. Posttraumatic osteoarthritis caused by battlefield injuries: the primary
28. Kujala UM, Sarna S, Kaprio J, Koskenvuo M, Karjalainen J. Heart source of disability in warriors. J Am Acad Orthop Surg. 2012;
attacks and lower-limb function in master endurance athletes. Med 20(suppl 1):S64–S69.
Sci Sports Exerc. 1999;31(7):1041–1046. 49. Rubertone MV, Brundage JF. The Defense Medical Surveillance
29. Kettunen JA, Kujala UM, Kaprio J, Sarna S. Health of master track System and the Department of Defense serum repository: glimpses of
and field athletes: a 16-year follow-up study. Clin J Sport Med. 2006; the future of public health surveillance. Am J Public Health. 2002;
16(2):142–148. 92(12):1900–1904.
30. Kettunen JA, Kujala UM, Kaprio J, Koskenvuo M, Sarna S. Lower- 50. Sugimoto D, Myer GD, Foss KD, Hewett TE. Specific exercise
limb function among former elite male athletes. Am J Sports Med. effects of preventive neuromuscular training intervention on anterior
2001;29(1):2–8. cruciate ligament injury risk reduction in young females: meta-

960 Volume 51  Number 11  November 2016

 analysis and subgroup analysis. Br J Sports Med. 2014;49(5):282– 56. Lau EC, Cooper C, Lam D, Chan VN, Tsang KK, Sham A. Factors
289. associated with osteoarthritis of the hip and knee in Hong Kong
51. Pappas E, Nightingale EJ, Simic M, Ford KR, Hewett TE, Myer GD. Chinese: obesity, joint injury, and occupational activities. Am J
Do exercises used in injury prevention programmes modify cutting Epidemiol. 2000;152(9):855–862.
task biomechanics? A systematic review with meta-analysis. Br J 57. Allen KD, Chen JC, Callahan LF, et al. Associations of occupational
Sports Med. 2015;49(10):673–680. tasks with knee and hip osteoarthritis: the Johnston County
52. Carow S, Haniuk E, Cameron K, et al. Risk of lower extremity injury Osteoarthritis Project. J Rheumatol. 2010;37(4):842–850.
in a military cadet population after a supervised injury-prevention 58. Coggon D, Kellingray S, Inskip H, Croft P, Campbell L, Cooper C.
Osteoarthritis of the hip and occupational lifting. Am J Epidemiol.
program. J Athl Train. 2016. In press.
1998;147(6):523–528.
53. Coggon D, Croft P, Kellingray S, Barrett D, McLaren M, Cooper C.
59. Yoshimura N, Sasaki S, Iwasaki K, et al. Occupational lifting is
Occupational physical activities and osteoarthritis of the knee. associated with hip osteoarthritis: a Japanese case-control study. J
Arthritis Rheum. 2000;43(7):1443–1449. Rheumatol. 2000;27(2):434–440.
54. Jensen LK, Mikkelsen S, Loft IP, Eenberg W, Bergmann I, Logager 60. US Army Center for Army Lessons Learned. Task Force Devil
V. Radiographic knee osteoarthritis in floorlayers and carpenters. Combined Arms Assessment Team (Devil CAAT). The Modern
Scand J Work Environ Health. 2000;26(3):257–262. Warrior’s Combat Load: Dismounted Operations in Afghanistan.

Downloaded from http://meridian.allenpress.com/jat/article-pdf/51/11/952/1457649/1062-6050-51_5_03.pdf by Vietnam user on 31 October 2024

55. Sandmark H, Hogstedt C, Vingard E. Primary osteoarthrosis of the Arlington, VA: Department of Defense; 2003:1–115.
knee in men and women as a result of lifelong physical load from 61. Central Intelligence Agency. The World Factbook 2014–2015.
work. Scand J Work Environ Health. 2000;26(1):20–25. Washington, DC: Central Intelligence Agency; 2014.

Address correspondence to Kenneth Cameron, PhD, MPH, ATC, Keller Army Hospital, John A. Feagin Jr Sports Medicine Fellowship,
900 Washington Road, West Point, NY 10996. Address e-mail to [email protected].

Journal of Athletic Training 961