Bone marrow lesions (BMLs) are considered as predictors of pain, disability, and structural progression of knee osteoarthritis. The relationship between knee loading and BMLs is not yet completely understood.
Purpose:
To summarize the available evidence regarding the relationship between joint loading and the prevalence and progression of BMLs in the tibiofemoral joint.
Study Design:
Meta-analysis.
Methods:
Three databases (PubMed, Web of Science, and The Cochrane Library) were systematically screened for studies encompassing BMLs and changes in knee loading. A methodological quality assessment was conducted, and a meta-analysis computing overall odds ratios (ORs) was performed where possible.
Results:
A total of 29 studies involving 7641 participants were included. Mechanical loading was categorized as body weight and composition, compartmental load, structural lesion, and physical activity. High compartmental loads and structural lesions increased the risk for BMLs (overall ORs ranging from 1.56 [95% CI, 1.13-2.15] to 8.2 [95% CI, 4.4-15.1]; P = .006). Body weight increased the risk for BMLs to a lesser extent (overall OR, 1.03; 95% CI, 1.01-1.05; P = .007). Contradictory results for the effect of physical activity on BMLs were found.
Conclusion:
Augmented compartmental loads and structural lesions increased the risk of the presence or progression of BMLs. Body weight increased the risk for BMLs to a lesser extent. Contradictory results for the effect of physical activity on BMLs may be explained by a dose-response relationship, knee alignment, and structural lesions.
Clinical Relevance:
It has been shown that unloading the knee temporarily may induce beneficial effects on osteoarthritis-related structural changes. Therefore, an early recognition of BMLs in the aging athlete’s knee may provide information to counter the onset and aggravation of symptomatic knee osteoarthritis by reducing the knee load.
AllaireRMuriukiMGilbertsonLHarnerCD. Biomechanical consequences of a tear of the posterior root of the medial meniscus: similar to total meniscectomy. J Bone Joint Surg Am. 2008;90(9):1922-1931.
2.
AltmanRAschEBlochD. Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29(8):1039-1049.
3.
AndriacchiTPMundermannA. The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Curr Opin Rheumatol. 2006;18(5):514-518.
4.
BaranyayFJWangYWlukaAE. Association of bone marrow lesions with knee structures and risk factors for bone marrow lesions in the knees of clinically healthy, community-based adults. Semin Arthritis Rheum. 2007;37(2):112-118.
5.
BeckweeDVaesPCnuddeMSwinnenEBautmansI. Osteoarthritis of the knee: why does exercise work? A qualitative study of the literature. Ageing Res Rev. 2013;12(1):226-236.
BennellKLBowlesKAWangYCicuttiniFDavies-TuckMHinmanRS. Higher dynamic medial knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis. Ann Rheum Dis. 2011;70(10):1770-1774.
8.
BennellKLCreabyMWWrigleyTV. Bone marrow lesions are related to dynamic knee loading in medial knee osteoarthritis. Ann Rheum Dis. 2010;69(6):1151-1154.
9.
BerryPAWlukaAEDavies-TuckML. The relationship between body composition and structural changes at the knee. Rheumatology (Oxford). 2010;49(12):2362-2369.
10.
BrennanSLCicuttiniFMPascoJA. Does an increase in body mass index over 10 years affect knee structure in a population-based cohort study of adult women?Arthritis Res Ther. 2010;12(4):R139.
11.
ChaudhariAMBriantPLBevillSLKooSAndriacchiTP. Knee kinematics, cartilage morphology, and osteoarthritis after ACL injury. Med Sci Sports Exerc. 2008;40(2):215-222.
12.
CicuttiniFMBakerJRSpectorTD. The association of obesity with osteoarthritis of the hand and knee in women: a twin study. J Rheumatol. 1996;23(7):1221-1226.
13.
ClarysJPScafoglieriAProvynSBautmansI. Body mass index as a measure of bone mass. J Sports Med Phys Fitness. 2010;50(2):202-206.
Davies-TuckMLWlukaAEForbesA. Development of bone marrow lesions is associated with adverse effects on knee cartilage while resolution is associated with improvement: a potential target for prevention of knee osteoarthritis. A longitudinal study. Arthritis Res Ther. 2010;12(1):R10.
17.
DeeksJJHigginsJPTAltmanDG. Analysing data and undertaking meta-analyses. In: HigginsJPTGreenS eds. Cochrane Handbook for Systematic Reviews of Interventions: Version 5.0.1 [Updated September 2008]. Oxford: Cochrane Collaboration; 2008:9.1-9.43
18.
DerSimonianRLairdN. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-188.
19.
DoréDQuinnSDingC. Natural history and clinical significance of MRI-detected bone marrow lesions at the knee: a prospective study in community dwelling older adults. Arthritis Res Ther. 2010;12(6):R223.
20.
DoréDAWinzenbergTMDingC. The association between objectively measured physical activity and knee structural change using MRI. Ann Rheum Dis. 2013;72(7):1170-1175.
EnglundMGuermaziARoemerFW. Meniscal pathology on MRI increases the risk for both incident and enlarging subchondral bone marrow lesions of the knee: the MOST Study. Ann Rheum Dis. 2010;69(10):1796-1802.
24.
FelsonDTMcLaughlinSGogginsJ. Bone marrow edema and its relation to progression of knee osteoarthritis. Ann Intern Med. 2003;139(5 Pt 1):330-336.
25.
FelsonDTNiuJGuermaziA. Correlation of the development of knee pain with enlarging bone marrow lesions on magnetic resonance imaging. Arthritis Rheum. 2007;56(9):2986-2992.
26.
FernandesLHagenKBBijlsmaJW. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7):1125-1135.
27.
FrobellRBLe GraverandMPBuckR. The acutely ACL injured knee assessed by MRI: changes in joint fluid, bone marrow lesions, and cartilage during the first year. Osteoarthritis Cartilage. 2009;17(2):161-167.
28.
GauglerMWirzDRonkenS. Fibrous cartilage of human menisci is less shock-absorbing and energy-dissipating than hyaline cartilage [published online March 11, 2014]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-2926-4.
29.
GudbergsenHBoesenMChristensenR. Changes in bone marrow lesions in response to weight-loss in obese knee osteoarthritis patients: a prospective cohort study. BMC Musculoskelet Disord. 2013;14:106.
30.
GuermaziANiuJHayashiD. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012;345:e5339.
31.
GuymerEBaranyayFWlukaAE. A study of the prevalence and associations of subchondral bone marrow lesions in the knees of healthy, middle-aged women. Osteoarthritis Cartilage. 2007;15(12):1437-1442.
32.
HayashiDEnglundMRoemerFW. Knee malalignment is associated with an increased risk for incident and enlarging bone marrow lesions in the more loaded compartments: the MOST study. Osteoarthritis Cartilage. 2012;20(11):1227-1233.
33.
HigginsJPThompsonSGDeeksJJAltmanDG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560.
34.
HinmanRSPayneCMetcalfBRWrigleyTVBennellKL. Lateral wedges in knee osteoarthritis: what are their immediate clinical and biomechanical effects and can these predict a three-month clinical outcome?Arthritis Rheum. 2008;59(3):408-415.
35.
HohmannEWortlerKImhoffAB. MR imaging of the hip and knee before and after marathon running. Am J Sports Med. 2004;32(1):55-59.
36.
HovisKKAlizaiHThamS-C. Non-traumatic anterior cruciate ligament abnormalities and their relationship to osteoarthritis using morphological grading and cartilage T2 relaxation times: data from the Osteoarthritis Initiative (OAI). Skeletal Radiol. 2012;41(11):1435-1443.
37.
HuetinkKNelissenRGHHWattIvan ErkelARBloemJL. Localized development of knee osteoarthritis can be predicted from MR imaging findings a decade earlier. Radiology. 2010;256(2):536-546.
38.
HunterDJGerstenfeldLBishopG. Bone marrow lesions from osteoarthritis knees are characterized by sclerotic bone that is less well mineralized. Arthritis Res Ther. 2009;11(1):R11.
39.
HunterDJLoGHGaleDGraingerAJGuermaziAConaghanPG. The reliability of a new scoring system for knee osteoarthritis MRI and the validity of bone marrow lesion assessment: BLOKS (Boston-Leeds Osteoarthritis Knee Score). Ann Rheum Dis. 2008;67(2):206-211.
40.
HunterDJZhangYNiuJ. Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis. Arthritis Rheum. 2006;54(5):1529-1535.
41.
IssaSNDunlopDChangA. Full-limb and knee radiography assessments of varus-valgus alignment and their relationship to osteoarthritis disease features by magnetic resonance imaging. Arthritis Rheum. 2007;57(3):398-406.
42.
KarsdalMAChristiansenCLadelCHenriksenKKrausVBBay-JensenAC. Osteoarthritis: a case for personalized health care?Osteoarthritis Cartilage. 2014;22(1):7-16.
43.
KeanCOHinmanRSBowlesKACicuttiniFDavies-TuckMBennellKL. Comparison of peak knee adduction moment and knee adduction moment impulse in distinguishing between severities of knee osteoarthritis. Clin Biomech (Bristol, Avon). 2012;27(5):520-523.
44.
KramplaWMayrhoferRMalcherJKristenKHUrbanMHrubyW. MR imaging of the knee in marathon runners before and after competition. Skeletal Radiol. 2001;30(2):72-76.
45.
LabergeMABaumTVirayavanichW. Obesity increases the prevalence and severity of focal knee abnormalities diagnosed using 3T MRI in middle-aged subjects: data from the Osteoarthritis Initiative. Skeletal Radiol. 2012;41(6):633-641.
46.
LiberatiAAltmanDGTetzlaffJ. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.
47.
LimYZWangYWlukaAE. Are biomechanical factors, meniscal pathology, and physical activity risk factors for bone marrow lesions at the knee? A systematic review. Semin Arthritis Rheum. 2013;43(2):187-194.
48.
LitwicAEdwardsMHDennisonEMCooperC. Epidemiology and burden of osteoarthritis. Br Med Bull. 2013;105:185-199.
49.
LoGHHunterDJNevittMLynchJMcAlindonTE. Strong association of MRI meniscal derangement and bone marrow lesions in knee osteoarthritis: data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2009;17(6):743-747.
50.
LowitzTMuseykoOBoussonV. Bone marrow lesions identified by MRI in knee osteoarthritis are associated with locally increased bone mineral density measured by QCT. Osteoarthritis Cartilage. 2013;21(7):957-964.
51.
McAlindonTEBannuruRRSullivanMC. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-388.
52.
MessierSPGutekunstDJDavisCDeVitaP. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 2005;52(7):2026-2032.
53.
MessierSPLegaultCLoeserRF. Does high weight loss in older adults with knee osteoarthritis affect bone-on-bone joint loads and muscle forces during walking?Osteoarthritis Cartilage. 2011;19(3):272-280.
54.
OberlanderKDBruggemannGPHoherJKaramanidisK. Knee mechanics during landing in anterior cruciate ligament patients: a longitudinal study from pre- to 12 months post-reconstruction. Clin Biomech (Bristol, Avon). 2014;29(5):512-517.
55.
OliveriaSAFelsonDTCirilloPAReedJIWalkerAM. Body weight, body mass index, and incident symptomatic osteoarthritis of the hand, hip, and knee. Epidemiology. 1999;10(2):161-166.
56.
PottiePPresleNTerlainBNetterPMainardDBerenbaumF. Obesity and osteoarthritis: more complex than predicted!Ann Rheum Dis. 2006;65(11):1403-1405.
57.
RacunicaTLTeichtahlAJWangY. Effect of physical activity on articular knee joint structures in community-based adults. Arthritis Rheum. 2007;57(7):1261-1268.
58.
RatzlaffCGuermaziACollinsJ. A rapid, novel method of volumetric assessment of MRI-detected subchondral bone marrow lesions in knee osteoarthritis. Osteoarthritis Cartilage. 2013;21(6): 806-814.
59.
RoemerFWFrobellRHunterDJ. MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis. Osteoarthritis Cartilage. 2009;17(9):1115-1131.
60.
ScafoglieriAProvynSBautmansIVan RoyPClarysJP. Body mass index: misleading popular science? In: ErgenEUlkarBGunerR, eds. Proceedings of the 6th European Sports Medicine Congress (EFSMA). Bologna, Italy: Medimond International Proceedings; 2009:15-20.
61.
ScafoglieriAProvynSBautmansIVan RoyPClarysJP. Direct relationship of body mass index and waist circumference with body tissue distribution in elderly persons. J Nutr Health Aging. 2011;15(10):924-931.
62.
Schueller-WeidekammCSchuellerGUffmannMBaderT. Incidence of chronic knee lesions in long-distance runners based on training level: findings at MRI. Eur J Radiol. 2006;58(2):286-293.
63.
SegalNAKernAMAndersonDD. Elevated tibiofemoral articular contact stress predicts risk for bone marrow lesions and cartilage damage at 30 months. Osteoarthritis Cartilage. 2012;20(10):1120-1126.
64.
StahlRLukeAMaCB. Prevalence of pathologic findings in asymptomatic knees of marathon runners before and after a competition in comparison with physically active subjects: a 3.0 T magnetic resonance imaging study. Skeletal Radiol. 2008;37(7):627-638.
65.
StehlingCLaneNENevittMCLynchJMcCullochCELinkTM. Subjects with higher physical activity levels have more severe focal knee lesions diagnosed with 3 T MRI: analysis of a non-symptomatic cohort of the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2010;18(6):776-786.
66.
TanamasSKWlukaAEPelletierJP. Bone marrow lesions in people with knee osteoarthritis predict progression of disease and joint replacement: a longitudinal study. Rheumatology (Oxford). 2010;49(12):2413-2419.
67.
ThorpLEWimmerMABlockJA. Bone mineral density in the proximal tibia varies as a function of static alignment and knee adduction angular momentum in individuals with medial knee osteoarthritis. Bone. 2006;39(5):1116-1122.
68.
WallaceBCSchmidCHLauJTrikalinosTA. Meta-Analyst: software for meta-analysis of binary, continuous and diagnostic data. BMC Med Res Methodol. 2009;9:80.
69.
WangYWlukaAEPelletierJP. Meniscal extrusion predicts increases in subchondral bone marrow lesions and bone cysts and expansion of subchondral bone in osteoarthritic knees. Rheumatology (Oxford). 2010;49(5):997-1004.
70.
WiegantKvan RoermundPMIntemaF. Sustained clinical and structural benefit after joint distraction in the treatment of severe knee osteoarthritis. Osteoarthritis Cartilage. 2013;21(11):1660-1667.
71.
ZanettiMBruderERomeroJHodlerJ. Bone marrow edema pattern in osteoarthritic knees: correlation between MR imaging and histologic findings. Radiology. 2000;215(3):835-840.
72.
ZhaiGBlizzardLSrikanthV. Correlates of knee pain in older adults: Tasmanian Older Adult Cohort Study. Arthritis Rheum. 2006;55(2):264-271.
73.
ZhaiGStankovichJCicuttiniFDingCJonesG. Familial, structural, and environmental correlates of MRI-defined bone marrow lesions: a sibpair study. Arthritis Res Ther. 2006;8(4):R137.
74.
ZhangYNevittMNiuJ. Fluctuation of knee pain and changes in bone marrow lesions, effusions, and synovitis on magnetic resonance imaging. Arthritis Rheum. 2011;63(3):691-699.
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