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No athlete likes to think about getting older. But it's a fact that as we train and put our bodies through rigorous physical tasks, we risk injury, and with injury comes rehab and longer term consequences. And even if you make it through surgery, physical therapy and beyond, you still run the risk of cartilage deterioration in the joint. Overtime, this can cause osteoarthritis in the joint itself.

It's well known that women get more arthritis than men during their lifetimes in general, but that doesn't mean that guys are in the clear. In fact, according to the National Institute on Aging, people who struggle with osteoarthritis under the age of 45 are more likely to be men, and the disease can be triggered by sports injuries, among other things. It's serious, chronic, and if left untreated and unmanaged, can contribute to physical inabilities later in life. Here's what the deal is, and why athletes should be extra careful with knee injury rehab, especially.

What is Knee Osteoarthritis and How Does it Progress?

Osteoarthritis is essentially, simply put, caused by cartilage loss in a joint. It can be painful, debilitating and literally (overtime) take you out of the game. For athletes under 45 years old, knee injuries are one of the most common sports ailments around—especially for Spartans, who run, jump, climb, crawl and send it hard on the course. When a knee goes through an injury, like an ACL, MCL, PCL or meniscus tear, the muscles, tendons and ligaments must heal in order to get the knee functioning properly again. But the rehab doesn't (or shouldn't) stop there. More on that in a minute. 

"The most direct link for sports-related osteoarthritis is through a knee injury—something like tearing an anterior cruciate ligament (ACL)—which is very common in sports, and will cause about half of the people who experience this to have symptomatic radiographic knee osteoarthritis within 10-15 years," says Constance Chu, M.D. and Professor of Orthopedic Surgery at Stanford University. "That’s horrible because the peak years when people tear their ACLs are the teenage and young adult years, the vast majority of tears being before 35. So 10 years later, you have osteoarthritis but you’re still very young." 

How Does Knee Osteoarthritis Affect Athletes?

"Early arthritis typically presents as lingering knee pain and as swelling, with increasing activity," says Karen M. Sutton, M.D., F.A.A.O.S., Associate Professor at Weill Cornell Medicine and Team Physician for the U.S. National Lacrosse and Ski & Snowboard teams. "In the early phases of osteoarthritis, pain is related to activity and becomes more constant over time."

Arthritis that starts at an earlier age can be associated with other knee injuries, because you don't often tear just one part, and if you tear it once, you're more likely to tear it again. For example, athletes with meniscus tears have a higher average rate of cartilage deterioration (early arthritis) than those who have an intact meniscus, she says. Another cause can be a ligament injury as the initial bruising from that—and the instability of the knee—can progress to cartilage loss. For example, an ACL rupture can often result in knee osteoarthritis if not rehabilitated properly.

Anytime the knee suffers from either minor or major instability, the cartilage is placed at risk, similar to a train being slightly off track, wearing on the wheels. In other words, who ever said "no pain, no gain" was full of B.S. Pain is an indicator that something isn't right. But the thing is, cartilage itself cannot feel pain. It's the ligaments, muscles and tendons around it that signify there's an issue. If the knee feels healed, but the cartilage is still damaged, it can cause early onset arthritis, which won't present for years. Therefore, this makes knee-injury rehab dicey when it comes to knowing when to get back into the game. (Your doctor may recommend additional X-rays to identify how extensive the damage is, and make a more personalized rehab program for you.)

Cartilage is Key to Knee Osteoarthritis

The key is to avoid writing pain off—even if you feel young and healthy, and are eager to get back into your fitness routine. Why? Because your cartilage won't grow back. Dr. Chu, who has done research in the knee OA field for over 25 years, says while she can very easily grow cartilage in a laboratory, it's just not on par with human cartilage found in the body. It doesn't have the same structure and ability to withstand forces that our non-synthetic cartilage can, and that once it’s worn away, there’s really nothing that will bring that back, she says. And at that point, you're reduced to treating the symptoms of knee pain and swelling.

"If you have pain and swelling after a sport, that’s not normal," says Dr Chu. "That’s one of the earliest signs of osteoarthritis, especially in people under age 30. This can go on for a while, and I do have patients who say, 'my knee hurts just after I run and it goes away', and they keep running and take an occasional anti-inflammatory to help." If this becomes a habit, she says, and the athlete continues to chase the same workouts thinking that the pain itself is just a symptom of being active, it can lead to even greater consequences down the line. Especially if left undiagnosed and untreated. 

Why Guys Should Care About Knee Pain from Early Onset Osteoarthritis

"The lifetime risk is actually greater for women, but for the under 45-ers, simply put, men are just harder on their knees as a group," says Dr. Chu. "These statistics come from men being more likely to perform hard physical labor and perform more sports more often than women, which increases risk for injuries that weaken the tissues within the joint and make it even more susceptible to long term wear and tear, and this type of arthritis." Though you find osteoarthritis all over the body, knee injuries are the ones that track most closely with sports, she says. So men (and younger women with knee injuries) should be very careful. 

Take it slow when you get back into your fitness routine. If you continually push your physical training forward without attending to the pain, or adjusting your fitness routine to include more cross-training and less powerlifting, it can be detrimental in the long term, perhaps even resulting in death of the bone joint and the necessity of a total replacement. In other words, if you are coming back from a knee injury and think you're ready to return to racing, tread lightly. "It’s kind of challenging, it’s like finding COVID-19 in patients who don’t have symptoms," says Chu. "Cartilage can't feel pain and people don’t feel symptoms until it’s damaged, wounded or completely gone. That’s where recovery can be challenging because you feel like your knee is good already, go back to the activity with weakness, and it just needs more time to be strengthened." 

What Can You Do About Knee Osteoarthritis?

In addition to more healing time post injury, and careful low-impact cross training like swimming and cycling, diet adjustments to avoid inflammation can help. "Male athletes can protect their knees by maintaining appropriate body mass index (BMI) and a healthy diet," says Dr. Sutton. "Obesity increases the risk for knee osteoarthritis by three times. Increased consumption of fat and higher cholesterol have been shown to worsen cartilage integrity." It's also important to have appropriate amounts of Vitamin D in the diet, since Vitamin D deficiency can play a role in early osteoarthritis changes, she says.

Dr. Chu concurs, saying that in general, the healthier your diet, and the more you maintain your overall physical, mental and emotional health, the better it will be for a joint that is essentially undergoing a chronic process of wearing away. "Anything you can do to reduce overall inflammation, like eating a heart-healthy diet of lean proteins, fruits and vegetables, and avoiding sugary or fried food, I would say, will help keep your knee as healthy as possible, for as long as possible," she says. Not to mention, focusing on your core, posture and form will go a long way to preventing further injury. 

Though knee osteoarthritis is a lifelong condition, and while there is no cure, there are many treatment options clinically proven to help successfully manage symptoms over the long run. Hyaluronic acid injections, like Durolane injections, can help mitigate pain from osteoarthritis and support you as you continue your physical activity. Be sure to speak with your doctor about what treatment regimen is right for you, and what changes you need to make to get the most out of your knees—right now. And before it's too late.