Intra-articular Injection Administration in UK Ex-professional Footballers During Their Playing Careers and the Association with Post-career Knee Osteoarthritis

Fernandes, Gwen S.; Parekh, Sanjay M.; Moses, Jonathan P.; Fuller, Colin W.; Scammell, Brigitte E.; Batt, Mark E.; Zhang, Weiya; Doherty, Michael

Abstract

© 2020, The Author(s). Background: The long-term risk from knee intra-articular (KIA) injections in professional athletes such as ex-footballers remains unknown. The use of KIA injections is controversial and remains anecdotally prolific as it is perceived as being safe/beneficial. The aim of this study was to determine the number, type and frequency KIA injections administered to retired professional footballers during their playing careers and the associations with post-career knee osteoarthritis (KOA). Methods: This is a cross-sectional study involving a postal questionnaire (n = 1207) and subsequent knee radiographs in a random sample of questionnaire responders (n = 470). Footballers self-reported in the questionnaire whether they had received KIA injections and the estimated total number over the course of their playing career. Participant characteristics and football career-related details were also recorded. KOA was measured as self-reported knee pain (KP), total knee replacement (TKR) and radiographic KOA (RKOA). Results: 44.5% of footballers had received at least one KIA injection (mean: 7.5; SD ± 11.2) during their professional career. 71% of knee injections were cortisone/corticosteroid based. Multivariate logistic regression, adjusting for age, body mass index (BMI) and significant knee injury identified that footballers with injections weretwo times more likely to have KP (OR 1.81, 95% CI 1.40–2.34) and TKR (OR 2.21, 95% CI 1.43–3.42) than those without injections. However, there was no association with RKOA (OR 1.30, 95% CI 0.85–2.01). Given, the association with KP and TKR, we found a significant dose–response relationship as the more injections a player received (by dose–response groups), the greater the risk of KP and TKR outcomes after adjustment for knee injury and other confounders (p for trend < 0.01). Conclusion: On average, 8 KIA injections were given to the ex-footballers during their professional career. The most commonly administered injections were cortisone based. These injections associated with KP and TKR after they retired. The associations are independent of knee injuries and are dose dependent. The study suggests that there may have been excessive use of KIA injections to expedite return to play and this contributed to detrimental long-term outcomes such as KP and TKR post-retirement from professional football.

Citation

Fernandes, G. S., Parekh, S. M., Moses, J. P., Fuller, C. W., Scammell, B. E., Batt, M. E., …Doherty, M. (2020). Intra-articular Injection Administration in UK Ex-professional Footballers During Their Playing Careers and the Association with Post-career Knee Osteoarthritis. Sports Medicine, 50, 1039–1046. https://doi.org/10.1007/s40279-019-01255-x

• Journal Article Type: Article
• Acceptance Date: Dec 23, 2019
• Online Publication Date: Jan 10, 2020
• Publication Date: 2020-05
• Deposit Date: Jan 9, 2020
• Publicly Available Date: Jan 9, 2020
• Journal: Sports Medicine
• Print ISSN: 0112-1642
• Electronic ISSN: 1179-2035
• Publisher: Springer Verlag
• Peer Reviewed: Peer Reviewed
• Volume: 50
• Pages: 1039–1046
• DOI: https://doi.org/10.1007/s40279-019-01255-x
• Keywords: Physical Therapy, Sports Therapy and Rehabilitation; Orthopedics and Sports Medicine
• Public URL: https://nottingham-repository.worktribe.com/output/3695551
• Publisher URL: https://link.springer.com/article/10.1007/s40279-019-01255-x
• Additional Information: First Online: 10 January 2020; : ; : All authors have completed the ICMJE uniform disclosure form at ExternalRef removed and declare: financial support (research grant) for the submitted work from FIFA Medical Assessment and Research Centre, other from Arthritis Research UK Centre for Sports, Exercise and Osteoarthritis (Grant Reference 20194); research grant from the Professional Footballers’ Association and financial support from the SPIRE Healthcare Group at the Football Association (St George’s Park); Colin Fuller did paid consultancy for FIFA Medical Assessment and Research Centre, the Football Association and the Premier League in the past 3years and has received personal fees from these bodies outside the remit of the submitted work; Michael Doherty received research funding by AstraZeneca, Nordic Biosciences, Roche, outside the submitted work; Weiya Zhang reports grants from Arthritis Research UK, grants from Arthritis Research UK, during the conduct of the study; other from AstraZenica, other from Daiichi Sankyo, other from Biobarica, other from Hisun, outside the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous 3years for any other authors; no other relationships or activities that could appear to have influenced the submitted work. Gwen Fernandes, Sanjay Parekh, Jonathan Moses, Brigitte Scammel and Mark Batt declare that they have no conflicts of interest.; : The study was approved by Nottingham University Hospitals NHS Trust and the Nottingham Research Ethics Committee 1 (Refs 14/EM/0045) and registered (clinicaltrials.gov portal: NCT02098044). All participants offered consent by responding to the postal questionnaire survey and written informed consent prior to radiographic assessment at the SPIRE Hospitals and the Nottingham City Hospital.; : The study was supported by a patient advisory group which provided input to the programme of research. Patients and ex-professional footballers partnered with us for the design of the study, the informational material to support the intervention, and the burden of the questionnairefrom the patient’s perspective. At the end of the study, the patient advisory group commented on the findings and contributed to the dissemination plan and this included input on poster and oral presentations at local, national and international conferences.; : The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licenseto the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to (i) publish, reproduce, distribute, display and store the Contribution, (ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, (iii) create any other derivative work(s) based on the Contribution, (iv) to exploit all subsidiary rights in the Contribution, (v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, (vi) license any third party to do any or all of the above.; : No additional data available.; : Professor Michael Doherty (MD) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported and that no important aspects of the study have been omitted.; : Study approved by Nottingham University Hospitals NHS Trust and the Nottingham Research Ethics Committee (Ref 14/EM/0045). Clinicaltrials.gov portal: NCT02098044.