Our expert is Mary I. O’Connor, MD, the Founding Director, Center for Musculoskeletal Care at Yale School of Medicine and Yale New Haven Hospital, and Professor of Orthopedics and Rehabilitation at the Yale School of Medicine.
WOMEN HAVE MORE KNEE OSTEOARTHRITIS THAN MEN
At every age, women develop more knee osteoarthritis than men. This disparity increases with age, particularly after menopause. The loss of cartilage is the hallmark of osteoarthritis that leads to joint space narrowing, pain, and loss of function. Using advanced MRI imaging, researchers have found that over a two-year time interval, adult women tend to lose four times more cartilage in the tibia and three times more in the patella than men. It is this loss of cartilage that may ultimately lead to the need for total joint replacement.
FOR PREVENTION, MAINTAIN A HEALTHY WEIGHT
One of the major risk factors for osteoarthritis is obesity. Added weight puts more pressure on your patient’s knee joint, and it’s not just a one-to-one effect. If she gains ten pounds, she’s not adding ten pounds of extra pressure on her knee joints, she’s adding an extra 30 to 60 pounds of pressure on her knees. Further, obesity causes harmful biochemical changes including increased production of pro-inflammatory cytokines. These play a role in the destruction of cartilage and may increase the likelihood of needing knee replacement surgery.
Obesity is also a factor in why there’s a higher burden of knee osteoarthritis in African-American women and in Latinas. Fifty-seven percent of African American women are obese, while the percentage of Caucasian women with obesity is 38%. Latinas are in-between at 44 percent.
EXERCISE IS ALSO KEY TO PREVENTION
Your patients should avoid being sedentary. Patients experiencing knee arthritis may feel like reducing their mobility to avoid the pain and stiffness that accompanies movement. Unfortunately, lack of use will only increase her joint pain and stiffness. It becomes a vicious cycle: her pain reduces her mobility, which causes more pain, which in turn causes even less movement. Compounding all of this, as your patient becomes less physically active, she is likely to gain weight, and the added weight will increase her joint pain when she moves. But her knees are not the only part of her body impacted by her weight gain: she will increase her risk of developing hypertension, diabetes, and heart disease.
BEWARE OF UNCONSCIOUS BIAS IN TREATING KNEE OSTEOARTHRITIS
Cornelia Borkhoff and her colleagues uncovered a serious bias in how women with moderate knee osteoarthritis are treated. They selected a man and a woman with the same moderate degree of knee arthritis symptoms and the same x-ray findings. These two people were evaluated by many different orthopedic surgeons for their knee complaints. The team discovered that orthopedic surgeons were 22 times more likely to say the man should consider knee replacement surgery, even though the symptoms for the man and the woman were identical. While critics of this study note that there is limitation of drawing conclusions with only one subject of each gender, the findings do raise concerns regarding unconscious bias in treatment recommendations.
Other research shows that women wait longer to have knee replacement surgery than men. Women have the surgery later in the course of their disease when their pain, functional loss and degenerative joint changes are greater than those for men. Both men and women experience significant improvement after the surgery, but women generally don’t do quite as well as men with their final outcomes. Women never “catch up” for reasons which are not understood. Be aware that you may be recommending knee surgery for your female patients at a point where it will do them less good than if you had been recommending such treatment earlier in the course of their disease.
WOMEN ARE A KEY FACTOR IN LIFESTYLE IMPROVEMENTS THAT PREVENT OSTEOARTHRITIS
Women are an under-recognized resource for influencing families to have a healthier diet and more exercise. In populations where the health disparities are greatest, it’s typically the mother who more or less defines how the family eats. This means that when you improve the diet and exercise patterns of one female patient, you are likely to be impacting her family, too.
The program Movement is Life, which I chair, focuses on decreasing musculoskeletal disparities for people of color. We created a 16-week program, “Operation Change” for African-American and Latina women in which we taught how to embrace a healthier lifestyle through the value of movement, culturally appropriate meal preparation, and recognition and management of depression. One of the wonderful benefits of this program was the “flow over” of these healthier choices to the children (and even husbands) of these women, as healthier meals were prepared and movement increased. Furthermore, objective outcomes showed reduced blood pressure and more normalized blood sugar in our “Operation Change” women. Movement is the key to life!