Annals of Physical and Rehabilitation Medicine 59 (2016) 134–138

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Risk factors and burden of osteoarthritis

Clémence Palazzo *, Christelle Nguyen, Marie-Martine Lefevre-Colau,
François Rannou, Serge Poiraudeau
Service de rééducation et réadaptation de l’appareil locomoteur et des pathologies du rachis, université Paris Descartes, PRES Sorbonne Paris Cité, U1153,
Inserm, hôpital Cochin, AP–HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France

A R T I C L E I N F O A B S T R A C T

Article history: Osteoarthritis (OA) is one of the most common joint disorders worldwide. Its prevalence is increasing
Received 3 November 2015 because of the growing aging of the population in developed and developing countries as well as an
Accepted 5 January 2016 increase in risk factors leading to OA, particularly obesity and a sedentary lifestyle. Risk factors of OA can
be divided into person-level factors (age, gender, obesity, genetics and diet) and joint-level factors
Keywords: (injury, malalignment and abnormal loading of the joints) that interact in a complex manner. OA is the
Epidemiology 11th cause of disability in the world. It is responsible for activity limitations, particularly walking, and
Osteoarthritis
affects participation and quality of life. Patients with OA are at greater risk of all-cause mortality,
Risk factors
Mortality
particularly for cardiovascular diseases, than the general population. This excess mortality is closely
Disability associated with disability level. Consequently, strategies to reduce burden through primary and
Prevalence secondary prevention programs are increasingly important.
Burden ß 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction Consequently, when interpreting results of epidemiological

Osteoarthritis (OA) is one of the most common joint disorders
worldwide [1,2]; it typically affects knees, hips, hands, spine, and
feet [3]. The prevalence and incidence rates reported in epidemio-
logical studies vary widely, because the estimates depend on the
definition of cases (pathological, radiographic or clinical OA), the
population sampled (primary versus tertiary care, developed versus
developing countries), and the joint(s) involved [4].
Radiographic OA is mainly assessed by the Kellgren and Lawrence
score, which grades the severity of the disease from 0 to 4 by the
appearance of osteophytes, joint space loss, sclerosis and cysts. These
criteria were adopted by the World Health Organisation (WHO) to
define radiographic OA in epidemiologic studies [5].
Clinical OA is defined by the history and the examination.
Several standards have been proposed for the diagnosis of clinical
OA; the most recognized may be the criteria of the American
College of Rheumatology [6].
There is a strong dissociation between radiographic findings and
clinical symptoms: for example, only 40% of patients with moderate
radiographic knee OA and 60% of those with severe knee OA have
symptoms [7]. The diagnosis of symptomatic radiographic OA has
been developed to take into consideration both structural change
and joint symptoms.
studies, the setting of the study, the definition of cases and the
method of data collection must be kept in mind. Here we
summarize the risk factors and burden of OA.
2. Prevalence and incidence of OA
In the literature, the prevalence of OA ranges from 12.3% [8]
(self-reported in the ‘‘Disability-Health’’ 2008 population-based
survey in France) to 21.6% [9] (physician-diagnosed OA in the
United States estimated by the 2003–2005 US National Health
Interview Survey). The disease is more common in women than
men [2,8]. It increases with age, occurring after the age 40 to
50 years [2,8,10,11] (Fig. 1 Fig. 1), and is greater in developed than
developing countries [2,12], although in certain countries such as
Iran, the prevalence was high in rural areas (knee OA: 19.3%
according to the COPCORD study) [12].
The incidence of OA is high as well. A recent Spanish study
investigating > 3 million subjects reported incidence rates of
clinically defined OA of 6.5, 2.1, and 2.4/1000 person-years for
knee, hip, and hand, respectively [11], which is higher than the
rates found in older studies [13].
2.1. Hip and knee OA

* Corresponding author. According to the 2010 WHO Global Burden of Disease Study, the
E-mail address: clemence.palazzo@aphp.fr (C. Palazzo). global prevalence of radiographically confirmed symptomatic knee

http://dx.doi.org/10.1016/j.rehab.2016.01.006
1877-0657/ß 2016 Elsevier Masson SAS. All rights reserved.
 C. Palazzo et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 134–138
Fig. 1. Prevalence of rheumatic and musculoskeletal diseases in France by age [8].
OA in 2010 was estimated at 3.8% (95% uncertainty interval [95%
UI] 3.6–4.1%) [2]. Hip OA is less common. The global age-
standardized prevalence of symptomatic radiographically con-
firmed hip OA in 2010 was 0.85% (95% UI 0.74% to 1.02%). There
was no evidence of a change in age-standardized prevalence
between 1990 and 2010, for hip or knee OA [2]. This finding is
surprising and contrasts with other international and national
reports that concluded an increasing incidence of knee or hip OA
[8,10]. In fact, the growing age of the population in developed and
developing countries as well as increased risk factors for OA,
particularly obesity and a sedentary lifestyle, suggested that the
number of people living with hip or knee OA will increase
substantially over the coming decades [14]. The results of the
2010 WHO study could be explained by the modeling process
itself or by an insufficient period of data collection (20 years could
be insufficient to detect a difference) [2].
2.2. Hand OA
The prevalence of radiographic hand OA ranges from 27% to 80%
[15]. Two large national surveys were conducted (the Zoertermeer
Survey in The Netherlands and the Framingham survey in the
United States). In the Zoertermeer Survey, 10% to 20% of
patients < 40 years old showed a radiographic change in hands
or feet and 75% of women 60 to 70 years old had radiographic hand
OA in the distal interphalangeal joints [16]. Data from the
Framingham cohort demonstrated a prevalence of 13.2% in men
and 26.2% in women  70 years old with at least one hand joint
with symptomatic OA [17].
Symptomatic hand OA is far less common. Its prevalence was
found to be 8% in the US National Health and Nutrition
Examination Survey (NHANES III) and 7% in the Framingham
cohort [15,17].
3. Risk factors of OA
The risk factors of OA can be divided into person-level factors,
including age, gender, obesity and genetics and diet, and joint-level
135
factors, including injury and abnormal loading of the joints
[18]. Knee malalignment is the strongest predictor of progression
of knee OA.
3.1. Person-level risk factors
3.1.1. Age
Age may be the main risk factor of OA [19]. The suspected
mechanism leading to joint damage is poorly understood but is
probably multifactorial (including oxidative damage, thinning of
cartilage, muscle weakening, and a reduction in proprioception) [5].
Sarcopenia itself may be an independent risk factor of knee OA
[5] but could also participate in its progression [18]. In fact,
quadriceps weakness has been observed in patients with
symptomatic knee OA; it could be due to atrophy with disuse,
but data suggest an arthrogenous inhibition of muscle contraction.
This weakness also results in a lack of stability and should be
specifically managed during rehabilitation programs.
3.1.2. Gender
The prevalence of hip, knee and hand OA is higher in women
than men, and the incidence increases around menopause
[20]. Several authors have suspected a role of hormonal factors
in the development of OA. However, results are conflicting [21],
and the difference between men and women could be explained by
other factors (reduced volume of cartilage, bone loss or lack of
muscle strength) [18].
3.1.3. Obesity
Obesity, defined as body mass index (BMI) > 30 kg/m2, is strongly
associated with knee OA (pooled odds ratio [OR] in a recent meta-
analysis including 22 studies: 2.66 [95% CI 2.15–3.28]), whereas the
relationship between overweight (BMI > 25 kg/m2) and knee OA is
lower but still significant (pooled OR 1.98 [95% CI 1.57–2.20])
[22]. Several authors showed a dose–response relationship between
obesity and risk of knee OA: for every 5-unit increase in BMI, the
associated increased risk of knee OA was 35%, with the magnitude of
the association significantly stronger for women than men [23].
136 C. Palazzo et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 134–138
Silverwood et al. estimated that in patients with new-onset
knee pain, 24.6% of cases were related to overweight or obesity
[22]. Several studies showed that weight loss improved pain and
function and decreased low-grade inflammation [24]. The Framin-
gham Study estimated that weight reduction by 5 kg decreased the
risk of developing knee OA by 50% [25].
Obesity is also associated with hand OA (OR 2.59 [95% CI 1.08–
6.19]) [26], so the impact of obesity may not be just biomechanical
but also has some metabolic and inflammatory systemic effects.
This hypothesis is reinforced by recent literature showing an
association between OA and metabolic syndrome [27].
The relationship between body weight and hip OA is inconsis-
tent and weaker than with knee or hand OA [26].
3.1.4. Genetics
Genetic factors account for 60% of hand and hip OA and 40% of
knee OA. Many genes could play a role in the disease onset and so
could provide targets for future pharmacological treatments (e.g.,
genes encoded for vitamin D receptor, insulin-like growth factor 1,
type 2 collagen, growth differentiation factor 5) [28–30].
3.1.5. Diet
Several dietary factors suspected to increase the development
of OA include a low level of vitamins D, C and K [31,32]. However,
further studies are needed to better define the association between
OA and these dietary factors.
3.2. Joint-level risk factors
Injury: the knee is one of the most frequently injured joints. The
rupture of the anterior cruciate ligament (ACL) leads to early-onset
knee OA in 13% of cases after 10 to 15 years. When such rupture is
associated with damaged cartilage, subchondral bone, collateral
ligaments and/or menisci (observed in approximately 65–75% of
ACL-injured knees), the prevalence of knee OA is higher, between
21% and 40% [33,34].
ACL surgical reconstruction improves joint stability, but it may
not prevent knee OA in the long term, nor protect the knee from re-
injury or restore normal knee kinematics as compared with
conservative treatment [35,36]. Patients who undergo ACL recon-
struction have poorer outcomes if the injury is associated with a
meniscal tear, even if they undergo a meniscal repair or a meniscal
resection at the same time [37]. Meniscal repair is the treatment of
choice for young athletes with an acute meniscal tear [38], but its
efficacy for OA onset is unknown. Total meniscectomy has been
found detrimental to the knee joint in that radiographic OA was
estimated to be 14 times more common in people 20 years after
undergoing total menisectomy as compared with controls [39]. Ar-
throscopic partial meniscectomy was not efficacious as compared
with sham surgery for people with degenerative meniscal tears
without OA [40,41] and could participate in the development of OA.
3.3. Abnormal loading of joints
Data suggested that repetitive joint use was associated with the
development of OA. Knee OA was more frequently observed in
people with occupations that required squatting and kneeling,
whereas hip OA was associated with prolonged lifting and standing
[42], and hand OA was more frequent in people with occupations
requiring increased manual dexterity [18].
The relationship between physical activity and OA is complex
and is developed in another part of this special issue. Briefly, highly
repetitive, intense and high-impact physical activity seems to
confer increased risk of developing radiographic hip and knee OA
as compared with controls, but whether this association is due to
only sports participation or results from injury is unclear [18].
4. Malalignment
Abnormal alignment is strongly associated with increased
structural degradation in the compartment under the greatest
compressive stress [43]. Cerejo et al. showed that medial
progression of knee OA was four-fold greater in patients with
varus alignment and lateral progression five-fold greater in those
with valgus alignment [44]. The association between malalign-
ment and OA onset is less apparent [18].
5. The burden of OA
5.1. Disability
The morbidity burden of OA is well documented. In the
2010 WHO Global Burden of Disease Study, OA was the 11th cause
of years lived with disability in the world but only 15th in 1990
[1]. The burden was 6th in East Asia and high-income East Pacific
countries, 10th in North America, 7th in Eastern Europe but 13th in
Western Europe.
OA is responsible for activity limitations, particularly walking.
According to the French ‘‘Disability-Health survey’’, people
reporting OA were almost twice as limited as those without OA
in walking (adjusted OR 1.9 [95% CI 1.7–2.2]) and carrying objects
(adjusted OR 1.7 [1.5–2.0]) [8]. OA was the main contributor to
limitations in activities, with 22% difficulties in walking, 18.6%
difficulties in carrying objects, and 12.8% difficulties in dressing
attributable to OA in France. OA was also a contributor to the need
for human assistance (9.2% of the need for help from immediate
family, 11.8% help from health professionals, and 8.9% health
service delivery attributable to OA) [8] (Fig. 2 Fig. 2). These findings
should promote the use of assistive devices such as walking aids
and the adaptation of the environment for people with OA and
show that more emphasis should be placed on accessibility in
public places and transportation in France. However, these data
may be not transposable to other settings because disability
associated with OA depends on the cultural and socioeconomic
context [45,46]; more national studies are needed to better assess
the needs of local populations [2].
5.2. Mortality
Patients with OA are at greater risk of mortality than the general
population. Nüesch et al. assessed all-cause and disease-specific
mortality in patients with symptomatic and radiographically
confirmed knee or hip OA in a large population-based sample of
men and women [47]. They found an excess of all-cause mortality
(standardized mortality ratio 1.55 [95% CI 1.41–1.70]); cause-
specific mortality was particularly high for cardiovascular disease
(1.71 [1.49–1.98]) and dementia (1.99 [1.22–3.25]). However, the
excess mortality was not associated with non-steroid anti-
inflammatory drugs consumption or obesity. The more severe
the walking disability, the greater the risk of death (P
trend < 0.001). The authors suggested that this increased risk
may result from low-grade systemic inflammation or a lack of
physical activity.
Those results were confirmed by Hawker et al. [48]; in a
population cohort with at least moderately severe symptomatic
hip and/or knee OA, all-cause mortality was associated with
baseline functional limitations, particularly walking disability
(adjusted hazard ratio [aHR] per 10-point increase in WOMAC
function score: 1.04 [95% CI 1.01–1.07]; aHR per unit increase in
Health Assessment Questionnaire [HAQ] walking score:
1.30 [1.22–1.39]; aHR for using versus not using a walking aid:
1.51 [1.34-1.70]). The risk of cardiovascular events was associated
with only greater baseline walking disability.
 C. Palazzo et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 134–138
Fig. 2. Average attributable fraction (AAF) estimates (%) for disability categories of the core set of rheumatic and musculoskeletal diseases of the WHO-International
Classification of Functioning, Disability and Health from the 2008–2009 Disability-Health Survey in France. AAF represents the proportion of disability that could be avoided
by eliminating the disease in the population [8].
Barbour et al. [49] had similar findings on analyzing the
association between hip radiographic OA and mortality from the
Study of Osteoporotic Fractures, a US population-based cohort
study of 9704 white women aged  65 years (aHR for all-cause
mortality: 1.14 [95% CI 1.05–1.24]; aHR for cardiovascular disease
(CVD) mortality: 1.24 [1.09–1.41]). As a result, 42.9% and 25.0% of
the increased risk of all-cause and CVD mortality among women
with hip OA could be explained by poor physical function.
Recently, Hoeven et al. suggested that the increased risk of CVD in
the OA population was not explained by the disease but was only
associated with increased disability rate in this population [50].
However, the analysis of two OA cohorts in The Netherlands did
not show any increased risk of death for patients consulting health
care for their OA [51]. Such a difference with previous findings
could be explained by the patients included in these cohorts having
hip or knee OA but also spine or hand OA. According to the authors,
hand OA was not associated with increased risk of mortality [52];
to our knowledge, this association was not specifically studied for
spine OA. Moreover, people included in the Dutch cohorts actively
sought healthcare professionals and their OA may have been
managed at the same time as their co-morbidities, particularly
CVD risk factors.
Regarding these data, there is moderate evidence to conclude that
knee and hip OA reduces life expectancy. Even if the causal pathway
remains unclear, walking disability seems to be the main risk factor.
The OA was associated with an increased risk of premature death
from CVD, which suggests that healthcare professionals should pay
more attention to modifiable cardiovascular risk factors in this
population (including hypertension, diabetes, hyperlipidemia,
smoking, and physical inactivity) [53], as it is already done for
(other) inflammatory arthritis diseases [54]. Healthcare professio-
nals should also have a more aggressive approach to reduce walking
disability, by suggesting walking devices, a rehabilitation program,
and joint replacement to their patients. Ravi et al. showed a
cardioprotective benefit of primary elective total joint arthroplasty in
a propensity-matched landmark analysis of a population cohort with
advanced hip or knee OA [55] (HR 0.56 [95% CI 0.43–0.74]). Within
7 years after exposure, the absolute risk reduction was 12.4% (1.7–
23.1%) and number needed to treat was 8 (4–57 patients).
5.3. Economic burden
OA remains a major public burden, with direct costs in 2002 in
France exceeding 1.6 billion Euros, about 1.7% of the expenses of the
137
French health system. Patients made more than 13 million visits to
physicians for OA. Medication costs were 570 million Euros and
inpatient treatment 820 million Euros [56].
Among treatments for OA, joint replacement is by far the most
expensive. In 1997, the annual cost of knee and hip replacement in
the United States was estimated at $7.9 billion. In 2004, less than
10 years later, the annual total cost of joint replacement had risen
to $22.6 billion [57]. Since the rate of total hip and knee
replacement is still increasing [58], the situation may be
worsening.
Indirect costs are incurred mostly for time lost from employ-
ment and for unpaid informal caregivers, with caregiver time
accounting for 40% of indirect costs. The indirect cost of
absenteeism was estimated at approximately $10.3 billion in
the United States [59].
However, we should also consider that improvements in pain and
physical function from joint arthroplasty could yield benefits in the
form of increased work life and lower disability payments. Ruiz et al.
showed that the estimated lifetime societal savings from the more
than 600,000 total knee arthroplasties performed in the United
States in 2009 were estimated at approximately $12 billion [60].
6. Conclusion
With the aging of the population throughout the world, the
health professions must prepare for the large increase in the
number of people with OA requiring health services. Strategies to
reduce the burden of hip and knee OA through primary and
secondary prevention have become increasingly important.
Disclosure of interest
The authors declare that they have no competing interest.
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