Military Service Leads to Post-Traumatic Osteoarthritis

By Jill Tyrer

Chester Jones never liked being Grumpy Grandpa. He didn’t get the name from a cantankerous disposition. He got it as a result of unrelenting pain he had dealt with since his 20s and the depression it brought on.

Chester Jones III, sergeant first class E7, retired from the Army in 2013 after 24 years, three months and three days of service — and with knee and back arthritis, degenerative disc disease, sciatica, peripheral neuropathy and other conditions that gave him chronic pain.

He hadn’t had any back problems before he joined the Army at age 18, but by age 25, he had osteoarthritis (OA) pain in his back and knee. “You’re going to hear that from a lot of military veterans,” he says. “It’s almost a given that if you do any amount of time, it’s going to happen, unfortunately.”

The evidence bears him out. In a study looking at doctor-diagnosed OA in active-duty service members, Kenneth Cameron PhD, MPH, ATC, a leading clinical researcher with several published studies on OA in the military, found that it is far more common than in the general population.

“We looked specifically at the knee joint for prevalence of osteoarthritis, and it was five times higher in the military than published estimates in the general population,” says Dr. Cameron, director of Orthopaedic Research at Keller Army Hospital at West Point.

That’s largely due to a particular type of OA called post-traumatic osteoarthritis (PTOA), which occurs as a result of an injury to the joint.

“We know that people who sustain a joint injury, like an ACL tear, are five to seven times more likely to develop PTOA,” Dr. Cameron says. “People usually have substantial degenerative changes within 10 years after joint injury, and in combat trauma injuries, we’ve seen that average is less than two years.”



The Price of PTOA

Primary OA typically affects older people and develops slowly over time. But post-traumatic OA is different. It results from an injury, develops much more quickly than “primary OA,” and can start in people at a younger age and when they are most active, often due to sports-related injuries or those sustained during military service.

Because people are often in their 20s and early 30s when PTOA begins, it can have a lasting impact on their ability to work and overall quality of life.

“Once that injury happens, we don’t really do anything to intervene to alter that trajectory, and that’s partly because we don’t have any good interventions,” Dr. Cameron adds. “This is a critical problem not just for our military service members but for our young athletes across the nation who are tearing their ACLs and tearing their meniscus and dislocating their shoulders playing sports.”

Like Jones, men and women join the military at a young age, and military life significantly raises the risk of joint injury. In fact, non-battle related joint injuries were “by far the leading cause of medical evacuation from recent operations in Iraq and Afghanistan,” Dr. Cameron says. “But the vast majority of joint injuries in military populations occur during physical training, during military training and during recreational activities.”

The personal price (and economic burden) is significant. Not only do people with PTOA generally live longer with OA pain and functional limitations, but they also are more likely to have joint replacement surgery at a younger age than the general population — and probably revision surgery after the implant wears out. “We know it’s bad to have one knee replacement, but it’s even worse to have a second knee replacement or hip replacement,” Dr. Cameron says.

They’re also at increased risk of developing comorbidities, such as obesity, diabetes and heart disease, at an earlier age, which also can undermine their quality of life and health.

In addition, PTOA can cost them their job, forcing them to give up their career path and start over in a job that is less physically demanding, if they can. In a study to identify conditions that led to medical discharge, Jessica Rivera, MD, PhD, found that PTOA accounted for nearly 95% of medical discharges among Iraq and Afghanistan veterans injured in combat. Even for those who experience “high-energy impact” type injuries — from explosives or gunshot, for example — it’s often injury to their extremities that leads to medical discharge.

“What we found was once they survived their head trauma and their chest trauma and their abdominal trauma, they still had extremities with sometimes irrevocable injuries,” Dr. Rivera explains. “The knees and the ankles are very prone to injury, just because there's no armor to protect them.”

Dr. Rivera, an orthopedic surgeon who spent 11 years in the Army, serving primarily at the San Antonio Military Medical Center, is now at South Louisiana Veterans Healthcare System, where OA and post-traumatic OA are still dominant factors among her patients.

In another study, Dr. Rivera looked at the reasons for medical discharge in 2001 and in 2009 among service members serving in Iraq and Afghanistan. The leading causes: OA and back pain.

“The shocking take-home message was that after a decade of combat operations in these theaters, osteoarthritis and back pain were still the primary drivers of disability discharge in the military,” Dr. Cameron says.

Chester Jones wasn’t discharged, but he did lose a job he loved. For years, he sucked up the pain and soldiered on, in line with the pervasive macho culture. But when he could no longer stand the pain, he gave in and sought medical care.

“They ended up changing my medical classification, so I wasn’t in a [position] that was so physical. I went from infantry to logistics,” Jones says. “I was devastated. I spent 18 years of my life as an infantryman. I worked my way up from the lowest rank that we have, which is an E1, up to become a senior noncommissioned officer. I’ve taken men to war and brought them back, and then they wanted to put me behind a desk?”

Eventually, the pain, loss of function and other impacts took their toll. “With all these things piled on me, it was depression, just to be totally honest. And I wasn’t a nice person to be around either. I was kind of cranky, thus the name Grumpy Grandpa.”

Research Challenges

It is clear now that osteoarthritis is not simply a result of joint “wear and tear,” an inevitable part of aging. It’s a disease of the joint that involves inflammation, but scientists don’t know understand much about how it develops, which means they also don’t understand enough about how PTOA develops. What biochemical and molecular changes lead to the structural and mechanical changes in OA? And what level of trauma is enough to trigger the process that results in PTOA?

That depends on whom you ask, says Dr. Rivera. As a scientist, doctor and veteran who cares for veterans, she has seen plenty of battlefield-type injuries, so she has good reason to believe that a joint fracture will lead to OA. However, a sports medicine specialist will argue that other joint injuries, like an ACL tear, also triggers PTOA. And someone in rehabilitation might say that “repeated micro stress on the joints from heavy load training” in the military or sports puts you at higher risk than others of developing OA, she explains.

Why does it matter? Because researchers need to identify study targets to find better treatments for OA.

“We don’t really understand the early mechanical and biological processes that go on after that joint injury that contribute to the initiation or progression of PTOA,” Dr. Cameron says, “and that really is a critical need from the research side.”

That, and federal funding. “I think there needs to be dedicated funding, particularly through research programs managed by the Department of Defense, to really address this. And I think it would have far-reaching benefits to the general population, especially the young people who would benefit from this as well,” Dr. Cameron says.

Prevention and Intervention

In the military, there’s no avoiding the rigorous physical exertion, heavy loads and pounding on weight-bearing joints.  

“The typical combat load is significant, ranging from 52 pounds to well over 100 pounds,” Dr. Cameron says. “So we take young and fit individuals and we put a load like this on them, we can obviously see how that affects mechanics as well as ergonomics.”

And even after a service member’s joint injury is successfully treated and rehabilitated, “What do we do? We ask them to continue the very high demand job with a military load on their body,” Dr. Rivera says.

Since there aren’t yet any effective, long-term treatments for OA, experts like Drs. Cameron and Rivera are looking for other options, such as preventing OA from developing in the first place or intervening after a joint injury to slow its development.

“When someone has high cholesterol or high blood pressure, we see those signs as, ‘OK, this person may be at risk of developing a chronic condition, like heart disease or having a heart attack down the road,’” Dr. Cameron says.

There’s no changing the physical requirements of military service, Dr. Rivera says, but “how could we [have] a preventative, even, to keep folks’ joints protected while they do their highly demanding jobs? I think that would be fantastic.”

Even just urging service people to reduce their high-impact recreational activities, like basketball in their free time, or running once or twice a week instead of five times a week, might help, Dr. Cameron adds.

Living With OA

Jones tried just about everything to ease his pain, including corticosteroid joint injections, having fluid drained from his knee, chiropractic treatments and pain medications. In 2017, he was implanted with a spinal cord stimulator — a device that uses electrical pulses to stimulate nerves in the spine to block pain signals. His pain isn’t completely gone — he still has bad days occasionally, and “the cold is my worst enemy,” he says. That means he can’t spend as much time playing with his grandkids on the waterslide or driving his Dune Buggy in the snow or sitting for a long time to watch a movie with his family.

But it has helped a lot and changed his life for the better. He’s such a believer in the device that he has become a patient representative for the company that does the implants.

But it also took support and a change in mindset to cope. Initially, he was resistant to support groups and seeking emotional help — or even medical help when he first started having OA symptoms.

“But as I progressed in the ranks and as I got older, I crossed the line from thinking about Army, Army, Army, to thinking ‘OK, I’ve got to do what I need to do to take care of myself,’” Jones says. As a soldier, “we signed up knowing that we may not come home the next day. However, you still have to take care of yourself. You still have to make yourself priority No. 1.”

His advice? “For one, you have to take care of yourself. If you don’t take care of yourself, then all you’re going to do is go downhill quicker, and what good are you going to be to the military?” he says. “Put your pride to the side. Pride will get you hurt; it’s not going to help you. And don’t be embarrassed about going and seeking help, whether it be for physical pain or mental pain, because pain can cause depression, and depression can lead to suicide. You’re stronger when you ask for help.”

 

Watch the recording of “Impact of OA in the Military,” featuring Ken Cameron and Jessica Rivera.