Every second retired elite female football player has MRI evidence of knee osteoarthritis before age 50 years: a cross-sectional study of clinical and MRI outcomes

  • Annika PrienEmail author
  • Sana Boudabous
  • Astrid Junge
  • Evert Verhagen
  • Bénédicte M. A. Delattre
  • Philippe M. Tscholl



To assess knee health in retired female football players, using magnetic resonance imaging (MRI) and self-report. The focus of analysis were degenerative changes of the tibiofemoral joint, and their relationship to osteoarthritis symptoms and previous knee injury.


Forty-nine retired elite, female football players (98 knees) aged 37 years on average participated. Tibiofemoral cartilage and meniscus status of both knees were evaluated using MRI and graded according to modified Outerbridge and Stoller classifications, respectively. Symptoms were assessed through a standardised questionnaire (Knee Osteoarthritis Outcome Score: KOOS). Knee injury history was recorded via a semi-structured interview. To investigate how injury variables relate to outcomes, binary logistic regression models were used and reported with odds ratios (OR).


Fifty-one per cent of players (n = 25) fulfilled the MRI criterion for knee osteoarthritis, 69.4% (n = 34) had substantial meniscal loss and 59.6% (n = 28) reported substantial clinical symptoms. Chondral- and meniscal loss were associated with significantly lower scores on three of five KOOS subscales (p < .05). Both chondral and meniscal loss were significantly predicted by previous traumatic knee injury (OR = 4.6, OR = 2.6), the injury affecting the non-striking leg (OR = 8.6, OR = 10.6) and type of injury; participants with combined ACL/meniscus injuries had the highest risk for substantial chondral and meniscal loss (OR = 14.8, OR = 9.5). Chondral loss was significantly predicted by isolated meniscus injury treated with partial meniscectomy (OR = 5.4), but not by isolated reconstructed ACL injury. Clinical symptoms were only significantly predicted by previous traumatic knee injury (OR = 5.1).


Serious degenerative changes were found in a high number of retired female football players’ knees 10 years after their career. Meniscal integrity is key for knee osteoarthritis outcomes in young adults, and thus, its preservation should be a priority.


Football (soccer) Osteoarthritis Knee injury Long-term outcomes Meniscus Female athlete 



The authors highly appreciate the cooperation of all participating players who volunteered their time to provide the data for this project. They especially thank Birgit Prinz without whom this study would not have been possible. The authors gratefully acknowledge the Fédération Internationale de Football Association (FIFA) for funding this project.

Compliance with ethical standards

Conflict of interest

Annika Prien, Sana Boudabou, Astrid Junge, Evert Verhagen, Bénédicte M. A. Delattre and Philippe M. Tscholl declare that they have no conflict of interest.


The study was funded by the Fédération Internationale de Football Association (FIFA).

Ethical approval

The study has ethic approval 2016-449-f-S of the ethics commission Münster, Germany.


  1. 1.
    Ackerman IN, Kemp JL, Crossley KM, Culvenor AG, Hinman RS (2017) Hip and knee osteoarthritis affects younger people, too. J Orthop Sports Phys Ther 47:67–79CrossRefGoogle Scholar
  2. 2.
    Ahn JH, Kim JG, Wang JH, Jung CH, Lim HC (2012) Long-term results of anterior cruciate ligament reconstruction using bone-patellar tendon-bone: an analysis of the factors affecting the development of osteoarthritis. Arthroscopy 28:1114–1123CrossRefGoogle Scholar
  3. 3.
    Arliani GG, Astur DC, Yamada RKF, Yamada AF, Miyashita GK, Mandelbaum B et al (2014) Early osteoarthritis and reduced quality of life after retirement in former professional soccer players. Clinics 69:589–594CrossRefGoogle Scholar
  4. 4.
    Beaufils P, Becker R, Kopf S, Matthieu O, Pujol N (2017) The knee meniscus: management of traumatic tears and degenerative lesions. EFORT Open Rev 2:195–203CrossRefGoogle Scholar
  5. 5.
    Brandt KD, Radin EL, Dieppe PA, van de Putte L (2006) Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis 65:1261–1264CrossRefGoogle Scholar
  6. 6.
    Chatain F, Adeleine P, Chambat P, Neyret P (2003) A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up. Arthroscopy 19:842–849CrossRefGoogle Scholar
  7. 7.
    Claes S, Hermie L, Verdonk R, Bellemans J, Verdonk P (2013) Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc 21:1967–1976CrossRefGoogle Scholar
  8. 8.
    Cohen M, Amaro JT, Ejnisman B, Carvalho RT, Nakano KK, Peccin MS et al (2007) Anterior cruciate ligament reconstruction after 10–15 years: association between meniscectomy and osteoarthrosis. Arthroscopy 23:629–634CrossRefGoogle Scholar
  9. 9.
    Collins NJ, Prinsen CAC, Christensen R, Bartels EM, Terwee CB, Roos EM (2016) Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties. Osteoarthr Cartil 24:1317–1329CrossRefGoogle Scholar
  10. 10.
    Crema MD, Roemer FW, Marra MD, Burstein D, Gold GE, Eckstein F et al (2011) Articular cartilage in the knee: current MR imaging techniques and applications in clinical practice and research. Radiographics 31:37–61CrossRefGoogle Scholar
  11. 11.
    Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M et al (2014) The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 73:1323–1330CrossRefGoogle Scholar
  12. 12.
    Dieppe PA (2011) Developments in osteoarthritis. Rheumatology 50:245–247CrossRefGoogle Scholar
  13. 13.
    Dieppe PA, Lohmander LS (2005) Pathogenesis and management of pain in osteoarthritis. Lancet 365:965–973CrossRefGoogle Scholar
  14. 14.
    Driban JB, Hootman JM, Sitler MR, Harris KP, Cattano NM (2017) Is participation in certain sports associated with knee osteoarthritis? a systematic review. J Athl Train 52:497–506CrossRefGoogle Scholar
  15. 15.
    Englund M (2004) Meniscal tear—a feature of osteoarthritis. Acta Orthop Scand 75:1–45Google Scholar
  16. 16.
    Englund M, Roos EM, Lohmander LS (2003) Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a 16-year followup of meniscectomy with matched controls. Arthritis Rheum 48:2178–2187CrossRefGoogle Scholar
  17. 17.
    Fernandes GS, Parekh SM, Moses J, Fuller C, Scammell B, Batt ME et al (2018) Prevalence of knee pain, radiographic osteoarthritis and arthroplasty in retired professional footballers compared with men in the general population: a cross-sectional study. Br J Sports Med 52:678–683CrossRefGoogle Scholar
  18. 18.
    Gouttebarge V, Inklaar H, Backx F, Kerkhoffs G (2015) Prevalence of osteoarthritis in former elite athletes: a systematic overview of the recent literature. Rheumatol Int 35:405–418CrossRefGoogle Scholar
  19. 19.
    Iosifidis MI, Tsarouhas A, Fylaktou A (2015) Lower limb clinical and radiographic osteoarthritis in former elite male athletes. Knee Surg Sports Traumatol Arthrosc 23:2528–2535CrossRefGoogle Scholar
  20. 20.
    Kessler S, Lang S, Puhl W, Stöve J (2003) Der knee injury and osteoarthritis outcome score—ein funktionsfragebogen zur outcome-messung in der knieendoprothetik. Z Orthop 141:277–282CrossRefGoogle Scholar
  21. 21.
    Krajnc Z, Vogrin M, Recnik G, Crnjac A, Drobnic M, Antolic V (2010) Increased risk of knee injuries and osteoarthritis in the non-dominant leg of former professional football players. Wien Klin Wochenschr 122(Suppl 2):40–43CrossRefGoogle Scholar
  22. 22.
    Kuijt MT, Inklaar H, Gouttebarge V, Frings-Dresen MH (2012) Knee and ankle osteoarthritis in former elite soccer players: a systematic review of the recent literature. J Sci Med Sport 15:480–487CrossRefGoogle Scholar
  23. 23.
    Larsen E, Jensen PK, Jensen PR (1999) Long-term outcome of knee and ankle injuries in elite football. Scand J Med Sci Sports 9:285–289CrossRefGoogle Scholar
  24. 24.
    Lohkamp M, Kromer TO, Schmitt H (2017) Osteoarthritis and joint replacements of the lower limb and spine in ex-professional soccer players: a systematic review. Scand J Med Sci Sports 27:1038–1049CrossRefGoogle Scholar
  25. 25.
    Lohmander LS, Ostenberg A, Englund M, Roos H (2004) High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players 12 years after anterior cruciate ligament injury. Arthritis Rheum 50:3145–3152CrossRefGoogle Scholar
  26. 26.
    Outerbridge RE (1961) The etiology of chondromalacia patellae. J Bone Joint Surg Br 43B:752–757CrossRefGoogle Scholar
  27. 27.
    Paradowski PT, Bergman S, Sundén-Lundius A, Lohmander LS, Roos EM (2006) Knee complaints vary with age and gender in the adult population. Population-based reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS). BMC Musculoskelet Disord 7:38CrossRefGoogle Scholar
  28. 28.
    Paxinos O, Karavasili A, Delimpasis G, Stathi A (2016) Prevalence of knee osteoarthritis in 100 athletically active veteran soccer players compared with a matched group of 100 military personnel. Am J Sports Med 44:1447–1454CrossRefGoogle Scholar
  29. 29.
    Pereira D, Peleteiro B, Araújo J, Branco J, Santos RA, Ramos E (2011) The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review. Osteoarthr Cartil 19:1270–1285CrossRefGoogle Scholar
  30. 30.
    Petrillo S, Papalia R, Maffulli N, Volpi P, Denaro V (2018) Osteoarthritis of the hip and knee in former male professional soccer players. Br Med Bull 125:121–130CrossRefGoogle Scholar
  31. 31.
    Prien A, Prinz B, Dvořák J, Junge A (2017) Health problems in former elite female football players: prevalence and risk factors. Scand J Med Sci Sports 27:1404–1410CrossRefGoogle Scholar
  32. 32.
    Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K (2007) A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 23:1320–1325CrossRefGoogle Scholar
  33. 33.
    Roos EM (2005) Joint injury causes knee osteoarthritis in young adults. Curr Opin Rheumatol 17:195–200CrossRefGoogle Scholar
  34. 34.
    Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD (1998) Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther 28:88–96CrossRefGoogle Scholar
  35. 35.
    Seil R, Becker R (2016) Time for a paradigm change in meniscal repair: save the meniscus! Knee Surg Sports Traumatol Arthrosc 24:1421–1423CrossRefGoogle Scholar
  36. 36.
    Stein T, Mehling AP, Welsch F, von Eisenhart-Rothe R, Jäger A (2010) Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med 38:1542–1548CrossRefGoogle Scholar
  37. 37.
    Stoller DW, Martin C, Crues J 3rd, Kaplan L, Mink JH (1987) Meniscal tears: pathologic correlation with MR imaging. Radiology 163:731–735CrossRefGoogle Scholar
  38. 38.
    Sutton KM, Bullock JM (2013) Anterior cruciate ligament rupture: differences between males and females. J Am Acad Orthop Surg 21:41–50CrossRefGoogle Scholar
  39. 39.
    Tveit M, Rosengren BE, Nilsson J-Å, Karlsson MK (2012) Former male elite athletes have a higher prevalence of osteoarthritis and arthroplasty in the hip and knee than expected. Am J Sports Med 40:527–533CrossRefGoogle Scholar
  40. 40.
    van Meer BL, Meuffels DE, van Eijsden WA, Verhaar JA, Bierma-Zeinstra SM, Reijman M (2015) Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review. Br J Sports Med 49:975–983CrossRefGoogle Scholar
  41. 41.
    von Porat A (2004) High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes. Ann Rheum Dis 63:269–273CrossRefGoogle Scholar
  42. 42.
    Weber J, Koch M, Angele P, Zellner J (2018) The role of meniscal repair for prevention of early onset of osteoarthritis. J Exp Orthop 5:10CrossRefGoogle Scholar
  43. 43.
    Woolf AD, Pfleger B (2003) Burden of major musculoskeletal conditions. Bull World Health Organ 81:646–656Google Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Prevention, Health Promotion and Sports MedicineMedical School Hamburg (MSH)HamburgGermany
  2. 2.Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement SciencesAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
  3. 3.Division of RadiologyUniversity Hospital of GenevaGenevaSwitzerland
  4. 4.Schulthess ClinicZurichSwitzerland
  5. 5.Division of Exercise Science and Sports Medicine, Department of Human BiologyUniversity of Cape TownCape TownSouth Africa
  6. 6.Department of Orthopaedic Surgery and TraumatologyUniversity Hospital of GenevaGenevaSwitzerland

Personalised recommendations