Dr Oliver O'Sullivan - Osteoarthritis in serving or ex- Military personnel: A new understanding of an ‘old’ condition

Within the military body and mind theme, we need to consider the depth and breadth of risks that military personnel are exposed to. Whilst combat injuries often dominate headlines, the burden of ‘disease, non-battle injuries’ cause far more attrition, especially musculoskeletal. In this blog, I will explore the long-term impact of musculoskeletal injuries and the work we have been doing to predict and prevent the common sequalae of post-traumatic osteoarthritis, a condition requiring far more attention than it has at present.

Musculoskeletal injuries are the leading reason why people cannot fully undertake their military job or have to retire early on medical grounds. These injuries, literally ‘muscles and bones’, aka sports injuries, can happen during training, deployment or when undertaking regular or adventure sports.

Whilst initial treatment is often good, and allows individuals to return to their job in a timely manner, for certain people, there is something still happening below the surface. These ongoing processes, often prolonged inflammation, incomplete healing or an enthusiasm to get back to work before 100%, can result in long-term pain or reduced function. Some of these processes can result in the development of post-traumatic osteoarthritis.

Osteoarthritis is a condition often associated with older people, and it correct to say that it becomes more common as we age. However, it is not the preserve of the elderly and can occur, often without recognition, in those in their 20’s and 30’s. Infact, previous work has demonstrated that osteoarthritis is underdiagnosed in British military individuals (https://bit.ly/3GZpa0o). Post-traumatic osteoarthritis is far more common in a younger population, with active populations such as the military, emergency services and sports players particularly susceptible.

Unlike our traditional thinking, osteoarthritis is not a progressive, degenerative ‘wear and tear’ process, but an initially dynamic, and then pathological, adaptive response to how we use our joints with many key mechanisms underpinning it including aberrant heading, altered biomechanics, ongoing inflammation, and metabolic dysregulation (https://bit.ly/48HwZ4k). This means we are able to modify the initiation and progression of the disease process, and influence how individuals respond to their illness presentations using a combination of different interventions that we know work for all people with osteoarthritis, refined for those in physically active occupations (https://bit.ly/3x4kEJ7).

In my PhD, and subsequent role as a Clinical Assistant Professor, at the University of Nottingham, I have been seeking to understand how we can better predict those at risk of developing post-traumatic osteoarthritis, so we can risk-stratify and phenotype (group) into those different categories who are more likely to respond to certain interventions. My primary work until now has been looking at blood tests (https://bit.ly/3CqQ4eG) however, it is clear that on their own, they are not enough. A combination of different tests, including blood, walking tests, imaging and questionnaires, will be required to accurately predict and stratify and create a Future Osteoarthritis Risk (“FOAR” score). Collaborations with world-leading academic institutions is also enabling the use of cutting-edge analyses, including assessment of an individuals lipid and protein composition to improve and refine these predictive tools.

Whilst this work is ongoing, (and it will be for some time!), we need to introduce appropriate clinical guidance for those with osteoarthritis in the military, especially as they are younger and have physically demanding occupations. This risk extends into their post-Service career as a veteran. Work has begun in this area, with a new military osteoarthritis group established and tasked to develop these, using best-practice recommendations from around the world (https://bit.ly/3BGDzeY). 

There is a lot to do to improve the identification and management of osteoarthritis in military personnel, including diagnostic recommendations, preventative measures and clinical management guidance. However, there is also an urgent need for this work, and now, a community of engaged researchers and clinicians in the UK military with strong collaborations around the world in place to deliver it, especially now we have a new understanding of an ‘old’ condition.