Prevalence and risk factors of foot/ankle osteoarthritis and pain in retired male professional footballers compared to general population male controls: a cross-sectional study
Publication Date
December 10, 2025
Creator
Abstract
Background:
Osteoarthritis (OA) is the most common form of arthritis that affects synovial joints. The prevalence of foot/ankle OA is less understood than hip, knee and hand OA. Foot and ankle injuries account for approximately one-fifth of all injuries sustained during professional football play. Injury is the major risk factor associated with a four-fold increased risk of knee OA in male professional footballers. However, despite the high incidence of injuries to the foot/ankle in professional footballers, there is a lack of evidence relating this to OA development and the associated risk factors at this site. Whether foot/ankle OA in professional footballers is more common than in the general population remains unknown. This study examined the prevalence of foot/ankle OA and pain in retired male professional footballers compared to general population male controls and risk factors associated with the increased risk in retired male professional footballers.
Objectives:
This research aimed to answer three questions: [1] whether retired male professional footballers are more likely to have foot/ankle OA and pain than general population male controls; [2] what specific risk factors are associated with foot/ankle OA within retired male professional footballers; and [3] is there any difference in the quality of life and performance of functional tests between retired male professional footballers and general population male controls?
Methods:
A cross-sectional comparative study was conducted in the United Kingdom (UK) between August 2020 and March 2023. Postal questionnaires were sent to 878 retired professional footballers in the UK and to 1060 men in the general population in the East Midlands region of England, all of whom had participated in our previous study that focused on knee OA. Participants who completed and returned their questionnaires, who indicated willingness to attend hospital for foot/ankle radiographs, and who resided reasonably close to one of five collaborating National Health Service (NHS) hospitals (Nottingham, Manchester, Leeds, Southampton and London) were invited to undergo bilateral foot and ankle radiographic assessment, irrespective of any self-reported foot/ankle OA outcomes. During the same visit, the Four-Square Step Test (FSST) and a 10-Metre Walk Test (10-MWT) were performed to measure objective performance-related functional outcomes. Pain was defined as current pain for most days in the past month and as ever pain for ≥ 3 months in the past. General practitioner (GP) diagnosed foot/ankle OA and forefoot/ankle surgery were self-reported. Radiographic OA (ROA) was defined as osteophytes (OP) ≥2 or joint space narrowing (JSN) ≥2 on either dorso-plantar or lateral views using the Menz atlas (scale 0-3). Symptomatic radiographic OA (sROA) was defined as the presence of ROA and pain for most days in the past month at the same joint using foot manikin.The prevalence of each foot/ankle OA outcome was compared between footballers and controls. Robust Poisson regression model was used to calculate the adjusted relative risks (aRRs) with 95% confidence interval (CI). The aRR was adjusted for the significant potential confounding factors identified from the univariate analysis. A nested case-control study was conducted on 63 cases (footballers with self-reported foot/ankle OA) and 361 controls (footballers without self-reported foot/ankle OA). Logistic regression was used to calculate the adjusted odds ratio (aOR) and 95% CI.
Results:
In total, 468 footballers (53%) and 619 controls (58%) completed the questionnaire. Of 362 footballers and 497 controls who consented to radiographic assessment, 113 footballers and 319 controls completed the radiographic assessment and performance functional tests. Compared to controls, footballers were younger (mean age 63.27 versus 68.42 years; p<0.001) and had a higher socioeconomic status (median 8.00 versus 6.50; p<0.001), and a significantly higher prevalence of current foot/ankle pain (35%, 95% CI 29.7-39.5 versus 26%, 95% CI 21.4-28.9; p=0.003) and GP-diagnosed foot/ankle OA (13%, 95% CI 9.1-15.9 versus 8%, 95% CI 4.3-8.5; p=0.011) than controls. Footballers scored higher on the SF-36 physical component than controls (mean 72.02 versus 69.25; p=0.046), with no significant difference in mental component scores (mean 77.98 versus 77.27; p=0.559).After adjusting for confounding factors, footballers were more likely to have current foot/ankle pain (aRR 1.33, 95% CI 1.09-1.62), GP-diagnosed foot/ankle OA (aRR 1.77, 95%CI 1.22-2.57), forefoot/ankle surgery (aRR 2.80, 95% CI 2.04-3.84), foot/ankle ROA (aRR 1.04, 95% CI 1.01-1.07) and sROA (aRR 1.63, 95% CI 1.21-2.19) but not ever foot/ankle pain for ≥ 3 months. According to Menz's definition (either osteophyte or JSN≥2), the prevalence of ROA of the foot/ankle OA was not different between footballers and controls. However, it was significantly different when “definite osteophyte plus definite narrowing” was used to define OA. The joint-specific analysis demonstrated that the ankle was the most common joint to be affected by OA in footballers compared controls. Foot/ankle injury (44.71% versus 18.73%, p<0.001) and injection (53.13% versus 6.25%; p<0.001) were different between the two groups. These were identified as the major risk factors associated with the increased odds of self-reported foot/ankle OA within footballers, the aOR being 4.23 (95% CI 1.88-9.48, p<0.001) for foot/ankle injury and 2.62 (95% CI 1.19-5.78, p=0.017) for foot/ankle injection, respectively.
Conclusion:
Retired male professional footballers were more likely to have self-reported and radiographic foot/ankle OA than general population male controls. The ankle appeared to be the joint most affected by OA in footballers compared to general population. Injury and injection were the two major risk factors associated with the increased risk of foot/ankle OA in footballers. Further studies are needed to develop preventive strategies to reduce the risk of foot and ankle OA in current and future professional footballers.
Item Type
ethesis
Thesis Type
PhD
Supervisors
Subjects (LC)
Associated Schools / Departments
School of Medicine
eprints ID
82671
UoN Repository URI
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