Does Injection of Hyaluronic Acid Protect Against Early Cartilage Injury Seen After Marathon Running? A Randomized Controlled Trial Utilizing High-Field Magnetic Resonance Imaging

Abstract

Background: Previous studies have shown that runners demonstrate elevated T2 and T1ρ values on magnetic resonance imaging (MRI) after running a marathon, with the greatest changes in the patellofemoral and medial compartment, which can persist after 3 months of reduced activity. Additionally, marathon running has been shown to increase serum inflammatory markers. Hyaluronic acid (HA) purportedly improves viscoelasticity of synovial fluid, serving as a lubricant while also having chondroprotective and anti-inflammatory effects. Purpose/Hypothesis: The purpose was to investigate whether intra-articular HA injection can protect articular cartilage from injury attributed to marathon running. The hypothesis was that the addition of intra-articular HA 1 week before running a marathon would reduce the magnitude of early cartilage breakdown measured by MRI. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: After institutional review board approval, 20 runners were randomized into receiving an intra-articular injection of HA or normal saline (NS) 1 week before running a marathon. Exclusionary criteria included any prior knee injury or surgery and having run >3 prior marathons. Baseline 3-T knee MRI was obtained within 48 hours before the marathon (approximately 5 days after injection). Follow-up 3-T MRI scans of the same knee were obtained 48 to 72 hours and 3 months after the marathon. The T2 and T1ρ relaxation times of articular cartilage were measured in 8 locations—the medial and lateral compartments (including 2 areas of each femoral condyle) and the patellofemoral joint. The statistical analysis compared changes in T2 and T1ρ relaxation times (ms) from baseline to immediate and 3-month postmarathon scans between the HA and NS groups with repeated measures analysis of variance. Results: Fifteen runners completed the study: 6 women and 2 men in the HA group (mean age, 31 years; range, 23-50 years) and 6 women and 1 man in the NS group (mean age, 27 years; range, 20-49 years). There were no gross morphologic MRI changes after running the marathon. Postmarathon studies revealed no statistically significant changes between the HA and NS groups in all articular cartilage areas of the knee on both T2 and T1ρ relaxation times. Conclusion: Increased T2 and T1ρ relaxation times have been observed in marathon runners, suggesting early cartilage injury. The addition of intra-articular HA did not significantly affect relaxation times in all areas of the knee when compared with an NS control.

Change in Susceptibility Values in Knee Cartilage After Marathon Running Measured Using Quantitative Susceptibility Mapping

“…The cartilage thickness was used to quantitatively describe the morphological condition of knee cartilage. The cartilage thickness of each subregion was calculated by averaging the minimum distance of each point on the cartilage surface to the corresponding bone–cartilage interface across all segmented slices for each runner based on the GRE magnitude image 29 . The declined morphology would be reported if there was obvious thinning in cartilage.…”

“…The cartilage thickness of each subregion was calculated by averaging the minimum distance of each point on the cartilage surface to the corresponding bonecartilage interface across all segmented slices for each runner based on the GRE magnitude image. 29 The declined morphology would be reported if there was obvious thinning in cartilage. Obvious thinning was defined as more than a 50% reduction of cartilage thickness.…”

Host Response to Biomaterials for Cartilage Tissue Engineering: Key to Remodeling

“…However, these methods have achieved limited success. HA offers little protection against early cartilage damage ( Nathani et al, 2019 ). Microfracture is used to treat small articular cartilage lesions that form fibrocartilage and are therefore mechanically weak and prone to degeneration ( Benthien and Behrens, 2013 ).…”

Variation characteristics of stress distribution in the subchondral bone of the knee joint of judo athletes with long-term stress changes

“…One study found elevated T2-relaxation values within the articular cartilage of the knee after marathon exercise in a high BMI population, presumably as a result of changes in biochemical indicators of articular cartilage ( 28 ). However, it has also been found that such tissues do not undergo morphological changes ( 29 ). The fact that knee cartilage can recover its structural and functional properties after being subjected to running-related loads reflects the fact that articular cartilage can withstand higher loads and repeated stimulation after short periods of rest.…”