Thoracic Spine Arthritis

Thoracic spine arthritis is a painful, degenerative condition of the thoracic spine. It is characterized by the inflammation and breakdown of the cartilage in the thoracic joints. This can lead to pain, stiffness, swelling, and restriction in the range of motion in the mid back.

What Is Thoracic Arthritis?

Osteoarthritis is a common type of arthritis. It is a degenerative joint disease that principally affects the cartilage in your joints. Cartilage is the slippery connective tissue that covers the ends of bones that form joints, and it allows for smooth, effortless movement. Osteoarthritis involves the breakdown of the cartilage with subsequent pain, swelling, and reduced range of motion.

The thoracic spine is that section of the spine that is below the neck and above the low back. It is often referred to as the “mid-back.” Thoracic spine arthritis involves the breakdown of the cartilage in joints within the thoracic spine.

Types of Arthritis Conditions Impacting the Thoracic Spine

There are many different types of arthritis. The most common include:

Osteoarthritis

Osteoarthritis is the most common degenerative joint disease and it affects more than 25% of the population over 18 years old.¹ It is classified into two categories: primary osteoarthritis and secondary osteoarthritis (post-traumatic arthritis). Clinically, it typically presents with loss of joint cartilage, bone thickening, bone spurs, inflammation, and loss of movement. 

Symptoms vary from mild discomfort to disabling pain and restricted movement.² Risk factors include age, female gender, obesity, muscle weakness, and joint trauma.³

Ankylosing Spondylitis

Ankylosing spondylitis is a type of arthritis that causes inflammation in the joints and ligaments of the spine. It is a symmetrical autoimmune disease in which the cartilage and ligaments are eroded, leading to pain, reduced range of motion, and, in some cases, fusion of the spine.⁴ It can also affect peripheral joints such as the knees, ankles, and hips.

Rheumatoid Arthritis (RA)

Rheumatoid arthritis is a chronic, symmetrical autoimmune disease that primarily affects the joints. It occurs when the body’s autoimmune system mistakenly attacks the synovium, which is the capsule that surrounds the joints. This leads to inflammation, pain, and swelling. Initially, it affects the smaller joints and then progresses to the larger ones. 

Over time, the joint can become visibly deformed. Rheumatoid arthritis can also affect the skin, eyes, heart, kidneys, and lungs.⁵

Psoriatic Arthritis

Psoriatic arthritis is a chronic autoimmune disorder that affects some individuals who have the skin condition psoriasis. It causes joint inflammation, leading to pain and swelling. Unlike rheumatoid arthritis, which is symmetrical in its clinical presentation, psoriatic arthritis can affect different joints on each side of the body and can therefore have an asymmetric pattern.

In addition to joint problems, it can also lead to skin and nail issues such as pitting and skin plaques. It affects men and women almost equally, with a peak onset of 40-50 years.⁶

Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis encompasses a collection of persistent autoimmune conditions that impact children and adolescents. Inflammation and pain in the joints can result in stiffness and swelling, leading to discomfort and reduced mobility. The exact cause is unknown. 

Various subtypes exist, each exhibiting distinct symptoms and exerting diverse effects on the body. These subtypes possess unique characteristics that differentiate them from one another.

Septic Arthritis

Septic arthritis, also known as infectious arthritis, is a serious medical condition where there is inflammation of the joint or joints due to an infection. It can arise from a bacterial, fungal, or viral infection. It usually involves one joint. This condition typically arises from the spread of the infectious agent through the bloodstream or from direct introduction into the joint, leading to pain, swelling, and reduced range of motion.⁷

Symptoms of Arthritis in the Thoracic Spine

Arthritis in the thoracic spine is a degenerative condition in which there is a breakdown of the cartilage in the thoracic spine joints. This leads to a number of different symptoms that depend upon the severity of the arthritis and the number of joints involved. The most common symptoms include the following:

Swelling and Tenderness

Arthritis in the thoracic spine can lead to swelling and tenderness. The swelling occurs due to the loss of cartilage in the joints and the subsequent friction and inflammation.

Numbness, Tingling, and Muscle Weakness

Arthritis in the thoracic spine can cause structural changes in the spine. As a result of cartilage breakdown, bone spurs can develop along with irritation of the exiting nerve roots. This, in turn, can compromise the signal to the muscles in the thoracic region and lower extremities. Clinically, this can lead to numbness, tingling, and muscle weakness.

Stiffness

Stiffness is a common symptom of arthritis in the thoracic spine. Damage to the joint cartilage can lead to increased friction and reduced mobility in the spine. Bone spurs can arise, which further limit the range of motion. Inflammation can arise due the cartilage breakdown and trigger muscle spasms, further limiting the range of motion.

Pain That Radiates to Shoulders, Arms or Legs

Thoracic arthritis can cause pain that radiates into the shoulders, arms, and legs through a combination of mechanisms involving inflammation, nerve compression, and referred pain.

Arthritis is characterized by a breakdown in joint cartilage with inflammation, swelling, and pain.

The inflammation can trigger nerve irritation or dysfunction, causing pain both locally in the thoracic spine and radiating into the shoulders, arms, and legs. 

Arthritis can also lead to structural changes within the thoracic spine. Examples include the creation of bone spurs and ligamental laxity. Bone spurs can cause nerve root irritation or compression, causing referred pain that is felt in the shoulders, arms, or legs. 

Referred pain is pain that is perceived in an area different from where the actual tissue damage is occurring. The classic example is that of a heart attack. The actual tissue damage occurs in the heart but in some cases, patients have arm or jaw pain. The thoracic facet, ligaments, and costovertebral joints all have documented referral patterns, which have been discussed previously.

Back Pain in Ribs

Experiencing thoracic spine and rib pain? Learn more about what could be causing this and the treatment options that can provide lasting relief. Back pain in the ribs can be a common and often debilitating condition, causing discomfort and limiting mobility for many individuals. The pain can range from mild to severe and may be caused by various underlying conditions. Understanding the many causes of rib and back pain is important and can assist in securing an accurate diagnosis. Treatment options vary depending on the underlying cause and severity of symptoms.

Read More About Back Pain in Ribs

Chronic Fatigue

Have you ever had a challenging all-day hike, athletic endeavor, or worked a double shift and felt exhausted the next day? Later that day or the next morning, moving across the room may have seemed almost impossible and took herculean power. Now image this occurs on a daily basis without any provocation. 24/7 simple tasks are nearly impossible due to a lack of strength and energy. This is chronic fatigue, and it is one of the common symptoms associated with craniocervical instability. Severity can vary and in severe cases, patients are confined to their beds. Aggravating and alleviating factors often times can not be identified.

Read More About Chronic Fatigue

Motor Issues

Cervical radiculopathy is a condition caused by compression of a cervical nerve root, which can result in pain and sensorimotor deficits. Nerve roots are mixed nerves which are responsible for sensory and motor function.  There are eight cervical nerve roots that branch off from the spinal cord, labeled from C1-C8. Each cervical nerve root supplies a particular region of skin, called a dermatome,and innervates certain groups of muscles, called a myotome. When the cervical nerve root is compressed, the sensory supply to the dermatome in the upper limb can be altered. This can lead to pain, decreased sensation, the feeling of pins and needles, and even numbness. This can also coincide with muscle weakness, and a decreased reflex response.

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Nerve Pain in the Thoracic Spine

The thoracic spine is the part of the spine below the neck (cervical spine) and above the low back (lumbar spine). It is often referred to as the mid back. Nerves exit the thoracic spine at each level and can become irritated, compressed or injured, resulting in pain and dysfunction. This is commonly referred to as thoracic radiculopathy or pinched nerve.

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Referred Pain From The Thoracic Spine

Pain is the body’s way of signaling distress or injury. But what if your body manifests pain in a certain area of your body and yet the actual source of the discomfort is a completely different part of your body? In this article, we will explore the intricacies of referred pain, specifically referred pain from the thoracic spine. We’ll explore what this typically feels like, what conditions commonly cause referred pain, and the treatment options available to treat the root cause of this symptom.

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Shoulder Pain Radiating Down Arm to Fingers

Common Cervical Radiculopathy symptoms include neck pain, arm pain, shoulder pain radiating down arm to fingers, numbness, tingling, and weakness. Cervical Radiculopathy is a clinical condition in which a nerve or nerves in your neck become irritated or compressed. It is also known as ” a pinched nerve,” The causes are discussed below. It can affect individuals of any age with peak prominence between ages 40-50 years of age. Cervical Radiculopathy is due to spinal nerve inflammation, irritation, or compression. The most common causes of Cervical Radiculopathy are: Disc Injury – The disc is an important shock absorber. Unfortunately, it is susceptible to injury.

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Thoracic Facet Joint Pain

Symptoms of a thoracic facet joint injury will vary depending upon severity of the injury and which facet joint is injured. The joints have established pain referral patterns (2). Drefus et al demonstrated that pain from a given facet joint does not occur in the immediate area of the joint in 75% of cases. Rather, it refers to an area away from the joint. For example, pain from injury of the T3/4 facet is felt along the inside border of the scapula. Unfortunately, there is significant overlap between the thoracic referral patterns which can complicate identifying the exact facet joint…

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Thoracic Spine Pain

Simply put thoracic spine pain is pain that arises from the thoracic spine.  It may be acute or chronic.  It may be constant or intermittent. It may be mild or can be so severe as to take your breath away.  To better understand thoracic spine pain please review the sections below. The thoracic spine is that part of the spine that is sandwiched between the neck and low back.  Many refer to it as the middle section of your spine.  It starts at the base of your neck and ends at the bottom of your ribs. The thoracic spine is the longest region in the spine.

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Thoracic Spine Tightness

Thoracic spine tightness can be caused by a number of different conditions. Many providers and medical practices focus on treating symptoms, with the aim of reducing them. Therefore, they provide prescriptions for different medications and referral to physical therapy with the hope that this will reduce or eliminate symptoms. At the Centeno-Schultz Clinic, we take a different approach. We believe that the first step is an accurate diagnosis. By identifying the accurate underlying issue, patients can receive the appropriate therapy and get the best clinical results. The process starts with a board-certified, fellowship-trained physician taking a detailed history that includes the onset of symptoms, presence or absence of trauma, aggravating factors, alleviating factors, and treatment to date.

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Causes of Arthritis in the Thoracic Spine

Arthritis in the thoracic spine can be the result of many different factors. The actual cause of arthritis also varies with the type of arthritis. The most common causes of osteoarthritis are:

Aging

Aging is one of the most common risk factors for osteoarthritis.⁸ As we age, our cells have less energy and ability to repair damage from injuries or degeneration.

Obesity

There is an established association between obesity and osteoarthritis.⁹ Patients with obesity develop osteoarthritis earlier, have more severe symptoms, and have a higher risk for infection with total joint replacement surgery.

Trauma or Injury

Trauma is a major cause of osteoarthritis. This is referred to as post-traumatic osteoarthritis (PTOA). Common causes leading to PTOAs include intra-articular fractures, and meniscus, ligament, and cartilage injuries. It is significant and accounts for 12% of all osteoarthritis.¹⁰

Genetics

There is a strong genetic component to osteoarthritis. Experts claim that up to 30% of the risk of OA is genetically determined.

Spinal Alignment

Spinal alignment is critical to the health and proper functioning of the spine. When out of alignment, there are increased forces on the facet joints, ligaments, and discs. This in turn can lead to injury and degeneration.

Ankylosing spondylitis is a specific type of arthritis that affects the spine. It can lead to inflammation of the vertebrae, causing them to fuse over time. This can affect spinal alignment as well as leading to a rigid and inflexible spine. In severe cases of ankylosing spondylitis, there is a development of hyper kyphosis (hunchback).

Infections

Infections can lead to a form of arthritis known as infectious arthritis or septic arthritis. A joint can become infected by bacteria, viruses, or fungi, with bacteria being the most common. The infection can cause inflammation and damage to the joint. Risk factors for septic arthritis include liver disease, skin infections, rheumatoid arthritis, and existing joint problems.¹¹

Metabolic Disorders

There are two principal metabolic disorders associated with arthritis: gout and metabolic syndrome.

Gout is a form of arthritis where there is an elevated uric acid level in the blood. The uric acid crystals cause pain, inflammation, swelling, and injury to the joint. 

Metabolic syndrome is a medical condition characterized by obesity, high blood pressure, high blood triglycerides, low HDL levels, and insulin resistance. It is associated with an increased risk of developing diabetes, cardiovascular disease, and gout. The latter is known to be associated with the development of arthritis and is thought to affect 20-30% of the adult population.

How Is Arthritis in the Thoracic Spine Diagnosed?

The diagnosis of arthritis involves multiple steps: medical history and physical examination, blood tests, and radiographic studies.

Medical history should involve exploration of the duration of current symptoms, severity, aggravating and alleviating factors, history of trauma, family history of arthritis, and treatment to date.

The physical examination will include an assessment of joint function, swelling, tenderness, and range of motion.

Blood tests are helpful to check for markers of inflammation and specific antibodies associated with various types of arthritis. Common blood tests include:

• C reactive protein
• Erythrocyte sedimentation rate
• Rheumatoid factor
• Uric acid levels

Radiographic studies are commonly utilized. The most common studies include:

• X-rays: X-rays are helpful to identify joint damage, bone spurs, and joint alignment.
• MRI: MRI is a powerful imaging technology that provides detailed images of soft tissue such as tendons, ligaments, cartilage, and nerves. 
• CT: Computed tomography can be helpful in certain types of arthritis.

Common Treatments for Arthritis in the Thoracic Spine

The most common treatments for arthritis aim to reduce the pain, diminish the inflammation, and improve joint function. These treatments include:

Heat and Cold Therapy

Heat and cold therapy are utilized by many patients with arthritis. Both are natural treatment options that are convenient, readily accessible, and affordable. Heat therapy can relax muscles, promote increased blood flow, and reduce inflammation and pain. 

Cold therapy constricts blood vessels, which reduces blood flow. This can reduce inflammation, swelling, and pain.

Medications

A number of different medications are utilized for arthritis. These include:

• Natural anti-inflammatories: Good quality fish oil and curcumin.
• Pharmaceutical anti-inflammatories: Examples include ibuprofen, naproxen, and diclofenac. These medications are powerful anti-inflammatory agents that should be avoided due to their significant side effects, which have been discussed previously. 
• Disease-modifying anti-rheumatic drugs (DMARDs): These medications work to slow down the progression of the disease. They help to preserve joints by blocking inflammation. Common examples include methotrexate and sulfasalazine. 
• Biologic response modifiers (biologics): These are a subgroup of DMARDs that are designed to target specific components of the immune system. Examples include adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade).
• Corticosteroids: Commonly referred to as steroids, these possess potent anti-inflammatory properties that effectively alleviate pain and swelling associated with arthritis. There are several examples of corticosteroids commonly used, such as cortisone, prednisone, methylprednisolone, and dexamethasone. These medications can be administered either orally or through injections. 
  
  Corticosteroids have significant side effects, which include weight gain, increased blood pressure, high blood sugar levels, and osteoporosis. Because of this, they should not be used as first-line treatments for arthritis.

• Steroid-sparing: In some cases, a steroid-sparing agent may be prescribed in addition to traditional medications. These drugs help reduce the amount of steroids needed to control inflammation and pain. Examples of such agents include colchicine, which is prescribed to treat and prevent gout by reducing the inflammation associated with this condition. This medication effectively alleviates the inflammatory symptoms, thus providing relief to individuals suffering from gout.
• Xanthine oxidase inhibitors: Another medication employed in the management of gout is allopurinol, a xanthine oxidase inhibitor. It effectively reduces the uric acid levels in the bloodstream and serves to prevent gout attacks.

Physical Therapy

Physical therapy can be an effective tool in the treatment of arthritis. It can improve joint function and mobility, strengthen muscles, and help posture and body mechanics. Other valuable benefits include improved walking patterns, balance, and stability.

Surgery

Surgery as a treatment for arthritis should only be considered when conservative, nonsurgical treatments have failed to provide significant pain relief or improved function. Surgery is not a first-line treatment for patients with arthritis. Common surgical procedures include arthroscopy and joint replacement.

The Centeno-Schultz Protocol for Arthritis in the Thoracic Spine

PRP, bone marrow concentrates, and prolotherapy are treatment options when conservative therapy has failed.

Facet Joint Injections

A facet joint injection is a common medical procedure utilized in the diagnosis and treatment of facet joint injuries. It can be performed in the cervical, thoracic, and lumbar spine and may involve one or more facet joints. A facet injection involves the placement of a needle under an x-ray or ultrasound directly into the targeted facet joint and the administration of medication. The injected medicine goes directly into the joint and for this reason, some may refer to a facet injection as an intra-articular facet injection. Intra-articular refers to within the joint. The procedure can be diagnostic or therapeutic.

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Prolotherapy For Thoracic Pain

Prolotherapy is an injection based regenerative therapy used in the treatment of ligament, tendon, muscle and spine injuries. It is minimally invasive and involves the injection of an irritant such as dextrose into the damaged or painful area. The injected irritant stimulates a delayed or frozen healing cycle thereby increasing blood flow and tissue healing. The thoracic spine is that section of the spine that is below the neck and above the low back. It is also referred to as the mid back. It has multiple components that include: Vertebral Bodies: Boney building blocks that stack one upon another…

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Prolotherapy Injections

It has been successful in the treatment of many disorders including neck, shoulder, knee, and ankle pain. Dr. Centeno recently published an article in The Journal of Prolotherapy in which he discusses the use of x-ray guidance with prolotherapy. This ensures that the injection is in the correct place to maximize clinical results. Dr. Centeno discusses the use of prolotherapy for the treatment of neck, knee, sacroiliac joint, ankle, ischial tuberosity, and shoulder pain. At the Centeno-Schultz Clinic x-ray guided prolotherapy is just one of the therapies utilized in the successful treatment of pain. Regenerative injection therapy (RIT) or prolotherapy…

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PRP Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

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Thoracic Spine Surgery

Thoracic spine surgery is a major surgery aimed at treating injuries in the thoracic spine. Because of the complex anatomy and close proximity to the heart and lungs, there are significant surgical risks and complications. Surgery on the thoracic spine can take hours and may require deflating the lung in order to gain access to the thoracic injury. Recovery can be lengthy depending upon the specific thoracic spine surgery performed. There are several different types of thoracic spine surgery.  The specific thoracic spine performed depends upon the underlying thoracic injury and a symptoms of the patient.  For example, a thoracic disc herniation…

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Bone Marrow Aspirate Concentrate

Bone marrow concentrate is an increasingly popular treatment option for joint arthritis. It involves extracting bone marrow from the patient’s hip, concentrating the stem cells, and injecting them into the affected joint to promote healing and regeneration of damaged tissue. This regenerative approach helps to provide long-term relief from pain and improved function.

Experience Relief, Improve Spinal Health

Arthritis in the thoracic spine is a degenerative condition in which there is a breakdown of the cartilage in the thoracic spine joints. There are many different types of arthritis, including osteoarthritis, ankylosing spondylitis, rheumatoid, psoriatic, juvenile, and septic arthritis.

The breakdown of cartilage can lead to several different symptoms that depend upon the severity of the arthritis and the number of joints involved. The most common symptoms include pain, swelling, tenderness, stiffness, numbness, tingling, and muscle weakness. There are many different causes of arthritis. The most common include aging, obesity, trauma, genetics, infections, and metabolic disorders.

Diagnosis involves many different steps that include medical history, physical examination, blood tests, and radiographic studies. Common treatment options include heat, cold therapy, medications, physical therapy, and surgery.

Prolotherapy, PRP, and bone marrow concentrate are orthobiologics that can reduce inflammation, enhance stability, and improve blood flow to the cartilage and joint. PRP and bone marrow concentrate do not cause the adverse effects associated with steroids and other pharmaceutical treatment options.

Arthritis typically gets worse over time. If you or a loved one is suffering from arthritis-related pain or impaired mobility, please consider a consultation with one of the board-certified, fellowship-trained physicians. Learn if PRP or bone marrow concentrate are viable options for you.

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Thoracic Spine Physician and Expert

John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate and PRP for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI).

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References

1. Chen D, Shen J, Zhao W, Wang T, Han L, Hamilton JL, Im HJ. Osteoarthritis: toward a comprehensive understanding of pathological mechanism. Bone Res. 2017 Jan 17;5:16044. doi: 10.1038/boneres.2016.44. PMID: 28149655; PMCID: PMC5240031.
2. Bortoluzzi A, Furini F, Scirè CA. Osteoarthritis and its management – Epidemiology, nutritional aspects and environmental factors. Autoimmun Rev. 2018 Nov;17(11):1097-1104. doi: 10.1016/j.autrev.2018.06.002. Epub 2018 Sep 11. PMID: 30213694.
3. Loeser RF. Aging and osteoarthritis. Curr Opin Rheumatol. 2011 Sep;23(5):492-6. doi: 10.1097/BOR.0b013e3283494005. PMID: 21709557; PMCID: PMC3377970.
4. Zhu W, He X, Cheng K, Zhang L, Chen D, Wang X, Qiu G, Cao X, Weng X. Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone Res. 2019 Aug 5;7:22. doi: 10.1038/s41413-019-0057-8. PMID: 31666997; PMCID: PMC6804882.
5. Bullock J, Rizvi SAA, Saleh AM, Ahmed SS, Do DP, Ansari RA, Ahmed J. Rheumatoid Arthritis: A Brief Overview of the Treatment. Med Princ Pract. 2018;27(6):501-507. doi: 10.1159/000493390. Epub 2018 Sep 2. PMID: 30173215; PMCID: PMC6422329.
6. Ocampo D V, Gladman D. Psoriatic arthritis. F1000Res. 2019 Sep 20;8:F1000 Faculty Rev-1665. doi: 10.12688/f1000research.19144.1. PMID: 31583079; PMCID: PMC6758836.
7. Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. West J Emerg Med. 2019 Mar;20(2):331-341. doi: 10.5811/westjem.2018.10.40974. Epub 2018 Dec 6. PMID: 30881554; PMCID: PMC6404712.
8. Chen D, Shen J, Zhao W, Wang T, Han L, Hamilton JL, Im HJ. Osteoarthritis: toward a comprehensive understanding of pathological mechanism. Bone Res. 2017 Jan 17;5:16044. doi: 10.1038/boneres.2016.44. PMID: 28149655; PMCID: PMC5240031.
9. Anandacoomarasamy A, Caterson I, Sambrook P, Fransen M, March L. The impact of obesity on the musculoskeletal system. Int J Obes (Lond). 2008 Feb;32(2):211-22. doi: 10.1038/sj.ijo.0803715. Epub 2007 Sep 11. PMID: 17848940.
10. Dilley JE, Bello MA, Roman N, McKinley T, Sankar U. Post-traumatic osteoarthritis: A review of pathogenic mechanisms and novel targets for mitigation. Bone Rep. 2023 Jan 30;18:101658. doi: 10.1016/j.bonr.2023.101658. PMID: 37425196; PMCID: PMC10323219.
11. Lu V, Zhou A, Hussain HA, Thahir A, Krkovic M. Risk factors for septic arthritis and multiple arthroscopic washouts: minimum 2-year follow-up at a major trauma centre. Clin Rheumatol. 2022 Aug;41(8):2513-2523. doi: 10.1007/s10067-022-06151-w. Epub 2022 Apr 2. PMID: 35366159; PMCID: PMC9287235.