Extended report
Association of bone attrition with knee pain, stiffness
1Division of Clinical Epidemiology
and Biostatistics, Institute of
Social and Preventive Medicine,
University of Bern, Switzerland
2Department of Rheumatology,
Clinical Immunology, and
Allergology, Bern University
Hospital, Switzerland
3Institute of Clinical Education
Research, Peninsula Medical
School, Universities of Exeter
and Plymouth, UK
4CTU Bern, Bern University
Hospital, Switzerland
5Department of Social Medicine,
University of Bristol, Bristol, UK
Correspondence to
Dr Stephan Reichenbach,
Institute of Social and
Preventive Medicine, University
of Bern, Finkenhubelweg
11, 3012 Bern, Switzerland;
rbach@ispm.unibe.ch
Accepted 11 August 2010
Published Online First
24 September 2010
Ann Rheum Dis 2011;70:293–298. doi:10.1136/ard.2010.132985
and disability: a cross-sectional study
Stephan Reichenbach,1,2 Paul A Dieppe,3 Eveline Nüesch,1,4 Susan Williams,5
Peter M Villiger,2 Peter Jüni1,4
ABSTRACT
Objectives Bone pathologies as detected on MRI
are associated with the presence of pain in knee
osteoarthritis (OA). The authors examined whether bone
attrition assessed on x-rays was associated with pain,
stiffness and disability.
Methods The authors analysed x-rays of 1326 knees
with OA from 783 individuals participating in the
cross-sectional population-based Somerset and Avon
Survey of Health. The diagnosis of OA was defined by
the presence of osteophytes in anteroposterior (AP)
or lateral views. Bone attrition was graded from 0 (no
attrition) to 3 (severe attrition >10 mm) and Kellgren
and Lawrence (K/L) scores were assigned on AP views.
Logistic regression models adjusted for gender, age,
body mass index, effusion and K/L scores were used to
determine whether bone attrition was associated with
pain, stiffness and disability.
Results Pain was reported in 84 knees (74%) with
radiographic bone attrition compared with 505 (42%)
without bone attrition (adjusted OR 2.22, 95% CI 1.29 to
3.80). The adjusted OR was increased for day pain but
not for night pain (p for interaction <0.001). Stiffness
was reported for 85 knees with bone attrition (75%) and
437 knees without (36%) (adjusted OR 3.23, 95% CI 1.85
to 5.64). Disability was reported by 40 individuals with
bone attrition (50%) and 140 individuals without (24%)
(adjusted OR 2.09, 95% CI 1.19 to 3.68).
Conclusions Bone attrition detected on conventional
x-rays using a simple cheap technique is strongly
associated with the presence of day pain, stiffness and
disability in knee OA.
INTRODUCTION
Knee pain is a major public health problem.1–3 In
older people the cause of knee pain is generally
attributed to osteoarthritis (OA).4 However, we
know that many people with radiographic changes
suggestive of knee OA are not in pain.5–7 In addition,
knee pain can be due to a number of other patholo-
gies including periarticular problems such as anser-
ine bursitis8 and bone pathologies such as bone
marrow lesions.9 Joint pathology has been assessed
radiographically in the past.10 However, because of
the relatively poor correlation between symptoms
and radiographic changes,5–7 most investigators
now opt to use more sophisticated joint imaging
techniques such as MRI.11 12 Alternatively, they
have looked for other technologies with which to
explore the problem, such as functional imaging of
the brain.13 These techniques may provide us with
valuable insights into pain mechanisms but cannot
easily be used in routine clinical work or in epide-
miological studies.
We recently described a simple method with
which to assess bone attrition at the knee joint on
routine x-rays.14 Bone attrition was defined as a
vertical loss of bone volume in the affected condyle.
Our data, derived from a cohort with advanced OA
of the knee, suggested that bone attrition might be
related to night pain.14 Others have found subchon-
dral bone marrow oedema as detected on MRI to
be associated with pain in the osteoarthritic knee.9
Using data from the community-based Somerset
and Avon Survey of Health (SASH),15 16 we deter-
mined whether bone attrition as detected on con-
ventional anteroposterior (AP) x-rays is associated
not only with knee pain but also with stiffness and
disability.
METHODS
Sampling of participants
SASH is a population-based cross-sectional study
of 28 080 people randomly selected from 40 general
practices in the south-west of England.15 17 After
exclusion of 2034 people who had either moved
out of the study area, suffered from a severe mental
or terminal illness or were deceased, 26 046 people
were included in the study.
Screening process
All 26 046 subjects were sent a screening ques-
tionnaire comprising questions on general health,
utilisation of health services and symptoms of
hip and knee disease. Non-respondents were sent
two reminders and contacted by telephone if
necessary.17 18 We screened people for knee pain
using a modified version of the question used in the
first National Health and Nutrition Examination
Survey:19 ‘During the past 12 months, have you
had pain in or around either of your knees (hips)
on most days for 1 month or longer?’ Participants
who reported knee or hip pain were invited for fur-
ther examination either at a clinic or by home visit.
Examinations were organised into two phases by
location of participating practices.
Assessment of symptoms and signs
Examined participants were asked about knee pain,
stiffness and disability using the following ques-
tions: ‘In the past 12 months, have you had pain
in or around your left (right) knee on most days for
1 month or longer during the day?’ (yes/no). This
question was repeated for night pain, referring to
‘during the night’. Participants were considered to
suffer from knee pain if they reported either day
or night pain. ‘In the past 12 months, have you
experienced stiffness in or around your left (right)
293
 Extended report
knee on most days for 1 month or longer (yes/no)?’ and ‘How
difficult is it for you to go outdoors and walk down the road
on your own (not difficult/quite difficult/very difficult/impos-
sible)?’ Disability was not assessed in the first 127 participants
who underwent clinical examination during the first phase of
the study and considered present if participants indicated that
walking was at least ‘quite difficult’. The presence of an effusion
in either knee was determined based on clinical examination.
Radiographic evaluation
Participants underwent weightbearing AP and lateral x-rays of
the knees according to a standardised protocol. For AP views
the legs were extended in slight internal rotation. All films were
processed and assessed in a blinded manner. We used weight-
bearing AP knee x-rays that were considered to be normal to
develop templates of knee joint contour outlines.14 These could
be overlaid onto the knee x-rays of the study subjects to deter-
mine the presence of bone attrition, defined as a vertical loss of
bone volume in the affected condyle (figure 1). Alignment of
the normal contours of the femur and tibia allowed measure-
ment of the extent of bone attrition separately for the femo-
ral condyles and tibial plateaus. Three different template sizes
were used for knees of small, medium or large dimensions. As
previously described, we graded attrition on a scale from 0 to 3
(0 = no attrition, 1 = attrition of doubtful significance (<5 mm),
2 = definite attrition of a moderate degree (5–10 mm), 3 = severe
attrition (>10 mm).14 Using a standard atlas,10 we then rated the
worst osteophytes from 0 to 3 (0 = none; 1 = minute; 2 = def-
inite, of a moderate degree; 3 = severe) for both parts of the
tibiofemoral joint on AP and lateral x-rayss. OA was defined by
the presence of grade 1 osteophytes or higher on AP or lateral
views.9 Finally, we assigned Kellgren/Lawrence (K/L) grades of
global radiological severity on AP views using a scale from 0
to 4 (0 = no features of OA, 1 = minute osteophytes of doubtful
significance; 2 = definite osteophytes, no definite joint space
narrowing; 3 = definite joint space narrowing of a moderate
degree; 4 = severe joint space impairment).20 One investigator
(SR) who was blinded to each participant’s clinical information
performed a single assessment of all x-rays. A random sample of
30 films was also assessed by one independent observer (PAD).
Intrarater agreement was moderate for the semiquantitative
grading of bone attrition with a weighted κ value of 0.82 (95%
CI 0.61 to 1.00), was high for semiquantitative K/L grading with
a weighed κ value of 0.88 (95% CI 0.70 to 1.00) and was high
for detection of osteophytes with a κ of 1.00 (95% CI 0.74 to
1.00). Inter-rater agreement was moderate for the semiquantita-
tive grading of bone attrition with a weighted κ value of 0.58
(95% CI 0.39 to 0.78), was moderate for semiquantitative K/L
grading with a weighed κ value of 0.81 (95% CI 0.69 to 0.92)
and was moderate for detection of osteophytes with a κ of 0.72
(95% CI 0.59 to 0.86).
Statistical analysis
Analyses were at knee level for the analysis of pain and stiffness
and at participant level for disability. Logistic regression mod-
els were used based on robust standard errors that accounted
for the clustering of knees within participants where appropri-
ate and the association of bone attrition grade ≥1 (pre-speci-
fied) with knee pain, stiffness and disability was determined.
We estimated crude OR with corresponding 95% CIs and OR
adjusted for gender, age, body mass index and overall radio-
graphic severity based on K/L scores and the presence of joint
effusion. Analyses were restricted to knees or participants with
294
radiographic knee OA9 with complete covariate information.
To explore the impact of excluding knees or participants with
missing covariate information, we calculated estimates of the
associations of bone attrition with symptoms separately for
complete and incomplete datasets. In sensitivity analyses we
distinguished between grade 1 and 2 bone attrition. p Values
for interaction between estimated OR and extent of bone attri-
tion were derived from the appropriate interaction term in the
logistic regression model. We then estimated separately the
association of bone attrition with day pain and with night pain
using matched pairs logistic regression, which accounted for the
correlation between the two pain types within knees. All analy-
ses were performed in STATA 10.1 (Stata Corporation, College
Station, Texas, USA).
RESULTS
The flow of participants from screening stage to stage of clini-
cal examination was reported previously.15 16 In short, 22 978
individuals responded to the screening questionnaire, 22 217
completed the question on hip pain and 22 379 the question
on knee pain. A total of 6416 participants reported hip or knee
pain (29%). Of these, 4304 were invited for further examination
(67%) and 2703 attended (63%).15 16 Figure 2 shows the flow
of clinic attendees through the study; 938 participants did not
have a radiographic examination, most frequently because they
refused or because they felt unable to attend due to general frailty
or comorbid conditions. A total of 3530 knees from 1765 partici-
pants had undergone radiographic examination but 430 knees
were excluded, most frequently because radiographic examina-
tions performed before the beginning of the study could not be
obtained for central reading. Films of 3100 knees from 1571 par-
ticipants were read and 1615 knees from 957 participants were
diagnosed with radiographic OA. Complete clinical data were
available for 1326 knees from 783 participants. Disability was
not assessed for the first 127 participants with radiographic OA
during the first phase, so data on disability was available for 656
participants with radiographic OA (figure 2).
The characteristics of the 783 participants (1326 knees) with
radiographic and clinical information are shown in table 1.
Participants with bone attrition were on average 4 years older
than participants without bone attrition (p<0.001). The 114
knees all had a K/L score ≥2, with a trend towards higher K/L
scores in knees with bone attrition as opposed to predominantly
low K/L scores in knees without (p<0.001). A total of 270 knees
without attrition were assigned a K/L score of 0, with osteo-
phytes only detectable on lateral views. Effusions were detected
clinically in 77 knees overall (6%), and the percentages were
much the same in knees with and without bone attrition.
Pain was reported in 84 knees (74%) with radiographic bone
attrition compared with 505 knees (42%) without bone attri-
tion. Figure 3 shows crude and adjusted associations of bone
attrition with pain. In the crude analysis, the odds of pain were
3.92 times higher in knees with bone attrition compared with
knees without attrition (95% CI 2.37 to 6.48). After adjustment
for age, gender, body mass index, K/L score and the presence of
joint effusion, the OR was 2.22 (95% CI 1.29 to 3.80). Figure 4
shows associations separately for knees with small and moder-
ate bone attrition compared with knees without bone attrition.
Crude and adjusted ORs were similar, CIs wide and tests for
interaction between estimated OR and extent of bone attrition
negative. Figure 5 shows separate estimates of the association of
bone attrition with day pain and with night pain. In crude and
adjusted analyses, ORs were more pronounced for day pain but
Ann Rheum Dis 2011;70:293–298. doi:10.1136/ard.2010.132985
 Extended report

not for night pain, with positive tests for interaction between
estimated OR and type of pain. In the adjusted analysis the OR
was increased for day pain (OR 2.37, 95% CI 1.48 to 3.80) but
not for night pain (OR 0.94, 95% CI 0.58 to 1.53).
Stiffness was reported for 85 knees with bone attrition (75%)
and 437 knees without (36%). The OR for the association of
bone attrition with stiffness was 5.20 in the crude analysis (95%
CI 3.09 to 8.75) and 3.23 after adjustment (95% CI 1.85 to 5.64,
figure 3). ORs of stiffness were similar for knees with small bone
attrition and those with moderate bone attrition, CIs wide and
tests for interaction between estimated OR and extent of bone
attrition negative (figure 4). Disability was assessed at the par-
ticipant level and reported by 40 individuals with bone attrition
Attendees were more likely than non-attendees to report pain
(71% vs 29%), stiffness (68% vs 32%) and disability (58% vs
42%). A total of 1765 attendees with 3530 knees underwent
radiographic examination (65%) and films of 3100 knees were
read (88%). Those with knee films available were more likely
than those without films to report pain (88% vs 12%), stiffness
(89% vs 11%) and disability (79% vs 21%). Among participants
with knee films, those with complete clinical data were again
A
Clinically examined:
2703 participants (5406 knees)
C

(50%) and 140 individuals without (24%). The OR for the asso- No radiographic examination: 938 participants
ciation of bone attrition with disability was 3.11 in the crude Refused: 450 participants
analysis (95% CI 1.93 to 5.02) and 2.09 after adjustment (95% Unable to attend: 223 participants
Logistic reasons: 120 participants
CI 1.19 to 3.68, figure 3). ORs of disability were similar for knees Reason unclear: 145 participants
with small bone attrition and those with moderate bone attri-
tion, CIs wide and tests for interaction between estimated OR
and extent of bone attrition negative (figure 4). Had radiographic examination
1765 participants (3530 knees)

A C Excluded: 430 knees

Films requested, not received: 377 knees
Knee implant: 48 knees
Technical difficulties: five knees
B

Radiographs read
1571 participants (3100 knees)

No knee osteoarthritis: 1485 knees

B

Radiographs with knee osteoarthritis

957 participants (1615 knees)

Incomplete clinical data: 289 knees

Complete clinical data available

Figure 1 Different grades of bone attrition. (A) Grade 1 bone attrition
(white arrow) of <5 mm of the medial tibia plateau. (B) Grade 2 bone
attrition (white arrow) of 5–10 mm of the lateral tibia plateau. (C) Grade
3 bone attrition of >10 mm of the lateral tibia with the overlaid template
to outline the joint contour. Broken lines on the template indicate the
cut-off points for levels of bone loss. Modified from Dieppe et al14.
Pain: 783 participants (1326 knees)
Stiffness: 783 participants (1326 knees)
Disability: 656 participants§§
Figure 2 Study flowchart. Note that disability was not assessed in
the first 127 participants of the first phase of the study, so only 656
participants contributed to the analysis of disability.

Table 1 Characteristics of participants

Presence of bone attrition
Yes No p Value
Participant-level data n=80 n=576
Age (years) 79.5 (10.3) 75.3 (9.6) <0.001
Men 38 (48%) 228 (40%) 0.19
BMI (kg/m2) 28.3 (4.3) 28.3 (4.7) 0.60

Knee-level data n=114 n=1212

Kellgren-Lawrence score <0.001
0 0 (0%) 270 (22%)
1 0 (0%) 222 (18%)
2 15 (13%) 519 (43%)
3 40 (35%) 179 (15%)
4 59 (52%) 22 (2%)
Effusion 8 (7%) 69 (6%) 0.63
BMI, body mass index.

Ann Rheum Dis 2011;70:293–298. doi:10.1136/ard.2010.132985 295

 Extended report

(A) Crude analyses A) Crude P<0.001

Knee pain 3.92 (2.37 to 6.48) Day pain 4.01 (2.61 to 6.19)

Night pain 1.64 (1.05 to 2.55)

Stiffness 5.20 (3.09 to 8.75)
B) Adjusted* P<0.001
Disability 3.11 (1.93 to 5.02) Day pain 2.37 (1.48 to 3.80)
(B) Adjusted analyses* Night pain 0.94 (0.58 to 1.53)
Knee pain 2.22 (1.29 to 3.80)

Stiffness 3.23 (1.85 to 5.64) 0.125 0.25 0.5 1.0 2.0 4.0 8.0 OR

Disability 2.09 (1.19 to 3.68) Figure 5 Associations of bone attrition with day pain and night pain
0.125 0.25 0.5 1.0 2.0 4.0 8.0 OR
separately. *Analyses were adjusted for gender, age, body mass index,
Kellgren-Lawrence score and presence of joint effusion.
Figure 3 Association between presence of bone attrition and knee
pain, stiffness and disability. Analyses of knee pain and stiffness were at the time at which the x-rays were obtained and we could
performed in 1326 knees and analyses of disability in 656 participants. not determine the association between bone attrition and pain
*Analyses were adjusted for gender, age, body mass index, Kellgren- intensity. Third, our analysis is based on individuals experienc-
Lawrence score and presence of joint effusion. ing hip or knee pain in the community and cannot necessarily
be generalised to other settings. Finally, participants in the study
Knee pain P=0.86 did not undergo MRI examination so we were unable to account
for other pathologies including meniscal damage, bone marrow
Small 2.33 (1.31 to 4.13)
lesions or bursitis. Since subchondral bone marrow lesions are
associated with bone attrition in MRI,21 the observed associa-
Moderate 2.09 (0.70 to 6.26)
tion of bone attrition with pain might be partially confounded
by bone marrow lesions undetected on conventional x-rays.
Stiffness P=0.52
The range of causes for knee pain in adults is large, ranging
Small 3.58 (1.95 to 6.57) from local problems such as trauma and arthritis to referred
pain from the hip or central pain sensitisation problems.22 The
Moderate 2.42 (0.86 to 6.79) usual diagnosis established as a cause for knee pain in those
aged ≥45 years in daily practice is OA,23 which is unsurprising in
Disability P=0.42
view of the high prevalence of patients with clinical and radio-
graphic signs of OA.24 However, the association of bone attri-
Small 3.25 (1.55 to 6.78) tion as assessed on conventional x-rays has only been partially
explored, and its association with stiffness and self-reported dis-
Moderate 1.79 (0.52 to 6.14) ability has never been addressed to our knowledge. Despite the
advent of MRI studies in patients with knee OA to investigate
0.125 0.25 0.5 1.0 2.0 4.0 8.0 OR bone pathologies,9 25 26 it is too expensive for routine use and
is unlikely to become part of clinical practice in patients with
Figure 4 Associations of bone attrition with knee pain according to
extent of bone attrition. All analyses were adjusted for gender, age, body OA in many healthcare settings other than cases of suspected
mass index, Kellgren-Lawrence score and presence of joint effusion. meniscal tears. Our study contributes to widening the focus
Only one knee with severe bone attrition was included in the study and when interpreting conventional x-rays from exclusive attention
therefore associations in knees with severe bone attrition could not be to joint space narrowing and osteophytes to a more integrated
estimated. view which also involves subchondral bone. The approach of
using conventional AP x-rays to detect bone attrition14 is cheap,
more likely than those without films to report pain (80% vs simple and applicable to population-based research and clinical
20%), stiffness (81% vs 19%) and disability (78% vs 22%). practice.
Pioneering work on the association between bone patholo-
DISCUSSION gies and pain was undertaken by Arnoldi et al27 28 in the 1970s
This analysis of adults aged ≥35 years shows that the presence and 1980s using intraosseous pressure measurement and other
of bone attrition found on plain x-rays is associated with 2–3- techniques. In the 1990s, bone scintigraphy was used to deter-
fold increased odds of pain, stiffness and disability. In both crude mine whether subchondral bone activity was related to both
and adjusted analyses the associations were pronounced for day pain and progression of OA,29–31 providing an impetus to bone
pain but not for night pain. When the associations were deter- research in OA. In the last decade, MRI studies tell a similar
mined separately for grades 1 and 2 bone attrition we found story with associations found between bone marrow lesions or
similar increases in the odds of pain, with widely overlapping bone attrition and knee pain.9 26 32 33 Distinguishing between
CIs and negative tests for interaction between extent of attrition day and night pain, Hernández-Molina et al32 found an asso-
and association with knee pain. ciation of bone attrition with day pain but not night pain. In
The strengths of the study include the large number of people agreement with Hernández-Molina et al32 but contrary to our
involved, the population-based recruitment of study participants, earlier suggestion that bone attrition could be associated with
their transparent pathway to clinical and radiographic exami- night pain,14 we found a strong association of bone attrition
nation15 and the fact that the x-rays were assessed by a single with day pain but none with night pain in the adjusted analysis.
observer. However, there are four major limitations to the study. Taken together, a variety of techniques has been used during the
First, it is purely cross-sectional, which implicitly prevents us last 40 years to explore the association between bone patholo-
from drawing any conclusions about the causality of observed gies and pain but, to our knowledge, this is the first study to
associations. Second, pain was only assessed as present or absent use conventional x-rays for assessing bone attrition in a large

296 Ann Rheum Dis 2011;70:293–298. doi:10.1136/ard.2010.132985


population-based sample and to determine the association of
bone attrition, not only with pain but also with stiffness and
disability. These three measures of disease severity are likely to
be interrelated, and both pain and stiffness may be on the causal
pathway between bone attrition and disability. This could be
partially addressed by including either of the two measures as
independent variables in the logistic regression model. In our
study the crude OR for the association between bone attrition
and disability of 3.11 (95% CI 1.93 to 5.02) became somewhat
less pronounced after adjusting for knee pain (OR 2.75, 95% CI
1.69 to 4.47) and stiffness (OR 2.45, 95% CI 1.50 to 4.02).
MRI studies suggest that many knees with mild radiographic
OA without joint space narrowing have some evidence of bone
attrition.33 Several interrelated observations deserve further
attention. First, malalignment of the knee was found to be asso-
ciated with the prevalence and incidence of subchondral bone
attrition in a compartment-specific manner.34 Second, bone mar-
row lesions were associated with and predictive for subchon-
dral bone attrition.21 26 Third, subchondral bone attrition was
strongly associated with cartilage loss within the same subre-
gion of the knee.35 Taken together, this may suggest a sequen-
tial process with overload due to malalignment causing bone
marrow lesions first which, in turn, lead to weakening of the
subchondral osseous plate and eventual bone attrition and sub-
sequent damage of the cartilage.
There are implications of our findings, both for research and
clinical practice. The data suggest that we need to investigate
subchondral bone changes as well as articular cartilage when
studying the pathogenesis of both joint damage and pain in OA.
Bone loss of the sort detected by our method implies serious
damage to subchondral bone; this may be a critical feature in
the sequential disease process and it may be more important
to focus on the subchondral bone rather then the joint cartilage
when developing novel potentially disease-modifying drugs for
OA.
In conclusion, we found bone attrition detected on conven-
tional AP x-rays using a simple and cheap technique14 associated
with the presence of day pain, stiffness and disability in partici-
pants of a population-based study of individuals with knee OA.
Acknowledgements The authors thank all study participants and the partners
and staff of participating general practices for their support and interest in the study.
The authors are indebted to the whole of the Somerset and Avon Survey of Health
research team: Kirsty Alchin, Ros Berkeley-Hill, Jane Brooks, Hilary Brownett, Phil
Chan, Clare Cross, Catherine Dawe, Cathy Doel, Jenny Eachus, Helen Forward,
Matthew Grainge, Fiona Hollyman, Sue Jones, Helen Moore, Kate Morris, Nicky
Pearson, Brian Quilty, Chris Smith, Lynne Smith, Gwyn Williams, Mark Williams and
Andrea Wilson; and Allan Douglas and Doreen Cook at Dillon Computing. Finally, we
are grateful to our co-investigators, Jenny Donovan, Tim Peters and Stephen Frankel.
The Department of Social Medicine is the lead centre for the MRC Health Services
Research Collaboration. The authors are grateful to Pete Shiarly for the management
and maintenance of the database.
Funding The Somerset and Avon Survey of Health was originally funded by the
Department of Health and the South and West NHS Research and Development
Directorate. This work was funded by the Swiss National Science Foundation (grants
nos 3233-066377 and 3200-066378) and by the British Arthritis Research Campaign.
The funding bodies had no role in the design or conduct of the study; collection,
management, analysis or interpretation of the data; or preparation, review or approval
of the manuscript. SR is the recipient of a Research Fellowship from the Swiss
National Science Foundation (grant number PBBEB-115067) and of an educational
grant from the Swiss Society of Rheumatology.
Competing interests None.
Contributors PJ and PAD conceived the study and were primarily responsible for
protocol development. SR, PJ, SW and PAD contributed to data collection. EN, SR
and PJ performed the data preparation and analysis. All authors reviewed the protocol
and participated in data interpretation. SR, PJ and PAD wrote the first draft of the
Ann Rheum Dis 2011;70:293–298. doi:10.1136/ard.2010.132985
Extended report
paper and all authors contributed to the final draft. PJ and PAD are the guarantors of
the study.
Ethics approval This study was conducted with the approval of the local research
ethics committees of Somerset and Avon and all participants provided written
informed consent.
Provenance and peer review Not commissioned; externally peer reviewed.
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