Rigors of war leave troops battling arthritis at a young age
By SETH ROBBINS | STARS AND STRIPES Published: September 25, 2011
BAUMHOLDER, Germany — Staff Sgt. Thomas Wenzke would sit for hours, hunched over the five-ton truck’s window, scanning for hints of bombs along Iraq’s garbage-lined roadways.
The truck — reinforced with heavy armored plates that had ruined its suspension — motored over crater-sized potholes, and Wenzke’s spine would feel every jolt. His body armor, weighing 50 to 60 pounds, added to the strain.
Convoy forays like this lasted from three to 30 hours, he said, depending on the number of breakdowns and firefights.
“By the time we got back,” he said, “I’d be bent over and hobbled like I was an old man of 50 or 60.”
Wenzke said, since his yearlong deployment in 2006, he has suffered from a herniated disk and degenerative arthritis in his spine, for which there is no cure.
He is 29 years old.
“When you hear ‘arthritis,’ you think it’s a disease you get as you age, an elderly person’s condition,” Wenzke said. “It’s nothing I ever thought about having. I thought it was just a tweaked muscle, something like that, definitely not arthritis.”
But degenerative arthritis is all too common among troops. A study published in the July issue of the journal Arthritis and Rheumatism found that servicemembers are developing the disease at much higher rates and at younger ages than civilians. Post-traumatic arthritis is also one of the leading reasons why soldiers injured in combat become medically separated from the military.
The increased prevalence of the painful joint disease among troops is likely due to the physical demands of military service — lifting weights for years, carrying heavy loads in combat zones and sustaining injuries on repeated deployments.
“I really think that it’s a cumulative effect of military service,” said Dr. Kenneth L. Cameron, the study’s lead author.
Troops at risk
From 1998 to 2008, military doctors diagnosed 108,266 cases of mechanical degenerative arthritis, or osteoarthritis, Cameron’s study found.
Osteoarthritis rates were 26 percent higher in servicememembers age 20 to 24 than in the general population. Troops over the age of 40 were more than twice as likely to develop the disease as civilians.
“It was a little surprising that it was so much higher,” Cameron said.
More than 75 percent of the cases were diagnosed in senior and junior enlisted servicemembers, whose jobs are often the most physically demanding. The disease was most prevalent in the Army, followed by the Air Force, Navy and Marines.
Though osteoarthritis can affect any joint, it most often occurs in weight-bearing joints: the hips, knees, spine, ankles, as well as in the fingers. It is a wear-and-tear disease that results from the breakdown of cartilage at the end of bones. When the cartilage breaks down, the bones rub together, causing pain.
Over time, the bones can become misshapen and thickened, and bony spurs can form where the joint’s soft tissue is attached. Fluid-filled cysts may also form under the cartilage, and the synovial membrane and fluid, which serves as a shock absorber and lubricant, may diminish.
The joint pain can be debilitating and devastating.
“The arthritis is a constant ache,” said Wenzke. “It’s not a muscle ache, it’s much deeper and in the bone.”
Osteoarthritis was once believed to mostly affect people age 65 and older, but recent research has shown that younger men and women can develop the disease, especially when they perform work that puts heavy stress on their joints.
According to the Centers for Disease Control and Prevention, 27 million Americans suffer from osteoarthritis, making it the most common form of arthritis in the United States.
Dr. Grant Cannon, attending physician in rheumatology at the George E. Wahlen Veterans Administration hospital in Salt Lake City, Utah, said that he has not seen an uptick in younger patients seeking treatment for arthritis. But Iraq and Afghanistan veterans with minor aches and strains in their joints are likely receiving care from their primary care physicians, he said.
“I’m going to be seeing these guys in 30 years,” Cannon said. “And I think that we may see an earlier prevalence” of osteoarthritis.
Contributing to troops’ increased risk for osteoarthritis may be a lifetime of lifting weights and performing other strenuous physical activities to pass fitness exams. Intense training and multiple deployments cause injuries, such as torn ligaments, that can leave servicemembers susceptible to developing the disease.
“Lower-energy knee injuries, like an ACL tear or a meniscus tear, predispose people to osteoarthritis at a much earlier age,” Cameron said. “And there is no shortage of those type of injuries within the military.”
The rigors of Iraq and Afghanistan, where servicemembers must carry heavy packs and body armor, also could make troops more prone to the joint disease.
“We really don’t know for sure,” Cameron said, “But if I had to make a guess, carrying heavy loads probably contributes.”
Early in the wars in Iraq and Afghanistan, soldiers often carried between 80 and 120 pounds of gear.
Lt. Col. Frank Lanzano, program manager for soldier protective equipment at Program Executive Office Soldier, which equips soldiers with body armor, said the organization is always looking for ways to ease soldiers’ loads without sacrificing protection.
Troops in Afghanistan now have access to tactical vests that weigh less than 20 pounds, but still protect vital organs, he said. Commanders decide in what circumstances soldiers can wear the lighter armor.
The organization is also researching using nanotechnology and new fibers to make the armor lighter. Lanzano said he hopes to reduce the weight of body armor by 10 percent.
“It’s very easy to get heavier,” he said. “The hard work is to keep current protection levels and get lighter.”
Combat and arthritis
Battlefield injuries, such as broken bones from blasts and joints injured by gunshots and shrapnel, can also lead to osteoarthritis. A study of soldiers injured in combat during the Iraq war found that osteoarthritis was the top reason for their subsequent discharges.
Among the 450 Iraq war veterans in the study, 29 percent had post-traumatic arthritis listed as a condition that made them unfit for service. Dr. (Lt. Col.) Anthony Johnson, assistant chief of orthopaedic surgery services at San Antonio Military Medical Center and lead author of the study, said that combat-injured veterans develop the joint disease much faster and at earlier ages than those who suffer athletic injuries.
Whereas people who tear a ligament may develop traumatic arthritis a decade after their injuries, veterans are being diagnosed about two years after being exposed to a blast. Explosive shock waves not only break bones and injure tissue, but also kill cartilage cells, which the body can’t replace, Johnson said.
“There is much more energy to the joint than if you were playing a sport and tear your ACL,” he said. “And the higher the energy, the earlier the onset of symptoms.”
Few treatments and no cure
There is no cure or way to reverse osteoarthritis. Most sufferers rely on oral pain relievers to provide partial relief and physical therapy to strengthen the muscles around the injured joint, said Johnson. Anti-inflammatory medications, steroid injections and painkillers can relieve more severe pain, he said.
Wenzke received all three medications, as well as nerve blockers, to relieve the pain from his herniated disk and arthritis. He said these were mostly ineffective and the painkillers left him lethargic.
“They don’t make the pain go away,” he said. “They make you not care about the pain.”
Beyond the medications and physical therapy, Johnson said there are few options for treating osteoarthritis patients in their 20s and 30s. Most are too young to have a hip or knee replacement because the metal parts will wear out in 10 to 15 years, requiring them to have more difficult and dangerous operations by the time they reach middle age. Many simply live with the pain, he said.
And the number of Iraq and Afghanistan veterans with traumatic arthritis is likely to grow, flooding the VA system as the World War II vets once did, he said.
“I think this is going to be the next batch, except they are going to have arthritis at a much younger age,” he said.
Adding to the problem is the fact that little research has been done on how to treat younger veterans with osteoarthritis, though recently Johnson said he and colleagues have begun looking into drugs to slow the disease’s progress and devices that will take pressure off and support arthritic joints.
“It’s a lot easier to get funding to improve on a prosthesis for a patient that has an amputation than it is to get funding on how to treat arthritis,” he said. “But now we have the data to say this is a pressing need.”
Living with the pain
Wenzke eventually had surgery to remove the herniated disk that was pinching the nerve within his spinal cord. The surgery eliminated much of the pain, but he still wakes in the morning with his back aching, he said, and his mobility is severely limited. Before separating from the Army earlier this month, Wenzke received a rating of 40 percent from the physical evaluation board, which means he will receive lifetime medical benefits from the military.
But he worries about how he will support his family. After the military, he planned on becoming a police officer and had studied criminal justice. But that option is no longer possible. He also considered becoming a physician, like his father, but he is unsure whether he could handle the demands of standing for long hours during residency.
“As far as job prospects, I’m going to have to do something that is easy on my back,” he said. “That’s something that I never really thought I would have to take into consideration.”
To slow the progression of the arthritis, Wenzke performs stretches and takes care not to lift heavy objects or do activities that will further injure his back. But he knows there is no stopping it, and he fears that the pain will be so great that, one of these days, he will be unable to lift his young daughter.
“It’s going to continue to get worse,” he said. “It’s just a matter of how fast.”