J Orthop Sci (2006) 11:439445

DOI 10.1007/s00776-006-1040-y

Original article
Prevalence, patterns, and risk factors of knee osteoarthritis in
Thai monks
Boonsin Tangtrakulwanich1, Alan F. Geater2, and Virasakdi Chongsuvivatwong2
1
Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Haadyai, Songkhla 90110,
Thailand
2
Epidemiological Unit, Department of Community Medicine, Faculty of Medicine, Prince of Songkla University, Haadyai, Songkhla,
Thailand

Abstract
Background. Patterns and risk factors of knee osteoarthritis in
Asian countries where most people have habitual knee bending activities remain unclear. The objective of this study was to
evaluate the prevalence, patterns, and risk factors of knee
osteoarthritis in Thai monks.
Methods. The study was a cross-sectional survey of monks
who lived in temples in southern Thailand. Investigations included history, physical examination, and radiographic evaluation including weight-bearing antero-posterior, lateral, and
skyline views.
Results. There were 261 monks from 85 temples included in
this study. The overall prevalence of radiographic knee
osteoarthritis was 59.4%, with 29.6% having symptomatic radiographic knee osteoarthritis. The patterns of involvement
were isolated tibiofemoral compartment (7.7%), isolated
patellofemoral compartment (18.8%), and combined (32.9%).
Obesity (OR 5.6, 95% CI; 1.619.8), age equal to or more than
60 years (OR 3.0, 95% CI; 1.56.0), and age at ordainment
equal to or more than 46 years (OR 2.2, 95% CI; 1.14.6) were
associated with risk of developing radiographic knee
osteoarthritis. Obesity (OR 17.9, 95% CI; 2.4132.1) and current smoking (OR 7.7, 95% CI; 2.424.3) were associated with
symptomatic radiographic knee osteoarthritis. Severity of involvement was associated with obesity (OR 12.0, 95% CI; 2.3
60.9), older age (OR 3.8, 95% CI; 1.35.1), and older age at
ordainment (OR 2.8, 95% CI; 1.36.1).
Conclusions. The prevalence of radiographic knee
osteoarthritis with patellofemoral involvement in Thai monks
is high and is more common among the elderly, those who
were older at ordainment, and obese subgroups. Each pattern
of knee osteoarthritis might have a different pathomechanism
in the development of osteoarthritis.

Introduction
Knee osteoarthritis is a major public health problem.13
It is the most common joint disease in humans and is
associated with major disability in the elderly as much
as cardiovascular disease.4 The prevalence depends on
the population selected, study design and criteria used,
and ranges from 11.042.8%,513 with relatively higher
rates in Eastern countries than in Western countries. In
addition, a recent study from Beijing revealed that the
patterns of knee osteoarthritis in Asians differ from
those in Western countries.13
Patellofemoral knee osteoarthritis has recently
been of increasing concern because of its significantly
greater disability rate compared to tibiofemoral knee
osteoarthritis.14 Its prevalence has been reported to be
from 6.9% to 36.1%.1418 The pathogenesis of each compartment-specific type of knee osteoarthritis remains
unclear. Both systemic and local factors have been
linked to each pattern of involvement. In addition, cultural lifestyle has been postulated to be associated with
the pathomechanisms of knee osteoarthritis in Asian
people. However, there is still debate about whether
habitual knee-bending activities increase the risk of
knee osteoarthritis.1921 Thai monks comprise a subgroup with a special lifestyle. Over 95% of monks in
Thailand are Hinnayana (small vessel cult), which requires regular sitting cross-legged on the floor, often for
long periods. There has been no previous study exploring the problems and factors associated with knee
osteoarthritis in Thai monks. This study aimed to evaluate the prevalence, patterns, and risk factors of knee
osteoarthritis in Thai monks.

Material and methods

Offprint requests to: B. Tangtrakulwanich
Received: February 9, 2006 / Accepted: May 15, 2006

This study was a population-based cross-sectional survey done in Songkhla province in the southern part of

440

B. Tangtrakulwanich et al.: Knee osteoarthritis in Thai monks

Fig. 1. Common cross-leg sitting position of Thai Buddhist

monks: side-knee bending (A) and lotus (B)

Thailand. Eighty-five of 313 Hinnayana temples located

within 30 kilometers of Haadyai city, the largest city in
southern Thailand, were included in the study. Monks
aged 40 years or older without other underlying rheumatic conditions were invited to join this study. After
informed consent was obtained, they were taken to a
private clinic for history taking, physical examination,
and radiographic evaluation. A face-to-face interview
by a well-trained nurse obtained demographic data:
temple area, age, previous occupation, underlying disease, previous knee injuries if any, family histories of
knee osteoarthritis and knee pain and age at ordainment, duration of ordainment, and average daily crossleg sitting exposure (Fig. 1). Body weight and height
were measured. Radiographic evaluation included
weight-bearing antero-posterior, lateral, and skyline
views by one well-trained musculoskeletal-imaging
technician. The skyline view was taken according to the
method of Davies.22 There was a fixed distance from the
patella to the plate of 20 cm to minimize magnification
error. Ethical approval from the Faculty of Medicine
was granted before the start of the study.
Sample size calculation
With an estimated prevalence of 30% and precision
of 0.05, the sample size required in this study was
244 persons.
Radiographic classification of knee osteoarthritis
Reliability of radiographic evaluation was evaluated for
both inter- and intra-observer agreement. Thirty radiographs from this survey with different severities were
randomly selected and independently evaluated by two
musculoskeletal radiologists blinded to the clinical
results, twice, one month apart. The involvement of
osteoarthritis in each compartment (medial tibiofemoral and lateral tibiofemoral) was evaluated by 1
senior musculoskeletal radiologist. Osteoarthritis was
established if the radiographic result was grade 2 or
more according to the Kellgren and Lawrence classifica-

tion (definite osteophyte with questionable joint space

narrowing) in at least one knee. Severity of involvement
was categorized into 3 levels: grade 2 = mild, grade
3 = moderate, and grade 4 = severe. For evaluation of
patellofemoral involvement, skyline radiographs were
graded from 0 to 3: 0 = normal, 1 = osteophyte without
joint space narrowing, 2 = moderate joint space narrowing, and 3 = marked joint space narrowing. Grade 1 or
more was classified as patellofemoral involvement.
The patterns of osteoarthritis involvement were
classified into 3 groups: isolated patellofemoral, isolated
patellofemoral, and combined. Isolated patellofemoral
involvement referred to involvement without any
tibiofemoral osteoarthritis. Isolated tibiofemoral referred to involvement in either the medial in lateral
tibiofemoral compartment without patellofemoral
osteoarthritis. A combined pattern was involvement in
both the patellofemoral and tibiofemoral compartments. Where there was discrepancy between the two
knees, the more severe side was taken as the outcome as
this would determine the need for care of the individual.
Definition of symptomatic knee osteoarthritis
The monks were requested to answer a standard question about pain in each knee. (Have you ever had knee
pain lasting at least one month during the last year?). If
the radiographic finding was consistent with the
osteoarthritic criteria and the response was yes to this
question, they were categorized as having symptomatic
knee osteoarthritis.
Statistical analysis
The kappa statistic was used to test the reliability of the
radiographic interpretations. The prevalence of osteoarthritis was analyzed and cross-tabulated against age
groups. Chi squared independent tests were used to
identify crude associations with various factors. For
continuous exposure variables, one-way analysis of
variance was employed. Factors having a P value of less
than 0.20 were included for multivariate analysis. Logistic regression analysis was used to identify factors independently associated with knee osteoarthritis.

Results
Among 280 monks invited, 261 (93%) from 85 temples
agreed to participate in this study. About 37% of the
monks lived in temples located in a rural area. The
mean age (SD) and BMI of the monks were 60.4 (12.7)
years and 23.2 (4.5) kg/m2, respectively. The average age
at ordainment was 44.4 (+/17.6) years with a mean
duration of ordainment of 16.9 (+/14.7) years. Eighty

B. Tangtrakulwanich et al.: Knee osteoarthritis in Thai monks

percent of the monks had at least one underlying disease. Thirty-eight percent were current smokers. The
average daily exposure of cross-leg sitting position in
minutes (SD) was 69.0 (87.7) for lotus and 37.1 (62.8)
for side-knee bending.
There were no significant differences in baseline
demographic characteristics between the response
and non-response groups except for the monks rank;
abbots were significantly more prevalent in the nonparticipating group than the response group. The reliability (kappa statistic) of radiographic evaluation was
at a good to excellent level of agreement in both intrarater (0.740.86) and inter-rater reliability tests (0.62
0.85) for each site of involvement.
The overall prevalence of radiographic osteoarthritis
in this study was 59.4%. Only 50% of monks with
radiographic knee osteoarthritis had chronic pain.
Figure 2 summarizes the knee osteoarthritis data. The
prevalence among each pattern of involvement of
osteoarthritis was isolated tibiofemoral involvement
(7.7%) (a + b + c), isolated patellofemoral involvement
(18.8%) (d), and combined (32.9%) (e + f + g).
Age and age at ordainment were significantly different among patterns of knee osteoarthritis. The combined pattern had the highest mean BMI, mean age, and
mean age at ordainment. Otherwise, other potential
risk factors did not differ with the pattern of knee
osteoarthritis (Table 1).
Risk factors found to be significant in univariate
analysis were confirmed through multivariate logistic
regression. BMI was also an important predictor for
knee osteoarthritis. Monks with BMI equal to or
greater than 30 kg/m2 had 5.6 times the odds of developing radiographic knee osteoarthritis compared to those
with BMI less than 20 kg/m2. Monks older than 60 years
had 3.0 times the odds compared to those younger than
60 years. Monks who were equal to or older than 46
years of age at ordainment had 2.2 times higher odds of
developing knee osteoarthritis (Table 2). Of the three
risk factors identified in the previous tables for sympto-

441

matic radiographic knee osteoarthritis, only BMI was

significant in addition to smoking status (Table 3).
In multivariate analysis using polynomial logistic
analysis, the three risk factors were confirmed for
the combined pattern. However, for the isolated
tibiofemoral and isolated patellofemoral patterns, BMI
was the only significant factor (Table 4). The same risk
factors were identified as predictors for osteoarthritis
when the outcome was classified as severe knee
osteoarthritis against the remaining groups (Table 5).

Discussion
We found a high prevalence (59.4%) of radiographic
knee osteoarthritis in Thai monks. The most common
pattern of involvement was the combined pattern

Fig. 2. Venn diagram of the prevalence of knee osteoarthritis

according to the location of involvement. LTF, lateral
tibiofemoral compartment; MTF, medial tibiofemoral compartment; PF, patellofemoral compartment. See text for explanation of af

Table 1. Distribution of potential risk factors among normal and osteoarthritic knee subjects for each pattern of involvement

Variablea

Normal
(n = 106)

BMI (kg/m2)
Age (years)
Age at ordainment (years)
Duration of ordainment (years)
Current smoker (no.)
Family history of osteoarthritis (no.)
Previous knee injury (no.)

22.4 (1.6)
54.8 (11.5)
39.3 (15.4)
17.0 (13.5)
61 (42.4%)
12 (11.8%)
2 (2.0%)

Isolated
patellofemoral
OA (n = 49)
23.6 (4.1)
61.2 (11.6)
43.9 (17.7)
23.6 (4.1)
23 (41.8%)
8 (15.4%)
2 (3.8%)

Isolated
tibiofemoral
OA (n = 20)
21.3 (5.6)
61.6 (11.6)
45.1 (16.2)
21.3 (5.6)
8 (40.0%)
1 (5.0%)
0

Combined
OA (n = 86)
24.1 (5.1)
67.2 (11.2)
52.3 (18.1)
24.1 (5.1)
30 (34.5%)
8 (9.3%)
7 (8.0%)

OA, osteoarthritis; BMI, body mass index

Results for BMI, age, age at ordainment, and duration of ordainment are given as the means and SD (in parentheses)

P
0.103
0.001
0.001
0.249
0.458
0.691
0.176

442

B. Tangtrakulwanich et al.: Knee osteoarthritis in Thai monks

Table 2. Relation of risk factors to radiographic knee osteoarthritis

Variable
Body mass index (kg/m2)
<20
20.024.9
25.029.9
30
Age (yrs)
<60
60
Age at ordainment (years)
<46
46
Duration of ordainment (years)
<17
17
Smoking status
Never
Former
Current
Family history of osteoarthritis
No
Yes
Previous knee injury
No
Yes

Crude odds ratio

(95% CI)

Adjusted odds ratio

(95% CI)

1
1.6 (0.82.9)
1.3 (0.62.7)
5.0 (1.319.0)

1
1.6 (0.83.2)
2.4 (1.05.4)
5.6 (1.619.8)

1
4.2 (2.57.1)

1
3.0 (1.56.0)

1
3.4 (2.05.7)

1
2.2 (1.14.6)

1
0.9 (0.51.5)

1
0.8 (0.41.5)

1
1.1 (0.62.1)
0.9 (0.51.7)

1
1.0 (0.52.0)
1.0 (0.52.0)

1
0.9 (0.42.1)

1
3.0 (0.713.0)

1
3.8 (0.818.1)

1
1.5 (0.37.7)

P*
0.006

0.001
0.001
0.441
0.997

0.149
0.080

* From likelihood ratio test

Table 3. Relation of risk factors to symptomatic radiographic knee osteoarthritis

Variable
Body mass index (kg/m2)
<20
20.024.9
25.029.9
30
Age (years)
<60
60
Age at ordainment (years)
<46
46
Smoking status
Never
Former
Current
Family history of osteoarthritis
No
Yes
Previous knee injury
No
Yes
* From likelihood ratio test

Crude odds ratio

(95% CI)

Adjusted odds ratio

(95% CI)

1
1.6 (0.83.3)
4.3 (1.214.9)
5.7 (1.916.6)

1
1.9 (0.75.4)
4.7 (1.317.1)
17.9 (2.4132.1)

1
1.7 (0.83.5)

1
1.8 (0.74.7)

1
1.1 (0.52.3)

1
1.0 (0.43.1)

1
2.8 (1.36.2)
2.8 (1.25.8)

1
5.9 (2.017.9)
7.7 (2.424.3)

1
3.6 (1.013.3)

1
3.0 (0.713.0)

1
1.0 (0.34.0)

1
1.5 (0.37.7)

P*
0.002

0.385
0.500
0.002

0.344
0.586

B. Tangtrakulwanich et al.: Knee osteoarthritis in Thai monks

443

Table 4. Risk factors affecting severity of knee osteoarthritis

Variable
Body mass index (kg/m2)
<20
20.024.9
25.029.9
30
Age (years)
<60
60
Age at ordainment (years)
<46
46
Smoking status
Never
Former
Current
Family history of osteoarthritis
No
Yes
Previous knee injury
No
Yes

Crude odds ratio

(95% CI)

Adjusted odds ratio

(95% CI)

1
0.9 (0.42.3)
1.3 (0.62.8)
7.0 (1.533.2)

1
1.2 (0.62.3)
1.8 (0.84.2)
12.0 (2.360.9)

1
3.8 (2.36.5)

1
2.6 (1.35.1)

1
3.1 (1.85.2)

1
2.8 (1.36.1)

1
1.3 (0.72.6)
1.0 (0.51.9)

1
1.2 (0.62.4)
1.1 (0.52.3)

1
0.8 (0.41.9)

1
1.0 (0.42.4)

1
3.0 (0.614.2)

1
2.9 (0.615.0)

P*
0.003

0.006
0.007
0.926

0.866
0.168

* From likelihood ratio test

Table 5. Relation between risk factors and patterns of knee osteoarthritis, using monks without knee osteoarthritis as a referent
group

Variables
Body mass index (kg/m2)
<20
20.024.9
25.029.9
30
Age (years)
<60
60
Age at ordainment (years)
<46
46
Smoking status
Never
Former
Current
Family history of osteoarthritis
No
Yes
Previous knee injury
No
Yes

Isolated
patellofemoral OA
(n = 49)

Isolated tibiofemoral OA
(n = 20)

Combined OA
(n = 86)

1
1.2 (0.53.1)
2.0 (0.75.7)
9.1 (1.459.2)

1
0.3 (0.11.1)
0.4 (0.11.9)
5.9 (0.747.7)

1
1.9 (0.84.5)
3.2 (1.19.4)
22.5 (3.5142.2)

1
1.7 (0.74.0)

1
1.0 (0.33.4)

1
5.1 (2.211.8)

1
2.2 (0.85.8)

1
3.4 (0.813.9)

1
3.0 (1.27.8)

1
0.7 (0.31.9)
1.1 (0.42.7)

1
2.8 (0.515.1)
2.4 (0.4-13.4)

1
1.3 (0.53.2)
1.0 (0.42.5)

1
1.3 (0.43.9)

1
0.2 (0.12.2)

1
1.1 (0.43.6)

1
2.4 (0.318.4)

1
4.5 (0.726.4)

Ranges in parentheses represent the relative risk ratio

444

(32.9%), which had involvement of both the tibiofemoral and patellofemoral compartments, followed by
the isolated patellofemoral pattern (18.8%). Only a
small proportion of Thai monks had the isolated
tibiofemoral pattern (7.7%). Obesity increased the risk
of developing radiographic, symptomatic knee osteoarthritis and severe knee osteoarthritis. Elderly monks
and those of older age at ordainment had an increased
risk of radiographic knee osteoarthritis, especially
the combined pattern, and both factors were also associated with severity of involvement. The effect of smoking was less consistent. The only subtype of knee
osteoarthritis associated with smoking was symptomatic
knee osteoarthritis.
The prevalence of radiographic knee osteoarthritis
in Thai monks in this study is higher than previously
reported in lay populations, especially from Western
countries.612 The prevalence of patellofemoral involvement in knee osteoarthritis (51.7%) is the highest
ever reported.13,14 This might be explained in two ways.
First, skyline view X-rays, which have a higher sensitivity than conventional lateral radiographs, have not been
normally used in other studies.18 Secondly, our subjects
were Thai monks, who usually have prolonged and regular knee-bending floor activities in their daily life and
work. Both the lotus position and side-knee bending
require knee bending of more than 120 degrees. Furthermore, from a biomechanical point of view, the contact pressure of the patella increases as the knee is flexed
further.23 This may also result in an increased pressure
load on the patellofemoral joint, which can compromise
articular nutrition.24 However, we did not measure knee
flexion angle and duration of knee-bending activities in
all monks, so we cannot confirm the association between
patellofemoral osteoarthritis and these factors.
Obesity and older age were major risk factors associated with both radiographic knee osteoarthritis and severity of knee osteoarthritis in the studied monks, which
are similar to risk factors previously reported in nonmonk subjects.11,25 An increased load across the knee
joint in obese monks could lead to increased stress or
cartilage breakdown, while there is decreased ability of
chondrocytes to repair joint problems and thus an
increased risk of joint degeneration in the elderly.
Unexpectedly, increased age at ordainment was also
associated with increased risk of radiographic knee
osteoarthritis in monks. This has never been reported as
a risk factor of knee osteoarthritis. Since Thai monks
have a unique lifestyle that requires regular and
prolonged knee-bending activity, earlier exposure to
knee-bending activities may stretch the soft tissue
surrounding the knee and decrease stiffness over time
via changes in the viscoelastic properties.26 This might
result in lower contact pressure of the articular cartilage
than in monks who ordain at an older age.

B. Tangtrakulwanich et al.: Knee osteoarthritis in Thai monks

The association between smoking and knee osteoarthritis remains unclear. Several studies within the past
10 years have suggested that cigarette smoking may play
a modestly protective role against knee osteoarthritis,27
although at least one other recent prospective study
found no connection between smoking and radiographic knee osteoarthritis, as with ours.28 However, we
found that the risk of knee pain in monks with radiographic osteoarthritis was higher in those monks who
were smokers. This might be associated with nicotine,
which is a psychostimulant in cigarettes and can thus
affect both cortical and autonomic arousal, resulting in
a lower pain threshold.29 Another possibility is that
smoking can cause damage to musculoskeletal tissue
through vasoconstriction hypoxia, defective fibrinolysis,
or impaired nutrition of articular cartilage resulting in
poorer healing capacity.30 However, further longitudinal study needs to be done to confirm this result.
The pathomechanisms of patellofemoral and tibiofemoral knee osteoarthritis might be different. Cooper 17
suggested that isolated patellofemoral osteoarthritis is
more strongly linked to family history and Heberden
nodes, although this was not supported by statistical
significance. McAlindon 15 found that obesity was a
major risk factor for both tibiofemoral and patellofemoral osteoarthritis. From our data, both patterns share
the same risk factors, obesity, and older age. That there
was no significant association between family history or
previous knee injury and knee osteoarthritis in the
monks in our study might simply reflect the limited
number of cases we had, especially of tibiofemoral
osteoarthritis.
The strength of this study is in its homogeneous population of monks who were exposed to lengthy kneebending floor activities over a long period. This is the
first study reporting on the prevalence and patterns of
osteoarthritis in Thai monks. We had a high response
rate from the monks, and those who did not respond
had a comparable risk profile except for the senior
monks; however, this rank was not associated with risk
of knee osteoarthritis.
The implications arising from this study mainly concern indications for potential preventive strategies.
Monks, especially those who have asymptomatic radiographic knee osteoarthritis, should control their body
weight and should stop smoking to lessen the risk of the
symptoms developing. Monks who ordain at an older
age should have regular exercise to prevent knee stiffness, which may result in osteoarthritis development.
However, generalization of this information to nonmonks should be done with caution because of the differences in lifestyles and activities.
The main limitations of the study were that we could
not confirm the causal relationships, and there may
have been some selection bias from the cross-sectional

B. Tangtrakulwanich et al.: Knee osteoarthritis in Thai monks

study design. Only monks who were still ordained were

included in the investigation, so healthy ex-monks, if
included, might have led to different results. Another
limitation was we did not measure the knee flexion
angle and knee alignment in our subjects. These factors
may affect the association between the risk factors and
knee osteoarthritis in our study.

Conclusionss
In conclusion, we found a high prevalence of
radiographic osteoarthritis with patellofemoral involvement in Thai monks. Obesity, older age, and older age
at ordainment were major risk factors of knee
osteoarthritis.
Acknowledgments. This paper is a part of the PhD thesis of
Dr. Boonsin Tangtrakulwanich and was supported by funding
from the Royal Golden Jubilee programme through the
Epidemiology Unit of the Faculty of Medicine, Prince of
Songkla University.

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