Racial disparities in the prevalence of spinal conditions have sparsely been discussed in the literature. Most spinal deformities, including scoliosis, have the higher rates of diagnosis in Caucasians (BMUS). A 2011 retrospective study of patients over 40 years old revealed a prevalence of almost twice the rate of scoliosis in whites compared to African-Americans (AA).1 Specific to adolescent idiopathic scoliosis (AIS), African-American patients had higher curvatures at presentation compared with whites and Hispanics. Therefore, they were more likely to have surgery as their initial treatment.2 For this reason, AA patients may need to present at an earlier age for screening. There is a general belief that genetics play a role in progression of AIS; however, it is unknown which genetic factors or whether race is involved.

Lumbar radiculopathy is a spinal nerve root condition caused by nerve compression, inflammation, or injury in the lumbar spine. In a database study of a young, military population, lumbar radiculopathy was found to be more common among white patients.3 Lumbar spinal stenosis, a narrowing of the spinal canal resulting in nerve compression, is another major cause of low back pain and nerve symptom. Overall, hospitalizations for this condition have been reported to be much more common in whites. Blacks and Hispanics have lower rates of surgical hospitalization for lumbar spinal stenosis than did whites.4 Cultural barriers and attitude toward surgery may be responsible for this difference. In patients undergoing surgery for lumbar stenosis, blacks have higher complication rates, longer hospital stays, less likelihood of discharge home, and short preoperative and postoperative follow-up.5^,6 African-American patients also accrue higher hospital-related costs and are prescribed fewer medications.5 Cervical spine surgeries have also been analyzed. African-American patients have higher rates of in-hospital complications and mortality than other ethnicities.7 Much of this difference was likely due to socioeconomic status, insurance status, and access issues.

Ankylosing spondylitis (AS) is an inflammatory arthritis that primarily affects the spine. AS is highly associated with the HLA B27 gene. AS is three times more common in whites than in blacks.8 This is mostly due to the lower prevalence of HLA-B27 in individuals of African descent. A prospective study by Jamalyaria et al compared the disease severity of AS in different ethnic groups. They determined that African-Americans, and Hispanics to a lesser degree, have greater functional impairment, higher disease activity, and greater radiographic severity compared to whites.9 The reason for this could not be determine; however, access to care and genetics are potential factors.

There is conflicting data related to racial differences in back pain. Hootman and Strine reported on 3-month prevalence rates of neck and back pain and found a higher prevalence in whites than other ethnic groups.10 Knox et al analyzed the rates of low back pain in military service members resulting in a visit to a health care provider and reported the highest incidence rates among African-Americans.11 The reason behind the variability is unknown; however, there is believed to be a genetic component. Importantly, a survey study found no significant differences in care-seeking behavior between racial groups for acute or chronic low back pain.12

Self-Reported Back Pain

Non-Hispanic white persons report experiencing neck/cervical and lumbar/low back pain at slightly higher rates in the previous year than members of other racial/ethnic groups. However, back pain with radiating leg pain was reported at similar rates among all racial/ethnic groups except for other/mixed non-Hispanic persons, who reported a lower rate.

In 2015, 36.4% of non-Hispanic white persons reported back pain, compared to 31.0% of non-Hispanic blacks, 30.3% of persons of Hispanic ethnicity, and 26.4% of non-Hispanic others. Low back/lumbar pain was mentioned about twice as often as neck/cervical pain. Respondents are asked if they have radiating leg pain only if the identify suffering from low back pain. Approximately one-third of persons with low back pain also reported radiating leg pain, with non-Hispanic black persons highest (39%) and non-Hispanic other/mixed persons lowest (34%). (Reference Table 7D.2 PDF [11] CSV [12])

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[14]

Healthcare Visits

Non-Hispanic whites (18.4 per 100 persons) were slightly more likely to seek healthcare for treatment of low back/lumbar pain in 2013 than non-Hispanic blacks (17.1/100) and Hispanics (14.2/100). However, non-Hispanic others/mixed race were much less likely to seek healthcare for back pain (7.3/100). Rates for non-Hispanic whites (6.2/100) and non-Hispanic others (6.0) were similar for healthcare visits for neck/cervical pain, but lower for non-Hispanic blacks (4.5) and Hispanics (3.0). (Reference Table 7D.2 PDF [11] CSV [12])

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Back Pain Burden

Non-Hispanic black persons report the highest number of bed days in the previous year due to back pain (8.7 days on average), while those of Hispanic ethnicity lost, on average, the most work days (14.1 days).  (Reference Table 7D.2 PDF [11] CSV [12])

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[18]

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[20]

• 1. Kebaish KM, MD; Neubauer PR, Voros GD, et al. Scoliosis in adults aged forty years and older: prevalence and relationship to age, race, and gender. Spine 2011;36(9):731-736.
• 2. Zavatsky JM. Disease severity and treatment in adolescent idiopathic scoliosis: the impact of race and economic status. Spine J 2015;15(5):939-943.
• 3. Schoenfeld AJ, Laughlin M, Bader JO, Bono CM. Characterization of the incidence and risk factors for the development of lumbar radiculopathy. J Spinal Disord Tech 2012;25(3):163-167.
• 4. Skolasky RL, Maggard AM, Thorpe RJ Jr, et al. United States hospital admissions for lumbar spinal stenosis: racial and ethnic differences, 2000 through 2009. Spine (Phila PA 1976) 2013;38(26):2272-2278.
• 5. a. b. Lad SP, Bagley JH, Kenney KT, et al. Racial disparities in outcomes of spinal surgery for lumbar stenosis. Spine (Phila PA 1976) 2013;38(11):927-935.
• 6. Drazin D, Shweikeh F, Lagman C, Ugiliweneza B, Boakye M. Racial disparities in elderly patients receiving lumbar spinal stenosis surgery. Global Spine J 2017;7(2):162-169.
• 7. Krause JS, Broderick LE, Saladin LK, Broyles J. Racial disparities in health outcomes after spinal cord injury: mediating effects of education and income. J Spinal Cord Med 2006;29(1):17-25.
• 8. Khan MA. Race-related differences in HLA association with ankylosing spondylitis and Reiter's disease in American blacks and whites. J Natl Med Assoc 1978;70(1):41-42.
• 9. Jamalyaria F, Ward MM, Assassi S, et al. Ethnicity and disease severity in ankylosing spondylitis: a cross-sectional analysis of three ethnic groups. Clin Rheumatol 2017;36(10):2359-2364.
• 10. Strine TW, Hootman JM. US national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum 2007;57(4):656-665.
• 11. Knox JB, Orchowski JR, Owens B. Racial differences in the incidence of acute low back pain in United States military service members. Spine (Phila PA 1976) 2012;37(19):1688-1692.
• 12. Carey TS, Freburger JK, Holmes GM, et al. Race, care seeking, and utilization for chronic back and neck pain: population perspectives. J Pain 2009;11(4):343-350.

Research starting in the late 1980s and extending to 2011 shows a consistent pattern of doctor-diagnosed arthritis prevalence among races and ethnicities, although prevalence rose among all groups. Persons of Hispanic ethnicity and Asian/Pacific Islanders have lower arthritis prevalence than non-Hispanic whites, non-Hispanic blacks, and non-Hispanics of other races. However, a study of the 2013 Behavioral Risk Factor Surveillance Survey (BRFSS) participants residing in Hawaii of health disparities of Native Hawaiians and Pacific Islanders (NHPI), Whites, and Asians found that NHPI males had a significantly higher prevalence of arthritis, which peaked twenty years earlier, than White and Asian males. The prevalence of arthritis peaked at 65-79 years in males and females in all racial groups, except NHPI males where it peaked at 45-54 years. At the NHPI peak age range, arthritis prevalence was 49.4% among NHPI males compared to White males (222.2%) and Asian males (17.9%).  No significant differences were found among females.1

American Indians/Alaska Natives higher than non-Hispanic blacks and resembling non-Hispanic whites.2^,3 A 2009-2011 study of prevalence rates among females only reported the same pattern, but with higher rates than found in both sexes.4 Arthritis-attributable activity limitation, arthritis-attributable work limitation, and severe joint pain were found to be higher for non-Hispanic blacks, Hispanics, and multiracial or other respondents with arthritis compared with non-Hispanic whites with arthritis.3 

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[22]

Osteoarthritis

Osteoarthritis, or degenerative joint disease, is the most common form of arthritis. The incidence of osteoarthritis in different ethnicities is similar. Disabling OA is at least as prevalent among African Americans and Hispanics as among non-Hispanic whites.5 African-Americans, however, report greater pain and activity limitation in comparison to Caucasians.6^,7^,8 African-Americans have higher prevalence of knee symptoms, radiographic knee osteoarthritis, and symptomatic knee osteoarthritis than whites,8 and 77% more likely to have knee and spine osteoarthritis together.9 Hispanics are 50% more likely than non-Hispanic Whites to report needing assistance with at least one instrumental activity of daily living and report difficulty walking.10 Prevalence of osteoarthritis of the knee is on the rise, due in part to the growing epidemic of obesity. Hispanic and African-American women have disproportionatly high rates of obesity leading to higher rates of knee osteoporosis, with subsequent quality-adjusted life-years losses, than found among Caucasian women.11  

Rheumatoid Arthritis

There is evidence of race-based differences in rheumatoid arthritis (RA). Ethnic variations have been found in the clinical expression of RA, both in the frequency and types of SE-carrying HLA–DRB1 alleles,12 with non-Hispanic whites having the lowest percentage of rheumatoid factor positive results.13 Hispanics exhibit more tender and swollen joints than non-Hispanic whites, while African-Americans are slightly older at onset.12 African American and Hispanic patients have higher disease activity level, lower rates of remission, and worse functional status than white patients, in spite of more aggressive treatment strategies in recent years.13^,14 There are also differences in utilization of disease-modifying anti-rheumatoid drugs (DMARDs), the gold standard treatment of RA. Certain studies suggest that treatment differences may be related to patient preference. Constantinescu et al found that fewer African-American patients preferred aggressive treatment compared to white patients with similar disease severity.15 This study suggests that improvement in patient literacy about rheumatoid arthritis could decrease the disparity in management.

Gout

Gout, one of the most common forms of inflammatory arthritis, is characterized by severe joint pain and destruction. A population-based cohort study demonstrated that African-Americans were at an increased risk of gout.16 African-Americans with gout have also been found to function worse than their Caucasian counterparts.17 Another database study found that African-Americans with gout were less likely to receive urate-lowering therapy with allopurinol.18 Studies have shown a similar efficacy of ULT between black and white patients.19^,20 These results suggest that decreasing the disparity in gout treatment will improve disease severity in African-Americans.

SLE/Lupus

Ethnic disparity has been widely studied in SLE, with findings that West-African immigrants experience SLE (lupus) more than those native to Europe or America, with many having the condition before migration. A San Francisco study found SLE was four times higher in African-American women than in Caucasian women. Among Asians, SLE is reported to be more frequent among Chinese settling outside China.21

Joint Replacement

Total hip and knee replacements, generally indicated for end-stage arthritis, are two of the most common and successful major surgical procedures performed in the United States. Outcomes after total joint replacement are similar between black and white patients after controlling for socioeconomic factors.22 Unfortunately, racial disparities in the utilization of these procedures has been demonstrated in multiple studies. A Medicare database study by Singh et al demonstrated that blacks are less likely to receive joint replacement surgery compared to whites. Importantly, the utilization disparity did not improve over an 18-year period. Blacks also had inferior outcomes including longer hospital stays and higher rates of readmission.23 Another prospective study revealed that blacks are less likely to receive a recommendation for joint replacement surgery; however, this difference appeared to be related to patient treatment preference.24 African American patients are also less familiar with TKA than their white counterparts and more likely to anticipate greater perioperative pain and longer recovery.25,26 Thus, patient education about the procedure is likely a major factor that will increase utilization of joint replacement procedures by African-Americans.

Self-Reported Arthritis

In 2015, non-Hispanic whites and Non-Hispanic blacks self-reported doctor-diagnosed arthritis (told be a doctor they have arthritis) at similar rates (22.6/100 persons and 22.2/100, respectively), while persons of Hispanic ethnicity reported a lower rate (15.4/100). Persons of non-Hispanic other/mixed race did not report in sufficient numbers to be cited. (Reference Table 7D.4.1 PDF [23] CSV [24])

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[26]

The numbers reported for arthritis-attributable activity limitations as a total followed the same pattern as doctor-diagnosed arthritis, with non-Hispanic whites and non-Hispanic blacks similar (11.1/100, 10.9/100, respectively), Hispanics much lower (5.7/100), and insufficient numbers of non-Hispanic others/mixed race to be cited. However, by specific type of limitation, non-Hispanic blacks report higher rates than other racial/ethnic groups. (Reference Table 7D.4.1 PDF [23] CSV [24])

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[28]

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[30]

In 2015, those of Hispanic ethnicity reported more lost work days due to arthritis, on average, than other racial/ethnic groups. (Reference Table 7D.4.2 PDF [31] CSV [32])

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[34]

Hospital Discharges for Arthritis

Considering only hospitalizations with an arthritis diagnosis, in 2013, non-Hispanic blacks had a slightly higher rate (2.8/100 persons) than non-Hispanic whites or Hispanics (2.6/100), with non-Hispanic others/mixed race much lower (1.1/100). The HCUP NEDS (emergency department) database does not report race/ethnicity, hence no numbers are available for other types of healthcare visits. Non-Hispanic blacks also had slightly longer hospital stays with an arthritis diagnosis. (Reference Table 7D.4.2 PDF [31] CSV [32])

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[36]

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[38]

Arthroplasty Procedures

Joint replacement is a common procedure performed to alleviate the pain from arthritis. As noted above, the literature reports lower rates of hip and knee procedures among non-Hispanic blacks. This finding is supported by the rates of all arthroplasty procedures performed in hospitals in 2013. Non-Hispanic white persons received 80% of hip replacements and 77% of knee replacements compared to the 62% of the population they represented. All other racial/ethnic groups had small shares of procedures than they represented in the population. (Reference Table 7D.4.3 PDF [39] CSV [40])

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[42]

• 1. Obana KK, Davis J. Racial disparities in the prevalence of arthritis among Native Hawaiians and Pacific Islanders, Whites, and Asians. Hawaii J Med Public Health 2016:75(6);155-161.
• 2. CDC. Racial/ethnic differences in the prevalence and Impact of doctor-diagnosed arthritis, United States, 1989-1991. MMWR Weekly 1996:45(8);373-378. https://www.cdc.gov/mmwr/preview/mmwrhtml/00041424.htm [43]. Accessed April 5, 2019.
• 3. a. b. Bolen J, Schieb L, Hootman JM, et al. Differences in the prevalence and impact of arthritis among racial/ethnic groups in the United States, National Health Interview Survey, 2002, 2003, and 2006. Prev Chronic Dis 2010;7(3):A64. http://www.cdc.gov/pcd/issues/2010/may/10_0035.htm [44]. Accessed April 5, 2019.
• 4. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Women's Health USA 2013. Rockville, Maryland: U.S. Department of Health and Human Services, 2013.
• 5. Burns R, Graney MJ, Lummus AC, Nichols LO, Martindale-Adams J. Differences in self-reported osteoarthritis disability and race. J Natl Med Assoc 2007;99(9):1046e51.
• 6. Golightly YM, Dominick KL. Racial variations in self-reported osteoarthritis symptom severity among veterans. Aging (Milano) 2005;17: 264e9.
• 7. Song J, Chang HJ, Tirodkar M, et al. Racial/ethnic differences in activities of daily living disability in older adults with arthritis: a longitudinal study. Arthritis Care Res 2007; 57(6):1058e66.
• 8. a. b. Bolen J. Racial/ethnic differences in the prevalence and impact of doctor-diagnosed arthritis-United States 2002. MMWR 2005:54(5);119-123.
• 9. “Race Tied to Risk for Arthritis in Large Joints." US Department of Health and Human Services, Health Day, October 21, 2011 - http://healthfinder. gov/news/newsstorv.aspx?Docid=658088 [45].
• 10. Jordan JM., Effect of race and ethnicity on outcomes in arthritis and rheumatic conditions. Curr Opin Rheumatol 1999:11(2);98-103.
• 11. Losina E, Walensky RP, Reichmann WM, et al. Impact of obesity and knee osteoarthritis on morbidity and mortality in older Americans. Ann Intern Med 2011;154(4):217–226. doi:10.7326/0003-4819-154-4-201102150-00001.
• 12. a. b. Del Rincon I, Battafarano DF, Arroyo RA, et al. Ethnic variation in the clinical manifestations of rheumatoid arthritis: role of HLA–DRB1 alleles. Arthritis Rheum 2003:49(2);200-208.
• 13. a. b. Greenberg JD, Spruill T, Shan Y, et al. Racial and ethnic disparities in disease activity in rheumatoid arthritis patients. Am J Med 2013:126(12);1089-1098]
• 14. Bruce B, Fries JF, Murtagh KN. Health status disparities in ethnic minority patients with rheumatoid arthritis: a cross-sectional study. J Rheumatol 2007;34(7):1475-1479.
• 15. Constantinescu F, Goucher S, Weinstein A, Fraenkel L. Racial disparities in treatment preferences for rheumatoid arthritis. Med Care 2009;47(3):350-355.
• 16. Maynard JW, McAdams-DeMarco MA, Law A, et al. Racial differences in gout incidence in a population-based cohort: atherosclerosis risk in communities study. Am J Epidemiol 2014;179(5):576-583.
• 17. Singh JA. Racial and gender disparities among patients with gout. Curr Rheumatol Rep 2013;15(2):307.
• 18. Krishnan E, Lienesch D, Kwoh CK. Gout in ambulatory care settings in the United States. J Rheumatol 2008;35(3):498-501.
• 19. Becker MA, Schumacher HR, Espinoza LR, et al. The urate-lowering efficacy and safety of febuxostat in the treatment of the hyperuricemia of gout: the CONFIRMS trial. Arthritis Res Ther 2010;12(2):R63.
• 20. Singh JA. Can racial disparities in optimal gout treatment be reduced? evidence from a randomized trial. BMC Medicine 2012;10:15.
• 21. Siddiq AB. Editorial: Ethnicity in rheumatic disease. Int J Clin Rheumat 2018:13(3);159-161.
• 22. Goodman SM, Mehta B, Zhang M, et al. Disparities in total hip arthroplasty outcomes: census tract data show interactions between race and community deprivation. JAAOS 2018;26(21):e457-e464.
• 23. Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis 2013;73(12):2107-2115.
• 24. Hausmann LR, Mor M, Hanusa BH, et al. The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting. J Gen Intern Med 2010;25(9):982-988.
• 25. National Institutes of Health (NIH) Consensus Statement on total knee replacement. NIH Consens State Sci Statements 2003;20:1–34.
• 26. Byrne MM, Souchek J, Richardson M, Suarez-Almazor M. Racial/ethnic differences in preferences for total knee replacement surgery. J Clin Epidemiol 2006;59:1078–1086.

Race and ethnicity are important factors in the incidence of osteoporosis. The World Health Organization defines osteoporosis as a T score less than -2.5.1 African-Americans tend to have higher bone mass levels than Caucasians and Asians.2^,3 In adults 50 years of age and older, approximately 10% of non-Hispanic white women have osteoporosis, compared with 6% of non-Hispanic black women and 10% of Hispanic women. It is estimated that an additional 50% of non-Hispanic white and Asian women have osteopenia, compared with 39% of black women and another 38% of Hispanic women.4^,5

Osteoporotic fractures are a major health care concern due to their morbidity and mortality along with health expenditures. In 1995, the estimated health care costs associated with osteoporotic fractures was 13.8 billion.6 Decreased bone strength predisposes patients to an increased risk of fragility fractures, especially hip fractures. African-Americans have the lowest rates of hip fractures since they have the highest bone density.7 In a database study, Cheng et al reported that among traditional Medicare beneficiaries with fractures, osteoporosis was diagnosed nearly twice-as-often for white women compared with black women across all age groups.8 Ethnicity and race influenced the risk of fracture even after adjusting for multiple variables. Overall, the risk of fracture was 49% lower among African American women than among white women.9 Longer hip axis lengths have also been linked to an increased risk of hip fracture and hip axis lengths are reportedly shorter among African Americans and Asians, even after adjusting for height.10 African-American women who sustain an osteoporotic fracture, unfortunately, experience higher morbidity and mortality in comparison.11 This is possibly due to differences in hospital volume or it could reflect variations in care.

Race and ethnicity also are important factors in the screening and treatment of osteoporosis. In a retrospective review, Curtis et al found a significant disparity in recommendation for osteoporosis screening between AA and white women. Among Medicare enrollees, 33% of white women have screenings for BMD, but only 5% of African American women have such screenings.12 Among women with fractures, African Americans had a lower likelihood of both BMD testing and treatment.10^,13 Hamrick et al reported that while 80% of white women received pharmacotherapy after osteoporosis diagnoses, only 68% of black women did.14 A cross sectional study by Curtis et al showed that African Americans are significantly less likely than Caucasians to receive osteoporosis medication. Minority women are less likely to receive hormone replacement therapy.15

Hospital Discharges for Osteoporosis

In 2013, 892,600 patients discharged from hospitals in the US had a primary (first) diagnosis of osteoporosis. The distribution of persons with a primary diagnosis of osteoporosis did not reflect other data that indicates lower rates of osteoporosis among non-Hispanic blacks and higher rates among non-Hispanic whites and those of Hispanic ethnicity. Among this group, only 7% were classified as non-Hispanic whites.

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[47]

Within the same time period, 540,600 patients were discharged with a fragility fracture diagnosis, and may or may not have had a diagnosis of osteoporosis. Among those with a fracture diagnosis, 82% were non-Hispanic white persons, with all other racial/ethnic groups accounting for only 4%-5% of discharges with a fracture. (Reference Table 7D.5 PDF [48] CSV [49])

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[51]

The differences in hospital discharges for osteoporosis and fragility fractures from known prevalence rates may reflect treatment rates among racial/ethnic groups and coding of fractures before the underlying cause of the fracture in medical records, particularly among non-Hispanic white patients.

• 1. Kanis JA, McCloskey EV, Johansson H, et al. A reference standard for the description of osteoporosis. Bone 2008;42(3):467–475.
• 2. Tracy JK, Meyer WA, Flores RH, Wilson PD, Hochberg MC. Racial differences in rate of decline in bone mass in older men: the Baltimore men's osteoporosis study. J Bone Miner ResI 2005;20(7):1228-1234.
• 3. Hochberg MC. Racial differences in bone strength. Trans Am Clin Climatol Assoc 2007;118:305-315.
• 4. Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res 2014;29(11):2520-2526.
• 5. Looker AC, Melton LJ 3rd, Harris TB, Borrud LG, Shepherd JA. Prevalence and trends in low femur bone density among older US adults: NHANES 2005–2006 compared with NHANES III. J Bone Miner Res 2010;25:64–71.
• 6. Ray NF, Chan JK, Thamer M, Melton LJ. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 1997;12(1):24-35.
• 7. Silverman SL, Madison RE. Decreased incidence of hip fracture in Hispanics, Asians, and blacks: California Hospital Discharge Data. Am J Public Health 1988;78:1482–1483.
• 8. Cheng H, Gary LC, Curtis JR, et al. Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data. Osteoporos Int 2009;20(9):1507-1515.
• 9. Cauley JA. Defining ethnic and racial differences in osteoporosis and fragility fractures. Clin Orthop Relat Res 2011;469(7):1891-1899.
• 10. a. b. Cummings SR, Cauley JA, Palermo L, et al. Racial differences in hip axis lengths might explain racial differences in rates of hip fracture. Study of Osteoporotic Fractures Research Group. Osteoporos Int 1994;4(4):226-229.
• 11. Jacobsen SJ, Goldberg J, Miles TP, et al. Race and sex differences in mortality following fracture of the hip. Am J Public Health 1992;82:1147–1150.
• 12. Curtis JR, Carbone L, Cheng H, et al. Longitudinal trends in use of bone mass measurement among older Americans, 1999– 2005. J Bone Miner Res 2008;23:1061–1067.
• 13. Faulkner KG, Cummings SR, Nevitt MC, et al. Hip axis length and osteoporotic fractures: study of Osteoporotic Fractures Research Group. J Bone Miner Res 1995;10:506–508.
• 14. Hamrick I, Whetstone LM, Cummings DM. Racial disparity in treatment of osteoporosis after diagnosis. Osteoporos Int 2006;17(11):1653-1658.
• 15. Curtis JR, McClure LA, Delzell E, et al. Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med 2009;24:956–962.

There is a paucity of literature regarding racial differences in sports-related injuries. Anterior cruciate ligament rupture is a common sports injury. A retrospective study of women’s professional basketball players over a 4-year span reported a higher rate of ACL tears in white players than their African-American counterparts.1 A difference in femoral morphology has been found between racial groups and may be a contributor to the potential difference in ACL injury rates.2 Another significant sports injury, lower extremity tendon ruptures, was analyzed in a military database study. Quadriceps, patellar, and Achilles tendon ruptures were examined. African-American service members had a significantly higher rate of lower extremity tendon rupture when compared to white service members.3 A biomechanical study showed a higher Achilles tendon stiffness in black athletes which potentially makes them more susceptible to rupture.4

Ankle sprains are the most common injury in athletic populations.5 Both AA and white races have a higher rate of ankle sprains than Hispanics.6 This is potentially due to the difference in type of athletic activities, for example soccer vs basketball.

Falls are an important cause of hospital admission and can lead to injuries such as hip and distal radius fractures. Whites have a higher incidence of falls than African-Americans.7 In a prospective study, Kiely et al also found a higher rate of falls in whites; however, after adjusting for confounding variables including types of activity and community characteristics, the difference was minimized.8 According to a retrospective study by Strong et al, in patients 65 and older admitted for falls, AA patients have a higher risk of mortality after discharge from the hospital.9 This highlights the need for improved follow-up after discharge.

African-Americans have a lower overall incidence of fractures than whites.10^,11; however, there is minimal research on fracture risk other than in the hip. Much of this is related to higher bone density in blacks along with the difference in activities engaged in. Some studies have also investigated for disparities in the management of fractures. Opel et al found that after adjusting for insurance status and severity of injury, African-Americans had significantly lower odds of receiving surgical treatment for humeral shaft fractures than white males.12 The results suggested a possible bias in treatment decision-making, leading to less aggressive management in African-Americans.

Self-Reported Injuries

Non-Hispanic whites self-report the highest rate of injuries (3.3/100 persons) for which they sought medical care in 2013-2015. Non-Hispanic other/mixed race persons reported the lowest rate 1.3/100). (Reference Table 7D.6 PDF [52] CSV [53])

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[55]

Cause of Injuries

Data for both self-reported injuries for which medical care was sought and for hospital discharges support research findings reported above. Non-Hispanic white persons represented two-thirds or more of reported injuries from falls, trauma, or other causes, but were a smaller share of trauma accidents than falls or other causes.

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[57]

Among hospital discharges for injuries, 55% of non-Hispanic white persons were hospitalized due to a fall, compared to 33% of non-Hispanic black persons. Persons of Hispanic ethnicity had the highest share of discharges due to trauma injuries (34%) , followed closely by non-Hispanic blacks (31%). (Reference Table 7D.6 PDF [52] CSV [53])

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[59]

• 1. Trojian TH, Collins S. The anterior cruciate ligament tear rate varies by race in professional women’s basketball. Am J Sports Med 2006;34(6):895–898.
• 2. Craig E. Intercondylar shelf angle: a new method to determine race from the distal femur. J Forensic Sci 1995;40(5):777-782.
• 3. Owens B, Mountcastle S, White D. Racial differences in tendon rupture incidence. Int J Sports Med 2007;28(7):617-620.
• 4. Fukashiro S, Abe T, Shibayama A, Brechue WF. Comparison of viscoelastic characteristics in triceps surae between Black and White athletes. Acta Physiol Scand 2002;175(3):183-187.
• 5. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med 2007;37(1):73-94.
• 6. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains  in the United States. J Bone Joint Surg Am 2010;92(13):2279-2284.
• 7. Geng Y, Lo JC, Brickner L, Gordon NP. Racial-ethnic differences in fall prevalence among older women: a cross-sectional survey study. BMC Geriatr 2017;17(1):65.
• 8. Kiely DK, Kim DH, Gross AL, et al. Fall risk is not black and white. J Health Dispar Res Pract 2015;8(3):72-84.
• 9. Strong BL, Torain JM, Greene CR, Smith GS. Outcomes of trauma admission for falls: influence of race and age on in hospital and post-discharge mortality. Am J Surg 2016;212(4):638-644.
• 10. Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology 1996;7(6):612-618.
• 11. Griffin MR, Ray WA, Fought RL, Melton LJ 3rd. Black-white differences in fracture rates. Am J Epidemiol 1992;136(11):1378-1385.
• 12. Opel D, Rapone B, Krishnamoorthy B, Yoo J, Meeker J. Race and gender influence management of humerus shaft fractures. J Orthop 2018;15(2):540-544.

Primary sarcomas represent the least common malignancies in bone, although osteosarcoma represents the most common nonhemoapoietic primary tumor of bone. Osteosarcoma is a primary malignant bone-producing tumor. In a review by Ottaviani, osteosarcoma had a higher incidence in African-Americans (AA) (6.8 per million persons per year] and Hispanics (6.5 per million) than in whites (4.6 per million).1 The reason for a potential higher incidence in blacks may be due to genetic factors, but it has not been determined.

Ewing sarcoma is a malignant tumor of bone and soft tissue. Race is an important factor in the incidence of ES, with Caucasians more likely to develop ES than African Americans or Asians. In a database study, Worch et al showed that ES is 8 times more likely to occur in the white population compared with African Americans and 1.9 times more likely to occur in the white population compared with Asian-Americans and Native Americans.2 Another database study by Worch et al., however, showed overall survival was significantly worse for patients. These results suggest a genetic component to the disease.3

Soft tissue sarcomas are the sixth most common primary cancer among young adults and adolescents aged 15-29.4^,5 Musculoskeletal tumors included in this group include rhabdomyosarcoma, synovial sarcoma, and liposarcoma. Hsieh et al. showed that AA had the highest incidence rates of fibromatous neoplasms, rhabdomyosarcoma, and Kaposi sarcoma among all racial/ethnic groups. This study also revealed that Hispanic males and females had significantly higher liposarcoma rates than other racial/ethnic groups.6 A database study by Alamanda et al found that African Americans encounter death due to soft tissue sarcomas at a much larger proportion and faster rate than their respective white counterparts. African Americans frequently presented with a larger size tumor, do not undergo surgical resection, or receive radiation therapy as frequently as compared with their white peers.7^,8

Multiple myeloma is a cancer of plasma cells and is the most common malignancy arising in bone. Multiple myeloma (MM) is the most common hematologic malignancy among blacks in the US and the second most common hematologic malignancy in the country.9 A large database study concluded that blacks have an earlier onset and a higher incidence of MM This study also found African-Americans to have better survival rates, which is different than most conditions found in the literature.10 These results suggest a different disease biology. Fiala et al performed a database study regarding racial disparities in multiple myeloma treatment. After controlling for overall health and potential access barriers, black patients were found to be 37% less likely to undergo stem cell transplantation, and 21% less likely to be treated with bortezomib, an antineoplastic agent which is considered the gold standard in chemotherapy treatment of MM. Moreover, the authors found that the underuse of these treatments was associated with an increase in the incidence of death among black patients.11 The difference in treatment may be due to patient preference, patient education, or implicit biases in management. More research is needed to examine these factors.

Musculoskeletal Cancers

Incidence of musculoskeletal cancers is reported in BMUS based on data published by the National Cancer Institute’s Surveillance, Epidemiology and End Results Program (SEER). Data is shown for bones and joints cancers but is not broken down for specific types of sarcomas. Myeloma (multiple myeloma) is a cancer of plasma cells in the bone marrow. Based on SEER data 2010-2014, non-Hispanic whites have a higher incidence of bones and joints cancers than do non-Hispanic blacks and those of Hispanic ethnicity, but all have very low incidence. Non-Hispanic white males had the highest incidence at 12 cases per one million persons. Myeloma has a higher incidence, with non-Hispanic blacks higher than non-Hispanic whites. Incidence was not reported for those of Hispanic ethnicity. SEER reported death rates for musculoskeletal cancers follow the same pattern as incidence rates but are much lower. (Reference Table 7D.7 PDF [60] CSV [61])

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• 1. Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. Cancer Treat Res 2009;152:3-13.[\fn] Another study examined the epidemiology of osteosarcoma in New York (NY) state and found higher incidence in AA in NY residents.Polednak AP. Primary bone cancer incidence in black and white residents of New York State. Cancer 1985;55(12):2883-2888.
• 2. Worch J, Cyrus J, Goldsby R, et al. Racial differences in the incidence of mesenchymal tumors associated with EWSR1 translocation. Cancer Epidemiol Biomarkers Prev 2011;20(3):449-453.
• 3. Worch J, Matthay KK, Neuhaus J, Goldsby R, DuBois SG. Ethnic and racial differences in patients with Ewing sarcoma. Cancer 2010;116(4):983-988.
• 4. Bleyer A, O’Leary M, Barr R, Ries LAG. Cancer epidemiology in older adolescents and young adults 15 to 29 years of age, including SEER incidence and survival: 1975–2000 (NIH Publication No. 06-5767). Bethesda, MD: National Cancer Institute; 2006. 2.
• 5. Albritton KH. Sarcomas in adolescents and young adults. Hematol Oncol Clin North Am 2005;19(3):527–546.
• 6. Hsieh MC, Wu XC, Andrews PA, Chen VW. Racial and ethnic disparities in the incidence and trends of soft tissue sarcoma among adolescents and young adults in the United States, 1995-2008. J Adolesc Young Adult Oncol 2013;2(3):89-94.
• 7. Alamanda VK, Song Y, Schwartz HS, Holt GE. Racial disparities in extremity soft-tissue sarcoma outcomes: a nationwide analysis. Am J Clin Oncol 2015;38(6):595-599.
• 8. Lazarides AL, Visgauss JD, Nussbaum DP, et al. Race is an independent predictor of survival in patients with soft tissue sarcoma of the extremities. BMC Cancer 2018;18(1):488.
• 9. Benjamin M, Reddy S, Brawley OW. Myeloma and race: a review of the literature. Cancer Metastasis Rev 2003;22(1):87-93.
• 10. Waxman AJ, Mink PJ, Devesa SS, et al. Racial disparities in incidence and outcome in multiple myeloma: a population-based study. Blood 2010;116(25):5501-5506.
• 11. Fiala MA, Wildes TM. Racial disparities in treatment use for multiple myeloma. Cancer 2017;123(9):1590-1596.

The impact of race and ethnicity on the etiology and management of musculoskeletal conditions requires more extensive investigation. The influence of race and ethnicity on the incidence of musculoskeletal conditions may be due to genetics along with difference in activities participated in. Genetic differences, however, have not been well defined in the vast majority of conditions. Clarifying this may lead to advancements in the management of certain conditions including osteoporosis, multiple myeloma, and spinal deformities.

The difference in incidence is also largely influenced by the lower rate of presentation by ethnic minorities to a physician. We also need to enhance awareness of any disparities in the management of musculoskeletal conditions. Race-based differences in the treatment of certain conditions may indicate an inherent bias. They may also be related to access issues and patient perception. The treatment of disabling osteoarthritis is a good example. Osteoarthritis has been found to be as prevalent in AA and Hispanic populations as in non-Hispanic white populations. Several studies, however, have shown that minorities undergo joint replacement procedures at a significantly lower rate. Ethnic minorities are less familiar with certain surgical procedures. Also, certain primary care physicians are less likely to refer patients to surgeons for consultations depending on their access to these services or their perception of what their patient's insurance may allow for. Unfortunately, AAs may have a higher rate of adverse outcomes.1 The reasons for this disparity are multifactorial but include less familiarity and lower expectations with the procedure in minority populations. Also, minorities tend to have procedures at lower volume hospitals which may contribute to more adverse outcomes.

Lastly, access to adequate postoperative care should be considered in adverse outcomes, be it from another family member that can afford to miss workdays or certain ancillary services provided to the patient.

• 1. Zhang W, Lyman S, Boutin-Foster C, et al. Racial and ethnic disparities in utilization rate, hospital volume, and perioperative outcomes after total knee arthroplasty. J Bone Joint Surg Am. 2016 Aug 3;98(15):1243-52. doi: 10.2106/JBJS.15.01009.

A greater awareness regarding the disparities in musculoskeletal conditions and their management is needed. Further research into the reasons for differences in incidence of certain conditions will allow for better and possible earlier intervention. Moreover, enhanced understanding and defining the causes of racial disparities in the management of musculoskeletal diseases will allow improved and more equitable care in an increasingly diverse population.