 | | This X-ray of an arthritic knee shows bone spurs (white arrows) and loss of the cartilage joint space (black arrows). In a normal knee, the space between the bones is the same on both sides. |
What are the Symptoms?
Osteoarthritis can affect any joint in the body, with symptoms ranging from mild to disabling. It tends to be most noticeable in weight bearing joints such as the hip and knee. Pain or a dull ache usually develops gradually.
The symptoms are variable and do not always reflect the amount of wear in the joint. Some completely worn out, bone-on-bone joints are minimally symptomatic. Others with only mild x-ray changes can be quite painful as the cartilage is actively breaking down, releasing enzymes and inflaming the joint.
Symptoms include pain, stiffness, swelling (effusion), grinding or crunching, and jelling (when the joint jells up or is stiff for the first few movements after being still). Knees in particular may catch and "lock up" or buckle.
 | Normal joint space between the
Femur and Tibia. |
Increasing wear over time can cause deformity of the joint. Symptoms are usually worse with use or weight bearing and relieved by rest. Pain may be worse in the morning and feel better with activity which "loosens up" the joint. As the process progresses, however, rest pain can develop.
Symptoms are often worse in cold, damp weather conditions. Atmospheric conditions have been proven to affect arthritis symptoms, and explain why some people like to go south to hotter, drier climates in winter.
How is it treated?
There are many things that can be done to help the symptoms of arthritis. Although the wear will inevitably slowly progress over time, no one can predict the rate of progression. The ultimate fix for the worn out joint is to do a joint replacement, which involves putting new artificial surfaces on the ends of the worn out bones. Although the following treatments can be done individually, most commonly they are used in conjunction with each other as they all provide additive benefits.
WEIGHT LOSS: Weight loss is extremely helpful as it decreases the forces on the joint. Slow, steady weight loss by decreasing calorie consumption is the most effective and sustainable. Ten pounds taken off the body can relieve up to 50 pounds of pressure on the knee during weight bearing activities.
EXERCISE: Exercise is helpful and important to joint health. Arthritis pain naturally causes most adults to slow down and limit activity. Not exercising, however, can result in more problems. Recent research shows that over time inactivity actually worsens osteoarthritis pain.Strong muscles around a joint help to protect it. Your doctor can recommend ways to exercise that would not put further stress on the joint. In general, impact loading exercises (eg. running and jumping) are avoided. Sometimes a physical therapist is used to teach a good home exercise program.
Because exercise is painful for so many adults with arthritis, it may be hard to understand how exercise helps to actually relieve pain. First, exercise increases blood flow to cartilage, bringing it the nutrients it needs to stay healthy.
In addition, specific exercises will strengthen the muscles that surround your joints. The stronger your muscles are, the more weight they can handle. As a result, the bones in your joints carry less weight, and your damaged cartilage is better protected.
Having strong muscles to support your joints is even more important if you are overweight. And exercise, of course, can help you with weight loss. Losing just a few pounds can make a big difference in the amount of stress you place on your weight-bearing joints, like your hips and knees.
Studies have also found that people who exercise are less likely to be depressed or feel anxious. Exercise can help you manage stress and improve your sleep patterns. Getting a full night's sleep is especially important because arthritis symptoms often worsen when you are tired. With hip and knee arthritis, it can be helpful to sleep with a pillow under your knees or between your legs for comfort.
Your program should include three types of exercise:
- Range-of-Motion Exercises to improve your flexibility and reduce stiffness in your joints.
- Strengthening Exercises to help build muscle mass and protect your joints.
- Aerobic Exercise to strengthen your heart and lungs, and improve your overall fitness. Aerobic exercise is key to controlling your weight, as well.
Typically, a moderate, balanced fitness program is recommended. If you regularly do high-impact aerobic exercises, such as running or competitive sports, your doctor may recommend that you switch to low-impact activities that place less stress on your weight-bearing joints. Walking, swimming, and cycling are good alternatives. A stationary exercise bike, even a recumbent one, can provide aerobic exercise for those who cannot walk well or have balance problems. To help with balance, strength, and flexibility, your doctor or therapist may suggest you try yoga or tai-chi, a program of exercises, breathing, and movements based on ancient Chinese practices.
If it has been awhile since you have exercised, slow and steady is the safest and most effective way to begin a fitness program. Your goal is 20 to 30 minutes of aerobic activity, 3 to 4 times a week. If this is challenging for you, you can break it up into shorter segments, such as a 10-minute walk in the morning and a 10-minute walk in the evening.Strength exercises can be done every other day, and you can work on your range of motion every day. Always begin with a warm up to prepare your body for all types of exercise.As you get stronger, gradually increase the duration of your aerobic exercise and the number of strength exercise repetitions. Be sure not to overdo it. You should not feel serious pain after exercise, but a little bit of muscle "burn" is OK. It is typical to feel some muscle soreness the day after you exercise, but if you feel so sore that it is difficult to move, then you have overdone your exercise. Iceing for up to 20 min after exercise or activity can help with swelling and pain. You can reduce muscle soreness with a heating pad, warm bath or shower. Some "over the counter" topical creams / rubs can also help.
BRACES: The use of braces and/or assistive devices such as a cane can help decrease the pressure on the joint and allow further and longer use of the joint without pain. Even simple joint sleeves or wraps can help to decrease pain and more elaborate braces (unloaders) can take weight off the joint. In general, canes should be held on the same side as an affected knee, and on the opposite side of an affected hip.
NUTRITIONAL SUPPLEMENTS: There are a variety of supplements available that claim benefit in treating arthritis. Most of them have not been rigorously studied, and they are not subject to FDA quality monitoring. Dietary supplements like Glucosamine and Chondroitin sulfate are not tested or analyzed by the FDA before they are sold to consumers. That means consumers can't be sure they're getting what they pay for when they purchase bottles of supplements.
Glucosamine with Chondroitin sulfate is the best known arthritis supplement and does help some patients.These are two large molecules that are found in the cartilage of our joints. Supplements sold over-the-counter are usually made from synthetic or animal products. Glucosamine is found naturally in the body and stimulates the formation and repair of articular cartilage. Chondroitin sulfate is another natural substance found in the body. It prevents other body enzymes from degrading the building blocks of joint cartilage.Glucosamine and/or chondroitin sulfate may be particularly helpful in the early stages of osteoarthritis of the knee. They can help reduce swelling and tenderness, as well as improve mobility and function. If you decide to take this supplement, it is important not to discontinue it too soon. At least two months of continuous use is necessary before the full effect is realized. Although Glucosamine and Chondroitin sulfate are natural substances, they can cause side effects such as headaches, stomach upset, nausea, vomiting, and skin reactions. These supplements can interact with other medications, so keep your doctor informed about your use of them.
Adequate vitamin D levels are also important for bone and joint health, and many people in the Northwest are deficient due to lack of adequate sun exposure. A blood test can determine your levels, and your doctor can recommend an appropriate amount to supplement with.
MEDICATION: Acetaminophen (Tylenol) is a great medicine to use to treat joint pain. It is one of the safest drugs available as long as not more than 4 grams a day is used. Patients need to be careful because acetaminophen is often combined with other medicines, especially those for treating colds and fevers. It works synergistically with other medicines such as nonsteroidals (NSAIDs), and can be taken with them. We typically recommend 2 extra-strength (500mg) Tylenol be taken 3 times a day, and many patients find that taking the last dose before bed helps with night time aching.
Nonsteroidal anti-inflammatories (NSAIDs) such as Ibuprofen (Advil), Naprosyn (Aleve), and others available by prescription are often recommended. These help by blocking the inflammation producing action of enzymes created in arthritic joints. The most common side effects involves stomach upset or irritation and sometimes several should be tried to find the one that works best for you.
Some antidepressants, notably Cymbalta, have recently been found to be helpful in treating arthritis pain. In general, physicians try to minimize narcotic use for arthritis as it is very easy for patients to get addicted, even to low doses, and the pain relieving effects decrease with longer term use.
Cortisone injections into joints, particularly when they are swollen, can be very helpful, especially in the short term. Cortisone acts by quieting down the inflamed lining tissue in the joint, thereby decreasing the production of inflammatory enzymes and joint fluid. Cortisone injections are generally recommended no more than 4 times a year in the same joint.
VISCOSUPPLEMENTATION: Another treatment option is a procedure called viscosupplementation. In this procedure, a thick fluid called hyaluronic acid is injected into the knee joint. Hyaluronic acid is a naturally occurring substance found in the synovial (joint) fluid. It acts as a lubricant to enable bones to move smoothly over each other and helps cartilage act as a shock absorber for joint loads. People with osteoarthritis have a lower-than-normal concentration of hyaluronic acid in their joints. Injecting it helps to normalize the biochemical environment of the arthritic joint. Viscosupplementation can give up to six months improvement in some people. It works best in joints that are not too worn down and is currently only FDA approved for use in the knee.
Commonly used viscosupplements include Synvisc, Euflexxa, and Hyalagan. Although Synvisc can be given as a single large injection, viscosupplementation is commonly given as a series of 3 injections one week apart. The maximum benefit is often not achieved until 6 weeks after the injections start, and the series can be repeated at a minimum of 6 month intervals if it is effective. Although viscosupplementation may be effective in relieving the symptoms of arthritis, it has never been shown to reverse the arthritic process or re-grow cartilage.
ALTERNATIVE THERAPIES: Alternative therapies include the use of acupuncture and magnetic pulse therapy. Many forms of therapy are unproven, but reasonable to try, provided you find a qualified practitioner and keep your physician informed of your decisions.
Acupuncture uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices.
Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Like many alternative therapies, magnetic pulse therapy has its devotees but has yet to be proven to be effective.
SURGERY: Arthroscopic surgery to clean up the joint can be helpful if there are mechanical symptoms of catching and locking such as from a torn meniscus. However, arthroscopic surgery to "wash out" the joint provides very limited short term benefits if it is used to treat only the osteoarthritic symptoms of swelling, grinding, and pain.
Other surgical treatments include: osteotomies, which involve realigning the bones to take pressure off the joint; fusions, which eliminate the joint altogether; and joint replacement, which resurfaces the joint with a smooth artificial surface. Your doctor would be happy to discuss the pros, cons, and appropriateness of these interventions with you.
Osteoarthritis is a condition that does not go away. Although symptoms wax and wane in an unpredictable fashion, osteoarthritis ultimately progresses. Patients must learn to live within the limitations their joints impose. However, these limitations can be minimized by appropriate use of the above interventions.
If you have questions or wish to schedule an evaluation during which you may discuss your options with a physician, please call us at (253) 833-7750.
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