By James A. Shapiro, MD
Osteoarthritis (OA), also known as Degenerative Joint Disease (DJD), is caused by the breakdown of the joint (articular cartilage) surfaces. OA is a very common and costly disease and is the most common source of disability. The chance of developing OA increases with age; 70% of the population older than 70 years has x-ray evidence of OA. Approximately 20 million people in the United States are affected by OA and this number is expected to increase to 67 million by 2030. This will lead to 25 million people with limitations from OA by 2030.
Osteoarthritis can occur in any joint, but most commonly affects the weight-bearing joints of the body; lower back, hip, knee, and ankle. It may also affect the neck, fingers, and the big toes. As the disease progresses, motion becomes more painful, less smooth, and limited. This causes inflammation, which in turn causes pain, swelling, and more stiffness. (Two good analogies for OA, might be a rusty hinge and an asphalt road with potholes.) Currently there is no “cure” for OA and there are risks for OA that cannot be modified such as age, sex, and genetics. There are some things to try to slow its progress, make the joint feel better, and maybe delay the need for surgery.
Since OA is a breakdown of cartilage or “wear and tear” process, reducing the stress on the joint is an essential portion of the treatment. The joint was designed to tolerate a certain amount of stress when it was healthy. Now that it is damaged, it can’t even deal with the “normal joint stresses.” The stress on the joint can be reduced by exercising, potentially altering your activities, and weight loss.
- Exercises. Exercises must work on improving your range of motion, strength, and aerobic capacity. Some good exercises include swimming, water aerobics/exercises, walking, cross-country skiing on level ground, and other “non-pounding” sports. A physical therapist or trainer can be helpful in setting up a program for you. Most important, if an exercise hurts, don’t do it and if you try an exercise and it doesn’t cause pain, it will probably work for you.
- Activity Modification. Alteration of your activities includes changing how you do certain activities, using assistive devices for certain activities, and possibly reducing or dropping some activities. This is best determined with the assistance of an occupational or physical therapist. Trial and error can also be used to determine which activities are okay. If you try an activity and it causes pain, don’t do it. On the other hand, if you try an activity and it doesn’t cause pain, it is probably okay for you.
- Weight Loss. For every pound of weight lose there is roughly a 4 pound reduction in stress to the knee when walking and up to a 10 pound reduction in stress to the knee with activities like stair climbing. There are studies that show a 5% reduction in weight resulted in an 18% improvement in function. This can be very difficult to achieve, especially when you are having pain, but it is essential. Before undertaking any weight loss program, please consult your medical doctor.
- Brace. In addition to reducing the stress on the joint through exercise, weight loss and activity modification a brace may be tried if your arthritis is only in one area for the knee.
Osteoarthritis causes pain and secondary inflammation due to the breakdown of the articular cartilage and creation of osteophytes (new bone around the arthritic joint). The pain and inflammation cause a reduction in the joint motion and daily function. Medications may be needed to help in reducing some of the symptoms of OA.
- Safest drug is Tylenol (acetaminophen). Acetaminophen is not an anti-inflammatory, but it may help with pain. Take up to 1 gram (2 extra-strength pills) 4 times a day. More then 4 grams per day may cause liver problems.
- Nonselective non-steroidal anti-inflammatory drug (NSAID). There is very good evidence that these medicines are helpful. There is no evidence that one nonselective NSAID is better than another. The biggest problem with these drugs is the possible gastro-intestinal (GI) and cardio-vascular (CV) problems. The longer you take these drugs, the higher the risk of problems. (Before starting on one of these drugs, please contact your medical doctor for his/her approval.) The NSAID’s available without prescriptions include ibuprofen and Aleve.
- Selective NSAID. These drugs were created to reduce the risks seen with the nonselective NSAIDs. There is only one still available, Celebrex. It has been found to be no better than the nonselective NSAIDs. Celebrex is only recommended in the case of patients at high GI risk. (A bleeding ulcer can occur even with Celebrex.)
- Topical pain relief options. Capsaicin is made from chili peppers. It is found in various lotions and it causes irritation to the nerves desensitizing then and reducing the pain. (You may need to use this cream for up to two weeks before seeing results.) Another option that has some possible benefit anti-inflammatory lotions. These are prescription lotions that are applied three to four times a day.
- Injections. Despite your best efforts, the OA joint may still be problematic. Your doctor will continue conservative treatment by having you keep up your stress relieving activities. If there is a large swelling inside the joint (an effusion), some of the fluid may be removed (an aspiration). An injection of steroids and/or visco-supplementation [hyaluronate or hyluronic acid (HA)] into the joint may be tried.
- Steroids. Steroids may be helpful for relieving rapid onset pain, but won’t last long. It helps by reducing the inflammation, but doesn’t change the arthritis. You can only get 3 injections per year into the joint.
- Hyluronic Acid. The HA may be tried to help relieve long standing pain. It may only help about 60-70% of the time, but has no adverse effects. It is slow to work, but may last for up to 6-months to a year if helpful. It works like putting a fancy oil on a rusty hinge. Depending on the HA used there will need to be one injection or one injection a week for three weeks.
Acupuncture is an oriental medical practice which uses fine needles to stimulate specific body areas and “energy flow” to relieve pain. Studies done have shown that acupuncture is better at relieving pain than improving function due to arthritis. Be sure your acupuncturist is certified, and be sure to ask about his/her sterilization practices for the needles.
If all of the conservative treatments have been tried and have been unsuccessful in sufficiently relieving the symptoms of OA, then you may want to talk to your doctor about surgical options. Surgical options include an arthroscopy, an osteotomy (a cut in the bone used to change the alignment of the limb), a partial replacement or resurfacing, or complete replacement. Be sure to talk to your medical team about the benefits and risks of these options.
If all of the conservative treatments have been tried and have been unsuccessful in sufficiently relieving the symptoms of OA, then you may want to talk to your doctor about surgical options. Surgical options include an arthroscopy, an osteotomy (a cut in the bone used to change the alignment of the limb), a partial replacement or resurfacing, or complete replacement. Be sure to talk to your orthopaedic surgeon about the benefits and risks of these options.