Osteoarthritis 

Osteoarthritis (OA) is the most common form of arthritis, affecting over 20 million people in the United States alone.  By the age of 50, most people have some signs of osteoarthritis.  Before age 45, osteoarthritis is more common in men.  After age 55, osteoarthritis is more common in women.

            Osteoarthritis is also known as degenerative osteoarthritis.  It is caused by a degeneration of the cartilage in joints.  Cartilage is a smooth, protein substance that serves as the shock-absorber between the joints.  As with any shock-absorber, repetitive use year after year takes its toll, causing the cartilage to become irritated, inflamed, and ultimately degenerate.  When cartilage degenerates, its cushioning effect is diminished and friction is created between bones.  In severe cases, the cartilage is essentially gone and bones grate directly on other bones.  As the cartilage degenerates, irritation, inflammation, pain, and loss of range of motion occurs within the joint itself.  In response, to bone rubbing on bone, new bony outgrowths called bone spurs may develop in and around the joint.  These bony outgrowths can be an additional cause of irritation and inflammation to the joint and surrounding soft tissues as they rub across the new bone spurs. 

            The joints that are most commonly affected by osteoarthritis are the hands, wrists, feet, and major weight-bearing joints such as the hips, knees, and spine.  These joints bear the brunt of repetitive trauma throughout one’s life and are therefore subject to the most stresses on the cartilage, leading to degeneration of the cartilage. 

            Most cases of osteoarthritis are caused by daily mechanical stresses from wear and tear.  These cases are termed primary osteoarthritis.  However, some cases of osteoarthritis are caused by an identifiable inciting cause.  These cases of osteoarthritis are termed secondary osteoarthritis.  Conditions that result in secondary osteoarthritis include obesity (the increased weight places increased stresses on the joints), a history of trauma or surgery to a joint, history of joint infection, bone disease, gout, pseudogout, diabetes, and congenital joint abnormalities.

How is osteoarthritis diagnosed?

            There is no blood test, radiograph, physical exam test, biopsy or other medical test that can in and of itself diagnose osteoarthritis.  Instead, your physician must listen to your story, take some tests, and ultimately put your whole picture together to determine if you have osteoarthritis and, more importantly, if it is the cause of your pain and/or stiffness.  The most important part of the diagnosis of osteoarthritis is the history that you give your doctor about your symptoms.  Unlike other forms of arthritis, osteoarthritis does not cause systemic illness such as fever, fatigue, and weight loss.  The most common symptom of osteoarthritis is joint pain that is worse after prolonged activity.  Often, people with osteoarthritis will complain of pain and stiffness in the morning or after prolong inactivity (watching a movie or taking a nap).  This pain and stiffness will typically get better after 10-30 minutes.  Once the joints are “warmed-up” the pain and stiffness tend to resolve.  However, after performing an activity such as walking, hiking, playing tennis, or using the affected joint for a prolonged period (playing the piano in hand osteoarthritis), the joint will become painful and stiff.  In severe osteoarthritis, the joint may be painful even at rest.

            Your doctor may take blood tests to exclude other potential causes of your joint pain.  An arthrocentesis may also be performed. This is a test in which a needle is inserted into the affected joint and the joint fluid is aspirated.  This fluid is then analyzed in a laboratory to also exclude other causes of joint pain including gout, pseudogout, infection, as well as other causes.  Most commonly a radiograph (x-ray) may be taken of the affected joint.  Common findings on x-ray evaluation indicative of osteoarthritis include joint space narrowing and bone spur formation, and subchondral cysts.  An x-ray is very good at showing bones but is not able to visualize cartilage.  However, it is important to realize that many people over the age of 50 will have evidence of osteoarthritis on x-ray even if they don’t have any symptoms.  Furthermore, the degree of osteoarthritis on x-ray does not necessarily correlate with the severity of symptoms that the person may be experiencing.  Some people will have very osteoarthritic appearing x-rays but be pain free.  Therefore it is very important for your health care provider to always treat you, not your x-ray.

            Other tests that your doctor may consider, depending on your symptoms, include a bone scan to help rule out other potential causes of your pain such as cancer or bone infection (osteomyelitis).

How is osteoarthritis treated?

            Osteoarthritis can be treated in a variety of ways depending on the symptoms. 

Weight reduction: If you are overweight or obese, weight reduction is very important.  Increased weight puts continual stress on your joints.  If overweight patients decrease their weight, they often notice a marked improvement in symptoms. 

Avoiding painful activities: It is also important to eliminate or reduce activities that cause excessive pain.  In osteoarthritis, pain is a good guide as to what you should and should not be doing. If you jog every morning and jogging causes a great deal of pain, it is important to limit that activity.  Try doing the offending activity fewer times per week. 

Rest: Resting the painful joint or joints allows the inflammation a chance to quiet down. 

Exercise:  While rest and avoidance of painful activities is important, it is also very important that you do not become inactive.  Exercise is excellent not just for your osteoarthritis but for your health in general.  Most forms of exercise do not aggravate osteoarthritic symptoms when performed at moderate intensity levels.  Swimming and other aquatic exercises is a terrific way to exercise.  When you are in the water, the effect of gravity on your joints is counterbalanced and your joints do not undergo the same stresses as they do on land.  Cycling, running on an elliptical machine, and other non-impact activities are particularly well-suited for people with osteoarthritis.  Be sure to consult with your individual doctor for an exercise regimen that is right for you.

Supportive Devices:  For some people, a supportive device such as a cane, walker, splint, or brace may be helpful.  People with hip osteoarthritis often use a cane to help unload stress from the hip joint.   In this case, the cane should be used in the hand opposite the painful hip (e.g. hand in right hand for left hip pain).  If indicated, your doctor and/or physical therapist will fit you for a cane and instruct you on how to use it.

Physical therapy:  It is important to stretch and strengthen your core muscles in your trunk and spine as well as the muscles surrounding the painful joint or joints.  By strengthening your core muscles, you improve your posture, use your body more efficiently, and ultimately decrease unnecessary load on your individual joints.  In a similar manner, strengthening the muscles around the painful joint(s) takes the load off the joint(s).  Stretching and keeping limber is likewise important because contracted, tight, or stiff muscles pull unnecessarily on your joints causing increased wear and tear.       

            Occupational therapy; Occupational therapists are particularly suited to help with hand splints and other splints and exercises to help with activities of daily living. 

            Modalities:  Your physician, chiropractor, physical therapist, and/or occupational therapist may use modalities as part of their treatment for you.  These include ultrasound, heat, ice, electrical stimulation, and massage.  Heat and/or ice may be helpful for you to use at home before and after activities. 

            Oral medications:  You should always check with your physician before starting any medication.   Even mild pain relievers such as acetaminophen (Tylenol) can be dangerous in people with liver conditions and other medical problems.  However, in general, acetaminophen is well tolerated and is very effective in treating the pain of mild‑to‑moderate osteoarthritis.  

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuopren and naproxen also may reduce pain and inflammation.  The problem with these medications is that they may cause stomach problems, increase blood pressure, and cause kidney problems.  Meloxicam (Mobic) is an NSAID that requires a doctor’s prescription and may be useful for the pain caused by osteoarthritis.

Recently, Cox-2 inhibitors have received a lot of attention.  Cox‑2 inhibitors are similar to NSAIDs but are designed to reduce stomach side effects.  Cox-2 inhibitors require a doctor’s prescription.  Examples of Cox-2 inhibitors include Celebrex, Vioxx, and Bextra.  First, these medications received attention because they seemed to reduce pain better than NSAIDs without many of the potential side effects of NSAIDs.  Next, these medications received media attention because they were feared to cause even more side effects. Vioxx and Bextra have since been pulled from the market and Celebrex remains under increased scrutiny.  The true picture of benefit-to-side effect ratio may be more complicated and will be discussed in another section.  As with any medication, consult your doctor before starting Cox-2 inhibitors. 

Tramadol (Ultram) is another medication that can be used for the pain of osteoarthritis.  Tramadol is a prescription medication that is also packaged in a combination form with acetaminophen.  This combination pill is called Ultracet.  Ultram and Ultracet are generally well tolerated and can be used for mild-severe pain.  A benefit of Ultram and Ultracet over narcotics is that they don’t have as much sedating qualities as narcotics.  Also, Ultram and Ultracet do not carry the same addictive qualities as do narcotics.  All medications, without exception, have some potential side effects and you should consult your doctor before starting them.

Cortisone is a potent anti-inflammatory agent but oral cortisone is generally not used for treating the pain and inflammation of osteoarthritis.

Glucosamine and chondroitin sulfate:   Glucosamine is an amino sugar and chondroitin sulfate is a large protein.  These substances are found naturally in your body.  Chondrointin sulfate is a proteoglycan that gives your cartilage some of its elasticity.  When taken together as an oral supplement over prolonged periods of time, these substances have been shown to help with the pain of osteoarthritis.  In addition, some physicians believe that when taken over a prolonged period of time (2-3 months), glucosamine and chondroitin sulfate may slow the progression of osteoarthritis.  A large study is currently being conducted by the National Institutes of Health (NIH) that should help clarify the exact role of glucosamine and chondroitin sulfate for the treatment and prevention of osteoarthritis.  In the meantime, they appear to be effective for many people when taken daily.  The amount used in research studies is 1,500 mg per day of glucosamine and 1,200 mg per day of chondroitin sulfate.  Remember that supplements are not regulated by the FDA so the quality of the product may vary from company to company and bottle to bottle. Try to only purchase your supplements from reputable companies.  Most common side effects include stomach upset, gas, and soft stools.  Diabetics may experience an increase in blood sugar because glucosamine is a sugar.  Chondroitin sulfate may interfere with blood thinners.  Always consult your doctor before beginning any medication or supplement, particularly if you have other medical conditions.

Injections:  For people with knee and/or hip pain from osteoarthritis, there are two types of injections that your doctor may offer you.  Both injections involve your doctor placing a needle, under sterile conditions, into the affected joint.  A corticosteroid injection introduces the steroid directly to the site of inflammation.  Steroids are powerful anti-inflammatory medications.  Because steroids cannot be repeatedly injected more than 3-4 times per year, these injections are reserved for moderate-severe pain.  Another injection procedure is an injection series of hyaluronic acid (Synvisc or Hyalgan).  Hyaluronic acid is a fluid substance that bathes the joint and keeps it well lubricated.  It can be injected into the affected knee or hip in the form of Synvisc or Hyalgan.  Currently, it is typically only injected into the knee in most clinics.  However, academic institutions are experimenting with the injection for hip osteoarthritis as well.    Many patients receive good pain relief with these injections.  However, the relief is temporary and the injections will generally need to be repeated periodically.  As with any injection procedure, there is always a small risk of bleeding and infection.  For this reason, it is important that your doctor use sterile technique and that you have an open discussion with your doctor about the potential risks and benefits.

Surgery:  When symptoms of osteoarthritis become severe and interfere with your activities of daily living, it may be reasonable to consider surgical intervention.   The ability of surgery to effectively treat an osteoarthritic joint depends to a great extent on which joint is involved.  Hips and knees that suffer from severe osteoarthritis may respond well to surgical replacement of the affected joint.  Total hip replacement and total knee replacement surgery are becoming more common and the techniques and replacements continue to improve.  However, surgical intervention always comes with risks and conservative treatments should generally be exhausted before surgery is pursued.  Discuss with your doctor if a surgical intervention is appropriate for you.

How can I prevent osteoarthritis?

While there is no proven method to prevent osteoarthritis, there are certain steps you can take to reduce your risk factors.  The first is to lose weight if you are overweight.  Excess weight is a major risk factor for developing osteoarthritis.  Taking glucosamine and chondroitin sulfate daily may reduce your chances of developing osteoarthritis, though ongoing research by the NIH will help shed light over how effective this may be.   Reducing your participation in impact activities such as jogging (particularly on hard surfaces or with poor footwear) and weight-lifting large amounts of weight (particularly squatting will help reduce the chronic stresses that you place on your joints.  Staying active is also very important.  Participating in a well-balanced exercise regimen that incorporates cardiovascular fitness, stretching, and strengthening exercises will help you avoid the pain of osteoarthritis as well as maintain and improve your general health.   Consult your physician for guidance as to a tailored exercise regimen to suit your needs.