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Understanding Your Osteoarthritis

Comparison of a Normal Knee and an Osteoarthritic Knee

Reproduced from Osteoarthritis, David J Hunter and David T Felson, BMJ 333, 639-642, 2006, with permission from BMJ Publishing Group Ltd.

Osteoarthritis (OA) is the most common form of arthritis. It is a disease that affects all the tissues of the joint, including the cartilage, bone, ligaments, and muscles. It can develop in any number of joints, but most commonly affects the knees, hands, and hips. Osteoarthritis typically occurs later in life, usually after age 50, although may start earlier in the case of joint injury. The symptoms of OA can vary in severity, but in its more severe forms OA is a painful condition that restricts mobility, interrupts sleep, and interferes with the sufferer’s enjoyment of life. OA is considered a chronic (long-lasting) disease and other than joint replacement surgery there is presently no cure. There are, however, treatments that can reduce pain, improve function, and in some instances delay the progression of the disease. 

The progression of OA may be charted by comparing a normal healthy joint with an osteoarthritic joint. In a healthy joint, protective cartilage caps the ends of joint bones. Around the bones and cartilage is a further protective “wrapping” called the synovial membrane. This membrane contains synovial fluid, the joint’s lubrication that allows cartilage-capped joint bones to glide smoothly for pain-free range of motion.

In contrast, a joint with osteoarthritis will have, to varying degrees:

  • Damage to the joint’s cartilage as it becomes less elastic and more brittle
  • Bony spurs growing around the edge of the joint
  • Swelling of the joint due to inflammation 
  • Inadequate lubricating synovial fluid for the cartilage and joint bones
  • Breakdown of ligaments (tough bands that hold the joint together) and tendons (cords attaching muscles to bones).

Early in the disease process, the body has resources to repair detrimental changes within an OA joint. As the disease progresses, the body’s repair system can no longer keep up with these processes, resulting in the tissue damage that is called “osteoarthritis”. It is important to note, however, that OA does not necessarily progress to more severe disease and that a significant number of people experience no progression or even improvement. Furthermore, the structural changes seen in the joint on an x-ray do not correspond well to the symptoms that you feel. In some cases, the structural changes may be severe but the person feels very little pain.

Lay version of the OARSI definition of osteoarthritis

“Osteoarthritis is a disorder that can affect any moveable joint of the body, for example knees, hips, and hands. It can show itself as a breakdown of tissues and abnormal changes to cell structures of joints, which can be initiated by injury. As the joint tries to repair, it can lead to other problems.

Osteoarthritis first shows itself as a change to the biological processes within a joint, followed by abnormal changes to the joint, such as the breakdown of cartilage, bone reshaping, bony lumps, joint inflammation, and loss of joint function. This can result in pain, stiffness and loss of movement. There are certain factors which make some people more vulnerable to developing osteoarthritis, such as genetic factors, other joint disorders (such as rheumatoid arthritis), injury to the joint from accidents or surgery, being overweight or doing heavy physical activity in some sports or a person’s job”.

Research User Group, Institute of Primary Care and Health Sciences, Keele University, UK

If you are suffering from stiff, painful, or less mobile joints, getting the right diagnosis for your condition will ensure that you receive the right type of treatment for your joint problem. Several types of arthritis can affect joints and treatment options can differ depending on which type of arthritis you have. Osteoarthritis (OA) may be the most common type, but others are common enough. Among the more common are:

Rheumatoid arthritis (RA): Unlike OA, RA is an autoimmune disease that occurs when the body’s protective immune system turns on what it should protect. Although RA can affect a number of systems in our bodies, it most commonly affects joints. Common sites are hands, wrists, feet, elbows, knees, and ankles. RA causes joint swelling, pain, and eventually can cause damage and loss of movement in the affected joints. Morning stiffness is a common symptom that usually lasts much longer in RA than in OA. The damage from RA is usually more progressive and severe than OA and can occur over a shorter period of time.

Untreated, RA can result in deformity of the affected joints. Just as for OA, there is no cure for RA, but there are treatments available that can prevent the progression of the disease. Early diagnosis leads to better control of the progression of RA.

RA is diagnosed by a rheumatologist, a specialist doctor, who will take a history of symptoms, do a physical examination, and order blood tests. RA, which is more common in women than in men, can occur at any age but the disease tends to develop earlier in women.

Gout: This painful type of inflammatory arthritis is caused, in part, by high uric acid levels in the blood. The severe pain and swelling in the joints is due to uric acid crystals causing inflammation, most commonly in the big toe or foot. Flare ups of gout are episodic, with sudden onset of pain and swelling that usually go away after about a week, with no symptoms between episodes. Gout can affect anyone, but it is extremely rare in children. Your doctor will diagnose your gout by asking about your medical history, examining the affected joint, and doing a blood test. The definitive diagnosis, though, is to find uric acid crystals in a sample of fluid drawn from the affected joint.

Pseudogout: This form of arthritis, which is characterized by sudden, painful swelling in one or more joints, is similar to gout, but is caused by calcium crystals instead of uric acid crystals. Calcium crystal deposits increase with age and can sometimes be seen on x-rays even without causing any symptoms. Identification of the crystal in joint fluid is the definitive diagnosis. The most commonly affected joints in pseudogout are the knee and wrist.

Psoriatic arthritis: This form of arthritis affects some people who have psoriasis, a skin condition that features red patches of skin topped with silvery scales. Most people develop psoriasis first and are later diagnosed with psoriatic arthritis, but the joint problems can sometimes begin before skin lesions appear. Joint pain, stiffness, and swelling are the main symptoms of psoriatic arthritis. Diagnosing psoriatic arthritis can be a challenge because its symptoms are similar to other arthritic conditions.

Osteoporosis: Although not a form of arthritis, people sometimes confuse OA with osteoporosis. Osteoporosis is a condition in which there is a loss of bone mass, causing the bone to become weak, brittle, and easily broken (fractured). Osteoporosis fractures most commonly occur in the hip, wrist or spine. Seeking an osteoporosis diagnosis is important because medical treatments and self-help approaches can improve or slow the progression of the disease. Both men and women may develop osteoporosis as they age, but the disease is more common in women.

Any joint can be affected by osteoarthritis (OA) but the disease occurs most commonly in joints that have experienced repetitive stress or injury.

Knee: The knee is the most common lower-limb joint affected by OA. People with OA often experience knee pain when doing routine activities such as walking and going up and down stairs.

Hip: OA of the hip can be deceptive. Some people feel pain in the groin area, while others feel pain in the buttocks, front of the thigh, sides of the hips, or lower back. Some of these pain symptoms are not necessarily due to OA of the hip. They may be due to conditions in other areas causing pain in the hip region, known as “referred” pain. Likewise, patients can be surprised when their doctor tells them the problem is their hip joint when they experience pain elsewhere.

Hand: OA of the hand is commonly linked to a family history of the condition. What causes osteoarthritis? In the fingers, symptoms include pain and swelling of the joints. In the thumb, pain is most commonly experienced at the base of the thumb and worsens with gripping and pinching movements.

Foot and ankle: OA can affect the ankle and the joints within the foot, commonly the joint at the base of the big toe. This causes pain when walking and can result in swelling or deformity at the joint that can lead to the formation of bunions. In addition to the big toe, bunions can have a “knock on” effect when the angle and displacement of the big toe results in the second toe putting pressure on the third toe. Bunions have the potential to compound foot pain and deformity.

Back and neck: The first sign of OA is typically stiffness or pain. In general, once the source of the pain is identified, an OA diagnosis is straightforward. Unfortunately, an OA diagnosis of the back and neck is not always straightforward. Although back pain is very common, definitively diagnosing the source of back pain is a challenge. Is the cause OA (a joint problem) or is it something else (a disc or injury-related problem)? The challenge arises because osteoarthritic changes in the spine seen on x-ray and other imaging studies do not always cause pain. Since the incidence of OA increases with age, you may indeed have OA in your older back but the source of your pain may be another condition, injury, or disease.

Several risk factors can increase your likelihood of developing osteoarthritis (OA).

  • Longevity: Living to 65 or more does not mean you will inevitably develop OA, but being older considerably increases your risk of developing the disease.
  • Family history: If other members of your family have or did have OA, your risk of developing OA increases. OA of the hand, for instance, has been found to run in some families. A family trait, though, does not mean you will inevitably develop the disease. Hereditary traits are complex and genetic research has shown that several genetic traits can lead to OA. Although a family history of OA is not necessarily your destiny, taking preventive measures such as staying active, watching your weight, and being on the lookout for early symptoms will serve you well. At the first signs of OA take early action, a wise self-help approach. 
  • Gender or, more precisely, being female: OA is more common in women than it is in men. As well as an overall gender imbalance, some female joints, such as those in the hands, can have a genetic link to OA.
  • Being overweight or obese: Excess weight puts unnecessary stress on joints, especially knee and hip joints. Add time into the mix and you can see how carrying too much weight could cause excessive strain on the joint under years of additional pressure. Excess weight appears to affect hands too, suggesting that factors circulating in the blood related to obesity may contribute to OA.
  • Past joint injury:  A medical history of joint damage, joint surgery, or damage to joint-supporting ligaments and tendons can result in OA.

Osteoarthritis (OA) can affect anyone of any race or gender, but not everyone has the same experience of the condition. Symptoms, and their degree of severity, can vary from day to day and from person to person. There are, however, a number of common symptoms associated with OA. Are you experiencing any of the following symptoms:

  • Joint pain that usually occurs when using the joint or at the end of the day after using the joint
  • Stiffness that occurs more frequently first thing in the morning; or stiffness later in the day after sitting for periods of time but which lasts for less than around 30 minutes once you get moving
  • Joint noises such as cracking, crunching, grinding sounds when the joint moves
  • Swelling, when your joint appears larger and feels warm to touch, can be caused by the inflammation associated with OA leading to joint fluid buildup
  • Instability, when the joint may feel weak or likely to give way when you put pressure on it?

If you are experiencing one or more of these symptoms, consult your doctor. It is time check if you have OA.

Doctors diagnose osteoarthritis (OA) based on asking questions about your symptoms and examining your joints. While OA typically occurs in people aged 50 and older, it can sometimes start at a younger age if there has been a prior injury or surgery. The most commonly affected joints are the knees, hands, and hips although most any joint (and the spine) can be affected. Which joints does osteoarthritis affect?  

Your doctor will diagnose OA by reviewing your medical history and current symptoms with you, including the level of discomfort or pain you are experiencing, especially when engaging in certain types of activities. This conversation will be followed by a thorough examination of your joints to assess tenderness, ease and range of motion, presence of swelling, joint sounds such as cracking and grating, joint stability, and whether you are “knock-kneed” or “bow-legged”.

Imaging studies, such as x-ray, are not needed to make a diagnosis of OA. Do not be surprised if your doctor does not order or rely on imaging tests to make a diagnosis of your OA. If there are any concerns that there may be a different cause of your symptoms, your doctor may, in certain circumstances, decide to order imaging tests.

Osteoarthritis (OA) is a condition that can worsen over time causing increased pain and disability. Currently there is no proven cure to slow down or stop OA from worsening. The condition, however, affects people differently and it is hard to predict how the condition will progress in any individual. Unfortunately, changes that appear on an x-ray and other imaging studies do not indicate how quickly your symptoms will intensify, or how you will respond to treatment. On the other hand, for many people, their OA symptoms can lessen with appropriate management or at least remain the same.

Your treatment will vary depending on your symptoms and which joints are affected. Talk with your doctor so that together you may design a treatment plan that best meets your needs. This may mean trying one or more treatments to find the one or the combination of treatments that works well for you. Working with your doctor is important because you may have other conditions that would make certain medications used in the treatment of OA inadvisable in your case.

General guidelines: You should start with exercise, weight-loss, lifestyle modification, and physical therapy. Often these steps can be sufficient to manage the symptoms, avoiding use of medications. For many patients, though, medications to help with pain are also needed. Surgery is reserved for symptoms that don’t respond to these other options, including medications.

When joint movement hurts an understandable instinct is to limit movement. Contrary though it may sound, you need to go against your instinct. Exercise and physical activity are among the best treatments for the management of the symptoms of osteoarthritis (OA), especially for the relief of discomfort and pain associated with the disease.

Exercise and physical activity

Exercise is good for everyone but for people with OA it is a key treatment option. Exercise is a vital part of keeping joints healthy and mobile.

A beneficial exercise plan can be as simple as increasing general physical activity in your everyday life. Daily activities such as taking the dog for an extra walk, signing up for a fun, not too strenuous exercise class, or parking your car farther away from a destination and finishing your journey on foot can contribute significantly to an exercise plan.

When it comes to more focused exercises seek professional advice from a physical therapist or exercise specialist. Following this recommendation will make sure your exercises are appropriate for the relief of your particular symptoms. You want to be sure you start an exercise program at the right level. You want to be sure you pace yourself by starting slowly and increasing your activity as you become stronger and fitter. Appropriate pacing will avoid aggravating your symptoms. 

An exercise program that builds and strengthens the muscles around joints affected by OA is very beneficial. Strong muscles better support and take pressure off painful joints, improve balance, and lessen the feeling of giving way. As well as a tailored exercise program, a balance exercise program worth considering is t’ai chi that has been proven to improve muscle tone, flexibility, and bone density. Strengthening exercises can be done using a variety of aids: weights or dumbbells, resistance bands, or body weight.

  • Stretching and flexibility exercises aim to improve the range of movement of your joints and muscles. Exercises can include muscle stretches, t’ai chi, and yoga.
  • Water exercises, known as hydrotherapy, could also benefit you. The support provided by the water takes pressure off painful joints as you perform water aerobic exercise. Walking in water, which requires you to push against the resistance of the water, burns more calories and helps in a weight-reduction exercise plan.
  • Aerobic exercises that keep your heart and lungs strong are always a good idea. Aerobic workouts will develop your stamina, build up your energy level, and exercise your joints and muscles. Walking briskly, cycling, and swimming are activities that increase your heart rate. Regular aerobic workouts can also help as part of a weight management program. Exercising on a stationary bicycle has several advantages. As well as taking pressure off your joints while you exercise them and burning up calories as you peddle, you can cycle regardless of weather conditions. In other words, you have no excuses to stop you getting on your bike!

Stick with your exercise program!

We all find it difficult to develop new habits but exercise is only beneficial if you do it! Like many New Year resolutions, our best exercise intentions can fade over time. We are good at finding reasons not to exercise be they time constraints, convenience, diminishing enthusiasm, or cost reasons. Any one of these can make sticking to an exercise program a challenge.

Fortunately there are many things you can do to help keep going with your exercise program. Consider these approaches that do not involve signing-up with a costly gym.

  • Set yourself short and long term goals about what you would like to achieve.
  • Plan how, where, and when you are going to exercise.
  • Set reminders to do your exercises.
  • Keep a diary of when you do your exercises.
  • Join an exercise class or group.
  • Get a friend on board to exercise with you.

Be persistent. Above all, do not become discouraged.

Graph

Watch your weight

Being overweight is a risk factor for developing OA, especially in the knees or hips. Excess pounds are also linked to a worsening of symptoms. But how do you know if you are overweight? You need to know your body mass index (BMI), a commonly used index of a weight-for-height relationship. Your BMI is determined by taking your weight in kilograms and dividing that number by the square of your height in meters (kg/m2). The World Health Organization (WHO) defines overweight as a BMI greater than or equal to 25 and defines obesity as a BMI greater than or equal to 30.

Excess weight puts increased strain on joints. Losing even a small amount of weight can make a big difference in your OA symptoms. Research has shown that people should aim to lose at least 5% of their body weight and ideally 10%. A combination of dietary advice and lifestyle modification, which includes an increase in physical activity, is recommended. Some people find seeking professional advice beneficial in managing their weight. Cases of severe obesity warrant consideration of bariatric weight loss surgery.

While it can be difficult to change diet and exercise habits and make them stick, this diagram shows some steps and tips to help you to increase your likelihood of success.

Medications may be categorized in several ways. Is the medication topical, meaning do you apply the medication to a localized area of your body such as your skin? Is the medication designed to be taken orally, in which case the medication does its job via absorption in your gastrointestinal tract? Can the medication be injected directly into the joint? Can the medication be bought without a prescription, known as an over-the-counter (OTC) medication? Does the medication require a doctor’s prescription?

When you and your doctor are deciding on an appropriate medication to manage your OA symptoms of pain and inflammation, you should discuss and consider the side-effects associated with a particular medication, including the risk of damage to other organs of your body. Caution: Although the recommended doses of OTC medications are typically less potent than those of prescription medications, know that an OTC medication is not necessarily safe. OTC medications can be harmful especially when taken in larger than recommended doses or for an extended period of time. One essential aspect of selecting a medication is to read the label carefully; another is to talk with your doctor. This is the person who knows your medical history and can make recommendations or advise you if a medication can have an adverse effect because of conditions you have other than OA.

First try a topical: Creams and ointments, which include creams that induce heat or cold, can bring pain relief when applied to the skin of the tender joint. Some products also contain anti-inflammatory ingredients. Since creams and ointments have a much lower risk of side effects compared to oral medications exploring a topical medication is a reasonable place to start your search. The challenge is determining which topical might work for you. There are many to choose from. Talk with a pharmacist or your doctor before investing in a product.

If you find you need or prefer an oral pain medication, you can select from OTC or prescription medications. Some medications are available as both, depending on potency and dosage.

Analgesics: Available as OTC or prescription medications, analgesics relieve mild-to-moderate pain and fever but do not reduce the inflammation associated with OA. The most common analgesic taken in the United States is acetaminophen (Tylenol), known elsewhere as paracetamol (Panadol). Regardless of name, used inappropriately this analgesic can cause severe liver damage. Talk to you doctor. Opioids (narcotics) are strong prescription-only analgesics that have a lot of side effects.

Anti-inflammatories: Available as OTC or prescription medications, non-steroidal anti-inflammatory drugs (NSAIDs) can be effective in managing the inflammatory pain associated with OA. Common NSAIDS are aspirin, ibuprofen (Advil, Motrin, others), and naproxen (Aleve, Naprosyn). NSAIDs can have side effects including stomach ulcers, kidney damage, and effects on your heart and blood pressure. Talk to your doctor and pharmacist about a suitable length of time to be taking the medication (a course of 5-10 days is usually recommended) and make sure it does not interact with other medications you are taking.

Glucocorticoids: These are potent, prescription-only anti-inflammatory medications that can be injected into the painful joint by your doctor. They are often used when there is inflammation and joint fluid present.

Surgery to replace a joint is an option when your pain has become too severe to manage and/or your function is substantially impaired and other treatment options have not been successful. If you are considering surgery, you should discuss your feelings and concerns with your doctor. If your doctor considers you eligible for surgery, he or she will refer you to an orthopedic surgeon. As with all surgeries, joint replacement surgery is not without risk. Factors that increase surgical risk are your age, being overweight/obese, and your other chronic conditions. On the other hand, successful joint replacement surgery can make you pain-free at least in terms of the affected OA joint. The most common OA surgeries are knee and hip replacement surgeries.

A team approach is recommended when getting advice on how best to manage your osteoarthritis (OA). Here are the various professionals who make up an OA team.

Your Primary Care Doctor/ General Practitioner will assess and diagnose your OA. Your first “go to” professional will also advise you on a pain management plan that will include lifestyle modifications, exercise, weight loss, physical therapy, and, if needed, analgesics. After the plan is in motion, your doctor will monitor your symptoms and your response to the treatments. When appropriate, this professional will refer you to other health professionals that can assist you.

Physiatrists are specialist doctors with expertise in physical medicine and rehabilitation. A physiatrist may lead and co-ordinate your care, focusing on making sure you can continue your daily activities.

Rheumatologists are specialist doctors with expertise in joint conditions including OA. Your primary care doctor may refer you to a rheumatologist if unsure about your symptoms and considers you require further assessment.

Physiotherapists/Physical Therapists can prescribe an individualised and suitable exercise program to strengthen the muscles around your joint to reduce pain and make it easy for you to move again. They can also teach you techniques to help relieve your pain.

Exercise Therapists can assist with your physical activity and exercise prescription. They can also help with recommendations for exercises to help you manage your weight.

Podiatrists can assess how you walk and provide exercises and shoe inserts to reduce the pressure on your ankles, knees, and hips. They can also give you advice about the best footwear for you.

Occupational Therapists can give you recommendations about modifications or equipment for your home or workplace that can make it easier for you to continue doing your daily activities.

Dieticians/Nutritionists can give you personalised advice to help you lose or maintain your weight.

Orthopaedic Surgeons are professionals who come into the picture later in the progression of OA when other treatment avenues have been explored. For instance, your primary care doctor may refer you to an orthopaedic surgeon if your pain and function are not responding to other treatments. An orthopaedic surgeon will examine you, advise on the best treatment, and perform surgery if necessary.

The take-home message of the team approach is that you are not alone. Wonderfully qualified professionals will help you manage your OA so you may live your life to the fullest. Stay positive!

As the disease progresses, without effective management osteoarthritis (OA) can become more painful and debilitating. Pain can impact all aspects of your life, affecting your mood, energy level, sleep, and your relationships with others. Fortunately a number of effective approaches are available to help you manage and cope with your pain. Keep in mind that our perception of and tolerance for pain varies from individual to individual. This means your pain-control management plan should be customized to address your particular needs. As with all OA treatments, it is recommended that you explore the various pain-control approaches to find the one or combination of several that work best for you.

Understanding pain: Knowing what types of activities and movements increase your pain is vital to managing it. When we feel pain we tend to reduce or avoid activity all together, however, it is important to remember that not all pain is harmful. Pain can be a normal body response to the healing process. You may find it useful to talk to a health professional if you notice you are experiencing a fear of pain that is stopping you from moving and taking part in physical activity.

Activity pacing: Spacing out activities during the day or breaking them up into smaller segments can be an effective way to manage your pain and avoid a flare up. This is especially important when you are doing physically demanding tasks or activities that you know will cause you pain.

Mind techniques: Relaxation techniques and stress management can be helpful in reducing the muscle tension and pain associated with OA. Techniques to better help you cope with your pain can also be useful. Advice from a physiotherapist or psychologist can help you learn these techniques.

Heat or cold treatments: The application of hot or cold packs can be soothing and help to relieve pain symptoms in tender joints.

Transcutaneous Electrical Nerve Stimulation :(TENS) is a small device with electrodes that stick onto the skin. The electrodes release small signals through the skin to your nerve endings. It is thought that the electrical signals change the pain message the brain receives. You will feel a tingling sensation on the skin. Evidence on the effectiveness of TENS is varied. Most pharmacies or physiotherapists will supply TENS units for purchase or loan.

Suitable footwear: Shoes with a low heel and supportive sole are best to reduce excessive strain on the joints in your legs. Look for a good quality sports shoe or comparable footwear.

Braces and supportive devices: These may provide some benefit when worn during exercise or physical activity such as household activities. Some devices are best used for short periods of time only to avoid skin irritation. Others, such as knee sleeves, may be comfortable to wear all the time. Research has found that they do not help everyone but may be worth a try. Seek advice from a physical therapist or podiatrist.

Walking sticks or canes can be useful in reducing the pressure on your ankle, knee, and hip joints while walking. A walking stick can also improve your confidence to walk if you feel less stable walking. A note about scooters: Although useful in some instances, the downside of scooters is no exercise is required which defeats the goal of including an exercise program in your treatment plan.

Modifications to your home or workplace: Consider making changes around your house or in your workplace to lessen the effort and strain on your joints. Modifications can include using a chair in the shower, installing a rail in the toilet, and using specialized equipment such as long-handled shoe horns, modified vegetable peelers, jar and can openers, and various other grips. Speak to an occupational therapist for advice about what devices and modifications might help you and where you might obtain them.

Exercise and weight loss are also important aspects of managing your OA pain. Understanding Your Osteoarthritis

An important aspect of managing your OA is to take control through knowledge. Here are some useful informational websites that can add to your knowledge.

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