A dear friend of mine is 48 years old. He is a physician and has been very physically active most of his life. Recently he has been complaining that his joints have been hurting more and more with his activities. He loves to jog—it relaxes him and takes his mind off his busy and hectic life. But the for past year or two he has had to quit jogging. His ankle hurts. His knee hurts. His low back hurts.
He is an anesthesiologist and in his work he performs a lot of epidural injections, using his left hand a lot. About two years ago he started having pain in his left wrist. He went to physical therapy, but to no avail. He went to a hand surgeon who did x-rays and an MRI, which showed osteoarthritis of the wrist joint, with severe degeneration of the lateral wrist ligaments. He had surgery, which helped somewhat. But he still has pain everyday in his wrist.
Now his other joints are acting up as well. He came to me one day and said he was concerned he might have a more severe form of arthritis, like rheumatoid or lupus. I examined his joints and did not see any evidence of severe joint disease. I ordered the appropriate lab tests for the more serious inflammatory arthritides and they were all negative. My diagnosis was osteoarthritis.
He was surprised, even though he had been diagnosed with some degenerative arthritis in his wrist two years earlier. He thought his wrist problem was from over-use at work, and was surprised that his other joints were following suit. He had thought he was young for this to be happening to him. He remarked to me, “If I feel this bad at 48, what will it be like at 68?”
I replied that that was the dilemma we all face. There is no way to prevent the aging process, particularly the degeneration we see in our joints, tendons, and ligaments. For some people it is a very slow and gradual process, almost to the point of being unnoticeable. For others it is a much more rapid course. But, to each and every one of us, these degenerative changes will come. And at that day you and I alike will find ourselves saying, “My back hurts today; my hip is bothering me; my knee hurts, I wonder what I did to it.”
One of the primary syndromes we face as we age is degenerative arthritis, more commonly known as osteoarthritis. There are many factors which play a role, some of which are controllable (such as lifestyle) and some of which are not (genetics and environment). But you can be assured that someday (if not presently) you will be asking your friends, your family, your doctor, “What can I do about this pain? I seem to hurt all over!”
Well, this bleak picture I have painted is not necessarily a hopeless situation. There have been some advances in the treatment of osteoarthritis in the past years, which make life quite livable, even in the face of chronic joint pain. But before I discuss treatments I would like to teach you a bit about the pathophysiology of joint disease.
The Human Musculoskeletal Joint:
Our joints are complex structures that are built to allow bones and tendons to move freely without pain, stiffness, or swelling. Joints are composed of: bones, which come together in the joint and touch each other (articulation); cartilage (on the ends of the bones where they touch each other—it acts as a protective surface for bone to bone contact); joint capsule (a fibrous sac which surrounds and encloses the entire joint); synovium (the glistening membrane which lines the inside of the fibrous joint capsule); and synovial fluid (which acts as a lubricant to promote smooth joint movement, and which is secreted by the synovial lining).
Some joints have ligaments within them to connect one bone to another. Other joints have tendons outside the joint capsule to attach muscles to the bones. And some joints have cartilage plates between the bones to act as shock absorbers (such as the menisci in the knee). And finally some joints have bursa (little fluid filled sacs lying between the tendons and the joint itself to act as a cushion).
The joint also has a relatively good blood supply to the fibrous capsule, but very little blood flow to the deeper structures inside the joint, like the cartilage and ligaments. Nerve supply goes to the joint capsule and to the external lining of the bones, called the periosteum.
Joint Disease
Many things can happen to the normal joint to make it diseased. A disease process can harm the joint in several ways. It can attack the cartilage on the ends of the bones, it can affect the inside lining of the joint capsule (the synovium), or attack the joint capsule itself.
A diseased joint is usually painful, stiff, and sometimes swells. Movement is hampered by these symptoms. One would think that simply resting a painful joint would make it better, but often this is not the case—it might actually get worse with rest. You see, rest decreases the blood supply to the joint and also causes the joint lubricating fluid (synovial fluid) to thicken. On the other hand, movement increases blood flow, which then increases the supply of nutrients and fluids to the joint for nourishment and joint repair. That is why you might feel stiff and sore in your joints in the morning after lying around all night, but feel better after you get up and move around.
As I said, there are many different diseases that can affect the joint, and a discussion of all of them is beyond the scope of this article. So today I want to focus on the most common joint condition, a disease that afflicts all of us: osteoarthritis.
Osteoarthritis develops in our joints after years of “wear and rear.” You see, after walking thousands of miles, after grasping and turning a thousand bottle lids, after getting up and down from a chair a thousand times, the cartilage on the ends of our bones has undergone numerous little insults which result in tiny microscopic cracks. These tiny little cracks in the cartilage have been repaired over and over again with non-cartilaginous scar tissue (it is difficult to get cartilage to reform and repair itself because the blood supply is so poor).
After our bone ends have become riddled with hundreds, even thousands of little cracks, they begin to show changes visible to the naked eye. We can see fibrous scars and calcium deposits on the surface of our long bone ends where the normal smooth cartilage used to be. This creates an irregular, rough surface. The normally smooth movement of one bone upon another is now disrupted and the movement is more coarse and “sand-papery”.
This rubbing of one rough surface upon another creates joint irritation with thickening of the synovial fluid, and leads to the process we call inflammation, the body’s way of trying to repair damage.
Inflammation causes pain, increased blood flow into the joint (which causes redness and warmth) and leaky capillaries, which increases fluid accumulation into and around the joint (resulting in swelling).
.Treatment of Osteoarthritis:
Inflammation is mediated through prostaglandins, histamine, and other related chemicals. Medications like aspirin, the cortisone-type steroids (Prednisone), and the non-cortisone anti-inflammatory drugs (such as ibuprophen and naproxen, also known as “NSAIDS”) can decrease prostaglandin formation and thus decrease the symptoms and effects of inflammation. Therefore, physicians often prescribe aspirin, NSAIDS, or even cortisone to arthritic patients. This helps a lot in some patients, a little in some, and not at all in others. It is difficult to predict which patient will benefit, so we try this approach first.
Unfortunately, all of these medications have side effects, some of which can be very serious. You see, prostaglandins, while harmful to our joints, is beneficial to our stomach linings. Prostaglandins increase the mucous production in the stomach, which helps protect it from the very acidic environment that exists way down there. So when you take a pill which decreases prostaglandins (in an attempt to help your joint inflammation) you might at the same time be causing stomach problems by reducing the protective stomach mucous. This can be so severe that bleeding stomach ulcers can develop.
Another potential problem exists in using anti-inflammatories: prostaglandins enhance blood flow through the kidneys. So by decreasing it, you can cause kidney damage, but this is much more rare.
And of course, some patients are simply allergic to these types of medications, and one must watch for this when first starting them.
A newer type of NSAID, called a COX 2 inhibitor, is supposed to be more specific for the joint prostaglandin while leaving alone the stomach prostaglandin, and therefore be easier on the stomach than regular NSAIDS. This does seem to be the case for most patients, but not all. And so we must still be on the lookout for stomach problems when using even the newer COX 2 NSAIDS. Examples of COX 2 medications are Celebrex, Vioxx, and Bextra.
Acetaminophen (Tylenol, etc) is purely a pain medication and does not work on inflammation. Nevertheless, many patients respond well to acetaminophen for arthritic pain, and in so doing escape the risks of NSAID use. So I advocate trying acetaminophen for mild osteoarthritis.
What about glucosamine and chondroitin? You have seen these chemicals advertised for osteoarthritis. They are the two major substances in human cartilage. But do they really work? Well, actually they do seem to work for some patients, and the good news is that there do not appear to be any significant side effects. Unfortunately they are no “magic bullet” and do not help everyone. So feel free to try this approach and hopefully you will see some benefit.
What about the topical medications like Ben-Gay or Icy-Hot? These also seem to help some patients, and since there are no significant side effects I suggest you try them. We think these topicals work by irritating the skin and underlying soft tissues, thereby increasing blood flow to the deeper structures.
Exercise and Weight Loss
Don’t you get tired of my mentioning these modalities in the treatment of every disease I talk about in these articles? Well, sorry, but exercise and weight loss help osteroarthritis, just like so many other diseases. As you can readily see, reducing the weight placed upon the cartilage on the ends of our bones reduces the wear and tear. Weight loss reduces the microfractures occurring in the cartilage.
And exercise, as alluded to above, increases the blood flow and nutrients to the joint, and thins the synovial fluid. But with exercise we must be careful not to over do it, which I define as exercising to the point of worsening the joint pain. A slight increase in pain is to be expected with exercise, but it should disappear in a short time (hours). If you are acutely worse after exercise, and the bad pain you are experiencing lasts into the next day, you are pushing too hard. A physical therapist can help a lot in these situations.
Physical Therapy, Massage, Acupuncture
As I said, a good physical therapist can tailor-make a regimen for you so that you are getting the right type and amount of exercise. Therapists also stretch the muscles and tendons, and passively move inflamed joints, thereby lessening the risk of joints tightening up and becoming “frozen.”
Some patients benefit from massage. This seems to help by increasing the blood flow to the affected area, similar to other treatments we have discussed. Massage also seems to help muscles relax which allows joints to be more mobile. And because massage is so relaxing, it helps to improve one’s mental health as well.
Acupuncture also seems to be effective in some patients. No one knows for sure how or why acupuncture works, but the theory is this: the needle stimulates the area around the pain, thus flooding the brain with impulses from the normal area, which competes with the information coming from the nerve that serves the painful joint and thus overtaking its ability to get its “pain” message to the central nervous system. It is like flooding the telephone lines with false information so that the real pain message can’t get through. Acupuncture, however, does not cure anything—it only helps reduce the pain. But by reducing pain one can then start exercising and stretching better, and this increased movement in the joint is very helpful.
Other Considerations:
The joints are just one part of the total organism. We must not forget that having chronic pain can be frustrating, depressing, and anxiety provoking. One’s mental health can suffer. Also, chronic pain can often disrupt one’s sleeping habits, resulting in chronically tired and depressed patients as well. It is difficult to get a patient to follow a physical therapy regimen if he is depressed or chronically tired. We, as physicians, must pay attention to the total person and not let ourselves just focus on the joint pain. To this end the physician must realize that a patient may need far more than an aspirin and a heating pad to deal with his chronic pain. Emotional support, sleeping aids, and even anti-depressant medication may be needed as well. Often as a patient’s mental outlook improves their pain becomes more manageable.
