Living Well with Osteoarthritis: A guide to keeping your joints healthy
/ Sep 20, 2013 / By / No Comments

Dear Reader,

For a disease that affects 50 million adults in the United States—about one in five—arthritis is remarkably misunderstood. Many people believe it’s a crippling and inevitable part of growing old. But things are changing. Treatments are better, and plenty of people age well without much arthritis.

This report focuses primarily on osteoarthritis, which is the most common type of arthritis, affecting 27 million Americans. But arthritis is not a single disease. In fact, there are more than 100 different types of arthritis. Though all of them affect joints, their causes and treatments can vary considerably.

Despite all that is known about arthritis, myths abound. For example, arthritis symptoms are not caused by changes in the weather, and people don’t develop arthritis from being under too much stress, having allergies, or cracking their knuckles too much. And unless you are a jackhammer operator or a serious athlete prone to high-impact injuries, you are unlikely to develop arthritis from overusing your joints.

In this report, you’ll learn how osteoarthritis affects joints and how it is diagnosed and treated. Because describing your symptoms is so important for a correct diagnosis, this report discusses the variety of symptoms that may occur.

While arthritis is painful and can interfere with your ability to do things you enjoy, it doesn’t have to be severely disabling. If you have arthritis, you can take steps to protect your joints, reduce discomfort, and improve mobility. This report includes information on established medical therapies as well as complementary treatments such as acupuncture, chiropractic care, and massage. Because living with arthritis requires more than finding a drug treatment, a special section provides advice about how to care for yourself through exercise, diet, and useful gadgets.

Though treatment for osteoarthritis usually centers on managing the pain, researchers are examining possible new treatments that might halt or even reverse the effects of osteoarthritis. These are discussed in the report as well.

Millions of people must live with arthritis. This report suggests ways to live well.

Sincerely,
Robert H. Shmerling, M.D.
Medical Editor

When joints cause pain

The word arthritis is derived from the Greek word arthron (joint) and the suffix -itis (inflammation). For people who have arthritis, the word variously signifies the pain, swelling, redness, and heat that may be caused by tissue injury or disease in the joint.

The most common type of arthritis is osteoarthritis. It is also called “degenerative joint disease” because it results from the deterioration of the cartilage in the joints. The second most common type of arthritis, rheumatoid arthritis, is an inflammatory disease that affects the lining of multiple joints, especially in the hands and feet. (The term rheumatism refers broadly to connective tissue disorders that cause pain and stiffness.) Other rheumatic diseases—gout, pseudogout, ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthritis, and infectious arthritis—are also characterized by joint inflammation.

The musculoskeletal system

Before examining the specific changes that occur in osteoarthritis, it’s useful to understand the anatomy of joints and how they function.

The arrangement of bones and muscles in the body is a marvel of engineering. A model of a skeleton may look rickety and frail, but bones have a compression strength equaling that of cast iron or oak. Although incredibly light—the average adult skeleton weighs only 20 pounds or so—bones are capable of bearing tremendous weight. Their strength is necessary to withstand the forces of movement. When you walk at a leisurely pace, each foot strikes the ground with a force about three times your weight. At a brisk walk or run, the pressure increases to five to six times your weight. In other words, a 150-pound person’s lower extremities are repeatedly subjected to 450 to 900 pounds of force during normal daily activity.

The arrangement of muscles helps hold the skeleton together and, at the same time, provides a means of moving individual bones. Tendons and ligaments, the structures that bind bone and muscle, are made of connective tissue. The main proteins that make up connective tissue are collagens and elastins, which imbue it with tensile strength and elasticity.

Types of joints

There are three basic types of joints (see Figure 1).

Figure 1: Types of joints

There are three basic types of joints. Fixed joints connect the platelike bones of the skull. Cartilaginous joints, such as those in the spine, contain tough cartilage-like plates that bend. The most mobile are synovial joints, which are surrounded by a loose fibrous capsule lined with a thin membrane called the synovium.

Fixed joints, or sutures, are thin bands of fibrous tissue that connect the platelike bones of the skull, allowing the skull to expand and accommodate the growing brain. When brain growth is complete, these fibrous joints disappear as the skull bones fuse together.

Cartilaginous joints contain tough cartilage plates. In the pelvis, these joints permit slight movement of the pubic bones and the sacroiliac joint, where the sacrum (part of the spinal column) and pelvis meet. The disks between the vertebral bones in the spine are thicker and accommodate greater mobility.

Synovial joints are the most mobile. These are found in the shoulders, elbows, wrists, fingers, hips, knees, ankles, and toes. Synovial joints have a protective layer of cartilage covering the ends of the bones. But they take their name from the synovium, a membrane that lines the joint. The synovium produces synovial fluid, which provides nutrition and lubrication for movement and allows these joints to be more mobile than cartilaginous joints. Synovial joints are designed for a variety of movements that make possible all manner of activity, from playing tennis to playing piano. Some—for example, the outermost joints of the fingers—are limited to flexion and extension (bending and straightening) within a single plane. Others, such as the shoulder, wrist, and hip, are capable of complex movements in multiple planes.


Joint design

Synovial joints, like machines with moving parts, are vulnerable to friction. If a machine’s moving parts come in contact with one another, friction will scratch the surfaces and cause pitting, distortion, and eventually breakage. Two strategies can prevent such friction: applying a lubricant, or inserting a cushion, such as a rubber gasket. Human joints are protected in both ways (see Figure 2).

Figure 2: Anatomy of a synovial joint

Ligaments bind the bones together and keep them in proper alignment. Muscles and their tendons stabilize the joint as well as move it. Cartilage, a tough and somewhat elastic tissue, provides a smooth, slippery surface for movement and cushions the joint. The viscous synovial fluid nourishes and lubricates the joint to provide frictionless movement; it’s produced by microscopic cells in the synovium, the membrane that lines the joint. The bursae allow the soft tissues around the joint to move smoothly as the joint moves.

Lubrication comes from synovial fluid, a viscous, yellowish, translucent liquid that’s produced by the synovium. Synovial fluid not only oils the joint and minimizes friction. It also helps protect joints by forming a sticky seal that enables abutting bones to slide freely against each other but resist pulling apart.

Cushioning is provided by articular cartilage, a tough and somewhat elastic tissue that covers the ends of bones. Because it’s about 75% water, cartilage compresses under pressure (as occurs with jumping or even walking) and resumes its original thickness when the force is released, much like a very tough sponge. Because the articular cartilage can mold to its surroundings, the opposing surfaces of a joint are perfectly matched.

Places where tendons and muscles cross a bone or another muscle are also subject to friction. These sites are protected by bursae, sacs that not only contain lubricating fluid, but also act as cushions.

Several things help maintain stability through a joint’s range of motion so that the joint can function normally. One is the contour and fit of the joint surfaces themselves. The hip, for example, is a ball-and-socket arrangement. With each stride, the head of the femur (thighbone) pushes deep into the cup-shaped cavity of the pelvis, providing maximum stability during walking. Most other joints, by contrast, are more like hinges.

Ligaments—the tough, slightly elastic, fibrous bands that bind one bone to another—also help with alignment. For example, ligaments on the sides of the finger joints prevent side-to-side bending, while ligaments stretching across the palm keep the fingers from bending too far backward.

Muscles and tendons, the fibrous cords that attach muscle to bone, stabilize joints as well as move them. The best example of how this works is in the shoulder, which has such a wide range of motion that ligaments would impede it. While the large, visible shoulder muscles supply the power to move the shoulder, the small rotator cuff muscles and tendons keep the head of the humerus (upper arm bone) from slipping out of the glenoid fossa, a shallow cuplike indentation in the shoulder blade.




What is osteoarthritis?

Osteoarthritis develops when cartilage deteriorates. Over time, the space between bones narrows and the surfaces of the bones change shape, leading eventually to friction and joint damage (see Figure 3). Osteoarthritis often affects more than one joint, and while it can strike any joint in the body, some are much more likely to be involved than others. For example, osteoarthritis is common in the hip, knee, lower back, neck, feet, and certain finger joints, but it is rare in the elbow.

The most common of all joint diseases, osteoarthritis affects approximately 27 million Americans and accounts for about half of arthritis diagnoses in the United States. But these numbers only hint at the impact of osteoarthritis, which can send people to pain clinics and doctors’ offices, make them reach for medications, keep them home from work, and curtail leisure and everyday activities. Nearly half of all people over age 65 have symptoms of osteoarthritis, and many have difficulty performing daily activities because of the disease.

Roughly equal numbers of men and women have osteoarthritis, but it tends to affect them differently. Before age 40, more men than women have osteoarthritis, while from ages 40 to 70, osteoarthritis is more common in women. After age 70, both genders have it in equal numbers. Women more often have osteoarthritis in the hands and knees. Men are more likely to have it in the hips, knees, and spine. Women are 10 times more likely to develop Heberden’s nodes, in which hard, bony growths form on the joint nearest the fingertip.

More than wear and tear

Osteoarthritis was long considered a natural product of aging, reflecting everyday wear and tear on cartilage. The demographics seemed to bear that out. The ailment is virtually unheard of in children and is rare in young adults, but common among older people and those who are overweight or obese.

Although this view still prevails among many doctors, experts now believe the cause is much more complex than simple wear and tear. External factors, such as injuries, are now known to be important initiators, and the rate of progression is probably affected by genes as well.

The severity of symptoms also depends on many factors, including how people use their joints. While it’s true that the risk increases with age, many people whose x-rays indicate joint changes typical of osteoarthritis have no symptoms. That’s why taking the time to protect your joints is so important (see “Joint protection strategies”).

So how does osteoarthritis develop? The first signs are microscopic pits and fissures in the surface of the cartilage in your joints (see Figure 3). These fissures indicate that biochemical changes are gradually making the cartilage less resilient. Cartilage cells themselves produce enzymes that damage the molecules making up the structure of the cartilage, and tiny pieces of cartilage may flake off into the joint cavity. As a result, the shape of the cartilage lining the bone changes, causing further damage as the altered surfaces move against each other.

As cartilage degenerates, patches of exposed bone appear. Just as a damaged gasket leads to metal-on-metal contact in a machine, your bones experience mechanical friction and irritation. They try to repair themselves. But the renovation attempts are uneven, causing bony overgrowths, known as osteophytes, to form along the margins of the damaged joints.

Figure 3: Joint changes in osteoarthritis

A. The first signs of osteoarthritis are microscopic pits and fissures on the cartilage surface, which are sometimes accompanied by inflammation.

B. The contours of the joint change and the cartilage thins.

C. The bone surface thickens and osteophytes (abnormal bony growths) develop over time, while continued thinning of cartilage leaves the bone exposed. The joint space narrows until it nearly disappears

Once your cartilage is damaged, the resulting abnormalities can irritate the surrounding soft tissues and cause inflammation. Doctors sometimes refer to osteoarthritis as noninflammatory to distinguish it from rheumatoid arthritis and other joint diseases in which inflammation is a cardinal feature. However, low-grade inflammation is not unusual in osteoarthritis. It may arise when the articular cartilage in a joint fails to recover fully from an injury, or it may reflect your joint’s attempt to repair the damage to articular cartilage caused by such an injury. People with severely damaged joints can also have episodes of synovitis (inflammation of the synovium, the membrane lining the joint); however, this inflammation also tends to be much milder than in rheumatoid arthritis. Whatever the cause, the combination of damaged cartilage, bone rubbing on bone, and the inflammation make movement painful.

Symptoms of osteoarthritis

  • Increased joint pain and swelling after activity

  • Brief joint stiffness in the morning

  • Grinding sensation when the joint is used



Possible causes of osteoarthritis

Doctors sometimes categorize osteoarthritis as primary or secondary. In primary osteoarthritis, the principal cause is unknown, although age, excess weight, and genetics probably contribute. Some scientists believe primary osteoarthritis begins with repeated minor injuries. The cartilage is able to repair itself for a time, but eventually this effort fails.

In secondary osteoarthritis, the disease originates from more significant injuries (such as a fracture near a joint), past inflammation (from rheumatoid arthritis, for example), or a disorder such as hemophilia.

Excess weight

Excess body fat can lead to a host of health problems, including osteoarthritis of the knee. Your knees simply don’t hold up well under the continued strain of extra pounds—and extra pounding.

One study found that obese women had about four times greater risk for knee osteoarthritis than non-obese women, and for obese men the risk was five times greater. An ongoing study of people living in Framingham, Mass., found that adults who were overweight in their 30s and 40s were more likely than their slimmer counterparts to develop osteoarthritis of the knee later in life. Women who were the heaviest were twice as likely as thinner women to get osteoarthritis and had three times the risk for severe knee osteoarthritis. According to the Centers for Disease Control and Prevention, 35.7% of adults in the United States—more than one-third—are obese. Given the strong link between obesity and osteoarthritis, it is likely that the prevalence of knee osteoarthritis will continue to rise in this country.

By contrast, losing excess weight can reduce the risk of developing osteoarthritis or, for people who already have the ailment, make daily living much easier. The Framingham study revealed that overweight women who lost an average of 11 pounds cut their risk of developing osteoarthritis of the knee by half.

Weight loss and osteoarthritis symptoms

For people with knee osteoarthritis who are overweight, shedding pounds reduces pain only slightly, but it clearly improves daily functioning, according to a review that pooled results from several studies. In this review, overweight or obese people saw benefits when they lost 5% or more of their weight over a period of five months. Most of the data came from a study of 316 overweight and obese adults who were randomly assigned to a diet program, an exercise program, a program that combined diet and exercise, or no program at all.

People in the combination diet-and-exercise group had much less pain and were better able to function than those who were not enrolled in any kind of weight loss program. They also had more mobility in their joints. (For more information on diet and exercise, see the special section, “Self-care strategies for coping with arthritis”.)


Genetic factors

Most experts agree that genetic factors most likely control the development and progression of osteoarthritis. Studies in identical twins—who share the same genes and thus offer insight into the relative importance of genetic and environmental factors—suggest that roughly half the risk of developing osteoarthritis can be attributed to genetic factors. Multiple genes are thought to play a role. And to complicate matters further, the genes may have different effects depending on the joint in question and whether someone is male or female.

Unfortunately, several factors limit genetic studies of a disease like osteoarthritis. First, the sheer number of people with the disorder makes it impossible to discount the influence of external factors. Second, scientists must establish that a certain gene is present in most people with the disease, but is absent in those who are healthy.


Hormones

Osteoarthritis is common among postmenopausal women. One study found that women who were taking hormone therapy appeared to have a lower risk of developing the disease, suggesting that estrogen may have a protective effect on cartilage in much the same way that it protects bones from the bone-thinning disease osteoporosis. However, these findings remain controversial: estrogen has many, and in some cases conflicting, effects on connective tissue and bone, making the association between the hormone and arthritis difficult to sort out. Even if it did help prevent osteoarthritis, hormone therapy has been associated with a number of other health risks that make it an unacceptable treatment for joint health.


Joint injury

As athletes know, severe knee injury disrupts the normal mechanics of joint function. Nearly all tissues heal by scarring, leaving irregularities on their surfaces. Because bones, joints, or muscles that are damaged rarely heal perfectly, joint injuries can create unusual mechanical stresses that lead to abnormal wear.

People in certain occupations are prone to developing osteoarthritis in those joints subjected to the most stress. For example, osteoarthritis may affect the hips, ankles, and feet of ballet dancers, the knees of soccer players, the hips of farmers, the elbows of riveters, and the hands and wrists of pneumatic tool operators. The cause is thought to be repetitive, high-intensity stress leading to bone fatigue, microscopic fractures, and eventually cartilage breakdown.

By contrast, day-to-day use, even “overuse,” of joints does not necessarily increase risk. For example, people who spend a lot of time using a keyboard aren’t more likely to develop osteoarthritis of the hands, because typing puts very little mechanical stress on the joints. Even regular jogging on pavement does not predictably lead to osteoarthritis of the knee, perhaps because the large muscles in the legs tend to dampen the impact on joints. (In soccer, it’s not the running, but more likely the twisting and torsion, that can injure the meniscus and lead to osteoarthritis.) In fact, in some studies runners appear to have a lower rate of osteoarthritis than nonrunners—possibly because they’re fit and trim to start with.


Other diseases

Osteoarthritis can develop in a joint damaged by a related disease, such as rheumatoid arthritis, infectious arthritis, or gout (see “Other types of arthritis,” and Table 1). Alternately, osteoarthritis may develop because of a growth abnormality. Such abnormalities include acromegaly (the irregular overgrowth of bone and cartilage due to abnormal production of growth hormone) and slipped femoral epiphysis (displacement of the growth plate at the end of the femur, which is the bone extending from the hip to the knee).

Osteoarthritis can also arise from certain hereditary metabolic diseases, such as hemochromatosis (the harmful accumulation of iron in tissues). Even hemophilia, in which blood does not clot properly, can lead to osteoarthritis as a result of repeated bleeding in the joint.



Symptoms of osteoarthritis

The symptoms of osteoarthritis usually develop over many years. Often, people first experience pain after engaging in strenuous activity or overusing a joint. The joint may be stiff in the morning, but after a few minutes of movement, it loosens up. Gradually, this stiffness becomes a routine part of waking up.

Cartilage is insensitive to pain, but the soft tissue around the joints is not. As more cartilage wears away, the soft tissue becomes increasingly irritated, even by slight movement. Some people have continual joint pain that interferes with sleep. Alternatively, the joint may be mildly tender, and movement may produce crepitus, a sensation of crackling or grating. In addition, gradual joint enlargement may interfere with normal mobility. Swelling may occur as synovial tissues become irritated, or when inflammation develops. Pain is usually confined to the affected joint, although it may extend elsewhere.

Pain and stiffness in affected joints may slowly worsen over the years, but most people are able to lead normal lives.

Knee

Early in the process of knee osteoarthritis, the space between the tibia (the bone below the knee) and the femur (the bone above the knee) decreases as the cartilage wears away. Bone rubs on bone, and osteophytes (irregular bony projections) can form around the joint. The result is pain, swelling, and stiffness of that joint (see Figure 4). What starts out as discomfort after a period of disuse can progress to difficulty walking, climbing, bathing, and getting in and out of bed. There may be intermittent or steady pain, swelling or tenderness, and grinding or crunching sounds. For many people, the pain tends to worsen as muscles tire during the day.

Figure 4: Osteoarthritis of the knee

Multiple factors contribute to the development of knee osteoarthritis. But once it begins, the wear and tear of repeated motion and weight placed on the joint may cause the cartilage there to degenerate more quickly than in some other joints. In this illustration, the articular cartilage of the condyles (knobs at the lower end of the thighbone) is degraded.


Hip

The hip is a common site for osteoarthritis. Pain radiating to the buttocks or knees is often the most striking feature. You may also feel pain in the groin or radiating down the inside of the thigh or when you pivot or rotate the hip inward. Other symptoms of hip osteoarthritis include the following:

  • stiffness after inactivity and first thing in the morning

  • difficulty bending

  • limping or other gait changes

  • apparent shortness of the leg on the affected side

  • difficulty with foot care

  • groin pain when you get out of a chair

  • difficulty getting in and out of a car.


Spine

Osteoarthritis can affect the cervical spine (the neck) and the lumbar spine (lower back). Osteoarthritis of the cervical spine may cause pain in your shoulders and arms. You may hear a crunching or grinding sound as you turn your head. In the lumbar spine, osteoarthritis causes low back pain, limited motion, and the formation of osteophytes (bony projections that may impinge on adjacent nerves and send pain radiating to your buttocks or legs).


Hand

Certain joints of the hands (see Figure 5) are especially susceptible to osteoarthritis:

Figure 5: Inside the hand

Under the skin, the hand’s 27 bones and 34 muscles work in synchrony to perform a range of movements, from a powerful hammer blow to a gentle caress.

The main bone of the hand is the metacarpal, which connects to the finger bones, or phalanges. The knuckle joint that connects these two bones is the metacarpophalangeal (MCP) joint. Each finger has three phalanges and the thumb has two. The middle joint of the finger is the proximal interphalangeal (PIP) joint. The joint near the end of the finger is the distal interphalangeal (DIP) joint. The thumb has only an interphalangeal (IP) joint.

  • The distal interphalangeal (DIP) joint (the last joint before the nail) is the most common site for osteoarthritis of the hands. These joints sometimes develop fibrous, bony nodules called Heberden’s nodes.

  • The first carpometacarpal (CMC) joint, which is at the base of the thumb, where it meets the wrist, is the second most common hand joint to develop osteoarthritis.

  • The proximal interphalangeal (PIP) joints—the middle joint of each finger can also develop osteoarthritis, causing the fingers to stiffen and swell. Fibrous and bony nodules, known as Bouchard’s nodes, may develop in these joints.

Osteoarthritis of the hand often starts with stiffness and soreness of the affected joint, particularly in the morning. You may find it becomes harder to pinch, and your joints crackle when moved. As the condition worsens, the pain at the base of your thumb may become more of a problem, and your ability to grip may decrease even further. The entire area may seem unstable. People with osteoarthritis of the hand may eventually find it impossible to open jars, turn a key, write, or type. Many people with osteoarthritis of the hand find that, with age, their hands thicken and become stiff. Stiffness is gradually followed by pain or instability. In other people, the pain and stiffness of hand osteoarthritis may subside over time, despite marked bony enlargement typical of the disease.

Does knuckle cracking cause arthritis?

Cracking your knuckles may provoke an annoyed grimace from those around you, but it probably won’t raise your risk for arthritis. That’s the conclusion of several studies that compared rates of hand arthritis among habitual knucklecrackers and people who didn’t crack their knuckles.

The “pop” of a cracked knuckle is caused by bubbles bursting in the synovial fluid. The bubbles pop when you pull the bones apart, either by stretching the fingers or bending them backward, creating negative pressure.


Feet

As in the hand, certain joints of the foot are more susceptible than others to osteoarthritis. Joints in the midfoot and ankle may be affected, but the most common site of foot osteoarthritis is the metatarsophalangeal (MTP) joint of the big toe, where it joins the rest of the foot.

Over time, osteoarthritic joints may stiffen and become sore, making walking difficult. Some people develop osteophytes, or abnormal bony protrusions, at the joint.

In some people with osteoarthritis at the first MTP joint, the bones become misaligned, forcing the toe to bend toward the others. This contributes to the formation of a bunion—a painful lump on the side of the foot at the base of the big toe. Bunions can be painful and make it difficult to wear shoes.




Diagnosing osteoarthritis

Diagnosing osteoarthritis can be challenging because numerous conditions can cause joint discomfort. When making a diagnosis, doctors rely heavily on your description of symptoms and other relevant information, plus a physical examination. That’s why you should prepare for your appointment by making a list of your symptoms and the circumstances under which they occur. Do you notice them during or after a particular activity? Are your symptoms worse first thing in the morning?

Primary care doctors can usually determine at the first visit whether the problem is arthritis or some other musculoskeletal problem. But it may take several visits for your physician to make a more specific diagnosis regarding the particular type of arthritis (see “Other types of arthritis,” and Table 1, for more information on those conditions). While this delay can be frustrating for you and your family, charting the course of your symptoms is often the only way a doctor can accurately diagnose arthritis.

X-rays can be used to establish a diagnosis of osteoarthritis, although early arthritic changes may not be pronounced enough to show up on the image. This means that you can have a normal-looking x-ray and still have osteoarthritis.

When symptoms don’t fit the usual pattern for osteoarthritis, further investigation, often by x-ray or other imaging techniques, may be necessary. Such atypical examples may involve arthritis of joints that are usually spared, such as the elbow or ankle, or swelling of the synovium, a condition known as synovitis.

Your medical history

Your symptoms—what they are, when they first began, and how they’ve changed over time—provide important clues to whether arthritis is inflammatory or noninflammatory. Your doctor will need to know about the following:

  • type of joint symptoms (such as pain or stiffness)

  • effect of activity (such as increased pain or relief of stiffness during or after a particular activity)

  • general pattern of joint symptoms (started gradually or suddenly, worsened over time or stayed about the same, migrated from one joint to another, or fluctuated in intensity)

  • any other symptoms (fever, fatigue, weight loss, skin problems, bowel problems)

  • events that occurred near the time the symptoms first appeared (such as viral illness, bacterial infection, injury, vaccination, new medication, or change in activity)

  • time of day that joint symptoms are worst (prolonged morning stiffness suggests inflammatory arthritis; night pain is more typical of osteoarthritis, a meniscal tear, or ligament injury)

  • presence or absence of joint swelling, redness, or warmth

  • previous episodes of similar symptoms

  • family history of arthritis or rheumatic disease.

When to see a doctor

Because arthritis is rarely a medical emergency, you can usually schedule a routine appointment for evaluation. However, certain situations and symptoms demand immediate attention. These include the following:

  • joint injury, especially if the joint cannot function or there is a feeling of instability; this may require orthopedic treatment

  • joint pain accompanied by broader systemic problems such as fever, rash, fatigue, headache, or weight loss; this can indicate other autoimmune diseases, chronic infection, or cancer

  • severe pain in one or a few joints; this can indicate joint infection or gout

  • neurologic symptoms, such as numbness or pain in the hands or legs, radiating from the neck, or in the lower back; this may indicate nerve compression.


Pain and stiffness

Pain is a subjective experience that’s often difficult for people to describe, quantify, or even pinpoint. Chronic arthritis produces aching pain when the affected joints are moved, as opposed to the burning or prickling pain unrelated to motion that typifies neurologic disorders. Most people can describe the location of pain in small joints, such as the hands or feet. However, with large joints, the pain is generally more diffuse and may radiate, making it difficult to pinpoint. For example, hip arthritis may cause pain in the groin, thighs, buttocks, or even knees.

People often describe vague muscle aches as stiffness, but rheumatologists (doctors specializing in arthritis and other ailments affecting joints, muscles, and bones) use the term more specifically for joint discomfort when a person attempts to move. Stiffness is the tendency of a joint not to move easily and may be prominent even when joint pain is not.

The duration of stiffness in the morning or after any period of inactivity can help doctors distinguish osteoarthritis from rheumatoid arthritis and other types of arthritis. Mild morning stiffness is common in osteoarthritis and resolves after a few minutes of activity. In rheumatoid arthritis, however, morning stiffness may not begin to improve for an hour or longer. Occasionally, morning stiffness is the first symptom of rheumatoid arthritis. Sometimes people with osteoarthritis notice more stiffness during the day after resting for an hour or so.

To understand the intensity of your pain, your doctor may use a pain scale (see Figure 6). In addition, he or she will want to know about the nature and duration of your symptoms. Pain and stiffness that develop gradually and intermittently over several months or years suggest osteoarthritis. By contrast, rheumatoid arthritis or another inflammatory arthritis may cause pain, stiffness, and fatigue that worsen in as little as several weeks or a few months. Sudden pain over a day or two is more likely a result of injury or fracture, and pain that intensifies over several hours is typical of bacterial infection or gout.

Figure 6: How much does it hurt? Keeping track

A pain record is useful. For two weeks preceding your doctor’s appointment, keep a record of your pain, its intensity and duration, its characteristics, and any action that makes it worse or better. Your doctor will use this information in diagnosis.


Physical examination

Because many other disorders can masquerade as arthritis, a complete physical examination is a necessary part of the diagnostic process. During your visit, the doctor watches how you move and gains information from a visual assessment of how you use your joints. He or she may ask you to take a few steps, move your hands and arms, and so forth. The doctor will also move your joints through their range of motion to detect any pain, resistance, unusual sounds, or instability, and will examine your joints for abnormalities.

Swelling. An inflamed synovial membrane often produces mild joint swelling. People may describe a sensation of tightness or fullness inside the joint, or it may feel tender. Doctors describe the joint as feeling “boggy” or soft to the touch. Marked swelling usually indicates excessive joint fluid, a sign of inflammation or perhaps bleeding into the joint.

Enlargement. Enlargement of a joint is not the same as swelling. Bony enlargement without joint swelling feels hard to the touch and is not usually tender—a classic sign of osteoarthritis.

Limited motion. Doctors assess joint mobility in two ways: active range of motion in which the person voluntarily moves the joints, and passive range of motion in which the examiner moves the person’s joints. By comparing active and passive movement, doctors can often determine whether the cause is muscle weakness, bursitis, or tendinitis (in which case the joint has wider range of motion during passive movement), or whether the problem is with the joint itself. Doctors listen and feel for crepitus, a crunching or grating sensation and sound caused by rough surfaces rubbing together inside the joint.

Limited spine flexibility. This may indicate osteoarthritis or another arthritis, such as ankylosing spondylitis. To evaluate spine flexibility, the doctor may ask you to stand and bend forward and backward, lean from side to side, and twist your torso.


Diagnostic tests

In addition to a medical history and physical examination, your physician may need an x-ray of the affected joint to help make a diagnosis of osteoarthritis. Blood tests, imaging, and a procedure called arthrocentesis may also be recommended to rule out other types of the disease, such as rheumatoid arthritis (see “Diagnosing rheumatoid arthritis”).

Blood tests

Although these tests are not diagnostic for osteoarthritis, doctors may use them “just in case” to rule out other forms of arthritis.

Antibody tests. When rheumatoid arthritis is a possibility, many doctors order tests for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP). An antinuclear antibody test may be used if lupus or related conditions are under consideration.

Erythrocyte sedimentation rate and C-reactive protein. These blood tests are general measurements for inflammation of any kind: the higher the result, the more severe the inflammation. Most people with osteoarthritis have normal values, but those who have inflammatory conditions, such as rheumatoid arthritis, usually have elevated levels.

Serum uric acid test. This test measures the level of uric acid in the blood, which is usually elevated in people with gout.

Other blood tests. A person’s history may indicate the need to test for Lyme disease or other infections, which can cause reactive arthritis and other types of infectious arthritis.


Imaging tests

Doctors may order one or more imaging tests to better evaluate your joints. The type of test ordered depends on the suspected diagnosis.

X-rays. Most forms of arthritis can cause joint abnormalities that are visible on x-rays (see Figure 7), including a reduction in the joint space and increased bone density (sclerosis). But in most cases, such changes can’t be detected until months after the onset of the disease. Sometimes the changes are reasonably specific and suggest a particular kind of arthritis. In other cases, they are more general. For example, bone damage (erosion) is often found in rheumatoid arthritis and may occur in gout, but the damage from each of these differs enough in appearance that a radiologist can usually tell them apart.

Figure 7: Osteoarthritis of the hip

This x-ray shows osteoarthritic changes of the left hip (marked by red arrow). The normal “ball-and-socket” shape has noticeably deteriorated.

Often, the changes revealed in x-rays bear little relationship to the actual symptoms, especially in osteoarthritis. An x-ray showing large osteophytes (irregular bony projections) on the finger joints may belong to a woman with occasional mild aching in her hands, while an x-ray revealing much less dramatic abnormalities may be that of a woman who can no longer garden because of hand pain.

In their early stages, osteoarthritis and rheumatoid arthritis may appear quite different on x-ray examination, but later they may look similar. In rheumatoid arthritis, the inflamed tissue (pannus) erodes cartilage, and in many cases, the joint damage eventually leads to secondary osteoarthritis, even after the inflammation subsides.

Magnetic resonance imaging (MRI). In evaluating people with joint problems, this test can help doctors assess soft tissues, cartilage, tendons, and joint inflammation. It’s also quite good for detecting spinal cord and nerve root compression that can be caused by spondylitis or degenerative disk disease. In addition, MRI has been used to help diagnose rheumatoid arthritis.

Ultrasound. This technique uses sound waves to assess fluid in soft tissues and abnormalities in muscles or tendons. Many doctors are using ultrasound to identify inflammation and joint damage and to guide procedures such as arthrocentesis (see “Arthrocentesis”). Researchers are studying whether ultrasound can also detect erosions in rheumatoid arthritis and other types of arthritis.

Computed tomography (CT). CT imaging uses a rotating x-ray tube housed in a doughnut-shaped machine to show thin x-ray slices of your anatomy. A computer then assembles these slices into a three-dimensional picture. Doctors occasionally order CT scans to detect hidden fractures, bone infection, or other abnormalities of bone.


Arthrocentesis

In this diagnostic procedure, which is most commonly performed when a person develops sudden or unexplained joint swelling, a physician uses a needle to remove some of the synovial fluid for examination. Excess synovial fluid may indicate a bacterial infection in the joint, crystal deposits, injury, bleeding into the joint, or synovial inflammation. In cases of relatively mild chronic arthritis, arthrocentesis may help distinguish between osteoarthritis and inflammatory joint disease; this can help to narrow down the diagnostic possibilities and guide treatment.

Physicians can often get a good idea of whether the problem is inflammatory by the appearance of the fluid. Normally, it’s translucent and pale-to-medium yellow. Significant inflammation may produce a deep yellow or greenish-yellow opaque fluid. Cloudy fluid may be a sign of crystals or infection.

A laboratory technician or physician examines the fluid under a microscope for crystals that indicate gout or similar disorders. Your doctor may request other laboratory tests on the fluid, such as a white blood cell count; a large number of white blood cells could indicate either infection or severe inflammation. Arthrocentesis itself is often beneficial because removing some of the excess synovial fluid can relieve pain and pressure.




Treating osteoarthritis without surgery

Damaged cartilage does not heal on its own, and there is currently no cure for osteoarthritis. But treatment can greatly improve your quality of life by relieving pain, protecting joints, and increasing range of motion. Therapy usually involves a combination of strategies, including drugs, assistive devices, and exercises to strengthen the muscles that help stabilize a joint. In some cases, more aggressive treatment with surgery may be needed.

Drug treatment

Although no drug that currently exists will cure or reverse the progression of osteoarthritis, pain and inflammation can usually be alleviated. Medications form the basis of treatment for osteoarthritis, but are best used in conjunction with other pain relief strategies, such as exercising to build your muscles and protecting your joints from injury or overuse.

Topical pain relievers

Topical pain relievers, which are applied to the skin, offer one alternative for mild pain relief. You can use these alone or in combination with oral analgesics. Creams containing salicylate (including Aspercreme and Bengay) and others containing capsaicin (including Zostrix) are available without a prescription. However, it’s important to avoid touching any mucous membrane around the mouth, nose, or eyes after applying the cream, in order to avoid irritation.

Diclofenac, a prescription nonsteroidal anti-inflammatory drug (NSAID), is available for topical use as a gel (Voltaren Gel) and a patch (Flector Patch). Both carry some of the same risks as oral NSAIDs, but they are less likely to cause stomach and intestinal irritation because they don’t enter the gastrointestinal tract. If you develop an upset stomach when taking the pill form, consider trying one of the topical versions.

NSAIDs and risk for heart disease and stroke

In 2004 the COX-2 inhibitor rofecoxib (Vioxx) was taken off the market because it was found to significantly increase risk for heart attack and stroke. Since then several investigators have examined whether other NSAIDs might have similar effects. Numerous studies have been conducted, and the results of many of them have been combined to get a better overall picture. These show that not all NSAIDs are the same.

Naproxen seemed to be the least harmful, according to a study in the journal BMJ in January 2011, while a study published in September 2011 in PLOS Medicine found that low doses of either naproxen or ibuprofen were least likely to increase risk for heart disease. Diclofenac was found to slightly increase risk. Indomethacin, an older NSAID drug, also increased risk.

If you have heart disease or are at risk for it, talk to your doctor about the safest NSAID to take or whether you should avoid them altogether. (Note: These studies did not include low-dose aspirin, which helps prevent clotting and is still recommended for some people at risk for heart attacks. The low dosage may account for its different risk profile.)

While the notion of applying medicine right to the spot that hurts has intuitive appeal, there are some doubts about how well such remedies work. With something as subjective as pain, it can be hard to figure out whether a treatment is effective. For example, an ointment that provides a soothing sensation might be said to work by some definitions. And the placebo effect—benefit that comes from a person’s expectations rather than the treatment itself—is a major complicating factor.

On the other hand, there’s no question that active medicine can penetrate the skin and get into the body; how much is absorbed is a separate question. And, at least in theory, exposing just the hurting part of the body to a pain medicine might mean fewer side effects than taking a pill, which involves gastrointestinal absorption and the drug being carried in the blood throughout the entire body.


Acetaminophen

To relieve the pain and stiffness of osteoarthritis, the first step is usually an over-the-counter pill. Doctors often recommend acetaminophen (Tylenol) first because it relieves mild pain and is easy on the stomach. Recent research has suggested that it may be even more effective when combined with ibuprofen (Advil or Motrin). A study published in 2011 in the journal Annals of the Rheumatic Diseases found that people with knee osteoarthritis who took a combination pill for slightly over three months had better pain relief than those taking acetaminophen alone.

But acetaminophen, like any drug, has its own risks—especially for the liver. According to the American Association for the Study of Liver Diseases, each year about 50,000 emergency room visits and 500 fatalities are attributed to acetaminophen overdose—at least half of which are unintentional. Considering that millions of people take acetaminophen for pain relief every day, the number of people with acetaminophen-related liver failure is relatively small. Still, it remains the most common form of acute liver failure in the United States.

To avoid an accidental poisoning, don’t exceed the recommended maximum, which is generally set at 3 grams (3,000 milligrams) per day—the equivalent of six extra-strength Tylenol tablets. According to the FDA, liver damage may occur if you take more than 4 grams (4,000 milligrams) in a day or if you drink three or more alcoholic beverages while taking acetaminophen. Remember that acetaminophen is often included in other drugs such as cough and cold medications, so it’s important to read the labels carefully.


NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally considered more effective than acetaminophen in treating osteoarthritis because they not only relieve pain, but also reduce inflammation that contributes to pain, swelling, and stiffness.

The arsenal of NSAIDs has grown over the years to include about 20 different drugs. Among them are such well-known medications as aspirin, ibuprofen (including Advil and Motrin) and naproxen (including Aleve and Naprosyn). They are available in both prescription and nonprescription strengths. These drugs reduce pain and inflammation by blocking the production of prostaglandins, leukotrienes, and other chemical mediators. For many people with arthritis, they are slightly more effective than acetaminophen, especially during flare-ups. Recent research has shown that a combination of acetaminophen and ibuprofen may bring more relief than acetaminophen alone.

The most common side effects of NSAIDs are stomach problems, including gastrointestinal bleeding and ulcers, often occurring without warning. That’s because NSAIDs work by inhibiting both the COX-1 enzyme (which helps protect the stomach lining from the corrosive effects of stomach acids and digestive enzymes) and the COX-2 enzyme (which causes pain and inflammation). It’s estimated that NSAIDs contribute to as many as 16,500 deaths and 100,000 hospitalizations in the United States each year.

Most of the time, these complications can be avoided—but you and your doctor must work together to determine your risk of experiencing them. The older you are, the higher your risk of developing bleeding and ulcers. Others at risk include people who have had ulcers in the past, those with rheumatoid arthritis, and people who are also taking a blood thinner or corticosteroids. Prolonged use and higher doses of NSAIDs also increase the risk. And some NSAIDs are more prone than others to causing ulcers; for example, aspirin (including Anacin and Bayer) and indomethacin (Indocin) appear to have the highest risk.

If you are in a high-risk group, avoid NSAIDs if possible, and try other pain relief strategies. The COX-2 inhibitor celecoxib (Celebrex) is safer for the stomach, but poses other risks (see “COX-2 inhibitors”). If other strategies don’t work, talk with your doctor about stomach-protecting drugs to take along with the NSAID. These include histamine blockers such as cimetidine (Tagamet) and ranitidine hydrochloride (Zantac), and proton-pump inhibitors such as esomeprazole (Nexium), lansoprazole (Prevacid), and omeprazole (Prilosec). Another option is taking misoprostol (Cytotec) with the NSAID. Some medicines (Arthrotec, Prevacid NapraPAC) combine an NSAID with a medication that protects the stomach.

If taking NSAIDs produces stomach upset but not a bleeding ulcer, good initial strategies are to reduce the dose of the NSAID you’re taking, try an entirely different pain reliever (such as acetaminophen), or switch to a drug such as celecoxib, which is more selective for COX-2 and therefore might be better tolerated. Nabumetone (Relafen), although not officially a COX-2 selective agent, is relatively selective for COX-2 and would be a better choice than a traditional NSAID such as indomethacin if stomach upset is a limiting factor. Other more selective medications to consider, as they may be more easily tolerated, are meloxicam (Mobic) and diclofenac (Voltaren).

No matter what your risk profile, to be on the safe side, do not use NSAIDs on a daily basis except under the supervision of your doctor, and do not combine NSAIDs with other medications without talking to your doctor first. Also take time at each doctor’s visit to reassess the medications you are using for your arthritis and to evaluate your symptoms. All too often, people take more medication than they really need. Other pain relief strategies might be used in combination with the drugs so you can lower the dose.


COX-2 inhibitors

COX-2 inhibitors, a newer type of NSAID, were designed to be more selective in their effects than traditional NSAIDs. As their name implies, these drugs inhibit only the COX-2 enzyme involved in pain and inflammation, while sparing the COX-1 enzyme that protects the stomach lining. As such, they are able to relieve pain as well as the strongest NSAIDs, while causing less stomach irritation (although the risk of this side effect isn’t eliminated). However, these drugs were later found to increase the risk of heart attack and stroke, which led the FDA to remove two COX-2 inhibitors from the market. The remaining one, celecoxib (Celebrex), comes with a warning of the increased risk. For this reason, most people now choose other pain medications.

More potent painkillers

Occasionally, arthritis pain requires a stronger painkiller, such as tramadol (Ultram) or a combination of acetaminophen with codeine (Tylenol No. 3). Usually, people take these medications intermittently for short periods (a week or so). But if other therapies are not effective or are not tolerated, these prescription painkillers can be taken on a long-term basis. However, side effects may limit their use. Tramadol commonly causes sleepiness and gastrointestinal symptoms, while codeine may cause constipation, nausea, and sleepiness.


Corticosteroid injections

If your joints feel warm and swollen (a sign of inflammation), your doctor may remove a small amount of joint fluid and then inject a corticosteroid. This procedure can relieve inflammation quickly, but usually only for a short time. It is used almost exclusively for severe symptoms associated with these signs of inflammation, especially for osteoarthritis of the knee. This approach is usually used infrequently—up to two or three times per year—and only when absolutely necessary, because more frequent injections of these drugs may increase the risk of infection and can damage the joints.


Hyaluronate injections

Injections of hyaluronate (Hyalgan, Synvisc) may provide mild relief of symptoms of knee osteoarthritis in some people. In its natural form, hyaluronate lubricates the joint and supplies it with nutrients. Synthesized forms of this chemical can be injected directly into an osteoarthritic knee. But the jury is still out on the desirability of this treatment: some doctors do not believe the modest benefits are worth the risk and discomfort of the injections.



Physical and occupational therapy

Despite the variety of medications available for arthritis, physical therapy and occupational therapy remain cornerstones of traditional treatment. Both types of therapists will start by thoroughly evaluating your pain, functional ability, strength, and endurance levels. They will then focus on restoring or maintaining physical function by designing an individualized treatment program for you. But there are differences between them.

Occupational therapists focus primarily on the hands and wrists. For a person with osteoarthritis, an occupational therapist may offer suggestions about how to better perform and manage everyday tasks, such as preparing meals, writing, typing, and using tools and utensils. He or she will also give you advice about ways to ease pressure on your joints and may provide you with special assistive devices, such a splint, brace, sling, elastic bandage, or cane, to reduce pressure on tender joints and protect them from further injury.

Physical therapists focus on the broader musculoskeletal system. They promote mobility, function, and pain reduction through a specially tailored program that usually includes exercises, but may also include ultrasound, transcutaneous electrical nerve stimulation (TENS), heat and cold therapies, and traction. Physical therapy can take place at a hospital or outpatient clinic, in the therapist’s office, or in your home. Some activities can be done alone; others require the therapist’s assistance. (Exercises to preserve mobility and increase strength are described in the special section, “Self-care strategies for coping with arthritis”.)


Assistive devices

Not many studies have been published on using splints or braces for joints affected by osteoarthritis, but research suggests these devices may relieve some symptoms. Because it is important to get the right brace or splint and the correct fit, be sure to consult a doctor or physical therapist before buying any kind of assistive device.

Knees

If you have knee arthritis, braces and shoe inserts may reduce pain and help you to function by reducing the amount of stress walking puts on your knee. If you have early, mild arthritis with sudden flare-ups, a simple knee wrap made of neoprene or elastic (see photo) may help to relieve pain. Because the sleeve itself doesn’t provide much support, any benefit is thought to be due to improvements in the knee’s movement and position. However, your physical therapist may prescribe a variation of this type of brace that incorporates pulsed electrical stimulation, which has proven especially effective in treating knee osteoarthritis.

If you have knee osteoarthritis affecting only one part of the joint, a different type of brace known as an unloader brace may help by taking some of the pressure off that part of the knee and redistributing the weight (or load) to other parts (see photo). These braces change the angle of the knee joint using special hinges to reduce force on the joint. However, many people find these types of braces cumbersome or uncomfortable.

Another kind of brace is used in people with arthritis affecting the joint beneath the undersurface of the kneecap. Consisting of a sleeve with a cutout at the kneecap and pads below and to the outside, this brace is designed to reduce compression of the kneecap, improve its alignment, and prevent side-to-side shifting.

Foot orthotics, or specialized shoe inserts (which can be ordered by a podiatrist and custom-made), may also prove helpful for people with knee arthritis because flat feet or other foot problems can affect the alignment of the ankle and knee, placing additional stress on the joints. Shock-absorbing insoles made of a gel-like material may also help reduce the symptoms of knee osteoarthritis. One study showed that these shoe inserts reduced the force of each step by 42% and improved symptoms in 78% of the people who used them.


Ankles

If you have ankle osteoarthritis, you may change the way you walk to compensate for pain and limited movement, which can put stress on your other joints. Ankle supports are designed to improve balance and normalize your walking patterns. Devices range from an ankle brace (see photo), to a semirigid foot orthotic, to shoe modifications (such as a lateral wedge insert or rocker sole and cushioned heel), to custom-made, molded-plastic orthotics for people with more severe disease. Ask your doctor or therapist which is right for you. If your arthritis is severe, he or she may order one of various forms of immobilization boots, which can be effective when used for walking and standing.


Feet

If you have arthritis in your feet, a podiatrist may be able to provide orthotics, recommend special shoes, or suggest other treatments to reduce pain and improve your ability to function.


Hips

Except in rare situations, using a brace to support the hip doesn’t seem to be helpful. A straight cane, on the other hand, can help quite a bit. When you stand without leaning on a cane, the pressure on the hip increases as much as four times. If you have pain in both hips, you should use the cane on the side opposite to the hip that is the most troublesome, and alternate sides as needed (see “Easing the strain with a cane”).

Easing the strain with a cane

For something so low-tech and simple in design, a cane performs complex functions. You hold the cane in the hand opposite the side that needs support, about four inches to the side of your stronger leg. This redistributes weight to improve stability, helps reduce demand on muscles that may be weak, and takes the load off weight-bearing structures such as the hip, knee, and spine.

A cane can help you maintain mobility and ward off further disability if you have arthritis of the knee or hip, as well as assist in recovery after surgery. So don’t let self-consciousness stop you from using a cane if your doctor recommends that you try one.

A physical therapist or other clinician can help you select a cane, check that it’s the proper height, and show you how to use it. He or she may also suggest certain muscle-strengthening exercises before you start walking with your cane.

Canes are available at medical supply stores and pharmacies, through specialty catalogs, and on the Internet. They generally come in standard, offset, and multiple-legged versions. Government or private insurance usually covers the cost of a basic cane if you have a written prescription from your doctor.

Standard canes. These are low-tech, lightweight, and generally inexpensive. They usually come with a curved or T-shaped handle and a rubber-capped tip at the bottom. Many people find that a T-shaped handle is more comfortable than a curved one. A standard model is good for people who need help with balance but don’t need the cane to bear a lot of weight.

Offset canes. The upper shaft of an offset cane bends outward, and the handle grip is usually flat—often a good choice for people whose hands are weak or who need a cane that bears more weight than the standard type.

Multiple-legged canes. Multiple legs offer considerable support and allow the cane to stand on its own when not in use. One drawback to using such a cane is that for maximum support, you must plant all the legs solidly on the ground. Doing so takes time and can slow the pace of walking.


Hands

Hand splints can provide pain relief, improve function, or realign the joints of the hand to a more anatomically correct position. They come in a wide range of materials and forms. A prefabricated splint from the drugstore or medical supply store works well for certain hand problems, provided it is chosen and adjusted correctly. Other conditions require specially fabricated splints, which are usually made of thermoplastic materials and molded to fit around the contours of the hand. Static splints hold the joint in one position, while dynamic splints allow movement. Some are designed to help lengthen tightened joint capsules, muscles, and tendons. Others, which feature elastic or spring-loaded parts, make up for missing motion in the hands and wrists caused by muscle weakness or nerve damage.

Several types of splints are designed to address problems with the finger joints. These include a figure-eight splint and a prefabricated “oval-eight” splint, which allow you to fully bend the finger joint closest to the hand but protect the joint from hyperextension. In addition, custom-made splints prevent the joint from bending backward and from moving sideways. Last, a “gutter” splint may be fabricated to immobilize only the joints that are painful or swollen. Various custom-made splints can also be made to help with problems at the base of the thumb. Your doctor or therapist will help you determine which one is most appropriate. Even if you use a splint or brace, it is important to take steps to protect your joints (see “Joint protection strategies”). Adaptive aids may also be useful (see “Helpful gadgets”).


Wrists

There are several options for wrist splinting, depending on your needs. For people with early disease, simple off-the-shelf elastic or neoprene splints may be enough to reduce pain and improve function. If your arthritis is more severe, custom-molded splints may be a better option because they provide more joint control. The type of splint and materials used in its fabrication will depend on the demands of the wrist. For example, a laborer will need sturdier material than someone who works at a desk.


Elbows

Elbow braces are designed to maintain range of motion and relieve pain. This is especially important during flare-ups. During the early stages of the disease, it may be helpful to rest the elbow with a soft or rigid support, depending on whether it needs to be held in place. People who plan to wear the splint during periods of activity should use one that supports the back of the elbow and add a wrist brace during acute flares. At night, a splint that supports the front of the elbow may be more comfortable.



Complementary therapies

Compared with conventional treatments, you are likely to have much less guidance when it comes to deciding on whether to use complementary therapies, and which ones. Although hundreds of such therapies exist, only a few have actually proved to be effective when evaluated in rigorous studies.

Don’t buy into any treatment that promises a cure. And be sure to ask questions: Do the claims rely only on testimonials from people who have tried the treatment, rather than on scientific studies? Are the promises extravagant? Do proponents advise not telling your doctor about the treatment? Do they suggest stopping medical treatment? Are the ingredients unidentified or “secret”? Is the source of your information selling the treatment? If your answer to any of these questions is “yes,” your best response to the therapy may be “no.”

The following are therapies with at least some evidence behind them. But before trying any complementary therapy, discuss it with your doctor first to make sure it will support, rather than hinder, your arthritis management plan.

Glucosamine and chondroitin

Glucosamine and chondroitin are over-the-counter dietary supplements that may relieve pain in people with moderate to severe pain from osteoarthritis. Both are chemical components of cartilage, and in theory, supplements containing synthetic versions of these substances might help stop joint destruction and ease arthritis pain.

Over the years, some people with osteoarthritis have claimed to have less pain and stiffness when regularly taking such products. Some people swear by them. However, a major study of these supplements in The New England Journal of Medicine concluded that the degree of benefit may depend on the severity of a person’s pain. Among 1,500 participants with knee osteoarthritis, glucosamine and chondroitin taken alone or in combination provided no more relief than placebo—largely because those with mild pain did not see greater benefit. Those whose pain was more severe experienced modest relief with the combination of glucosamine and chondroitin that was similar to that provided by celecoxib (Celebrex).

If you’re wondering whether you should take glucosamine and chondroitin, the answer is “it depends.” If you are experiencing moderate to severe osteoarthritis pain, try the glucosamine-chondroitin combination for two to three months. If you find it eases your pain, it’s reasonable to keep using it. If not, save your money. As always, if you choose to take these or any other alternative preparations, be sure to inform your physician.


Acupuncture

Many Americans undergo acupuncture treatments to help relieve pain, including the pain of arthritis. Acupuncture, which involves the application of tiny, sterile needles to specific points in the skin, has been a staple of Chinese medicine for 2,000 years. It seems counterintuitive that needles could relieve pain, but the body’s response may be to release endorphins, a natural morphine-like chemical in the nervous system. An article in Cochrane Database of Systematic Reviews looked at 16 studies involving nearly 3,500 people with osteoarthritis of the knee, hip, or hand. The studies compared acupuncture with sham acupuncture (in which needles were either inserted at incorrect points or didn’t penetrate the skin), another treatment such as medication, or a waiting list control group. Compared with fake acupuncture or the control group, real acupuncture offered small improvements in pain and function. But much of the benefit may have resulted from the placebo effect (the participants’ expectations of improvements).

If you decide to try acupuncture, talk with your doctor first, and find a licensed acupuncturist.


Massage

Many people with pain in their muscles and joints turn to massage therapy (also called muscular therapy) for relief. Some studies have shown that massage therapy is safe and possibly effective. One study of knee osteoarthritis, published in Archives of Internal Medicine, found that those who received Swedish massage had significant improvements in pain and function, compared with people who did not receive massage. However, the study used only one form of massage therapy (and there are many), so further research is needed to determine which forms of massage therapy may be helpful for osteoarthritis.


Chiropractic care

Chiropractors use spinal adjustments and other joint and soft-tissue manipulations to prevent and treat a variety of disorders of the muscles, bones, and nervous system. This therapy is often used for back pain. In one study, researchers randomly assigned 250 people with disease of the vertebral joints, intervertebral disks, or both to receive either moist heat and chiropractic treatment or only moist heat. The people who got both therapies had less pain and a greater range of motion than those who did not receive the chiropractic treatment. But more research is needed to confirm the effectiveness of this approach.


Other complementary therapies

A variety of other therapies have been suggested for the pain of arthritis. For example, a technique called diathermy (deep heat) uses electromagnetic waves of different frequencies to deliver heat deep into the tissues. Microwave and ultrasound are the most common wave frequencies used in physical therapy, chiefly to relieve muscle spasm. Microwaves relax muscles, while ultrasound penetrates deeper to reach other soft tissues as well. Diathermy should not be used on actively inflamed joints, and people with pacemakers cannot be treated with microwaves (although ultrasound is safe for such people).

Doctors sometimes recommend transcutaneous electrical nerve stimulation (TENS) for people with chronic pain. TENS works by stimulating large nerve fibers, which theoretically blocks transmission of pain signals from small fibers. Some people with chronic pain from rheumatoid arthritis or osteoarthritis find TENS quite effective. The TENS device consists of a battery pack and electrodes that attach near the painful joint. The battery generates a very low electrical current to the electrodes, producing a pleasant tingling, vibrating, or massaging sensation.

But the scientific evidence for both these therapies is scant. If you choose to explore them and find them useful, be sure to continue your conventional therapy and visit your physician regularly.




Surgical treatment of osteoarthritis

Sometimes, people need surgery to relieve extremely painful or badly misaligned joints. The option your doctor recommends will depend on your age, activity level, and overall health. Surgical options are usually recommended only when drug therapies and other strategies no longer work and osteoarthritis significantly limits daily activities.

Making the decision

If the pain and limitations of osteoarthritis are significantly interfering with your life, talk with your doctor about whether replacing your knee or hip joint is a good solution. Joint replacement is an elective procedure, and it is not an option for everyone. The ideal candidate is in good general health and not overweight. The average age for total knee replacement is 70; for total hip replacement, it is 66. The decision to have joint replacement is ultimately up to you and your physician, who, together, must weigh the benefits and risks.

You may want to consider joint replacement if one or more of the following statements apply to you:

  • You are unable to complete normal daily tasks without help.

  • You have significant pain daily.

  • Pain keeps you awake at night despite the use of medications.

  • Nonsurgical approaches—such as medications, the use of a cane, and diligent physical therapy—have not relieved your pain.

  • Less complicated surgical procedures are unlikely to help.

  • Pain keeps you from walking or bending over.

  • Pain doesn’t stop when you rest.

  • You can’t bend or straighten your knee, or your hip is so stiff that you can’t lift your leg.

  • You are suffering severe side effects from the medications for your joint symptoms.

  • X-rays show advanced arthritis.

Joint replacement is generally not an option for people with any of the following problems:

  • systemic infection or infection in the damaged knee or hip

  • leg circulation so poor that it will interfere with healing

  • severely damaged or nonworking knee muscles or ligaments

  • damaged nerves in the legs

  • neuromuscular disease such as multiple sclerosis, Parkinson’s disease, or stroke

  • allergy to metal or plastic

  • medical illness that makes any major surgery risky.

Like any major operation, joint replacement surgery carries the risk of possible complications. For example, there are small risks that you may have a reaction to the anesthesia, develop a blood clot, or contract an infection (see “Possible complications of joint replacement surgery”).

Arthroscopy

Arthroscopy is considered minor surgery because the incisions are small and the procedure generally does not require an overnight stay in the hospital. An arthroscope is an instrument with a tiny light and a camera on its tip. A variety of surgical attachments can be inserted through the arthroscope or through separate, small incisions. The surgeon inserts the instrument into the joint and uses it to remove torn cartilage, debris, and loose material.

Depending on the condition of the joint, arthroscopy can result in mild to moderate improvement that may last several months or perhaps a few years. But while arthroscopy can be helpful for patients with osteoarthritis who fail other treatments, recent studies have questioned the usefulness of arthroscopy for most cases of osteoarthritis. Unless there is a specific finding or abnormality that can be addressed with this technique, arthroscopy as a means for treating osteoarthritis may not be helpful.


Alternatives to joint replacement

While joint replacement is considered the definitive treatment for a badly damaged knee or hip, it is generally considered a last resort and is not right for everyone. Here are some other surgical options.

Realignment

Surgery can be performed to realign bones that are no longer correctly lined up as a result of osteoarthritis. In the case of knee osteoarthritis, for example, the surgeon reshapes the tibia and femur to improve the alignment of the knee joint. This may be an alternative to joint replacement for people who are young and active and not yet candidates for an implant that lasts only 15 to 20 years.


Fusion

Another possibility involves permanently fusing two bones at the affected joint. This is an option when arthritis occurs in parts of the body such as the wrist, ankle, and small joints of the fingers and toes, where joint replacement is less reliable and rarely performed.


Hip resurfacing

Hip resurfacing may offer an attractive alternative to traditional hip replacement, especially for younger and more active people. Instead of removing the head of the femur and replacing it with an artificial ball, the surgeon reshapes the head and caps it with a cobalt-chromium prosthetic that fits into an artificial metal lining in the socket. Resurfacing uses a bigger ball, which some surgeons say makes dislocation less likely and gives the joint the ability to handle greater stress. Because resurfacing preserves the neck and part of the head of the thighbone, it also makes it easier and less complicated to have a traditional hip replacement in the future when the resurfacing wears out, compared with redoing a failed total hip replacement.

Hip resurfacing was first tried in the 1970s, but it fell out of favor because of problems with the polyethylene parts used at the time. Since then, a newer generation of metal-on-metal caps and socket linings has been approved by the FDA. Still, the procedure has not been studied as extensively or for as long as hip replacement, and people with hip resurfacing seem to be more likely to have complications, including fractures of the upper portion of the thighbone, than those who have had conventional hip replacement. These complications appear to be more common among women. Studies going back 10 years suggest that hip resurfacing offers the best benefit-to-risk ratio for men under age 60 who need a total hip replacement and would like to remain active.



Joint replacement

Doctors recommend joint replacement in cases of severe osteoarthritis in which the joint shows significant deterioration. This surgery is most often recommended for osteoarthritis of the knee or hip, because severe disease of these joints can impede movement. In fact, knee replacement and hip replacement are among the most common surgeries in the United States, with more than 580,000 total knee replacements and over 230,000 total hip replacements performed each year.

Success rates for these procedures are high, at over 90%, but it is important to have realistic expectations. You probably won’t regain the function you had in your youth. A new hip or knee, however, should allow you to engage in normal activities again and function much better. The major consistent benefit of joint replacement is substantial relief from pain. To maximize the chances of good results, it’s important to participate in physical therapy after surgery.

A replaced joint will last an average of 15 to 20 years. Surgeons may encourage young, physically active people to delay joint replacement because artificial joints may need to be replaced after a decade or two. The younger the person, the greater the chances that surgery will need to be repeated later on—and repeat surgery is more difficult because there is less bone to work with after removing the first implant.

Knee implants

With knee replacement, the surgeon fits a metal im-plant over the end of the thighbone and another one over the shin bone where the two bones meet (see Figure 8). A thick piece of plastic mounted onto the shin implant serves the same purpose as natural cartilage, allowing for smooth flowing movement. The kneecap is fitted with a small metal and plastic disk.

Figure 8: Total knee replacement

The surgeon first cuts away thin slices of bone with damaged cartilage from the end of the femur and the top of the tibia, making sure that the bones are cut to precisely fit the shape of the replacement pieces. The artificial joint is attached to the bones with cement or screws. A small plastic piece goes on the back of the kneecap (patella) to ride smoothly over the other parts of the artificial joint when you bend your knee.

There are many brands and designs of knee implants to choose from, depending on your age, weight, activity level, and health. The most common type is called a fixed-bearing knee prosthesis. The tibial component of the prosthesis is topped with a flat metal piece that securely holds a polyethylene (plastic) insert. When the knee is in motion, the femoral component glides across the polyethylene. Another type of implant is a rotating-platform knee prosthesis, in which the polyethylene insert can rotate slightly, theoretically lessening stress and wear on the implant and improving movement.

If damage to the cartilage is limited to one of the bumps (condyles) on the end of the femur, a partial knee replacement may be performed. This is a less invasive procedure with a shorter hospital stay and quicker recovery. But it lasts only about 10 years, compared with 15 to 20 years for total knee replacement.


Hip implants

There are dozens of hip implant models. The decision on which one to use depends on a person’s weight, bone quality, age, occupation, and activity level, as well as the surgeon’s experience with particular brands and models.

Hip implants have two parts: a socket and a ball mounted on a long stem (see Figure 9). The components are a combination of hard polished metal (generally titanium-based or cobalt/chromium-based alloy), hard ceramic, or tough, slick plastic called polyethylene. There are currently five types of hip implants:

Figure 9: Hip replacement surgery

When rough and damaged cartilage prevents the bones of the hip from moving smoothly, an orthopedic surgeon can install an artificial joint with two parts. The head of the femur (thighbone) is replaced with an artificial ball with a long stem that fits down inside the femur. An artificial cup, called the acetabular cup, fits inside the hip socket. The two pieces fit smoothly together to restore comfortable ball-in-socket movement.

  • Metal on polyethylene: The ball is made of metal and the socket is made of polyethylene (plastic) or has a plastic lining.

  • Ceramic on polyethylene: The ball is made of ceramic and the socket is made of polyethylene (plastic) or has a plastic lining.

  • Metal on metal: The ball and socket are both made of metal.

  • Ceramic on ceramic: The ball is made of ceramic and the socket has a ceramic lining.

  • Ceramic on metal: The ball is made of ceramic and the socket has a metal lining.

Over time, the ball and socket components of any hip implant will rub together as the hip is moved, wearing down the material. But recently the FDA has warned that the metal-on-metal implants pose unique risks. As the metal ball and metal cup slide against each other, tiny metal particles can wear off and enter the space around the implant. In many cases, this has resulted in loosening of the implant, requiring a second surgery. Several, but not all, metal-on-metal hip implants have been taken off the market.

If you have a metal-on-metal device already implanted, this does not mean you necessarily have to undergo surgery to replace the hip implant. As long as it continues to function without problems, you should simply follow up with your surgeon as often as he or she recommends (usually every one to two years). If you develop new or significantly worsening symptoms, such as hip or groin pain, swelling, numbness, noise (popping, grinding, clicking, or squeaking of your hip), or a change in your ability to walk, contact your surgeon.


Minimally invasive techniques

In the late 1990s, surgeons began using minimally invasive techniques to insert artificial hip joints through smaller incisions (usually measuring less than four inches in total) and with smaller instruments. The goals are to reduce soft-tissue injury and blood loss and to speed recovery. So far, results have been promising, at least among young, active individuals who were treated in hospitals that perform a large number of these procedures. But whether the overall results are better than (or even comparable to) traditional hip replacement surgery for the general public is not clear, especially considering that even traditional hip replacement is now often done with a smaller incision than in the past.


Cementing the implant

Traditionally, artificial joints were attached to bone with pins and acrylic cement. Today, however, a cementless design is more widely used. In the cementless design, the surface of the metal parts is porous, allowing bone to grow into the surfaces of the joint. Researchers believe cementless hip replacements may last longer and reduce the chance of infection and loosening. However, such designs must be tested for 10 to 20 years to determine how well they perform.


Two joints at the same time

Some people have significant osteoarthritic pain in both knees or both hips and want to have joint replacement on both sides. This can be done in two separate surgeries several months apart, but it is also possible to have both joints replaced at the same time (simultaneous replacement). The benefits of simultaneous replacement are a single anesthesia, shorter total hospitalization, and one rehabilitation that allows you to resume normal activities sooner. However, having simultaneous replacement increases the risk of some complications. For example, with simultaneous replacement there is a slightly increased risk for blood clots.

Replacing both knees at once is a good option if the condition of your joints is so poor that replacing only one joint would still leave you unable to function during physical therapy, thereby slowing your recovery.


Having the surgery

Because joint replacement for osteoarthritis is elective surgery, it will be scheduled weeks or even months ahead of time. In the period leading up to the surgery you may be asked to take some steps to ensure a successful outcome. For example, if you are overweight you may be advised to lose some pounds, because excess weight can lead to postsurgical complications. If you smoke, try to quit, as smoking affects blood flow and may slow recovery.

Postoperative recovery will vary depending on your health and age. The average length of a hospital stay following total knee or hip replacement is four days. But this doesn’t mean you’ll be just lying in bed. A nurse or physical therapist is likely to get you up and walking a short distance with crutches or a walker a day or two after surgery. You will also be given exercises to perform.

Before you can safely return home, you are usually expected to be able to do the following: get in and out of bed, walk with crutches or a walker, step on and off a curb, climb the same number of steps you must negotiate at home, perform your rehab exercises, and show you can carry out necessary tasks with little or no assistance. If you had knee replacement, you should be able to straighten your knee and bend it 90 degrees.

If you are unable to do these things or need extra nursing care, you may be discharged temporarily to a rehabilitation facility.


Postsurgical pain

While you are in the hospital recovering from the surgery, your pain will be controlled with powerful medications, usually delivered intravenously. The amount of pain you will experience once you return home is hard to predict. Some people have very little pain and get relief from ordinary nonprescription pain relievers. Others have more severe pain and need something stronger.

It’s not always clear why a person may experience exceptional pain. It can be a matter of perception—people’s thresholds for pain vary tremendously. In other cases, there may be an underlying problem causing the pain, such as an inflamed tendon or an infection. The important thing to remember is that you should never suffer in silence. If your pain level is unacceptable, call your surgeon or primary care physician. If there’s an underlying cause, he or she can address it. For example, pain caused by an inflamed tendon can be alleviated with a steroid shot, and infections can be cured with antibiotics (or, on occasion, reoperation).

If there is no direct cause, the doctor can prescribe a more powerful medication, such as oxycodone (OxyContin, Percocet). This drug is an opioid medication (also called a narcotic) and is tightly regulated because of its potential for abuse. However, it’s unlikely to be misused by people following surgery for osteoarthritis and is generally effective.

Dos and don’ts after surgery

These tips can help ensure that your return to mobility following surgery goes smoothly.

Don’t soak your wound. Upon returning from the hospital, keep your wound dry until it has thoroughly sealed and dried.

Do eat right. Eating a healthy diet, including lots of fruits, vegetables, and whole grains, is important to promote proper tissue healing and restore muscle strength.

Do learn the signs of blood clots. Warning signs of a leg clot include increasing pain, tenderness, redness, or swelling in your knee and leg. Signs a clot has traveled to your lung include shortness of breath and chest pain that comes on suddenly with coughing. Call your doctor if you develop any of these signs.

Don’t take risks that could cause you to fall. Be especially careful on stairs. Use a cane, crutches, or a walker until you have improved your balance and strength.

Do look for signs of infection. These include persistent fever, shaking, chills, increasing redness or swelling of the knee, drainage from the surgical site, and increasing pain with both activity and rest.

Do exercise wisely. Performing the exercises your physical therapist recommends is crucial to restoring movement in your new joint and strengthening the surrounding muscles.

Possible complications of joint replacement

The success rate for knee and hip replacement is very high. However, complications can occur that shorten the life of an implant, and you may need to take certain precautions.

Infection. Your implant can become infected soon after surgery or years later. When it occurs later, it is almost always because infection elsewhere in the body has spread to the area. Seek immediate treatment if you have symptoms of a urinary tract or other infection, and inform all your doctors that you have a joint replacement.

At least for the first couple of years, you may be advised to take antibiotics as a preventive measure before certain medical procedures, such as invasive dental work (extractions, gum surgery, root canals, and any cleaning or procedure likely to result in bleeding), a colonoscopy, or any type of surgery. Your doctor can advise you on how long to continue these precautions, which are particularly important for people who have an illness or have undergone medical treatment that impairs the immune system.

Leg-length discrepancy. A difference in leg length occurs only rarely after knee replacement. But it happens frequently, at least temporarily, after hip replacement. Before surgery, one leg is often shorter than the other—or feels shorter because the joint has deteriorated. Your orthopedic surgeon chooses an implant and plans surgery so that your legs will be equal in length after healing. After hip replacement, muscle weakness or spasm and swelling around the hip may temporarily cause an abnormal tilt to your pelvis and make you feel as though your legs are unequal in length. Stretching and strengthening exercises help restore your pelvis to its proper position. It may be several months before you can tell if the discrepancy is real and needs to be addressed with the use of a lift in one shoe. When the discrepancy is accompanied by pain, surgery can correct both problems.

Dislocation. In the weeks after a hip replacement, you’ll need to take great care to keep from dislocating the implant before the surrounding tissues have healed enough to hold it in place. Even afterward, there is a chance of a painful dislocation—five out of every 100 implants dislocate after total hip replacement surgery. If your hip dislocates, your doctor gives you a sedative while he or she manipulates the implant ball back into the socket. A hip that dislocates more than once usually requires surgery to make the joint more stable.

Loosening. A replacement joint can loosen because the cement never secured it properly or eventually wore out, or because the surrounding bone never grew into the implant to create a tight attachment. This may require a second surgery.

Bone loss. As a joint implant suffers wear and tear, loose particles can be released into the joint. As your immune system attacks these foreign particles, it can also attack surrounding bone, weakening it in a process called osteolysis. This, in turn, may loosen the bone’s connection to the implant. Osteolysis is a major factor leading to the need for more surgery after hip and knee replacement.


Rehabilitation after joint replacement

Because joint replacement is an elective surgery, you will have time before the procedure to plan for the recovery period afterward. It can take several months to return to normal functioning. During this time, you will gradually improve and regain strength and agility in the joint. But be aware that you will have limited mobility at first.

To ease the recovery, plan ahead. Set up an area in your home in which you’ll spend most of your time. Your phone, remote control, reading materials, medications, and water should be within easy reach. Remove scatter rugs. Prepare some meals ahead of time and store them in the freezer, or purchase frozen prepared foods. You may be eligible for a temporary disabled parking permit, which can be obtained from your state department of motor vehicles.

You will need some assistance at first with household tasks like cleaning and shopping and with some personal tasks, like bathing. Depending on your medical condition, a visiting nurse or home health aide may be helpful.

You have a major role to play in the success of your surgery. Your active participation in a rehabilitation program is the key. Think of yourself as an athlete training to come back from an injury. The first several weeks require much effort. Several times a day, you will perform exercises your physical therapist has recommended to restore movement in the joint and strengthen the surrounding muscles (see Figure 10, and Figure 11). You can do many of these exercises while sitting or lying down. A physical therapist may come to your home or schedule regular appointments for the first few weeks. In addition to formal exercises, if you gradually increase the amount you walk and do normal tasks, this will improve your strength and stamina.

Figure 10: Exercises after knee replacement

Under the guidance of your physical therapist, you’ll gradually be able to do the following exercises:

Sitting knee bends: Sit in a chair with a towel under the operated knee. Straighten your knee as far as possible and hold for five seconds. Repeat 10 times. Gradually work up to 25 repetitions.

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Standing knee bends: Hold on to a steady surface such as a table. Bend your operated knee back as far as it will go. Hold for five seconds, then lower the leg to the floor. Repeat 10 times. Gradually work up to 25 repetitions.

Figure 11: Exercises after hip replacement

Check with your physical therapist to find out if you are ready to do the following exercises to strengthen your hip.

Standing knee raises: Standing with the aid of a walker or holding a stable surface, lift your thigh and bend your knee. Hold for five to 10 seconds. Repeat until your leg feels fatigued.

Hip abduction: Standing with your hand on a stable surface, lift your leg out to the side as far as you can and hold for five to 10 seconds. Keep your hip, knee, and foot pointing straight forward. Repeat until your leg feels fatigued.

You will need to use crutches or a walker for a period of time to keep weight off the implant. How long you will need to do this depends on different factors, including the type of implant. Most people can put a little weight on a cemented implant right away. An uncemented implant isn’t secure until bone grows into it. You will probably be allowed to put only about half your weight on the joint for the first six weeks. With both types of implant, you should be able to walk without crutches or a walker by six weeks.

At that point, rehabilitation goals will shift toward restoring your ability to do normal activities, although you may still experience muscle pain and fatigue for several months as your tissues heal.

You should be able to function normally six months after the surgery. You can expect to have at least as much movement as you had before the operation, but with much less pain.


Guidelines for recovery from knee replacement

Ask your doctor and physical therapist how soon you can return to specific activities after knee replacement.

Driving. If your left knee was replaced, you may be able to drive a car with an automatic transmission as soon as you are not taking opioid medication and feel up to it. If the right knee was operated on, you will probably have to wait six to eight weeks.

Work. If you sit at a desk most of time while at your job, you can probably return to work after six to eight weeks. If your job requires you to stand, walk, or lift heavy objects, it may be three or four months before you can return.

Sex. The incisions and tissues in the front of the knee must be healed (about six weeks). To avoid putting weight on your knees during sex, try a position that involves lying on your back or side or even sitting.

Sports. By eight weeks after surgery, you may be able to resume activities such as golfing, bowling, ballroom dancing, biking, swimming, or scuba diving.

Some sports should be avoided. A knee implant will not hold up to sports that require lots of jumping, twisting, or repeated impact, such as running, soccer, basketball, volleyball, or contact sports. You may be able to engage in some sports. Ask your doctor whether a return to your favorite sport is realistic; if so, your physical therapist can help tailor your rehab program to prepare you for the safest return possible.


Guidelines for recovery from hip replacement

After hip replacement, talk to your doctor and physical therapist about activities that are encouraged or prohibited.

Car travel. Your physical therapist can provide instructions for getting in and out of the car and riding safely. Some vehicles are unacceptably high or low, forcing your hip into an unhealthy position. In some cars, sitting on a firm pillow can help you avoid overflexing your hip. On long drives, stop and get out at least once an hour.

Driving. It usually takes about six weeks before you can drive a car with an automatic transmission and 12 weeks for a stick shift. You must not be taking opioid pain medications, and you need to be able to put weight on your right leg (for an automatic transmission) or both legs (in the case of a manual transmission). You must also be able to brake without violating your hip precautions.

Sex. Wait until muscles and incisions have healed. You may need to lie on your back or on your nonoperated side. Avoid flexing your hips more than 90 degrees, and don’t raise your knees higher than your hips. Also, do not rotate your hips out (either sitting or lying with knees wide apart).

Work. It may take three to six months before you can return to work. If you have a desk job you can return sooner than if your job is more physically demanding. If you sit at a desk, your chair should have arms and be high enough to properly position your hips.

Sports. After a few months, you should be able to return to activities such as golf, biking (without steep hills), and ballroom or square dancing.

Avoid activities that require jumping or heavy lifting, might jolt or stress your hip, or make it likely you might fall or have something (or someone) bump into your hip. This means that tennis, volleyball, horseback riding, skating, contact sports, soccer, squash, and racquetball usually are not advisable.




On the horizon

Research is under way to discover and test new approaches to treating osteoarthritis. So far, no cures have been discovered, and all these treatments require further study—but they are intriguing nontheless. They include new drug therapies, nondrug therapies, and surgical procedures.

Potential new treatments

Some of these experimental approaches would have sounded like science fiction a generation ago, especially those that call upon the body’s own regenerative capacities.

Platelet-rich plasma injections

Blood is made of several components, including red blood cells, white blood cells, plasma, and platelets. Platelets are of potential interest in treating osteoarthritis because they release proteins called growth factors, which have healing qualities. Platelet-rich plasma (PRP) therapy involves removing a small amount of blood from a person and putting it in a device called a centrifuge, which increases the concentration of platelets. The platelet-rich plasma that results from this process is then injected into the site where healing is desired, such as in the knee joint of a person with knee osteoarthritis.

Two studies published in 2012 found that PRP therapy was better than hyaluronate injections for people with minimal osteoarthritis. Young patients benefited more than older ones. This technique is not used in routine practice but continues to be studied.


Stem cell injections

The body’s stem cells have the ability to develop into any type of specialized cell, including chondrocytes, which produce cartilage. An experimental technique involves harvesting stem cells from a person’s bone marrow, spinning them down in a centrifuge to concentrate their numbers, and then injecting the cells into the patient’s affected joint. It’s thought that these stem cells may transform into chondrocytes, thus restoring cartilage, reducing inflammation, and improving the ability to function.

Though this technique is being used experimentally, most of the formal studies on it have been conducted in animals or in people with traumatic injuries rather than osteoarthritis. More studies are needed to establish how effective it might be in people with osteoarthritis.


Tetracyclines

This family of antibiotic drugs not only fights bacterial infections, but also reduces inflammation.

Long-term use of the tetracycline drug doxycycline was tested in a study of 431 obese women with knee osteoarthritis. After two-and-a-half years, there was less narrowing in the joint space of the affected knee in those who took tetracycline compared with those who took a placebo. The results were promising, but more studies are needed before this drug can be recommended for people with osteoarthritis.

One drawback to this approach may be concerns about antibiotic resistance.


Chondrocyte grafting

In some people it may be possible to replace sections of degenerated cartilage. Chondrocyte grafting involves removing a small piece of cartilage, which is sent to a laboratory. The chondrocytes (cells that produce cartilage) are removed from the specimen and then processed to multiply in number. They are then injected into the joint, where they form new cartilage.

This technique appears to be most helpful for people with less severe defects in cartilage. People with severe osteoarthritis would require a large graft, which is not practical.




Special section: Self-care strategies for coping with arthritis

The pain and stiffness of arthritis can make it difficult to perform the daily tasks most people take for granted, from putting on socks to cooking dinner. But taking good care of yourself in general—eating healthful foods, shedding pounds if you are overweight, strengthening muscles, and learning to move your joints safely—can help to relieve pain, improve function, and cope with difficult emotions, no matter what form of arthritis you have. In addition, you may find relief by trying physical therapy (see “Physical and occupational therapy”) or complementary therapies, such as acupuncture and massage (see “Complementary therapies”). The American College of Rheumatology recommends not only medication but also nondrug treatments for people with osteoarthritis of the hip and knee.

Following are some do-it-yourself strategies and therapies that can make coping with arthritis a little easier.

Heat therapy

In the 19th and early 20th centuries, wealthy Europeans embraced hydrotherapy (warm baths) and sought cures at exotic spas for real and imagined ailments. Most resorts claimed that the health benefits were from minerals in the water. The therapeutic value probably lay mostly in the water’s temperature. Heat raises the pain threshold and relaxes muscles.

Hydrotherapy remains a standard part of the physical therapist’s practice, and its techniques can be used at home. A bathtub equipped with water jets or a hot tub can closely duplicate the warm-water massage of whirlpool baths used by professionals. Of course, oversized tubs are expensive. For most people, the bathtub works nearly as well. Soaking for 15 to 20 minutes in a warm bath exposes the body to warmth and allows the weight-bearing muscles to relax.

A warm shower can relieve the stiffness of arthritis. People can upgrade their showers with an adjustable shower-head massager that’s inexpensive and easy to install. It should deliver a steady, fine spray or a pulsing stream, usually with a few options in between. Therapists also recommend taking a warm shower or bath before exercising to relax joints and muscles. Dress warmly after a shower or bath to prolong the benefit.

A heating pad is another good idea, but keep in mind that moist heat penetrates more deeply. Although you can purchase hot packs and moist/dry heating pads, a homemade hot pack works just as well. Heat a damp folded towel in a microwave oven (usually for about 20 to 60 seconds, depending on the oven and the towel’s thickness) or in an oven set at 300° F (for five to 10 minutes—again, this depends on the oven and towel thickness). To prevent burns, always test the heated towel on the inside of your arm before applying to a joint: it should feel comfortably warm, not hot. To be extra safe, wrap the heated, moist towel in a thin, dry one before placing it on the skin.

Sometimes therapists recommend a paraffin bath. You dip your hands or feet into wax melted in an electric appliance that maintains a safe temperature. After the wax hardens, the therapist wraps the treated area in a plastic sheet and blanket to retain the heat. Treatments generally take about 20 minutes, after which the wax is peeled off. Paraffin bath kits are also available for home use, but to avoid burning yourself, talk with your physical therapist for recommendations and cautions before purchasing one.


Cold therapy

Cold has painkilling effects similar to those of heat. Especially after an injury, an ice pack on the joint relieves pain. Gel-filled cold packs are inexpensive and available in different sizes and shapes. Keep two or more in the freezer so you’ll have cold therapy available instantly. Ice chips in a plastic bag also work well. Cold packs should be applied for 15 to 20 minutes and can be reapplied hourly or as needed. Coolant sprays, available from pharmacies, may also be used. Cooling is a temporary measure to relieve pain; too much may induce muscle stiffness and painful circulatory disturbances.


Exercise

Even the healthiest people find it difficult to stick with an exercise regimen. But those with arthritis commonly discover that if they don’t exercise regularly, they’ll pay the price in pain, stiffness, and fatigue. Regular exercise not only helps maintain joint function, but also relieves stiffness and decreases pain and fatigue. Feeling tired may be partly the result of inflammation and medications, but it’s also caused by muscle weakness and poor stamina. If a muscle isn’t used, it can lose 3% of its function every day and 30% of its bulk in just a week.

A recent review of numerous studies on the benefits of exercise for people with osteoarthritis found that strength training, water-based exercises, balance therapy, and techniques to improve reaction times were the most helpful for reducing pain and improving function.

Following are brief descriptions of various forms of structured exercise programs (most of which are offered by local Arthritis Foundation chapters), along with a summary of their potential benefits.

Land-based programs. These include community-based group classes led by health or fitness professionals with specialized training in instructing people with arthritis. These programs typically include some combination of a warm-up routine and several standard exercise goals (see “Four exercise goals”), plus specialized activities to enhance body awareness, balance, and coordination. Examples include Fit and Strong!, a program targeted to older adults with osteoarthritis; the Arthritis Foundation’s Exercise Program (AFEP); and its Walk with Ease program. Studies have found that people with arthritis in their hips, legs, and feet who took Fit and Strong! classes were able to exercise longer, felt more confident about their ability to exercise, and reported less joint stiffness compared with those in a control group. Many of the benefits lasted between six and 12 months. Those attending AFEP classes for eight weeks had less pain, stiffness, and fatigue, and these improvements persisted at least six months, as well. In one study, people who completed the Walk with Ease program (which also teaches participants about managing their disease) had more confidence, less depression, and less pain, compared with participants who attended classes focused only on pain management.

Four exercise goals

Structured exercise programs commonly emphasize one or more of these goals. You can also work with your physician or physical therapist to develop your own exercise program that addresses them all.

  1. Increase range of motion. These exercises aim to improve the mobility and flexibility of your joints. To increase your range of motion, move a joint as far as it can go and then try to push a little farther. These exercises can be done any time, even when your joints are painful or swollen, as long as you do them gently. For several examples of range-of-motion exercises you can do at home, see Figure 13.

  2. Strengthen your muscles. An excellent way to provide aching joints with more support is to strengthen the muscles surrounding them. Strengthening exercises use resistance to build muscles. You can use your own body weight as resistance. One example: Sit in a chair. Now lean forward and stand by pushing up with your thigh muscles (try to use your arms only for balance). Stand a moment, then sit back down, using your thigh muscles. This simple exercise will help ease the strain on your knees by building up your thigh muscles. Research has shown that strengthening the thigh muscles is just as effective as aerobic exercise or NSAIDs for reducing pain and disability. Furthermore, research suggests that strengthening these muscles might even slow joint space narrowing in people with arthritis of the knee. Just remember to avoid these exercises during arthritis flare-ups.

  3. Build endurance. Aerobic activities such as walking, swimming, and bicycling can all build your heart and lung function, which in turn increases endurance and overall health. Be careful to pick activities with low impact on your joints, and avoid high-impact activities such as jogging. If you’re having a flare-up of symptoms, wait until it subsides before doing endurance exercise.

  4. Improve balance. Physical therapists often include improved balance in their lists of goals. There are simple ways to work on balance. For example, stand with your weight on both feet. Then try lifting one foot while you balance on the other foot for 5 seconds. Repeat on the other side. (You might want to stand by a chair that you can grab on to just in case.) Over time, see if you can work your way up to 30 seconds. Yoga and tai chi are also good for balance.

Figure 13: Range-of-motion exercises for arthritis

Hand Open your hand, holding the fingers straight. Bend the middle finger joints. Next, touch your fingertips to the top of your palm. Open your hand. Repeat 10 times with each hand. Next, reach your thumb across your hand to touch the base of your little finger. Stretch your thumb back out. Repeat 10 times.

Knee Sit in a chair that is high enough for you to swing your legs. Keep your thighs on the seat and straighten out one leg. Hold for a few seconds. Then bend your knee and bring your foot as far back as possible. Repeat with the other leg. Repeat 10 times.

Shoulder Lie on your back with your hands at your sides. Raise one arm slowly over your head, keeping your arm close to your ear and your elbow straight. Return your arm to your side. Repeat with the other arm. Repeat 10 times.

Hip Lie on your back, legs straight and about 6 inches apart. Point your toes toward the ceiling. Slide one leg out to the side and then back to its original position. Try to keep your toes pointed up the whole time. Repeat 10 times with each leg.

Water-based programs. Also known as aquatic or pool therapy, these group classes are done in water that’s nearly 90° F and feature a variety of exercises, including range-of-motion exercises and aerobics. According to one study, people who took the Arthritis Foundation Aquatic Program improved knee and hip flexibility, as well as strength and aerobic fitness. Other investigations suggest water exercise lessens pain and boosts physical functioning, and the benefits can last three months after the last class in a 12-week session.

Strength and resistance training. This form of exercise, which uses equipment such as weight machines, free weights, and resistance bands or tubing, strengthens not only your muscles but also your bones and cardiovascular system. Resistance training improves muscle strength, physical functioning, and pain. One Japanese study compared people with knee osteoarthritis who either took NSAIDs or did twice-daily knee extension exercises to strengthen their quadriceps (the muscles on the front of the thigh). At the end of the eight-week study, both groups had less pain and stiffness, as well as improved functioning and quality of life.

Tai chi. With origins in Chinese martial arts, this low-impact, slow-motion exercise also emphasizes breathing and mental focus (see Figure 12). A number of small studies suggest tai chi helps people with different forms of arthritis, mainly by increasing flexibility and improving muscle strength in the lower body, as well as aiding gait and balance. The Arthritis Foundation, along with Dr. Paul Lam, a family physician and tai chi instructor, developed a standardized form of tai chi designed specifically for people with arthritis. Based on Sun-style tai chi, one of the discipline’s five major recognized styles, it includes agile steps and a high stance (meaning the legs bend only slightly).

Figure 12: Tai chi: An exemplary exercise for people with arthritis

Tai chi involves moving continuously through a series of motions named for animal actions—for example, “white crane spreads its wings”—or martial arts moves, such as “box both ears.” The movements are usually circular and never forced, the muscles are relaxed rather than tensed, the joints are not fully extended or bent, and connective tissues are not stretched.

Yoga. Scant research has explored the benefits of yoga for people with arthritis. One study showed that people with knee osteoarthritis who took eight weeks of Iyengar yoga (a form of yoga that focuses on correct body alignment and uses blocks, belts, and other props to assist in performing postures) had less pain and could function better at the end of the study. Another study of people with rheumatoid arthritis found benefits from participating in twice-weekly Iyengar sessions for six weeks—namely, less pain and depression and greater mobility. But both studies were quite small, and neither included a comparison group.

Balance exercises. Stiff, sore joints hamper movement. If your ankles or knees are arthritic, it’s hard to bend them, which affects your ability to balance and react when you trip. If your neck is stiff, your range of motion—how far you can move in any direction—may be limited, so that you tend to move your upper body to look behind you. This can upset your balance, too.

Tai chi and some yoga poses help with balance. There also are exercises specifically designed to improve balance that can be safely performed, even if your balance is shaky.

Figure 14: An exercise to relieve neck pain

Here is a simple, gentle exercise to do when moderate neck pain first strikes. For severe pain, contact your health care provider immediately.

  1. Sit in a neutral position, holding your head in a normal resting position.

  2. Next, slowly glide your head backward, tucking your chin in until you have pulled your head and chin as far back as they will go. Keep your head level and do not tilt or nod your head. Pull in gently for three to five seconds, then release. Repeat 10 times.

  3. For a stronger stretch, gently apply pressure to your chin with your fingers and release. Repeat every two hours as needed.

  4. If this exercise increases your pain, try it lying down on your back. Tuck your chin in and make a double chin. Hold for a second or two and release (your head never leaves the pillow). If pain increases or you develop numbness or tingling, stop and contact your doctor.


Joint protection strategies

When you have arthritis, it’s important to pay attention to your body’s signals. Overuse of arthritic joints can lead to pain, swelling, and additional joint damage. A physical or occupational therapist can teach you how to conserve energy, protect your joints, accomplish daily tasks more easily, and adapt to lifestyle disruptions. Many of these strategies are simple common sense.

Keep moving. Avoid holding one position for too long. When working at a desk, for example, get up and stretch every 15 minutes. Do the same while sitting at home reading or watching television.

Avoid stressing your joints. Avoid positions or movements that put extra stress on joints. For example, opening a tight lid can be difficult if you have hand arthritis. One solution is to set the jar on a cloth, lean on the jar with your palm, and turn the lid using a shoulder motion. Better yet, purchase a wall-mounted jar opener that grips the lid, leaving both hands free to turn the jar.

Discover your strength. Use your strongest joints and muscles. To protect finger and wrist joints, push open heavy doors with the side of the arm or shoulder. To reduce hip or knee stress on stairs, lead with the stronger leg going up and the weaker leg going down.

Plan ahead. Simplify life as much as possible. Eliminate unnecessary activities. (For example, save yourself work by buying clothing that doesn’t need ironing.) Organize work and storage areas, and place frequently used items within easy reach. Keep duplicate household items in several locations; for example, stock the kitchen and all bathrooms with cleaning supplies.

Use labor-saving items and adaptive aids. In the kitchen, use electric can openers and mixers. In the bathroom, cut down on scrubbing by using automatic toilet bowl cleaners and, in showers or tubs, spray-on mildew remover. Other devices on the market can help you avoid unnecessary bending, stooping, or reaching (see “Helpful gadgets”).

Helpful gadgets

Simple gadgets and devices can sometimes make it easier to perform daily activities, such as cooking, gardening, or even getting dressed. For example, people with limited movement might have an easier time using long-handled hooks when putting on socks and long-handled shoehorns for shoes. Also helpful are shoes that slip on or fasten with Velcro, pre-tied neckties, and garments with Velcro fasteners, zippers, or hooks and eyes instead of buttons. For other tasks, long-handled grippers are designed to grasp and retrieve out-of-reach objects. Rubber grips are available to help you get a better hold on faucets, pens, toothbrushes, and silverware. Ergonomic tools with long necks and comfortable grips are also useful. Pharmacies, medical supply stores, and online vendors stock a variety of aids for people with arthritis. The following will give you an idea of the broad array of tools available.

In the kitchen

  • mini chopper

  • electric can opener

  • wall-mounted jar opener

  • small, nonskid gripper mats to increase traction when opening jars and to place under bowls and other items to prevent slippage

  • utensils with built-up, padded handles

  • loop or spring-loaded scissors

  • cheese slicer

  • bottle brush, for washing cups and glasses

  • cookbook stand

In the bathroom

  • electric toothbrush

  • dental floss holder

  • electric razor

  • soap-on-a-rope or mitts to hold soap

  • brushes or combs with long handles

  • raised toilet seat

  • long-handled brush to clean the bathtub

In the garden

  • kneeler and seat

  • ergonomic tools (with long necks and comfortable grips)

  • motor-driven hose reel

  • hose caddy

  • raised garden beds

  • low-maintenance plants

  • carpenter’s apron with several pockets for carrying frequently used tools

Throughout your home and car

  • key turners

  • doorknob turners

  • light switch adapters

  • lightweight vacuum cleaner

  • scissors with padded handles or swivel blades (loop or spring-loaded)

  • phone with automatic dialing

  • rollerball or gel pens, pencils with padded grips

  • car door openers

Make home modifications. Using casters on furniture can make housecleaning easier. A grab bar mounted over the tub is a necessity for many people, as is a suction mat in the tub to prevent falls. Putting a bathing stool in the tub or shower is a good idea for people who have arthritis in the legs.

Ask for help. Maintaining independence is essential to self-esteem, but independence at all costs is a recipe for disaster. Achieve a balance by educating family members and friends about the disease and the limitations it imposes and enlisting their support. Ask for help with specific tasks.

Choosing shoes: What not to wear

Many types of arthritis affect the feet, so choosing a comfortable shoe is key. People with osteoarthritis may develop osteophytes (irregular bony projections) at the base of their big toes. These abnormal bone growths can contribute to the joint enlargement and toe pain associated with bunions.

Clearly, pointy-toed shoes and high heels—which crowd the toes and put undue pressure on them—are not a good idea. High heels are also hard on the knees. Experts say that even a modest 1.5-inch heel increases pressure in two common sites for osteoarthritis damage: the joint beneath the undersurface of the kneecap (the patellofemoral compartment) and the joint surfaces on the inner side of the knee (the medial compartment). Instead, choose a fairly flat shoe with little arch support that allows the foot to strike the ground and move forward as naturally as possible. Good choices for people with toe problems include shoes with a wide toe box, such as square-toed boots. Rheumatologists also recommend running shoes because they’re lightweight and typically have good support and padding both in the soles and around the ankles. Look for styles with nontie laces or Velcro fasteners, especially if you have hand arthritis that makes tying laces tricky.


Healthy eating

There is no definitive evidence that any particular foods contribute to osteoarthritis pain or help to treat it. Yet, diet is important, especially if you are overweight. Excess pounds increase the stress on your joints, and obesity is a known risk factor for hand and knee osteoarthritis. To shed pounds or keep them off, exercise regularly and eat a diet low in saturated fats, trans fats, and refined and processed foods, and high in vegetables, whole grains, and lean proteins.

Recently scientists have also been studying whether foods with anti-inflammatory properties can help, since the wear and tear of osteoarthritis can be accompanied by mild inflammation in joints. Some evidence suggests that omega-3 fats, found in cold-water fish such as salmon, herring, sardines, and mackerel, may be beneficial. The anti-inflammatory spice turmeric (an ingredient in curry) has also been tested for its ability to reduce the pain and tenderness of arthritis (both osteoarthritis and rheumatoid arthritis). Early results showed promise, but larger studies are needed.


Coping with your emotions

People with arthritis often worry about the possibility of losing mobility, being unable to work, or growing dependent on others. But only a very small percentage of people with arthritis ever become severely disabled. Still, the emotional burdens of arthritis are considerable and may result in stress, anxiety, and depression.

Because living with chronic arthritis can be difficult, many physicians use questionnaires to assess a person’s psychological function. Depression and anxiety are of particular concern, as these disorders are twice as common among people with arthritis than people without it.

Your doctor may also ask questions about what type of family and social support you have available, to determine whether you need additional help. For example, if you live alone and have trouble walking, your doctor may refer you to a social worker who can help arrange for someone to handle shopping and other chores. If you are depressed or have anxiety, you may be referred to a psychiatrist.

Sexual intimacy

Arthritis may interfere with sexual intimacy, especially when the hips, knees, or spine are involved. However, even people with severe arthritis can enjoy an active sex life. A flexible attitude often compensates quite well for having a less-than-flexible body. For example, couples might experiment with different positions to find the one most comfortable for intercourse; people with hip, knee, or spine arthritis often find it most comfortable when both parties lie on their side. There are also other mutually gratifying sexual activities besides intercourse.

Many people find that taking a pain reliever an hour before sex or having a warm shower lessens muscle and joint stiffness. Rescheduling sexual activity may also help; afternoons may be better if pain and fatigue are worse in the mornings or evenings, for example.

Depression is common in people with chronic diseases of all kinds. Some arthritis specialists have assumed that depression is directly related to the amount of pain and the number of swollen joints a person has, but this isn’t always the case. While some people equate a large number of swollen joints with severe disability, those whose favorite pastime is reading or spending time with family might not consider themselves disabled. However, a relatively slight impairment in hand mobility could be devastating for a pianist or artist, and could have a profound emotional impact. Diagnosing and treating depression can be challenging because its symptoms differ from person to person. But effective medications are available, and they often work best in combination with counseling or psychotherapy. A form of counseling called cognitive behavioral therapy (CBT) involves changing people’s behaviors by changing their thinking.



Other types of arthritis

There are more than 100 types of arthritis. After osteoarthritis, the most common ones are rheumatoid arthritis and gout. These and some other less common forms of arthritis are discussed below and in Table 1.

Table 1: Other types of arthritis

Type

Symptoms

Causes

Diagnostic tests

Treatment

Pseudogout

Occurs when calcium crystals accumulate in the joints, especially the knee or wrist, though other joints may also be affected.

Severe pain, swelling, and stiffness around the joint(s)

Fever, usually low-grade

Usually unknown

Risk increases with age

X-ray to look for calcium deposits in the cartilage

Removal of fluid from the affected joint to look for calcium crystals, inflammation, or infection

Blood tests

NSAIDs, corticosteroids, or colchicine for pain and swelling

Removal of fluid (aspiration) from the joint to relieve pressure

Ankylosing spondylitis

Chronic, systemic inflammatory disease that often strikes people ages 20 to 40 and causes inflammation of the joints in the spine and pelvis. Eventually vertebrae in the spinal column may fuse.

Back pain and stiffness that develop gradually over weeks and persist for months

Discomfort that is most noticeable in the morning, but improves with exercise

Some people inherit genes that make them more susceptible to this condition

X-rays, although it may take several years for the effects of the condition to show up on an image

CT or MRI scan to detect inflammation in joints

HLA-B27 (a genetic test)

NSAIDs

Physical therapy

Stretching exercises to extend the spine

If symptoms do not improve, a DMARD (sulfasalazine, metho-trexate) or an anti-TNF medication may be used

Infectious arthritis (bacterial)

Bacteria enter a joint or joints (most often the knees), causing arthritis. The germs may enter directly through a puncture wound or, more often, travel through the bloodstream from somewhere else in the body.

Joint inflammation, pain, and stiffness, typically in the knee, shoulder, ankle, or hip joints

Fever and chills

Rash (at isolated spots or all over the body)

Bacteria and other infectious organisms, including Borrellia (which causes Lyme disease), Staphylococcus, Streptococcus, gonorrhea, and tuberculosis

Removal of fluid from the affected joint for analysis

Blood and urine tests

Antibiotics

In some cases, surgery may be necessary

Infectious arthritis (viral)

Viruses cause more cases of infectious arthritis than bacteria, but they are generally less serious.

Symptoms are similar to those with infectious arthritis from bacteria, but they usually abate as the virus is eliminated from the body

Viruses, including those that cause colds and respiratory infections

Viruses causing serious illnesses such as AIDS and hepatitis C

Removal of fluid from the affected joint for analysis

Blood and urine tests

No effective treatment for milder forms, as viruses don’t respond to antibiotics

Antiviral therapy for cases related to AIDS or hepatitis

Reactive arthritis

Arthritis symptoms resulting from the immune system’s response to an infection elsewhere in the body. Symptoms may develop weeks or months after the infection has cleared up and may flare suddenly, causing pain and stiffness, especially in the wrists, knees, ankles, and feet.

Fatigue and fever, muscle aches and joint pain

Low back pain radiating to the buttocks or thighs

Discomfort aggravated by inactivity, eased by exercise

Burning with urination

Painful or irritated red eyes, blurry vision

May develop after infection with a sexually transmitted organism

May be caused by gastrointestinal infection from bacteria such as Salmonella, Shigella, Campylobacter, or Yersinia

Symptoms, physical examination, history of prior infection

Antibiotics to treat the underlying infection

NSAIDs or cortico-steroids for pain and inflammation

DMARDs (sulfasalazine or methotrexate) in the case of prolonged attacks

Psoriatic arthritis

About 15% of people with psoriasis, a chronic skin disease, develop arthritis. It usually develops between the ages of 20 and 50.

Morning joint stiffness

Joint pain and inflammation, particularly in the fingers, toes, or spine

Pink or salmon scales on the scalp, knees, elbows, chest, or lower back

Pitting of the fingernails or toenails

Unknown, although it probably arises from a combination of genetic and environmental factors

Physical examination

X-rays, blood tests, and skin biopsy may be performed

NSAIDs

If symptoms do not improve, a DMARD or anti-TNF agent

Corticosteroid injections may be used to control severe inflammation

Enteropathic arthritis

Develops in about 9% to 20% of people with ulcerative colitis or Crohn’s disease, which are types of inflammatory bowel disease.

Arthritis in several joints, especially the knees, ankles, elbows, and wrists, and sometimes in the spine, hips, or shoulders

Worsening of symptoms during flare-ups of inflammatory bowel disease

People with this form of arthritis have a hereditary disposition, but no specific gene has been identified

Medical history and physical examination

Colonoscopy

NSAIDs

Corticosteroids

DMARDs (sulfasalazine, methotrexate)

Anti-TNF agents

Rheumatoid arthritis

Rheumatoid arthritis is a chronic autoimmune disease in which the body’s immune system attacks healthy tissue lining the joints. It affects an estimated 1.5 million American adults. Although the disease usually first appears during middle age, onset may occur as early as a person’s 20s and 30s.

The chronic inflammation of rheumatoid arthritis begins in the synovium, where an unknown event triggers an inflammatory reaction. As a result, synovial and other cells produce a variety of chemical mediators, including cytokines and proteolytic enzymes, which together can destroy all the components of the joint. The synovial tissue also begins to proliferate, causing the normally smooth synovium to form pannus—a rough, grainy tissue that grows into the joint cavity and erodes cartilage (see Figure 15). If the tendons become inflamed, they may shorten and immobilize the joint, which can cause bone fusion and loss of mobility. If the tendons rupture, the joint may become loose or floppy.

Figure 15: Joint changes in rheumatoid arthritis

A. Inflammation begins in the synovium.

B. The synovium begins to proliferate and forms ­pannus, a rough, grainy ­tissue that erodes cartilage.

C. Cells in the pannus release enzymes that eat into the cartilage, bone, and soft tissues. Nearby tendons and the joint capsule may become inflamed, causing pain, instability, deformity, weakness, loss of motion, and, occasionally, tendon rupture.

Rheumatoid arthritis attacks multiple joints and is usually symmetrical, affecting joints on both sides of the body, particularly the finger joints, base of the thumbs, wrists, elbows, knees, ankles, or feet. It nearly always involves the wrists and the middle and large knuckles, but seldom the joints nearest the fingertips (see Figure 16). At times, joint pain may be constant, even without movement. Morning stiffness that lasts for 30 minutes or longer is a hallmark of the disease and one of the main ways doctors gauge the severity of inflammation.

Figure 16: Rheumatoid arthritis of the hand

An x-ray revealing rheumatoid arthritis of the right hand.

The course of rheumatoid arthritis is unpredictable. Early on, the symptoms frequently abate or even disappear, only to flare up weeks or months later. Occasionally, complete remission occurs, usually within the first year. But for some people the process is destructive, ending in severe disability within a few years.

People with rheumatoid arthritis often develop eye conditions, including keratoconjunctivitis sicca (dry eye), which causes redness, burning, itching, reduced tearing, and sensitivity to light. Other complications include respiratory, heart, and neurologic disorders. In rare cases, the ligaments that tether the uppermost vertebrae (which support the skull) are damaged, allowing the vertebrae to slip out of alignment and pinch the spinal cord.

At advanced stages, rheumatoid arthritis can limit a person’s ability to carry out normal daily activities such as dressing, bathing, and walking. Those affected often experience feelings of depression and helplessness as the disease progresses. However, medications are now helping to slow the progression of rheumatoid arthritis and make a dramatic difference in the lives of many of those affected.

One of the most important steps you can take if you are diagnosed with the disease is to become an active participant in your own care. This includes working with your doctor so that you can learn to recognize flare-ups and drug side effects, take medication as prescribed, and engage in activities to maintain joint function in order to prevent disability. Balancing rest with activity, dealing with the emotional impact of rheumatoid arthritis, and using assistive devices to protect your joints against overuse are among the most helpful coping strategies (see “Physical and occupational therapy”). The ultimate goals in managing rheumatoid arthritis are to prevent or control joint damage, prevent loss of function, and reduce pain.

Symptoms of rheumatoid arthritis

  • Constant or recurring pain or tenderness in joints

  • Stiffness and difficulty using or moving joints normally

  • Swelling in and around multiple joints

  • Warmth and redness in multiple joints

  • Difficulty in performing daily tasks

  • Arthritis in large and small joints in a more or less symmetrical pattern on both sides of the body

  • Weight loss

  • Low-grade fever

  • Fatigue

  • Prolonged morning stiffness (more than 30 minutes)


Causes of rheumatoid arthritis

Scientists don’t know what causes rheumatoid arthritis, but they are investigating many hypotheses. The disorder runs in families, is more common among women, and may initially resemble some forms of infectious diseases, such as viral arthritis.

Genetic factors. Rheumatologists have long theorized that some insult (perhaps a microbe or an environmental toxin) triggers rheumatoid arthritis in genetically susceptible people. Researchers have linked a number of genes to the disease.

Infectious agents. Scientists have searched—without success—for evidence that people with rheumatoid arthritis might harbor certain bacteria known to cause other types of arthritis, such as Mycoplasma (which causes pneumonia or genital infections) or Chlamydia (one of several sexually transmitted organisms that can cause a condition called reactive arthritis). A more likely role for bacteria would be provoking an immune system response in which antibodies that are intended to attack the microbes also target a connective tissue protein. Other researchers believe a virus is the most likely culprit.


Diagnosing rheumatoid arthritis

People who have symptoms of arthritis should have a complete medical evaluation. The symptoms and physical examination are the most important parts of the diagnostic process. The early joint symptoms of other conditions, such as lupus, are sometimes indistinguishable from those of rheumatoid arthritis, making a definitive diagnosis difficult soon after symptoms start. Blood and imaging tests are often ordered to help with diagnosis.

It may take several weeks (and several visits) before you receive a definite diagnosis. People often find this wait frustrating and worry that they are not receiving prompt treatment. But you may find it reassuring to know that a few weeks’ delay will not jeopardize your health, whereas undergoing the wrong therapy could.

Blood tests for rheumatoid arthritis. Your doctor may order several types of blood tests, because no test by itself is sufficient to confirm a diagnosis.

  • Rheumatoid factor. The majority (about 70%) of people with rheumatoid arthritis have an abnormal antibody called rheumatoid factor in their blood, so you will probably undergo a simple blood test for this. While this test provides important information, it does not give definitive proof of rheumatoid arthritis, however. About 10% of people who do not have rheumatoid arthritis will test positive for rheumatoid factor. Such people may be perfectly healthy or suffering from another disorder such as systemic lupus erythematosus (see “Related disorders”). At the same time, some people with rheumatoid arthritis will test negative for rheumatoid factor. Therefore, your doctor is likely to order additional blood tests to look for causes of joint pain.

Related disorders

Rheumatoid arthritis has several relatives. All are connective tissue diseases and are considered autoimmune disorders because they are thought to originate from abnormal immune system responses. All can cause arthritis, but some have a proclivity for attacking skin and other organs. As with rheumatoid arthritis, their causes are unknown.

Systemic lupus erythematosus. Systemic lupus erythematosus (SLE) often causes a distinctive facial discoloration called butterfly rash because it appears on both cheeks and the bridge of the nose. Rashes and other skin eruptions can occur virtually anywhere on the body. SLE also affects the internal organs. Most people with the condition develop arthritis that may wax and wane in severity. Other complications may arise from immune system damage to the heart, lungs, kidneys, blood vessels, blood cells, and nervous system.

Scleroderma. This disease causes skin to thicken, tighten, and look shiny. Often, muscles atrophy. Some people have rheumatoid-like arthritis, while others have a combination of arthritis and tightening of the tendons. Scleroderma can affect the gastrointestinal tract, lungs, heart, and kidneys.

Sjögren’s syndrome. In this disease, immune system cells usually attack the tear and saliva glands, causing dry eyes and dry mouth. The disease may cause other complications, including joint pain and swelling that mimic rheumatoid arthritis.

  • Anti-CCP. The anti-cyclic citrullinated peptide (anti-CCP) test measures the presence of an antibody strongly associated with rheumatoid arthritis. The anti-CCP test is gradually becoming more common. (Some rheumatologists now order it routinely whenever they order a rheumatoid factor test.) Small, early studies have shown that the anti-CCP test can reliably help to diagnose rheumatoid arthritis in three types of people: those with early-stage disease for whom uncertainty remains about diagnosis, those with mild symptoms who test negative for rheumatoid factor, and those who test positive for rheumatoid factor but may suffer from some other condition.

  • ESR. The erythrocyte sedimentation rate (ESR) provides a measure of inflammation throughout the body. When there are high levels of inflammation, proteins in a blood sample cause the red blood cells (erythrocytes) to clump more and settle faster to the bottom of a long, thin test tube. The higher the rate of sedimentation, the greater the likelihood that you are suffering from inflammation, which could be caused by rheumatoid arthritis. This test can also help determine how active your condition is.

  • CRP. The C-reactive protein (CRP) test also measures inflammation, but tends to change more rapidly than the ESR; minor elevations have also been associated with an increased risk of cardiovascular disease. In assessing inflammation resulting from rheumatoid arthritis, this test offers no clear advantages over the ESR test.

Imaging tests for rheumatoid arthritis. Since rheumatoid arthritis often involves the hands and feet, your doctor may also order x-rays and possibly magnetic resonance imaging (MRI) scans of these joints and others to check for bone erosions. Initial studies of MRI show that it is better at detecting bone erosions than x-rays, but its use is controversial because it may detect cysts or other bone changes that resemble erosions, and thus could lead to unnecessary treatment. The issue is important, because rheumatoid arthritis varies greatly in its progression and impact: treatment should be directed by symptoms, findings on physical examination, the results of joint imaging, and the preferences of the patient, not just by the results of a single imaging test. In addition, MRI is expensive, and routine use could dramatically drive up the cost of caring for people with rheumatoid arthritis. Increasingly, ultrasound has been used to evaluate the joints of people with rheumatoid arthritis and other types of arthritis.


Medications for rheumatoid arthritis

In the 1990s, the treatment of rheumatoid arthritis changed significantly, as researchers developed more effective medications to fight the disease. In the past, doctors treated rheumatoid arthritis very conservatively. But evidence that joint damage starts early in the course of the disease has prompted physicians to treat it more aggressively from the beginning.

Given the complex nature of rheumatoid arthritis, and the fact that its progression varies from person to person, there are no easy answers when it comes to deciding on a treatment plan. In general, early treatment is considered the best strategy to avoid joint damage. It is also important to remember that treatment should be tailored to the individual: although some people with rheumatoid arthritis begin aggressive therapy within weeks of diagnosis, others may not need it right away.

Drugs for rheumatoid arthritis fall into several classes and may be given in combination or sequentially. Although newly approved drugs tend to generate a lot of excitement, it’s best to be cautious when using any new drug, as the true benefits and risks may not be known for years. A dramatic illustration of this was the 2004 withdrawal of the painkillers Vioxx and Bextra, then relatively new drugs, when it was discovered that people taking the pills for more than 18 months had increased cardiovascular risks. There are many reasons why such effects may not show up in the trials used in the drug approval process. Pre-approval studies are often limited in duration, while people taking the drugs for a disease like rheumatoid arthritis may take them for years. What’s more, studies may enroll no more than a few hundred or a few thousand people, who may be healthier than the tens of thousands or more who take the drug after it is approved. Uncommon side effects, interactions with other drugs, and long-term effects may only emerge in the general population in the years following approval. Unfortunately, there is no system in place to reliably identify these problems sooner. That means you need to carefully weigh the risks and benefits before deciding to try a novel therapy.

Antibiotics for rheumatoid arthritis?

Over the years, some physicians have prescribed long courses of antibiotics to treat rheumatoid arthritis, in the belief that infection may be the source of the problem, or because an antibiotic may reduce inflammation in addition to having effects on bacteria. The infection hypothesis has never been proved, although some studies have suggested a role for bacteria as a cause of a rare form of arthritis that affects the spine and other joints but in which rheumatoid factor is not present in the blood. Although a few trials of antibiotics such as minocycline have been reported to bring about improvement, the overall benefit has been modest.


NSAIDs and steroids

To alleviate the pain and inflammation of rheumatoid arthritis, most doctors prescribe a nonsteroidal anti-inflammatory drug, or NSAID—either a traditional one such as ibuprofen, or the more targeted COX-2 inhibitor celecoxib (Celebrex). Although all NSAIDs can reduce pain and swelling, they have little, if any, effect on the disease process involved in rheumatoid arthritis. As a result, most people with rheumatoid arthritis need disease-modifying antirheumatic drugs (DMARDs) to control disease activity.

Although NSAIDs can provide considerable benefit, they may also have a variety of side effects. If you are considering long-term use of any NSAID (including celecoxib), talk with your doctor about your personal health risks, particularly any gastrointestinal, kidney, or cardiovascular problems you may have. (For more on these medications, see “NSAIDs”.)

Like NSAIDs, corticosteroids such as prednisone also dampen the body’s inflammatory response. But long-term use can actually damage the joints and cause other health problems such as osteoporosis, diabetes, increased susceptibility to infections, cataracts, and hypertension. Today, corticosteroids are used very cautiously. They may be injected directly into a very inflamed joint or taken orally in low doses if other drugs fail to control inflammation. High doses are reserved for rare, life-threatening crises.


DMARDs

Disease-modifying antirheumatic drugs alter the function of the immune system, which can slow the progression of rheumatoid arthritis. Because these medications can reduce or prevent joint damage and preserve joint function, they have become the first-line treatment and standard of care for most people with ongoing symptoms of joint damage.

DMARDs may be prescribed alone or in combination with drugs from other categories. When carefully prescribed, methotrexate (Folex, Rheumatrex, Trexall) has an excellent safety profile, is highly effective, and is usually the first choice of therapy. It’s also the drug against which all newer agents are judged. For example, leflunomide (Arava), a newer DMARD, may be nearly as effective as methotrexate. It has a different, but acceptable, safety profile. Like methotrexate, leflunomide can lead to liver toxicity. And it shouldn’t be taken by anyone with compromised kidney function.

Other commonly prescribed DMARDs include hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine), although these are usually chosen for mild disease, in combination with methotrexate, or when methotrexate is not tolerated. Additional options include cyclosporine (Neoral) and penicillamine (Cuprimine, Depen), but these are used much less often because they appear to be less effective, less safe, or both.

Although DMARDs are often highly effective, their toxicity may extend to frequently proliferating cells that are vital to the body’s renewal processes. For example, they may have damaging effects on the bone marrow, bladder, lung, liver, intestine, and reproductive organs. Some also carry the risk of birth defects if taken by pregnant women. Anyone taking a DMARD is regularly monitored and may need to have frequent tests, including complete blood cell counts, liver function tests, and urinalyses. The specific monitoring tests and frequency of testing vary depending on the drug taken.

One thing to keep in mind is that DMARDs are slow-acting drugs. Do not become discouraged and stop taking a DMARD before it has had a chance to work. Your doctor will probably advise you to take an NSAID, a corticosteroid, or both during the early weeks or months of treatment until the DMARD begins to take effect. Failure to respond to one DMARD does not mean you will fail to respond to another.


Biological response modifiers

Biological response modifiers, also called biologics, are a type of DMARD designed to alter the function of cytokines, signaling molecules that help mount an inflammatory reaction. These drugs may be able to do what other drugs have failed to do so far: put a halt to joint deterioration.

Anti-TNF agents. These drugs block the action of tumor necrosis factor (TNF), which appears to play a pivotal role in joint inflammation (see Figure 17). Five anti-TNF agents are now available: adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), infliximab (Remicade), and golimumab (Simponi). About 60% to 70% of people with rheumatoid arthritis respond well to anti-TNF agents.

Figure 17: How anti-TNF agents work

When the immune system attacks the body’s own cells, autoimmune conditions such as rheumatoid arthritis can develop, triggering inflammation and destruction of tissues. One of the chemical messengers involved in inflammation is tumor necrosis factor (TNF). TNF binds to normal joint tissues and increases inflammation (A). But an anti-TNF drug binds to the receptor sites on the joint tissue cells, blocking the TNF from causing destructive inflammation (B).

A. Attacking immune cells release TNF, which stimulates destruction of bone and cartilage and increases inflammation.

B. A TNF blocker prevents TNF from binding to its receptor, limiting its destructive inflammatory effects.

In a number of people with rheumatoid arthritis, these drugs have induced something close to remission. However, like anti-cancer chemotherapy, these drugs are potent and expensive. In addition, infliximab requires frequent visits to the hospital for infusions. As such, anti-TNF agents may be too aggressive for people with a mild or benign form of rheumatoid arthritis. And not everyone with rheumatoid arthritis responds to anti-TNF therapy. Even those who do may find their disease flares up again once therapy is stopped. For these reasons, most experts recommend that anti-TNFs be used only when first-line treatment with methotrexate or some other DMARD fails.

Anti-TNF agents are often used in combination with methotrexate to benefit people with active rheumatoid arthritis whose symptoms don’t respond to methotrexate alone. These medications are taken by intravenous infusion or injection (see Appendix for more details). Several studies have shown that people with moderate to severe disease who combine methotrexate and anti-TNF treatment have fewer symptoms and less joint destruction, especially if the treatment begins early.

In rare cases, anti-TNF therapy has been associated with long-term neurological side effects, including numbness, tingling, and weakness. These symptoms may mimic multiple sclerosis (MS), so people with MS are generally advised not to take anti-TNF drugs. These drugs have also been linked to tuberculosis (especially in people previously exposed to the infection) and fungal lung infections such as histoplasmosis. Infliximab (Remicade) should not be taken by anyone with heart failure.

Other immune system modulators. Drugs such as abatacept (Orenecia), rituximab (Rituxan), and tocilizumab (Actemra) target different parts of the immune system to dampen inflammation. Some are given to people who haven’t responded well to DMARDS, but they are often given in combination with a DMARD such as methotrexate to boost effectiveness (see Appendix).


Surgery for rheumatoid arthritis

Some people with rheumatoid arthritis require surgery to reconstruct or replace a damaged joint. Surgery is usually recommended when drug treatment alone can no longer improve the situation, although the timing of such surgery—and whether to go ahead with it—is up to you and your physician. Surgery is usually viewed as a last resort to reduce pain and improve function. One possible exception is hand surgery, as many hand surgeons advocate early surgical intervention to remove inflamed tissue and to help protect the joints and nearby tendons.

Many procedures used to repair joints damaged by osteoarthritis are also used in rheumatoid arthritis. The most common surgical procedures for rheumatoid arthritis are arthroscopy, synovectomy (removal of the inflamed tissue that lines the joint), and arthroplasty (joint repair, including joint replacement). The choice depends, in part, on which joints are involved and whether you have any other medical problems. Joint replacement, most commonly used for severe hip or knee arthritis, is a major operation and carries the associated risks. However, the benefits afforded by early DMARD treatment mean that today, fewer people need joint replacement surgery than in the past.



Gout

Gout, a painful and potentially debilitating form of arthritis, has afflicted such famed figures as Benjamin Franklin and Henry VIII. Today it affects roughly three million Americans, up from 2.1 million in 1995. This disorder develops after tiny, needle-shaped crystals of uric acid (a biological waste product) accumulate in joints, causing swelling and extreme sensitivity, sometimes to the point where even the slight touch of a sheet is unbearable. The same crystals may cause kidney stones if they accumulate in the kidneys.

Gout usually affects a single joint at a time, most often the big toe, but sometimes a knee, ankle, wrist, foot, or finger instead. If gout persists for many years, uric acid crystals may collect in the joints or tendons and under the skin, forming whitish deposits known as tophi. About 90% of people with gout are men older than 40, and African American men are twice as likely as Caucasian men to be affected. Gout tends not to occur in women until at least 10 years after menopause.

Symptoms of GOUT

  • Pain and swelling within a joint

  • Often, an initial episode that occurs at night

  • Shiny red or purple skin around the affected joint

  • Extreme tenderness around the joint


Causes of gout

For many people, gout develops after a combination of factors contributes to the buildup of excessive levels of uric acid in the body. Abnormally high levels of uric acid may result in part from a diet that is rich in purines, chemicals that are broken down into uric acid by the body. Purines can be found in anchovies, nuts, and organ foods such as liver, kidney, and sweetbreads. Several studies have also suggested a link between gout and a high intake of high fructose corn syrup, a sweetener widely used in soft drinks. In fact, uric acid is one of the breakdown products of fructose, and research shows that consuming fructose raises uric acid levels in the blood.

Often, for unknown reasons, the body will produce too much uric acid regardless of diet. Gout can also develop when the kidneys excrete too little uric acid, which can happen in people with kidney disease. In addition, obesity, sudden weight gain, or alcohol use can cause elevated levels of uric acid. Some medications, particularly diuretics, also contribute to high uric acid levels. People at risk for developing gout include those with a family history of the disease and those with high blood pressure, high cholesterol, or diabetes.


Diagnosing gout

Your doctor will ask you about your diet, your medication use, your alcohol consumption, and whether you have a family history of gout. During a physical exam, your doctor will inspect your inflamed joints and look for tophi, whitish deposits of uric acid on your skin. Your doctor may use a needle to withdraw a small fluid sample from your affected joint. This fluid will be examined under a microscope to determine whether uric acid crystals are present. Your doctor may also order a blood test to determine your uric acid level, but this test is not definitive because—for a variety of different reasons—many people without gout experience elevated uric acid levels, and even in people with gout, the results may be normal.


Treating gout

Gout is usually treated with a two-pronged medication strategy: the first goal is to ease attacks of joint pain and inflammation, while the second, longer-term goal is to decrease blood uric acid level and actually prevent further attacks.

Usually a doctor begins by prescribing an NSAID to control pain and inflammation. If you cannot tolerate an NSAID or if these drugs are ineffective, your doctor may suggest a corticosteroid. Oral colchicine may be prescribed, but be aware that this drug may cause unpleasant side effects (nausea, vomiting, cramps, diarrhea) and in one trial was effective in only 38% of gout sufferers.

For people with attacks that respond poorly to therapy, involve multiple joints, or occur frequently, or when kidney stones or tophi are present, a second type of drug may be prescribed to prevent future gout attacks. It’s important to keep taking this drug even after you feel better.

The first choice is usually allopurinol (Aloprim, Zyloprim), which decreases your body’s production of uric acid. It is available as a generic and therefore is the least expensive option. Another drug, febuxostat (Uloric), which also cuts uric acid production, can be a good alternative for people who can’t tolerate allopurinol. Probenecid (Benemid, Probalan) helps the kidneys eliminate uric acid, but people with kidney stones or kidney disease shouldn’t take it. Yet another option is pegloticase (Krystexxa), which is usually reserved for people who can’t take or don’t get relief from the other medications. This drug, which is given via intravenous infusion every two weeks, works by breaking down uric acid into a harmless chemical that’s excreted in the urine. Because one in four people who receive this drug develops severe allergic reactions, health care providers should give corticosteroids and antihistamines before the infusion to minimize the risk of this reaction (see the Appendix for additional details on these medications).

Foods rich in purines

  • All meats, especially organ meats

  • Meat extracts and gravies

  • Yeast and yeast extracts

  • Beans, peas, and lentils

  • Spinach and asparagus

  • Cauliflower

  • Mushrooms

  • Seafood, especially sardines and anchovies

You can help prevent further attacks by avoiding diuretics (if your doctors agree), limiting your alcohol intake, drinking plenty of water, and maintaining a healthy weight. You may also want to avoid foods that seem to trigger gout attacks, such as meat and certain types of seafood and vegetables (see “Foods rich in purines”)—although many people find that dietary restrictions have few benefits.




Appendix: Drugs for treating arthritis

Topical pain relievers

One of these, diclofenac, is available only by prescription as a gel or patch; both forms relieve mild to moderate joint pain and inflammation. The others, which are available over the counter, are moderately effective for mild pain. Topical pain relievers work best on joints close to the skin surface, such as those in the knees and hands. Do not use on broken or irritated skin or in combination with a heating pad or bandage.

GENERIC NAME (BRAND NAME)

ACTIVE INGREDIENT

HOW IT WORKS

SIDE EFFECTS

COMMENTS

capsaicin-based creams (Capzasin, Zostrix, others)

Capsaicin, derived from cayenne peppers

Depletes substance P, believed to send pain messages to the brain

Temporary burning or stinging at the application site, which usually disappears in a few weeks of continuous use

Wash your hands thoroughly after use. Avoid contact with the eyes.

diclofenac (Voltaren Gel, Flector Patch)

A nonsteroidal anti-inflammatory drug (NSAID)

Inhibits hormone-like substances (prostaglandins) that contribute to pain and inflammation

Skin redness and irritation at application site

Do not use with oral NSAIDs. Long-term users of either product should receive periodic blood tests to monitor liver function.

counterirritants

(ArthriCare, Icy Hot, Eucalyptamint, Therapeutic Mineral Ice, others)

Includes pungent oils derived from mint, wintergreen, eucalyptus, and other plants

Stimulate or irritate nerve endings to distract the brain’s awareness of pain

Many of these products have strong odors.

salicylates (Aspercreme, Bengay, Flexall, Mobisyl, Sportscreme, others)

A type of NSAID derived from willow tree bark

Same as both diclofenac and counterirritants (see above)

Do not use if you are allergic to aspirin or are taking blood thinners.

Oral pain relievers

These medications include over-the-counter drugs for mild to moderate pain, prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for moderate pain, and prescription narcotics, which are typically used only when other medications don’t provide adequate relief.

Over-the-counter products

All of these medications except acetaminophen are NSAIDs and should be taken with food, milk, or an antacid to minimize stomach problems.

GENERIC NAME (BRAND NAME)

USE

SIDE EFFECTS

COMMENTS

acetaminophen (Tylenol, others)

Relieves pain

Nausea, vomiting, diarrhea, jaundice, rash, tiredness, weakness; less likely to cause gastric bleeding than other pain relievers

Drinking large amounts of alcohol during long-term therapy with acetaminophen may cause liver damage. Kidney damage also possible with long-term use.

aspirin (Bayer, Bufferin, others)

Reduces inflammation and relieves pain

Stomach pain, bleeding, ulcers

High doses may cause ringing in the ears. Before using, let your doctor know if you are on blood thinners or have liver or kidney problems.

ibuprofen* (Advil, Motrin, others)

Stronger and generally longer-lasting than aspirin.

naproxen* (Aleve)

Longer-lasting than ibuprofen.

*Ibuprofen and naproxen are available in higher doses by prescription only. Naproxen is also sold by prescription in combination with a medication to suppress stomach acid (either lansoprazole or esomeprazole), under the brand names Prevacid NapraPAC 500 and Vimovo.

Prescription NSAIDs

All NSAIDs should be taken with milk, food, or an antacid to reduce the likelihood of gastrointestinal distress.

GENERIC NAME (BRAND NAME)

USE

SIDE EFFECTS

COMMENTS

diclofenac (Voltaren, others)

diflunisal (Dolobid)

etodolac (generics)

fenoprofen (Nalfon, others)

flurbiprofen (Ansaid, others)

indomethacin (Indocin, others)

ketoprofen (Orudis, others)

meclofenamate (Meclomen, others)

mefenamic acid (Ponstel)

nabumetone (Relafen)

oxaprozin (Daypro)

piroxicam (Feldene)

sulindac (Clinoril)

tolmetin (generic)

Reduces inflammation and relieves pain

Stomach pain or bleeding, ulcers, weight loss, nausea, vomiting, drowsiness, dizziness, fluid retention, heartburn, diarrhea, constipation, blurred vision, tinnitus

Rare allergic reactions; do not take if you are allergic to aspirin. High doses can cause ringing in the ears. People who take high doses for a long time should have periodic blood tests to check for bleeding and liver or kidney damage. May cause kidney damage in people who are dehydrated, or who already have a kidney problem or heart failure.

celecoxib (Celebrex)

Stomach upset, fluid retention; fewer gastrointestinal side effects than traditional NSAIDs, but a possible increased risk of heart attack or stroke

Same as above. In addition, do not take celecoxib if you are allergic to sulfonamide antibiotics, and talk with your doctor first if you have heart disease.

Prescription narcotics

Because of the risk of addiction, these medications should be taken intermittently for short periods (a week or so).

codeine (usually generic, combined with other pain relievers such as acetaminophen, as in Tylenol No. 3)

Relieves pain

Constipation, dizziness, nausea or vomiting, sleepiness

Take with food or milk. Do not drive while taking this medication. May lead to physical or emotional dependence; do not take if you have a history of substance abuse.

tramadol (Ultram)

Constipation, dizziness, headache, nausea, sleepiness

Do not use if you have a history of substance abuse or if you suffer from asthma, kidney problems, or liver problems.

Corticosteroids

These medications, commonly known as steroids, temper inflammation and are used for both osteoarthritis (by injection) and rheumatoid arthritis (orally or by injection). Abruptly stopping oral steroids after taking them for more than 10 to 14 days can cause a life-threatening condition called Addisonian crisis. For this reason, corticosteroids must be taken exactly as prescribed. Before stopping corticosteroids, check with your doctor: it may be best to lower the dosage gradually (“tapering” the medication), often over a period of several weeks or months.

GENERIC NAME (BRAND NAME)

USE

SIDE EFFECTS

COMMENTS

methylprednisolone (Medrol)

Suppresses inflammation in severe organ disease or life-threatening disease

Fluid retention, weight gain, facial hair growth, easy bruising, ulcers, loss of calcium from bones (increases risk of fractures), cataracts, acne, bacterial infection, adrenal suppression (at doses above 5 mg per day), sleeplessness, muscle wasting and weakness, headache, glucose intolerance (among others)

Side effects are related to dosage and length of therapy. If a low dose is taken for a week or less, side effects are rare. Therapy for several months or years causes more noticeable and serious side effects, even at low doses.

prednisone (Deltasone, Orasone, others), prednisolone, methylprednisolone, and others

Suppresses inflammation

injectable corticosteroids (various)

Relieve pain and suppress inflammation of synovitis, bursitis, tendinitis, or carpal tunnel syndrome

Same as above; also tenderness, burning, or tingling at injection site, thinning of skin at injection site, joint infections, cartilage damage

Injected into joints, tendon sheaths, or bursae. Serious systemic side effects seldom occur.

Disease-modifying antirheumatic drugs (DMARDs)

These medications are prescribed for people with rheumatoid arthritis and related types of inflammatory arthritis. While you are taking a DMARD, your doctor may recommend frequent monitoring to avoid complications, which may include eye examinations, blood pressure measurements, and urine and blood tests.

GENERIC NAME (BRAND NAME)

USE

SIDE EFFECTS

COMMENTS

azathioprine (Imuran)

Suppresses immune system; most commonly used in lupus and vasculitis

Nausea, vomiting, diarrhea, liver damage, blood abnormalities, risk of cancer with long-term therapy, infertility

Effective dosage and side effects highly variable; genetic testing may be recommended prior to starting medication to determine risk of side effects.

cyclophosphamide (Cytoxan)

Suppresses immune system in severe lupus, rheumatoid arthritis, and other rheumatic diseases

Urinary tract bleeding, risk of infection (including shingles), infertility in men and women, risk of cancers (including bladder cancer and leukemia)

Generally used to treat people who are unresponsive to other therapy, or who have dangerous inflammatory conditions. This drug was originally used to treat cancer. Rarely used for rheumatoid arthritis; more commonly used to treat lupus-related kidney disease or vasculitis.

cyclosporine (Neoral)

Reduces inflammation
in rheumatoid arthritis

Impaired kidney function, high blood pressure, hair growth, gum swelling, tremor, convulsions, headache

This drug was originally used to prevent organ rejection in transplant patients. Occasionally used for rheumatoid arthritis.

hydroxychloroquine (Plaquenil)

Suppresses inflammation in rheumatoid arthritis; reduces disease activity in lupus

Nausea, vomiting, diarrhea, irritability, nervousness, rash, visual problems

This antimalarial drug is less likely to cause side effects than chloroquine; most commonly used to treat mild rheumatoid arthritis or lupus.

leflunomide (Arava)

Reduces inflammation in rheumatoid arthritis

Birth defects, liver damage

Should not be used by people with liver disease or by women who are or plan to become pregnant. Women of childbearing age should use contraception while taking leflunomide.

mycophenolate mofetil (CellCept)

Suppresses the immune system; most commonly used in lupus

Upset stomach, nausea, diarrhea, lack of energy

May interact with other medications, so be sure your doctor and pharmacist review your entire medication list.

methotrexate (Folex, Rheumatrex, Trexall)

Suppresses inflammation in rheumatoid arthritis

Nausea, abdominal pain, ulcers, appetite loss, rash, liver damage, lung damage, headaches, blurred vision, drowsiness; long-term use results in immunosuppression

Folic acid supplements may reduce side effects. This drug is usually the first choice of DMARDs for rheumatoid arthritis; it is as effective as or slightly better than other DMARDs and works more rapidly (in one to two months) than many other DMARDs.

sulfasalazine (Azulfidine)

Suppresses inflammation in rheumatoid arthritis, ankylosing spondylitis, and other spondyloarthropathies

Nausea, vomiting, loss of appetite, severe rash, abdominal pain, blood abnormalities, headache, low sperm count

Should not be taken by people allergic to sulfonamide antibiotics.

tofacitinib (Xeljanz)

Disrupts chemical signalling that leads to inflammation; used for rheumatoid arthritis when methotrexate alone has not worked well

Ulceration of the stomach or intestines, diarrhea, headache, upper respiratory tract infections that don’t go away

Lowers the ability of the immune system to respond to viral, fungal, and bacterial infections, including tuberculosis. May also increase the risk of certain cancers.

Biological response modifiers

These drugs, also known as biologics, are created from genetically engineered proteins derived from human genes. Given by injection or intravenous infusion, they inhibit specific components of the immune system, which helps suppress inflammation and slow the progression of rheumatoid arthritis. Biologics are usually prescribed to people with moderate to severe rheumatoid arthritis who have not responded to other treatments; they may be used alone but are commonly given with other medications. The most common side effects are bruising, pain, and a rash at the injection site; these medications also make you more prone to infections and other diseases. Those that are administered intravenously can cause infusion reactions, which occur during or shortly after the infusion and include blood pressure changes, chest pain, and breathing difficulties.

Anti-TNF compounds

These medications block the action of tumor necrosis factor (TNF), which is thought to play a role in inflammation.

GENERIC NAME (BRAND NAME)

SIDE EFFECTS

HOW IT’S TAKEN

adalimumab (Humira)

Headache and infections, including colds and sinus and urinary tract infections; people with heart failure should not take infliximab

Self-injection every one to two weeks.

certolizumab (Cimzia)

Intravenously once or twice a month in a medical setting.

etanercept (Enbrel)

Self-injection once or twice a week.

golimumab (Simponi)

Self-injection once a month.

infliximab (Remicade)

Intravenously every two to eight weeks in a medical setting.

Other biological response modifiers

These medications inhibit other immune system molecules involved in the inflammation process.

abatacept (Orencia)

Headache, upper respiratory tract infection, sore throat, nausea

Intravenously over 30 minutes every two weeks for first three doses, then monthly.

anakinra (Kineret)

Headache, nausea, diarrhea, runny nose, flulike symptoms

Daily self-injection.

rituximab (Rituxan)

Nausea, diarrhea, heartburn, muscle or back pain, tiredness, weakness, numbness in the hands or feet, stomach area pain

Intravenously over several hours, up to two or three times a year.

tocilizumab (Actemra)

Serious infections, diverticulitis, severe allergic reactions; possible increases in blood lipids

Intravenously over one hour, once per month.

Anti-gout medications

In addition to NSAIDs and corticosteroids, which can ease the pain and swelling of a gout attack, people may take colchicine to treat acute attacks, although many find the side effects intolerable. The other medications in this table are prescribed to prevent future attacks; all are taken in pill form except pegloticase, which must be administered intravenously in a medical setting.

GENERIC NAME (BRAND NAME)

HOW IT WORKS

SIDE EFFECTS

COMMENTS

allopurinol (Zyloprim)

Prevents gout by lowering the body’s production of uric acid

Stomach upset, diarrhea, drowsiness

Requires periodic blood tests to monitor liver enzyme levels, which may rise during treatment. Rarely causes severe allergic reactions. Often the first choice for gout prevention.

colchicine (Colcrys)

Helps prevent inflammation triggered by uric acid crystals

Nausea, vomiting, diarrhea, stomach cramps

Used to treat acute attacks and for long-term prevention.

febuxostat (Uloric)

Lowers the body’s production of uric acid

Nausea, joint pain, rash, chest pain

Requires periodic blood tests to monitor liver enzyme levels, which may rise during treatment.

pegloticase (Krystexxa)

Lowers levels of uric acid by converting it to a compound that’s excreted in the urine

Allergic reactions, including breathing problems, chest tightness, weak or fast heartbeat

Used only for people who do not respond well to other gout medications; given intravenously every two weeks.

probenecid* (Benemid, Probalan, generics)

Works in the kidneys to help eliminate uric acid

Headache, upset stomach, vomiting, loss of appetite, kidney stones

Drink six to eight glasses of water daily while taking this drug to prevent kidney stones.

*Probenecid is also marketed in combination with colchicine in a generic formula and under several trade names (Col-Probenecid and others).


Resources

Organizations

American Academy of Orthopaedic Surgeons

6300 N. River Road
Rosemont, IL 60018
847-823-7186
www.aaos.org

This nonprofit organization provides education and services for orthopedic surgeons and other health professionals. The website includes patient information and a doctor referral service.

American College of Rheumatology

2200 Lake Blvd. NE
Atlanta, GA 30319
404-633-3777
www.rheumatology.org

This professional organization of physicians, health professionals, and scientists engages in education, research, and advocacy to improve the care of people with arthritis and other rheumatic and musculoskeletal diseases. It also offers practice support to health care providers.

Arthritis Foundation

1330 W. Peachtree St., Suite 100
Atlanta, GA 30309
800-283-7800 (toll-free)
www.arthritis.org

This nonprofit foundation sponsors public education programs and continuing education for professionals, raises money for research, and publishes patient information materials. Local chapters can advise about doctors and sponsor activities such as swimming and self-help classes.

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse

National Institutes of Health
1 AMS Circle
Bethesda, MD 20892
877-226-4267 (toll-free)
www.niams.nih.gov

This federal agency distributes patient and professional education materials about arthritis and rheumatic diseases. It also refers people to other sources of information.


Special Health Reports

These Special Health Reports will give you more in-depth information about some of the topics addressed in this report. You can order them online at www.health.harvard.edu or by calling 877-649-9457 (toll-free):

Hands: Strategies for strong, pain-free hands

Barry P. Simmons, M.D., and Joanne P. Bosch, P.T., C.H.T.,
Medical Editors
(Harvard Medical School, 2012)

Beneath the skin, your hands have an intricate architecture of tendons, joints, ligaments, nerves, and bones. Each of these structures is vulnerable to damage from illness or injury. This report covers many common and uncommon hand conditions that can cause pain and other symptoms. It also provides information about solutions, including exercise, medication, surgery, and more.

Knees and Hips: A troubleshooting guide to knee and hip pain

Scott David Martin, M.D., Medical Editor
(Harvard Medical School, 2012)

Your knees and hips are your largest joints. They support your body’s weight and must work in close coordination to provide the mobility most people take for granted, until injury, arthritis, or other problems interfere. This report describes the most common knee and hip conditions, including arthritis. It highlights information about medical treatments and surgery, including joint replacement options.

Better Balance: Easy exercises to improve stability and prevent falls

Suzanne Salamon, M.D., and Brad Manor, Ph.D., Medical Editors, with master trainers Josie Gardiner and Joy Prouty
(Harvard Medical School, 2012)

Stiff, sore joints hamper movement. If your ankles or knees are arthritic it’s hard to bend them, which affects your ability to balance and react when you trip. Often, people begin moving less, and muscles essential to balance grow weaker still. For this report, two physicians with expertise in balance and aging join forces with two master trainers to develop safe, effective balance exercises that can help stop this cycle. 



Glossary

anti-cyclic citrullinated peptide (anti-CCP): An antibody found in about 70% of people with rheumatoid arthritis; rarely present in other diseases or in healthy people; used to help diagnose rheumatoid arthritis.

articular cartilage: Tough, rubbery tissue that forms the surface of bones within joints.

Bouchard’s node: A fibrous and bony nodule on the middle joint of each finger, caused by osteoarthritis.

bursitis: Inflammation of the bursae, fluid-filled sacs that ease friction between tendons and bones (and tendons and ligaments), causing swelling and pain.

cartilaginous joint: A joint that contains a tough cartilage plate that permits slight movement.

crepitus: A crunching or grating sensation and sound caused by rough surfaces rubbing together inside a joint.

cytokines: Messenger molecules that allow cells to communicate and alter one another’s function.

diathermy: Physical therapy using high-frequency electric current, ultrasound, or microwaves to deliver heat to muscles and ligaments.

DMARDs: Disease-modifying antirheumatic drugs, used to treat rheumatoid arthritis and related conditions.

fixed joint: Fibrous tissue connecting the plates of the skull.

Heberden’s node: A bony growth on the joint nearest the fingertip, caused by osteoarthritis.

osteophyte: A bony projection that forms most commonly along the margin of an osteoarthritic joint, as the body tries to repair itself.

psoriasis: A common skin disease characterized by thickened patches of inflamed, red skin; sometimes accompanied by painful joint swelling and stiffness.

rheumatic disease: Any one of over 100 disorders that cause inflammation in connective tissues.

rheumatoid factor (RF): An antibody found in about 70% of people with rheumatoid arthritis; may be present in other diseases and sometimes in healthy people; used to help diagnose rheumatoid arthritis.

rheumatology: The branch of medicine devoted to the study and treatment of arthritis, inflammation, and connective tissue diseases.

synovial joint: The most mobile type of joint; found in the shoulders, wrists, fingers, hips, etc.

synovitis: Inflammation of the synovium.

synovium: A thin membrane lining joint capsules that produces synovial fluid.

tendinitis: Inflammation of a tendon, usually caused by injury, which may restrict movement of the muscle attached to the tendon.


Credits

Medical Editor
Robert H. Shmerling, M.D.


Associate Professor of Medicine, Harvard



Medical School



Clinical Chief, Division of Rheumatology, Beth



Israel Deaconess Medical Center, Boston



Senior Editor, Harvard Health Publications

Executive Editor
Anne Underwood

Writers
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Julie Corliss

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Illustrators
Harriet Greenfield, Scott Leighton

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Patrick J. Skerrett, Executive Editor

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