Osteoarthritis (OA), sometimes called “wear-and-tear” arthritis, or degenerative joint disease, is the most common cause of joint pain in adults. More than 25 million people in the United States have already been diagnosed with osteoarthritis, and as the population ages, increasing numbers are expected to suffer from the symptoms of this disease. It is very likely that anyone who lives long enough has osteoarthritis in one or another joint, even if they don’t have a lot of pain or go to the doctor for it.
Some people are completely disabled by osteoarthritis, while others have only mild symptoms.
Osteoarthritis occurs because of damage to the joint and the joint lining, known as the cartilage. It causes pain, stiffness, and the loss of the normal range of motion in affected joints. The hands, knees, hips and spine are the most common sites for osteoarthritis, although any joint can be affected. The tendency toward developing osteoarthritis in certain sites can be inherited, especially in the hands. How much damage actually occurs depends on activities, injuries, use of the joints, weight and age.
A significant injury, like a fracture extending into a joint, frequently leads to osteoarthritis of that joint later in life. Consistent use and overuse can also lead to osteoarthritis. Elite athletes like professional basketball players frequently develop some degree of OA in their knees and/or hips at relatively early ages.
How does a doctor diagnose osteoarthritis?
The diagnosis of OA is based on symptoms and physical examination by a doctor. On examination, the affected joints may be tender to the touch, show limited range of motion, and may have a kind of crunching feeling with movement. With osteoarthritis, joints are not severely swollen, red or hot.
X-rays may be useful because they can show indirect evidence of cartilage damage and loss of the normal joint space. MRI scans are usually only done if a recent injury has occurred and there is evidence of something other than just osteoarthritis. Blood tests are not necessary or useful in diagnosing OA. The only reason to do blood tests is if some other kind of arthritis is suspected.
How is osteoarthritis treated?
There are a wide variety of ways to deal with the discomfort and disability caused by osteoarthritis.
Almost everyone with OA, especially in the larger joints, benefits from physical therapy. The correct type of exercise must be picked which will allow the muscles around affected joints to be strengthened. Exercise with muscle strengthening and range of motion stretches has been proven to improve the symptoms of OA.
For anyone who is overweight, weight loss improves the symptoms of OA in the weight-bearing joints. A weight loss of even 5% can help: a weight loss of 13.2 pounds usually reduces pain and disability.
Treatments that can be temporarily useful when used directly on the joints include heat and ice. There are conflicting results as to whether or not acupuncture helps, or TENS units, which use very small electrical currents to block the sensation of pain. Some people get relief from paraffin wax treatments and spa therapy.
Medications for osteoarthritis
The first recommended oral medication is acetaminophen, or Tylenol®. It is available over the counter and as inexpensive generics. It is the safest over-the-counter drug for pain. However, too much can cause liver damage. No more than 4000 mg (4 grams) should be taken in a 24 hour period, or four two-pill doses of extra strength (500 mg). Anyone who needs to take medication constantly over a long period should see a doctor to make sure this is the best choice for them.
There are other over-the-counter medications known as non-steroidal anti-inflammatory drugs or NSAIDs. Examples are ibuprofen (Motrin® and others) and naproxen (Aleve® and others). These may be more effective for the pain of OA because they actually work to reduce the inflammation in the joints. They have more risks when taken consistently over time. They can cause ulcers of the stomach lining which can be felt as heartburn; this can also cause bleeding which can be life threatening. NSAIDs can also cause kidney damage when taken for a lengthy period as well as raise blood pressure.
There are other NSAIDs that require a prescription, such as sulindac (Clinoril®). One may work better than another for any given individual. The only way to know which one will help the most is to try it. Closely related medications (called COX-2 selective inhibitors) include Celebrex® (celecoxib). Its slightly different action lowers the risk of bleeding. However, there is a chance of risk of heart problems when this type of medication is taken for a long time.
Two medications work in other ways and may be useful. Tramadol (Ultram®), while related to opiates, relieves pain via a different mechanism in the brain, is thought to be less addictive and may be given to help control OA pain. Duloxetine (Cymbalta®) may also reduce pain in general. There is not complete agreement on the usefulness of these medications in treating OA, but they can be used.
Because of the risks that come when any medicine is taken on a regular basis for a long time, people who have osteoarthritis should discuss this with their doctors, also taking into account other medical problems and other prescription medications they use.
There are creams that have been shown to be somewhat effective. One over-the-counter cream called Capzasin® is made from capsaicin, a derivative of chili peppers. When rubbed into the skin around the affected joint, it can decrease pain. This cream must be used with great care because it burns if it gets into the mouth or other areas not protected by skin. Some believe that creams made from salicylates (related to aspirin) like Aspercreme® may provide some pain relief. There are also creams made with NSAIDs that can help when rubbed into the skin around affected joints but these are only available by prescription.
There now is evidence that the supplements chondroitin and glucosamine taken together lessen the symptoms of knee osteoarthritis for some people. If these supplements are going to help, they will do so within a three month period. If they are not helping after three months, there is no reason to continue to take them. S-adenosylmethionine (SAM-e) may also improve functioning in some people with OA.
The more joints are involved, the bigger the joints, and the more they are used, the harder it is too control pain with treatment applied to the skin as well as some of the above mentioned medications.
Patients with disabling pain from osteoarthritis can be given narcotics for pain relief. This may be the only way for some people to function, especially if they have many involved joints. Doctors and patients have to be aware of the risk of physical dependence and abuse of medications like Vicodin®, Norco® and even stronger drugs like Oxycontin®. However, some narcotics may be essential for certain people. The notoriety of some of these drugs and their abuses make some patients and some doctors uncomfortable with using them. Anyone with severe pain from osteoarthritis should consider discussing this with their doctor or going to a pain relief specialist because pain medicine may be the best and/or only option.
What if medication and therapy does not help enough?
People whose osteoarthritis is not significantly improved with one or more of the above treatments may choose to have more invasive procedures. Very painful knee joints can be injected with cortisone. This will frequently relieve symptoms for four to eight weeks, but can usually only be done four times a year without risk to the joint. Injections into the shoulders or hands do not work as well.
The knees can also be injected with hyaluronic acid, one of the substances in cartilage. This may not reduce pain as quickly as cortisone injections but lasts longer, up to four months. Hyaluronic acid injections cost more than cortisone injections.
For those people whose large joint OA is not tolerable or improved with the most medical therapy possible, a joint replacement is the only solution. The knee, hip and shoulder joints can be replaced. These surgeries are usually very successful and remove the source of the pain. Prosthetic joints made now usually continue to work for between 15 and 20 years. Other therapies are usually tried in younger people first, because the prosthetic joints will need replacement during the life of a relative young person with OA.
If you think you have osteoarthritis in one or more joints and you are having pain relieved by acetaminophen, ibuprofen or naproxen, and you are not disabled by the problem, you can often take care of it yourself, discussing it with your doctor if you need medication every day. If over-the-counter medications are not helping you, it is time to see your doctor to pursue other treatment options.
References
Hochberg M.C., Altman R.D., April K.T., et al. American College of Rheumatology 2012. Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research 2012;64(4):465-474.
Jacofsky D.J., Anderson M.L., Wolf III L.H. Osteoarthritis. Hospital Physician 2005;41(7):17-24.
Sinusas K. Osteoarthritis: Diagnosis and Treatment. American Family Physician 2012;85(1):49-56.