Osteoarthritis

Joint wear and tear

Sooner or later, almost everyone gets some form of osteoarthritis; it affects 30% to 50% of the adult population. Women are more susceptible than men, but virtually everyone has X-ray evidence of degeneration by the time they are in their 50s. Fortunately, more than 50% of people with X-ray-visible changes are pain-free.

The two major categories of osteoarthritis are known as primary and secondary. Primary osteoarthritis requires no predisposition or abnormality in order to develop -- it is simply a result of aging. Symptoms from this type of osteoarthritis usually appear after the sixth decade of a person's life. On the other hand, people with secondary osteoarthritis usually have some predisposing factor, such as a hereditary abnormality in bone or joint structure, abnormal cartilage, trauma to the joint, or a bout with another inflammatory joint disease.

The progression of osteoarthritis can often be slowed, and in some cases, minimized. Beneficial treatments include weight loss, sensible exercise programs, vitamin and supplement therapy, and limiting or increasing the intake of certain foods in the diet.

Pronunciation

OS-tee-o-ar-THR-tiss

Synonyms

    • Degenerative joint disease
    • Hypertrophic arthritis
    • Degenerative arthritis

Detailed Description

Also known as degenerative joint disease, osteoarthritis is characterized by a loss of the smooth, elastic cartilage that cushions the bones of the joint. As the cushion is worn away, the bones are put under increased stress. This increased mechanical load causes further cartilage destruction and induces new bone growth and some bone reshaping. Then, as you move, these bony changes rub against each other, causing inflammation and pain.

Just how is this cartilage lost? Over the years, normal wear and tear causes a certain amount of stress, which in turn prompts the release of enzymes that destroy more of the cartilage. To make matters worse, as we age, our bodies lose the ability to restore the damaged cartilage. Understandably, the joints that receive the most stress -- our hand joints and weight-bearing joints like the knees, hips, and spine -- are the most common areas for osteoarthritis to develop. These joints are also, of course, the most important for movement and daily living.

The severity of the condition and the severity of pain are not always related. In some cases, osteoarthritis changes can be seen on X-rays for years before symptoms appear. In fact, about 40% of those with the most severe osteoarthritis that shows as extreme deformity in X-rays are pain-free. Conversely, your doctor might not see any abnormality, even under X-ray, and you could be in pain. For those who do experience the pain of osteoarthritis, it can be the most distressing and debilitating feature of this disorder.

Characteristics of Osteoarthritis

    • Disease characterized by degeneration of joint cartilage
    • Leading cause of disability for those over age 65
    • Symptoms include muscle spasms, joint irritation, stiffness, and pain

How Common Is Osteoarthritis?

Common among older adults, osteoarthritis is the leading cause of disability for those over age 65. Approximately 21 million people in the United States are currently affected. People over age 60 are most frequently affected. Osteoarthritis is more common in women than men.

What You Can Expect

As you age, the likelihood of developing symptoms increases. A combination of weight loss, physical therapy, nutrition, medication, and surgery may help ease pain.

Established Causes

The primary cause of osteoarthritis is unknown.

Theoretical Causes

Osteoarthritis may be hereditary. It is possible that genetic defects in cartilage may increase the likelihood of developing osteoarthritis, since the joints are less able to handle normal deterioration.

Risk Factors

Since osteoarthritis is most common in those over age 60, age is the greatest risk factor. Other risk factors include the following:

    • Obesity
    • Any prolonged physical stress (from sports, occupational factors, etc.)
    • Joint injury
    • Poor posture
    • Other joint disorders

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

The following signs and symptoms are associated with osteoarthritis:

    • A gradual development of pain in the affected joints
    • Pain during joint movement that is relieved by rest
    • Minimal pain upon awakening, increasing throughout the day
    • Decreased range of motion
    • Gradual enlargement of the joints
    • Transient stiffness (lasting under 15 minutes)
    • Joints may emit crackling or grating sounds upon movement

Conditions That May Be Mistaken for Osteoarthritis

The following conditions may resemble osteoarthritis:

    • Osteonecrosis (death of living tissue in bone)
    • Osteochondritis (inflammation of bone and cartilage)
    • Sarcoidosis (abnormal formation of nodules)
    • Rheumatoid arthritis
    • Psoriatic arthritis
    • Systemic lupus erythematosus (a condition marked by skin inflammation)
    • Chronic gout

How Osteoarthritis Is Diagnosed

In addition to giving you blood tests and X-rays, your doctor will take your medical history and perform a physical exam to help diagnose osteoarthritis.

Laboratory Work

Blood tests may be ordered to rule out inflammatory forms of arthritis.

Imaging

X-rays are used to identify abnormal changes in bone. Imaging can identify the following:

    • Joint-space narrowing
    • Scarring of bone surfaces within joints
    • Osteophytes (spurs)
    • Cysts at the joint surface

Goals of Treatment

Relieving pain and stress in the joints are the goals here, as are increasing mobility and restoring any lost activities. While osteoarthritis can't be cured, the progression of the disease can be slowed, and sometimes arrested. The pain that accompanies osteoarthritis can also be greatly relieved.

Treatment Overview

Treatment focuses on relieving pain, preventing the joints from further damage, and helping you stay active. Working with health professionals, you can learn to avoid stressing your joints, compensate for any loss of flexibility or mobility, and strengthen muscles to better support already weakened joints.

In cases of severe cartilage loss, surgery can help. Total joint replacement is now commonplace, relieving pain and restoring mobility to many people who would be unable to function otherwise.

Drug Therapy

Drugs most commonly prescribed

Among the most-used medications for OA are:

    • Over-the-counter (OTC) pain relievers such as acetaminophen (Tylenol)
    • OTC NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin and ibuprofen (Advil, Motrin IB, Nuprin), naproxen (Aleve), and ketoprofen (Orudis KT)
    • Prescription NSAIDs such as:

      • Naproxen (Naprosyn or Anaprox)
      • Ketoprofen (Orudis)
      • Nabumetone (Relafen)
      • Ibuprofen (Motrin)
      • Diclofenac Potassium (Cataflam)
      • Diclofenac Sodium (Voltaren)
      • Diclofenac with misoprostol (Arthrotec)
      • Indomethacin (Indocin)
      • COX-2 inhibitors such as rofecoxib (Vioxx) and celecoxib (Celebrex)

For severe pain, narcotics are available, such as:

    • Acetaminophen with codeine (Tylenol #3)
    • Propoxyphene hydrochloride (Darvon) and propoxyphene with acetaminophen (Darvocet-N)
    • Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab)

A note about medications: Many of the prescription drugs prescribed for osteoarthritis have side effects. Be sure to discuss treatment benefits and risks with your doctor.

Weight loss

Extra stress on your joints wears out your cartilage faster. If you are carrying any extra weight, your doctor will urge you to trim down to a weight appropriate for your age and height. Avoid fad or crash diets, though. A combination of exercise and diet works best (see the Weight Loss eCenter for specific articles).

Exercise

Doctors used to think exercise wore joints out faster; now they know it is essential to keep joints healthy. Your doctor will recommend exercises, and will probably send you to a physical or occupational therapist to teach you exercises appropriate for your particular OA, age, and overall condition. See Exercise for Energy & Flexibility in the Arthritis eCenter to help you get started.

Topical painkillers

Creams, gels, and lotions containing various kinds of pain killers are popular over-the-counter treatments. Rubbed onto the painful joint, they work either by stimulating sensations that distract the pain, or by blocking pain nerves.

Counterirritants distract the sensation of pain. Some brands include ArthriCare, Eucalyptamint, Icy Hot, and Therapeutic Mineral Ice.

Some contain salicylates, which are aspirin and work as local pain relievers. Some brands are Aspercreme, Bengay, Flexall, Mobisyl, and Sportscreme (only the extra-strength versions seem to contain aspirin, so read the labels).

Hot pepper might cool your pain as well. A cream or gel that contains capsaicin, which is found in cayenne pepper, interrupts substance P, a neurotransmitter believed to carry pain messages to the brain. Brands include Zostrix, Zostrix HP, and Capzasin-P.

Glucocorticoid injections

Injections directly into or around the joint are sometimes given to relieve pain and swelling. People have different reactions. For some, it gives immediate relief that can last for a long time. Others don't respond at all. Doctors don't like to give these injections more than four times a year because of the risk of cartilage damage.

Assistive devices

Canes, splints, braces, and other assistive devices that help support your joints or relieve stress and pain can help you get around better and reduce your risk of falling. If you have OA in your hands or wrists, specially designed kitchen tools, doorknobs, and other gadgets can ease the strain of day-to-day tasks.

Warm-water exercise

Swimming and doing other aerobic water exercises in a heated pool can help you exercise without putting pressure on your joints.

Hyaluronan injections

This newly approved treatment may give temporary relief for knee joint pain. Hyaluronic acid exists naturally in joint fluid and acts as a lubricant and shock absorber. Inflammation causes the acid to break down, so this therapy places hyaluronan (Hyalgan, Synvisc), a synthetic version of the substance, directly into the joint in a series of three shots given once a week

It's not a permanent solution, but pain relief can last for months. It's especially helpful for those who can't take steady high doses of NSAIDs or whose pain hasn't been managed by the usual pain relievers. So far, hyaluronan hasn't been approved for use in any other joints.

Surgery

Surgery may be recommended if the disease progresses to the point of deformity or if movement is severely impaired. Specific surgeries include the following:

    • Debridement: smooths irregular joint surfaces and remove loose remnants of bone or cartilage.
    • Osteotomy: realigns the joint by cutting the bone to shape. Most commonly performed on the knees.
    • Arthrodesis: also called joint fusion; usually performed on the cervical or lumbar spinal area.
    • Arthroplasty: replaces the afflicted joint in part, or in its entirety, with a plastic or metal replica, or prosthesis. Performed most often on knee and hip joints, but can be done on any joint except those of the spine. Artificial joints often wear out over time, and may need to be replaced. It is sometimes preferable, therefore, to reshape the existing joint to delay the need for joint replacement.

Appropriate Healthcare Settings

Diet changes, physical therapy, and medication are given on an outpatient basis. Surgical intervention usually requires a hospital stay.

Healthcare Professionals Who May Be Involved in Treatment

A diverse group of health care professionals can treat osteoarthritis:

    • Family physicians
    • General internists
    • Geriatricians
    • Rheumatologists
    • Physiatrists
    • Orthopedic surgeons
    • Podiatrists
    • Pharmacists
    • Physical therapists
    • Occupational therapists
    • Physician assistants
    • Nurse practitioners
    • Dieticians
    • Medical social workers

Activity and Diet Recommendations

A program that combines strength-building and flexibility exercises is a key component of treatment. While it is important to keep joints mobile and muscles strong, you should also allow your body time to rest. Rest is critical to restore and repair joints and reduce inflammation. Rest, however, does not mean bed rest, since an extensive period of inactivity will only bring more stiffness and joint pain.

Some things to look for in a therapeutic exercise program include the following:

    • Weight loss (if overweight)
    • Range of motion (ROM) exercises
    • Isometric exercises
    • Hydrotherapeutic (water) exercise: the buoyancy of water alleviates joint stress
    • Strength-building exercises

Much of the pain of osteoarthritis comes from the weight load on the affected joints. Relieving some of this weight with external supports, including canes, crutches, or a walker, may greatly reduce pain.

Diet

If you are overweight, dieting or losing weight in a healthy manner is recommended. Increased weight causes an increased load and increased stress on the joints, which in turn wears out your cartilage and bone. If you are overweight, no other treatment will give maximal relief unless your weight is reduced as well.

Monitoring the Condition

Since osteoarthritis is a degenerative disease, you should have your condition and medication checked regularly. This is especially important if you notice an increase in pain or stiffness, or any loss of motion. If your condition has progressed, your course of treatment might be altered.

Possible Complications

As the disease progresses, your your range of motion may decrease. Muscles around the affected joints may atrophy, and in severe cases, the condition may be crippling.

Quality of Life

Joint pain can become so severe that it interferes with regular activities and even sleep. Talk to your doctor about ways to minimize discomfort. If your pain is debilitating, don't hesitate to ask others for assistance.

Considerations for Older People

Osteoarthritis is much more prevalent in people over age 60, and many treatments have been developed with this group in mind. Range of motion (ROM) and isometric exercises can be performed by people of all ages.

The dosage and the prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) are of special concern. Particularly with the elderly, the dosage of NSAIDs required to alleviate osteoarthritic pain can be large enough to cause ulcer disease, kidney damage, or even tinnitus and hearing loss. Elderly individuals are also more susceptible to the common side effects of aspirin and NSAIDs, such as gastrointestinal problems, bleeding of the stomach, and ulcers. NSAIDs (but not aspirin) have also been connected to impairment of the kidney, and should be used with particular care by people over age 50.


Supplements

    • SAM-e: An antidepressant that also eases arthritis and detoxifies the body? That's what some researchers are saying about SAM-e, a substance only recently gaining public attention in the United States despite its use abroad and many positive studies.
    • Vitamin E: Like vitamin C, vitamin E is an potent antioxidant. In one study, 32 people with osteoarthritis took either a placebo or vitamin E (600 IU/day). Participants in the vitamin E group experienced significantly greater relief. [1]
    • Glucosamine and chondroitin: About one-half to two-thirds of people with osteoarthritis who try these supplements benefit. Both relieve pain.

      Glucosamine may help repair damaged cartilage. Experts suggest 500 mg three times a day for a month. If it helps, feel free to keep taking it. [2] If not, stop after a month.

      Chondroitin helps draw fluid into cartilage, improving its shock-absorbing ability. Experts suggest 400 mg three times a day for a month. [3] If it helps, feel free to keep taking it. If not, stop.

      Neither glucosamine nor chondroitin supplements has been reported to cause significant side effects.

Herbs

    • Ginger: Ginger is an age-old treatment for pain and inflammation. Indian researchers had arthritis sufferers (18 with osteoarthritis, 28 with rheumatoid arthritis) take ginger powder daily (500 to 4,000 mg). Two years later, most participants reported significant pain relief, with no side effects. [4]

Yoga

Researchers at the University of Pennsylvania gave people with osteoarthritis of the hands either pain medication or a weekly yoga class. After eight weeks, the yoga group reported significantly less hand pain. [5]

An ancient Hindu discipline, yoga provides gentle stretching and strengthening exercises combined with controlled breathing, focused concentration, and meditation.

Acupuncture

At the University of Maryland, researchers gave standard care to a group of 58 people with osteoarthritis of the knee. In addition, half of the group also received acupuncture treatment for eight weeks. Afterwards, the acupuncture group reported significantly less pain. [6]

An ancient Chinese practice, acupuncture consists of inserting very fine needles into the skin along a series of energy channels or paths known as meridians. It stimulates particular areas or systems of the body to promote healing and wellness.For more in-depth arthritis information, news, and products, visit the Arthritis eCenter.

1 McAlindon, T.E. et al. "Do Antioxidant Micronutrients Protect Against Development and Progression of Knee Osteoarthritis?" Arthritis and Rheumatism (1996) 39:648.

2,3 "Relieving Arthritis Pain: Can Supplements Help?" Nutrition Action Healthletter 1-2/98. Holt, S. "Bone and Joint Health: Part 2, Dietary Supplements," Alternative and Complementary Therapies 6-98.

4 Srivastava, K.C. and T. Mustafa. "Ginger in Rheumatism and Musculoskeletal Disorders," Medical Hypotheses (1992) 39:342.

5 Garfinkel, M.S., et al. "Evaluation of a Yoga-Based Regimen for Treatment of Osteoarthritis of the Hands," Journal of Rheumatology (1994) 21:2341.

6 "Patients with Osteoarthritis of Knee May Pin Hopes on Acupuncture," Modern Medicine 8-97.

Preventing Osteoarthritis

Maintaining a healthy weight is helpful in preventing osteoarthritis, since carrying extra pounds puts additional pressure on joints. Exercise regularly to keep your muscles strong and your bones healthy. Avoid repetitive motions and risky activities that may contribute to joint injury, especially after age 40. Gentle exercises like walking, stretching, and yoga can help keep your body functioning well.

Self-Care Measures

    • Exercise daily. Inactivity leads to loss of cartilage, which aggravates osteoarthritis pain. Walking is great exercise for osteoarthritis of the knee. At the Hospital for Special Surgery in New York City, researchers recruited 102 people with osteoarthritis of the knee and had some of them take regular walks. After eight weeks, the non-walkers reported the same amount of pain, but the walkers reported 27% less, plus less need for pain medication.
    • Move around. Try not to stay in one position for long periods of time.
    • Spare your joints. Invest in household items that reduce joint strain: an electric can opener, various step stools, and so on. Place frequently used items on shelves you can reach easily.
    • Avoid overexertion. Learn your limits and don't push yourself beyond them. Be kind to your body.
    • Win by losing. The more you weigh, the greater the stress on your joints, especially your hips, knees, and ankles. At the Boston University School of Medicine, researchers monitored 598 older people for 10 years. The participants' risk of osteoarthritis was clearly linked to how much weight they gained. If you are overweight, losing even 10 to 15 pounds can help reduce your pain.
    • Take vitamin C. Antioxidant nutrients, including vitamin C, help prevent the cell damage linked to many age-related conditions, including osteoarthritis. For 10 years, researchers at the Arthritis Center of the Boston University Medical Center surveyed the diets of 640 older adults who had osteoarthritis of the knee. Compared with those who consumed the least vitamin C in foods, those who ate the most had just one-third the risk of their osteoarthritis getting worse. Among other things, vitamin C helps prevent cartilage loss. Foods high in vitamin C include broccoli, bell peppers, citrus fruits, cabbage, cauliflower, spinach, and strawberries.
    • Take vitamin D. The same researchers of vitamin C also investigated their subjects' vitamin D intake. It, too, significantly decreased the risk of osteoarthritis progression. Vitamin D also helps preserve cartilage. Foods high in vitamin D include fortified dairy products and the following fish: salmon, halibut, sea bass, tuna, cod, and herring.

Websites & Organizations

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777
Fax: 404-633-1870

Arthritis Foundation
National Office
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800

Association for People with Arthritis
6 Commercial St.
P.O. Box 954
Hicksville NY, 11802.
Phone: 800-323-2243

National Council on the Aging
409 Third Street NW
Washington, DC 20024
Phone: 202-479-1200

National Institute of Arthritis and Musculoskeletal and Skin Diseases Clearinghouse
1 AMS Circle
Bethesda, MD 20892

The Pain Center of the Hospital for Joint Diseases
301 East 17th Street
New York, NY 10003
Phone: 212-598-6606

Thurston Arthritis Research Center
3330 Thurston-Bowles
Building UNC-CH CB# 7280
Chapel Hill, NC 27599-7280
Phone: 919-966-4191
Fax: 919-966-1739

Wheeless' Textbook of Orthopedics

Sources for This Article

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Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, LM, McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.



Articles

B'alint, G, Szebenyi, B. "Diagnosis of Osteoarthritis. Guidelines and Current Pitfalls." Drugs. 1-13. 1996.

Buckwalter, JA, Lane, NE. "Athletics and Osteoarthritis." Am J Sports Med. 873-81. Nov-Dec 1997.

Cicuttini, FM, Spector, TD. "What is the Evidence that Osteoarthritis is Genetically Determined?" Baillieres Clin Rheumatol. 657-69. Nov 1997.

Cooper, C, Inskip, H, Croft, P, Campbell, L, Smith, G, McLaren, M, Coggon, D. "Individual Risk Factors for Hip Osteoarthritis: Obesity, Hip Injury, and Physical Activity." Am J Epidemiol. 516-22. Mar 15, 1998.

Felson, DT, Nevitt, MC. "The Effects of Estrogen on Osteoarthritis." Curr Opin Rheumatol. 269-72. May 1998.

Garfinkel, MS, et al. "Evaluation of a Yoga-Based Regimen for Treatment of Osteoarthritis of the Hands," J. Rheumatology (1994) 21:2341.

Hochberg, MC. "Epidemiology and Genetics of Osteoarthritis." Curr Opin Rheumatol. 662-8. Aug 1991.

Kirkwood, TB. "What is the Relationship Between Osteoarthritis and Ageing?" Baillieres Clin Rheumatol. 683-94. Nov 1997.

Kovar, PA et al. "Supervised Fitness Walking in Patients with Osteoarthritis of the Knee," Annals of Internal Med. (1992) 116:529.

Lane, NE. "Physical Activity at Leisure and Risk of Osteoarthritis." Ann Rheum Dis. 682-4. Sep 1996.

Liu, G, Peacock, M, Eilam, O, Dorulla, G, Braunstein, E, Johnston, CC. "Effect of Osteoarthritis in the Lumbar Spine and Hip on Bone Mineral Density and Diagnosis of Osteoporosis in Elderly Men and Women." Osteoporos Int. 564-9. 1997.

Machtey, I and L Ouakhine. "Tocopherol in Osteoarthritis: A Controlled Pilot Study," J. Am. Geriatric Soc. (1978) 26:328.

McAlindon, TE et al. "Do Antioxidant Micronutrients Protect Against Development and Progression of Knee Osteoarthritis?" Arthritis and Rheumatism (1996) 39:648.

"Patients with Osteoarthritis of Knee May Pin Hopes on Acupuncture," Modern Med. 8-97.

"Relieving Arthritis Pain: Can Supplements Help?" Nutrition Action Healthletter 1-2/98. Holt, S. "Bone and Joint Health: Part 2, Dietary Supplements," Alt. and Comp. Therapies, 6-98.

Srivastava, KC and T Mustafa. "Ginger in Rheumatism and Musculoskeletal Disorders," Med. Hypotheses (1992) 39:342.

Swedberg, JA, Steinbauer, JR. "Osteoarthritis." Am Fam Physician. 557-68. Feb 1992.

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