April 28, 2015
Some people are surprised to learn that, as an orthopedic surgeon at Riverside Medical Clinic, I view surgery as a last resort for patients suffering from joint pain due to arthritis. Don’t get me wrong, hip and knee joint replacement technologies have advanced tremendously and I am a huge proponent of them because they offer a comprehensive, lasting solution to almost miraculously make patients pain free.
Yet many patients are not at the point of requiring total joint replacement, so they are generally open to learning about new approaches to living with arthritic joints from one of two types of arthritis. The first is osteoarthritis, a degenerative joint disease affecting 27 million Americans; it is a chronic condition caused by breakdown of cartilage in one or more joints. This deterioration of the cartilage removes the cushioning in the joints, allowing bone to rub on bone and causing stiffness, pain and loss of movement.
The second, less common (but more serious) form is rheumatoid arthritis, affecting about 1.3 million Americans and characterized by inflammation of the lining, or synovium, of the joints. It is not curable, but there is a war chest of new treatment approaches such as drug therapy, exercise, joint-protection and self-management techniques.
Arthritis generally manifests in mechanical pain, which is generally experienced with weight-bearing, pressure or use of the joint. Inflammatory pain can cause discomfort and nerve pain without movement or by merely stretching the joint.
Osteoarthritis, because it is caused by repeated use and strain on the joint which results in the loss of cartilage (and allows bones to rub against each other), is most often seen in patients over the age of 50 and primarily in the hips and knees. Mechanical pain from osteoarthritis results from wear and tear, so minimizing impact and force on the joint can go a long way to minimizing pain. Wearing soft shoes or gel inserts in shoes can help achieve this by lessening the peak forces exerted during mobility.
The single best way to reduce impact is weight loss; the compressive force on the hip joint when walking can be about three times the body weight. When going up stairs, the force exerted on the patella, knee cap, femur and thigh bone can be up to a stunning six times body weight. So every pound lost equates to six pounds less force on the knees with stair climbing and three pounds less force on the hip during walking. Losing just 10 pounds can have a huge benefit on these weight-bearing joints.
Because it hurts patients to move, they often tell me it prohibits them from exercising, which is one of the best treatments for arthritis. They then fall into a precarious cycle: they don’t move around much so they get more depressed, they hurt more, they tend to eat more and end up gaining weight. Next, additional weight bearing down on the joint causes more pain and the cycle continues.
In actuality, exercise can lessen pain. Higher levels of endorphins released during and following exercise provide natural pain relief and also help boost mood. The best exercises are the types that have soft impact on the joint; I like to recommend swimming or simply walking with resistance in water or riding a stationary bike.
For patients who aren’t too proud, carrying a cane can help ease the force during mobility. The trick is to use it on the opposite side of the arthritic hip and the more common bowed leg form of the arthritic knee. Conversely, although it can seem incongruous at first, it’s best to carry a heavy object, such as groceries, on the same side as the arthritic joint. These techniques lessen the joint reactive force by pushing the body’s center of gravity toward the joint. Therefore, when using the cane, push down on it when pulling the non-painful leg off the ground and advance it in tandem with the arthritic leg.
Some people experience relief by using a pillow under their knees while they sleep, while others can have problems with flexibility and extension, so I have generally found no discernable difference among patients who employ this technique.
Many arthritis sufferers find adequate pain relief through over-the-counter medications that reduce inflammation such as Motrin or Naprosyn. I encourage patients to use the lowest possible dose of anti-inflammatory medications on a regular basis rather than high doses during acute flare ups, when they have a lot of pain, swelling and stiffness.
Supplements, particularly glucosamine and chondroitin, can produce joint relief on the magnitude of NSAIDs (non-steriodal anti-inflammatory drugs) without the attendant side effects.
Cortisone injections can be very helpful for acute inflammation in accessible joints such as the knee or in patients who can not tolerate NSAIDs. A series of injections of visco-elastic fluid such as Synvisc into the joint provides long-term relief for about half of my patients, the others experience little to no effect from this therapy.
Because the rate of progression is vary variable, it is difficult to assess and almost impossible to predict. It is believed to be correlated to the use and extent of force exerted on the joint. For example, assume a patient has lost half of the cartilage in one year, it doesn’t mean they will lose the other half in the following year; it can progress more quickly or more slowly.
Progression can be measured through X-rays. Over time, the bones get closer and cartilage is not visible, until the point at which you have bone rubbing on bone. Increased bone spur formation over times will lead to gradual loss of joint range of motion. Bone-on-bone grinding will lead to increasing bone loss and resultant angular deformity in the knee (bowed legged or knocked knee) or leg length discrepancy in the hip.
For patients with constant or debilitating pain, surgical joint replacement offers a permanent solution that works exceptionally well. As physicians, we prefer to intervene with non-invasive therapies first, and turn to the modern miracle of surgery after those options have been exhausted. Talk to your doctor if you are living with arthritis pain, there are many approaches that can help you to remain active and minimize your arthritis pain.
Dr. Michael Mai is an orthopedic surgeon at the Corona outpatient care facility of Riverside Medical Clinic. A graduate of Stanford University School of Medicine, he completed his internship, residency and fellowship at University of California at San Diego Medical Center. He has authored a number of medical science articles on leading edge research and techniques and is a member of the American Academy of Orthopedic Surgeons and the Riverside County Medical Association.
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