MEDICAL CONDITIONS
Osteoarthritis
(Degenerative Arthritis) Medical Author: William C. Shiel Jr., MD, FACP, FACR
What is osteoarthritis?
Osteoarthritis is a type of arthritis that is caused by the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a "cushion" between the bones of the joints. Osteoarthritis is also known as degenerative arthritis. Among the over 100 different types of arthritis conditions, osteoarthritis is the most common, affecting over 20 million people in the United States. Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After age 55 years, it occurs more frequently in females. In the United States, all races appear equally affected. A higher incidence of osteoarthritis exists in the Japanese population, while South African blacks, East Indians and Southern Chinese have lower rates.
Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause and are referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary osteoarthritis.
What causes osteoarthritis?
Primary osteoarthritis is mostly related to aging. With aging, the water content of the cartilage increases and the protein makeup of cartilage degenerates. Repetitive use of the joints over the years irritates and inflames the cartilage, causing joint pain and swelling. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. In advanced cases, there is a total loss of the cartilage cushion between the bones of the joints. Loss of cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths (spurs) to form around the joints. Osteoarthritis occasionally can be found in multiple members of the same family, implying an heredity (genetic) basis for this condition. 
Secondary osteoarthritis is caused by another disease or condition. Conditions that can lead to secondary osteoarthritis include obesity , repeated trauma or surgery to the joint structures, abnormal joints at birth (congenital abnormalities), gout, diabetes, and other hormone disorders.
Obesity causes osteoarthritis by increasing the mechanical stress on the cartilage. The early development of osteoarthritis of the knees among weight lifters is believed to be in part due to their high body weight. Repeated trauma to joint tissues (ligaments, bones and cartilage) is believed to lead to early osteoarthritis of the knees in soccer players. Interestingly, recent studies have not found an increased risk of osteoarthritis in long-distance runners.
Crystal deposits in the cartilage can cause cartilage degeneration, and osteoarthritis. Uric acid crystals cause arthritis in gout, while calcium pyrophosphate crystals cause arthritis in pseudogout .
Some people are born with abnormally formed joints (congenital abnormalities) that are vulnerable to mechanical wear, causing early degeneration and loss of joint cartilage. Osteoarthritis of the hip joints is commonly related to design abnormalities of these joints that had been present since birth.
Hormone disturbances, such as diabetes and growth hormone disorders, are also associated with early cartilage wear and secondary osteoarthritis.
What are symptoms of osteoarthritis?
Osteoarthritis is a disease of the joints. Unlike many other forms of arthritis that are systemic illnesses, such as rheumatoid arthritis and systemic lupus, osteoarthritis does not affect other organs of the body. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. Joint pain is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long periods of inactivity, for example, sitting in a theater. In severe osteoarthritis, complete loss of cartilage cushion causes friction between bones, causing pain at rest or pain with limited motion.
Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can be debilitated by their symptoms. On the other hand, others may have remarkably few symptoms in spite of dramatic degeneration of the joints apparent on x-rays. Symptoms also can be intermittent. It is not unusual for patients with osteoarthritis of the hands and knees to have years of pain-free intervals between symptoms.
Osteoarthritis of the knees is often associated with obesity or a history of repeated injury and/or joint surgery. Progressive cartilage degeneration of the knee joints can lead to deformity and outward curvature of the knees referred to as "bow legged." Patients with osteoarthritis of the weight bearing joints (like the knees) can develop a limp. The limping can worsen as more cartilage degenerates. In some patients, the pain, limping, and joint dysfunction may not respond to medications or other conservative measures. Therefore, severe osteoarthritis of the knees is one of the most common reasons for total knee replacement surgical procedures in the United States.
Osteoarthritis of the spine causes pain in the neck or low back. Bony spurs that form along the arthritic spine can irritate spinal nerves, causing severe pain, numbness, and tingling of the affected parts of the body.
Osteoarthritis causes the formation of hard bony enlargements of the small joints of the fingers. Classic bony enlargement of the small joint at the end of the fingers is called a Heberden's node, named after a very famous British doctor. The bony deformity is a result of the bone spurs from the osteoarthritis in that joint. Another common bony knob (node) occurs at the middle joint of the fingers in many patients with osteoarthritis and is called a Bouchard's node. Dr. Bouchard was a famous French doctor who also studied arthritis patients in the late 1800s. The Heberden's and Bouchard's nodes may not be painful, but they are often associated with limitation of motion of the joint. The characteristic appearances of these finger nodes can be helpful in diagnosing osteoarthritis. Osteoarthritis of the joint at the base of the big toes leads to the formation of a bunion. Osteoarthritis of the fingers and the toes may have a genetic basis, and can be found in numerous women members of some families.
How is osteoarthritis diagnosed?
There is no blood test for the diagnosis of osteoarthritis. Blood tests are performed to exclude diseases that can cause secondary osteoarthritis, as well as to exclude other arthritis conditions that can mimic osteoarthritis.
X-rays of the affected joints can suggest osteoarthritis. The common x-ray findings of osteoarthritis include loss of joint cartilage, narrowing of the joint space between adjacent bones, and bone spur formation. Simple x-ray testing can be very helpful to exclude other causes of pain in a particular joint as well as assist the decision-making as to when surgical intervention should be considered.
Arthrocentesis is often performed in the doctor's office. During arthrocentesis, a sterile needle is used to remove joint fluid for analysis. Joint fluid analysis is useful in excluding gout, infection, and other causes of arthritis. Removal of joint fluid and injection of corticosteroids into the joints during arthrocentesis can help relieve pain, swelling, and inflammation.
Arthroscopy is a surgical technique whereby a doctor inserts a viewing tube into the joint space. Abnormalities of and damage to the cartilage and ligaments can be detected and sometimes repaired through the arthroscope. If successful, patients can recover from the arthroscopic surgery much more quickly than from open joint surgery.
Finally, a careful analysis of the location, duration, and character of the joint symptoms and the appearance of the joints helps the doctor in diagnosing osteoarthritis. Bony enlargement of the joints from spur formations is characteristic of osteoarthritis. Therefore, Heberden's nodes, Bouchard's nodes, and bunions of the feet can help the doctor make a diagnosis of osteoarthritis.
How is osteoarthritis treated?
Aside from weight reduction and avoiding activities that exert excessive stress on the joint cartilage, there is no specific treatment to halt cartilage degeneration or to repair damaged cartilage in osteoarthritis. The goal of treatment in osteoarthritis is to reduce joint pain and inflammation while improving and maintaining joint function. Some patients with osteoarthritis have minimal or no pain, and may not need treatment. Others may benefit from conservative measures such as rest, exercise, weight reduction, physical and occupational therapy, and mechanical support devices. These measures are particularly important when large, weight-bearing joints are involved, such as the hips or knees. Medication may be taken orally or injected into the joints to decrease joint inflammation and pain. When conservative measures fail to control pain and improve joint function, surgery can be considered.
Resting sore joints decreases stress on the joints, and relieves pain and swelling. Patients are asked to simply decrease the intensity and/or frequency of the activities that consistently cause joint pain.
Exercise usually does not aggravate osteoarthritis when performed at levels that do not cause joint pain. Exercise is helpful in osteoarthritis in several ways. First, it strengthens the muscular support around the joints. It also prevents the joints from "freezing up" and improves and maintains joint mobility. Finally, it helps with weight reduction and promotes endurance. Applying local heat before and cold packs after exercise can help relieve pain and inflammation. Swimming is particularly suited for patients with osteoarthritis because it allows patients to exercise with minimal impact stress to the joints. Other popular exercises include walking, stationary cycling, and light weight training.
Physical therapists can provide support devices, such as splints, canes, walkers, and braces. These devices can be helpful in reducing stress on the joints. Occupational therapists can assess daily activities and determine additional devices that may help patients at work or home. Finger splints can support individual joints of the fingers. Paraffin wax dips, warm water soaks, and nighttime cotton gloves can help ease hand symptoms. Spine symptoms can improve with a neck collar, lumbar corset, or a firm mattress, depending on what areas are involved.
In many patients with osteoarthritis, mild pain relievers such as aspirin and acetaminophen (Tylenol) may be sufficient treatment. Studies have shown that acetaminophen given in adequate doses can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis of the knees. Since acetaminophen has fewer gastrointestinal side effects than NSAIDS, especially among the elderly patients, acetaminophen is generally the preferred initial drug given to patients with osteoarthritis. Medicine to relax muscles in spasm might also be given temporarily. Pain-relieving creams applied to the skin over the joints can provide relief of minor arthritis pain. Examples include capsaicin (Arthricare, Zostrix), salycin (Aspercreme), methyl salicylate (Bengay, Icy Hot), and menthol (Flexall).
Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications that are used to reduce pain and inflammation in the joints. Examples of NSAIDs include aspirin (Ecotrin), ibuprofen (Motrin), nabumetone (Relafen), and naproxen (Naprosyn).
The most common side effects of NSAIDs involve gastrointestinal distress, such as stomach upset, cramping diarrhea , ulcer and even bleeding. The risk of these and other side effects increases in the elderly. Newer NSAIDs called Cox-2 Inhibitors have been designed that have less toxicity to the stomach and bowels. Because osteoarthritis symptoms vary and can be intermittent, these medicines might be given only when joint pains occur or prior to activities that have traditionally brought on symptoms. Recently, the food supplements glucosamine and chondroitin have been shown to relieve symptoms of pain and stiffness for some persons with osteoarthritis. These supplements are available in pharmacies and health food stores without a prescription, although there is no certainty about the purity of the products or the dose of the active ingredients because they are not monitored by the FDA. The National Institutes of Health is studying glucosamine and chondroitin in the treatment of osteoarthritis and this research will clarify many issues regarding dosing, safety, and effectiveness of these products for osteoarthritis. Patients taking blood-thinners should be careful taking chondroitin as it can increase the blood-thinning and cause excessive bleeding. Fish oil supplements have been shown to have some anti-inflammation properties and increasing the dietary fish intake and/or fish oil capsules (omega 3 capsules) can sometimes reduce inflammation of arthritis.
While oral cortisone is generally not used in treating osteoarthritis, when injected directly into the inflamed joints, it can rapidly decrease pain and restore function. Since repetitive cortisone injections can be harmful to the tissue and bones, they are reserved for patients with more pronounced symptoms.
For persisting pain of severe osteoarthritis of the knee that does not respond to weight reduction, exercise or medications, a series of injections of hyaluronic acid (Synvisc, Hyalgan) into the joint can sometimes be helpful, especially if surgery is not being considered. These products seem to work by temporarily restoring the thickness of the joint fluid, allowing better joint lubrication and impact capability, and perhaps by directly affecting pain receptors.
Surgery is generally reserved for those patients with osteoarthritis that is particularly severe and unresponsive to the conservative treatments. Arthroscopy, discussed above, can be helpful when cartilage tears are suspected. Osteotomy is a bone removal procedure that can help realign some of the deformity in selected patients, usually those with knee disease. In some cases, severely degenerated joints are best treated by fusion (arthrodesis) or replacement with an artificial joint (arthroplasty). Total hip and total knee replacements are now commonly performed in community hospitals throughout the United States. These can bring dramatic pain relief and improved function. For further information on joint surgeries, please read the Arthroscopy , Total Knee Replacement , and Total Hip Replacement articles.
"If I have minimal or no symptoms with early signs of osteoarthritis, what should I do?"
The ideal steps to take should lead to a proper diagnosis and an optimal long-term treatment plan. While many steps are discussed here, the plan must be customized for each person affected by osteoarthritis, depending on the joints affected and the severity of symptoms.
An opinion regarding the cause or the type of the arthritis can usually be adequately obtained by consulting a general family doctor. It is often unnecessary to see an arthritis specialist (rheumatologist), like myself, for this purpose. However, if the diagnosis or treatment plan is unclear, a rheumatologist might be consulted.
When I determine that a patient has a classic node formation from osteoarthritis (Heberden's node), I may make the diagnosis solely based upon the examination, without the need for any additional tests, such as blood or X-ray testing. Sometimes, testing can be helpful to better understand the degree and character of the osteoarthritis affecting a certain joint. It can also be helpful for monitoring and to exclude other conditions.
Treatment may not be necessary for osteoarthritis of the hands with minimal or no symptoms. When symptoms are troubling and persist, however, treatment might include pain and antiinflammatory medications, with or without food supplements, such as glucosamine and/or chondroitin. Furthermore, heat/cold applications and topical pain creams can be helpful.
As a first step, I recommend that patients go ahead and try the over-the-counter food supplements, glucosamine and chondroitin. Each of these supplements has been independently shown, by studies presented at the national arthritis meeting in 1999, to relieve the pain and stiffness of some (but not all) patients with osteoarthritis. These supplements are available in pharmacies and health food stores without a prescription. If patients do not benefit after a two-month trial, I tell them that they may discontinue these supplements. The manufacturers sometimes make claims that these supplements "rebuild" cartilage. This claim has not been adequately verified by scientific studies to date.
Researchers found that glucosamine (in a radioactive form that could be identified in tissues) fed to Beagle dogs by mouth was detectable in the cartilage of their joints. I spoke with the author of this study, who interpreted the results to imply that glucosamine supplements taken by mouth actually can reach the cartilage of the joints. Perhaps, in future studies, glucosamine will be shown to not only provide some relief of symptoms (already reported in some patients), but also be shown to protect the joints affected by osteoarthritis. In fact, investigators at the National Institutes of Health are currently looking into whether or not taking glucosamine or chondroitin could actually improve or protect the quality of the cartilage in joints affected by osteoarthritis.
For another type of dietary supplementation, it should be noted that fish oils have been shown to have some anti-inflammation properties. Moreover, increasing the dietary fish intake and/or fish oil capsules (omega 3 capsules) can sometimes reduce the inflammation of arthritis.
Obesity has long been known to be a risk factor for osteoarthritis of the knee. I recommend weight reduction for patients with early signs of osteoarthritis of the hands who are overweight, because they are at a risk for also developing osteoarthritis of their knees.
Pain medications that are available over-the-counter, such as acetaminophen (Tylenol) can be very helpful in relieving the pain symptoms of mild osteoarthritis and I recommend these as the first medication treatment. Studies have shown that acetaminophen, given in adequate doses, can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis of the knees. Since acetaminophen has fewer gastrointestinal side effects than nonsteroidal antiinflammatory drugs (NSAIDS), especially in elderly patients, acetaminophen is generally the preferred initial drug given to patients with osteoarthritis. If symptoms persist, then I recommend trials of over-the-counter antiinflammatory drugs, such as ibuprofen (Advil, Motrin IB, Nuprin), ketoprofen (Orudis), and naproxen (Aleve). Many patients do best when they take these medications along with their glucosamine and chondroitin.
Some patients get significant relief of pain symptoms by dipping their hands in hot wax (paraffin) dips in the morning. Hot wax can often be obtained at local pharmacies or medical supplies stores. It can be prepared in a crockpot and be reused after it hardens as a warm covering over the hands by peeling off and replacing it into the melted wax. Warm water soaks and nighttime cotton gloves (to keep the hands warm during sleep ) can also help ease hand symptoms. Gentle range of motion exercising regularly can help to preserve function of the joints. These exercises are easiest to perform after early morning hand warming.
Pain-relieving creams that are applied to the skin over the joints can provide relief of daytime minor arthritis pain. Examples include capsaicin (Arthricare, Zostrix), salycin (Aspercreme), methyl salicylate (Bengay, Icy Hot), and menthol (Flexall). For additional relief of mild symptoms, local ice application can sometimes be helpful, especially towards the end of the day. Occupational therapists can assess daily activities and determine which additional techniques may help patients at work or home.
Finally, when arthritis symptoms persist, it is best to seek the advice of a doctor who can properly guide the optimal management for each individual patient. Many other prescription medications are available for the treatment of osteoarthritis for patients with chronic, annoying symptoms. And, if you are concerned that osteoarthritis could be associated with injury to internal organs-don't be. This disease does not cause internal organ damage or blood test abnormalities.
In addition to the steps described above, you should pay attention to joint problems elsewhere in your body if you develop early signs and symptoms of osteoarthritis of the hands.
What does the future hold for osteoarthritis?
In the future, medications may be available which protect the cartilage from the deteriorating consequences of osteoarthritis. New treatments, including an antiinflammatory lotion, diclofenac (Pennsaid) are being studied for the relief of the pain of osteoarthritis.
Recently, surgical innovation has led to a technique for the repair of isolated splits of cartilage (fissures) of the knee. In this procedure, a patient's own cartilage is actually grown in the laboratory, then inserted into the fissure area and sealed over with a "patch" of the patient's own bone covering the tissue. While this is not a procedure for the cartilage damage of osteoarthritis, it does open the door for future cartilage research. These and other developing areas hold promise for new approaches to an old problem.
Investigators at the National Institutes of Health are currently looking into whether or not taking glucosamine or chondroitin could actually improve or protect the quality of the cartilage in joints affected by osteoarthritis. - Osteoarthritis is a joint inflammation that results from cartilage degeneration.
- Osteoarthritis can be caused by aging, heredity, and injury from trauma or disease.
- The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use.
- There is no blood test for the diagnosis of osteoarthritis.
- The goal of treatment in osteoarthritis is to reduce joint pain and inflammation while improving and maintaining joint function.
For further information about osteoarthritis, please visit the following site:
Arthritis Foundation (www.arthritis.org)
For additional information contact:
Arthritis Foundation
P.O Box 19000
Atlanta, Georgia 30326
or contact your local chapter
National Arthritis and Musculoskeletal and Skin Diseases Clearinghouse
Box AMS
Bethesda, Maryland 20892
301-495-4484
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