Wear and tear of joints at a glance
By Dr. Himantha Atukorale
MBBS (Colombo), MD Consultant in
Joint Disease and Rehabilitation
"An old lady is struggling to stand up from a seated position. Even after standing, her grimace of pain says it all. She has unbearable knee joint soreness. The lady is fidgety with a walking stick. Her fingers are swollen over the joints, making it even more difficult to firmly grip the handle. The legs are bowed at the knees – what we call 'bow legs' is evident even from a distance."
What is the underlying cause of knee pain, and what affects the hands and other joints simultaneously to create generalized joint pain? How does the body select certain joints, damage them, and spare some of the most weight-bearing joints like the ankles?
This is a condition called osteoarthritis, which is the most common type of arthritis out of nearly a hundred different types of diseases affecting the joints. We believe that osteoarthritis is the key joint disease among Sri Lankans although nationwide surveys have never been done. Osteoarthritis is quite a common occurrence at our joint clinics. This is also known as wear and tear arthritis, although research has shown lately that it's not just that.
Who gets osteoarthritis?
The following categories of people are at risk of developing osteoarthritis: Females, people who are 40 years or above, those who have had fractures or injuries in the joints, people with a familial tendency to have osteoarthritis (hereditary), overweight people, people who do jobs that put too much strain on the joints, people with other joint diseases like rheumatoid arthritis.
How do you feel osteoarthritis?
This is important to know as not all patients might feel severe pain from within the joint. Pain is the most common symptom, especially pain that is felt immediately after prolonged periods of rest, for example, after sitting down for half an hour, and pain that becomes worse at the end of the day. It could become so severe that it might even prevent the patient from falling asleep.
Another symptom might be stiffness, which again is felt after prolonged periods of rest. Stiffness might prevent you from moving your joints properly. Some patients recalled instances where they had to put more effort in order to move that particular joint.
Swelling is also a common symptom. There are several types of swelling that we observe. Certain joints get swollen when joint fluid collects inside a small space called the joint cavity. This fluid swelling increases the pressure within the joint, and as a result the skin bulges out. There is also a bony swelling which occurs because of bone fragments called osteophytes. Unlike fluid swelling, this can be felt when the affected area is pressed.
The crackling sensation or bone grinding feeling is called crepitus. Crepitus is also felt by patients in most instances. This happens when you move your joint.
Do note that even healthy individuals might feel a bit of crepitus. Crepitus alone doesn't always mean that you have osteoarthritis.
How is osteoarthritis evaluated?
The rheumatologist will first of all test how severe the osteoarthritis is, especially in the weight-bearing joints like the hips, knees, and ankles. The evaluation includes a detailed history and a complete examination of not just the joints that are affected, but the healthy ones as well. During the examination, you might be asked to perform certain joint movements or the specialist might do them passively.
Then, sometimes, the consultant might order certain blood tests to see whether there is a bit of inflammation coming from within the joint. Inflammation is swelling related to increased blood supply to a certain part of your body. They might also order X-rays to see how well the bony architecture is preserved. Joint ultrasound scans are very useful as well.
Rarely, we order special imaging like Computerized Tomography (CT) scans and Magnetic Resonance Imaging (MRI) scans to have a more clear view of the joint damage, which is not visible on conventional images.
How can osteoarthritis be managed/treated?
Whenever I tell people who have osteoarthritis, that fifty per cent of the cure is achieved by the patient himself/herself, they shake their head in disbelief. Here in Sri Lanka, patients expect the rheumatologist to cure them 100 per cent, whereas in developed countries 'self-help' plays a major role in 'controlling' arthritis.
Most of the proven treatment strategies are patient-based ones and the rheumatologists simply guide them. It is a fact that joint protection strategies and exercise can ease off the pain completely.
There are several types of medication which help patients control the symptoms of osteoarthritis. Out of these, painkillers play a major role. Starting from ointments, paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and there are occasions where we even prescribe opioid analgesics for severe pain. Certain drugs which relax the muscles also help.
Joint injections consist of a mixture of steroids and pain relieving medication. Injections are very useful in rapidly bringing down the swelling and providing great relief.
New methods of controlling symptoms
There are more than ten different new methods of treating osteoarthritis. As I stated previously, joint protection strategies are useful in preventing further damage. We use braces/guards/splints that are worn over joints to control unwanted movement.
Again, these come in several different types and sizes. We also recommend supports to be worn with your footwear.
Muscle strengthening, if properly done, protects the joint that lies underneath. There is evidence that suggests that this might even halt the joint from getting deformed. Aerobic exercises, cycling, and swimming are very useful in treating osteoarthritis.
There is evidence that suggests that even Tai chi, which is all about gradual limb movements while maintaining body balance alleviates joint pain.
Transcutaneous electrical nerve stimulation (TENS) therapy, which involves applying an electrical impulse over the affected joints, is very popular in Western countries. Guided physiotherapy also helps reduce symptoms of osteoarthritis.
Certain nutritional supplements like glucosamine and chondroitin, which are compounds that are normally found in joint cartilage, may improve the health of damaged cartilage according to a few studies.
Weight reduction has been known to improve pain, especially in the weight-bearing joints.
Sometimes, patients with osteoarthritis need early referral to orthopaedic surgeons for joint operations. There are numerous surgical methods of treating worn out joints and the patient needs to decide what is best for him/her.
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