Disease, Illness and Condition Library
Osteoarthritis Osteoarthritis (previously known as degenerative arthritis, degenerative joint disease) is a chronic disorder of joint cartilage and surrounding tissues that is characterized by pain, stiffness, and loss of function. Osteoarthritis, the most common joint disorder, affects most people to some degree by the age of 70. Before the age of 40, men develop osteoarthritis more frequently than do women, mainly because of injury. From age 40 to 70, women develop the disorder more frequently than do men. After age 70, the disorder develops in both sexes equally. Osteoarthritis also can be observed in almost all animals with a backbone – including fish, amphibians, and birds. Because the disorder is so common in the animal kingdom, some authorities believe that osteoarthritis may have evolved from an ancient method of cartilage repair. Many myths about osteoarthritis exist – for example, that it is an inevitable part of aging, like gray hair and skin changes; that it results in little disability; and that treatment is not effective. Although osteoarthritis is more widespread in older people, it is not caused simply by the wear and tear that occurs with years of use. Instead, microscopic changes in the structure and composition of cartilage appear to be to blame. Most people who have the disorder, particularly younger people, have few if any symptoms; however, some older people develop considerable disabilities. Causes Normally joints have such a low friction level that they are protected from wearing out, even after years of use. Osteoarthritis probably begins most often with an abnormality of the cells that synthesize the components of cartilage, such as collagen (a tough, fibrous protein in connective tissue) and proteoglycans (substances that provide resilience). Next, the cartilage may swell because of water retention, become soft, and then develop cracks on the surface. Tiny cavities form in the bone beneath the cartilage, weakening the bone. Bone can overgrow at the edges of the joint, producing bumps (osteophytes) that can be seen and felt. Eventually, the smooth, slippery surface of the cartilage becomes rough and pitted, so that the joint can no longer move smoothly and absorb impact. All the components of the joint – bone, joint capsule (tissues that enclose most joints), synovial tissue (tissues lining the joint), tendons, ligaments, and cartilage – fail in various ways, thus altering the joint. Osteoarthritis is classified as primary (or idiopathic) when the cause is not know (the large majority of cases). It is classified as secondary when the cause is another disease or condition, such as Paget’s disease, an infection, deformity, injury, or overuse of a joint. Some people who repetitively put stress on joint or a group of joints, such as foundry workers, coal miners, and bus drivers, are particularly at risk. Much of the risk for osteoarthritis of the knee comes from occupations that involve bending of the joint. Remarkably, long distance running champions appear not to be at higher risk of developing the disorder. However, once osteoarthritis develops, this type of exercise often makes the disorder worse. Obesity may be a major factor in the development of osteoarthritis, particularly of the knee and especially in women. Symptoms In most cases symptoms develop gradually and affect only one or a few joints at first. Joints of the fingers, base of the thumbs, neck, lower back, big toes, hips, and knees are frequently affected. Pain, is usually made worse by activities that involve weight bearing activity (such as standing), and is the first symptom. In some people, the joint may be stiff after sleep or some other inactivity, but the stiffness usually subsides within 30 minutes of moving the joint. As the condition produces more symptoms, the joint may become less movable and eventually may not be able to fully straighten or bend. The attempt of the tissues to repair may lead to new growth or cartilage, bone, and other tissue, which can enlarge the joints. The irregular cartilage surfaces cause joint to grind, grate, or crackle when they are moved. Bony growths often develop in the joints at the ends or middle of the fingers (known as Heberden’s or Bouchard’s nodes). In some joints (such as the knee), the ligaments that surround and support the joint stretch, so that the joint becomes unstable. Alternatively, the hip or knee may become stiff, losing their range of motion. Touching or moving the joint (particularly when standing, climbing stairs, or walking) can be very painful. Osteoarthritis regularly affects the spine. Back pain is the most common symptom. Usually, damaged disks or joints in the spine cause only mild pain and stiffness. However, osteoarthritis in the neck or lower back can cause numbness, pain, and weakness in an arm or leg if the overgrowth of bone presses on nerves. The overgrowth of bone may be within the spinal canal, pressing on nerves before they exit the canal to go to the legs. This may cause leg pain after walking; suggesting incorrectly that the person has a reduced blood supply to the legs (intermittent claudication). Rarely, bony growths compress the esophagus, making swallowing difficult. Osteoarthritis may be stable for many years or may progress very rapidly, but most often it progresses slowly after symptoms develop. Many people develop some degree of disability. Diagnosis The doctor makes the diagnosis based on the characteristic symptoms, physical examination, and the x-ray appearance of joints (such as bone enlargement and narrowing of the joint space). By age 40, many people have some evidence of osteoarthritis on x-rays, especially in weight bearing joints such as the hip and knee, but only 50% of these people have symptoms. However, x-rays are not very useful for detecting osteoarthritis early because they do not show changes in cartilage, which is where the earliest abnormalities occur. Also, changes on the x-ray correlate poorly with symptoms. For example, and x-ray may show only a minor change while the person is having severe symptoms, or an x-ray may show numerous changes while the person is having very few, if any, symptoms. Magnetic resonance imaging (MRI) can expose early changes in cartilage, but it is rarely needed for the diagnosis. Also, MRI is too expensive to justify routine use. There are no blood tests for the diagnosis of osteoarthritis, although blood tests may help rule out other disorders (such as rheumatoid arthritis). Treatment Appropriate exercises – including stretching, strengthening, and postural exercises – help maintain healthy cartilage, increase a joint’s range of motion, and strengthen surrounding muscles so that they can absorb shock better. Exercise must be balanced with rest of painful joints, but immobilizing a joint is more likely to worsen osteoarthritis than to improve it. Using very soft chairs, recliners, mattresses, and car seats may worsen symptoms; using care seats moved forward, straight backed chairs with relatively high seats (such as kitchen or dining room chairs), firm mattresses, and bed boards (available at many lumber yards) is often recommended. For osteoarthritis of the spine, specific exercises sometimes help, and back supports or braces may be needed when pain is severe. Exercises should include both muscle strengthening as well as low impact aerobic exercises (such as walking, swimming, and bicycle riding). If possible, the person should maintain normal daily activities and continue to perform his or her regular activities, such as a hobby or job. However, physical activities may have to be modified to avoid bending and thus aggravating the pain of osteoarthritis. Physical therapy, often with heat therapy, can be helpful. Heat improves muscle function by reducing stiffness and muscle spasm. Cold may be applied to reduce pain. Splints or supports (such as a cone, crutch, brace, or even a walker) can protect specific joints during painful activities. Shoe inserts (orthotics) may help reduce pain from walking. Massage by trained therapist, traction, and deep heat treatment with diathermy or ultrasound may be useful. Drugs are used to supplement exercise and physical therapy. Drugs, which may be used in combination or individually, do not directly change the course of osteoarthritis; they are used to reduce symptoms and thus allow more suitable exercise. A simple pain medicine (analgesic), such as acetaminophen, may be all that is needed. Alternatively, a nonsteroidal anti-inflammatory drug (NSAID) may be taken to reduce pain and swelling. NSAIDs reduce pain and inflammation in joints. The cyclooxygenase-2 (COX-2) inhibitors (coxibs) provide relief equal to the other NSAAIDs but may have fewer gastrointestinal side effects. People at risk for gastrointestinal problems may prefer them. Sometimes other types of pain medicine may be needed, such as a skin cram derived from cayenne pepper – the active ingredient in capsaicin – which is applied directly to the skin over the joint. This treatment may provide only short term relief, and a joint treated with cortisone should not be used too often or damage may result. A series of injections of hyaluronate (a component of normal joint fluid) into the joint may provide significant pain relief in some people for prolonged periods of time. Several nutritional supplements (such as those containing glucosamine and chondroitin sulfate) are being tested for potential benefits in osteoarthritis and results seem to be positive thus far. Surgery may help when all other treatments fail to relieve pain. Some joints, most commonly the hip and knee, can be replaced with an artificial joint; replacement is usually very successful, almost always improving motion and function and dramatically decreasing pain. Therefore, joint replacement should be considered when function becomes limited. Because the artificial joint does not last forever, such surgery is often delayed as long as possible in young people so the need for repeated replacements can be minimized. A variety of methods that restore cells inside cartilage have been used in younger people with osteoarthritis to help heal small defects in cartilage. However, such methods have not yet been proved valuable when cartilage defects are extensive, as commonly occurs in older people.
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