It’s important to distinguish between the different causes of chronic pain, as that may determine the recommended intervention. This week, we’ll review one common cause of chronic pain, Osteoarthritis. We’ll continue this series of posts for the next several weeks, discussing other potential causes of chronic pain (check back every Friday!).
Osteoarthritis (OA) or Degenerative Joint Disease (DJD):
DJD results from the breakdown of joint cartilage and the underlying bone. It’s often known as the “wear and tear” arthritis because the natural shock absorbers between the joints, the cartilage, wears away until you have bones of the joints rubbing against one anther. This causes pain, swelling, stiffness, and in some cases, loss of motion. In the beginning you might only feel pain when you exercise or stress the joint, but over time it can progress and become constant. The fingers, base of the thumb, lower back, knees and hips, often unilaterally, are the most likely to be involved. Unlike other types of arthritis, only the joints are typically affected, not other organs. Hands can develop knobby lesions in the middle joint called Bouchard Nodes and at the most distal digits called Herberdens Nodes. In the following photo, Bouchard Nodes are labeled “B,” and the Herberdens Nodes are labeled “H”.
Photo Credit:
http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/Family%20Medicine/Degenerative_joint_disease.htm
Thumbs are often affected especially at the MCP joint, metacarpal phalangeal joint, as it enters the palm. Too often, we pick up items with our thumbs, forcing them to take the full brunt of the weight being lifted. Ladies, think about those gorgeous, heavy shoulder bags we use that hold everything but the kitchen sink! Heaven forbid we leave anything we might possibly need at any time throughout the day, at home. We constantly pick it up by the strap with our hand, and rotating the arm, throw it onto the shoulder. As we drop it, for a moment, the brunt of the entire weight is solely on the thumb. Or men, what about when you sling that backpack over your arm? Or when we lift briefcases or bottles of milk- too often, the thumb is taking the primary load. Over time this stresses the joint, causing a breakdown and pain. Small changes of rotating the hand, so that the entire hand and fingers hold the items while the thumb is used to enclose and guide the item, can make a huge difference over time and limit the progression of degeneration. Next time think about lifting with your thumb up, not thumbs down!
Osteoarthritis is believed to be due to mechanical stress on the joints and a low-grade inflammation.
It’s the most common form of arthritis and increases in occurrence after the age of 45. According to the Arthritis Foundation, more than 27 million people in the US have osteoarthritis, most commonly in the knee, with a higher rate among women than men. Causes range from excess weight, genetics, gender, repetitive stress injury’s, athletics, and trauma. Pain is the most common symptom, usually worse later in the day, along with swelling, creaking of the joint and stiffness after long periods of inactivity. In severe osteoarthritis, the cartilage between the joint becomes stiff and loses its elasticity, making it more susceptible to injury. As the cartilage wears down, it can no longer act as a shock absorber, allowing the joint to deteriorate to “bone on bone” and even grow bone spurs. These can impinge on nerves, tendons and ligaments, increasing the distribution of pain.
Symptoms can vary. Some people may have dramatic degenerative joint disease on x-rays, but little or no symptoms. Others can be debilitated. Osteoarthritis of the knees is most associated with obesity or a history of injury or joint surgery. Osteoarthritis of the spine can cause pain in the neck or low back with bony spurs that can irritate spinal nerves, causing severe pain, along with numbness and tingling in the affected body parts of the arms or legs. We all know the most classic osteoarthritis- the base of the big toes which leads to the formation of bunions.
Activities that cause impact on the painful joints, such as jogging, can exacerbate symptoms and increase the damage. Low-impact sports are preferable, such as biking elliptical, and swimming. Wrapping the affected area can give added support as well as provide warmth, encouraging better circulation. Recommended treatments include: topical creams, physical therapy to decrease inflammation and improve range of motion, weight loss, activity, and Tylenol. Anti -inflammatories, such as Motrin and Aleve, should be used cautiously and under a healthcare providers direction. Opioids and pain medicines are used as a last resort, for as brief a period as possible, and under close supervision. Ultimately, when the pain interferes with daily activities, surgical intervention may be the answer i.e. knee and/or hip replacements.
Steroid pills and injections can be used to diminish inflammation at the source up to three times a year, often providing relief for months or longer. When I was in a moped accident 20 years ago, I injured my knee. Nothing I did made it better. One day a friend of mine who is an orthopedic surgeon walked into my practice with a needle, that I swear was 10 inches long, and demanded I go into one of my exam rooms so he could help me. After I got over the shock, I let him inject me. I haven’t had pain in that knee since. According to the American Family Physician Journal (4/15/18), hyaluronic acid injections, once touted as offering relief for months, are not effective for OA.
Erosive osteoarthritis or erosive changes seen on radiographs may require a rheumatological evaluation. Different treatment options can be explored, pinpointing which would be most beneficial in preventing the erosive changes that can eat the bone away, causing severe damage. Simple radiographs can confirm the diagnosis of osteoarthritis, erosive changes, and the degree of damage often helpful in deciding if a surgical or rheumatological referral is appropriate.
Laboratory studies, radiographs and a thorough examination with your provider will help determine if some other process is involved such as gout, stress, compression fractures, or trauma. It is important to rule out underlying connective tissue diseases, such as rheumatoid arthritis, lupus arthritis, and psoriatic arthritis, since they may be treated differently.
You may think this is just an old person’s disease or problem, but in many cases, when intermittent pain in a particular area persists over time, osteoarthritis should be ruled out with an exam and simple x-ray.
I’m a great example. I had no idea that my neck looked like it belonged to a 90-year-old with significant multilevel degenerative changes as you can see in the following picture (first photo) and marked narrowing of spaces between the vertebral bodies, spurring and straightening of my neck due to muscle spasms.
Apparently, the combination of genetics and lifestyle was too much for me. The second photo is my neck after several fusions. Decades of constant impact sports like gymnastics, horseback riding, jogging, downhill skiing, and jumping out of airplanes was too much for my neck and lower spine. Over the years it added up, causing degenerative changes far greater than I ever knew existed. Yes, I had chronic intermittent pain in the neck and shoulder blades for decades, but I always attributed this to stress over work, muscle strains and sprains from exercising, tension. . . You know, every day life. One day, I was rock climbing when I pulled up with my left arm and felt an immediate, excruciating, sharp, stabbing pain from my neck, radiating into my left arm. I was only in my 40’s, but my first thought was “I’m having a heart attack!” After an intense, thorough evaluation ruled out life threatening issues like cardiovascular disease, a herniated disc impinging on a nerve into the arm was found to be the the culprit. But more concerning was the severe degenerative changes seen in my neck that clearly had been there for years.
If I had known my neck was predisposed to injury, I could’ve adjusted my activities accordingly. I would’ve changed to lower impact sports long ago. Instead, it wasn’t until after almost a dozen surgeries that I realized my runners high was out and the elliptical was in. Lifting was no longer an option, especially at or above shoulder level because it increases stress on the neck, and only light amounts of weight, such as 2-3 pounds was recommended to keep me toned- not heavy barbells. Many yoga and Pilates positions are killers for someone like me. “Cracking” my neck, as a friend offered, could have impacted my spinal cord had I agreed! If I’d checked out my pain earlier, had that x-ray sooner, who knows how many surgical interventions I may have been spared.
Knowledge can make all the difference in the world. Listen to your body. Listen to your pain. Talk to your provider and explain your symptoms and get a thorough exam so together you can decide the best course of action to limit future deterioration and improve the quality of your life.
-Dr. Courtney
Header photo credit:
Supplemental information provided by:
-JAMA (Journal of American Medical Association)
-American Family Physician Journal 4/15/18