Arthritis: Not Just "Wear and Tear"
Okay, so I said I would save this for a rainy day. But it hasn’t rained in over a week! So, pull up a chair, this isn’t a quick one, and let’s talk about arthritis! There are many different kinds of arthritis. Some are autoimmune-related (your immune system starts to attack the joint leading to destruction), like rheumatoid arthritis. Some are related to other conditions such as psoriasis or inflammatory gastrointestinal conditions, and some are run of the mill “wear and tear” of the joint over time (osteoarthritis). In this post, I will be talking strictly about osteoarthritis and I will refer to it as simply arthritis from here on out. Arthritis is one of the leading causes of disability and societal costs, particularly in ageing and obese populations. Because of this, it has become important to have a better understanding of what it is, why it seems to affect some more than others and what to do about it. I’m sure if you or someone you know has dealt with or is dealing with arthritis, you also understand why it’s so important to understand what it is and what to do about it.
What Is It?
Arthritis is a slow progressive disease of the whole joint. It involves irreversible structural changes to the cartilage, the bone immediately under the cartilage, ligaments, capsule (surrounds the joint), synovial membrane (lining of the capsule that produces joint lubrication) and the muscles surrounding the joint. The knee is the most common site, followed by the hand and the hip. It is also most likely to “happen” between 50 to 75 years of age (if you look at the graph, you will see the slope of the line is steeper between about 50 to 75 years). Why is happen in quotation marks? Because arthritis isn’t something that occurs in a moment, it is something that develops and progresses over years. So, while arthritis develops over time, it is most likely to cause you pain between 50 and 75 years old.
Most people find out they have arthritis because they complain of joint pain or stiffness and get x-rays which show some type of degeneration of the joint. The problem is that x-ray findings of arthritis are more common than pain associated with arthritis. In other words, you could be walking around today with arthritis and not know it. That is actually more common than someone who has arthritis and has pain! So basically…
You can have arthritis and NO pain…
You can have arthritis AND pain…
You can NOT have arthritis and HAVE pain…
Or you can NOT have arthritis and NOT have pain (you want to be this guy).
What's A Joint?
Before we go any further, it’s important to understand the various structures of a joint. The different structures, how they change with age and how they respond to changes is important in how arthritis develops and may tell us more about who will have pain and who will not. I’ve already mentioned a few structures, so if you’re already lost, hopefully this clears some things up. Two bones come together to create a joint. The two surfaces that face each other are covered by cartilage. The joint is surrounded by a strong ligamentous capsule, which is lined with a synovial membrane. The synovial membrane produces synovium, the equivalent of lubrication for the joint. Muscles (not pictured here) attach to bones on either side. When muscles contract they move the bones and create movement at the joint. Muscles also act as the strongest support for the joint, reducing the stress that the surfaces experience.
How Does It Happen?
For a long time, it was thought that the continuous “wear and tear” of a joint would lead to arthritis. It is something that is logical to most of us, because you would expect the more you use something, the more likely it is to break down. The trouble with that thinking is we are not inanimate objects. Our body has processes in place to ensure that when we use something often, it gets stronger and the structures that are stressed are replenished.
What we are starting to learn is that arthritis develops through a very complicated process that MAY (it can, but not always) include mechanical factors, like forces that go through the joint from movement and activity, metabolic factors, which is influenced by the health of the person and how their systems and cells function, and inflammatory factors. Inflammatory factors can vary and be influenced by the general health of the person as well, such as obesity, diabetes or other chronic conditions.
Arthritis eventually comes down to structural destruction and failure of the joint. The old thinking of wear and tear of the joint has evolved to include a more active process where there is an imbalance between repair and destruction of joint tissues. For example, part of this process is a change in the cartilage properties which makes it more susceptible to breakdown by physical forces. The cartilage cells and synovial cells (cells that line the joint capsule and produce lubrication) of the joint try to repair the joint, but in doing so also release inflammatory products. The bone underlying the cartilage also tries to remodel and repair which results in lesions in the bone just below the cartilage lining. So, there is no one thing that leads to arthritis, a wide range of different pathways (inflammation, mechanical overload, metabolic changes and aging cells) lead to similar outcomes of joint destruction.
So why does arthritis happen when you’re older? The whole wear and tear story seemed to match well with that…
Well, the development of arthritis is now thought to happen because of cumulative exposure to risk factors and the changes that happen to the joint over time. Cumulative means that the impact that something has on the development of arthritis adds on to previous and other factors.
For knee arthritis, risk factors include:
Having a previous knee injury
Poor knee alignment
Weak knee extensor (quad) muscles
Now, for hip arthritis, actual bone deformities like cam deformity or acetabular dysplasia can increase the risk of arthritis. These bone deformities lead to changes in force distribution across the joint with certain areas experiencing higher forces and others less force.
Heavy work activities, such as farming or construction, can be risk factors for both hip and knee arthritis and work that involves frequent kneeling and heavy lifting is associated with knee arthritis.
High impact sports such as football, hockey, wrestling and long-distance running can be associated with increased risk of hip or knee arthritis, usually with a dose-response, meaning the more you do it, the more it is associated. Some of these sports can be risk factors because of the increased risk of injury, such as a meniscal tear or ligament injury. We know that major injuries of this kind are associated with an increased risk of arthritis.
Genetics can also contribute to arthritis, but more commonly in the hip and hands than in the knee.
Now, remember I said that not everyone with arthritis will have pain. Having one or more chronic diseases, such as diabetes or cardiovascular disease are predictive of faster worsening pain or deterioration. As arthritis continues to develop, the cause of pain can evolve from structural changes in the nerves of the joint or from nerves in the spinal cord. The brain becomes more sensitive to pain but this sensitivity is not associated with changes in the joint structure (as shown on x-ray), how severe your symptoms are, or how long you’ve been having pain. The increasing sensitivity of your brain to pain seems to be related to inflammation of the synovial lining and swelling of the knee as a result of increased synovial fluid production.
Diagnosing arthritis is still a clinical decision. That means it is dependent on the patient’s description of pain and their experience and the clinician’s physical assessment. Signs and symptoms of arthritis include morning stiffness, reduced range of motion, crackling/grinding of joints, bony enlargement, buckling or giving way of the joint, swelling, muscle weakness, fatigue and distress associated with pain. Whenever we have pain, we believe that getting imaging will give us answers. I get it, you want to see what is hurting you! However, in the case of arthritis there aren’t great associations between what you see on x-rays and the pain you are feeling. It doesn’t do much to tell us who will or won’t have pain. It also doesn’t do much to tell us whether your pain is because of arthritis. That also doesn’t mean there is no place for x-rays. X-rays can show us how severe arthritis is, and in some cases, after a trial of therapy, a referral for other options like injections or surgery may be warranted so knowing what you’re dealing with can be helpful in that situation.
Most of the time people can manage with pain that comes and goes or that happens when they’re weight-bearing on the joint. However, it is when it becomes more severe, frequent or unpredictable that people tend to experience more distress associated with their pain. If you think you might have arthritis, is important to see a clinician who can assess what’s going on and provide you with information on what to do next.
What To Do About It
Arthritis needs early and proactive management. It’s important to know that your symptoms can often be helped significantly without surgery. I will primarily be discussing the physical based approaches to arthritis management but I will touch briefly on the first-line pharmacological (drug) options for management. The American College of Rheumatology (ACR) and the Arthritis Foundation published an awesome article providing guidelines for the management of hand, hip and knee arthritis. This, in combination with the guidelines published by the Osteoarthritis Research Society International is what I am using to make suggestions. Both of these guidelines agree on the appropriate management of arthritis.
Exercise is strongly recommended, including aerobic and strength training. Remember… muscles reduce the stress that the joint experiences and exercise makes muscle stronger. The hardest part about exercise is compliance. It only helps if you do it, so you need to consider what your preference for exercise is and what you have access to. The specifics of exercise prescription are at the discretion of the treating practitioner. There is no predetermined level of pain which is deemed acceptable during exercise, so this must be based on a discussion between the practitioner and the patient. Remember… even people with pain and limitations due to arthritis have symptom improvement with exercise. Pain is not always a reason to avoid exercise!
When we talk about risk factors for developing arthritis, I mentioned knee injuries such as meniscal tears or ligament injuries. For active people and athletes, you should consider what you can do to prevent these major injuries and therefore reduce your risk of future arthritis. Neuromuscular training programs in high-injury sports, such as soccer and basketball, can reduce knee injuries by 45-83%!
Weight loss is strongly recommended. There is a dose response associated with the amount of weight loss and symptomatic or functional improvement. Weight loss of more than 5% body weight can be associated with changes, but benefits continue with weight loss up to greater than 20% of body weight. The efficacy of weight loss for managing arthritis symptoms is enhanced by also including an exercise program.
The use of a cane is strongly recommended for patients with knee or hip arthritis and knee braces are strongly recommended for knee arthritis where there is a large impact on being able to walk, joint stability or pain. Braces for the patellofemoral joint (knee cap) are only conditionally recommended because of variability in results. With regards to the hand, a brace or support for the thumb joint is recommended, but has not been shown to be helpful for other joints of the hand.
Acupuncture is only conditionally recommended for arthritis of the knee, hip or hand because of the variability in results.
As good as it is to know what to do, it’s also important to know what to avoid. There are recommendations AGAINST modified shoes and wedged insoles to alter the biomechanics of the lower limb and the use of transcutaneous electrical stimulation (TENS). There are also conditional recommendations against the use of massage therapy and manual therapy.
I know there is a lot of information here, so just to remind you… all of these recommendations are from the ACR guideline. Now, while it falls outside of my scope of practice, I would like to briefly touch on topical and oral NSAIDs because they are over-the-counter drugs and injections because they are often recommended. These are anti-inflammatories that can be applied directly to the skin or taken orally. Topical NSAIDs are strongly recommended for patients with knee arthritis and conditionally recommended for patients with hand arthritis. Because the hip joint is so deep and there are so many layers of muscles between the skin and bone, topical NSAIDs are unlikely to work for hip arthritis. Oral anti-inflammatories are strongly recommended for patient’s hip knee, hip or hand arthritis and is the first-line of treatment when it comes to arthritis. If this is something you would like to try, make sure to talk to your doctor about the options including how much and how often you should be using it.
Other treatment options you may see for the treatment of arthritis include intraarticular corticosteroids or intraarticular glucocorticoid injections. The benefit of corticosteroids remains unclear; however, it appears that patients with more severe pain respond better. Glucocorticoid injections are conditionally recommended particularly over other types of injections such as hyaluronic acid. That being said, if you are considering these options it is important to ask your doctor or orthopaedic surgeon!
I really like this graphic from the ACR which summarizes which physical interventions they recommend. In dark green are the strong recommendations from high quality research, in light green are weaker recommendations based on more variable results in studies.
Arthroscopic knee surgery is a less invasive form of surgery where they put a scope through small holes in the knee and “clean up” the joint. It is widely used for the management of knee arthritis, but there is no good evidence of efficacy. Actually, a number of studies show that it has minimal benefit (if any) and there is a risk of harm compared to sham (fake) surgeries or less invasive treatments. This evidence is true for both arthritis and degenerative meniscal tears. The exception is an arthroscopic partial meniscectomy in people with knee locking (unable to fully extend the knee). In this case, they are removing part of the meniscus that is causing locking or a movement block in the knee. It is important to note that meniscectomy, whether partial or full, can increase the speed at which arthritis progresses. In general, arthroscopy increases the risk and shortens the time to joint replacement.
There are definitely cases where surgery might be needed. Generally, patients with end-stage arthritis can be considered for surgery if all conservative options have been tried for 6 months and have been unsuccessful. Surgery can also be considered when quality of life is greatly reduced because of end-stage arthritis, such as joint pain that disrupts your normal sleep patterns, severe reduction in walking distance and marked restriction of daily activities.
This post is intended to be informative! It in no way replaces a full assessment by a licensed healthcare professional or is intended to act as medical advice. If any of this resonates with you or if you have further questions, I strongly recommend you follow up with a professional who can give you an individualized assessment and advice regarding what you’re experiencing!
Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr Cartil. 2019;27(11):1578-1589. doi:10.1016/j.joca.2019.06.011.
Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745-1759. doi:10.1016/S0140-6736(19)30417-9.
Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res. 2020;72(2):149-162. doi:10.1002/acr.24131.
About The Author
Dr. Melissa Corso has an undergraduate degree in biomedical sciences and a Masters degree in human health and nutritional sciences from the University of Guelph and was a former Varsity soccer player. She graduated from the Canadian Memorial Chiropractic College (CMCC) in 2016 and completed the Sports Science residency in 2018. In 2019 she became a fellow of the Royal College of Chiropractic Sports Sciences (Canada). Dr. Corso is in private practice at an inter-disciplinary clinic in Richmond Hill, Ontario and a research associate at the Centre for Disability Prevention and Rehabilitation at Ontario Tech and CMCC. In her spare time, she enjoys working out, playing soccer and reading.