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Osteoarthritis (OA)

(Degenerative Arthritis; Degenerative Joint Disease; Osteoarthrosis)

By Apostolos Kontzias, MD, Assistant Professor of Medicine and Director, Autoinflammatory Clinic, Cleveland Clinic Foundation

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Osteoarthritis is a chronic disorder associated with damage to the cartilage and surrounding tissues and characterized by pain, stiffness, and loss of function.

  • Arthritis due to damage of joint cartilage and surrounding tissues becomes very common with aging.

  • Pain, swelling, and bony overgrowth are common, as well as stiffness that follows awakening or inactivity and disappears within 30 minutes, particularly if the joint is moved.

  • The diagnosis is based on symptoms and x-rays.

  • Treatment includes exercises and other physical measures, drugs that reduce pain and improve function, and, for very severe changes, joint replacement or other surgery.

Osteoarthritis, the most common joint disorder, often begins in the 40s and 50s and affects almost all people to some degree by age 80. Before the age of 40, men develop osteoarthritis more often than do women, often because of injury. Many people have some evidence of osteoarthritis on x-rays (often by age 40), but only half of these people have symptoms. From age 40 to 70, women develop the disorder more often than do men. After age 70, the disorder develops in both sexes equally.

Osteoarthritis is classified as

  • Primary

  • Secondary

In primary (or idiopathic) osteoarthritis, the cause is not known (as in the large majority of cases). Primary osteoarthritis may affect only certain joints, such as the knee, or many joints.

In secondary osteoarthritis, the cause is another disease or condition, such as

  • An infection

  • A joint abnormality that appeared at birth

  • An injury

  • A metabolic disorder—for example, excess iron in the body (hemochromatosis) or excess copper in the liver (Wilson disease)

  • A disorder that has damaged joint cartilage—for example, rheumatoid arthritis or gout

Some people who repetitively stress one joint or a group of joints, such as foundry workers, farmers, coal miners, and bus drivers, are particularly at risk. The major risk factor for osteoarthritis of the knee comes from having an occupation that involves bending the joint. Curiously, long-distance running does not increase the 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.

Causes of Osteoarthritis

Normally, joints have such a low friction level that they are protected from wearing out, even after years of typical use, overuse, or injury. Osteoarthritis is caused most often by tissue damage. In an attempt to repair a damaged joint, chemicals accumulate in the joint and increase the production of 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.

The attempt of the tissues to repair the damage may lead to new growth of cartilage, bone, and other tissue. Bone can overgrow at the edges of the joint, causing bumps (osteophytes) that can be seen and felt. Ultimately, 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 (tissue lining the joint cavity), tendons, ligaments, and cartilage—fail in various ways, thus altering the function of the joint.

Symptoms of Osteoarthritis

Usually, osteoarthritis 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 commonly affected.

Pain, often described as a deep ache, is the first symptom and, when in the weight-bearing joints, is usually made worse by activities that involve weight bearing (such as standing). In some people, the joint may be stiff after sleep or some other inactivity, but the stiffness usually subsides within 30 minutes, particularly if the joint is moved.

As the condition causes more symptoms, the joint may become less movable and eventually may not be able to fully straighten or bend. New growth of cartilage, bone, and other tissue can enlarge the joints. The irregular cartilage surfaces cause joints to grind, grate, or crackle when they are moved and tenderness develops.

Bony growths commonly develop in the joints closest to the fingertips (called Heberden nodes) or middle of the fingers (called Bouchard nodes).

In some joints (such as the knee), the ligaments, which surround and support the joint, stretch so that the joint becomes unstable. Alternatively, the hip or knee may become stiff, losing its range of motion. Touching or moving the joint (particularly when standing, climbing stairs, or walking) can be very painful.

Osteoarthritis often 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 in the lower back (lumbar spinal stenosis), pressing on nerves before they exit the canal to go to the legs. This pressure 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.

People who have episodes of red, hot, and swollen joints should be evaluated by a doctor because these episodes are not usually caused by osteoarthritis and could result from an infection or gout.

Diagnosis of Osteoarthritis

  • A doctor's evaluation

  • X-rays

The doctor makes the diagnosis of osteoarthritis based on the characteristic symptoms, physical examination, certain blood tests, and the appearance of joints on x-rays (such as bone enlargement and narrowing of the joint space). 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 often do not closely correspond with a person's symptoms. For example, an x-ray may show only a minor change in a person who has severe symptoms, or an x-ray may show numerous changes in a person who has very few if any symptoms.

Magnetic resonance imaging (MRI) can reveal early changes in cartilage, but it is rarely needed for the diagnosis.

There are no blood tests for the diagnosis of osteoarthritis, but certain blood tests may help rule out other disorders (such as rheumatoid arthritis).

If a joint is swollen, doctors may inject an anesthetic to numb the area and then insert a needle into the joint to draw a sample of the joint fluid. The fluid is examined to differentiate osteoarthritis from other joint disorders such as infection and gout.

Treatment of Osteoarthritis

  • Physical measures, including physical and occupational therapy

  • Drugs

  • Surgery

The main goals of osteoarthritis treatment are to

  • Relieve pain

  • Maintain joint flexibility

  • Optimize joint and overall function

These goals are primarily achieved by physical measures that involve exercises for strength, flexibility, and endurance and rehabilitation (physical and occupational therapy). People are taught how modifying their daily activities can help them live with osteoarthritis. Additional treatment includes drugs, surgery (for some people), and newer therapies.

Physical measures

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 stress better. Exercise can sometimes stop or even reverse osteoarthritis of the hip and knee. Doctors recommended people exercise in water (such as in a pool) because water spares the joints from stress.

Stretching exercises should be done daily.

Exercise must be balanced with a few minutes of rest of painful joints (every 4 to 6 hours during the day), but immobilizing a joint is more likely to worsen the disease than relieve it.

Using excessively soft chairs, recliners, mattresses, and car seats may worsen symptoms.

People should not put pillows under their knees when reclining because doing so can cause the hip and knee muscles to become tight. (This recommendation contrasts with the recommendation that people with low back pain and sciatica put a pillow between their knees. For such people, using a pillow relieves the stress on the lower back and hip [see What Is Sciatica?].)

Moving car seats forward, using straight-backed chairs with relatively high seats (such as kitchen or dining room chairs), firm mattresses, and bed boards (available at many lumber yards), and wearing supportive shoes or athletic shoes are often recommended.

Toilet seat risers can make standing up easier and less uncomfortable for people who have painful osteoarthritis of the knees or hips, particularly if their muscles are weak.

For osteoarthritis of the spine, specific exercises sometimes help, and back supports 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, people should maintain ordinary daily activities and continue to perform their normal activities, such as a hobby or job. However, physical activities may have to be adjusted to avoid bending and thus aggravating the pain of osteoarthritis.

Other additional measures can help relieve pain. They include

  • Physical therapy, often with heat therapy, such as heating pads, and occupational therapy can be helpful.

  • Range-of-motion exercises done in warm water are helpful because heat improves muscle function by reducing stiffness and muscle spasm.

  • Cold may also be applied to reduce pain caused by temporary worsening in one joint.

  • Shoe inserts (orthotics) may help reduce pain caused by walking.

  • Massage by trained therapists and deep heat treatment with diathermy or ultrasonography may be useful.

  • Weight loss can relieve some of the pressure on joints.

  • Electrical stimulation, such as transcutaneous electrical nerve stimulation (TENS), may help relieve pain.

  • Acupuncture releases various chemical messengers in the brain (neurotransmitters) that serve as natural painkillers and may be helpful.

Drugs

Drugs are used to supplement exercise and physical therapy. Drugs, which may be used in combination or individually, do not directly alter the course of osteoarthritis. They are used to reduce symptoms and thus allow more normal daily activities.

A simple pain reliever (analgesic), such as acetaminophen, used before activities that cause discomfort or used regularly to relieve more constant joint discomfort, may be all that is needed for mild to moderate pain. Although side effects are not common, people should not take acetaminophen in higher than recommended doses, particularly if they have liver disease. When taking acetaminophen, people should also make sure not to simultaneously take one of the numerous over-the-counter drug products that contain acetaminophen.

Sometimes, however, people may need a more potent analgesic, such as tramadol or rarely opioids.

Alternatively, a nonsteroidal anti-inflammatory drug (NSAID) may be taken to lessen pain and swelling. NSAIDs reduce pain and inflammation in joints and can be used in combination with other analgesics. NSAIDs also come in gel and cream forms that can be rubbed into the skin (such as diclofenac gel 1%) over the joints of the hands and knees and may help relieve symptoms. However, NSAIDs have a higher risk of serious side effects than acetaminophen when used long term.

Sometimes other types of pain medicine may be needed. For example, a cream made from cayenne pepper—the active ingredient is capsaicin—can be applied directly to the skin over the joint. Doctors may also recommend lidocaine patches for pain relief, but there is no evidence these patches are effective. Duloxetine, a type of antidepressant taken by mouth, reduces the pain caused by osteoarthritis.

Muscle relaxants (usually in low doses) occasionally relieve pain caused by muscles straining to support joints affected by osteoarthritis. In older people, however, they tend to cause more side effects than relief.

If a joint suddenly becomes inflamed, swollen, and painful, most of the fluid inside the joint may need to be removed and a special form of cortisone may be injected directly into the joint. This treatment may provide temporary pain relief and increased joint flexibility in some people.

A series of 1 to 5 weekly injections of hyaluronate (a substance similar to normal joint fluid) into the knee joint may provide some pain relief in some people for prolonged periods of time. These injections should not be given more often than every 6 months. Hyaluronate injections are less effective in people with severe osteoarthritis.

Several nutritional supplements (such as glucosamine sulfate and chondroitin sulfate) have been tested for potential benefit in treating osteoarthritis. So far, results are mixed, and the potential benefit of glucosamine sulfate and chondroitin sulfate in treating pain is unclear and they do not seem to change the progression of joint damage. There is no good evidence that any other nutritional supplements work.

Surgery

Surgical treatment may help when all other treatments fail to relieve pain or improve function. Some joints, most commonly the hip and knee, can be replaced with an artificial joint. Replacement, particularly of the hip, is usually very successful, almost always improving motion and function and dramatically decreasing pain. Therefore, joint replacement should be considered when pain is unmanageable and function becomes limited. Because an artificial joint does not last forever, the procedure is often delayed in very young people so the need for repeated replacements can be minimized. If all other treatments are ineffective, surgical procedures can be done to help relieve symptoms of back or neck osteoarthritis, particularly nerve compression. The benefit of limited, arthroscopic surgical procedures for osteoarthritis of the knee, such as repair of the meniscus or reconstruction of knee ligaments, is uncertain.

A variety of methods that restore cells inside cartilage have been used in younger people with osteoarthritis (often caused by an injury) to help heal small defects in cartilage. However, such methods have not yet proved valuable when cartilage defects are extensive, as commonly occurs in older people.

Replacing All of a Hip (Total Hip Replacement)

Sometimes the whole hip joint must be replaced. The whole hip joint is the top (head) of the thighbone (femur) and the surface of the socket into which the head of the thighbone fits. This procedure is called total hip replacement or total hip arthroplasty. The head of the thighbone is replaced with a ball-shaped part (prosthesis), made of metal. The prosthesis has a strong stem that fits within the center of the thighbone. The socket is replaced with a metal shell lined with durable plastic.

Replacing a Knee

A knee joint damaged by osteoarthritis may be replaced with an artificial joint. After a general anesthetic is given, the surgeon makes an incision over the damaged knee. The knee cap (patella) may be removed, and the ends of the thigh bone (femur) and shinbone (tibia) are smoothed so that the parts of the artificial joint (prosthesis) can be attached more easily. One part of the artificial joint is inserted into the thigh bone, the other part is inserted into the shinbone, and then the parts are cemented in place.

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