Merck Manual

Please confirm that you are not located inside the Russian Federation

honeypot link

Rheumatology Myths with Dr. Brian Mandell

05/27/20 By
Merck Manuals

Season 2 | Episode 8




>> Dr. Mandell: I’d be more worried about if you can wiggle your ears that you’re going go blind than I would worry about cracking your knuckles that you’re going get arthritis. Cracking the knuckles or when you turn your neck, you can hear cracking noises. These are just noises that normal joints can make, it doesn’t mean that the joints are necessarily damaged or that any damage is going to ensue from cracking them. 

>> Joe: Welcome to the Merck Manuals Medical Myths Podcast, where we set the record straight on today’s most talked about medical topics and questions. I’m your host, Joe McIntyre, and, on this episode, we welcome Dr. Brian Mandell. Dr. Mandell is the Professor and Chairman of Academic Medicine in the Department of Rheumatology at the Cleveland Clinic. Dr. Mandell, thanks for coming on the show.

>> Dr. Mandell: Totally my pleasure.

>> Joe: Today, we’re going to talk to Dr. Mandell about something that affects many of us as we get older: arthritis and general issues with our joints. So, let’s get right into it. Many people deal with osteoarthritis in some form as they get older. So, tell me. Is this just a normal part of aging?

>> Dr. Mandell: Well, osteoarthritis, which is also known as degenerative arthritis, which, of course, is a terrible term – nobody wants to think of themselves as either a degenerate or as degenerating. But, to a certain extent, as we do age, so do our joints and bones, and the bones and joints remodel, which, when you look at X-rays, can look and appear and will be labelled as a certain amount of osteoarthritis. But that doesn’t mean that everybody has symptoms in those joints that are affected. But our spine, our hips, particularly the knees, all these are weight-bearing areas. They will change over time, and they will remodel over time. And, in some patients, the remodeling of the bones around that form the joints will become uncomfortable and can cause discomfort. So it’s not at all unusual to see X-ray changes of osteoarthritis in virtually everybody as we age. It doesn’t mean that everybody is going to have symptomatic osteoarthritis or pain in all of those joints.

>> Joe: So, two terms that I’m sure a lot of us have seen over the years. One is rheumatoid arthritis, and the other is, obviously, osteoarthritis. Are these two the same thing?

>> Dr. Mandell: They are really totally different. While osteoarthritis has minimal amount of inflammation, is mainly a mechanical issue, causing discomfort and pain, rheumatoid arthritis is real inflammation. And this comes about not from mechanical imbalance per se but contributions of genetics, the environment, and other triggers that we don’t fully yet understand. But these joints are involved in a way that the joints will become swollen, they’ll become red, hot, and tender, and the medications that we use to treat rheumatoid arthritis, which, of course, many of you have seen advertised on TV now, are quite potent anti-inflammatory medications. The difference is also between the two is that rheumatoid arthritis can damage and destroy joints very quickly over time. Osteoarthritis is a far more slow-moving, progressive problem in different patients. So they really behave totally different, they affect different people. Rheumatoid arthritis affects much younger people, women more than men. And we can treat them dramatically differently.

>> Joe: So, when it comes to joint pain in general, is all joint pain no matter what it is arthritis in some form or another?

>> Dr. Mandell: Most likely not. I mean, when we, you know, as individuals and not as physicians, think, we have pain in our shoulder or knee, we’re really talking about the general area there. And the structure of a joint that moves like the knee or the shoulder is more than just the joint itself. Its tendons and muscles and sometimes even bursa, which are little sacks around the different joints. All of which can become either irritated from mechanical reasons or from inflammation. So you can have pain in your shoulder which is not arthritis at all, which is more likely a tendonitis, perhaps a rotator cuff tendonitis. You don’t have to be a major league pitcher to have problems with your rotator cuff. So a lot of what we call joint pain is not really arthritis itself.

>> Joe: Does rheumatoid arthritis only affect your joints, or does it kind of expand a little bit further beyond that?

>> Dr. Mandell: Yeah, rheumatoid is really rheumatoid disease. We know it as rheumatoid arthritis because the joint findings are the most striking, of swelling of the wrist, the large knuckles of the hands, the balls of the feet. And arthritis really means arth-, joint, and -itis, inflammation. And that’s the hallmark of the disease, but it really is a systemic disease. Rheumatoid arthritis, before we had the very potent and effective therapies that we have now, causes inflammation of the lining of the lungs. It causes scarring of the lungs themselves, the lining around the heart, can affect really many parts of the body in addition to the joints. And the nice thing about our therapies now being so potent and effective is we tend to see far less of any of those other, what we call, outside of the joint complications of rheumatoid disease now.

>> Joe: Now, I’m going to go back to something you mentioned a few seconds ago, this idea that young people can get arthritis. Is arthritis something that children can get as well?

>> Dr. Mandell: They absolutely can, and that’s kind of this concept that only the elderly develop arthritis. And that’s really far more focused on what we talked about before, of osteoarthritis being a disease of the mechanical aging of joints that causes them to have some dysfunction over time. But the inflammatory types of arthritis can really affect anyone, including children under the age of one. Inflammation, which can be trigged by factors, again, genetic determined or others that we don’t fully understand, sometimes triggered by a virus perhaps, can really affect anyone. And there are forms of arthritis known as juvenile rheumatoid arthritis which characteristically affect teenagers and younger. Some forms will burn out and go away as children grow into young adulthood. But others can stay for a lifetime, and, again, fortunately, we have medications that really do a wonderful job at controlling this.

>> Joe: Alright, let’s get to the big myth here, or, maybe it’s not a myth, you’ll have to tell me. Does cracking your knuckles, those people who crack their knuckles every day, maybe multiple times a day, does that cause arthritis?

>> Dr. Mandell: I’d be more worried about if you can wiggle your ears that you’re going to go blind than I’d worry about cracking your knuckles that you’re going to get arthritis. Cracking the knuckles or, when you turn your neck, you can hear cracking noises – these are just noises that normal joints can make. It doesn’t mean that the joint is necessarily damaged or that any damage is going to ensue from cracking them. Although, if you do it too loudly in the third grade, you may very well be injured by the ruler flying across the room if teachers can still do that, they’re probably not allowed anymore. But, so the answer to that is, it’s okay. You can crack your knuckles.

>> Joe: I’m sure that comes as a sigh of relief to a lot of people out there.

>> Dr. Mandell: I would think so.

>> Joe: So, what about people who are double jointed? Is that a form of arthritis? I’m not exactly sure how that works, can you explain it a bit?

>> Dr. Mandell: Yeah, so that is interesting because the concept there many people have – gee, if I’m double jointed and I’m flexible, this is great, I can be a gymnast, I can be a ballerina, and I’ll do great because my joints are more flexible. In fact, it’s the exact opposite. So, being loose jointed, or double jointed if you will, is in and of itself is not arthritis. Remember, arthritis, arth-, joint, -itis, inflammation. It is not. It is the structure of the tissue around the joint letting the bones that come together at a joint move more than the normal amount that other people can do. And what happens over time, particularly because this tends to be noticed when you’re really young, is people who are double jointed tend to do things with those double jointed fingers or shoulders. They pop them out, they move them in odd contortions. And over time, you actually stretch the capsule, the lining of the joint, and every time you do that, you stretch a little bit more. And what can happen then is that you’ve altered the mechanics of this joint because the joint is moving in ways that it really wasn’t designed to do. And what we chatted about before with osteoarthritis being a mechanical issue, you can understand now that with a joint that is stretched out of its normal position, you can alter the mechanics and then develop, secondarily to that, osteoarthritis over many, many years. So, in fact, the major concern that I have for kids that are double jointed is tell them don’t be popping them out, don’t be dislocating them on purpose because it’s kind of cool to show that you can pop your shoulder out and move it back because, over time, you’re going to predispose yourself to develop osteoarthritis.

>> Joe: Good to know. Now, let’s get to something that I’m sure a lot of people may have questions about who aren’t necessarily double jointed, this idea that certain foods can worsen your arthritis symptoms or improve them. Can you get into that a little bit?

>> Dr. Mandell: I can. And you can come at this from several ways. There is a thought that you can have food allergies that manifest as arthritis. I’m sure there are some folks who do have that. It really is very, very rare, if it happens at all, to be a true food allergy that will cause arthritis. That said, there are some foods in a certain individual that can either increase or decrease the inflammatory state of your body. The problem is, despite all the books written about anti-inflammatory and pro-inflammatory diets, we really don’t know what an anti-inflammatory diet is as a general concept. So, what I tell people who have inflammatory arthritis, such as rheumatoid arthritis, if you notice that a certain food will cause flares in your disease, avoid it. And I do believe that that does happen. But it could be different in one person as opposed to another person who has rheumatoid arthritis, what foods are going to help and what foods are going to worsen that. There are other forms of arthritis, such as gout, where food may certainly contribute to its development because you can have foods that increase the uric acid in your body, which is the ultimate cause of gout, and those you want to limit to a certain extent.

>> Joe: So, we’ll get into gout a little bit more later, but I want to talk a little about this idea that certain aspects of our lives can impact our arthritis. I know a lot of people may say or think that, when the rains are coming, they can feel it in their joints. They’re weaker, the pressure in the atmosphere changes things. Is that actually true?

>> Dr. Mandell: It is actually true, although it is not necessarily the moisture or the rain. It’s the barometric pressure, and decades and decades ago, an interesting study was done on patients who had arthritis of the hands. It was stuck in a box that the environment of that box could be controlled without the volunteer patient knowing what was being changed. And it turned out, if you changed the pressure in the box, patients would ache more. They would feel stiff. Moisture, temperature didn’t make so much of a predictable difference. But I think, absolutely, there are people who can predict a change in the weather because a drop in the barometric pressure often precedes a storm, and patients will feel that. The pressure changes outside get transmitted to the joint itself, and patients will feel that.

>> Joe: So, is that why cows lay down on the grass when the rains are coming?

>> Dr. Mandell: So, not being from Nebraska, I would have no clue why a cow would want to lay down on the grass. Although the idea of cow tipping has an enormous amount of appeal to me, that’s all I know other than I eat them.


>> Joe: Good to know. So, what about sleep? Does that have any effect on our ability to reduce the symptoms of arthritis?

>> Dr. Mandell: I am a huge fan of sleep, and, in the office, I can’t tell you that a day or a session in clinic, probably not even a time with an individual patient goes by that we don’t wind up in some manner of form discussing sleep because it is so critically important. And we tend to blow it off. We think if we can get by on less sleep, this is great, how much more productive we can be. But, the fact is, the time we spend sleeping is absolutely necessary, not only to mental alertness but also to physical state because, when you’re in a deep REM sleep, that is the only time during the day that your muscles will completely, completely relax. And, if you never get into that deep state of sleep, your muscles never completely relax, which means, essentially, you’re at the gym 24/7. And there is nobody who works out 24/7 that their muscles are going to feel good. And the other part of sleep, and we’re learning this from just fascinating work that is coming out of a number of different laboratories, predominantly from the University of Michigan, is to see that sleep affects the brain which basically affects our perception of pain. So the brain functions as a pain thermostat, and, if you don’t get adequate sleep, adequate quality of sleep, not just the hours but quality of sleep, your pain thermostat is set to low, and things that it normally would be just shrugged off as just a light touch can be uncomfortable. And this is even a major factor in patients who have fibromyalgia or other predominantly pain syndromes, but also with osteoarthritis and inflammatory arthritis like rheumatoid arthritis. So I think sleep is absolutely critical, and, when I talk to patients bout how well we’re controlling their disease with drugs, if I don’t get into the idea are they sleeping adequately, I’m really not paying attention to the ways that we can make them feel better.

>> Joe: Don’t go away. We’ll be back with more, right after this.

>> Joe: Whether you’re a parent or a seasoned professional, a medical student or a caregiver, the Merck Manuals has the right medical information in the best format, and it’s always free, easy to access, and readily available for you.

>> Joe: Now, beyond sleep, I’m sure there are a number of ways that folks can lessen the impact of the symptoms of arthritis. What about their weight? Does losing weight reduce the symptoms of arthritis?

>> Dr. Mandell: So, it really depends in this situation, what you’re talking about, in terms of what type of arthritis you’re discussing and what area of the body. We know that, in osteoarthritis, again, predominately mechanical issues, that if you have osteoarthritis of the knee, which is certainly one of the most common symptomatic areas of osteoarthritis, if you are overweight and lose weight, pain will decrease and your functionality will improve. You will feel better. The hips, again, a weight bearing area, it’ll be a little bit less that the knee in terms of its efficacy, but, again, you’re overweight, those joints are supporting all that extra weight. So you will feel better if you lose weight and maintain physical activity. On the other hand, if you think about a wrist disease or shoulder disease, losing weight there may not make much of a difference. So it really depends on what type of arthritis you’re talking about and what location.

>> Joe: Now, you mentioned physical activity. What about running? Does running increase the chance of arthritis in our knees?

>> Dr. Mandell: Well, it is traumatic to a certain extent. So, if you beat up a joint excessively, you are more prone to put mechanical stress on that joint which may aggravate osteoarthritis over the long term. That said, if you have normal mechanics and don’t overdo it, and the question is, how do you know when your overdoing it? And that’s a problem, you don’t. You’re probably okay. But, it’s not like marathon runners don’t get osteoarthritis, they certainly do, just as people who are not running marathons. People who are able to continue to run for decades and decades and not have pain, well it says two things. One is, they are in good shape, but, two it , that the mechanics of their joints are such that it lets them run. Because, if they were developing osteoarthritis, they would have to be decreasing their distance, or the surface that they’re running on has to be softer. So, it depends really on the individual whether they can continue to run or not.

>> Joe: Now, it seems to me living a generally healthy lifestyle is always the way to go. So, what about smoking? Does smoking increase your chance of suffering from arthritis later in life?

>> Dr. Mandell: Well, I guess it depends, smoking what, right? These days, depending on what state you’re in, this may make a big difference. What we do know is that, for rheumatoid arthritis, people with rheumatoid arthritis develop certain antibodies, which are proteins in the blood that drive and control inflammation. There is one in particular called CCP antibody. If you have that antibody, which is in part genetically determined, but, if you have that and you smoke cigarettes, you’re disease is going to be much more severe and much more difficult to control. The reason we think is from the foreign substances and the triggering of all the inflammation in the lung from the cigarette smoke drives this lung inflammation, which triggers inflammation in other parts of your body and dramatically worsens rheumatoid arthritis. We don’t know that smoking cigarettes, cigars, or anything else will necessarily worsen or affect osteoarthritis.

>> Joe: Now, let’s go back to something you mentioned a few minutes ago: gout. Can you explain to us what gout is? Is it just another way to say arthritis? How do they differ?

>> Dr. Mandell: So, gout is viewed as a form of arthritis. What people think about as gout is suddenly get this red-hot, swollen toe or ankle or foot. Which is very dramatic, it’s very, very dramatic. I heard a patient describe the pain of gout as being worse than when they were parachuting and broke both of their ankles landing from a parachute. And they said, when they’ve had attacks of gout, it’s been worse than that. I find it hard to imagine what it’s like to break both of my ankles jumping out of a plane, but that’s the severity of this disease. So that’s what people view gout as, as the attacks of inflammation in the joints, so actual arthritis. But the actual disease itself is not that. That’s a symptom of the disease. The disease is the excess deposition of uric acid, a normal chemical that all of us have, basically coming from inside of us from our cells turning over, a little bit from diet. But, too much uric acid that deposits in and around joints, and when that uric acid deposits, periodically the deposits of uric acid will break off as crystals, setting up a nasty, nasty, nasty inflammation because the immune system of the body thinks that those crystals are foreign invaders and attacks it just like it would attack a splinter with bacteria in it where you get a pussy finger that you can’t even touch because it’s so inflamed. That’s what gout is. So, gout is in a way a form, a specific form, of arthritis, but the disease is the deposition of the uric acid in and around joints. Which is really important because it means, if we get rid of those deposits, we can actually cure the disease. So, this is the one form of arthritis we can absolutely, positively, totally cure by getting rid of those deposits, which we do with medication by keeping the blood level of the uric acid very, very low. Those deposits will dissolve, and, once they’re dissolved, attacks will absolutely, positively stop. But, for some reason, we manage this disease incredibly poorly, and we don’t treat the disease, which is the deposition. People just treat their attacks of gout, and then they just keep happening over time.

>> Joe: How about fibromyalgia? Is that a form of arthritis?

>> Dr. Mandell: So, fibromyalgia is really, that’s a tough one. No, it is not a form of arthritis. Arthritis, again, arth-, joint, -itis, inflammation. Fibromyalgia has really nothing to do with the specific joints itself. Fibromyalgia as we now really understand it is a diffuse pain syndrome. The characteristic of the pain is it often is around joints and very, very painful. But it’s not necessarily related to the joints themselves. It really is viewed as a central pain syndrome. And this goes back to what we were talking before about sleep and the pain thermostat. The fibromyalgia patients have a pain thermostat that is set incorrectly, that getting a normal hug from somebody who they like, instead of being comfortable can be incredibly painful. It’s the pressure which is misinterpreted by a patient’s brain as being uncomfortable instead of comfortable. That a normal touch is a very heavy touch. So, it really is a pain sensitization syndrome.

>> Joe: Now, we’ve talked a lot about arthritis, and I’m sure busted a few myths along the way here. As we kind of give this podcast a close, can you give us a few tips or pointers for folks who want to either reduce their chance of getting arthritis as they get older or help manage their arthritis if they already have it?

>> Dr. Mandell: Well, the first thing is get a reliable diagnosis. You know, not everything that hurts is arthritis as we’ve talked about several examples that are not. Not everything that hurts is inflammatory arthritis. So, the first is an accurate diagnosis. Is there inflammation, or is there not? And if there is inflammation, that needs to be addressed and treated appropriately to prevent damage over time. If it’s not inflammatory and its osteoarthritis, you know, very, very common, then you want to preserve your muscle tone and strength around the joints to preserve that muscular stability, the joint structure stability, so you don’t get progressive mechanical deterioration of the joints because the mechanics are off. So, you want to stay in reasonable shape. So, staying active doesn’t mean that you have to work out at the gym two hours three times, four times a week, but you want to maintain good muscle tone and balance. Healthy diet is good, and you can think about a heart-healthy diet as being totally reasonable. Maintain your weight because you don’t want to put excess strain and pressure from the weight on your hips and your knees. And I think those are the common sense things that we do. I guess one other main thing is I just wouldn’t go after the fats, either the fat diet or any fat program thinking it’s going to be a quick fix because most of this really is not amenable to a quick fix.

>> Joe: So, Dr. Mandell, where should folks go if they have questions about their arthritis or they’re looking for more information about how to deal with arthritis?

>> Dr. Mandell: Certainly the Merck Manual has a home edition which is specifically directed to consumers, to patients, to normal people. It’s written by folks with true expertise but directed at the person, not at physicians. A number of medical centers have sites as well. The Arthritis Foundation is another excellent resource for patient information. And I would just mainly avoid the unpredictably reliable or unreliable sources of chat boards or bulletin boards for specific diseases cause you just don’t know who’s actually contributing to those, and you’ll see a lot of belief at the expense of facts on those.

>> Joe: And, for our listeners outside of the United States and Canada, we, of course, invite you to visit for more information. Well, Dr. Mandell, thank you so much again for joining us. I think we learned a lot about arthritis and how it affects our bodies, but also how it affects our families’ bodies and what we can do to support them through this as well. Before we go, I’ll ask you to say, as we always do at the Merck Manuals

>> Dr. Mandell: Medical knowledge is power. Pass it on.

>> Joe: Take care.