Osteoarthritis Questions
Arthritis Today Medical Experts Answer Your Questions About Osteoarthritis
One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.
OA and Kidney Concerns
Treating Subchondral Cysts
Try Glucosamine for OA
NSAID Safety
Are OA and Sarcoidosis Related?
Horseback Riding With Hip OA
Postponing Knee Replacement
Glucosamine And Chondroitin
For Knees' Sake, Lose Weight
Steroid Safety
A Lesser Known Bone Disease
The Pain-Anxiety Connection
Enlarged Joint Spaces: What are they?
Will Arthroscopy fix Arthritis in the shoulder?
Removing Joint Fluid to Treat OA
Bone Marrow Edema or AO?
Stopping the Spread of OA
Exercising with OA and Fibromyalgia
Inflammatory OA--an Oxymoron or Actual Condition?
Getting By Without Drugs
Do Magnets Help OA?
"Just Dealing with" OA Pain
OA and Headaches
Q: I have osteoarthritis (OA), but cannot take many medications because I have kidney problems. Is there any treatment I could try that would not affect my kidneys?
A: If you have diminished kidney function, you may need to avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn), but there are many other options. The first option is acetaminophen (Tylenol), which is an analgesic, not
Injections of hyaluronic acid compounds, which are designed to supplement a substance that gives joint fluid its viscosity, for example, may provide relief in affected joints (usually knees) without involving the kidneys. These products include Hyalgan, Orthovisc, Supartz and Synvisc.
There are also topical products for arthritis that affects only one or two joints. The FDA recently approved a gel form of the prescription NSAID diclofenac (Voltaren Gel). Only a very small amount of the drug gets into the bloodstream, so it may be safe for your kidneys. However, topicals may not work well for hip pain, because the joint is too deep for the medication to penetrate.
The most effective of the over-the-counter products is probably capsaicin cream (ArthriCare, Capzasin and Zostrix). Derived from red chili peppers, capsaicin has been found to reduce a chemical in the body that transmits pain signals.
Other nonprescription topicals include:
• Counterirritants, which include products such as menthol (in Absorbine Jr.) and camphor (JointFlex cream), and provide a mild cooling sensation that distracts from underlying pain.
• Salicylates, which are related to aspirin and relieve pain directly, include products such as Aspercreme and Myoflex.
• Combination products may contain ingredients such as methyl salicylate and menthol (mentholatum cream, BenGay), or capsaicin, salicylates and a counterirritant (Heet liniment).
Ask your pharmacist for help in choosing the right product for you.
Of course, there are several nondrug treatments, too, that would be completely safe for your kidneys. These include using a brace or cane, taping a joint, going to physical therapy and trying hot/cold therapy or acupuncture.
Don Miller, PharmD,
Treating Subchondral Cysts
Q: What are subchondral cysts and how are they treated?
A: Subchondral cysts are fluid-filled sacs extruding from the joint. They consist of thickened joint material, primarily hyaluronic acid, a substance found in the fluid that normally lubricates the joint. The cysts most commonly occur over the end or middle finger joints and represent the early phases of osteoarthritis of those joints. Usually the cysts (but not the OA itself) will improve on their own with time. In the meantime, if they are tender, taking an NSAID or avoiding activities that aggravate the particular joint may help. Usually leaving the cysts alone is the best treatment; they should not be lanced or removed, because doing so is not necessary and would put you at risk of complications such as infection or poor wound healing.
Doyt Conn, MD, Rheumatologist
Back to Top
Try Glucosamine for OA
Q: I would like to know if the supplements glucosamine and chondroitin sulfate are worth trying for osteoarthritis. I've heard of many people who have been helped. Do these supplements really work? Are they safe?
A: Glucosamine is found in high concentrations in the joints and is believed to stimulate the formation of cartilage that is essential for joint repair. Chondroitin sulfate is also found in cartilage and draws fluid into the tissue, giving the cartilage resistance and elasticity. In test tubes, chondroitin sulfate stimulates the formation of components for new cartilage and slows cartilage breakdown.
Chondroitin and glucosamine supplements appear to be more effective in patients with osteoarthritis than in people with inflammatory diseases such as rheumatoid arthritis. The supplements might lessen pain in 30 to 50 percent of patients with osteoarthritis. European research has shown that people with OA who took 1,500 mg of glucosamine a day had the same level of pain relief as those who took painkilling drugs such as ibuprofen. There are a few studies that show people taking 1,200 mg of chondroitin a day had the same level of pain relief as those who took drugs such as ibuprofen and diclofenac (Voltaren). Right now there is no research that shows whether greater relief occurs when both glucosamine and chondroitin are taken together.
I believe it is worthwhile to take both high quality glucosamine and chondroitin sulfate. These products are safe, as far as I can tell, and can be continued for as long as they seem to work. But be warned: The quality and effectiveness of these products varies because right now there is no regulation in the manufacturing of them. Look for a product with the word "standardized" on the label and buy from a reputable source. If you experience no relief after four to six weeks of supplement use, stop spending your money on it.
James McKoy, MD, Rheumatologist
Back to Top
NSAID Safety
Q: While taking Relafen for osteoarthritis, I developed nephrotic syndrome. It cleared up shortly after I stopped the drug. Is it safe for me to try other NSAIDs now, or should I avoid all of them from now on?
A: Certain NSAIDs have been reported to be associated with the nephrotic syndrome, a reversible degenerative condition of the kidney associated with the leakage of protein in the urine. These include indomethacin, naproxen, tolmetin and fenoprofen, but this syndrome can be caused by any NSAID. For osteoarthritis pain, acetaminophen would probably be a safer choice than these, or any other NSAID, for that matter. If you and your doctor feel that you need an NSAID, I would recommend using a nonacetylated salicylate preparation such as salsalate. To recognize or prevent problems in the future, your physician will need to monitor your kidney function.
Bernard Rubin, DO, Rheumatologist
Are OA and Sarcoidosis Related?
Q: Three months ago I was diagnosed with sarcoidosis after a lung biopsy. I have had osteoarthritis (OA) for many years, but it has never slowed me down like this disease has. Is there a relationship between my sarcoidosis and OA? Is there anything I can do about the constant fatigue and run-down feeling I have with this disease?
A: Sarcoidosis is a systemic disease that causes inflammation in tissues throughout the body including the lungs, lymph nodes, skin, liver, eyes and joints. There is probably no relationship between your OA and sarcoidosis. The pattern of joint involvement that occasionally occurs in people with sarcoidosis differs from the pattern in OA. Sarcoidosis, for example, can involve the ankles, which are rarely affected by OA. It can also affect tissue around the joints and cause fingers to swell. X-rays in sarcoidosis show "punched out" lesions that look like holes in the bone around the joints. Skin lesions often accompany joint involvement in sarcoidosis. The feelings of fatigue and malaise you are experiencing are common with sarcoidosis. Depending on the extent of the disease, it may be treated with corticosteroids, which may help relieve your tired, run-down feeling. When joint pain or inflammation is the main symptom, nonsteroidal anti-inflammatory drugs may suffice. Your doctor should be able help you find the most appropriate treatment for all of your symptoms.
David Pisetsky, MD, PhD, Rheumatologist
Back to Top
Horseback Riding With Hip OA
Q: I have osteoarthritis (OA) of the hip and will probably need a hip replacement eventually. I love riding horses, but I'm afraid doing so might make my OA worse. Can you offer any guidelines as to how -- or how long -- I should ride? Is it possible to ride after hip replacement?
A: Many people with mild or moderate osteoarthritis of the hip or hips can enjoy horseback riding. It is not considered a high-risk sport for increasing wear of the hip joint. However, pain can limit the amount of time it's possible to ride. This can be due to several factors. As the severity of the OA increases in a given hip, tightness occurs in the tendons and muscles on the inner side of the hip (near the groin), tighten, making it harder to comfortably spread the hip out to the side. The hip stiffens into what doctors call a contracture of the hip joint.
In addition, a severely arthritic hip can become more painful with the repetitive motions a long ride may require. Stiffness makes mounting and dismounting difficult, and people with severe OA of the hip may find it too uncomfortable to ride a horse at that point in time. Total hip replacement offers excellent pain relief and increased range of motion. And yes, it is possible to enjoy horseback riding after hip replacement, given some caveats.
Because a hip replacement does not give entirely normal range of motion, you should wait two or three months after your surgery before attempting to mount or dismount a horse. Even then, you may need to use a platform to ensure you don't bend the hip forward too far and risk dislocating it. Rough riding or large horses may not be practical for you. If you do undergo a total hip replacement, be sure to talk to your orthopaedic surgeon about your wish to continue horseback riding. If you have a severe contracture, your surgeon may need to modify the surgery slightly to give your new joint extra range of motion. Your surgeon should also be able to give you specific advice on riding based on the particulars of your hip.
Jeffrey Nugent, MD, Orthopaedic Surgeon
Back to Top
Postponing Knee Replacement
Q: I have had OA for years and may soon have to have my left knee replaced; however, I would like to try one of the drugs (namely Synvisc or Hyalgan) I read about. Yet I am still confused. Are these two brand names for the same drug? Would you recommend one of these drugs over the other?
A: Synvisc (hylan G-F 20) and Hyalgan (sodium hyaluronate) are two relatively new medical products commonly referred to as viscosupplements. Both are believed to work as lubricants by substituting for hyaluronic acid, the substance that gives joint fluid its viscosity, rather than through any pharmacologic action in the body. For that reason, they are considered to be injectable medical devices, rather than drugs. Both are used only for knee OA.
These two viscosupplements are similar but not the same. Their developers and manufacturers have conducted separate clinical trials, yet the benefits, side effects and allergic reactions reported have been similar. A major difference is that Hyalgan is administered in a series of five shots; Synvisc is given in three.
In my experience, the pain-relieving effects of both last up to six months. In my practice, I have chosen to use Synvisc for patients who have not experienced sufficient relief with NSAIDs and intra-articular cortisone shots. Because I charge a fee to administer each shot, Synvisc - which requires fewer shots - is a more economical choice for my patients. The cost of the two drugs is approximately the same. Although my colleagues and I use these products in our practices, many of us remain skeptical as to whether they are really more effective than more affordable therapies such as NSAIDs and injectable cortisone. Many of my patients, like you, have sought viscosupplementation in an effort to avoid knee replacement. However, my colleagues and I have found that patients with severe OA don't find lasting relief from these products. Viscosupplementation is much more effective for mild to moderate OA of the knee. More research is needed as to the long-term effectiveness and cost effectiveness of these products and their place in the total management of OA.
Jeffrey T. Nugent, MD, Orthopaedic Surgeon
Back to Top
Glucosamine And Chondroitin
Ever since Arthritis Today began reporting on the use of glucosamine and chondroitin to treat osteoarthritis, we have received numerous questions from readers on these substances' benefits, side effects and other issues. In this special section of "On Call," we invited Amal Das, MD, an orthopaedic surgeon who has conducted studies on these supplements, to answer some of the most frequently asked questions about them.
Q: Do glucosamine and chondroitin have harmful side effects?
A: So far, the two supplements appear to have few side effects at the dosages that are most commonly used - 1,500 milligrams (mg) glucosamine and 500 mg chondroitin sulfate per day. None of those amounts are dangerous. But that is not to say harmful side effects can't occur with their use. Human studies of the two supplements have involved only small numbers of patients (200 or less) - hardly enough people to uncover potential side effects. The most common side effect thus far for both supplements is mild gas. If the chondroitin sulfate is not extracted properly it may be contaminated by a protein that can cause allergic reactions such as hives.
Q: Because glucosamine is derived from crab, lobster or shrimp shells, should people with shellfish allergies avoid it?
A: Not necessarily. Glucosamine comes from chitin, a substance in these animals' shells. Allergic reactions to shellfish are usually to proteins unique to the fish part of shellfish. Because chitin contains no proteins, an allergic reaction to glucosamine in a person allergic to shellfish is unlikely. Of course, if you are allergic to shellfish and develop symptoms such as itching, hives or shortness of breath after taking glucosamine, stop taking it and call your doctor. Such reactions, if they do occur, can be dangerous or deadly.
Q: Do glucosamine and chondroitin provide any benefits besides pain relief?
A: Maybe, maybe not. Some scientific data suggests that glucosamine and chondroitin sulfate may slow down the degenerative process of osteoarthritis. Although this is an attractive theory, it is by no means proven. Longer-term studies are needed to document this effect if, in fact, it exists. Despite some advertising claims to the contrary, there is no data to suggest that either supplement - or both in conjunction - can help rebuild cartilage once it is lost.
Q: How long does it take glucosamine and chondroitin sulfate to produce noticeable effects?
A: Study results vary. Some say significant pain reduction and improvement in function can occur in as little as two weeks. Others suggest it may take as long as four months. It's important to realize that you may not get relief from these substances - no matter how long you use them. Some people don't. The general recommendation is that you take the supplements for two months. If you don't notice any improvement by then, you'd probably do better to try something different.
John Klippel, MD, Rheumatologist
Back to Top
For Knees' Sake, Lose Weight
Q: At 170 pounds, I am about 25 percent over my ideal body weight and have recently been diagnosed with osteoarthritis of the knee. My rheumatologist has told me to begin a low-fat diet and exercise program. I know that diet and exercise are important in preventing heart disease and cancer. But will they really help my arthritis?
A: The surprising answer is that yes, losing weight will help - at least in an indirect way. Although no diet has been shown to actually stop or reverse arthritis, a common-sense low-fat diet is a good idea for anyone - whether they have arthritis or not. Numerous studies have shown obesity to be a risk factor for knee OA development and progression. Weight loss is beneficial. In fact, in one study, a loss of only 10 to 15 pounds in women of medium height decreased the risk of developing knee OA by one-half. The news is equally good for people who already have OA. Lower weight may not only reduce the risk of OA progression, it can also lessen OA symptoms in the knee. Furthermore, studies have shown that losing weight may help reduce your risk of developing another form of arthritis, gout, which occurs when crystals of uric acid, a bodily waste product, build up in the joints and other tissues.
An exercise program would be beneficial in a number of ways. For one, it can help you to reach your weight-loss goals. Despite the abundance of diet plans and advice out there, weight loss boils down to one thing: creating a calorie deficit. In other words, to lose weight you must expend more calories than you consume. Of course, you can burn calories while sitting or watching TV, but to create a deficit that way you'd have to restrict calories pretty severely - too severely to get all the nutrients your body requires. An exercising body burns calories at a much higher rate and allows you to lose weight more quickly and/or with less severe calorie restrictions.
Another benefit of exercise is that it strengthens muscles that surround and support the body's joints. During weight- bearing activity, up to three times a person's weight - in your case 510 pounds - is transmitted directly to the knees and hips. This can be a problem if you already have OA of the hip or knee. Strong muscles can help relieve this pressure on the joints.
If you're unsure what foods or how many calories you should be consuming to ensure both proper nutrition and weight loss, I would recommend you consider scheduling at least one session with a registered dietitian. A physical therapist could help design an exercise program that will hasten your weight loss and strengthen the appropriate muscles without putting undue stress on your arthritic joints. In general, I recommend exercises that avoid jarring the affected joints. Swimming, water exercise, low-impact aerobics and walking are generally good. The best is one you enjoy enough to stick with. The actual amount of weight you lose is not as important as the fact that you at least lose some weight. Even modest weight loss - as the study of women who lost 10 to 15 pounds shows - can be beneficial and is an easier goal obtain. I recommend striving for modest goals at first. If you lose 10 to 15 pounds and want to lose more, set another goal. Remember, even a little bit helps. The same goes for exercise. I'm not surprised that the concept of weight loss for arthritis is unfamiliar to you. While most people have heard about diet and exercise for other diseases, the benefits of good lifestyle practices for arthritis are largely overlooked. But expect that to change.
A new effort by the Arthritis Foundation and the Centers for Disease Control and Prevention called the National Arthritis Action Plan (NAAP) should get that message out. The NAAP will guide the use and organization of our nation's health resources to combat arthritis and public misconceptions about it. The goal of NAAP is to achieve a greater recognition of the types of arthritis - among both the public and the medical establishment - its impact on society and what can be done to prevent, delay and better treat it.
Doyt L. Conn, MD, Rheumatologist
Back to Top
Steroid Safety
Q: I have both Ehlers-Danlos syndrome and osteoarthritis, and nothing eases my pain like steroids do. I have heard that steroids, particularly at high doses, have dangerous side effects. What is considered a high dose? Is it safe to take low doses of steroids daily or over a long period of time?
A: Taking high doses of steroid (more specifically, glucocorticoid) medications can cause serious side effects such as hypertension, diabetes, osteoporosis, cataracts, mood changes, weight gain and susceptibility to infection. Any dose of 10 milligrams (mg) or more is generally considered high, but even low doses (5 to 7.5 mg daily) aren't completely safe - particularly when taken for a number of months or years. As with any medication, when physicians prescribe glucocorticoids, they must weigh the benefits against the risks. For some people the benefits of glucocorticoids are great; even low doses can ease the inflammation of rheumatoid arthritis and very high doses (as high as 60 mg daily) can limit or prevent the damage of acute, serious conditions such as kidney disease in lupus. But these drugs are generally not prescribed for either Ehlers-Danlos syndrome or osteoarthritis, so I have to question why you are taking them. I would recommend a consultation with your doctor as well as a complete rheumatologic evaluation, if you're not already seeing a rheumatologist, to ensure you have been given the correct diagnoses.
David Pisetsky MD, PhD, Rheumatologist
Back to Top
A Lesser Known Bone Disease
Q: After several months of suffering pain in my right hip, I made an appointment with a rheumatologist, assuming I had arthritis. I found that I do, in fact, have osteoarthritis of my hip but I also found out that it was made worse -- and maybe even caused -- by Paget's disease of bone. What is that? Is it anything like osteoporosis? I am a 52-year-old man. Isn't this uncommon in men?
What can I expect from here on?
A: It's understandable that you are not familiar with Paget's disease of the bone, because it is relatively uncommon.
Named for Sir James Paget, who first described the disease in the 19th century, Paget's disease of the bone occurs when a malfunction in the normal process of bone breakdown and rebuilding leads to excessive and disorganized new bone growth. As a result, the new bone that is produced is highly vascular (meaning, it contains a lot of blood vessels) and is enlarged and softer than normal bone.
The accelerated bone growth, along with the resulting changes in bone structure, are among the features that differentiate Paget's disease from osteoporosis, another bone disease. In osteoporosis, bone breakdown exceeds bone growth, leading to thin, fragile bones. Also unlike osteoporosis, Paget's disease is slightly more common in men. It often begins between the ages of 50 and 70, and people of Western-European descent are more likely than African Americans to be affected.
Although Paget's disease is often painless, some people experience bone warmth and pain. Sometimes the pain comes from the joints. Because Paget's disease tends to affect the bones of the pelvis and legs and because bone changes may alter mechanical structure of the joints, painful osteoarthritis of the hips or knees can occur. Other common sites of Paget's disease are the skull, lower spine and sacrum (the tail bone).
Treatment for Paget's disease is based mainly on its symptoms and extent of involvement. The goal of treatment will be to relieve the pain in your hip. If there is only mild hip-joint damage and a good deal of bony change from the Paget's disease, your physician may want to treat the Paget's disease with one of several types of drugs you may have heard of in connection with osteoporosis. These include calcitonin, a parathyroid hormone derived from salmon; and bisphosphonates, including etidronate, pamidronate and the relative newcomer alendronate. There is also a newly approved bisphosphonate called tiludronate disodium. All of these drugs inhibit the process of bone turnover.
Fortunately, Paget's disease rarely spreads from one site to another. If the disease is, in fact, in your pelvis, it's not likely to affect your spine or skull. Also, the disease generally "burns out" in time, causing no additional pain or damage. Any damage the disease has already caused, however, is irreversible. If your hip joint has been damaged and the resulting pain is a problem, replacement may be needed to relieve pain.
You are wise to see a rheumatologist about this problem. Paget's disease is rarely life-threatening, but without proper treatment it can lead to fractures and other problems. In very rare cases, Paget's can transform into a life-threatening cancerous bone disease. With early and proper therapy, you should be able to maintain an active lifestyle and should experience few lasting effects of the disease.
Doyt Conn, MD, Rheumatologist
Back to Top
The Pain-Anxiety Connection
Q. Following a work-related injury I developed osteoarthritis (OA) of the knee that has caused severe pain. But even when I'm not in pain, I sometimes have difficulty sleeping or concentrating, just anticipating the pain's return. My doctor prescribed an anti-anxiety medication that has helped, yet my workers' comp won't cover it (with the reason that pain doesn't cause anxiety). Have you heard of pain-related anxiety?
A: Actual pain can be worsened by many emotions including sadness, anger, frustration and anxiety.
Anyone who has been around a child who falls and scrapes a knee has probably seen the powerful effect fear and anxiety can have on our reaction to pain. Similarly, the anticipation of pain and its results – not being able to go to work, enjoy a trip, etc. – will likely evoke feelings of anxiety. This can become a vicious cycle as the fear of pain elicits anxiety, which in turn increases pain, and so on.
You have several options. One is asking your doctor to talk with one of the case-managers of your insurance company. He can explain his reasoning in prescribing the medication for you – that it was done to help you function.
You could also file an appeal with your insurance company, but before doing that you may first want to educate yourself about pain and emotions. Two brochures published by the Arthritis Foundation – Managing Your Pain and Managing Your Stress – should be helpful. (Contact your local chapter to request free copies.)
Finally, you might ask your doctor to refer you to a psychologist or other health professional. She can teach you deep relaxation and other pain-control techniques.
Kristofer Hagglund, PhD, Psychologist
Back to Top
Enlarged Joint Spaces: What Are They?
Q. Several years ago I was diagnosed with osteoarthritis (OA). Now my doctor is telling me I don't have arthritis — just enlarged joint spaces. What does this mean?
A: That's hard to say without seeing your X-rays or speaking with your physician.
In evaluating the presence of arthritis, many physicians perform X-ray examinations of the joint. These X-rays provide information on the state of the soft tissues, cartilage and bone, and may allow diagnosis of specific joint diseases. Cartilage is measured by the distance between the bones, or joint space.
For most forms of arthritis, X-rays show a joint space that is narrowed or small because of loss of cartilage.
An enlargement of the joint space, therefore, suggests an increase, rather than a decrease, of cartilage. Such an increase [and, therefore, enlargement of joint space] can occur in certain rare metabolic conditions such as an excessive production of growth hormone (a condition known as acromegaly) that causes cartilage growth.
On the other hand, OA generally causes a loss of cartilage (reduced joint space) and an enlargement of the bones around a joint.
Without speaking to your physician and seeing your X-rays, I can't determine which, if either, of these situations applies to you. I would suggest clarifying this issue with your physician because it may determine the need for further evaluation or dictate the type of treatment you need.
David Pisetsky, MD, PhD, Rheumatologist
Back to Top
Will Arthroscopy Fix Arthritis in the Shoulder?
Q. My husband recently had arthroscopic surgery to “smooth off” the rough areas in his osteoarthritic shoulder. Is this a permanent fix for his problem?
A: When joint cartilage is damaged by osteoarthritis, smoothing the rough cartilage and removing cartilage debris through arthroscopic surgery can offer temporary, symptomatic relief. The procedure may slow down the arthritic process and relieve symptoms for a while -- maybe several months, maybe more -- but it can't stop the disease.
I can't say how long your husband will experience relief, as the effects vary from patient to patient; however, proper medication and exercise can help maximize the effectiveness of the surgery.
If your husband continues to have problems or suffers severe, chronic pain, total replacement of the shoulder joint offers excellent results.
Jeffrey Nugent, MD, Orthopaedic surgeon
Back to Top
Removing Joint Fluid to Treat OA
Q. Is removing fluid from the knee helpful for knee osteoarthritis? If so, how does it help and how often should it be done?
A: Most patients with osteoarthritis (OA) who have a swollen knee will not require removing fluid from the knee by needle. Instead, the swelling will be treated with medications. On occasion, however, removing fluid may be helpful in order to test the fluid or treat the painful knee.
Most rheumatologists and orthopaedists remove fluid from swollen knees by using a 16- or 18-gauge needle and sterile technique. Along with the fluid, small pieces of cartilage and inflammatory mediators are removed. This alone may lessen joint inflammation.
However, after removing the fluid, many times a doctor will inject cortisone or lubricants, such as hyaluronan (Hyalgan) or hylan G-F 20 (Synvisc), into the knee. These treatments can further reduce inflammation and/or ease pain. Sometimes the doctor will also irrigate the knee with saline. Arthroscopic surgery can be used to remove larger loose pieces of cartilage or bone, but is rarely needed.
In my practice, people with large accumulations of joint fluid are typically treated by needle aspiration and injection of cortisone three or four times a year, at most. This treatment, combined with anti-inflammatory medications usually gives satisfactory relief.
Jeffrey T. Nugent, MD, Orthopaedic Surgeon
Back to Top
Bone Marrow Edema or OA?
Q. My rheumatologist has diagnosed my knee pain as bone marrow edema. An orthopaedist, however, says this diagnosis is meaningless, that I have osteoarthritis (OA) and need a cortisone shot. Can you please tell me what bone marrow edema is and how it should be treated?
A: Edema is the term used to refer to accumulation of fluid in the body. This process can occur as part of inflammation and contribute to arthritis pain. Edema may occur in the bone marrow where it is usually detected by X-ray techniques like magnetic resonance imaging (MRI).
When bone marrow edema is part of arthritis, the treatment would be the same as that used to control the joint symptoms. Cortisone shots are sometimes used to treat OA, especially if there are signs of inflammation and the joint is swollen, tender or warm
David Pisetsky, MD, PHD, Rheumatologist
Back to Top
Stopping the Spread of OA
Q: Four years ago, I was diagnosed with osteoarthritis (OA) in my right ankle. Now X-rays show OA in my spine, neck, knuckles, wrists and knees. Can you tell me what caused OA to spread this way, and is there anything I can do to stop it?
A: OA is a degenerative disease of cartilage and results in overgrowth of bone underneath the cartilage. In some people, a traumatic joint injury can lead to OA, while in others genetics may play a role. The disease usually begins with a single large joint, such as a hip or knee. But it is not uncommon for a smaller joint, such as an ankle, to be affected initially -- particularly if that joint has had a significant injury, such as a sprain or cartilage tear.
While OA can be limited to a single joint, in many cases it progresses to involve other joints, often in a sequential fashion as you describe. In some cases, pain from OA in one joint (such as an ankle or knee) can prompt you to walk, stand or move differently, which can, in turn, force other joints (such as the hip or joints of the spine) out of alignment and predispose them to OA as well.
Unfortunately, we don't fully understand the reasons OA progresses or have therapies to effectively stop the progression. For OA in general, the most helpful advice is to maintain an ideal weight, avoid overusing joints that are damaged and follow a plan of exercise that strengthens the muscles supporting the joint. Your doctor or physical therapist should be able to help you with any of these.
Grant W. Cannon, MD, Rheumatologist
Back to Top
Exercising with OA and Fibromyalgia
Q: I have fibromyalgia as well as osteoarthritis (OA). I would like to do some exercises to regain muscle mass and improve flexibility, but weight-training leaves me with worse pain. What do you recommend?
A: Many of my fibromyalgia patients tell me their pain worsens when they exercise - particularly if they are just starting an exercise program. The truth is that you will have to stick with an exercise program for about six weeks, exercising two or three times per week, to start feeling or seeing any benefit.
Don't start a program while your fibromyalgia is flaring - wait until you're at your usual baseline. Then start slowly, giving yourself a day or two between workouts. If you can stick it out, I think you'll find the benefits of exercise worth the temporary increase in discomfort.
Start with lots of range of motion work, taking each joint through its full range of motion five to eight times. Continue your exercise session by walking in a warm pool, if you have access to one. If you don't have access to a pool, walking on land is acceptable, as is using an exercise bicycle or elliptical trainer. I don't recommend stairclimbers or running at this stage. The goal is to get your heart and lungs in shape and get the blood flowing to your muscles and joints.
After three to four weeks, add weight training, but instead of doing a lot of repetitions (reps) with a low weight, consider doing fewer reps (no more than six to eight at a time) with a higher weight. Aim for three sets of reps two to three times a week for each muscle group. How fast you progress depends on how you feel, and you have to judge for yourself if you feel you've overdone it.
In general, if it hurts when you do the exercise, you should back off on the intensity or the number of reps. However, feeling sore a day or two after exercise is often the normal response to muscles being challenged; as your muscles become conditioned to exercise, the soreness should diminish. A prolonged increase in pain, however, could be a sign you've done too much too soon and you should cut back to just range-of-motion and stretching exercises.
Ronenn Roubenoff, MD, Rheumatologist
Back to Top
Inflammatory OA -- an Oxymoron or Actual Condition?
Q: What is inflammatory osteoarthritis? Is this different from "regular" osteoarthritis?
A: For most people familiar with osteoarthritis (OA), the term “inflammatory osteoarthritis” sounds like an oxymoron. That’s because we typically think of arthritis as being either inflammatory (such as rheumatoid arthritis [RA]) or non-inflammatory (such as OA).
However, there is a form of OA that is clearly inflammatory. It typically comes on suddenly in middle-aged women, affecting the last (closest to the fingernail) and middle joints of the fingers. For someone unfamiliar with the condition, it can easily be confused with other forms of inflammatory arthritis that affect the fingers, such as RA or psoriatic arthritis.
If you have sudden pain and swelling of the joints in your fingers, it’s important to get a proper diagnosis, because treatment for this inflammatory form of OA is different from treatment for RA or typical OA. Inflammatory OA is generally treated with nonsteroidal anti-inflammatory drugs and, very rarely, corticosteroid injections directly into the affected joints. The disease-modifying antirheumatic drugs, such as methotrexate and leflunomide (Arava) prescribed for RA are not appropriate for this type of arthritis.
A physician who is familiar with your clinical, laboratory and X-ray findings will be able to provide the proper diagnosis and therapy for this condition.
Paul Howard, MD, Rheumatologist
Back to Top
Getting By Without Drugs
Q: I have osteoarthritis (OA) in both knees, which makes it very difficult for me to walk. I would like to avoid medications if possible.
Is there a diet or something other than drugs that might help?
Yes, there are plenty of options beside medications that can help OA of the knee. Diet, nutritional supplements, exercise and splinting are all important components of a comprehensive treatment plan to ease the symptoms of OA and possibly delay or retard its progression.
Diet. Diet is very important, but it has less to do with what you eat than how much you eat. Being overweight worsens arthritis pain and disability. Rather than going strictly by numbers on a scale, doctors commonly use a measure called body mass index (BMI) to determine obesity. A BMI of 19 to 24 is optimal. If yours is higher, you should lose weight. To calculate your BMI and determine how close you are to your ideal weight range, take your body weight and multiply it by 703, then divide that by your height in inches squared. Let's say, for example, you are 5 foot, 4 inches tall (64 inches) and you weigh 150 pounds. Your BMI would be (150 x 703) ÷ (64 x 64) = 25.74, slightly overwheight.
Supplements. One of the most promising treatments for OA is the dietary supplement glucosamine. Taken in doses of up to 1,500 mg a day, glucosamine has been shown to reduce pain and possibly slow the progression of cartilage loss. Most studies have been performed with pharmacy-grade glucosamine, so it is important to find a high-quality product. If you see "GMP" on the label, you can be assured that the product has been manufactured using "Good Manufacturing Principles."
Exercise. If walking to lose weight is out of the question, there is much more you can do to strengthen the large set of four muscles on the top of the thigh, called the quadriceps. When these muscles are strong, they support the knees, so that less stress is put on the joints themselves. As a result, movement is easier and less painful. Before you embark on an exercise program for your knees, speak to your physician or a physical therapist; either can prescribe helpful exercises. While exercise, in general, is good, you want to steer clear of heavy weights and squatting moves that may cause more damage.
Splints and braces. These devices used to support or stabilize a joint usually aren't a permanent solution by themselves. In cases of knee OA, for example, doctors often prescribe braces for people to use until they have sufficiently strengthened supporting muscles through exercise. Braces and splints may be store bought or custom designed and made by a physical or occupational therapist or orthotist, a person who specializes in making braces and splints.
In addition to these options, there are several other pain-relieving techniques you may try on your own. Apply heat or cold packs, or a combination of the two, to aching joints. Soak in a warm tub or spa, or try practicing relaxation techniques. Surgery, although it is a last resort, can be done using minimally invasive techniques. For more ideas, check out the article "When Knees Go Bad,"
Paul Howard, MD, Rheumatologist
Back to Top
Q: Is there scientific evidence that sleeping on a magnet-filled mattress pad will help OA?
A:One very small study suggested a magnet-filled mattress pad would help, but this would need to be replicated before I would recommend you pursue this therapy. My suggestion would be to consider purchasing a magnet to wear over the area of the body where you need pain relief before making a more substantive investment in a magnetic mattress pad. In one Harvard University study of people with knee OA, those who wore a sleeve containing a high-powered magnet over their affected knee reported greater pain relief after four hours than those wearing a placebo knee sleeve.
Daniel Clauw, MD, Rheumatologist
Q: With both fibromyalgia and osteoarthritis, I have constant pain. Even with treatment, it never goes away completely. I’ve just been “dealing with it.” Is that OK?
A: Chronic pain is not a problem you should just put up with; in fact, you should make every effort to reduce it because an increasing number of studies are showing serious consequences of having chronic pain. It may cause damage to certain areas of the brain, just as chronic stress does. It also may lead to psychological problems, such as depression; social problems, such as isolation or decreased earning potential; and functional problems, such as decreased activity or disability.
Overall, people do far better if they take an active role in aggressively managing their chronic pain-inducing condition(s). You should treat pain, as long as the treatments you use do not have side effects that exceed the benefits. Practicing relaxation techniques and sticking with a regular exercise plan may reduce pain in some of the same ways as pain medications. Massage and some supplements also may provide similar benefits, but these therapies have had less research documenting the benefits.
For moderate-to-severe knee osteoarthritis (OA), the supplement glucosamine may provide some relief, as may the right combination of analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs). The analgesic tramadol (Ultram), four antidepressant medications – amitriptyline (Endep), cyclobenzaprine (Cycloflex), duloxetine (Cymbalta) and fluoxetine (Prozac) – and two anti-seizure medications – gabapentin (Neurontin) and pregabalin (Lyrica) – have been studied in people with fibromyalgia. In fact, Lyrica, which eases pain, promotes sleep and reduces fatigue, has just been approved by the FDA to treat fibromyalgia.
Tell your doctor that the treatments you tried previously are not resolving your chronic pain, and then work with him to find the right combination of treatments for you. It may take some time, but the end result will be worth the effort.
Daniel Clauw, MD, Rheumatologist
Q: I have OA of the spine. I have frequent headaches and wonder if they could be related to my arthritis. If so, what can I do? Regular pain relievers don’t help.
A" Occasionally headaches can occur as a result of osteoarthritis (OA) high in the neck where the spine meets the skull, but that is unusual.
Because you say pain relievers do not help, I suspect you may be experiencing rebound headaches, also called medication-overuse or toxic headaches. Taking pain relievers or other headache medications (such as those prescribed for migraine headaches) too frequently can create a negative cycle. For example, the labels on some pain relievers say to use the medication for no more than 10 days; if you use them longer, your body may become accustomed to them. Then, when you do stop, your body goes through a form of withdrawal. You experience headaches, much like the ones that occur when some people don’t get their morning caffeine. That spurs you to take more pain-relief medicine, worsening the problem.
If rebound headaches aren’t your problem and over-the-counter (OTC) analgesic medications, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin) or naproxen (Aleve), don’t help, I suggest you see a physician and ask for a different type of medication, as there are many types. For example, an antidepressant, taken on a daily basis, may help prevent headaches without causing rebound headaches.
Also discuss with your physician the possibility that you may have a more diffuse pain syndrome, such as fibromyalgia. People with fibromyalgia often have pain in the spine as well as headaches that don’t respond to typical pain relievers. If your doctor does diagnose fibromyalgia, a treatment plan of exercise, analgesic medications and perhaps antidepressants to improve deep sleep can help relieve your headaches as well as the pain in your spine.
Daniel Clauw, MD, Rheumatologist
