Health & Wellness
Unhinged

Unhinged

Understanding joint pain

Often, we don't thoroughly appreciate the role our joints play in our body until they hurt. Suddenly, it's harder to climb stairs or a shoulder aches too much to blow-dry hair. Joint pain can not only take some of the fun out of life, but it can also make it harder just to get through the day. From running races to running errands, joint function impacts the daily quality of life. When is the pain a problem?

Basically Bent

A joint is a meeting place of bone and muscle, tendons and ligaments. Cartilage is also present and, depending on the joint, there may also be synovial fluid for lubrication. There are six different types of synovial joints in the body that move in different ways. One type can hinge, for example, like the elbow, while another fits together like a ball and socket, like in the shoulder.

The knee is your largest joint and the most complex, with three bones, two types of cartilage and ligaments, and tendons. According to Spero G. Karas, MD, director of Emory's Orthopaedic Sports Medicine Fellowship Program, the joints that are most problematic are the weight-bearing joints such as the knee, hip and ankle. When walking up and down stairs, for example, the knee bears three times one's body weight—so, a 150-pound person exerts 450 pounds of weight on the patella. A squat, like a lunge on the tennis court, can exert five to seven times your body weight on the same joint. The hip joint withstands similar forces, according to Stanley H. Dysart, MD, of Pinnacle Orthopaedics. Rising from a seated position to standing burdens the hip with three to five times your body's weight.

Joints are work horses, made for wear and tear and constant usage. But they weren't made to last forever, to endure severe or recurring trauma or to withstand certain diseases.

image-1Inflamed

All musculoskeletal pain is inflammatory in nature; joint pain falls into this category. When the body "diagnoses" itself as damaged or ill, it activates blood vessels, blood cells and hormones to initiate its own "treatment." That's what causes swelling and subsequent pain. This inflammation can be short-term, related to, say, a sprained ankle, or it could be chronic, as in conditions like osteoarthritis or lupus. For you to choose a correct course of treatment, the exact cause of the inflammation must be assessed.

Julia Kao, MD, a hip- and knee-replacement surgeon with Resurgens Orthopaedics, emphasizes the importance of getting a correct diagnosis and when to intervene. "If joint pain is affecting your life, figure out what it is. Don't self-treat for too long." She often sees patients who have waited until their problems are quite serious—a man who came in after his knee buckled to find out that he had severe arthritis, an older woman who had been seeing a chiropractor who actually had a broken hip. Pain that doesn't resolve itself is a clear indicator that it's time to make an appointment with a physician.

SB-1Some general practitioners are willing to take the first steps to diagnosis, while others prefer to direct a patient to an orthopaedist immediately. A provider will take a family history, inquire about your health habits and do a hands-on physical exam. They will usually schedule an X-ray and sometimes do lab tests as well.

Painful Truth

So when something goes wrong, what's the culprit?

Conditions like "tennis elbow," which is a type of tendinitis, muscle strains and bursitis are easily treated. Many autoimmune diseases that are tougher to treat cause joint pain, from lupus to fibromyalgia to rheumatoid arthritis (RA). Very often, the cause of joint pain is osteoarthritis (OA), a degenerative disease of the joints that breaks down the cartilage that keeps them moving smoothly and pain-free. When people talk about arthritis, they are usually talking about OA.

"Arthritis is caused by a mix of factors. If everyone in your family has terrible knees, you'll probably have terrible knees," says Dr. Kao. "If you were a college athlete and had terrible injuries, the effects will show up when you're older. If it's a factor we can't change, like genetics, we'll just deal with it. But if it's a modifiable risk factor, like weight or smoking or drinking or steroid use, let's change it." Nearly one in two people have knee arthritis by the time they're 85, and one in four have hip arthritis.
Obesity can make arthritis worse, much earlier. "The weight conversation is a tough one," says Dr. Kao. "Sometimes I see a patient in their thirties with terrible arthritis. The good news is that one pound lost [equals] four pounds of stress taken off your knee, for example. Losing even a little bit of weight helps with all joint pain." She recommends putting together a plan with your general practitioner or investigating medical weight-loss programs.

An important thing to remember about OA is that it's "persistent and progressive," says Dr. Dysart. It can, and will, get worse if you don't protect your joints.

The RICE Way

The first step of joint-pain treatment is always RICE: rest, ice, compression, elevation.

"Rest means relative rest, not the complete cessation of activities," says Dr. Karas. "The body needs movement. If you're completely sedentary, you're doing yourself more harm than good. An injured joint needs a gentle range of motion. Synovial fluid, the fluid that lubricates a joint, needs to bathe the joint, and the muscles need to activate or they atrophy. Keep moving or get stiff—and then you have two problems instead of one."

Anti-inflammatories, like ibuprofen, aspirin and naproxen, are also key. They're not like pain pills, which just mask the problem, although they do help with pain; they treat the cause of your pain as well. But anti-inflammatories are meant to be a short-term therapy. For chronic conditions, there are other options: steroid injections in the joint, or viscosupplementation, an injection of lubricating fluid in the knee. Physical therapy may be needed to strengthen the muscles around a joint. "The biggest misconception people have is thinking that because they do aerobic activity, they're strengthening all of their muscles," says Dr. Dysart. "Aerobic activities are good for the heart, but they don't necessarily strengthen the shock absorbers around the hip, for example." The exercises you learn in physical therapy can help with both strength and balance, warding against falls and instability.

Drs. Karas, Kao and Dysart, along with other experienced orthopaedists, recommend exhausting conservative therapies before moving on to surgical ones. "When the patient has failed non-operative treatments, they are functionally disabled, and the pain is unacceptable to them, then it's time to consider joint-replacement surgery," says Dr. Dysart. "Joint replacement is very much elective. It's always the patient's choice."

New surgical techniques, such as the anterior approach to hip replacement that spares the tendons, have vastly improved the patient experience. "It's quite remarkable," says Dr. Dysart. "Today, we can do outpatient, same-day joint-replacement surgeries with minimal pain afterward."

Mix the Risk

Often, changing activities offers a respite to the impacted joints while working a different set of muscles. Doctors recommend thinking of it as adding variety, not limiting your activity.

SB-2"A singles tennis player who's feeling stiff and finding it strenuous to cover the entire court can switch to doubles tennis," says Dr. Karas. "It's about finding reasonable modification. If running five miles a day has become uncomfortable, switch to doing it three times a week and take a good long walk, bike or go to the pool. One of the best exercises for cardiovascular health that's low impact on joints is a good long walk. The difference between calories burned running and walking a mile is only about 20 percent."

Dr. Kao finds that her older patients understand that the body gets creakier as they age, but her patients who are 40 to 60 are often in denial about their bodies getting older. "They're shocked when they see their X-ray and it shows arthritis. They want to get back to what they were doing when they were 20, but the body is saying to take it easy."

"Not everybody is born an opera singer, not everybody is born a comedian and not everybody is born a long-distance runner or a tennis player," says Dr. Karas. The trick to living a long and healthy life that doesn't hurt? Treating your joints with care, keeping an eye on the scale, seeing a doctor when you're in pain and trading in a few tough workouts for ones with gentle
motions.

 

Sources:

American Academy of Orthopaedic Surgeons, aaos.org
Centers for Disease Control and Prevention, cdc.gov
Emory Healthcare, emoryhealthcare.org
Pinnacle Orthopaedics, pinnacle-ortho.com
Resurgens Orthopaedics, resurgens.com