Osteoarthritis

Often the joint appears a little swollen, due to hard bony osteophytes, or extra synovial fluid in the joint (which will feel soft), while the muscles around the joint look a little thinner.

Symptoms often vary for no obvious reason, with bad spells of a few weeks or months being broken by much better periods. Changes in the weather (especially damp and low pressure) can make joint pain worse for some people while for others it is related to the amount of physical activity they've done.

Almost any joint can develop osteoarthritis but the knees, hips, hands, spine and big toes are most often affected.

Osteoarthritis of the knee

Osteoarthritis of the knee is a very common form of osteoarthritis. This is probably because the knee has to withstand extreme stresses, twists and turns.

Osteoarthritis of the knee affects the cartilage covering the main surfaces of the knee joint and also the cartilage underneath the kneecap (patella).

Osteoarthritis of the knee is twice as common in women as in men and usually affects both knees. It causes most problems from the late 50s onwards. A number of factors increase the risk of osteoarthritis of the knee:

• being overweight
• having nodal osteoarthritis (particularly in women)
• a previous sporting injury (such as a tear of the meniscal cartilage or ligaments)
• an operation to remove torn cartilage (meniscectomy).

Pain is usually felt at the front and sides of the knee. In severe cases, the knees may become bent and bowed. The knee joint may also become unstable so that it gives way when you put weight on it – this is usually because of damage to the ligaments.

It's estimated that:

• More than six million people in the UK have painful osteoarthritis of the knee.
• More than 650,000 have painful osteoarthritis in the hips.
• More than one million adults consult their GP each year with osteoarthritis.

Factors that can increase the risk of osteoarthritis include:

• Age – Osteoarthritis usually starts from the late 40s onwards. We don't fully understand why it's more common in older people but it's probably due to factors such as weakening of the muscles and the body being less able to heal itself.
• Gender – For most joints, especially the knees and hands, osteoarthritis is more common and more severe in women.
• Obesity – Being overweight is an important factor in causing osteoarthritis, especially at the knee. It also increases the chances of osteoarthritis becoming progressively worse.
• Joint injury – A major injury or operation on a joint may lead to osteoarthritis in that joint in later life. Normal activity and exercise don't cause osteoarthritis, but very hard, repetitive activity or physically demanding jobs can increase the risk.
• Joint abnormalities – There are some abnormalities that you can be born with or that develop in childhood, such as Perthes' disease of the hips, which lead to osteoarthritis in later life.
• Genetic factors – Nodal osteoarthritis, which particularly affects the hands of middle-aged women, runs strongly in families. And some rare forms of osteoarthritis that start at an earlier age are linked with genes that affect collagen – an essential component of cartilage. Genetic factors play a significant part in knee and hip osteoarthritis, although factors such as obesity and joint injury are also important in these types.
• Other types of joint disease – Sometimes osteoarthritis is a result of damage from a different kind of joint disease, such as rheumatoid arthritis, that occurred years before.

Osteoarthritis isn't associated with cancer or other serious illnesses, although osteoarthritis is so common that these things might occur together by chance sometimes.

Your doctor may look for the following symptoms:

• bony swelling
• creaking of the joint
• restricted movement
• tenderness over the joint
• thinning of the muscle
• excess fluid
• instability in the joints.

What tests are there?

There is no blood test for osteoarthritis, although blood tests are sometimes taken to help rule out other types of arthritis.

X-rays are the most useful test to confirm osteoarthritis, although often they won't be needed. The x-ray may show the space between the bones narrowing as the cartilage thins, and changes in the bone such as spurs. Calcium deposits may also show up on knee x-rays.

Occasionally, if the diagnosis is uncertain, musculoskeletal ultrasound or a magnetic resonance imaging (MRI) scan can be helpful. These show the soft tissues – cartilage, tendons, muscles – which cannot be seen on an x-ray and may show the type of mild inflammation which may be found in osteoarthritis.

Osteoarthritis drugs

• Painkillers (analgesics) often help the symptoms although they don't affect the arthritis itself. They are best used occasionally for bad spells, or when extra exercise is likely. Paracetamol is usually the best painkiller to try first. Combined painkillers (e.g. cocodamol, codydramol) contain paracetamol and a second codeine-like drug and may be helpful for more severe pain.
• Non-steroidal anti-inflammatory drugs (NSAIDs) may be prescribed if inflammation in the joint is contributing to the pain and stiffness. A low dose of ibuprofen or naproxen are common options. These will usually be given with a tablet to help protect the stomach.
• NSAID creams, gels or liquids to rub on often help, especially for knee and hand osteoarthritis. These can be helpful if you have trouble taking tablets.
• Capsaicin cream (made from capsicum, the pepper plant) is also an effective painkiller. It needs to be regularly applied each day to be effective.
• Stronger painkillers (e.g. tramadol, nefopam, meptazinol) may be required for people with severe pain if other medications don't provide adequate relief. Some opioids can be given as a plaster patch on the skin which can give pain relief for a number of days.

Because these tablets and creams work in different ways it may be useful to combine them. Your chemist can advise you and offer paracetamol, and some low-dose NSAID tablets and creams without a prescription. However, you can only get capsaicin cream, most NSAID tablets and creams, strong combined painkillers and opioids on prescription from your doctor.

Injections are sometimes given directly into the affected joint:

• A steroid injection into the joint may improve pain for several weeks or even months, especially in a hip, knee or thumb. This is mainly reserved for very painful osteoarthritis.
• An injection of hyaluronan into the knee may help a few people with knee osteoarthritis, although it is not often used. Hyaluronan is similar to the thick, viscous component of normal joint fluid and is normally given as a course of injections once a week for 3–5 weeks, or occasionally as a single injection.

Physical therapies

Physiotherapy can play an important part in keeping the joints mobile. A physiotherapist can devise a programme of exercises tailored to your individual needs. An occupational therapist will be able to advise on techniques, aids and appliances that will allow you to get on with your daily jobs without putting too much strain on your joints.

Surgery

Surgery may be recommended if pain is very severe and/or you have mobility problems. Hip and knee replacements can give substantial pain relief in cases where other treatments haven't helped.

Sometimes, if your knee locks, keyhole surgery techniques may be used to wash out loose fragments of bone and other tissue from the joint (this is called arthroscopic lavage and isn't recommended unless the knee locks). Additional procedures are occasionally carried out – such as smoothing the surfaces of the joint and trimming torn soft cartilage (this is called debridement). These techniques can't repair the damage to the knee but may offer pain relief in the earlier stages of osteoarthritis.

Exercise

It's very important to keep your joints moving. There are two types of exercise that you need to do.

• Strengthening exercises can improve the strength and tone of the muscles that move the osteoarthritic joint. This helps to stabilize and protect the joint, and reduces the pain.
• Aerobic exercise that increases your pulse rate and makes you breathless can also reduce your pain. Regular aerobic exercise encourages a better night's sleep, is good for your general health and well-being, and should improve your stamina.

Swimming can be very good for osteoarthritis. Because the water supports the body's weight very little force goes through the joints as you exercise. Prescribed exercises in a hydrotherapy pool can help get muscles and joints working better.

A physiotherapist can advise on appropriate exercises depending on what type of osteoarthritis you have. Exercising the thigh (quadriceps) muscle is especially important for knee osteoarthritis – as this muscle is almost always weakened by osteoarthritis of the knee.

Quadriceps-strenthening exercises

You will need to find the right balance between rest and exercise. Most people with osteoarthritis find that while too much exercise worsens their pain, their joints stiffen up if kept still for too long.

Diet and nutrition

Although no specific diet is recommended for osteoarthritis there is a great deal of evidence that any additional weight increases the strain on the joints – especially the back, hips, knees and feet – so it is important to maintain a healthy weight.

Complementary therapies

Many people find glucosamine and chondroitin tablets helpful, especially glucosamine sulphate at a dose of 1.5 g a day. Joint cartilage normally contains these compounds and some research suggests that taking supplements may improve the health of damaged cartilage. You may need to take them for several weeks before any pain relief is apparent. People with shellfish allergies should look for vegetarian or shellfish-free varieties.

Back and neck pain are often helped by manipulation from chiropractors or osteopaths, although the use of manipulation for osteoarthritis in other joints is limited.

Acupuncture has a proven, though short-term, pain-relieving effect. Regular sessions may produce longer-lasting benefits.

Research into complementary and alternative therapies is continuing all the time. Arthritis Research UK has published a detailed authoritative report on these therapies for rheumatoid arthritis, osteoarthritis and fibromyalgia. This report contains detailed information about a number of complementary and alternative medicines that are taken by mouth or applied to the skin.

Reducing strain on the joints

Apart from keeping an eye on your weight there are a number of ways you can reduce the strain on your joints:

• Pace your activities through the day – avoid tackling all the physical jobs at once.
• Wear shoes with thick soft soles that act as shock absorbers for your feet, knees, hips and back, and avoid high heels as these will alter the angle of the hip, knee and big toe joints and put additional strain on these joint.
• Use a walking stick to reduce the weight and stress on a painful hip or knee (a therapist or doctor can advise on the correct length of the stick).
• Use the hand-rail for support when climbing stairs – this is particularly important if you have osteoarthritis of the knee.
• Keep your joints moving. In particular, don't keep an osteoarthritic knee still in a bent position for too long as this will eventually affect the muscles.
• Avoid activities that put a lot of strain on your joints. Think about modifying your home, car or workplace to minimize unnecessary stresses. An occupational therapist can advise on joint protection techniques and on gadgets that may be helpful.
• Learning to relax your muscles and get the tension out of your body can also help. Physiotherapists and occupational therapists can advise on relaxation techniques.

What else should I know about osteoarthritis?

• Applying warmth to a painful joint often relieves the pain and stiffness of osteoarthritis. Heat lamps are popular, but a hot-water bottle is just as effective.
• Sex may be painful, particularly for women with osteoarthritis of the hips. Using different positions can often help.
• If you have difficulty opening childproof containers ask the pharmacist to put your drugs in a more suitable container. Contact Arthritis Research UK for a special request card which you can hand to your pharmacist with your prescription.