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Osteoarthritis

by © Arthritis Research Campaign 2006

Introduction

This booklet aims to help people who have osteoarthritis, and their families and friends. It helps you understand osteoarthritis – how it develops, and how to deal with it. It also puts to rest some of the myths about this common condition.

The booklet first explains the facts about osteoarthritis, and gives hints and advice on living with it more easily. It then answers some common questions. Three case histories give you an idea of how people usually manage with osteoarthritis.

Near the end of the booklet you will find addresses of organisations that can offer further help, including information on how to contact the Arthritis Research Campaign (arc). There is also a brief glossary of medical words (like cartilage). We have put these in italics when they are first used in the booklet.

What is osteoarthritis?

Osteoarthritis is a disease which affects joints in the body. The surface of the joint is damaged and the surrounding bone grows thicker. 'Osteo' means bone and 'arthritis' means joint damage and swelling (inflammation). Other words used to describe osteoarthritis are 'osteoarthrosis', 'arthrosis' and 'degenerative joint disease'.

To understand how osteoarthritis develops, you need to know how a normal joint works (see Figure 1). A joint is where two bones meet. Most of our joints are designed to allow the bones to move only in certain directions. For example, the knee joint allows the leg to bend fully but only allows limited movement sideways.

The ends of the bones are covered by a thin layer of gristle called cartilage. This cartilage cushions the joint and spreads the forces evenly when you put pressure on the joint. The smooth, slippery cartilage surface also allows the bone ends to move freely.

The knee is the largest joint in the body, and it has extra pieces of gristle (each called a meniscus) between the cartilage layers – these are small rings of cartilage in the shape of washers.

The joint is surrounded by a membrane (the synovium) which produces a small amount of thick fluid (synovial fluid). This fluid helps nourish the cartilage and keep it slippery. The synovium has a tough outer layer called the capsule which stops the bones moving too much.

The bones are kept firmly in place on both sides of the joint by the ligaments. These are thick, strong bands which run within or just outside the capsule. Together with the capsule, the ligaments prevent the bones moving too much or dislocating.

The tendons are strong guiders that attach the muscles to the bones either side of the joint. They also help to keep the joint in place. When a muscle contracts, it shortens and this pulls the bone and makes the joint move. Figure 2 shows what happens when a normal joint develops osteoarthritis.

When a joint develops osteoarthritis, the cartilage gradually roughens and becomes thin, and the bone underneath thickens. The bone at the edge of the joint grows outwards (this forms osteophytes or bony spurs). The synovium swells slightly and may produce extra fluid, which then makes the joint swell slightly. The capsule and ligaments slowly thicken and contract, as if they were trying to stabilise the joint as it gradually changes shape. Muscles that move the joint may weaken and become thin or wasted.

When we look at osteoarthritic joints under a microscope, we see the joint is trying to repair itself. All the tissues of the joint are more active than normal. For example, new tissue is produced to try to repair the damage, such as the osteophytes. In many cases, especially in small finger joints, the repair is successful. This explains why many people have osteoarthritis but experience few or no problems. However, sometimes the repair cannot compensate for the damage. Osteoarthritis may then seriously affect the joint, making it painful and difficult to move. This occurs particularly in large joints such as the knees and hips.

Osteoarthritis is a slow process that develops over many years. In most cases there are only small changes that affect only part of the joint. Sometimes, though, osteoarthritis can be more severe and extensive, and this is shown in Figure 3.

In severe osteoarthritis, the cartilage can become so thin that it no longer covers the thickened bone ends. The bone ends touch and start to wear away. The loss of cartilage, the wearing of bone, and the bony overgrowth at the edges can change the shape of the joint. This forces the bones out of their normal position and causes deformity.

A common complication is where chalky deposits of calcium crystals form in the cartilage (a process called calcification or chondrocalcinosis). These calcium crystals can shake loose from the cartilage, irritate the synovium and cause the joint to become hot, red and swollen (pseudogout). (See arc booklet 'Pseudogout and Calcium Crystal Diseases'.)

What causes osteoarthritis?

Like most other conditions, there are many factors that can increase the risk of getting osteoarthritis. Usually, several of these have to be present before osteoarthritis develops. These important risk factors include the following:

Age

Osteoarthritis usually starts in the late 40s, 50s or 60s and is uncommon before the age of 40. We do not fully understand why it is more common in older people. It is probably due to several factors that accompany growing older – muscles become weaker, we put on weight, and our body is less able to heal itself.

Sex

For most joints, especially the knees and hands, osteoarthritis is more common and severe in women.

Obesity

For many people, this is an important factor in causing osteoarthritis, especially at the knee. Being overweight also increases the chances of osteoarthritis worsening once it has developed.

Joint injury

A major injury or operation on a joint may lead to osteoarthritis at that site in later life. There are some abnormalities of the joint that you can be born with or which develop when you are a child, such as Perthes' disease of the hips, which also lead to osteoarthritis in later life.

Normal activity and exercise is good rather than bad for joints and does not cause osteoarthritis. However, very hard repetitive activity may injure joints. This explains why osteoarthritis is more common in people in some physically demanding jobs, such as farmers (osteoarthritis of the hip) and professional footballers (osteoarthritis of the knee).

Heredity

There is one common form of osteoarthritis (nodal osteoarthritis) that strongly runs in families. This particularly affects the hands of middle-aged women. We do not know which inherited genes lead to nodal osteoarthritis, but we do think that a lot of genes will be involved, not just one
(see 'Will my osteoarthritis affect sex, marriage or my family?').

In knee and hip osteoarthritis, heredity plays a smaller, though still significant, role. At these sites other risk factors such as obesity and joint injury become more important. There are some very rare but dramatic forms of osteoarthritis that start at a young age and run in families. We know these are linked with single genes that affect collagen – an essential component of cartilage.

Other types of joint disease

Sometimes osteoarthritis is caused by injury and damage from a different kind of joint disease that occurred years before. For example, people with rheumatoid arthritis can develop 'secondary' osteoarthritis in those joints in which the rheumatoid inflammation has largely burnt out but where the joint remains damaged by the disease.

Of course there must be other causes, though we do not know what they are yet. However, we know enough to correct some myths. Osteoarthritis is not caused by moderate exercise, by the weather or by a shock. It is not caused by specific items of diet, though it does not help to have poor nutrition as this is bad for muscles, cartilage and bone.

How common is osteoarthritis?

Osteoarthritis is by far the most common joint disease. Knee osteoarthritis is more common than hip osteoarthritis, but taken together they affect 10–20% of people aged over 65, becoming a major cause of pain and disability in the elderly. About 8 million people in this country are affected and about 1 million of these ask for treatment. Of the others, many never realise they have osteoarthritis, or suffer any pain, although it is very common to spot it on x-rays. Osteoarthritis occurs throughout the world, and has been common throughout history. All races are affected, though there are differences between races in how commonly the different joints are affected – for example, hip and hand osteoarthritis are common in Europeans and people of European descent but uncommon in people of Chinese and Afro-Caribbean descent.

What are the different types of osteoarthritis?

Osteoarthritis is very variable. There are many different types, affecting different joints (see Figure 4). The knees, hips, hands, spine and big toes are most often affected.

Osteoarthritis of the knee

Osteoarthritis of the knee is more common in women than men and it usually affects both knees. It causes most problems in the late 50s, 60s and 70s. Being overweight and having nodal osteoarthritis increase the risk of osteoarthritis of the knee in women. A previous sporting injury or operation (such as a cartilage being removed) are more common risks in men and may cause osteoarthritis of just one knee. Sometimes there is no obvious cause. Any pain is usually felt at the front and sides of the knee. In severe cases, the knees may become rather bent and bowed (as in Figure 5). (See arc booklet 'Osteoarthritis of the Knee'.)

Osteoarthritis of the hip

Osteoarthritis of the hip affects men as much as women and often starts in the 40s, 50s and 60s. It may affect one or both hips. The risk is increased in farmers. Sometimes hip problems at birth or childhood (congenital dislocation or abnormal development such as Perthes' disease) may later lead to osteoarthritis. However, in many people there is no obvious cause.

The hip joint is below the groin, and hip pain is usually felt mainly in the front of the groin, but sometimes around the side and front of the thigh, the buttock or down to the knee (so-called radiated pain).

In severe osteoarthritis of the hip, the affected leg may get a little shorter due to the bone on either side of the joint being 'crunched up'. As mentioned above, for some unexplained reason people of Chinese and Afro-Caribbean origin rarely get osteoarthritis of the hip joint. (See arc booklet 'A New Hip Joint'.)

Osteoarthritis of the hands

Osteoarthritis of the hands usually occurs as part of nodal osteoarthritis. This mainly affects women, and often starts in the 40s and 50s, around the time of the menopause ('the change'). Most often it affects the base of the thumb and the joints at the end of the fingers. At times these joints become red, swollen and tender, especially when the condition first appears.

Gradually, over several years, firm knobbly swellings form on the back of the joints (see Figure 6). These are called Heberden's nodes after the English physician, William Heberden, who first described them. Once the Heberden's nodes are fully formed, pain and tenderness often improve. However, the base joint of the thumb may continue as a persistent problem. Although the fingers are knobbly and sometimes slightly bent, they work well and rarely cause long-term problems. However, having nodal osteoarthritis in middle age means you are more likely to develop osteoarthritis of the knee, and occasionally a few other joints, as you get into your 60s and 70s. This is why it is sometimes called 'generalised' (widespread) osteoarthritis. Nodal osteoarthritis is mainly related to genes that are inherited and so it runs in families. It is almost completely confined to white people. (See also the x-ray shown in 'What tests can show osteoarthritis?' (Figure 8).)

Osteoarthritis of the neck and back

Osteoarthritis of the neck and back is often called spondylosis. X-rays show that it is extremely common, but it often causes no trouble, and what is seen on the x-ray bears little relationship to pain or stiffness in the spine. About half the population gets back pain from time to time, but osteoarthritis is not the most frequent cause of this. (See arc booklet 'Back Pain'.)

Osteoarthritis of the foot

Osteoarthritis of the foot generally affects the joint at the base of the big toe. Eventually the toe may become stiff (hallux rigidus), which makes walking difficult, or bent (hallux valgus), which can lead to painful bunions (see Figure 7). (See arc booklet 'Feet, Footwear and Arthritis'.)

Osteoarthritis with crystals

Chalky deposits of calcium crystals can form in the cartilage in joints (a process called calcification or chondrocalcinosis). This calcification mainly occurs in the knee joint, especially in older people. It shows on the x-ray, and the crystals can be identified in synovial fluid which has been removed from the knee through a needle.

Because most of the crystals are made of calcium pyrophosphate, this form of osteoarthritis with crystals is often called pyrophosphate arthritis (or chronic pyrophosphate arthritis). It tends to be more severe and to progress more rapidly than osteoarthritis without crystals. Also, the crystals can cause occasional attacks of very painful swelling (pseudogout, or acute pyrophosphate arthritis).
(See arc booklet 'Pseudogout and Calcium Crystal Diseases'.)

Does osteoarthritis vary for different people?

Osteoarthritis occasionally develops in different joints from those already mentioned. Almost any joint can develop osteoarthritis, especially if it has been badly injured. Even for two people with osteoarthritis of the same joint, their osteoarthritis can affect them very differently. Some people have no problems, or just mild trouble. Pain is the main problem for some, while others find it difficult to move and use the joint. Some stay the same for years, others experience a lot of change. Osteoarthritis is so variable it is difficult to generalise. So comparing yourself to someone else with osteoarthritis will not help much.

What are the symptoms and signs of osteoarthritis?

Osteoarthritis tends to creep up on you, gradually increasing over months or years. Stiff and painful joints are the main symptoms. The pain tends to be worse on exercising the joint and at the end of the day. Stiffness after resting usually 'works off' in just a minute or two as the joint gets moving again. The joint may not move as freely or as far as normal, and often 'creaks' or 'cracks' when moved. Occasionally the joint seems to give way because of weak muscles or loss of stability. Muscle exercises can strengthen the muscle and help prevent this (exercises and other helpful hints are discussed later in this booklet).

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 – others find it depends on how much physical activity they do.

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

In some advanced cases, more severe and constant pain may develop and occur not only with or after exercise but even at rest or at night. Certain daily tasks and activities may then prove difficult, depending on which joint is affected. For example, osteoarthritis of the knee or hip may cause difficulties going down and up stairs, getting in or out of the car, getting up from sitting, or putting on shoes and socks. Mobility may be affected due to pain on walking. These difficulties can restrict what you can do and limit your independence.

How does the doctor diagnose osteoarthritis?

It is usually the symptoms and signs mentioned above which lead your doctor to diagnose osteoarthritis. When your joints are examined, your doctor can feel the bony swelling and creaking of the joint and see any restricted movement. Your doctor will also be looking for tenderness over the joint, and any thinning muscle, excess fluid, or instability in the joints.

What tests can show osteoarthritis?

There is no blood test for osteoarthritis, although blood tests are sometimes done to help rule out other types of arthritis. The x-ray is the most useful test to confirm osteoarthritis. Often it will show the space between the bones narrowing as the cartilage thins, and changes in the bone such as spurs. Calcification may also show up on knee x-rays. Although the x-ray helps the diagnosis, it does not predict the amount of trouble you will have. An x-ray that looks bad does not necessarily mean a lot of pain or disability.

What are the prospects if I have osteoarthritis?

Osteoarthritis does not always get worse. Most people with osteoarthritis do not become severely disabled and they carry on a normal life. For many people, osteoarthritis reaches a peak a few years after the symptoms start and then either stays the same or gets a little easier. For others, one or more joints (especially a hip or knee) worsens as the years go by, and it may become painful and disabling.

Sometimes osteoarthritis gets better by itself, but this is unusual. Doctors cannot predict the outcome in individual cases. However, there are a number of treatments that can improve symptoms, and certain changes in lifestyle can greatly reduce the risks of osteoarthritis progressing. Regular appropriate exercise, reducing stress on the joints and maintaining an ideal weight through healthy eating will all help. So to a certain extent the person with osteoarthritis is in control of his or her own outcome.

What can I do to help myself?

Although there is no cure for osteoarthritis, there are many ways in which you can relieve your symptoms and reduce the likelihood of things progressing. Doctors, nurses and therapists are there to guide you, but it is important that you get to know about osteoarthritis and its treatments so you can take the lead in looking after yourself and your osteoarthritis.

Two aspects of your daily routine and lifestyle may need to be changed. These can prove more important in the long term in helping your osteoarthritis than any tablet or medication.

Reduce stress on the joints

Firstly, you can reduce the stress on painful osteoarthritic joints. This can be done in a variety of ways:

• Keep to your ideal weight. If you are overweight, losing even a few pounds will reduce the stress on your hips, knees and feet. Regaining your ideal weight is extremely important for your joints, but is difficult and you need to be determined. Combining regular exercise with a diet is often better than dieting alone. 'Dieting' means altering your eating habits forever, not just for a few months.
• Pace your activities through the day. Spread physically hard jobs (such as housework, mowing the lawn) at intervals through the day, rather than tackling them all at once.
• Wear shoes with thick soft soles that act as shock absorbers for your feet, knees, hips and back. Trainers with 'air' soles are ideal, but many fashion shoes now use these soles. For women it is also important to have flat heels. Raised heels alter the angle of the knee and hip and put additional strain on these joints.
• 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 and how to use it properly.
• Protect your joints. Avoid unnecessary activities that put a lot of strain on your joints. Think of modifying your home, car or workplace to minimise unnecessary stresses. If you find it hard to cope at home, an occupational therapist can give you advice on ways to protect your joints and improve the amount you can do. (See arc booklet 'Your Home and Arthritis' and leaflet 'Occupational Therapy and Arthritis'.)

Activity and exercise

Secondly, you need to keep your joints moving. There are two types of exercise that you need to do. Firstly, strengthening exercise will improve the strength and tone of the muscles that act over your osteoarthritic joint (for example, the front thigh muscle, or quadriceps, for knee osteoarthritis). This helps to stabilise and protect osteoarthritic joints and reduces the pain. Such strengthening exercise also reduces your risk of falling over, a common problem in older people. Secondly, any exercise that increases your pulse rate and makes you breathless (aerobic exercise) can also reduce your pain and allow you to do more. Regular aerobic exercise encourages a better night's sleep and is very good for your general health and well-being. Regularly undertaking both forms of exercise can greatly help people with osteoarthritis, and over several months can relieve pain and improve movement.

A physiotherapist can teach the correct exercises, but then it is up to you to continue them as part of your daily routine, just like brushing your teeth. Appropriate exercises can be planned to fit the individual and can benefit anybody regardless of age. (See arc leaflet 'Keep Moving'.)

Learning how to relax your muscles and get the tension out of your body can also help enormously, especially when you are in pain. Physiotherapists and occupational therapists can give you advice on how to relax, how to overcome mobility problems, how to avoid joint strain and how to cope with pain. (See arc booklet 'Pain and Arthritis'.)

Will any tablets or creams help?

Painkillers often help symptoms and make it easier to get about. They do not affect the arthritis itself, but take the edge off pain and stiffness. They are best used occasionally for bad spells, or when extra exercise is likely. Never take more than the recommended dose. Paracetamol is the simplest and safest painkiller and is the best one to try first. Combined painkillers (e.g. cocodamol, codydramol) contain paracetamol and a second codeine-like drug. They may be stronger than paracetamol but are more likely to cause side-effects, such as constipation or dizziness.

Inflammation in the joint may contribute to the pain and stiffness so your doctor may prescribe a course of non-steroidal anti-inflammatory drugs (NSAIDs). These help some people more than paracetamol, but are more likely to cause side-effects such as indigestion, diarrhoea, ankle swelling and skin rashes. There is a small but significant risk of bleeding from the stomach and NSAIDs should not be given to anyone who has had stomach ulcers. A low dose of ibuprofen is the safest of these and the usual one to try first. Newer NSAIDs ('coxibs') are safer on the stomach and gut but can still cause the other side-effects of NSAIDs. 'Coxibs' have been linked with increased risks of heart attack and stroke and should not be given to people who have had either in the past, or to people with uncontrolled high blood pressure. (See arc leaflets 'Drugs and Arthritis', 'Non-Steroidal Anti-Inflammatory Drugs' and booklet 'Pain and Arthritis'.)

NSAID creams and gels often help, especially for knee and hand osteoarthritis. These are extremely safe – very little is absorbed into the bloodstream.

Capsaicin cream (made from capsicum, the pepper plant) is also an effective and safe painkiller. The first few times it is applied it may cause a warming or burning feeling, but this wears off with regular use. It needs to be regularly applied each day to be effective.

There are stronger painkillers (e.g. tramadol, nefopam, meptazinol) that may be required for people with severe pain that is unrelieved by the medications mentioned above. Unfortunately, although they are stronger painkillers they commonly have side-effects, especially nausea, dizziness and confusion, and need to be taken carefully under regular supervision from your doctor.

Because these tablets and creams work in different ways it may be useful to combine them if each seems to work but is not strong enough on its own. 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, and strong combined painkillers on prescription from your doctor.

Many people try glucosamine and chondroitin tablets that they buy themselves from health food shops and chemists. These products may also be available on prescription. The reason behind their use is that joint cartilage normally contains glucosamine and chondroitin compounds and taking supplements of these natural ingredients may help improve the health of damaged osteoarthritic cartilage. Current research is trying to establish whether this is true. Nevertheless, many people report them to be effective and at least they appear to be safe, although they should not be taken by people who have an allergy to shellfish. They may need to be taken for several weeks before any pain relief is apparent.

How can severe osteoarthritis be treated?

A steroid injection into the joint may successfully improve pain for several weeks, especially in a knee or thumb. This is mainly reserved for very painful osteoarthritis, and for attacks of pseudogout. It often works very well and very quickly (within a day). Some people may be helped by an injection of hyaluronan into their knee. 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. It takes longer to work than a steroid injection.

Surgery can succeed in the few cases where severe pain has developed and caused mobility to be limited in spite of other treatment. Hip replacement is very successful in bad cases. Knee replacement is now also successful in bad cases (see Figure 11). New types of surgery for knees and other joints are developing, and the success rate is improving all the time. (See arc booklets 'A New Hip Joint', 'A New Knee Joint'.)

What if I have difficulty with containers?

If you have difficulty opening childproof bottles you can ask the pharmacist to put your drugs in a more suitable container. Apply to arc for a special request card which you can hand to your pharmacist with your prescription.

Next page:  Some Common Questions Answered