Nonsurgical Relief of Lower Joint Pain

with Omar Darr, M.D., sports medicine/arthroscopic surgery, Advanced Healthcare

Last Updated: Sept. 1, 2003

Osteoarthritis is the leading cause of physical disability, affecting approximately 40 million Americans. It is characterized by a loss of cartilage on the surface of the bones. Since it is the bones of the hips, knees and ankles that take most of the daily pounding of the weight of our bodies, these joints tend to be the ones most affected.

Omar Darr, M.D., orthopaedic surgery & sports medicine/arthroscopic surgery, Advanced Healthcare “Patients can come in with significant disability for everyday activities. For a lot of these patients, conservative measures do help.”

Arthritis is a disease that tends to get more painful as a person ages, making early diagnosis and treatment important. Nonsurgical treatment ranges from lifestyle changes to over-the-counter and prescription anti-inflammatory drugs to cortisone and other injections.

It is particularly important for a person suffering from arthritis to stick to a regimen that alleviates pain and stiffness. This is because the final treatment for severe arthritis, joint replacement, is recommended as a one-time-only procedure. Since artificial joints have an expected life of about 15 to 20 years, most physicians are reluctant to do joint replacement on younger patients.

Dr. Omar Darr, an orthopaedic surgeon and sports medicine specialist/arthroscopic surgeon with Advanced Healthcare, notes the following conservative treatments for osteoarthritis, in the order in which they are usually prescribed.

Lifestyle changes
One of the most beneficial things a patient can do to alleviate the pain and stiffness of arthritis is to lose weight to take stress off the joints. Even a small weight loss can help.

Patients may be asked to start a program of low-impact exercises such as swimming and cycling. Many times physicians also recommend specific exercises geared to help maintain stability and strength in the muscles supporting the joint. This is particularly important when arthritis is affecting the knees, as strong muscles will help the joint function the best that it can.

While exercise is good, Dr. Darr cautions patients to listen to their bodies. “Swelling is a sign of irritation to the joint. It doesn’t do any good to irritate an arthritic joint,” he said.

Braces and more
Arthritis often affects specific limbs and in some cases only a part of them. What is revealed on X-rays can sometimes be treated with devices called unloader braces – a term which describes the device’s ability to take some of the pressure off the damaged part of a joint.

An example of this would be uneven wear of the knee joint (the most common place to use an unloader brace) causing pain on the inside of the knee. A specific type of brace would reduce pressure on the inside of the joint transferring weight to the outside of the knee to alleviate the pain and additional wear.

Other ways of aligning the legs include shoe wedges that redirect the weight bearing forces on the ankle or knee.

Pharmacological options
When activity modifications are not enough to alleviate pain, physicians turn to medications like acetaminophen (the drug in Tylenol).

“Although some patients will not obtain adequate relief from acetaminophen, it merits trial based on its low toxicity profile. It should be used cautiously in patients with liver disease or on chronic blood thinners. Dosage should not exceed 4 grams per day,” Dr. Darr said.

If acetaminophen is not effective, there are other drugs that may work. These include non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen. The most common side effects of these are stomach upset and gastrointestinal bleeding.

Easier on the stomach are the newer COX-2 inhibitors, such as Vioxx and Celebrex. These work by targeting only the source of joint inflammation.

“Any NSAID can cause gastrointestinal (GI) upset or bleeding but there is a lower incidence of this with the COX-2 inhibitors. However, in a patient with no history of ulcers or GI upset who is younger than 60, it makes sense to start with a traditional NSAID,” the doctor said.

A relatively new arrival in the anti-arthritic arsenal is the natural substances, Glucosamine and Chondroitin Sulfate. Clinical studies show that about half of patients with osteoarthritis who take them feel better. “But you need to take enough of it and not give up on it for three to four months. If after that time you are not feeling better, stop taking it and save your money,” Dr. Darr said.

Injections
Injections of hyaluronic acid (Synvisc or Hyalgan) or steroids into an arthritic knee joint can sometimes relieve pain in a way that drugs cannot.

Injections of Synvisc or Hyalgan, called viscosupplementation, seem to work for about half the patients they are used on. Usually three to five injections are given. Sometimes one series will last indefinitely. If not, the injections can be repeated nine months or a year later.

Steroids are the most potent anti-inflammatories. “We usually recommend no more than three or four injections per year, as they become less effective with each successive injection,” Dr. Darr explained.

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