Osteoarthritis – Stages, Causes, Treatment and Prevention

Definition

Osteoarthritis (also known as OA) is a common joint disease that most often affects middle-age to elderly people. It is commonly referred to as “wear and tear” of the joints, but we now know that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. Although it is more common in older people, it is not really accurate to say that the joints are just “wearing out.” It is characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).

Osteoarthritis in knee joint

OA tends to affect commonly used joints such as the hands and spine, and the weight-bearing joints such as the hips and knees. Symptoms include:

• Joint pain and stiffness
• Knobby swelling at the joint
• Cracking or grinding noise with joint movement
• Decreased function of the joint

Stages of Osteoarthritis

There are four stages of OA that have symptoms ranging from mild to severe. Treatment options vary by stage.

Patient with early stage disease can take supplements and modify their exercise routine to minimize joint damage, while patients with late-stage disease may need surgery to relieve pain and loss of joint function.

Stage 1: Minor

People with stage one (doubtful) disease have minor wear-and-tear at the joint and typically feel little to no pain. This stage doesn’t usually call for treatment, but a doctor may advise supplements and modifying exercise routines to protect joints.

Stage 2: Mild

At this stage, X-rays will begin to show bone spurs at the joint. People will start to feel some pain and stiffness in the join, especially after long periods of rest or after activity. Treatments at this stage involve over-the-counter medications, modified exercise routines and a fitted joint brace.

Stage 3: Moderate

People with stage three OA have pain and stiffness during normal daily activity. This is caused by the cartilage that normally cushions the joints wearing down and further inflaming the joint. Treatments include over-the-counter medications and prescription pain medications. If symptoms are more severe, the doctor may recommend joint-lubricating injections called hyaluronic injections.

Stage 4: Severe

Stage four is the most severe stage. People experience more severe pain because the cartilage between joints is almost completely gone, and there are more bone spurs. The joint becomes stiff and may be difficult to move. In the hand, it makes gripping difficult. In the knee or foot, walking becomes a problem. At this stage, prescription pain relievers and surgery are the main treatments.

Pathophysiology

In normal joints hyaline cartilage covers the end of each bone. Hyaline cartilage provides a smooth, gliding surface for joint motion and acts as a cushion between the bones. In OA, the cartilage breaks down, causing pain, swelling and problems moving the joint. As OA worsens over time, bones may break down and develop growths called spurs. Bits of bone or cartilage may flake off and float around in the joint. In the body, an inflammatory process occurs and cytokines and enzymes develop, furtherer damaging the cartilage. In the final stages of OA, the cartilage wears away and bone rubs against bone leading to joint damage and more pain.

Osteoarthritis: A group of overlapping distinct diseases, which may have different etiologies but with similar biologic, morphologic, and clinical outcomes. The disease processes not only affect the articular cartilage, but involve the entire joint, including the subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles. Ultimately, the articular cartilage degenerates with fibrillation, fissures, ulceration, and full thickness loss of the joint surface.

Symptoms of Osteoarthritis

The symptoms of osteoarthritis often begin slowly and usually begin with one or a few joints. The common symptoms of osteoarthritis include:

• Pain when using the joint, which may improve with rest. For some people, in the later stages of the disease, the pain may be worse at night. Pain can be localized or widespread.
• Joint stiffness, usually lasting less than 30 minutes, in the morning or after resting for a period of time.
• Joint changes that can limit joint movement.
• Swelling in and around the joint, especially after a lot of activity or use of that area.
• Changes in the ability to move the joint.
• Feeling that the joint is loose or unstable.

Osteoarthritis symptoms can affect joints differently. For example:

Hands: Bony enlargements and shape changes in the finger joints can happen over time.

Knees: When walking or moving, you may hear a grinding or scaping noise. Over time, muscle and ligament weakness can cause the knee to buckle.

Hips: You might feel pain and stiffness in the hip joint or in the groin, inner thigh, or buttocks. Sometimes, the pain from arthritis in the hip can radiate (spread) to the knees. Over time, you may not be able to move your hip as far as you did in the past.

Spine: You may feel stiffness and pain in the neck or lower back. As changes in the spine happen, some people develop spinal stenosis, which can lead to other symptoms.

As your symptoms worsen over time, activities that you could participate in become difficult to do, such as stepping up, getting on or off the toilet or in and out of a chair, gripping a pan, or walking across a parking lot.

Pain and other symptoms of osteoarthritis may lead you to feel tired, have problems sleeping, and feel depressed.

Osteoarthritis in hand

Causes of Osteoarthritis

There are several factors that increase a person’s chances of developing osteoarthritis. These include:

Heredity: Some people have an inherited defect in one of the genes responsible for making cartilage. This causes defective cartilage, which leads to more rapid deterioration of joints. People born with joint abnormalities are more likely to develop osteoarthritis, and those born with an abnormality of the spine (such as scoliosis or curvature of the spine) are more likely to develop osteoarthritis of the spine.

Obesity: Obesity increases the risk for osteoarthritis of the knee, hip, and spine. Maintaining ideal weight or losing excess weight may help prevent osteoarthritis of these areas or decrease the rate of progression once osteoarthritis is established.

Injury: Injuries contribute to the development of osteoarthritis. For example, athletes who have knee-related injuries may be at higher risk of developing osteoarthritis of the knee. In addition, people who have had a severe back injury may be predisposed to develop osteoarthritis of the spine. People who have had a broken bone near a joint are prone to develop osteoarthritis in that joint.

Joint overuse: Overuse of certain joints increases the risk of developing osteoarthritis. For example, people in jobs requiring repeated bending of the knee are at increased risk for developing osteoarthritis of the knee.

Other diseases: People with rheumatoid arthritis, the second most common type of arthritis, are more likely to develop osteoarthritis. In addition, certain rare conditions, such as iron overload or excess growth hormone, increase the chance of developing OA.

Complications

Most people find osteoarthritis to be a nuisance that eventually becomes significant enough to affect their daily activities. And sometimes there are more serious complications.

Possible complications of osteoarthritis include:

• Rapid, complete breakdown of cartilage resulting in loose tissue material in the joint (chondrolysis)
• Bone death (osteonecrosis)
• Stress fractures (hairline crack in the bone that develops gradually in response to repeated injury or stress)
• Bleeding inside the joint
• Infection in the joint
• Deterioration or rupture of the tendons and ligaments around the joint, leading to loss of stability
• Pinched nerve (in osteoarthritis of the spine)

What are the risk factors of osteoarthritis?

Factors that can increase your risk of osteoarthritis include:

Older age: The risk of osteoarthritis increases with age.

Sex: Women are more likely to develop osteoarthritis, though it isn’t clear why.

Obesity: Carrying extra body weight contributes to osteoarthritis in several ways, and the more you weigh, the greater your risk. Increased weight adds stress to weight-bearing joints, such as your hips and knees. Also, fat tissue produces proteins that can cause harmful inflammation in and around your joints.

Joint injuries: Injuries, such as those that occur when playing sports or from an accident, can increase the risk of osteoarthritis. Even injuries that occurred many years ago and seemingly healed can increase your risk of osteoarthritis.

Repeated stress on the joint: If your job or a sport you play places repetitive stress on a joint, that joint might eventually develop osteoarthritis.

Genetics: Some people inherit a tendency to develop osteoarthritis.

Bone deformities: Some people are born with malformed joints or defective cartilage.

Certain metabolic diseases: These include diabetes and a condition in which your body has too much iron (hemochromatosis).

How to diagnosis osteoarthritis?

A doctor will usually ask about symptoms and perform a physical examination.

No definitive test can diagnose OA, but tests can show whether damage has occurred and help rule out other causes.

Tests include:

• X-rays and MRI scan: These can reveal bone spurs around a joint or a narrowing within a joint, suggesting that cartilage is breaking down. Doctors do not routinely use MRI scans, but they can detect OA at the earlier stages.
• Joint fluid analysis: A doctor will use a sterile needle to withdraw fluid from an inflamed joint for analysis. This can rule out gout or an infection.
• Blood tests: These can help rule out other conditions, such as inflammatory arthritis.
• Ultrasound: This scan can assess if there is inflammation.

Treatment

The goals of treatment for osteoarthritis are to control pain and swelling, minimize disability, improve the quality of life, and educate patients about their role in disease management. Treatment should be individualized to the patient’s level of function and activity, expectations, occupational needs, joints involved, and disease severity, and to any coexisting medical problems.

Physical Activity

One of the most beneficial ways to manage OA is to get moving. While it may be hard to think of exercise when the joints hurt, moving is considered an important part of the treatment plan. Studies show that simple activities like walking around the neighborhood or taking a fun, easy exercise class can reduce pain and help maintain (or attain) a healthy weight.

Strengthening exercises build muscles around OA-affected joints, easing the burden on those joints and reducing pain. Range-of-motion exercise helps maintain and improve joint flexibility and reduce stiffness. Aerobic exercise helps to improve stamina and energy levels and also help to reduce excess weight. Talk to a doctor before starting an exercise program.

Weight Management

Excess weight adds additional stress to weight-bearing joints, such as the hips, knees, feet and back. Losing weight can help people with OA reduce pain and limit further joint damage. The basic rule for losing weight is to eat fewer calories and increase physical activity.

Stretching

Slow, gentle stretching of joints may improve flexibility, lessen stiffness and reduce pain. Exercises such as yoga and tai chi are great ways to manage stiffness.

Occupational therapy

An occupational therapist may be able to help if you need aids or modifications to your home to cope with any disability caused by osteoarthritis. Special devices, such as tap turners to help with turning on a tap, may mean you can carry out tasks around the house more easily.

Diet

Many people that suffer from osteoarthritis also have diabetes. High glucose levels can stiffen your cartilage, making it more likely to break down. Diabetes can also cause inflammation, which weakens cartilage and affects the joints. Try to consume a balanced diet that contains fatty fish, dark leafy greens, nuts, and berries. Avoid sugar, saturated fat, and refined carbohydrates.

Medications

Pain and anti-inflammatory medicines for osteoarthritis are available as pills, syrups, patches, gels, creams or injectable. They include:

• Analgesics: These are pain relievers and include acetaminophen and opioids. Acetaminophen is available over the counter (OTC); opioids must be prescribed by a doctor.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): These are the most commonly used drugs to ease inflammation and pain. They include aspirin, ibuprofen, naproxen and celecoxib, available either OTC or by prescription. The OTC versions help with pain but not inflammation.
• Counterirritants: These OTC products contain ingredients like capsaicin, menthol and lidocaine that irritate nerve endings, so the painful area feels cold, warm or itchy to take focus away from the actual pain.
• Corticosteroids: These prescription anti-inflammatory medicines works in a similar way to a hormone called cortisol. The medicine is taken by mouth or injected into the joint at a doctor’s office.
• Platelet-rich plasma (PRP): Available from a doctor by injection, this product is intended to help ease pain and inflammation. This is not approved by the Food & Drug Administration and evidence is still emerging, so discuss it with your doctor before trying it.
• Other drugs: The antidepressant duloxetine (Cymbalta) and the anti-seizure drug pregabalin (Lyrica) are oral medicines that are FDA-approved to treat OA pain.

Surgery

The main goal of surgery is to relieve pain and, when possible, prevent progressive weakness and deformity. We perform three types of surgery for joints affected by arthritis:

Fusion (arthrodesis): An operation to make the bones on each side of a joint grows together. Fusion can be very helpful for joints that are stiff and painful, awkwardly crooked, or unstable.

Arthroplasty or joint reconstruction: Arthroplasty, also called joint replacement, is surgery to replace a damaged joint with an artificial joint (made of metal, ceramic or plastic). Providers usually replace the entire joint (total joint replacement). Less often, they replace only the damaged part of the joint. Hips, knees and shoulders are the most common joints they replace.

Hip arthroplasty

Osteotomy: Osteomy involves cutting bones in order to realign them in a way conducive to pain-free movement. For patients with osteoarthritis, realignment can reduce wear and tear on cartilage that has been damaged.

Prevention of Osteoarthritis

You may have risk factors for OA that you can’t change, such as heredity and age. However, other risk factors can be controlled. Managing them can help reduce your risk of OA.

The following tips can help you manage the risk factors under your control:

Support your body: If you’re an athlete or an avid exerciser, make sure you care for your body. Wear athletic supports and shoes that reduce impact on your knees. Also make sure to vary your sports, so that all of your muscles get a workout, not just the same muscles every time.

Maintain a moderate weight: Keep your body mass index in the appropriate range for your height and sex.

Eat a nutritious diet: Reach for a range of healthy foods, with a focus on fruits and vegetables.

Get enough rest:  Give your body ample opportunities to rest and sleep.

If you have diabetes, keeping track of your blood sugar can also help you manage your risk of OA.