Initial Core Management of Osteoarthritis

Contrary to popular perception, for the 58 million Americans with osteoarthritis, receiving this diagnosis does not mean inevitable deterioration and disability. The initial treatments for osteoarthritis include a variety of core management approaches that not only provide symptomatic relief for the aches, pains, and stiffness of osteoarthritis, but can also actually modify the course of this condition.

Overview of osteoarthritis

“Arthritis” is an umbrella term for a number of disease processes that cause damage to joints, resulting in pain and disability.

• Osteoarthritis is by far the most common type of arthritis, the incidence of which increases with age, increased weight and previous joint damage, such as an anterior cruciate ligament (ACL) rupture in the knee. Osteoarthritis used to be considered a condition that primarily resulted from damage to cartilage. We now know it is a condition of “the whole joint,” and includes dysfunction of muscle, tendons, and bone, as well as cartilage.
• Far fewer Americans are diagnosed with inflammatory arthritis than osteoarthritis. Rheumatoid arthritis and other forms of inflammatory arthritis are systemic immune disorders that can affect multiple joints. In such cases, the body perceives its own tissues to be “foreign” substances and attacks itself.

Osteoarthritis, especially of the knee, is more common in women than in men. Research also suggests that genetics and cartilage metabolism play a role in the condition, with some people being better able to withstand injury and wear and tear to the cartilage than others.

Regardless of which joint is affected, osteoarthritis can lead to pain, stiffness, decreased motion and disability. If the joint becomes painful to move, there is often a progressive weakening of the muscles around it, leading to limitations and disruption in both work and recreational activities. Patients may become discouraged and demoralized, and depression can interfere with personal relationships and intimacy.

Taking control of osteoarthritis

It is important to understand that two joints that show the same amount of damage on X-rays may be associated with very different levels of pain or disability. Additional factors, such as body weight, how many other joints are involved and a person’s general health are very important in determining disability and quality of life. Patients who engage in active core treatments for osteoarthritis can make a huge impact on their pain and function, resulting in the best possible outcomes.

One of the most important modifiable risk factors is body weight. It is crucial to try to prevent weight gain as we age, and also attempt to lose excess weight. While there is no one ideal weight for everyone, aiming for a body mass index (BMI) of 28 or less can decrease knee pain, and help prevent existing osteoarthritis from getting worse. BMI is calculated by dividing weight in kilograms by the square of height in meters.

Maintaining range of motion is important

Exercise helps both control weight and keep muscles strong, which in turn helps protect and stabilize joints. Stretching and strengthening exercises also help to maintain range of motion and alleviate stiffness. When initiating exercise, it is recommended to start with a monitored exercise program overseen by a physical therapist or other medical specialist. Exercises which are particularly good for osteoarthritis include tai chi, aquatic exercises and yoga. However, the best exercise is one that you will actually do! Many people enjoy group exercise classes, as these are social and can help with motivation.

Maintaining range of motion of arthritic joints is very important. This is true for arthritis of the shoulder, low back, hip and knee. Once motion is lost due to the contracture of surrounding soft tissues, it can be difficult to regain. But with stretching, severe stiffness can be avoided and progressive motion loss minimized.

Exercise

The benefits of strengthening muscles around joints is indisputable. For example, with hip arthritis, strong abductor muscles (muscles that lift the leg away from the midline) can reduce the load experienced by the joint surface and minimize the pain that can interfere with walking. (Guidance from a physical therapist is very helpful to ensure abductor muscle strengthening exercise is done properly.) For the knee, increased strength in the quadriceps muscle on the front of the thigh can dramatically improve knee function, such as while climbing stairs and getting up from a chair. Strengthening exercises are beneficial because better-conditioned muscles are able to power the joint through a range of motion and bear more of the load around the joint. This prevents overloading already weakened areas.

In addition to focusing on the affected joint, patients with hip or knee arthritis are advised to also do core exercises that help stretch and strengthen the lower back. Low back pain can exacerbate knee or hip pain, and vice versa. An exercise program may alleviate or even prevent low back symptoms.

Patients who receive a diagnosis of osteoarthritis sometimes feel depressed or resigned to the idea that knee or hip pain is just a normal part of aging and, thus, do not believe there is anything they can do to improve their pain. This is far from the truth! Although some X-ray damage to joints is likely inevitable as we age, painful osteoarthritis is not normal aging. Weight loss and exercise can lead to both pain relief and decrease the risk of progression of osteoarthritis.

Patients are advised to choose exercises they enjoy and can incorporate them into their schedule, ideally three or more times per week. For individuals who have not been exercising on a regular basis, getting started is the hurdle. It is also important to recognize that, at the start of an exercise program – especially in someone who has not been active – osteoarthritis often flares and may initially feel worse. This does not mean you are damaging your joints or that you should stop exercising! However, knowing how much to push yourself is best done under the initial guidance of a physical therapist; this is why a monitored exercise program is particularly beneficial when someone is just starting to exercise.

Canes, shoes and chairs

Although many people resist the idea − associating it with age and disability − using a cane can be very helpful for those with hip or knee pain, especially if they feel unstable. Using a cane on the opposite side of the affected joint diminishes the load on the hip or knee, allowing more comfortable movement. Patients can use a cane selectively, for example when they know they will be walking a significant distance, as at a fairground or shopping mall. Doing so can alleviate pain flare-ups both during and after activity, Using a cane also increases stability and can prevent falls. Braces can sometimes help with knee pain and are generally most effective if they are prescribed by a physical or occupational therapist.

Use of heat and cold

If a joint is irritated, application of heat and cold can offer pain relief. In general, individuals with arthritis may have variable results and may wish to experiment on their own for the most effective temperature. Some people find that if the discomfort is not related to specific activity, application of moist heat may be most effective, since it is more penetrating than dry heat and more likely to promote circulation and relieve muscle spasms. If the joint pain is exercise or sports-related, application of ice immediately after the activity may be more effective.

Medications, supplements and regenerative therapies

A number of medications are available for the treatment of arthritis symptoms:

• Topical NSAIDs (nonsteroidal anti-inflammatory drugs) are often a very helpful first line agent, as they have low absorption and minimal side effects.
• Oral NSAIDs or COX-2 inhibitors can be very effective, but they need to be used at the lowest dose and for the shortest period of time possible. They should be prescribed under a doctor’s guidance, as they carry the risk of stomach irritation, ulcers, kidney dysfunction, and can lead to higher rates of heart attacks and strokes. (Learn more about reducing side effects of NSAIDs and COX-2 inhibitors.)
• Acetaminophen in high doses can be effective for some patients.
• Duloxetine can be particularly helpful in patients who have neuropathic type pain associated with their osteoarthritis.
• Narcotics (opioids) are a poor choice for the chronic treatment of osteoarthritis, and these are reserved for very select circumstances.

Some physicians may also use corticosteroid injections or viscosupplementation injections as part of a treatment plan. Steroids are powerful anti-inflammatory drugs that can be effective treatment for painful flares of osteoarthritis. However, routinely using steroid injections for chronic pain relief can lead to increased joint damage and should be avoided. Viscosupplements are less well proven and, thus, more controversial. They may be helpful for some patients with knee osteoarthritis, but they do not appear to be helpful for hip osteoarthritis.

There are many oral supplements available to treat osteoarthritis:

• One common one, glucosamine/chondroitin sulfate, is very popular. Although studies have not found it to be particularly effective, some patients do find it provides some pain relief.
• Other supplements such as turmeric or fish oil may help with pain, although better studies are needed.

There is currently a tremendous interest in regenerative therapies, such as platelet-rich plasma and stem cell therapies, to treat osteoarthritis. While these hold promise, more studies are needed.

Staying Informed

A multitude of resources are available to patients with arthritis from books, support groups, and online education. It is crucial that patients with osteoarthritis take charge and try to be as knowledgeable as possible. There are many free online services that provide cutting edge information and recommendations. Self-help programs are also available online which are actually proven to help! View a list of external resources below.

If your osteoarthritis is significantly interfering with your ability to function or to enjoy life despite your best efforts with core therapies and medications, joint replacement is a highly effective and safe treatment option. Joint replacement can be performed safely in a wide range of patients, including the elderly and those who cannot lose weight. If you are considering a joint replacement, it is important that you discuss this with your primary care physician and orthopedic surgeon. Shared decision-making can help you understand the risks and benefits of the procedure, and if it is the right choice for you.

Regardless of the combination of core therapies the patient finds most helpful, it is critical to be proactive. Patients can help themselves in many ways to experience less pain, less disability, less rapid progression, and an enhanced sense of well-being. For patients who do eventually undergo surgery, good physical conditioning and an understanding of the process will speed their recovery and, what's more, improve their final outcome.

Osteoarthritis is common, and projected to become an even bigger public health burden over the next 50 years. Rates of osteoarthritis will increase as the population ages, and as rates of obesity and knee injuries (such as ACL tears) increase. All of these are critical risk factors for osteoarthritis. People with osteoarthritis also miss more workdays, require more care from family members or others, and are at risk of serious side effects from the long-term use of medication such as NSAIDS. However, osteoarthritis can be treated and even prevented, with physical activity and an attention to trying to prevent weight gain.

It is really important that people do not let their pain get them down and feel there is nothing they can do once their knees or hips start to hurt. The pain of osteoarthritis is not an inevitable part of normal aging! The most important things we can all do as we get older it to find actives that we like to do − either alone or with friends − and to try to stick to an exercise program. This is our best shot at trying to keep the pain of osteoarthritis at bay. Many core treatments for osteoarthritis are proven to be effective, and they should be viewed as a buffet from which you can choose the combination which works best for you!

Additional resources

• American College of Rheumatology
• Arthritis Foundation
• Osteoarthritis Action Alliance
• Osteoarthritis Research Society International

Updated: 9/12/2022

• Diagnostic imaging examinations provided by HSS Radiologists.

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