Osteoarthritis is the most common form of degenerative joint disease, and is a leading cause of disability in people over 50 years of age. It is can be a very debilitating form of arthritis in that it tends to affect the load-bearing joints, especially the hips and knees, that are crucial for normal movement.
Osteoarthritis occurs when the cartilage cushioning the joints breaks down and causes the bones to rub together, inducing a change in shape. Osteoarthritis is found most frequently in people over age 50, although it can occur at any age. It most commonly affects joints in the knees, hips, shoulders, elbows, ankles, and hands. There are currently close to 10 million Americans living with osteoarthritis .Explore in-depth symptoms and treatments articles for:
Typical Signs and Symptoms of Osteoarthritis
For many, osteoarthritis pain may become markedly worse over time or with specific activities. Characteristic signs and symptoms of osteoarthritis include:
- Stiffness. A common marker of osteoarthritis is stiffness in the joint that is most pronounced first thing in the morning, or after a prolonged period of inactivity (such as sitting in a car or airplane). The stiffness usually resolves within 30 minutes of light activity, as the joints “warm up” through gentle movement.
- Pain. Another common symptom is pain in the joint that worsens during or after too much movement. The pain may be experienced as dull and aching, or sharp and piercing. In the most severe cases of osteoarthritis, patients may also feel pain when the joints are at rest or only moving slightly.
- Soreness. The joint may feel tender to touch or with slight pressure.
- Inflexibility. Patients may experience loss of full range of motion in the affected joint.
- Swelling. The joint may swell due to excess fluid buildup. This type of swelling is clinically referred to as effusion. If the swelling is severe, the joint may also feel warm to touch.
- Grating or creaking. There might be a sensation of grating or slight grinding when moving the joint, as the surfaces of the articulating points of the joint no longer move smoothly against each other.
- Is the grating or grinding sensation harmful? See What Is Crepitus?
- Bone spurs. Sometimes, bone bumps – which are points of the bone that grow outward as a result of the joint friction and dysfunction – can be felt under the skin. Bone spurs may also be referred to as osteophytes.
- Deformity. In some types of osteoarthritis, physical deformity may be noticeable. For example, enlarged finger joints may result from the friction causes bony enlargements of the finger joints, or advanced degeneration of knee cartilage can lead to an outward, or bowlegged, curvature of the knee.
Symptoms of Hip Osteoarthritis
While osteoarthritis pain is usually felt in the affected joint, for some patients the pain may be referred to other areas of the body. For example, hip osteoarthritis may lead to knee pain, or spinal osteoarthritis may affect nerves that cause pain, numbness or other symptoms in the part of the body that the nerve leads to.
When the hips or knees are affected, walking can be a significant source of pain, and accommodating pain may induce a limp. Pain can be felt in areas outside the damaged joints, including the buttocks, groin, or thigh and may vary in severity from a dull ache to a sharp pain.
causes of osteo arthritis-
Osteoarthritis pain is caused by a wearing down of the cartilage that serves as a protective shock absorber between the joints. Cartilage is important for minimizing the impact of everyday activities on the joints, but the intensive use also means that it is subject to high levels of wear and tear.
There is no single known cause of osteoarthritis, but several risk factors can serve as strong indicators for the disease when present. Patients are at greater risk of developing osteoarthritis if they have one or more of the following factors.
- Age. The single most common cause of osteoarthritis is aging, as use of the joint over many years is likely to lead to breakdown of cartilage. Osteoarthritis develops most often in people over age 50.
- Family history. Genetics can play a role in bone abnormalities that result in distorted shape and problems with joint alignment. This is apparent in cases of bowed legs or double-jointed abilities, both of which are more likely to lead to development of osteoarthritis.
- Obesity or excess weight. Weight-bearing joints are at risk for osteoarthritis in people who are significantly overweight. It is estimated that every extra pound of weight adds three pounds of pressure on the knees, and increases the pressure on the hips as much as six times. Because weight gain gradually increases stress on the joints, the onset of osteoarthritis symptoms may take many years to develop.
- Injury or overuse of the joint. Occupations or sports that require repetitive motion over a long period of time increase one’s risk of developing osteoarthritis due to increased stress on specific joints. Old injuries can develop into osteoarthritis, especially where a fracture or surgery has occurred. Overcompensation for injuries can also cause osteoarthritis to develop due to a modified gait or other activities.
Having a risk factor for osteoarthritis does not guarantee that the condition will develop. But the presence of a combination of risk factors produces the highest likelihood that a given person will develop the disease.
diagnosis of osteo artritis-
Osteoarthritis of the major joints is most effectively diagnosed through a combination of medical history, physical examination, and various lab tests including imaging studies such as X-ray. A primary care physician can diagnose most cases, but depending on perceived severity a patient may be referred to a specialist, such as a physiatrist or orthopedic surgeon, for further evaluation.
Medical histories can often be the most useful tool for physicians in diagnosing osteoarthritis. Practitioners will look for family history of the disease as well as the presence of various risk factors to indicate the need for further testing. A careful review of the patient’s symptoms is important to obtaining an accurate diagnosis.
A physical examination will usually follow the medical history as the physician looks for physical signs of the disease. These include swelling and tenderness of the joints, loss of movement in specific joints, or visible joint damage such as bony growths in the surrounding area. The patient may also be asked to perform a variety of physical tasks so the physician can evaluate range of motion and general joint mobility.
Laboratory tests are used to help confirm a suspected diagnosis of osteoarthritis if the diagnosis is otherwise in doubt.
- Joint aspiration or arthrocentesis. This diagnostic tool involves removing a sample of fluid from the joint for further examination, and can be used to rule out other conditions. Further testing can reveal the presence of crystals and also rule out infection.
- X-ray. An X-ray is used to provide a picture of potential joint damage, but is not the most reliable tool. Most patients over the age of 60 display joint degeneration associated with osteoarthritis, but only a third or this population report actual symptoms. For this reason, an X-ray is usually used to confirm a suspected diagnosis made through a physical examination and medical history.
- MRI. Magnetic resonance imaging techniques can be used to provide a more accurate picture of damage to the joint and remaining cartilage.
The above combination of medical history, physical exam, and possibly diagnostic testing, all inform the diagnosis of osteoarthritis.
The most effective step toward controlling the symptoms of osteoarthritis is obtaining an early diagnosis and starting treatment as soon as possible. Non-surgical treatments are often sufficient for the management of physical symptoms and the preservation of daily functioning.
Osteoarthritis treatment programs typically include a combination of medication and exercise therapy.
Drug therapy is used to manage physical symptoms, with a focus on relieving pain and slowing progression of the disease. Some commonly used medications include:
- Analgesics. Pain relievers, or analgesics, such as acetaminophen (e.g. Tylenol), or tramadol (e.g. Ultram) are used to relieve pain, but do not alleviate inflammation or swelling. Because they have few side effects, analgesics are recommended for patients experiencing mild to moderate pain.
- Topical analgesics. Topical analgesics are creams that can be applied directly to the skin over the affected area. The primary ingredients in these creams are usually counterirritants, such as wintergreen and eucalyptus, which stimulate the nerve endings and distract the brain from joint pain. Topical analgesics are available in most drug stores, and can be used in combination with most oral pain medications.
- NSAIDs. Non-steroidal anti-inflammatory drugs, such as aspirin, ibuprofen (e.g. Advil), naproxen (e.g. Aleve), cox-2 inhibitors) are used to reduce swelling and inflammation, and are recommended for patients experiencing moderate to severe pain.
Physical therapy provides targeted exercises that help maintain the ability to perform everyday tasks such as walking, bathing, and dressing. Although rest is an important part of the healing process, it is important to keep up with moderate levels of activity to strengthen the muscles surrounding the damaged joint. Stronger muscles provide greater stability for the joint, which in turn helps reduce stress on the joint.
Occupational therapy may also be recommended to demonstrate appropriate modifications for everyday activities that may be causing pain.
Steroid injections are often performed if pain is moderate to severe and especially if the pain symptoms limit the patient’s ability to participate with exercises. When combined with physical therapy, steroid injections can offer a very important “window of opportunity” during which the patient may more fully participate with therapy because the pain is resolved or at least better controlled. By allowing the patient to participate with therapy, the patient may stretch and strengthen important muscles around the affected joint(s) and thereby decrease the load experienced by the joint(s) so that the inflammation and pain do not return
Why Get a Cortisone Injection?
In general, patients receive cortisone injections for one of two reasons: to treat a condition or to provide information for an accurate diagnosis.
Cortisone to treat joint pain
A cortisone injection typically relieves inflammation and pain for between 6 weeks and 6 months. The pain may return after that time or it may not, depending on the person, the condition being treated, and follow-up care.
Temporary pain relief allows the patient to:
- Treat an arthritic flare-up. For arthritic conditions such as a gout flare-up, a cortisone injection can relieve pain while the gout episode runs its course. The patient may also be prescribed oral medications and be advised to make dietary changes.
- Participate in physical therapy. Pain relief from a cortisone injection gives the patient an opportunity to participate in physical therapy to improve the affected joint’s biomechanics. Ideally, by the time the effects of the cortisone wear off, the joint is healthier so pain is tolerable or even eliminated.
- Rest the joint. A painfully inflamed joint needs to rest to recover. For example, patients with an inflamed bursa may need to adequately rest the affected joint in addition to participating in physical therapy.
- Postpone surgery. In moderate to severe cases of arthritis, a joint replacement or another surgical treatment may be recommended. For patients who want to postpone or avoid surgery, cortisone injections may allow them to live with less pain.
Almost all types of arthritis are chronic, and a cortisone injection is just one part of a larger treat Cortisone to Diagnose Pain
When the underlying cause of pain is uncertain, a doctor may recommend a cortisone shot to help narrow the list of possible diagnoses. This procedure is common in the hip and shoulder joints.
For example, a doctor may recommend a cortisone injection for a patient with persistent, undiagnosed hip pain.
- If the injection relieves the patient’s hip pain, the pain probably originates in the hip
- If the hip pain persists even after the injection, the doctor may consider problems affecting spine or the sacroiliac joint (where the spine and pelvis meet), both of which can cause referred hip pain.
If a diagnosis is still uncertain following a diagnostic injection, the doctor may recommend an MRI or other detailed imaging study.
Of course, an injection meant to aid in diagnosis can be useful for treatment, and vice versa. However, a doctor and patient should take time to discuss the primary purpose of the cortisone injection before it is administered. During this conversation a doctor should let the patient know what part of the joint is being targeted, what are reasonable expectations regarding pain relief, and if follow-up treatment will involve medications, physical therapy, or lifestyle changes.
What is Cortisone?
Cortisone refers to a category of man-made steroids that mimic the effects of cortisol, a hormone that naturally occurs in the body. Both cortisone and cortisol are types of corticosteroids.
It is important to note that these types of steroids differ from anabolic steroids (e.g. testosterone) that are used to enhance athletic performance. Both types of steroids share similar chemical structures but play different roles in the body.
Not a Cure-All for All Types of Joint Problems
A person usually receives a cortisone injection to help reduce pain-causing inflammation. Once this inflammation is reduced, the person can participate in physical therapy (which is essential for treatment in most situations). However, cortisone, like all medications, can have side effects.
Most notably, cortisone is known to break down tissues, such as articular cartilage in the joint.1,2Cartilage is crucial to joint health, acting as a shock absorber and reducing friction between bones when a person moves. Therefore, most physicians will refuse to administer repeated cortisone injections into the same joint over a short period of time, simply because too much cortisone can cause more harm than good.
What to Know Before Getting a Cortisone Injection
Cortisone injections allow doctors to deliver potent medicine directly to sites of inflammation with minimal side effects. Depending on the patient and the condition being treated, a successful cortisone injection can suppress localized inflammation for anywhere from 6 weeks to 6 months.
While cortisone injections can be an important tool in treating joint inflammation and pain, they do have limitations. Many of these limitations are described A Cortisone Injection Is Part of a Larger Treatment Plan
Cortisone injections typically provide temporary relief. Most patients seeking better, long-term relief are advised to participate in physical therapy to stretch and strengthen their joints, muscles, and other soft tissues. Patients may also be advised to lose weight or make other lifestyle changes, such as changing footwear. These steps can improve a joint’s biomechanics and possibly decrease or eliminate the need for additional cortisone shots.
Patients who do have repeated cortisone shots may notice that the period of pain relief becomes shorter and shorter over time. This is not necessarily because the patient has built up a tolerance to the medication but because the joint is degrading. Again, physical therapy, weight loss, and changes in day-to-day lifestyle can help slow down or stop joint degradation.
Activity Should Be Increased Gradually
It may take a few days for the benefits of the cortisone medication to take full effect. During this time, patients are usually told to rest and cut back on normal activities. Once the joint pain is relieved, a well-intentioned patient may be tempted to jump right into an exercise routine. However, in order to avoid injuries or possibly making the condition worse, a doctor typically advises a patient to resume normal activities gradually and add intensity over time.
Repeated Injections Can Affect Soft Tissue
Too many injections over a short period of time can cause damage to the tendons, ligaments, and articular cartilage at the injection site. For this reason:
- Injections should be spaced at least 4 to 6 weeks apart, and patients are advised to have 4 or fewer injections in the same place per year.
- A doctor will not inject cortisone medication directly into a tendon, even if a tendon is suspected to be the root of pain. Because cortisone works locally, an injection near a tendon can still reduce its inflammation.
In fact, the Achilles and patella tendons are particularly prone to injury post-injection, even if an injection is directed near, rather than in, the tendon. For this reason, doctors avoid cortisone injections for Achilles and patella tendinopathies.
Cortisone Injection Step-by-Step
Below is a step-by-step description of a typical cortisone injection procedure. An injection may be administered so that medication is delivered directly into the joint capsule or near the joint capsule, depending on the condition being treated.
- The patient will be asked to sit or lay down in a position that gives the doctor easy access to the joint. For example, if an injection is being administered to the knee, the patient may be told to recline on his or her back with the knee either straight or bent at a 20- or 30-degree angle with a rolled-up towel to support it.
- The injection site will be cleaned with disinfectant, such as alcohol or iodine.
- The patient will be encouraged to relax. Relaxing the joint’s muscles will make the injection process easier and more comfortable.
- If ultrasound is being used, a gel will be applied to small area of skin near the injection site, and a technician will gently press a hand-held ultrasound transducer against the gel-covered skin. An image of the joint space will be projected onscreen for the doctor to see.
- The doctor may administer a topical anesthetic to numb the area receiving the injection.
- People who get cortisone injections to reduce joint inflammation sometimes report side effects. Potential side effects include:
Cortisone Injection Risks and Side Effects
- Pain and swelling (cortisone flare). The injected cortisone medication can crystallize inside the body. The crystals can cause pain and inflammation that is worse than the pain and inflammation caused by the condition being treated. A cortisone flare typically lasts one or two days and can be treated with rest and intermittent cold packs.Skin discoloration. Some patients with darker skin may notice that the skin around the injection area becomes lighter. The discoloration can be permanent but is not harmful to patients’ health.Elevated blood sugar. In addition to decreasing inflammation, corticosteroids can raise blood sugar levels. Patients with diabetes should closely monitor blood sugar levels for a day or two following a cortisone injection. (The injection does not deliver cortisone directly to the bloodstream, but it can still influence blood sugar levels in some patients.)Infection. Though rare, it is possible for the injection site to become infected. Patients who suspect an infection or run a fever should contact their doctor.Allergic reaction. Patients should tell their doctor if they have ever had an allergic reaction following an injection. While uncommon, some patients have allergic reactions to the local anesthetic added to the injection. Allergic reactions to the cortisone itself are rare because cortisone is a synthetic version of cortisol, a steroid naturally found in the body.
Viscosupplementation for Knee Osteoarthritis
- Viscosupplementation is a medical procedure during which lubricating fluid is injected into a joint. Also called hyaluronic acid injections or hyaluronan injections, viscosupplementation is most commonly used to treat symptoms of symptoms of knee osteoarthritis.Hyaluronic acid is a key component of the joint fluid in healthy joints, but is found in lower concentrations in osteoarthritic jointsBy adding hyaluronic acid to the existing joint fluid of an osteoarthritic knee, the goal is to:
- Facilitate better knee movement
- Reduce pain
- Perhaps slow osteoarthritis progression
- Typical candidates for viscosupplementation are people with knee osteoarthritis who have failed to improve with other non-surgical treatments.Following the injections, it is generally recommended that patients engage in a rehabilitation program that includes gentle, progressive knee exercise. The goals of rehabilitation are to improve range of motion and develop muscle strength to support the knee.
How Viscosupplementation Works
During viscosupplementation a small amount of hyaluronic acid, often just 2 mL, is injected directly into a joint capsule.
A healthy knee joint has up to 4 mL of joint fluid within the joint capsule.1,2 Hyaluronic acid is a key component of the joint fluid. It gives the joint fluid its viscous, slippery quality, which does the following:
- Enables the bones’ cartilage-covered surfaces to glide against each other, thereby reducing joint friction
- Adds cushion to protect joints during impact (e.g. weight-bearing activity)
Joints affected by osteoarthritis typically have a lower concentration of hyaluronic acid in their joint fluid than healthy joints, and therefore less protection against joint friction and impact. Experts believe this further accelerates the joint degeneration process, setting in place a vicious cycle.
As its name implies, viscosupplementation artificially supplements the joint fluid’s natural viscosity. By injecting a man-made hyaluronan into the knee, doctors hope to temporarily lubricate the knee joint, thereby decreasing pain improving function and perhaps even slowing the degeneration process.
Hyaluronic Acid Injections for the Hip and Other Joints
The United States FDA has approved viscosupplementation for treating knee arthritis only, but treating hip osteoarthritis or other joints with viscosupplementation is permitted. Some doctors have found some patients respond to viscosupplementation for the hip, shoulder and ankle, but there is relatively little published research regarding its efficacy.
Using viscosupplementation for a joint other than the knee is considered an “off label” use of the injectable fluid. Insurance companies may consider the procedure “experimental” and not cover the cost, so patients should check with their insurance companies if considering viscosupplementation for hips or other joints.