Arthritis is the medical term used to describe a disease affecting the cartilage within any joint in the human body. In other words, it is not a bone or ligament problem, but a condition in which the protective cartilage on the end of a bone that allows bones to move in relation to one another breaks down. As the cartilage becomes more diseased, a patient may begin to experience pain and stiffness in the affected joint. Further deterioration of the cartilage will lead to a “bone on bone” circumstance that may cause severe and disabling pain.
The definitive symptom of arthritis is pain, though the nature and intensity can vary based disease severity. While certain types of arthritis cause consistent dull pain, others cause pain that is considerably worse in the morning than in the evening. Some patients deal with the pain by moving around less or by limping. This was minimize some symptoms but does not fix the problem. Other common symptoms of arthritis include swelling, stiffness and loss of movement in the affected joints.
There are several types of arthritis that can affect a joint. The most common type is osteoarthritis also known as OA. Other types of arthritis include: rheumatoid arthritis, psoriatic arthritis, post-traumatic arthritis or arthritis that develops due to other causes such as medications such as steroids.’
Osteoarthritis (OA) is the most commonly occurring joint disease affecting more than 30 million adults in the United States. OA is a common cause of joint pain and secondary disability, but also increases inflammation in the human body and elevated mortality risk. The knee is the joint most commonly affected by OA. Other joints often affected include: hips, shoulders, hands, spine and feet.
In OA, the cartilage protecting the bones of a joint wears down over time. OA is, therefore, commonly known as the “wear and tear” disease because it occurs much more frequently in older patients. This is because the condition requires a good deal of time to develop, and usually does not occur until a patient is well past their 30’s, unless involved in highly competitive athletics. As the cartilage is worn down, the bone underneath the cartilage becomes exposed, causing the body to react in a regenerative manner. However, the new bone produced is not functional because it replaces the space vacated by the cartilage. As the body keeps trying to heal itself, the condition worsens as more bone is produced in the wrong places, leading to more friction and wear and creating an unending cycle.
Increasingly, cases of “Post-traumatic” arthritis are being seen and treated. Patients who have had previous injuries to their joints are at risk for developing arthritis within that joint over time. Because of the original injury to a joint, the cartilage can breakdown over time, leading to disabling arthritis.
Rheumatoid arthritis (RA) is another type of arthritis that develops over a long period of time. This condition can be identified through blood tests and X-Rays, as well as a full evaluation of symptoms. The formation of rheumatoid nodules under the skin is usually indicative of RA, which tends to form over bony processes and frequently stressed joints. Although less frequent, RA can affect other parts of the body and cause subtle inflammation of the aforementioned nodules, lungs, sclera, pericardium and other internal tissue. The disease can progress faster or slower depending on certain personal autoimmune factors. Although there is no known cause or cure for RA, there are many treatments available to both control the symptoms and considerably slow the progression of the disease. The earlier RA is detected, the more effective these treatments are. Proper exercise and weight control are often suggested treatments, along with anti-inflammatory agents and Disease Modifying Anti-Rheumatic Drugs (DMARDs).
A less common form of arthritis is Juvenile Arthritis (JA), which mirrors the symptoms of arthritis but occurs in patients under the age of 18. Juvenile arthritis can either be Rheumatoid (JRA) or Idiopathic (JIA), the latter meaning there is no defined cause. JA is also split into various subtypes, which include Oligoarticular JA, Polyarticular JA and Systemic JA. Oligoarticular refers to JIA that affects four or fewer joints of the child’s body, while Polyarticular refers to JIA that affects five or more joints, in addition to being able to affect the neck and jaw joints. Systemic JIA can cause long-lasting severe fevers and rashes as well as the usual arthritic pains, though more commonly in the small joints. Although JA affects both boys and girls, Oligoarticular and Polyarticular tend to affect girls much more often than boys. Common treatments include NSAIDs along with Methotrexate; corticosteroid injections are also used but less frequently.
Other Types of Arthritis
Other related types of arthritis, such as gout and septic arthritis are less common but still exist. In fact, before modern medicine these were much more problematic forms of the disease. Gout occurs as a result of high levels of uric acid in the blood, which crystallize in the joints and cause immense pain. This elevated concentration of uric acid can be caused by very high protein diets, high alcohol intake, or complications with other parts of the body. Septic arthritis is the result of a bacterium actually entering the joint and causing the arthritis by its actions. This arthritis usually only occurs in one joint and is easily treated with antibiotics combined with a local painkiller.
More About Osteoarthritis
Risk Factors for Developing OA
OA is typically a disease of aging (as much as we might try to deny the aging of our bodies). The risk for developing OA begins to increase after age 50. The more birthdates we collect, the higher the risk of developing arthritis. Other risk factors include: obesity (defined as a BMI >30); female gender; diet; and variations in the anatomy of the knee.
Arthritis, significant enough to cause joint symptoms (aching, stiffness, swelling, etc.), is known to occur in 10% of men and 13% of women over the age of 60.
A previous injury to the knee can lead to osteoarthritis known as “post-traumatic” (after trauma) OA. Injuries such as ACL tears, meniscus tears or patellar dislocation can lead to the development of OA many years or decades after the trauma occurred. Some studies have suggested that up to half of patients with a ligament and/or meniscus injury will develop OA, causing pain and functional problems within 10-20 years.
Obesity is also strongly linked to the development of arthritis in the knee, at a much higher rate than even for hips. The World Health Organization (WHO) defines obesity based on the BMI (body mass index) scale. BMI is calculated based on a person’s height and weight (BMI apps are readily available online). Although to some of us it may seem a bit harsh, these are the WHO realities:
BMI 20-25 Optimal
BMI 26-30 Overweight
BMI 31-40 Obese
BMI 41-50 Morbidly Obese
BMI >50 Super Obese
With the increasing prevalence of obesity in the United States, the incidence of OA of the knee is also increasing. Whereas many patients look for the “magic pill” to fix their arthritis, the reality is that weight loss and weight optimization is the most reliable way to help an arthritic knee feel better. A simple biomechanical understanding can help motivate even the most stubborn patient:
With every step we take, the stress we put on our knees is 3-4x our body weight.
With stair climbing or jogging, the stress on the knees can be 5-6x our body weight.
This means that an individual weighing 200 pounds puts at least 600 pounds of pressure through their knee with step to the refrigerator. If that individual can lose 20 pounds, they will relieve at least 60 pounds of pressure on their knees. In other words, even a little bit of weight loss can start to make a big difference and help a patient feel better.
Diagnosis of Osteoarthritis
OA is diagnosed based on a combination of clinical symptoms, clinical exam and x-ray findings. Patients may present with complaints of joint aching, stiffness, swelling, popping, burning, or sharp pain. A physical exam may reveal loss of range of motion, especially the ability to fully straighten the knee; crepitus, or the noise an arthritic knee may make; a cyst on the back of the knee; tenderness over the joint; and palpable bone spurs (calcium deposits) around the edges of the bone. X-rays will reveal narrowing of the space between the thigh and shin bone, bone spurs, and even hardening of the bone next to the joint, known as sclerosis of the bone. Occasionally, MRI scans can help areas of arthritis not readily seen on plain x-rays. Severity of arthritis is typically described in stages, ranging from stage 0 (no arthritis) to stage 4 (most severe, that is “bone-on-bone” arthritis).
Ultimately, the diagnosis of arthritis, and how severe a specific case may be is, of course highly individualized.
Treatment for a patient’s arthritis symptoms is individualized. Options include:
Medications, such as Tylenol or Non-steriodal Anti-inflammatory drugs (NSAID’s)
PRP or Platelet Rich Plasma Treatment
One of the newer options in the treatments for arthritis is PRP injections. Platelets are naturally occurring cells in the human body that contain proteins that have been identified to help with the healing and regeneration of cartilage in the joints of the body.
Techniques are now available in which the platelets from a patient’s blood are separated and prepared for injection into an arthritic joint. This has most widely been studied with cases of arthritis of the knee joint. Although research is still evolving, there appears to be positive benefit to patients receiving these injections.
Please be aware that this treatment is still considered experimental and therefore not covered by insurance. Cash pay prices vary – for knee injections, charges are typically $1,000 per injection.
Dr. Kaper will be happy to share the most up-to-date research information to help patients make smart and educated decisions about their arthritis care.
Arthritis Stem Cell Treatment
Stem cells are basic human cells that have potential to develop into many different cell types in the body. They are simple or undifferentiated cells.
Stem cells help to create new cells in existing healthy tissues and may help to repair tissues in those structures that are injured or damaged. They are the basis for the specific cell types that makes up each organ in the body.
When stem cells divide they create progenitor cells. Unlike stem cells, progenitor cells can become cells with more specialized functions, such as brain cells, red blood cells or – of particular interest to orthopaedic surgeons—components of specialized tissue such as bone or cartilage.
Orthopaedic surgeons have focused their attention on mesenchymal stem cells. Unlike embryonal stem cells, mesenchymal stem cells are obtained from living adult tissue.
Bone marrow stromal cells are mesenchymal stem cells that, in the proper environment, can differentiate into cells that are part of the musculoskeletal system. They can help to form trabecular bone, tendon, articular cartilage, ligaments and part of the bone marrow.
At this point, stem cell procedures in orthopaedics are still at an experimental stage. Most procedures are performed at research centers as part of controlled clinical trials.
At the present time, there is little scientific evidence to use of support stem cell injections for treat arthritis or regenerate cartilage. We believe that ongoing and future research does hold promise for this type of treatment.
We encourage patients to ask questions about the “latest and greatest” claims that they may have heard about.
Dr. Kaper will be happy to share the most up-to-date research information to help patients make smart and educated decisions about their arthritis care. Please be aware that if you do choose to try this experimental treatment, it is not covered by insurance. Cash pay prices seem to vary – ranging from $2,000-10,000 per injection.