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Joint Pain in the Mornings: Osteoarthritis

Aging has its privileges, but one of the reasons it isn't always embraced is because we are more inclined to joint pain, and general aches and pains, as our body ages. Nearing my fifth decade, I'll admit, I've groaned a time or two after standing. Osteoarthritis is the moans that we feel first thing in the morning. More often this impacts our hands, knees, hips, and spine but any joint can be involved (Sinusas, 2012). The sort of classic symptom is pain in the morning but generally resolves in less than half-an-hour.


Osteoarthritis is a common degenerative disorder in the connective tissue present in the synovial joints, that sort of smooth, white tissue that covers the ends of bones where they come together to form joints. Genetics play a role, past trauma to the joints, obesity, advancing age and being female are all risk factors. As the U.S. population ages and becomes more obese, family practitioners are seeing more clients with osteoarthritis. Certainly though, this joint pain can be experienced by anyone.



This is a clinical diagnosis, so one your practitioner offers based on their experience and expertise. The pain tends to worsen with activity, especially following a period of rest. Some experience joint locking or joint instability. These symptoms result in loss of function, with individuals limiting their activities of daily living because of pain and stiffness.


Often clients will complain of pain that is far more significant on one side than the other. They may have severe, debilitating #osteoarthritis in one knee with almost normal function in the opposite knee (Sinusas, 2012). It is common to have limitation in range of motion and even pain when moving the full extent of one's range of movement in any particular joint, but each joint is unique.


In the hands, you might notice changes in your knuckles, particularly those closer to the ends of your fingers. They can develop nodules or what we call Heberden nodes and Bouchard nodes. You might also feel tenderness over joints in your thumb. In the shoulder, there may be pain with movement, limited range of motion especially externally, or crepitus when trying. The knee may cause pain with movement, or have crepitus, even a cyst behind the knee. There may be instability from side-to-side, swollen joints, or growing deformity in the end of the finger called a valgus or varus deformity.


The hips can also be painful, or you might even experience pain your bum. It may be hard to move the hips, especially rotating inward. Your feet may hurt when you walk, especially the big toe or it may be stiff (hallux rigidus). There may be limited range of motion in the hips, and even the spine. The lower body may experience sensory loss or loss of reflexes. There may be motor weakness caused by nerve root impingement.


Because osteoarthritis is primarily a clinical diagnosis, clinicians can confidently make the diagnosis based on the history and physical examination. Plain x-rays can confirm the diagnosis and rule out other conditions, but often unnecessary. Advanced imaging such as CT scans or MRIs are rarely needed, unless the diagnosis is in doubt and there is suspicion for another pathology, such as a meniscal injury. X-rays will show joint space narrowing and osteophyte formation, even joint destruction.


Laboratory testing is not required to make diagnosis. Markers of inflammation are typically normal. Immunologic tests, such as antinuclear antibodies and rheumatoid factor, are not indicated unless there is evidence of joint inflammation or synovitis, which makes autoimmune arthritis a more likely diagnosis. If suspecting gout, the clinician may order a uric acid. False positives are possible too, so this can create confusion leading the American College of Rheumatology to recommend against routine ordering of arthritis panels for joint problems (Sinusas, 2012).


How Does One Optimizing Outcomes After Diagnosis?


The least invasive and safest therapies should certainly be utilized first. Surgery should be the last resort, reserved for those who do not improve with behavioral and pharmacologic therapy, and who have intractable pain and loss of function. Movement is important and recommended for everyone. Consider new movements, like dancing and yoga. Balance training with or without strength training has demonstrated reduction in pain. One doesn't have to be flexible to benefit from yoga; in fact, those who are inflexible are exactly those who would benefit from yoga. Weight loss, as little as 5%, for those who are overweight or obese is essential, and potentially, physical therapy may be ordered, either land- or water-based. Bracing and splinting may be recommended as well.


Acetaminophen may be helpful (no more than 4g/day), or even Motrin, Ibuprofen, or Naproxen. Arnica oil can also be helpful, and may help minimize the NSAIDs which can cause gastrointestinal bleeding, renal dysfunction, and blood pressure elevation. If this fails to help, a combination of glucosamine and chondroitin for moderate to severe knee osteoarthritis may be indicated, but it should be noticeably helpful in three months or discontinued. Opioid therapy may be integrated into care for those in more severe pain, but with a pain specialist as this invites great risk.


Corticosteroid injections are another option, most especially for acute exacerbations in the knee. However, these can only be administered four times a year. Platelet-rich plasma, stem cells, and hyaluronic acid has not demonstrated clinical benefit. Worst case, a total joint replacement for osteoarthritis in the hip, knee, or shoulder may be recommended if these interventions are not helpful.


Acupuncture can be of benefit in chronic low back pain, but the most widely used supplements for osteoarthritis are glucosamine and chondroitin. The combination of the two is where the literature is most supportive, effective for moderate to severe osteoarthritis of the knee (Clegg et al., 2006). Spa therapy or mineral baths have shown to be beneficial in the literature (Verhagen et al., 2007).


Capsaicin cream is a topical analgesic derived from chili peppers and it has been found to be superior to placebo in treating osteoarthritis treatment. This is widely available, inexpensive, and can be used as an adjunct to standard treatments mentioned above. SAM-e is another approach, more natural method, of reducing functional limitations, but potentially no more effective than placebo. It does seem to be as effective as NSAIDs but with fewer adverse effects (Soeken et al., 2002).


References

Clegg, D.O., Reda, D. J., & Harris, C. L. (2006). Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med, 354(8), 795-808.

Sinusas, K. (2012). Osteoarthritis: diagnosis and treatment. American Family Physician, 85(1), 49-56.

Soeken, K. L., Lee, W. L., Bausell, R. B., Agelli, M., & Berman, B. M. (2002). Safety and efficacy of S-adenosylmethionine (SAMe) for osteoarthritis. J Fam Pract., 51(5), 425-430.

Verhagen, A. P., Bierma-Zeinstra, S. M., & Boers, M. (2007). Balneotherapy for osteoarthritis. Cochrane Database Syst Rev, 4, CD006864.

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