Many in our society, especially the elderly, suffer from multiple joint pains. However, the majority tends to ignore their symptoms during the early phase either due to busy lifestyles or ignorance about arthritis and the available treatment for it. According to the United Nations, the number of those above 65 years of age in Sri Lanka are expected to double during the coming decades.
We often discuss its impact on the country’s economy, yet focus less on the health issues that arise simultaneously with the aging population. Osteoarthritis is one of such diseases we need to be vigilant about. With the advances in medicine, it is inadmissible for any patient to suffer from joint pains. The main goal of the healthcare provider who treats a patient with arthritis should be to keep the patient pain-free and ambulant with no or minimal physical restraints.
The following is the history of a patient who was presented to the rheumatology clinic at the Hambantota District General Hospital:
Longstanding pain
The patient, ‘Mr. B’, is a 68-year-old farmer from a rural village about 40km from Hambantota. He was presented to the Hambantota Hospital joint clinic with longstanding knee pain. He has been a farmer for 50 years and his symptoms started around 10 years ago. Initially, he felt pain only during work and walking, which he attributed to his strenuous daily activities; but, with time, the pain increased in severity and frequency.
During this period, he did not seek medical attention; only treated himself with oil massages and paracetamol. In time, he noticed a swelling in his right knee and felt pain even during rest and sleeping. He found difficulty in walking and had to abandon his occupation, which resulted in many financial difficulties.
Intermittently, when the pain became unbearable, he had gone to the outpatient department (OPD) of his local hospital, from where he was referred to the Hambantota General Hospital’s joint clinic on several occasions. However, Mr. B had not gone to the Hambantota Hospital until recently.
Increased swelling
Two weeks ago, he had felt a sudden increased pain and swelling of his right knee to a level that he could not walk even 10 yards. He was then admitted to the local hospital. There, he was told that there were fluids in his knee and was given medicine, after which he felt some improvement.
This time, doctors were successful in convincing him to visit the Hambantota Hospital joint clinic for specialised care, where a Consultant Rheumatologist would be available.
There, he was inquired about the history of his illness. He was then thoroughly examined and found to have the following features:
Mr. B’s right knee was swollen and it hurt when touched. He found it difficult to bend the knee and there was a creaking sensation when he attempted it. There was no increase in temperature over the knee. His left knee joint had similar features, except for the swelling. Both knee joints showed abnormal angulation which increased the distance between the two knee joints.
He reported pains in his ankles as well, but had no problem with any other joints. A clinical evaluation was carried out afterward, in which blood reports, as well as x-rays of both knee joints, were taken.
Fluid removal
While waiting for results, Mr. B was given analgesics and was admitted to a ward for further assessment. The following day, his blood reports turned out normal, but the x-rays showed a significant narrowing of both his knee joints. He was then diagnosed with osteoarthritis. Following the diagnosis, Mr. B was on a few medications; then, a procedure was performed on his right knee, where a needle was inserted into the joint and the fluid within was removed, which was followed by a steroid injection.
He was much better after the procedure, with significant pain reduction and increased movement range. Small amounts of fluid removed from his knee joint were sent to the lab for further analysis. Two days after being admitted, he was able to walk without much difficulty and was referred to the physiotherapy unit. He was discharged from the hospital the next day, after a follow-up at the rheumatology clinic.
What is a joint?
A joint is a place in our body where two bones join with each other and where movements take place. There are several joints in our body; some large as the knee and hip, and some small as the wrist and knuckles. Any joint in our body can be affected by different types of arthritis. The patient in the above scenario had osteoarthritis involving mainly his knee.
What causes joint pain?
Pain is not a symptom of arthritis alone. Joint pain can arise due to many reasons other than arthritis. Minor trauma such as sprains, major trauma such as fractures, dislocations or metabolic/endocrine abnormalities, or even other illnesses ranging from simple flu to a dreadful malignancy, could initially present as joint pain.
What is arthritis?
Arthritis is a commonly-used term which technically means that there is an inflammation of a particular joint or joints. Sometimes, joints can ache without an inflammation, which is referred to as arthralgia.
What is osteoarthritis?
Osteoarthritis, which is the most common type of arthritis, is a degenerative disease where there is a breakdown of the joint cartilage. In most joints, there are cartilages that act as shock-absorbers and also smoothen the movement of those joints. With time, this cartilage undergoes wear and tear changes, which ultimately lead to the breakdown of the cartilage, causing disruption of joint function. Osteoarthritis is a disease associated mainly with the elderly; Seventy percent of the population above the age of 60 years has osteoarthritis of the knee.
Joints affected by osteoarthritis
Osteoarthritis can affect any joint in our body, but it has a predilection towards the weight-bearing joints of our body; such as the knees, hips, and ankles. However, small joints; such as those in the hand, as well as the joints between spinal bones, could also be affected by the disease.
Risk factors
Although age is the main determining factor, there are a few other risk factors which can increase the likelihood of osteoarthritis:
· Obesity
· Being female
· Previous injuries to joints
· Occupations involving strenuous physical work
Symptoms
Osteoarthritis is a long-term disease which starts slowly and progresses gradually. This could remain unnoticed to the patient before any significant symptoms are seen. Initially, the patient feels joint pain during activities such as walking, running, and climbing stairs; but gradually, the pain increase in frequency and severity. In the beginning, joint pain improves with rest, which is the main reason why most patients tend to ignore the early symptoms. Patients would ultimately complain of pains even during rest, and it can even disturb their sleep. Pain can disrupt a patient’s mobility, daily activities, productivity, and recreational activities.
Most patients disregard these initial symptoms and wait till latter symptoms appear. The main feature found in examinations is the swelling of the affected joints. For example, the affected knee can have hard swelling. Sometimes, the swelling can result from the collection of excess fluids inside the affected joint.
Most patients describe this as ‘water in the joint’. Then, with the progression of the disease, joints develop various deformities, such as increase and abnormal angulations. Joints could even become fixed, later on, resulting in the reduction of their movements. Other significant complaints from patients are that they can hear crackling noises from the joints, especially in the knees. When patients stand from sitting or squatting positions, these noises become more audible. It is very important that anyone with the aforementioned symptoms seek medical advice as soon as possible so that early diagnosis and timely intervention are possible to minimise the disability.
Tests
Once a patient suspected to have osteoarthritis is seen by a doctor, a few blood investigations would be arranged. Inflammatory markers such as Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP) tests are expected to be normal in osteoarthritis.
These investigations are of paramount importance, especially to rule out the presence of any other type of arthritis, such as rheumatoid arthritis. The most important diagnostic investigation for osteoarthritis is arranging for an x-ray of the affected joint/joints.
X-ray anomalies
There are various changes specific to osteoarthritis which can be seen in x-rays. Narrowing of the joint space, osteophyte formation, and subchondral sclerosis, are some of them.
Management of osteoarthritis
After a clear diagnosis is made, patients would be managed by a team led by a consultant rheumatologist.
This team would comprise of rheumatology medical officers, nutritionists, nurses, physiotherapists, and occupational therapists. Management of osteoarthritis is a long-term commitment which requires dedication from the patient, as well as the medical team.
The management of osteoarthritis will be discussed in a subsequent article.
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