Joint pain doesn’t have to be the inevitable conclusion of growing old. Learn how new techniques in joint surgery and therapy are making a difference.
Joint pain is widely considered a natural part of the aging process, catching up to most people around middle age. Cumulative factors – such as work-related wear and tear, chronic conditions like arthritis and diabetes, repetitive motion from sports or hobbies, and trauma – can contribute to joint deterioration, which ultimately may lead to surgery.
However, tremendous advancements in the medical field have greatly improved the treatment process and challenged the idea that joint pain is inevitable. By following a healthy diet, managing weight and doing appropriate conditioning exercises, most people can enjoy activities, including sports, well into old age.
“The body tolerates sports well, if the muscles, joints and tendons are given conditioning,” says Ciro Cirrincione, MD, of Barrington Orthopedic Specialists. “Of course, injuries happen, especially in contact sports such as football, or when a tennis player plants too hard, extending for that last little bit of reach. The torque on the knee at that point can cause cartilage to sheer off, sometimes because the player’s leg strength is not sufficient. When the force of the action is greater than the strength of the knee structure, damage occurs.”
The sooner one learns proper conditioning skills, the better, says Cirrincione.
Beginning in the very young athlete, good knee health requires cross-training to keep joints and tissue as strong and flexible as possible. “This is an important topic in preventive medicine with young athletes,” Cirrincione says. “As these young athletes reach puberty and beyond, they’re working hard to strengthen the power muscles. Oftentimes, the smaller control muscles and tendons are neglected, causing an imbalance in the joint. This joint is more prone to injury.”
For example, the young pitcher who has passed puberty suddenly starts weight training to develop strong deltoids, pectorals and trapezoids. Smaller muscles and tendons, like the rotator cuff and scapular stabilizers, are weaker and cause an imbalance, increasing stress on these areas – which may lead to injury. Proper training should include specific exercises that isolate and strengthen those smaller muscles.
“And along those lines, high school and college coaches often push training too hard,” Cirrincione says. “They focus heavily on developing power muscles, without considering the need to train smaller muscles. I think there is a strong need for education on proper training techniques.”
Still, the human body is tremendously resilient. In studying the knees of high-level runners who logged 60 miles per week, researchers found that the cartilage hadn’t significantly worn away. The body has remarkable ways of regenerating tissue and keeping it fresh to a certain extent.
“On the other hand, professional athletes such as football players may present with a tremendous amount of wear and tear on their joints,” Cirrincione says. “The joints of a 40-year-old football player, who’s experienced a lot of small, seemingly insignificant injuries, will wear down faster because of the cumulative traumatic effects. A large percentage of NFL players past age 40 suffer from post-traumatic arthritis in some of their joints.”
Teens who damage the cartilage in their joints are more likely to develop arthritis in later years. Genetics also play a role, since some people have stronger ligaments and more resilient cartilage. Cirrincione sees patients with post-traumatic arthritis, degenerative spinal and disc disease, rotator cuff damage, shoulder ligament tears, and elbow tendonitis that increasingly are common results of sports participation during formative years.
“Patients can lose cartilage until they have bone-on-bone degeneration and the joint seizes up,” Cirrincione says. “Our first goal is to decrease the pain with appropriate medications. At the same time, we try to increase flexibility and strength in the affected joint. Strengthening the muscles helps the joint absorb shock better. The less shock, the less work the joint has to do.”
Supports and braces can be used to reduce stress in problems like bowed legs, caused by inside wear on the knees. Cortisone injections are another temporary treatment aimed at reducing painful symptoms.
“Now we can add synthetic viscosupplementation compounds to knee joints by injections, which can alleviate symptoms, even if there’s no cartilage left,” Cirrincione explains. “And there are minimally invasive surgical options available which can clear the joint of cartilage debris that causes mechanical symptoms.”
Another procedure, done by arthroscopy, stimulates the bone marrow stem cells next to the cartilage defect, to produce cartilage in those areas.
One of the most promising new treatments involves tissue transplants. “Cartilage can be regenerated under laboratory conditions and implanted in sections of the joint that meet certain criteria,” Cirrincione explains. “We can also borrow tissue from one part of the knee and transplant it into the affected area.”
Donor tissue is an option, too. Orthopedic tissue can be harvested, just like organs. “Tissue is by far the largest donor transplant medium, with millions of tendon, bone and cartilage procedures performed each year,” Cirrincione concludes. “And if all else is eliminated, we can surgically replace part or all of the joint.”
As patients reach their middle years, the potential for disease and cumulative damage increases. It’s no surprise that arthritis is one of the most common causes of knee pain in older patients. But over time, other factors can lead to debilitating pain in the muscular and skeletal systems, too, says Dr. Ankur Chhadia, an orthopedic surgeon with Suburban Orthopedics in Elgin.
“Genetics, environment, trauma, lifestyle and work experiences can predispose any patient to chronic joint pain, not only in knees but in shoulders and hips as well,” Chhadia explains. “It’s possible to slow the process. While there’s no known cure for arthritis, changes in a patient’s daily habits can make a difference in the eventual outcome.”
Avoiding repetitive impact actions is one way to keep arthritis at bay. In the workplace, people who work on an assembly line or with industrial equipment are more prone to arthritis and joint pain than those whose professions don’t involve constant impact on their musculoskeletal systems.
Sports is another stressor. “Impact sports such as running will influence the intensity and speed at which arthritis develops,” Chhadia says. “I recommend alternating with swimming, water walking, biking and other non-impact sports. Also, for those who want to continue running, an anti-gravity treadmill has been developed, which reduces pain caused by impact.”
While people can’t avoid the effects of heredity and environment, maintaining an appropriate weight and eating well can slow the advance of arthritis. “Being overweight can cause pain in patients who might not experience it at normal weight,” Chhadia says. “We recommend that they lose weight and increase their activity levels, but it’s a catch-22, because it’s painful for them to exercise.”
Chhadia believes in treating a patient’s symptoms step by step, with joint replacement surgery being the very last choice. “Knee arthritis is most common in older patients,” he says. “Typically, we start to see it in the 40 to 50 age range. In some cases, these patients have rheumatoid arthritis, which is more aggressive. We see a big jump in the number of knee pain patients after 60 years of age. This is typically when the pain gets to the point where it adversely affects quality of life.”
Treatment usually begins with over-the-counter medications for joint inflammation and pain, and addresses underlying conditions such as weight. Some patients respond; some don’t.
“Depending on this reaction, we can prescribe pain medications,” Chhadia says. “We talk to the patient before doing this, to assess whether he or she has already tried the over-the-counter medications and what effect they had. We advise patients to check with their doctors regarding medication usage.”
Basic treatments also include icing the knee to relieve inflammation and swelling. “In general, patients should apply heat before exercising to relax and loosen joints, and then ice after, to ease any pain and swelling,” Chhadia says. “For patients with arthritis, I also highly recommend stretching and warming up before starting an exercise routine, to avoid injuries to muscles and tendons due to sudden force.”
Patients can also wear braces to help prevent injury and ease pain. “Pharmacies and major stores offer all levels of braces, from compression bands to the soft knee wraps and on,” Chhadia concludes. “It could help, and it certainly wouldn’t hurt to try them.”
People who’ve enjoyed decades of pain-free activity and careers may still find that joints wear down with time. Pain, stiffness and lack of flexibility can occur, despite good genes and the very best of conditioning and care.
David Morawski, MD, an orthopedic surgeon at Fox Valley Orthopedics in Elgin and Geneva, specializes in joint surgery for older patients. Most of the patients he sees are those whose bone health has deteriorated with age, but he’s treated people from age 19 up.
“Over time, the protective cartilage in joints wears away, vertebrae collapse and other things occur to cause joint failure,” Morawski says. “This happens not only because of calcium and mineral loss, but also because of insufficient exercise, poor kidney function, dialysis, being overweight, prednisone treatments, hormone imbalances, asthma, rheumatoid arthritis and even immunosuppression medications.”
For patients whose pain level significantly affects their quality of life, Morawski begins with medicines and braces, as well as an assessment of body mass index and exercise history. When the benefits derived from this course become less than the risk of surgery, it becomes the next step.
“Each patient must decide if and when,” Morawski says. “They tend to know when it’s time. However, some are so fearful of the surgery that they would rather sit in a wheelchair. We respect their decisions. I tell patients that if surgery is too risky, they need to take a proactive attitude, which can include losing weight, smoking cessation and bringing diabetes under strict control. These diminish risks and allow the patient to avoid surgery, or prolong the time until it becomes necessary.”
Certain standards are used to assess patients for surgery. Surprisingly, age isn’t as big a factor as physical condition. For example, if a patient’s body mass is 50 or more, or if the A1c blood test used to determine glucose levels over a three-month period exceeds 7.0, surgery may not be recommended.
“We didn’t have a lot of these markers when I began practicing years ago,” Morawski says. “Now, we can call on clinical trials and studies to determine what’s best for each patient. You can’t just lump all patients into one group.”
Improvements in artificial joint construction have also impacted outcomes. “Patients can expect a knee replacement to last about 15 years,” Morawski says. “They may need to exchange the plastic implant that replaces cartilage. Think of it as similar to replacing the brake pads on your car, as opposed to replacing the entire brake assembly.”
When partial replacement procedures first became common, Morawski feared he would spend all his time doing them. “I was very concerned, but patients do a good job of taking care of their new joints,” he says. “We just change the parts out, instead of redoing the entire knee. Plus, the newer joint replacements seem to be lasting longer.”
The importance of physical therapy can’t be overemphasized. Successful knee replacement surgery is augmented by the right rehabilitation programs both before and after the procedure, says David Feiza, physical therapist at the Geneva location of Fox Valley Orthopedics.
“The goal is to improve joint flexibility and strength,” he says. “My work begins with joint management therapy, to either avoid or postpone surgery. It buys time for patients with arthritis whose joints aren’t quite ready for total replacement. Depending on the patient’s diagnosis, we do preliminary exercises and manual therapy, and stress weight loss if necessary. My job is to motivate the patient by setting goals to be reached, including increasing range of motion so the patient can climb stairs. We want the patient to regain strength and flexibility to improve function and relieve pain.”
Patients who don’t complete the full course of post-op physical therapy or don’t reach their individual goals may jeopardize the level of success of the surgery. Their failure is often the result of fear.
“Many patients have heard others say it’s a rough and painful process,” Feiza explains. “First of all, we fully explain to patients what to expect, not only from surgery but also from physical therapy. It’s not a magic formula but common sense. Good surgery followed by good therapy naturally equals good results. Some of my patients breeze right through the physical therapy rehabilitation program.”
A home exercise regimen is recommended after therapist-guided rehabilitation has ended. Each patient’s individual outcome is influenced by factors such as pre-surgery lifestyle and how well he or she tolerates the physical therapy treatments. But it’s also impacted by continuing the home exercise programs.
“I encourage patients to follow through, no matter what worst-case scenarios they’ve heard,” Feiza concludes. “And I believe education is also critical to patient welfare. It’s just like anything else. If you know up front what’s going to happen, and you know what to expect, it’s easier to work through to meet your functional goals and have a successful outcome.”
It’s no longer necessary for active people to allow joint pain to leave them sidelined. Advancements in joint replacement and treatment of joint pain, coupled with a better understanding of prevention, allow people to enjoy all of the things that make their lives more fulfilled. ❚