Early Treatment Can Help Immensely

By Carol Eustice 

 Medically reviewed by Anita C. Chandrasekaran, MD

Degenerative arthritis is the most common type of arthritis, affecting around 30 million Americans. Also referred to as osteoarthritis, degenerative joint disease, and wear-and-tear arthritis, it occurs when joint cartilage and underlying bone begin to deteriorate, causing progressive pain, stiffness, and joint malformation.

While it can affect any joint, osteoarthritis typically develops in the hands, feet, shoulder, and neck and in the weight-bearing joints, so you may have degenerative arthritis of the spine, hips, or knees.1

Diagnosis is typically made based on the signs and symptoms of the disease and supported by imaging tests. Treatment can vary based on the severity of symptoms, with more modest options like heat or ice application helping mild cases and more significant interventions, like injections and surgery, being used for severe cases.

ZEPHYR / Getty Images

How Degenerative Arthritis Affects the Body

The biological mechanisms of osteoarthritis involve more than the deterioration of cartilage and bone. Once these structures have been compromised, the body will respond with a process known as ossification, a part of bone remodeling that refers to laying down new bone; reabsorption of old bone can also occur in the remodeling process. This is the same process that occurs if a bone is broken.

However, with osteoarthritis, the ongoing damage to the cartilage will outpace the body's ability to repair it. In an effort to stabilize the joint, bone tissue will be built upon bone tissue, leading to the development of bone spurs (osteophytes) and the enlargement and malformation of the joint.2

In many people with osteoarthritis, pain likely originates from the bone (just beneath the cartilage), the joint lining and capsule, and surrounding ligaments and tendons. Both mechanical forces and inflammation appear to trigger the pain.

Symptoms of Degenerative Arthritis

The central symptoms of degenerative arthritis are pain and stiffness. The pain typically increases with activity and is relieved by rest.

Joint stiffness is common in the morning hours but tends to improve as you move about, usually within 30 minutes. Inactivity during the day, such as sitting for long periods, can also lead to stiffness and may even cause the locking of joints in some people.1

Another common symptom of osteoarthritis is crepitus, in which a joint will make popping and crackling noises with movement. Crepitus most commonly affects the shoulder or knee joint but can also occur in the wrist, fingers, elbow, and ankle.3

As the disease progresses, it can affect a person's posture and gait, leading to instability and a decreased range of motion. As mobility is increasingly impaired, muscle loss may develop (referred to as muscle fiber atrophy).

In advanced stages, degenerative arthritis can cause the visible malformation of a joint, particularly in the fingers where hard, bony enlargements can develop on and around the joint.3 These small bony growths are known as Heberden's and Bouchard's nodes. The abnormal accumulation of fluid, known as an effusion, is also a common occurrence in people with advanced knee arthritis.

In some people, osteoarthritis can become so severe that the pain becomes relentless, making walking or even standing near impossible. While certain treatments can help ease symptoms, any damage sustained by a joint cannot be reversed without surgery.

Causes

At its very heart, degenerative arthritis is a condition in which the progressive damage to a joint occurs faster than the body's ability to repair it. Primary osteoarthritis occurs as a result of aging and is most common in adults over 65. Women are at a higher risk than men (perhaps due in part to hormonal changes).1

While genetics is believed to play a part, degenerative arthritis is often due to a secondary issue that promotes it. (This is especially true in children for whom early-onset osteoarthritis is owed to some other condition.)

Underlying factors for secondary arthritis include:1

• A congenital misalignment of bones

• A joint injury

• Any disease that causes damage to joint tissue or bone

• Obesity, which places persistent stress on a joint

• Loss of muscle strength to support a joint

• Neurologic disorders associated with uncoordinated movements

Exercise (even extreme sports like endurance running) is not associated with osteoarthritis unless a severe or recurrent injury is involved. And, contrary to the old wives' tale, cracking your knuckles does not cause arthritis.

Causes of Flare-Ups

It's very common for OA symptoms to suddenly become worse. You may experience increased stiffness and pain, reduced range of motion, and greater swelling.

Osteoarthritis flare-ups are different from the disease's progression and may not mean that there is further deterioration of the joints. Instead, the changes are often due to common triggers such as:4

• Overdoing an activity or repetitive activities

• Trauma to the joint

• Stress

• Cold weather

• Change in barometric pressure

• Infection

• Weight gain

Diagnosis

Diagnosis of osteoarthritis can be made with reasonable certainty based on a review of your symptoms and medical history, and a physical examination. X-rays can be used to confirm the diagnosis and characterize the severity of the disease.

Typical findings on X-ray include a narrowing of the joint space, the development of osteophytes, excessive bone growth (known as subchondral sclerosis), and the formation of fluid-filled nodules in the joint space (called subchondral cysts).3

Magnetic resonance imaging (MRI) and CT scans are often used for advanced imaging in OA.

Staging Osteoarthritis

With a diagnosis of OA, your healthcare provider may assign a stage to the disease based on radiographic images (such as X-rays). The four stages of osteoarthritis are based on the Kellgren-Lawrence classification system.5 

Understanding the Stages of Degenerative Arthritis

Differential Diagnoses

There are many causes of joint pain. Osteoarthritis is only one of over 100 different types of arthritis, some of which are caused by infection and others of which are triggered by an autoimmune disorder in which the body attacks its own cells.6

Degenerative arthritis is different from all these other causes in that it is not inherently inflammatory. While inflammation can result from the overuse of a joint, it is neither a central nor defining feature of osteoarthritis.

Osteoarthritis can also be differentiated from autoimmune forms of arthritis in that the latter may involve specific joints and/or develop bilaterally (on the same joint on both sides of the body). Moreover, autoimmune forms are characterized by persistent inflammation even when the outward symptoms are under control.7

Among some of the alternative conditions a healthcare provider may explore:

• Ankylosing spondylosis, principally involving the spine

• Gout or pseudogout, most typically involving the big toe

• Juvenile idiopathic arthritis

• Psoriatic arthritis

• Rheumatoid arthritis

• Septic arthritis (also known as infectious arthritis)

Degenerative arthritis can be differentiated from these other conditions by evaluating fluid extracted from the joint space.8 Infectious or autoimmune causes will invariably demonstrate a high number of white blood cells, a hallmark of inflammation. With osteoarthritis, there should not be a high number of white blood cells in the joint fluid.

Blood tests can also be used to rule out infectious or autoimmune causes.

Treatment

Treatment is aimed at managing symptoms, restoring/maintaining function, and slowing the progression of arthritis. Particularly in the early stages, the condition is managed conservatively with a combination of lifestyle changes, physical therapies, and pain medications.

If symptoms progress, more invasive interventions may be needed, including joint injections and surgery.3

Lifestyle Changes

Lifestyle changes are primarily focused on weight loss. This would not only involve a low-fat diet but a routine fitness plan aimed at maintaining joint mobility. A nutritionist may be needed to design an appropriate eating plan and ensure that your nutritional needs are met.9

Moderate exercise should be performed three times a week and under the guidance of a healthcare provider who can sign off on an appropriate fitness plan.

Physical Therapy

A physical therapist is often the best person to design a therapeutic exercise plan if you have degenerative arthritis. It may involve strength, gait, and balance training to address specific functional impairments. Massage therapy, hydrotherapy, thermotherapy, and electrotherapy may also be explored.

Occupational therapy may be needed to overcome day-to-day challenges. This may include mobility aids to prevent falls, shoe inserts or knee braces to correct imbalances, and oversized handles to accommodate arthritic hands.10

Over-the-Counter (OTC) Remedies

The preferred options for the treatment of arthritis pain are Tylenol (acetaminophen) and nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) or Aleve (naproxen). While beneficial, the drugs must be used with caution over the long term.

Tylenol can cause liver toxicity and damage if overused.11 Similarly, the long-term use of NSAIDs may increase the risk of gastrointestinal bleeding, kidney damage, and ulcers.12

For severe pain, NSAIDs tend to be more effective than Tylenol. Some NSAID drugs appear to be more effective for osteoarthritis pain than others. One NSAID, diclofenac, can be applied as gels, creams, ointments, sprays, and patches.13

Some people with arthritis turn to methylated creams like Bengay, while others find relief in capsaicin-based ointments or patches derived from chili peppers. Their effectiveness in treating osteoarthritis can vary, although they may be appropriate if the symptoms are mild and you are unable to tolerate other forms of an analgesic.

Prescriptions

If over-the-counter medications are unable to provide relief, your healthcare provider may prescribe a prescription-strength NSAID. In this situation, NSAIDs are often preferred over opioid pain medicines because they are more effective in the long run and are not associated with dependence.

A special group of NSAIDs known as COX-2 inhibitors is often effective in treating arthritis pain but with a far lower risk of gastrointestinal side effects compared to other NSAIDs. On the flip side, they are more expensive and, like all NSAIDs, linked to an increased risk of heart attack and stroke.

As such, they are used with caution in people with an underlying risk of cardiovascular disease. Celebrex (celecoxib) is the only prescription COX-2 inhibitor available in the U.S.14

If all else fails, your healthcare provider may prescribe a milder opioid drug like Ultram (tramadol) to relieve your pain. The drug is used with caution given the high risk of addiction and other adverse side effects. Stronger opioids are generally avoided.

Joint Injections

Joint injections, also known as intra-articular injections, involve either a corticosteroid drug to decrease inflammation or a lubricating fluid known as hyaluronic acid. Both are commonly used as a means to delay joint surgery.15

Corticosteroids work by tempering the immune response and, by doing so, alleviate the swelling and inflammation that can develop in later-stage disease. The effects generally last for around three months.16

Hyaluronic acid is a naturally occurring substance produced by the body. The type used for joint injections, referred to as hyaluronan, is either synthesized in the lab or extracted from rooster combs.

Research is conflicting on how effective these injections are. Those delivered to the knee tend to be more successful than other joints. Side effects include injection site pain and swelling. Euflexxa is a popular non-avian form of hyaluronan approved for the treatment of osteoarthritis knee pain.

Some healthcare providers have endorsed the use of platelet-rich plasma (PRP) as a form of treatment, although it appears to improve joint function more than pain. As the platelets and plasma are derived from the person's own blood, the risks tend to be minimal. As with hyaluronan, injection site pain and swelling are the most common concerns.16

Surgery

Surgery is only considered if conservative treatments have failed and the pain and disability are diminishing your quality of life. Some of the procedures are performed arthroscopically (with small keyhole incisions) or as open surgery (with large incisions).

Among the most commonly performed procedures are:17

• Arthroscopic debridement: Used to remove excess bone and tissue to restore joint movement

• Arthrodesis: Performed either arthroscopically or as an open surgery; involves the fusing of bones to alleviate pain, primarily in the spine, foot, ankle, or hand

• Osteotomy: Performed as an arthroscopic or open procedure; involves the shortening, lengthening, or realignment of bones

• Arthroplasty: Performed as an open surgery; involves the replacement of a joint with an artificial one

As a prosthetic joint tends to last between 10 and 15 years, arthroplasty surgery is delayed for as long as possible to avoid the need for a second replacement later in life.

Complementary and Alternative Medicine (CAM)

There is a wide variety of traditional, nutritional, herbal, naturopathic, and homeopathic medicines used to treat osteoarthritis. Many of these have little evidence to support their use.

Even popular supplements like chondroitin and glucosamine were not shown to improve outcomes, according to a large study conducted by the National Institutes of Health.18

With that being said, there are a number of complementary treatments that the National Center for Complementary and Integrative Health believes may offer benefits. Among them:19

• Acupuncture has been shown to provide modest arthritis pain relief, particularly in the knee.

• Boswellia serrata, an herb used in Ayurvedic medicine, is believed to have anti-inflammatory effects beneficial to osteoarthritis.

• S-adenosyl-L-methionine (SAMe) is a chemical naturally produced in the body that is sold as a dietary supplement. There is some evidence that SAMe may be as effective as over-the-counter NSAIDs in treating arthritis pain.

Coping

As the joint damage caused by osteoarthritis does not reverse, you need to take steps to slow the progression as much as you can through lifestyle and the proper management of symptoms.

Key to this is keeping the joint moving. If you do the opposite and avoid exercise and regular activity, the stiffness and damage will almost invariably progress at a far faster pace. However, overuse can worsen osteoarthritis.

It is never too late to start exercising. Even if you already have a significant impairment, you can find low-impact activities like swimming or cycling that place less strain on the joints. Over time, if you persist with the activity, the muscles supporting a joint will strengthen, providing you greater stability and confidence in your gait.

As you improve, you can move on to other forms of exercises like tai chi and yoga, which are great for improving balance, or strength training to target specific muscle groups.

If your joint is stiff prior to exercise, apply a heating pad or warm, moist cloth for around 10 to 15 minutes. The heat will draw blood to the joint and alleviate stiffness. After you finish, apply an ice pack or cold, moist cloth to the joint if there is any swelling or pain. Doing so may reduce inflammation faster than an NSAID.

It is important to remember that rest is just as important as exercise when dealing with degenerative arthritis. If you ever experience extreme pain, stop, rest the joint (elevating if possible), and apply ice for no longer than 15 minutes.

By listening to your body and treating it appropriately, you can get better control of your symptoms as well as your life.

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Cleveland Clinic. Bone Spurs.

Sinusas K. Osteoarthritis: diagnosis and treatment. Am Fam Physician.

Arthritis Foundation. What Triggers an Arthritis Flare?

Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: kellgren-lawrence classification of osteoarthritis. Clinical Orthopaedics & Related Research. 2016;474(8):1886-1893. doi:10.1007%2Fs11999-016-4732-4

Arthritis Foundation. What Is Arthritis?

NIH Osteoporosis and Related Bone Diseases ~ National Resource Center. Osteoporosis and Arthritis: Two Common but Different Conditions.

Lab Tests Online. Synovial Fluid Analysis.

Bliddal H, Leeds AR, Christensen R. Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons - a scoping review. Obes Rev. 2014;15(7):578–586. doi:10.1111/obr.12173

Cleveland Clinic. Arthritis Treatment: Occupational & Physical Therapy.

U.S. Food and Drug Administration. Acetaminophen: Avoiding Liver Injury.

Goldstein JL, Cryer B. Gastrointestinal injury associated with NSAID use: a case study and review of risk factors and preventative strategies. Drug Healthc Patient Saf. 2015;7:31-41. doi:10.2147/DHPS.S71976

Jorge LL, Feres CC, Teles VE. Topical preparations for pain relief: efficacy and patient adherence. J Pain Res. 2010;4:11–24. doi:10.2147/JPR.S9492

Das UN. Can COX-2 inhibitor-induced increase in cardiovascular disease risk be modified by essential fatty acids? J Assoc Physicians India.

Ayhan E, Kesmezacar H, Akgun I. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop. 2014;5(3):351–361. doi:10.5312/wjo.v5.i3.351

Wehling P, Evans C, Wehling J, Maixner W. Effectiveness of intra-articular therapies in osteoarthritis: a literature review. Ther Adv Musculoskelet Dis. 2017;9(8):183–196. doi:10.1177/1759720X17712695

Arthritis Foundation. Understanding Your Joint Procedure Options.

Sawitzke AD, Shi H, Finco MF, et al. The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial. Arthritis Rheum. 2008;58(10):3183-91. doi:10.1002/art.23973

National Center for Complementary and Integrative Health. Osteoarthritis: In Depth.

By Carol Eustice
Carol Eustice is a writer covering arthritis and chronic illness, who herself has been diagnosed with both rheumatoid arthritis and osteoarthritis.