Understanding joint pain and osteoarthritis with Dr Colin Tench

More than 10 million people in the UK are affected by arthritis which causes pain and inflammation in their joints, and although it is commonly associated with older people, the condition can impact people of all ages including children.

Dr Colin Tench is a Consultant Rheumatologist at St John & St Elizabeth Hospital, specialising in the management of osteoarthritis and soft tissue rheumatism and we spoke to him about the most effective ways of managing and treating joint pain and osteoarthritis.

What causes joint pain? 

There are various forms of joint pain and arthritis and the cause varies from condition to condition. In terms of osteoarthritis, the cartilage and underlying bone start to break down and degenerate, ceasing to function normally. The end-stage of osteoarthritis is often bone rubbing on bone, which is very painful when you load the joint – especially if it is knee or hip osteoarthritis. The pain is difficult to avoid because it’s movement-related, so many daily activities become painful; for example, walking up and down stairs can be uncomfortable or even very painful depending on the severity of the condition.

In terms of other types of arthritis, rheumatoid arthritis is an inflammatory form, which triggers pain receptors around the joint.

Why is it important to seek medical attention for joint pain sooner rather than later? 

It’s important to come up with a diagnosis because this informs the treatment options. There are quite a lot of potential explanations as to why someone’s knee hurts.  For example, it could be osteoarthritis but it could also be a mechanical problem like a cartilage tear, a damaged ligament or the knee-cap not tracking properly up and down the knee. The right diagnosis will then lead to the right treatment.

Taking a look at your history is important as well because osteoarthritis tends to come on insidiously over a number of years. Clinical examination often reveals changes suggestive of osteoarthritis such as bony swelling and you can also sometimes hear crunching noises from the joint with movement, typical of osteoarthritis, especially in joints like the knee. The reason for this is that when cartilage starts to fail it becomes fissured and uneven, which makes it much rougher, meaning you can hear when a patient bends their knees. This is called crepitus.

Can a joint injury lead to osteoarthritis?

There are a number of risk factors for developing osteoarthritis, the biggest one being ageing. But joint injury is a common feature we see when osteoarthritis develops; the altered biomechanics of a joint after an injury seem to predispose people to developing premature osteoarthritis. If you have a traumatic injury the chances are you’re going to damage the cartilage, which is very avascular, meaning it doesn’t have much of a blood supply and hence doesn’t heal very well.

What are some key ways of managing osteoarthritis? 

There are three key goals of management:

1. To try and improve the pain and stiffness of the patient’s joint.
2. Improve function – from the point of view of both the joint and what the patient can do.
3. In the longer term, to slow-down disease progression over time.

Exercise is key – especially in knee osteoarthritis and it’s about lower-limb strength exercise. If you can build up your quadriceps muscles, that can be helpful and improving your aerobic fitness can also reduce pain. We can tailor treatments to individuals depending on the severity and how old the patient is. We will refer the patient to a physiotherapist who will design both an exercise and a strength-building programme for that patient.

Among other non-pharmacological treatments, weight loss is important. Obesity is a big risk factor for osteoarthritis because cartilage acts as a shock-absorber for your joints. If you have a lot of extra load going through a shock absorber that is already damaged then it’s going to progress quickly. That makes sense with weight-bearing joints like knees and hips, but what’s interesting is obesity is also associated with hand osteoarthritis. We think this is because obesity is linked to a low-level inflammation, which can negatively impact joints.

What are the main treatments for osteoarthritis?

There are pharmacological options such as paracetamol, which a lot of patients are already taking, but it doesn’t seem to be very effective in tests. Topical anti-inflammatories like Ibu-gel and Voltarol can be helpful. The benefit of those is that they tend to be associated with a much lower risk of side-effects, compared to oral anti-inflammatories, such as ibuprofen, which can cause problems like heartburn, gastritis and in rare cases, stomach ulcers. We recommend using ibuprofen tablets in short bursts, in selected patients, often if you know you’re going to be doing something that might cause pain.

The other things we sometimes do are joint injections – particularly steroid injections. These can be quite helpful but often only last for two to three months and then wear off, and there is evidence that repeated injections might start to damage the cartilage. However, in selected cases, some patients do report much longer benefit. We also worry that steroid injections might potentially increase the risk of COVID so we’re wary of them at the moment.

We can also use something called viscosupplementation. The main component of synovial fluid, which is almost like the oil in your joint, is hyaluronic acid. There are synthetic forms of hyaluronic acid, which you can inject into joints. They have a similar effect as steroid injections and are significantly more expensive, but some people do respond to them. This type of injection is not thought to increase the risk of COVID and hence currently might be a better option in many patients.

If you have any joint pain and would like to speak with one of our expert consultants then call or email our Rheumatology Unit on +44 20 7806 4000 or email [email protected]