Richard A. Bernstein, MD
Patients with osteoarthritis of the hand (photo at left from David Nelson, M.D. and at right from Atlas of Rheumatology)
Osteoarthritis is a disease affecting the joints. It is very treatable. It is rarely deforming or crippling, although it can be painful if not treated. Osteoarthritis is very common and affects almost everybody as they get older. The older you get, the more likely you are to have it, and around eight out of ten people over the age of 50 are affected. In the hand, it typically affects the base of the thumb first (see the image above and the x-ray at right), then the finger joints. Women are affected more than men.
Osteoarthritis can be thought of as "wear and tear" arthritis. It is not the same as rheumatoid arthritis, which is an autoimmune disease that is very deforming and can be crippling. Osteoarthritis does not deform the hands in the way that rheumatoid arthritis does. What are the symptoms of osteoarthritis?
The hallmarks of osteoarthritis are joint stiffness, swelling, and pain. This often improves with light activity, but is usually worse again after forceful gripping or pinching, or after a period of rest.
Many people think osteoarthritis should come from a long history of hard work, but hard labor does not seem to be very related. Osteoarthritis can be due to trauma such as an old fracture, but it is usually just due to the effects of aging coupled with some hereditary contribution.
The diagnosis is made by listening to the patient and by examining the patient. Most patients will have a history of slowing increasing pain, stiffness, and swelling over a period of years. Sometimes there is a fairly sudden onset of symptoms, usually associated with a single episode of trauma (typically a fall) or a period of overuse (weeding the garden, say, or packing to move). An x-ray examination confirms the diagnosis. Often there will be no correlation between the amount of pain and the severity of the arthritis as shown by the x-ray.
The x-ray typically shows some joint space narrowing, that is, the white shape of the bones are closer together than they normally are (see the x-ray above). The bone along the joint is usually whiter (called "sclerosis") and may have little points of bone growing out (called "osteophytes"). There may be holes in the bone (called "cysts") and the bones may be starting to slide out of alignment (called "subluxation"). I will review your x-rays with you and explain exactly what I see.
My treatment includes:
I believe that the key part of treating osteoarthritis is patient education, which is why I created this website and wrote this paper. Once the patient understands what is going on, they can take charge of managing their condition. Osteoarthritis cannot be made to go away; getting younger is the only thing that will do that (we are working on it!). Osteoarthritis is not "cured", but managed. Patient involvement in that management is key.
The next step after patient education is activity modification. Learn what activities exacerbate your pain, and see if you can avoid them. For instance, opening tight jar lids puts a great strain on your thumb base joint. Get a plastic sheet from me when you see me, or ask someone else to open jars. If you have faucets that are leaky or stiff, replace the gasket or grease the threads. Look at the activities throughout your day and identify which ones cause you pain.
Along with activity modification, there are a number of patient-directed therapies which can help. Pain can be relieved by applying heat to stiff and painful joints for 20 minutes up to three times a day. Various deep heat lotions, heating pads, infrared lamps, hot baths etc. can be used. Swimming in a heated pool can help.
The first medication that you should try is acetaminophen (Tylenol). It will not upset your stomach and will help to offset the pain of minor arthritis. Most patients have tried this long before they have seen their doctor, and still need something more, so I will not dwell on this.
The next class of medications that should be tried are called non-steroidal antiinflammatory drugs, or NSAID's.
These can very useful. These drugs block the enzyme (cyclo-oxygenase) that creates the pain.
Steroid injections can be very helpful to calm down a very painful joint. These are not the systemic steroids that cause road rage, osteonecrosis, and all the other bad things you have heard about steroids. These are highly localized treatments of steroids, which are a class of substances that your own body makes to calm down unwanted or excessive inflammation. I am allergic to pain, and presume that you are, too.
Surgery is reserved for last. It is only for patients whose osteoarthritis is so bad that they cannot manage their disease with activity modification, antiinflammatory medication, and steroid injections. Indications for surgery generally involve patients who are so miserable with their arthritis that they cannot do the things in life that they want to do. Life is too short to give up all the things you like to do. If you have tried all of the above steps, and still have more pain and more limitations than you want to live with, talk to me about surgery. Some procedures are fairly simple and some are more complex. I can outline all of your options when you come in.
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