Arthritis is felt as joint pain, stiffness, swelling and restricted movement and function. Much of this reduced function is as a result of soft tissue changes around the joint and the limb in general and not only joint breakdown. This can be as a result of tightening of the tissues after cycles of inflammation or irritation as well as weakening and lack of coordination of the supporting muscles. This is one of the reasons that a patient can have significant pain yet minimal changes on imaging such as X-ray or MRI. On the other hand, some patients can have significant changes on imaging with minimal or no pain. The most common factor in these patients is the optimized state of their soft tissues. The soft tissues are addressed using appropriate rehabilitation to optimize alignment, coordination, flexibility, and strength. Lack of soft tissue support can lead to unnecessary accelerated joint breakdown.
The other factor causing pain and disability in arthritis is cartilage breakdown and joint remodelling. Left on its own, osteoarthritis generally progresses over time and is responsible for a significant cause of disability as a person ages.
Although we do not know the exact mechanisms involved in the onset and progression of arthritis, the process in part involves cartilage breakdown. Underlying factors usually include genetics, previous trauma – acute or repetitive, previous infection or significant anatomic variations in alignment and biomechanics. As part of the process there is breakdown of the molecular scaffold which makes up the cartilage lining of the joint structures. This scaffold breakdown allows the water normally trapped within the scaffold to be released changing the properties of the cartilage. This results in decreased shock absorption through the joint and increased friction during normal joint movement. This in turn leads to further breakdown of the cartilage and a vicious cycle of cartilage degradation in osteoarthritis. Once the cartilage starts to break down, excessive forces are transmitted to the bone surfaces which are usually protected by the cartilage. This leads to characteristic changes in the bone which lead to joint deformation and dysfunction including pain, swelling and restricted range of motion. The pain and stiffness lead to decreased use of the joint resulting in a weakening of the surrounding muscles. Muscles which act on a joint not only move the joint but provide it with appropriate support and shock absorption. With decreased use of the joint, the affected muscles lose this ability resulting in a loss of joint protection and further joint breakdown.
Arthritis is diagnosed on clinical grounds through a medical history and physical examination. The diagnosis is supported or confirmed by investigations including x-rays, bone scans, CT, and MRI. All joints in the body can be affected, however the most common joints include the spine the knees, hips, feet, and the shoulders. The most common joints that are replaced surgically include the knees and hips. Surgery is available for other joints such including the spine in selected cases.
Currently there is no known way of fully reversing arthritis once it starts. The treatment of arthritis involves providing biomechanical support (braces, orthotics, rehabilitation) and chemical support (hyaluronic acid, PRP) support to the joints involved and treating the pain stiffness and swelling, as necessary. The goal is to maintain function and slow down the further breakdown of the arthritic joint. This may delay or completely eliminate the need for surgery including joint replacement.
Viscosupplementation is the injection of hyaluronic acid (another molecular building block of the cartilage scaffold) into a joint. It has been found to relieve inflammation and pain and preserve joint function. There are many products available on the market, often covered by extended health plans. These products are injected during a short office procedure which is no more painful than receiving an immunization or blood test. The effect of these injections may last up to six months at which time they can be repeated. Patients with moderate arthritis have obtained significant relief and attained increased function of the injected joints. The most common joint injected is the knee.
One of the products we have injected extensively at our sports clinic in Toronto is
Durolane We are very excited about such products because the ease of administration (only one injection), the low rate of side effects and the excellent functional results patients have obtained.
Viscosupplementation should be considered in anyone with mild to moderate osteoarthritis especially of the knee.
PRP or platelet rich plasma is a technique that involves drawing a small amount of a patient’s blood and then isolating platelet growth factors found in the blood by centrifuging the sample. The isolated growth factors are then injected into the affected arthritic joint. These growth factors are thought to stimulate cartilage cells to produce more cartilage.
PRP has been around for at least 30 years however only in the last 10 years have we seen substantial and consistent scientific evidence that PRP does make a difference in relieving pain and improving function in arthritic joints. Due to the mechanism of action, PRP is felt to help to restore the cartilage of an arthritic joint. There are several protocols used in PRP treatment of arthritic joints which depend on individual patient factors. These details are determined after an appropriate medical assessment.
At the Toronto Centre for Sports Medicine we use the Harvest Smart Prep system for our platelet rich plasma treatments providing one of the highest concentration of platelet growth factors in the resulting PRP distillate. In addition, we go one step further and make use of The Harvest Terumo Clear Prep system which further separates out white cells from the growth factors in the platelet rich plasma. White cells are thought to increase the chances of pain and inflammation after PRP injections into joints.
nStride APS or Autologous Protein Solution by Zimmer Biomet is a technique similar to PRP with the added process of removing any inflammatory factors from the blood and concentrating the anti-inflammatory factors to results lasting 1-3 years in arthritic joints.
Anti-inflammatory diets including intermittent fasting, timed eating and fasting are additional powerful techniques to treat arthritis. These techniques can eliminate pain, improve function, prevent progression and in some cases reverse the disease process. A program of fasting is a powerful way of stimulating autophagy (breakdown of altered proteins and damaged tissues) and stem cell production which can help regenerate new tissue. A proper diet has the additional benefits of reducing the risk of heart disease, stroke, dementia and many other chronic illnesses. Diets need to be tailored to the individual for optimal results. Our doctor can guide you through this process.