What happens to the joint with Arthritis?
During the lifespan of an individual, joints are subjected to a lot of stresses. This can cause wear and tear of the joint cartilage. When these stresses are continuous over prolonged periods, the cartilage does not get time to heal and finally breaks down.
When cartilage is eroded the bony joint surfaces become exposed. This can result in the formation of bony spurs or ‘osteophytes’.
The cartilage itself does not have a nerve supply and therefore is not a source of joint pain; however, the outer surface of bone is innervated and is thought to be a source of pain in those with joint degeneration.
As we age, the muscles also weaken. The muscles provide support to the surrounding joint and decrease the load which the joint is subject to.
What are the Causes of Arthritis?
- Repeated Stresses: Osteoarthritis mainly affects the cartilage of weight bearing joints such as knee, hip and spine. Although, depending on the individual’s profession other joints like hand and shoulder may also be affected.
- Age: Arthritis is commonly seen in people above the age of 45
- Gender: Women are more susceptible to developing osteoarthritis, especially after menopause.
- Genetic make-up: Some people have defective cartilage which makes them prone to osteoarthritis.
- Previous injury: A prior trauma, fall or a fracture around the joint disturbs the line of force around the joint. This results in abnormal force distribution through the joint which increases the risk of osteoarthritis.
- Obesity: Increased body weight puts undue stress on the spine, hips and knees. This accelerates the arthritic changes.
- Lack of exercise: Joints require regular movement to remain healthy. Movement helps to “feed” the joint by encouraging movement of synovial fluid and nutrients into the joint which feed the cells within the joint.
Other considerations – Diet and Arthritis
- Research by Rolf Peterson looking at the bones of the moose of Lake Superior has shown that many suffer with arthritis. One might automatically presume that this is due to a particularly harsh environment which requires excess joint loading. As it turns out, nutritional factors in early life have been linked to the development of arthritis in the moose in later life.
- Obesity has also been linked to arthritis. Recent research has suggested a potential link between obesity and arthritis. This connection may be due to the inflammatory nature of the environment in such individual which may act as a driver of premature cartilage degeneration.
Physiotherapy for Arthritis
Physiotherapy plays an important role in managing the symptoms of arthritis. It can help you to remain active & maintain independence through improving your mobility, strength and flexibility.
Physiotherapists have an in-depth understanding of joint structure & function. The physiotherapy approach to arthritis treatment & management entails identifying potential causes of the condition. Arthritis is often driven through inappropriate movement patterns that over time lead to degeneration of a joint & its cartilage. This can give rise to a gradual increase in joint pain & possible clicking.
Physiotherapists can devise simple exercise programmes that you can practise at home to help you build your strength and flexibility. The goal of physiotherapy interventions is to improve movement patterns and avoid progression of joint degeneration.
If physio is applied at an early enough stage then the pain & clicking associated with arthritis can be reduced or eliminated in some cases.
Exercise is especially important for people with arthritis. It can help to reduce pain and increase mobility
How is Exercise Effective in Treating Arthritis?
The mechanisms with which exercise exerts a beneficial effect on hip & knee arthritis includes general effects (e.g. neural and systemic inflammation effects) and local effects at the level of the joint (e.g. improved muscle strength and control and impacts on local joint inflammation)
The mechanisms with which exercise exerts a benefit for knee and hip arthritis may be mediated by neural mechanisms, improved muscle strength and neuromuscular control, improved cartilage health, and reduced systemic and local joint inflammation.
Types of Arthritis
Arthritis is a degenerative condition of joints and comes in two primary forms referred to as osteoarthritis & rheumatoid arthritis. It manifests in the form of pain, swelling and stiffness of the affected joints.
Knees, hips and joints of the spine are the most common joints to bear the brunt of increased mechanical stresses.
Arthritis of the Spine
The spine is made up of small bones called vertebrae. They are separated from each other by a fluid filled intervertebral disc. The disc is important for shock absorption. On the back of each spinal bone (vertebra) there are superior and inferior extensions. These extensions have facets that form a synovial joint with the corresponding facets of the adjoining vertebra. The facets are lined by cartilage and the joint is encapsulated. These joints impart mobility to the spine.
The cervical (neck) and the lumbar (low back) portions of the spine are the most mobile regions.
What external forces do to the spine
During one’s lifetime, the spine is subjected to a lot of stress. This stress can come in the form of prolonged sitting at a desk or repeated bending & lifting which make the spine, especially the cervical and the lumbar regions, vulnerable to arthritic changes.
Some sports such as weight lifting, gymnastics, racquet sports and contact sports also increase the risk of spinal osteoarthritis. Construction site workers tend to develop osteoarthritis of the spine earlier than others due to repeated loading.
These external forces cause breakdown of cartilage and inflammation of synovial membrane around the facet joint. This is followed by development of bony spurs or osteophytes. The spinal (facet) joints of the adjoining vertebrae form a canal through which the nerve roots exit the spinal cord.
The osteophytes formed as a result of degeneration may sometimes compress these exiting nerve roots resulting in radiating pain which can go down the legs to the feet.
The intervertebral discs also undergo degeneration as a result of prolonged loading or insufficient loading. This can give rise to disc bulges and reduce the intervertebral disc space. The bulging disc may impinge upon the exiting nerve root.
In rare cases osteophytes may narrow the vertebral canal and cause cord compression. This is known as spinal canal stenosis. Cord compression can cause bowel/bladder incontinence, loss of sensation and muscle strength in both lower limbs and instability while walking.
Signs and Symptoms of Neck Arthritis
Patients with cervical spine osteoarthritis typically complain of pain in the neck and shoulder blade. It is common to report difficulty in looking over the shoulder while driving.
In cases of nerve root compression, there may be pain, tingling, numbness or weakness of the arm and hand.
Signs and Symptoms of Low Back Arthritis
Similarly patients with lumbar spine osteoarthritis complain of pain and stiffness in the low back, especially early in the morning. Turning in bed and getting up can be challenging. They may also complain of difficulty in bending down to tie shoe laces and lifting grocery. In case of nerve root compression there may be pain and tingling radiating down one leg. This may be accompanied by muscle weakness in the legs or feet.
Physiotherapy Treatment of Arthritis
The aim of physiotherapy is to slow down the process of degeneration and minimize discomfort associated with arthritis. Spinal manipulation along with exercises to regain mobility and strengthen the muscles around the spine are beneficial.
The physiotherapy session includes
- Soft tissue massage to reduce localised pain and muscle spasm
- Gentle vertebral mobilisations to restore joint motion
- Range of motion exercises to restore movement at the neck and low back
- Stretching of the back and leg muscles to relieve stiffness.
- Strengthening of the muscles around the neck or low back
- Re-education and retraining of correct movement and posture.
- Ergonomic advice regarding proper lifting and workstation evaluation.
- Advice on weight reduction
- Core muscle strengthening
- Home exercise programmes
It is the degeneration of the knee joint.
The knee joint has two compartments – the patellofemoral (between the knee cap and the thigh bone) and the tibiofemoral compartment (between the shin bone and the thigh bone). The patellofemoral compartment is more commonly involved in osteoarthritis.
Osteoarthritis of the knee is the most common cause of knee pain in people above the age of 45. Prolonged standing, running, contact sports involving sudden change in direction put a lot of stress on the joints which permanently damages the articular cartilage. A previous meniscal or ligament injury as seen in soccer or basketball players triggers early degenerative changes in the joint.
Signs and Symptoms of Knee Arthritis
Initially the patient complains of pain and morning stiffness. As the condition progresses, joints are constantly warm, swollen and painful. There is a clicking or grating sound when the patient moves his knee. In later stages, there is weakness of the muscles around the knee. As a result, the patient has difficulty in standing, walking or climbing stairs.
Increasing age, excessive body weight, previous knee injury and genetic make-up are the predisposing factors for knee joint OA.
How can Physiotherapy help Arthritis?
The aim of physiotherapy is to limit the progress of the disease and alleviate the symptoms so that you can return to normal activity as soon as possible.
During the physiotherapy session the therapist will aim to:
- Reduce pain and inflammation
- Restore knee joint range of motion through joint mobilisation and stretching
- Strengthen the Quadriceps. A strong quadriceps helps in proper movement of the knee cap or patella. A strong quadriceps also reduces the loads passing through the knee joint.
- Strengthen the hamstrings, calf and hip muscles of both sides.
- Taping to improve patellofemoral (knee cap) alignment
- Assess and correct lower limb biomechanics.
- Agility and balance training to improve proprioception
- Analysis and retraining of walking, running, & squatting movements if required
- Advice for knee supports, shoe inserts or orthotics as necessary
- Encourage weight management
- Plan pre and post-operative physiotherapy if knee replacement is indicated. Knee replacement surgery is recommended only in severely deformed knee joints which are very painful and severely lacking in range of motion. Post-operative physiotherapy after partial or total knee replacement is extremely important for early return to activity.
Anatomy of Hip Joint: The hip joint is a ball and socket joint. The head of the femur (thigh bone) articulates with the acetabular cup of the pelvis (hip bone). The joint surfaces are lined with articular cartilage.
Hip Arthritis: The hip joint can also develop osteoarthritis as it is a weight bearing joint. However, it is less common as compared to osteoarthritis of the knee. Long distance runners are at risk of developing osteoarthritis of the hip.
Signs and Symptoms of Hip Arthritis
Initially the patient complains of pain and stiffness in the hip early in the morning or after a period of prolonged inactivity. They also notice audible clicking or grating sound when the hip moves. Walking, climbing stairs and getting in and out of bed or the car becomes difficult in the advanced stages of the condition.
Arthritis of other Joints:
Osteoarthritis of the Hand
There are 5 metatarsal bones (between the wrist & fingers) and 19 phalanges (finger bones) in each hand. The wrist itself is made up of 8 small bones. Joints exist between the 8 bones of the wrist and these may be subject to injury. Joints are also present where the metatarsal bones articulate with the phalanges (fingers). These joints are synovial joints and are lined with articular cartilage. People who work more with their hands are likely to have early cartilaginous breakdown in the joints of the thumb and fingers.
Patients with osteoarthritis of the hands usually complain of early morning pain and stiffness in the fingers, weak grip and swelling around the knuckles. Bony spurs or Heberden’s nodes develop in the late stages around the finger tips. Bouchard’s nodes are bony outgrowths in the middle joints of the fingers. Such outgrowths make the fingers look disfigured.
Physiotherapy treatment aims at reducing pain, swelling and disability. The sessions include:
- Stretching and gentle mobilisations to increase range of motion of the wrist and fingers
- Grip strengthening exercises
- Suggestions on environmental modification at home and office:
The shoulder complex is made up of three joints – the glenohumeral joint which is formed between the scapula (shoulder blade) and humerus; the acromioclavicular joint which is formed between the collar bone (clavicle) and the acromion; and the sternoclavicular joint that is formed between the chest bone (sternum) and the collar bone. Of these, the acromioclavicular joint most frequently undergoes degenerative changes.
Swimmers, tennis or badminton players and gymnasts are usually affected by shoulder complex injuries and hence have higher risk of joint degeneration. A person who has suffered dislocation of shoulder joint may also succumb to early arthritic changes in the joint.
A person with arthritic changes in the shoulder joint will find it difficult to perform sustained overhead activities like shampooing hair or reaching towards high shelves. The may also complain of pain, swelling and tenderness over the tip of the shoulder. In longstanding cases there may be visible muscle wasting in the deltoid and shoulder blade muscles. In cases of severe limitation of movement joint replacement may be recommended.
Physiotherapy intervention for treatment of shoulder joint osteoarthritis involves:
- Application of electrotherapeutic modalities to reduce pain, swelling and tenderness
- Range of motion exercises and stretching to increase mobility
- Joint Mobilisation
- Strengthening of muscles of the shoulder joint complex
What will show up on an x-ray if I have arthritis?
- Loss of joint cartilage
- Bony outgrowths/Osteophytes
- Narrowing of the joint space
What will happen in my physiotherapy assessment?
Physiotherapy assessment will incorporate an assessment of your posture, movement & walking or running patterns. Orthopaedic tests will also be used to identify the source of the pain joint. This will determine the probable outcome of the physio interventions & the likely long-term prognosis.
This examination will be followed by advice and the provision of a personalised treatment plan. This may include:
- posture advice
- what is safe to do & what should be avoided
- education & movement re-education
For further information on conditions treated go to: