About 23% of adults in the United States have arthritis. The associated joint pain and stiffness can make everyday activities difficult --- so difficult, in fact, that 8-million working-age adults with arthritis report that their disease limits the kind of work they can do.
Where can arthritis sufferers turn for hope and help?
Host, Jonathan Fialkow, M.D., and his guest, Alan Saperstein, M.D., an orthopedic surgeon with Baptist Health Orthopedics & Sports Medicine talk about symptoms, causes and both surgical and non-surgical options for managing arthritis.
About 23% of adults in the United States have arthritis. The associated joint pain and stiffness can make everyday activities difficult --- so difficult, in fact, that 8-million working-age adults with arthritis report that their disease limits the kind of work they can do.
Where can arthritis sufferers turn for hope and help?
Host, Jonathan Fialkow, M.D., and his guest, Alan Saperstein, M.D., an orthopedic surgeon with Baptist Health Orthopedics & Sports Medicine talk about symptoms, causes and both surgical and non-surgical options for managing arthritis.
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Dr. Fialkow:
Welcome Baptist Health Talk Podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health Miami Cardiac And Vascular Institute, where I'm also chief of cardiology at Baptist Hospital, and the chief population health officer at Baptist Health.
Dr. Fialkow:
About 23% of adults in the United States have arthritis. The associated joint pain and stiffness can make everyday activities difficult. So difficult, in fact, that 8 million working age adults with arthritis report that their disease limits the kind of work they can do. Some forms of arthritis can even affect multiple organs in the body, causing widespread symptoms.
Dr. Fialkow:
As part of arthritis awareness month, I've invited an expert to the podcast, to talk about symptoms, diagnosis, and the latest information on what could be done to manage arthritis. It's my pleasure to welcome Dr. [Alan Saperstein 00:01:08] an orthopedic surgeon with Baptist Health Orthopedics And Sports Medicine Institute. Thanks for joining us Alan.
Dr. Alan Saperstein:
Pleasure to be here.
Dr. Fialkow:
Alan, just to get the conversation going. Arthritis is a broad term and many people refer to it, but what are the signs and symptoms of arthritis?
Dr. Alan Saperstein:
So osteoarthritis, or arthritis for short is a disease that affects joints. Joints are where bones come together. It's where we get movement in our body. Examples of some of the joints in our body are knees, shoulders, hips. Arthritis is degeneration of the cartilage that lines these joints. When you get that degeneration, your first symptom is typically pain. Other symptoms are things like swelling, loss of range of motion, stiffness and loss of function, inability to do your normal activities of daily life, or engage in sports or other fun pursuits, because of limitation of motion and pain.
Dr. Fialkow:
So the degenerative arthritis, the osteoarthritis, like we're talking about, the most common forms of arthritis. Do you ever see the other symptoms without pain or the loss of motion, et cetera? Is pain really the main driver, something hurts in that joint?
Dr. Alan Saperstein:
I think the main driver of people coming to the doctor is pain. So while there are some people who are going to just have some loss of motion or swelling, stiffness, they usually don't get to me so much. By the time you're going to see a doctor, usually you're hurting.
Dr. Fialkow:
So is the pain with movement? Is it with rest? Does it keep people up at night lying in bed? Or is it generally when you're trying to do something, the joint that's affected will hurt.
Dr. Alan Saperstein:
So it's interesting. Classically it's with movement, because if the joint is at rest, why should it hurt? But that said, even though people feel it during the day when they're moving, when they're walking, a lot of people feel it when they go to bed at night. It's almost like the damage that you've to the joint during the day finally comes to fulfillment, then you start to feel it at night. A big reason for that is you don't have a lot of sensory input when you're in bed at night, so you really can focus more on, on what you've been feeling all day, but that's been filtered out, because there's so much other information coming into your brain.
Dr. Fialkow:
What are the risk factors for arthritis? What are the components that make someone more likely to develop arthritis?
Dr. Alan Saperstein:
So there's been a lot of research into this recently, and it actually appears that somewhere around 50% of cases of arthritis are genetic in origin. We have an isolated a single one master gene that is responsible for arthritis, but we have found a lot of genes, about 15 to 20 genes, that either increased the risk of arthritis, or decreased the risk of arthritis. So your genetic makeup really goes a long way to determining whether or not you're someone who's going to get arthritis in various joints in your body.
Dr. Fialkow:
That's fascinating that there's a genetic component, so does it run the families?
Dr. Alan Saperstein:
Yeah, very much so. About half of cases are clearly, have the strong family history of arthritis.
Dr. Fialkow:
We said it's degenerative. So obviously it takes time to accumulate. So age would be a component as well, but do you see true arthritis, the wearing down of the joints as you say, in relatively younger people?
Dr. Alan Saperstein:
So osteoarthritis, which is, again, more that wear and tear arthritis, you seldom see in patients before they hit maybe their mid-30s, 40s or 50s. You do see the inflammatory arthritis, which is a whole different class of diseases, really class of auto-immune diseases, that type of arthritis you may see in younger individuals. You can frequently see it in children actually. But for most people, it's really a disease of aging, osteo-
Dr. Fialkow:
Actually, I [inaudible 00:04:51]. Let's clarify that for a second. We're talking about osteoarthritis, the degenerative condition, wear and tear. And then an inflammatory kind of arthritis, which can happen in younger people and have more significant components to it, right? There are two different kinds of arthritis?
Dr. Alan Saperstein:
Those inflammatory arthritis's are things like rheumatoid arthritis, or lupus, or psoriatic arthritis. And those are really lifelong diseases that can present young or in middle age.
Dr. Fialkow:
So going back to the degenerative arthritis, is it fair to say, if someone has some pain, they may have arthritis, but they also may have pain and it's not arthritis? Whether it be in a hip or shoulder or an-
Dr. Alan Saperstein:
Sure. I mean, there in each joint there's its own specific architecture, specific structures, both bony and soft tissue, and not everything that causes joint pain is arthritis. In the shoulder, more often a shoulder pain is due to tendonitis or bursitis, but sometimes it can be arthritis [crosstalk 00:05:55] in joints. So it's a more common for it to be arthritis.
Dr. Fialkow:
So when should people see a doctor? And when should it escalate past say a primary care doctor to more of an orthopedic specialist? Is there any rules, any recommendations in that area? I know it's obviously broad.
Dr. Alan Saperstein:
So it's really very much an individualized decision about when you feel enough is enough, that you want to have some professional help. I think when it starts to really interfere with your quality of life, where you're using medication on a frequent basis, even if it's over the counter type of medication. Where it's keeping you from doing activities that you want to be doing, I think that's the time that you reach out to see a physician. Many patients will go directly to a musculoskeletal specialist, and in my case, an orthopedic surgeon. Many will see their primary care doctor first. The primary care doctors will frequently treat with medications, or physical therapy. Sometimes even with injections, but usually when it gets any deeper than that will refer patients to an orthopedic surgeon, or other musculoskeletal specialist.
Dr. Fialkow:
Is there a relationship between heavy physical activity? Whether it be heavy runners, do they get more arthritis in their lower extremity joints or high-impact exercising, is that, or is that a fallacy?
Dr. Alan Saperstein:
So that's actually an excellent question. There was a study a few years ago that showed that actually runners have a lower incidence of knee arthritis than the general population. But the one thing we do know about high-impact loading activities, like running, is that if you already have arthritis in a knee or a hip, and you continue to run, you will hasten the progression of the arthritis. But if you don't have it already, it's okay to run.
Dr. Fialkow:
Does weight make a difference? Do you find arthritis worse in, or worsens and people who may be overweight, especially in the hips and the knees and other joints?
Dr. Alan Saperstein:
There, there is a relationship, and there are several studies that show that there is an increased risk of hip and knee arthritis in overweight patients, and certainly more rapid progression of arthritis in overweight patients. So yes, weight loss, in terms of the preventive modality, is important.
Dr. Fialkow:
So if someone has arthritis again, hip, knee shoulders, the larger joints, is it guaranteed it's going to get worse over the course of their life? Or now they come to see you, and what can you recommend to them in terms of either preventing progression, making the pain better? Then certainly the other question would be when would surgery be indicated, and what are the advancements in that area? So is it definitely going to get worse? Or is it something that can be stabilized?
Dr. Alan Saperstein:
No, so not every case progresses. Many cases of arthritis will progress over time, but I've also seen many cases where, over the course of decades, really nothing progressed. There are no clear cut ways of preventing progression. We, of course, for lower extremity arthritis, we recommend against high impact, so no running, no jumping, because we know those things make it worse. If someone's overweight, we do recommend weight loss. Because again, that, being heavy does increase the risk of progression.
Dr. Alan Saperstein:
But we don't have any drugs or other modalities that can stop it in its tracks. Again, I'm talking about degenerative osteoarthritis. Rheumatoid arthritis, inflammatory arthritis is a different story. There, there are drugs that may modify the disease. But osteoarthritis, we can't really modify the disease. As a result, our treatment modalities are really treating the symptoms for the most part. Everything we do, whether it's medication or injection or physical therapy, really are treating the symptoms of osteoarthritis to try to keep the patient from progressing to the point where they need an operation to really resolve the problem.
Dr. Fialkow:
So you've mentioned, appropriately, certain things one can do in their lifestyle to alleviate some of the symptoms and certainly slow the progression, like lose weight and avoid very high impact activities. Let's start with, from a scale standpoint, what people can do? Lots of advertisements out there for arthritis medications, are there any supplements or medications that can improve arthritis, especially degenerative that have been shown to improve that? Other than pain relief, which again, there's lots of things out there, which we clearly understand could improve pain.
Dr. Alan Saperstein:
So really not. Really the answer to that, is no. The most popular supplement that's been used is Glucosamine and Chondroitin. And there were some landmark studies a few years back that really patients on that medication in randomized controlled studies did no better than placebo group. So that's-
Dr. Fialkow:
Which means if you just give someone a sugar pill and say, "It's Chondroitin," they'll say, "Holy cow, I feel great." And it was the idea of of taking something.
Dr. Alan Saperstein:
Yeah, there are some. Turmeric, which is a natural supplement, does have some benefit in terms of symptomatic relief. So there is, for my patients who really are looking for something natural, and stay away from something that's a medication, turmeric mimics the anti-inflammatory medications in terms of pain relief. So that can be of some benefit, but it again does not modify the actual disease process.
Dr. Fialkow:
Sure. How about over the counter anti-inflammatories, the Ibuprofens and the Naproxens and what not? When do they come into play?
Dr. Alan Saperstein:
So I usually try to stock patients with Tylenol first. Only because the safety profile, I feel, is a little bit better. A lot of patients don't tolerate the anti-inflammatories, because of stomach upset, reflux and ulcers. Then many patients have reasons they can't take that class of medication, because they have coexisting medical problems, like renal disease or cardiac disease, that may preclude it. So I tend to start with Tylenol, which can be very effective. But in most patients who don't respond to Tylenol, if they have no reason they can't take an anti-inflammatory, I find Aleve works as well as any of the other anti-inflammatories, and that's usually my go-to anti-inflammatory, but any of them really are acceptable.
Dr. Fialkow:
Are there, do you ever prescribe doses beyond the over-the-counter dosing of those medications, the anti-inflammatories, does that come into play?
Dr. Alan Saperstein:
Yeah, sure.
Dr. Fialkow:
It may be a risk, but when would you use that?
Dr. Alan Saperstein:
Again, the risk associated with anti-inflammatory medication, whether we're talking about kidney risk or cardiac risk, is generally dose related. So the more you take, the harder your risk of complications. That's why I don't usually start with the prescription strength, but if somebody gets some relief from an over-the-counter NSAID, I'll frequently go to a prescription NSAID, which is a higher dose equivalent. But again, with the understanding, there are some risks associated with that.
Dr. Fialkow:
Take a pause for a second, and talk a little bit about an acute injury versus arthritis. Let's say someone goes out and plays basketball for the first time in a while, and then the next day their hip is sore, or their knees are sore. What would you recommend to that individual? Both to confirm it's not, true a degenerative condition, I guess, time tells, but do they put heat on? Do they put cold on it? What do you tell people to do when they've overused a joint for relief?
Dr. Alan Saperstein:
Yeah, so, I mean, I think the first, usually the first thing you'll do, if you have a sore joint after playing something you haven't played in a while, you ice it down, and you rest it, and you see what happens. For 90% of cases, things get better. I'm not talking about the situation where you were playing basketball and you're jumped and landed and twisted, heard a pop, it swelled up immediately, and you came out of the game, that's a different entity. That's an acute sports injury, where you have to start looking for injuries to cartilages and ligaments.
Dr. Alan Saperstein:
You're talking, I think, more about the person who plays and plays the whole game, but the next day, they're hurting. Again, if it's something new, usually icing and resting it. If it's something that persists beyond a few days, then it's something maybe you want someone to take a look at. And that would be the time to come into my office and just have a good examination, maybe take an x-ray. Obviously, if it's something that's happening on a recurrent basis, then that does bring up the question, is this an arthritic joint? And certainly the x-ray would be the way of determining that.
Dr. Fialkow:
I want to finish up with some questions regarding surgical interventions and new treatments. Before I do, you mentioned quite well, the difference between the inflammatory arthritis and the degenerative arthritis. I know what the inflammatory arthritis, we generally see swelling and redness and warmth in the joint. Do you see that with the osteoarthritis and the degenerative joint disease as well?
Dr. Alan Saperstein:
You can. Having swelling in a joint is a very common finding in an arthritic joint. Swelling is also a common symptom of other types of joint damage. So to me, a swollen joint is really an important finding on physical examination. The inflammatory arthritis, almost always swell, whereas the degenerative arthritis sometimes swell. In terms of redness, that usually you don't see so much redness with arthritic conditions. Redness always, usually when I see redness, it's because someone's been icing their knee tremendously, [crosstalk 00:15:30] for that.
Dr. Fialkow:
Okay, patient induced redness?
Dr. Alan Saperstein:
Yeah. That's the most common reason. The other thing one thinks about with redness, is infection. So that's always in the back of one's mind. But you don't see that so much with an arthritic joint, for any reason. And one, the last thing you mentioned was warmth. Warmth is very nonspecific. Sometimes, warmth just suggests to me that there's increased blood flow to the area. So yes, it can accompany an injury, or an arthritic condition, because your body's bringing more blood in there to try to repair the damage. But it's very non-specific, so it's not terribly helpful finding on examination.
Dr. Fialkow:
I appreciate that. So very interesting, osteoarthritis, degenerative joint disease, genetic component, which is fascinating and that we'll realize. Worse with wear and tear and age, worse with being overweight, some of the interventions can be to lose weight and decrease the progression of arthritis. No real supplements that have been proven to be beneficial, but maybe turmeric for symptom relief. Anti-inflammatories can help. So now it's either someone who needs improved function without pain, or just the pain is unbearable, comes to see you. All those things have failed. When do you decide there's a surgical option? And second part of that is what are the improvements you're seeing in the surgical approach towards arthritic joints?
Dr. Alan Saperstein:
Sure. So, every joint is a little bit different, but probably the most common arthritic joint I'll see in my practice will be a knee. Knee arthritis is extremely common. Again, all those conservative modalities can keep people going for a while, but comes a point where people can't live with the pain, and the surgical options for an arthritic knee for the most part are replacement options. Back 30 years ago, 40 years ago, when orthoscopic minimally invasive surgery came out. Many of these arthritic knees were treated with arthroscopic clean outs, but I think we've come to discover many years ago, that's really not terribly helpful surgery in the long run.
Dr. Alan Saperstein:
It might help for six months, but it really doesn't buy people that much time. So for the most part, if one's doing surgery, it's a replacement. Most of the time when we're replacing the knee, we're doing a total knee replacement, which means basically resurfacing each of the three bones in the knee with metal or plastic components. Such that now you've gotten rid of the arthritic cartilage and diseased bone underneath it, and replaced it with these metal and plastic surfaces. Those surfaces can move smoothly, one and another without friction. And thereby reducing pain.
Dr. Alan Saperstein:
Knee replacement, as I said, usually total, doing all three bones, but occasionally the arthritis is just limited to a single area in the knee, we will do a partial knee replacement or a uni-compartmental knee replacement, that's called. I'd say that might represent 10% of knee replacements that I do, are uni compartmental. Knee replacement, as well as hip replacements for that matter, or shoulder replacement, are really dramatically successful operations in terms of getting rid of pain. They really turn people's lives around and really get them up and moving, and comfortable in doing the things that they want to do with relatively low complication rates.
Dr. Alan Saperstein:
Over the years, each of the joints has gone through gradual steady improvements in terms of how we perform those surgeries to make them a little bit more effective. And a little bit easier to recover from, and a little bit more likely to be complication-free, and a little bit more likely to last for a longer period of time. But there was never one dramatic change in how these surgeries are done. It's just been more a gradual evolution.
Dr. Fialkow:
Oh geez, I remember in my training, people will be in the hospital for days, if not a week, after a hip replacement and sometimes even after a knee replacement, but nowadays a lot of these are even being done outpatient, right?
Dr. Alan Saperstein:
Yeah, I mean, our standard now for most joint replacements is one night stay in the hospital, but I've been doing maybe about 10, 15% of these patients outpatient, where people go home the same day. This really compares when I started practice, it was about a three or four day stay after a joint replacement. And I remember in training, it was even longer than that. So you're right, it's [crosstalk 00:20:12]-
Dr. Fialkow:
I'm a little older than you.
Dr. Alan Saperstein:
Just a little, [crosstalk 00:20:15]. Yeah, it has changed quite a bit. A lot of that has to do with really our, is not as much with the surgery as with the anesthetic techniques that are used now. We use nerve blocks, which basically numb up the joint and the limb postoperatively for a few days. And that really helps people get over what would have been the worst period of time after the surgery.
Dr. Fialkow:
And it's fair to say we're using much less pain medications because of the simpler surgery and the better anesthesia? There is a recuperation and a rehabilitation component. But as you're saying, the long-term outcomes to take these people, who are really going to be spending the rest of their lives in pain, and seeing the significant improvements in their quality of life is a substantial.
Dr. Fialkow:
So again, great information both in terms of, again, the difference between the degenerative arthritis, the more common components, as well as the inflammatory one which generally requires a broader medical assessment and treatment. Lots of information regarding treatments options, and I think one of the take-home points I got is, go to your doctor, go to an orthopedist, where appropriate. Customize the treatment towards your needs. There's no one size fits all, whether it's medications, or therapy, or injections, or surgeries, and certainly at Baptist Health Orthopedic And Sports Medicine Institutes, we've got the expertise across the spectrum for all the joints that may wear out over time, so to speak. Any final comments, any thoughts or anything we missed that you want to bring up before we wrap up?
Dr. Alan Saperstein:
No, I mean, I would just say probably the biggest regret I find from patients who we treat for arthritis, is that they didn't come in and start addressing it sooner. I mean, there are quite a few patients that I'll see, that will come in and will just have horrible disease in a knee or shoulder or a hip. And I'll say, "Well, who's been taking care of you?" And they'll say, "Oh, I've never seen anyone for this. You're the first." And I look at the X-ray I'm like, "I can't imagine how that's possible, but it's what it is." So just get things looked into, if something bothers you, come in and have someone take a look at it. At least know where you stand. It's okay if there's not a whole lot to do, and not a whole lot wrong. It's okay to say, "You're doing fine. Don't worry about it." But I think get checked out.
Dr. Fialkow:
Great advice. Again, dr. Alan Saperstein. I appreciate your time and your expertise.
Dr. Alan Saperstein:
Thank you for having me.
Dr. Fialkow:
Yep, as usual, I'd like to encourage all our listeners to take a moment to give this podcast a five star rating on whichever platform you listened to us on. If you have any comments or suggestions for future topics, we'd love to hear from you. Email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks for listening and stay safe.
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