Pain is the most common reason for a doctor's appointment – not surprising, considering that up to a half of all Brits live with daily pain.
On pain advice specialist and patient Helena Miranda on Saturday, today the Mail launches a series of essentials expert guides to tackle common problems – back pain, migraine, headache and, here, arthritis – tot help stop the pain that rules your life.
Osteoarthritis does not have to be the end of the world – or a great tennis career.
In January, after years of pain, triple Grand Slam tennis champion Andy Murray was operated on to "resurrect" his hip joint damaged by osteoarthritis.
He returned to court in June and took the Queen's title twice – not a bad result for an operation that many people associate with old age and declining mobility.
Joints supported by weak muscles are more sensitive to arthritis. Tellingly, the average body mass index (BMI) of hip surgery patients in the UK in 2016 was 28.8 (overweight). And with an average BMI of 31, many of those who had replaced a knee were obese (file photo)
Osteoarthritis occurs when the cartilage that protects our joints breaks down.
The body's attempts to repair the damage can make it worse because the synovium – the capsule containing the joint – becomes thicker and produces more lubricating synovial fluid, which in turn causes inflammation.
As part of this attempt at repair, extra bone can grow at the edge of the joint, causing it to become deformed. The result: stiffness and pain.
In the UK, an estimated nine million people have osteoarthritis, which usually affects the joints that suffer the most stress – more than two million people over 45 have it in their hips and five million in their knees – but it can affect any joint, from the fingers to the toes.
Age-related "wear and tear" is clearly a factor, but the exact cause of osteoarthritis remains unclear.
Injuries can play a role and there is evidence that the condition has been inherited. Women suffer more than men, presumably due to the decrease in estrogen during menopause.
One of the most effective methods to prevent arthritis and pain is to maintain strong thigh muscles, according to research that measures the strength of quadriceps muscles (at the front of the thigh) in 488 elderly people (file photo)
Although not many of us punish our joints in exactly the same way as Andy Murray, we do punish them – being overweight increases the risk of arthritis at least four times.
Each extra pound of weight increases the load on each knee by four pounds, with each step wearing down the cartilage. There are also indications that fat cells release chemicals that cause inflammation.
And a sedentary lifestyle does not help, because a lack of exercise weakens the muscles and ligaments that support joints.
The good news is that although there is no cure for osteoarthritis, there is much that it can fight – and the pain it causes.
What to do when it's early
There are two things you can do to prevent osteoarthritis or keep it at bay as soon as joints become stiff and painful: stay active and watch your weight.
"Staying mobile and maintaining good muscle strength is the best way to keep osteoarthritis at bay," says Professor Philip Conaghan, a rheumatologist consultant at Leeds Teaching Hospitals NHS Trust, who led the latest evaluation of the National Institute for Health and Care Excellence .
It is a myth that exercising can lead to osteoarthritis by wearing out joints (unless you are a top athlete with a criminal regime).
In fact, joints supported by weak muscles are more sensitive to arthritis. Tellingly, the average body mass index (BMI) of hip surgery patients in the UK in 2016 was 28.8 (overweight).
And with an average BMI of 31, many of those who had replaced a knee were obese.
But even if osteoarthritis has started, it is not too late to do anything about it.
Steps to avoid the surgeon
Build your strength
In his NHS clinic, Professor Conaghan sees patients with knee, hip, and other joint pain between the ages of around 40 and 75, & among them, muscle weakness is almost universal, & he says.
There are two things you can do to prevent osteoarthritis or keep it at bay as soon as joints become stiff and painful: stay active and watch your weight (photo of the file)
His advice is simple: "Get strong first, then get fit. Just telling people to walk around the block is a bad starting point – because they are weak, they cannot walk at a fast pace and they do not get any benefit.
& # 39; But once they have built up some muscle strength, they can start with aerobic fitness, such as on an exercise bike or cross trainer, or swim. Walking laps in a swimming pool is a fantastic exercise for weak people. & # 39;
And exercise will really help, with overwhelming evidence that it significantly reduces pain and improves function, performance and quality of life in people with knee and hip osteoarthritis, such as a review in the journal Annals of Physical and Rehabilitation Medicine this year said.
One of the most effective methods to prevent arthritis and pain is to maintain strong thigh muscles, according to research that measures the strength of quadriceps muscles (at the front of the thigh) in 488 elderly people.
The researchers, who wrote in Knee Surgery, Sports Traumatology, Arthroscopy last year, discovered that weak thigh muscles were directly related to arthritis in the knee.
Jar test to check the health of the joints
Professor Philip Conaghan, advisor rheumatologist at Leeds Teaching Hospitals NHS Trust, recommends two simple tests that you can do at home to see if you are likely to get osteoarthritis.
& # 39; If you cannot undo a pot or easily get out of a chair even before you have joint pain, these are warning signs that your muscles are starting to run downhill and that you are overloading your joints, & # 39; he says.
To combat this, you need to build up your muscle strength (see above).
Exercise works because joints depend on a network of supporting muscles and other tissue, Professor Conaghan explains. & # 39; A lot of joint pain actually comes from the tendons and structures around the joint, where the tendons attach to the bone & he says.
Tendons start to hurt when the weak muscles to which they are attached leave an unfair part of the load.
Sensible recreational exercise protects the joints, adds Martyn Porter, an orthopedic surgeon and medical director of the National Joint Registry, who keeps records of replacement procedures.
"People who train carefully and effectively are often people who don't get arthritis," he says. "These are people who are 60 or 70, who have trained during their lifetime, have good food and have good muscle strength."
But it's never too late
Every exercise that strengthens the quadriceps helps protect knees and hips. Cycling and swimming work well without straining the joints. The gluteal muscles that support the hip joints can be strengthened by simple leg increases when you lie on your side and back.
Did you know?
Andy Murray & # 39; s "resurfacing" operation covered the "ball" of the femur with metal.
Only 560 of 92,873 hip operations in 2018 were resurfacings.
Most people with knee problems notice that their pain starts to improve as their muscles get stronger, says Professor Conaghan. "Most knees won't need joint replacement – only about 15 percent of patients will eventually start surgery," he adds.
Exercise with hips is still useful, but not that much. "Hips do not respond as well to muscle strengthening as other joints," says Professor Conaghan. "But it must always be tried first."
Can special insoles help?
A range of expensive insoles has been designed to combat the pain of knee arthritis.
But it's probably better to invest in a pair of comfortable shoes, says Professor Conaghan.
"The evidence that insoles help knee pain is not good," he says. "I generally recommend wearing a shoe with thick soles, which gives you a bit of shock absorption."
The theory behind lateral wedge-shaped insoles that slightly increase the inside or outside of the foot, which changes the alignment of the femur and tibia, is that changing the load on the knee reduces pain and improves the function of the joint .
The truth about supplements
Supplements for joint health are not cheap – 84 tablets from a leading brand with glucosamine, omega-3, collagen and chondroitin cost £ 25.50.
Claims that they can help maintain healthy joints & # 39; and & # 39; manage anti-inflammatory responses & # 39; have not been proven.
Rheumatologist professor Philip Conaghan emphasizes: "There are no supplements that prevent you from getting arthritis."
An important review in the journal Reumatology looked at 16 popular supplements and found no evidence of benefit from omega-3, vitamins D and E, collagen hydrolyzate, glucosamine, chondroitin or rosehip.
There were indications that Boswellia serrata, an herbal extract; Pycnogenol, from pine trees; and curcumin, the yellow extract of turmeric, can relieve pain and improve mobility in arthritis.
But the quality of the tests was judged to be too poor to justify a recommendation.
But study after study has provided no evidence that they are effective.
Muted or lateral wedge shaped insoles are also sometimes prescribed to relieve the symptoms of hip arthritis – despite the fact that the National Institute for Health and Care Excellence recognizes that & # 39; a scarcity & # 39; yields any benefit to investigations.
Why acetaminophen will not help … and the treatments that will
Osteoarthritis patients all have one thing in common: pain.
Managing that pain is vital – not only to make life bearable, but also to help you stay fit and strong.
For many, acetaminophen is the first line of defense. Unfortunately, "acetaminophen has very little effect on osteoarthritis pain," says Professor Philip Conaghan, a rheumatologist who runs a clinic at Leeds Teaching Hospitals.
A study from 74 of 74 studies published in the Lancet found that acetaminophen had a 0 to 4 percent chance of improving osteoarthritis pain.
The next option is a non-steroidal anti-inflammatory (NSAID), such as ibuprofen or diclofenac.
NSAID's are very effective in relieving arthritis pain, concluded the same study from 2016. However, the pills are not for everyone. They can have side effects, including stomach problems. They can also interfere with other medicines, including those for high blood pressure.
Osteoarthritis patients all have one thing in common: pain. Managing that pain is vital – not only to make life bearable, but also to help you stay fit and strong (file photo)
But these problems can be avoided with NSAID & # 39; s in cream or gel form rubbed on the skin. Doctors can prescribe this. Weaker formulations can be obtained over the counter.
Capsaicin cream, also prescribed, can be offered if topical NSAIDs do not help. Derived from chili peppers, it blocks the nerves that carry pain messages to the brain.
Opioid pain killers, such as codeine, can be a last resort, but these are not very effective for osteoarthritis. A review by the authoritative Cochrane Collaboration in 2014 showed that opioids for osteoarthritis were little better than placebo's.
If opioids are used for a long time, they can become addictive. But for many, & # 39; the main problems are things like constipation and sleepiness & # 39 ;, says Professor Conaghan. "With a little too many opioids in your system, they can be a cause of falls."
Some patients may be offered injections of steroids into their knees. This allows them to buy pain relief for up to six weeks, he explains. "We use them as" circuit breakers "to give a patient a good chance to really work on building his muscles."
However, many people discover that the key to relieving the pain of osteoarthritis is not medicine, but sports.
NHS England is developing an exercise rehabilitation program for people with chronic knee and hip joint pain – ESCAPE pain is a six-week rehabilitation program of two-hour lessons per week. It is now being implemented in more than 200 community institutions, including recreation centers and church halls.
Each lesson includes 40 minutes of exercises tailored to each patient's ability, from stretching to stationary cycling. It is suitable for anyone over 45 years of age with osteoarthritis of the knee or hip. Research has shown that the long-term benefits are comparable to those of outpatient physiotherapy for chronic knee pain.
Your doctor can refer you, or some classes allow self-referral. Go to escape-pain.org to find a class.
New joints for the old
More than 230,000 joint replacements – hips, knees, shoulders, elbows and ankles – are performed every year and the number increases as people live longer, making them more susceptible to arthritis wear.
Here we guide you through the different types of implants that are offered.
The artificial elbow joint is made of metal and plastic and replaces the joint between the upper arm bone (upper arm bone) and ulna (inner arm bone)
Wrist replacement surgery can be difficult to perform due to the complex structure of the wrist and hand
There are 150 types of knee prostheses, and each comes in around 20 sizes – and each of these can have two or three different widths to achieve a perfect fit
The artificial joint is made of metal and plastic and replaces the joint between the upper arm bone (upper arm bone) and ulna (inner arm bone).
Two metal stems fit into the bone cavity of the upper and lower arms and are fixed in place with cement.
Most of the 900 elbow replacement operations per year are for rheumatoid arthritis (where the immune system mistakenly attacks cells in the joints, making them stiff and painful).
Only 6.1 percent of the replacement elbows fail after five years, which means that the patient may need further surgery.
Wrists, fingers and toes
Wrists and finger joints can be replaced, normally due to rheumatoid arthritis and toe joints, usually due to osteoarthritis (wear).
Wrist replacement surgery can be difficult to perform due to the complex structure of the wrist and hand, it takes months to recover from it and there are uncertainties about how well it works in the long run.
An incision is made in the wrist to remove some bone.
The artificial parts of the replacement joint are then attached to the remaining bone. Complications occur in approximately a quarter of the cases.
There are 150 types of knee prostheses, and each comes in around 20 sizes – and each of these can have two or three different widths to achieve a perfect fit.
There are three areas of the knee – the inner (medial), the outer (lateral) and the kneecap (patellofemoral).
During the operation, the worn ends of the femur and the upper part of the tibia and any remaining hard cartilage (most of which are worn away by arthritis) are removed and replaced by the artificial joint, which contains a spacer – made of plastic and in the middle placed to work as a hard cartilage – to help the joint made of titanium or chrome cobalt move freely.
About 6.4 fail 15 years and need more surgery, but most should last 20 to 25 years, says Mark Wilkinson, a professor of orthopedics at the University of Sheffield.
Approximately 8,000 shoulder replacement operations are performed every year in the UK. A shoulder replacement is shown above
In the UK, approximately 8,000 shoulder replacement operations are performed each year, the most common being a reverse total shoulder replacement – needed if there is muscle damage around the shoulder, usually as a result of a tennis injury.
Unlike other replacements of ball joints, such as for hips, here the foot and metal ball are connected to the joint, so that instead of the foot being in the shoulder joint, the new plastic foot is attached to the top of the arm.
A cemented stem holds it in place while the metal ball is attached to the existing shoulder sleeve, again with cement.
About 5.5 percent of cases fail after six years, which means that patients need more surgery.
Hip replacements are the second most common joint replacement surgery. A file photo is used above
With approximately 109,000 procedures performed per year, hip prostheses are the second most common joint replacement surgery.
These implants consist of three parts: the stem, placed in the top of the femur; the femoral head, made of metal or ceramic, that moves in the hip cup; and the cup or bowl made of metal or wear-resistant plastic that enters the basin.
The most commonly used implants are metal-on-plastic – a metal stem with a plastic ball joint.
"Most metals contain nickel, so if you have a severe nickel allergy, tell your surgeon if an alternative may be needed," says Professor Phil Turner, a knee surgeon at Stepping Hill Hospital in Stockport.
There are dozens of brands of hip implants, which are available in various sizes to suit the patient.
The procedure takes about an hour, normally under local anesthesia in the spine and, just as with knees, the artificial joint can be attached with or without cement.
Age is a good indication of whether cement is used.
Cemented hips are better for older people because they provide more stability for their weaker muscles and have less chance of fractures.
Hip prostheses have a failure rate of 7.82 percent after 15 years.
In the approximately 1000 ankle replacement procedures that are performed every year, a small incision is made at the front of the ankle
For the approximately 1000 ankle replacement procedures that are performed every year, a small incision is made at the front of the ankle; one part of the implant, made of metal and plastic, is attached to the end of the tibia, the other to the talus bone that is above the heel bone.
They generally do not require cement and are simply tapped into place.
About 8.5 percent of replacements fail within seven years, which means that patients need more surgery.
Quiz to determine if you need surgery
Do not consider joint replacement surgery & # 39; until you have exhausted all non-surgical management options, adopted lifestyle advice, optimized your weight as much as possible and were as active as possible & # 39 ;, says Mark Wilkinson, professor of orthopedics at Sheffield University .
But it has never been easier to decide if joint replacement surgery is for you, thanks to an online "Joint Replacement Risk Calculator."
Get two joints done simultaneously
It is possible to have both knees done at the same time – and it halves the recovery time.
A double or bilateral operation is no riskier than having one joint after the other, but it is not suitable for everyone.
Younger, healthier patients are better candidates "because patient demand is more difficult at the start of recovery," explains Martyn Porter, an orthopedic surgeon who works at Wrightington Hospital in Wigan.
This is based on data from the two million procedures that have been conducted in the UK over the last 15 years (registered in the National Joint Registry of NJR).
It has just been launched by a team at the University of Sheffield to help patients make a choice. It can be found at jointcalc.shef.ac.uk.
By entering your weight, height, age and gender and answering a number of multiple choice questions about your general health and how your hip or knee affects you, it is possible to get a good idea of what improvement you can expect from surgery.
The calculator also takes into account the risk that the patient needs repeat surgery (revision surgery).
Once it is clear that surgery is the solution, Professor Wilkinson says it makes no sense to postpone it – even if you are young and worried that you might need a replacement years later.
"If the pain and functional problems that a patient experiences are still seriously affecting their quality of life, it doesn't matter if they are 25 or 75," he says.
But, says Martyn Porter, surgeon and medical director of the NJR, "it is really important that we do not offer surgery as a lifestyle treatment.
& # 39; It would be wrong for patients to say: & # 39; I get a little bit of pain, I can't play 36 holes, it falls apart in three to four years, so why don't I get it done before it fails? & # 39; If things go wrong, they will be in big trouble. & # 39;
The most important news is that for the vast majority of patients, joint surgery is just as effective and safe as usual.
We know this thanks to the NJR, which registers most of the joint replacement activities in England, Wales, Northern Ireland and the Isle of Man.
Since the register was established 17 years ago, the anonymous details of more than 2.8 million edits have been registered, making it an unparalleled source of information.
It was thanks to the NJR that a replacement hip mark with a metal ball and metal base was withdrawn in 2010 after it was found to have failed in half of the patients, with metal fragments causing blood poisoning and tissue damage in some cases.
It is important to make sure that you are familiar with the surgeon you are going to operate on, says Professor Wilkinson.
"I would like to ask the consultant how good the implants they use are in terms of their chances of survival – how long they last," he says.
"I would also like to ask if they perform many such operations, and what their results are" – the extent to which patients report improvements in pain and mobility.
What is & # 39; many & # 39; ops?
Every year the average number of joint replacements performed per surgeon is: hips and knees, 53; shoulders, 14; ankles, 6; and elbows, 3.
It makes sense to choose a surgeon whose caseload at least matches this. The website njrsurgeonhospitalprofile.org.uk let patients view the file of each hospital or surgeon.
More information is available on the general file of a hospital, including improvements in pain, mobility and quality of life reported by patients.
Patients are entitled to treatment in a hospital of their choice. If you are not satisfied with your advisor, the General Medical Council says that doctors "must respect the patient's right to request a second opinion."
But if you change consultants, you will be treated as a new referral and you will go to the bottom of the waiting list.
Every year the average number of joint replacements performed per surgeon is: hips and knees, 53; shoulders, 14; ankles, 6; and elbows, 3. It makes sense to choose a surgeon whose caseload at least corresponds to this (file photo)
Get fit to get up again
The fitter you are, the faster you recover after the operation. That is why many patients are now offered "prehab," a program of simple strengthening exercises – such as straight leg raises – to do at home in the preceding weeks.
In Guy's and St Thomas Hospital in London, patients visit a day of "school" about the exercises and the operation.
They spend less time in the hospital and are much quicker to walk, with less pain and no increase in complications or re-admission, ”explains Zameer Shah, an orthopedic surgeon in the hospital.
Even if your hospital does not offer a prehab, the British Hip Society recommends staying as mobile as possible before the operation, eating healthily (with lots of fiber to prevent constipation) and stopping smoking.
Sticking to the regime that your physical therapist gives you after surgery is also vital.
You CAN eat to treat pains
Although there is no magical diet for osteoarthritis, there are indications that the omega-3 polyunsaturated fatty acids in oily fish have anti-inflammatory properties that may come in handy, says the British Dietetic Association (BDA). .
The BDA advises patients to consume at least one, and preferably two, servings of fatty fish per week, such as sardines, mackerel, salmon and tuna.
The journal of the pain expert
We speak with an expert in the field who is also a patient.
For over 35 years, Martyn Porter, the medical director of the National Joint Registry and an orthopedic surgeon, has relieved the suffering of more than 4,000 patients by providing them with artificial hip joints.
But the empathy he feels for his patients at Wrightington Hospital in Wigan comes in part from his own experiences.
Martyn Porter heeft het lijden van meer dan 4.000 patiënten verlicht door ze te voorzien van kunstmatige heupgewrichten
Op 20-jarige leeftijd had hij een motorcrash die zijn linkerheup beschadigde en artrose veroorzaakte. ‘Ik ging jaren met een hele slechte heup’, zegt hij. ‘Mijn linkerbeen was een centimeter korter dan mijn rechterbeen. Ik was behoorlijk beperkt.
‘Ik wist dat de operatie complex zou zijn, dus het lukte me 28 jaar voordat de pijn zo erg werd dat ik niet langer effectief kon werken’, zegt hij.
In 2004 vroeg hij vriend en collega Ian Stockley om zijn heup te vervangen. Hij loopt er 15 jaar later nog steeds op – wat 'niet zo ongewoon' is voor een heupgewricht. ‘Ik had een goede chirurg en implantaat en zorgde ervoor door actief te blijven’, zegt hij.
Zijn boodschap voor iedereen die een vervangend gewricht overweegt, is om eerst niet-chirurgische behandelingen te proberen, 'maar onthoud dat chirurgie voor de meeste patiënten veilig en zeer effectief is'.
Een mediterraan dieet eten kan ook helpen. In 2016 verdeelde een studie van de Universiteit van Kent 100 patiënten met artrose van de knie of heup in twee groepen.
De ene werd verteld om te eten zoals ze normaal zou doen, terwijl de andere 16 weken op een mediterraan dieet werd gezet, met meer fruit, groenten en vis, minder vlees en de vervanging van boter en kaas door plantaardige en plantaardige olie alternatieven.
Niet alleen verloor deze groep gewicht, maar tekenen van ontsteking en afbraak van kraakbeen waren verminderd, terwijl hun bereik van knieflexibiliteit of heuprotatie bleek te zijn toegenomen.
Vorig jaar voerden voedingsdeskundigen aan de Faculteit Gezondheid en Medische Wetenschappen aan de Universiteit van Surrey een beoordeling uit van meer dan 1.000 artikelen over de impact van obesitas, evenals meervoudig onverzadigde vetzuren, cholesterol en vitamine A, C, D, E en K, over het risico of de progressie van artrose.
De onderzoekers concludeerden dat, op basis van het bewijs, ‘gewichtsvermindering … samen met verhoogde fysieke activiteit’ de sterkste aanbevelingen waren die konden worden gedaan.
Desondanks onderschreven ze een aantal voedingsmiddelen als potentieel gunstig voor patiënten met artrose, die allemaal antioxidanten bevatten zoals vitamine A, C en E.
Rijke bronnen van vitamine A zijn onder meer wortelen, boerenkool, zoete aardappel en lever. Vitamine C is te vinden in citrusvruchten, zwarte bessen en rauwe groene en rode pepers, terwijl vitamine E van nature voorkomt in plantaardige oliën, margarine, volkoren granen, noten en zaden.
The theory — yet to be proved conclusively — is that an imbalance between harmful free radical and antioxidant molecules in the body may be involved in the development and progression of osteoarthritis, according to the BDA.
It also suggests that vitamin K, found in olive oil and margarine, ‘may influence osteoarthritis through its role in making bone and cartilage’.
However, some experts are not convinced the answer lies with particular foods. ‘It’s not possible for specific foods or nutritional supplements to cure osteoarthritis,’ says Helena Gibson-Moore, a nutrition scientist with the British Nutrition Foundation, which has just issued new guidance on healthy eating for people with osteoarthritis.
‘But following a healthy dietary pattern and taking regular physical activity can help to ease its symptoms.’
The only dietary measure people can usefully take for osteoarthritis, ‘is to lose weight’, insists Philip Conaghan, a professor of musculoskeletal medicine at the University of Leeds.