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Arthritis

by Paul Plante, M.D.   |  September 24th, 2010 0

The Hunt Doctors let loose on a stiff subject

It has been said that youth is wasted on the young. Time was, when this was uttered we’d roll our eyes, but not anymore. While wisdom may or may not come with age, arthritis in one form or another is certain to be a companion. The more adventurous and physically challenging the hunt is, the more we notice it as we start advancing past our early 30’s. Sitting for prolonged hours in sub-freezing temperatures hopefully awaiting the arrival of one of our beloved monster whitetail bucks generally ends up unsuccessful but with stiff joints to show for the effort.

On the other hand, scaling and clawing your way to the top of a treacherously steep peak in pursuit of one of the variety of mountain sheep or mountain goats is a whole other ball game. After the endeavor, you not only wake up with stiff joints but sore and probably swollen ones as well. It’s inevitable, the more active you are in the younger years–the more injuries/trauma you have sustained and the propensity of your family history towards arthritis–play major roles in the degree and timing of arthritis that you will encounter.

The word arthritis is derived from two roots; the first is arthro meaning joint or jointed and itis meaning inflammation. Hence arthritis is simply an inflammation of the joint that leads to joint destruction and deformities, most of the time slowly over the years but occasionally much more rapidly. Arthritis comes in many forms and severities, so to really understand what is going on, we need to start with some basic anatomy.

In an effort to thoroughly confuse those not admitted to the medical fraternity, there are actually three types of joints in the human body: synarthroses (immovable ie the skull), amphiarthroses (slightly movable ie the spine) and diarthroses (freely moveable ie hips, knees, hands, feet, shoulders and elbows). While inflammation can strike all three types of joints, we are going to focus on the more common diarthroses joints unless specified.

Joints occur where two or more bones meet. In healthy joints the bones never actually touch, but are separated from each other by a fluid-containing cavity (the synovial cavity). The ends of articulating bones are lined with a smooth cartilage cleverly called the articular cartilage. The bones of a joint are held in place by ligaments and a joint capsule, which naturally holds the synovial fluid in place, surrounds the joint itself. There is a very low coefficient of friction in a healthy joint.

Arthritis is the term used to describe problems related to inflammation inside the joint. Things can go wrong outside a joint and interfere with its function, but that would not be classified as arthritis. Inflammation has several distinct ways in how it shows up in us. The one we are all most familiar with is pain or tenderness. Swelling is also a sign of inflammation. Reduced range of motion, with or without stiffness, usually indicates arthritis. Deformity and decreased range of motion are end stage complications of arthritis.

Very thick books have been written to describe the types of arthritis and their treatments. We like these books because they look really sharp on the shelves, albeit they require a dusting off occasionally. Arthritis can be part of a larger inflammatory disease process like the auto-immune diseases of Lupus, Rheumatoid arthritis, Psoriasis or Sarcoidosis. Arthritis can also result from metabolic problems such as the dreaded Gout (known in some circles as Gouch). There are infectious arthritis illnesses such as Gonorrheal arthritis (yep same bug as you thought, though the route of infection of the joint requires the STD to be present). Most commonly however is just plain ‘ol worn out wear and tear “degenerative” arthritis.

What actually occurs in this wear and tear arthritic process is the destruction of the articular cartilage so that the underlying bone comes into contact with the other bony surface thus causing inflammation with its characteristic pain, swelling, stiffness and eventual deformity of the joint. That is where the term “bone on bone” comes from. Secondly, the body’s natural reaction to prolonged inflammation is to lay down calcium or in this case more bone which results in the knotty growths and angular deformities we develop over the years. Hence more bone-on bone, more inflammation and the cycle continues.

We all will suffer with this to some degree depending on the risks of injuries, activity levels, age, and family history. So what can we do about it? Since there is no reversal process, all we can do once it becomes important to us is to prevent arthritis from advancing. It’s impossible to understand the destructive process and the inevitable pain that will be encountered down the road when we are in our teens and twenties because at that time we are bulletproof anyway. In general though, the most important single thing that can be done to prevent its advancement is to avoid heavy repetitive impacts to the already affected joints.

An example of these repetitive impacts would be running as it pertains to the knees and hips especially. If this is your issue, you really should change to a non-impact exercise such as bicycling, which is an unbelievably effective endurance enhancing cardiovascular regime. Swimming is another excellent substitute for running. With small joints especially in the hands, simply engaging in a repetitive activity will negatively affect the joints if they already have underlying damage. Constant knitting is a good example of this, but for most of us, non-impact repetitive activity describes our work! Some things are unavoidable.

Although, exercise is crucial for our health, we have to modify our exercise programs to avoid the activities that are detrimental to our arthritic joints. Posture and position as well as safety equipment should be used in work environments as well as correct form and tools for the job. Protecting ourselves from further injury means avoiding impact exercises that cause further damage. Also, before engaging in an exercise routine, warming the joints up is very important especially in cool to cold weather. Bottom line, find an activity that promotes cardiovascular health that doesn’t cause you joint pain either then when the activity is being done or upon waking the day following the exercise. There are many different types of exercises as well as exercise equipment/machines in order to be able to accommodate all folks. Many companies in the exercise equipment business specialize in fitting the right equipment to their individual customers, so they are a very good place to start before going out and just buying a treadmill because you neighbor has one.

A word here for bowhunters is in order. Macho is the cause of many bowhunter’s problems with their shoulders. It really doesn’t take the huge poundage’s most of us use to put a big ‘ol hole in the chest of a whitetail, muley, bear or elk. It doesn’t and we know it. Sure there’s a flatter trajectory, but if we’re honest, it’s a macho thing and not a physics thing. Once you get a tear in the amphiarthroses that is the junction of the Clavicle and the Scapula (collar bone and shoulder blade) it will take a long time to heal up. Each and every winching pain you get is a
nother microscopic tear. Each tear brings on a fresh wave of inflammation and well, you know the rest by now. The dreaded Rotator cuff tear is not technically a joint injury, but oh boy, talk about long-term problems and rehab!

Treatment of this “degenerative” arthritis is multifaceted and often indirect. Primary is the reduction of further injury. Rest the affected area and let some healing go on, even if you have to rifle hunt this year instead of bow hunt; even if you have to leave the weight room or the treadmill unused; even if the running shoes remain in the closet. All this having been said, most of us aren’t able or willing to completely rest our aching joints either because of work, family responsibilities or, well, it’s deer season!

An accurate diagnosis is of primary importance. Is the back pain a neurologic issue, a muscle issue or an arthritis? In one study over 50% of MRI’s showed a “bulging disc” yet there was no pain or neurologic involvement. So if your back hurts, and your MRI shows a bulging disc, do not make the assumption of cause and effect. Don’t you know somebody with “failed” back surgery? You probably also know somebody with successful back surgery as well and now you may know something about why the outcomes were different!

Non-medication approaches include the application of heat. A warm paraffin dipping is awesome for hand and wrist. A hot shower or bath (or hot tub) followed by a gentle stretch routine really helps. Heat or warmth producing balms like “Icy Hot” are very useful not only in alleviating pain but also in warming up joints prior to exercising especially in winter. Watching posture, proper lifting, the right chair height and simple things like these make a huge difference.

Medications are our usual recourse, but are not without possible problems. Narcotics have a very limited, very limited, role in the treatment of degenerative arthritis. Narcotics cause a physical dependence and the daily use will start a cycle of intermittent withdrawal (experienced as pain) leading to increased intake to reduce the pain (take you out of withdrawal) and on you go. Tylenol will safely reduce the pain, but does nothing for the inflammation.

Anti-inflammatory drugs such as Ibuprofen and Asprin work. There’s a whole list of these, but they’re not as harmless as their over the counter status suggests. Consult your doctor, monitor the quantity used, and be on the lookout for side effects and complications. A newer class of anti-inflammatory drugs known as COX2 inhibitors is more effective, but carries higher risks. Celebrex is the only one still on the market. It’s usually safe, it’s very effective, but it’s not without real risk. Partner with your doctor about this class of meds. Glucosamine Chondrotin Sulfate (GCS) has been shown in many studies to help folks with arthritic pain but the dose of the Glucosamine must be at least 1500 mg per day. Luckily, this compound is widely available, cheap and without known side effects.

More invasive treatments such as Synvisc joint injections haven’t panned out as hopeful as when they were introduced. The topic of joint replacement is beyond our scope here.

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