"Come back when you're worse..."

Osteoarthritis is one of the leading causes of disability worldwide, being associated with significant joint pain and limiting activity. In practice, many patients are referred to an orthopaedic surgeon when they complain of pain and an inability to perform their normal work or sporting tasks. Often they are told that they are “too good” for a joint replacement and to return when their symptoms have become worse. This can lead to the perception that nothing further can be done - and that the patient must give up the painful activities. This often leads them to become progressively more sedentary and, in many cases, for them to gain weight.

In reality there are a large number of simple interventions that can have a huge impact on a patient’s pain. Education is an essential part of an effective treatment plan. It is important to explain to patients that their symptoms may well improve with treatment – despite them having an abnormal x-ray. This is often very helpful as many patients assume that they will not get better and resign themselves to ongoing disability. Encouraging activity, even when it is a little painful, is almost always a good idea. Targeted rehabilitation programmes, which incorporate muscle strengthening and non or partial-weight bearing activity, can be very effective treatments.

Weight loss is also a key strategy. Losing between 5-10% of body weight, generally though a combination of diet and exercise has been shown to reduce pain by approximately 50%. This compares with an average improvement of 25% with regular NSAID use. Orthotics and braces can also help improve pain and allow patients to remain active.

Medications and injections can also be useful. Recent research has shown that paracetamol, despite being widely prescribed, is generally not effective (with a less than 5% chance of helping a patient’s symptoms) while NSAID’s are very likely to help to some degree (>90% likely). This must be balanced with the side effect profile associated with these drugs (paracetamol is a better tolerated and safer drug). Other medication, like neuro-modulating agents (for example amitriptyline) and bisphosphonates may also have a role and should be considered when a patient’s symptoms prove refractory to treatment – or when longer term treatment is needed. A variety of injection therapies can be used. Corticosteroid injections are very effective in the short term, but on average only give 3 months of relief. In contrast visco-supplementation injections (synthetic hyaluronic acid) and platelet rich plasma (PRP) injections may provide longer term relief and may be more appropriate in younger patients with less significant joint disease. These injections have been shown to improve pain to a similar extent to regular NSAID for more than one year. Despite their cost, approximately $500, a single injection is often a more appealing option than regular NSAID use.

As there are a large number of treatment options available, it is important that a treatment plan is targeted to each individual patient. The Axis Arthritis Clinic has been developed to help deliver high-quality, evidence-based treatment. The clinic involves a multi-disciplinary approach including Sport and Exercise Physicians, orthopaedic surgeons, a dietician and clinical exercise physiologist. In this way we hope to be able to deliver high quality care for patients with a range of joint symptoms.