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Facet Joint Syndrome

Facet joint syndrome is a condition that causes pain, inflammation and stiffness in the facet joints of the spine.

Also called the zygapophyseal or z-joints, these structures allow the vertebrae of the spine to bend and move. Patients affected by facet disease often walk hunched over, as damage or degeneration in these joints can make it difficult to stand up straight. Many patients also have trouble looking left or right without turning their entire body.

Facet disease may be a factor in up to 40 percent of patients with chronic lower back pain. In addition, the z-joints are likely involved in most cases of mechanical back pain, or pain that arises from the spinal structures.

Causes of Facet Joint Syndrome

General wear and tear as a result of aging is a common cause of facet disease.

Repetitive stress to the z-joints can cause degenerative changes that affect how the spine is able to flex and twist. Osteoarthritis of the spine also can cause pain and swelling in these joints, resulting in issues with mobility and range of motion.

Athletes and those with physically demanding jobs, especially those who frequently perform repetitive spinal maneuvers, are susceptible to traumatic injury or damage to the z-joints. And certain risk factors — including excessive weight, poor posture and the use of tobacco and alcohol — may contribute to the development of this condition.

Facet Joint Syndrome Diagnosis

Diagnosing facet disease begins with a detailed medical history along with a review of the patient’s symptoms. The Spine specialist also performs a physical examination to determine the location and extent of pain as well as any limits in the ability to move the spine.

Because facet disease can mimic many other back conditions, diagnostic tests may be ordered to rule out other potential causes of pain and inflammation. X-rays are typically the first step, though a bone scan, CT scan or MRI also may be recommended.

To confirm a diagnosis, the Spine specialist may inject an anesthetic into the z-joint. If this results in the immediate reduction of back pain, facet disease is determined to be the cause of the patient’s symptoms.

Treatments for Facet Joint Syndrome

Conservative treatments are recommended for the first attempts at treating facet disease.

Physical therapy may be advised to correct bad posture and re-establish a normal range of motion. The doctor may recommend non-steroidal anti-inflammatory drugs to reduce swelling, while over-the-counter pain medications and muscle relaxers may be taken to manage other symptoms.

When a diagnostic facet joint injection is performed, the Spine specialist may also inject a steroid medication to provide long-term relief from back pain. Or, if one of the nerves that transmits pain signals to the joint is the source of the problem, a nerve block or radiofrequency ablation may be performed to interrupt the nerve’s signals and relieve pain.

If conservative measures are not successful in treating the symptoms of facet disease, surgical intervention may be necessary. Minimally invasive procedures will be considered first, though some patients may require open spine surgery. Robert Engelen DO, a Sports Medicine and Spine specialist practicing with Neuroscience & Rehabilitation Specialists in West Jordan would be pleased to evaluate your condition and recommend an appropriate treatment plan. You can learn more about Dr. Engelen here.


Spondylolisthesis is a condition in which one of the vertebrae in the spine slips out of place, shifting over the bone below. In most cases, this condition affects the lumbar or lower spine.

Patients with spondylolisthesis do not always have symptoms. But because the joints and nerves can be pinched when a vertebra is not in the proper position, some patients suffer low back pain, muscle tightness or weakness, sciatic leg pain and numbness or tingling in the thighs and buttocks.

Over time, lordosis (swayback) or kyphosis (roundback) can develop as a result.

Causes of Spondylolisthesis

Genetics may play a part in some cases of spondylolisthesis, as children may be born with thin vertebral bone or defective joints. Consequently, these individuals are more susceptible to bone slippage over the course of their lifetimes. When this condition occurs in children, it may be related to a birth defect in that portion of the spine.

Spondylolisthesis in adults is typically the result of aging or abnormal wear and tear on the bones and cartilage, such as from arthritis. Bone problems, such as osteoporosis or low bone density, also may be contributing factors.

Sudden injury or trauma to the spine also can cause spondylolisthesis.

More often, however, stress fractures caused by repeated use over time are responsible. Participating in sports activities that stress the spine, including gymnastics, football and weight lifting, can increase the risk of suffering spondylolisthesis, or cause the condition to worsen.

Spondylolisthesis Diagnosis

A medical history and physical exam are the first steps to diagnosing spondylolisthesis. The Sports and Spine specialist will observe the patient’s posture and range of motion, and test reflexes and muscle strength.

The doctor also will order X-rays to determine if a vertebra has slipped.

To see how the bone moves, it may be necessary to take X-rays of the patient while he or she is bending forward and backward. To confirm a spondylolisthesis diagnosis, a CT scan or MRI also may be ordered.

Treatments for Spondylolisthesis

Treatment for spondylolisthesis depends upon the severity of the vertebra slippage, but many patients are able to find symptomatic relief through conservative measures.

Physical therapy exercises may be recommended to stretch and strengthen the muscles of the lower back. In some spondylolisthesis cases, the Sports and Spine specialist may also recommend avoiding contact sports for a period of time, or wearing a back brace to limit spine movement.

For pain relief, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are often recommended. For persistent or severe pain, epidural steroid injections may be considered.

If conservative treatments are unsuccessful at reducing the symptoms of spondylolisthesis, or if the vertebra slippage progressively worsens, surgery may be needed. A procedure may be performed to relieve pressure on the nerves. Or if no other treatment can provide relief from spondylolisthesis, the orthopedic surgeon may perform a spinal fusion to maintain the vertebrae in the proper position.

If you believe you may be suffering from this condition, Dr. Robert Engelen, a Sports Medicine and Spine Specialist practicing with Neuroscience & Rehabilitation Specialists in West Jordan would be pleased to evaluate your condition and recommend an appropriate treatment plan. You can learn more about Dr. Engelen here.

Many sports injuries improve with platelet-rich plasma (PRP) injections.

Both professional athletes and weekend warriors can become sidelined by injury. Athletes were traditionally given the choice of either sitting out for weeks (or months) to heal or undergoing major surgery — neither of which is particularly desirable.

PRP injections offer a radical third alternative. Minimally invasive, safe and quick, this orthobiologic treatment is highly effective for many of the most common sports injuries.

What is PRP?

A form of regenerative medicine, PRP injections involve drawing a small quantity of the patient’s blood, then isolating and concentrating the healing platelets.

An orthopedic surgeon or sports medicine doctor then injects the concentrated plasma into a carefully chosen location near the injury. To ensure that the injection reaches its target, the doctor uses either ultrasound or fluoroscopy to visualize the targeted structure.

In addition to platelets, PRP contains components known as growth factors. Growth factors are a critical component of the human body’s natural bone and soft-tissue healing mechanisms.

For some sports injuries, the body can heal itself over a period of weeks or months. For more severe injuries, the body simply does not have enough self-healing power. In both cases, PRP jump-starts the natural healing process and speeds it along.

Treating Tennis Elbow with PRP

PRP injections are particularly effective for treating lateral epicondylitis, commonly known as tennis elbow.

In this condition, tendons of the forearm become inflamed, typically from overuse and repetitive stress. Although playing tennis can cause lateral epicondylitis (especially if you have biomechanical deficits), it is common in rock climbers, painters, carpenters, cooks, assembly line workers and anyone who engages in repetitive arm movement.

Because these tendons receive little blood, they are especially slow to heal. PRP injections address the pain of tennis elbow and initiate healing. Research demonstrates the efficacy of PRP injections for restoring function in patients suffering from tennis elbow.

PRP Injections for Rotator Cuff Injuries

The rotator cuff, a system of muscles and other soft tissues that allows the shoulder to function, is a common site for sports injuries. Any repetitive overhead arm motion (such as throwing a baseball or shooting baskets) can cause problems. However, the rotator cuff is also a common site of damage from falls and other accidents.

Although full rotator cuff tears typically require surgery, partial tears and inflammation in the bursa both respond especially well to PRP injections.

In addition, rotator cuff tendinopathy or tendinitis can also benefit significantly from platelet-rich plasma treatments.

Plantar Fasciitis and PRP Treatments

Plantar fasciitis is the most common injury experienced by runners and other patients who work on their feet or play sports. This chronic condition results in severe heel pain that, in many patients, resists conservative forms of treatment. Left untreated, plantar fasciitis can progress to bone spurs that require surgery.

Many patients undergo cortisone injections for this and other painful sports injuries. Although cortisone shots can reduce pain temporarily (up to one year), they do nothing to heal the injury. In fact, some research indicates that multiple cortisone injections over time may lead to calcaneal fat pad atrophy resulting in increased heel pain.

PRP injections also relieve pain, but more importantly, they initiate the healing process so that patients retain the majority of their restored function.

Many other types of sports injuries can also benefit from platelet-rich plasma injections, including Achilles tendinopathy, UCL (Ulnar Collateral Ligament) tears, and hamstring injuries.

Rotator cuff injuries have historically required invasive, surgical techniques for repair. Without surgery, patients were forced to live with pain, weakness and significantly reduced mobility.

Today, regenerative medicine treatments offer an exceptional alternative. Specifically, minimally invasive platelet-rich plasma injections may provide pain relief and restore strength while helping many patients avoid the risks and recovery associated with shoulder surgery.

What Is a Rotator Cuff Injury?

The rotator cuff stabilizes and moves the bone of the upper arm (humerus) within the shoulder joint. It is composed of four muscles that originate at the scapula (shoulder blade), all connecting to the head of the humerus.

These muscles are responsible for almost every movement of the shoulder and upper arm.

Common injuries include rotator cuff tears and tendinopathy or tendinitis. Tendinopathy without a full tear is a common type of orthopedic injury that can affect the patient’s ability to use their arm. Although this injury is common in overhead athletes, it can affect patients of any age or physical condition.

Previously, patients had to deal with a shoulder injury either with pain management — which does not facilitate healing or repair — or by undergoing invasive shoulder surgery.

What Is Platelet-Rich Plasma Therapy?

Platelet-rich plasma, or PRP, is a form of orthobiologic treatment that is sometimes referred to as regenerative medicine. Orthobiologics are substances that occur naturally in the human body. When extracted, concentrated and injected back into the body, these substances activate the body’s own healing mechanisms.

PRP is derived by taking approximately 30 to 90 milliliters of the patient’s blood and spinning it in a centrifuge to separate the platelet layer. Then, using ultrasound guidance, the doctor injects the PRP into the injured tissue.

How Is Platelet-Rich Plasma Used to Treat Rotator Cuff Injuries?

After diagnosing a shoulder injury, the orthopedic surgeon or sports medicine doctor may recommend using PRP injections to facilitate the body’s healing mechanisms.

PRP has been shown in the research to be highly effective for treating rotator cuff tears, without the risks and expense of surgery. Additionally,  as PRP injections are performed in the doctor’s office, there is no hospital stays or lengthy surgical recovery necessary.

The doctor administers the injections using ultrasound or fluoroscopic guidance, to ensure that the plasma is deposited in the precise location of the rotator cuff tear. The patient may experience an increase in pain in the period immediately after treatment. However, significant improvement typically occurs in the subsequent weeks.

A recent study compared PRP treatment to corticosteroid injections for a rotator cuff tear. Results showed that, at three months after treatment, the PRP patients had a significant reduction in pain and improvement in range of motion. Patients treated with PRP had “significantly better active forward flexion, abduction, and internal rotation” than did patients treated with corticosteroid injections.

Perhaps most impressive, only about 3 percent of the PRP patients in this study sought surgery for their injury after one year, whereas almost half of the corticosteroid group required surgery. In other words, patients in this study who were treated with platelet-rich plasma were 16 times less likely to need surgery than those treated with steroid injections for their rotator cuff injury.

Viscosupplementation is an encouraging option for relieving pain associated with knee osteoarthritis (OA) and restoring patient mobility and improving quality of life.

The Arthritis Foundation reports that 14 million Americans live with symptomatic knee arthritis, the risk of which increases significantly with each decade of life. Left untreated, more than half of these arthritis patients will experience sufficient progression to warrant a knee replacement.

Fortunately, medical technology offers a variety of effective treatments for OA. Today, viscosupplementation is one of the most promising options.

What Is Viscosupplementation?

In the knee, cartilage serves as padding for the joint, cushioning the bones and absorbing much of the shock of walking, running, jumping and twisting. Osteoarthritis is a degenerative disease resulting in the cartilage breaking down or becoming damaged. The damage may be caused by an accident, injury or long-term wear and tear.

In addition, the knee contains a gel-like substance called synovial fluid, which lubricates the joint and reduces friction — much like motor oil does for your car’s engine. When cartilage breaks down and synovial fluid levels drop, patients experience knee pain, stiffness, and eventually, bone spurs. Activity levels drop as pain increases, and in time, patients may lose most of their mobility.

Viscosupplementation augments the knee’s natural lubrication. Used appropriately, it can significantly reduce pain and slow the progression and damage of OA.

How Is Viscosupplementation Used for Knee Arthritis?

Viscosupplementation uses hyaluronic acid — the essential lubricating component of synovial fluid — to boost the level of this important chemical. The body produces hyaluronic acid (also known as hyaluronate or hyaluronan) naturally; however, over time, production decreases, reducing the synovial fluid’s ability to lubricate the joint.

By injecting hyaluronic acid into the synovial fluid, knee lubrication is improved. Some research also indicates that viscosupplementation stimulates the body to increase its natural production of hyaluronate.

Using ultrasound imaging technology, the orthopedic doctor can identify the ideal location to deliver the viscosupplement. Although patients may experience some improvement immediately, the most significant change will take place in the weeks following treatment.

Are You a Good Candidate for Viscosupplementation?

For patients who suffer from mild to moderate osteoarthritis of the knee, viscosupplementation is a highly effective and minimally invasive treatment. The sports medicine physician or joint replacement specialist may recommend this therapy as a part of an overall treatment program that may include diet, exercise, physical therapy, and potentially complementary treatments.

Patients who benefit from this treatment can utilize viscosupplementation every six months. Ongoing treatments can reduce pain, increase mobility and delay the progression of damage from OA.

Because some viscosupplementation solutions are created using avian sources (specifically, sterilized and processed rooster combs), this treatment is may not be available to patients who are allergic to poultry or poultry products. There are synthetic versions of viscosupplementation that would be more suitable for those with avian allergies. Anyone else who is in good overall health may be a good candidate for this treatment.

Radiofrequency nerve ablation (RFA) can provide highly effective, long-lasting relief for chronic back pain.

Also known as radiofrequency neurotomy or lesioning, this technique uses heat generated by RF energy to interrupt specific pain impulses in the spine. This minimally invasive technique can provide a safe and effective alternative for patients battling chronic pain in the lumbar or cervical spine.

What Is RF Nerve Ablation?

To disrupt the transmission of pain signals to the brain, RF ablation applies high radiofrequency waves — a type of electromagnetic energy — to a predetermined  region along on a sensory  nerve. A radiofrequency needle applies heat to the coating of the nerver or myelin,  creating a small, circular lesion.

Thanks to this tiny lesion, the nerve is unable to transmit pain signals to the brain.

For chronic conditions of the back, this procedure is used on medial branch or lateral branch nerves, depending on the location of the pain. These nerves don’t affect movement; this procedure only interrupts signal transmission.

To identify the location of the nerve, the doctor uses fluoroscopic imagery guidance. This form of guidance is also used for corticosteroid injections and regenerative medicine treatments like platelet-rich plasma (PRP) and bone marrow-derived stem cell injections.

When Is RF Nerve Ablation Used?

Neurotomy can be used for many types of spine pain.

One of the most common uses of RF nerve ablation is for osteoarthritis of the spine (spondylosis), knee osteoarthritis, hip osteoarthritis, and continued post-procedure pain following a joint replacement. It is also effective for treating back and neck pain from car accidents (whiplash) and work-related injuries.

This procedure may benefit patients who have pain on one or both sides of the spine, or in the hip or knee joints. If discomfort worsens when extending the back, twisting, laying on your stomach, or lifting, this procedure may provide relief.

Is Radiofrequency Nerve Ablation Right for You?

To determine whether you would benefit from spinal or joint RF (Radiofrequency/Thermal) neurotomy, the doctor will perform a preliminary diagnostic test. During the test, the doctor will administer a temporary nerve block to the identified area. If the procedure relieves your pain (albeit temporarily), you are likely a good candidate for the ablation.

Nerve ablation for back pain is an outpatient procedure that takes less than two hours. The procedure is typically performed in the doctor’s office. You can return home once it is complete and return to work the next day.

Although this procedure is not the answer for everyone, most patients report significant relief for as long as two years. Because the nerve will eventually regenerate and the lesion will heal, the doctor can simply repeat the procedure once the pain returns.

Sports injuries can result in chronic pain that affects athletic performance.

Although many athletes try to play through pain, many eventually are forced to seek treatment if the discomfort limits their ability to perform. Traditionally, steroid injections were used for this purpose. In fact, corticosteroid treatments remain one of the most popular types of minimally invasive treatments for sports injuries.

Today, however, the research has begun to suggest that the rewards may not be worth the risks, at least for some patients.

How Do Steroid Injections Treat Sports Injuries?

When we talk about steroid injections, we refer specifically to shots of cortisone, also known as a corticosteroid. Cortisone, a steroid hormone, is produced by the adrenal gland and released into the body (along with adrenaline) as a response to stress. When released by the body, cortisone and adrenaline prepare the body for the fight-or-flight response.

Synthetic steroid injections, delivered in or near the site of an injury, can reduce trauma-related inflammation and provide substantial pain relief. The results are not permanent, however, with most patients reporting relief for six to 12 months.

Side Effects and Risks of Steroid Injections for Sports Injuries

The side effects associated with steroid injections range from mild to severe, although severe reactions are rare. These include temporary pain, swelling, infection and discoloration of the skin at the injection site. In some cases, patients may experience allergic reactions or an increase in blood glucose levels.

Complications resulting from corticosteroid injections may include nerve damage, joint infection, a thinning of skin and soft tissue near the injection site, bone weakening (osteoporosis) or bone death (osteonecrosis) and tendon weakening or rupture.

The Mayo Clinic warns that steroid injections may also cause a deterioration of cartilage in the joint. Consequently, patients are advised to limit the number of treatments to not more than three or four a year, unless your doctor advises you otherwise.

Alternative Options for Treating Sports Injuries

Although orthopedic surgeons and sports medicine doctors use corticosteroid injections safely and effectively in many cases, some patients either cannot or prefer not to undergo this treatment. Fortunately, alternative treatment options can be effective for treating sports injuries.

For many patients, a conservative treatment approach can be effective. This typically is the RICE protocol of rest, ice (and/or heat), compression and elevation. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) can provide effective relief for pain and swelling.

Unfortunately, conservative treatments can be slow to provide relief, and ultimately, they may provide no benefit.

Orthobiologic (regenerative medicine) treatments are a highly effective alternative for many types of sports injuries. Both platelet-rich plasma and bone marrow-derived stem cell injections offer a minimally invasive alternative to steroid injections, but without the potential risks and side effects.

The right approach for treating your injury will depend on several factors, including the nature of the injury, your overall health and your goals for recovery and rehab. Consultation with an orthopedic or sports medicine physician is the only way to ensure that you receive the safest, most effective treatment for your sports injuries.

The sacroiliac or SI joint, located in the low back on either side of the spine, is a common source of back pain. However, despite its role in spine-related problems, few patients are familiar with the SI joint.

Because sacroiliac joint pain can present with symptoms that resemble a variety of other spine and back problems, it is a source of confusion for many patients and a potential diagnostic challenge for orthopedic and sports medicine physicians.

What Is the Sacroiliac (SI) Joint?

The SI joint is located to the side of the spine, just above the tailbone (coccyx). It connects the sacrum (a bone of the low spine composed of fused vertebrae) and the ilium, or pelvic bone.

Unlike most joints of the body, the sacroiliac joint sees little movement. This diminutive joint is strong, thanks to the many ligaments that support it. Its purpose is to act as a shock absorber (of sorts) and a buffer between the upper and lower portions of the body.

The symptoms of sacroiliac joint problems strongly resemble other issues of the lower spine, including sciatica. Pain radiates from the low back into the buttock and thigh, typically with a stabbing sensation. Patients may feel the pain on both sides; however, many experience it only on one side.

Causes and Diagnosis of SI Joint Pain

SI joint pain can be the result of trauma or another medical condition. Falls (specifically on the buttocks), car accidents, heavy lifting and sports injuries are some of the potential traumatic causes.

Sacroiliac problems also can emerge during pregnancy or as the result of an infection. Obesity, scoliosis, arthritis and problems in adjacent structures of the back can all lead to pain in the sacroiliac joint. Finally, overuse and repetitive motion, in sports, work, etc., can result in a cumulative injury to the SI.

Diagnosing SI problems is exceptionally difficult. Because pain can be referred and resembles other conditions, the origin is difficult to determine. Likewise, imaging tests are rarely conclusive.

Some physical manipulation tests, known as sacroiliac provocation tests, can be helpful. However, the most effective way to confirm the diagnosis is with a joint block injection. In this procedure, the orthopedic or sports medicine physician injects a nerve block into the joint. If the pain subsides by at least 50 percent — and stays away for six weeks — the doctor may confirm the diagnosis.

Treating SI Joint Pain

Sacroiliac joint pain can be treated with a conservative approach, including nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, postural or activity modifications or a supportive orthopedic belt. Periodic corticosteroid injections can help control pain.

Radiofrequency nerve ablation has been shown to be highly effective for chronic low back pain related to the sacroiliac joint.

Surgery for sacroiliac joint pain involves fusion of the joint, either arthroscopically or in an open procedure.

Some of the most effective, yet minimally invasive, treatment options involve orthobiologic (regenerative medicine) injections. Bone marrow-derived stem cells and platelet-rich plasma injections, performed with imagery guidance, are highly effective for treating this condition. With little risk of side effects, these treatment protocols are effective at reducing SI joint pain and restoring function in the long-term.

If you have knee pain, you might assume that you have a muscle or ligament-related injury. In some cases, however, your pain may be the result of a condition known as iliotibial band syndrome.

Also known as IT band syndrome or ITBS, this condition involves the band of fibrous tissue that runs along the outside of the thigh. The iliotibial band helps stabilize the knee and prevent dislocation. When it becomes inflamed, pain and swelling often occur as a result.

If left untreated, IT band syndrome can lead to scarring in the bursa, the small fluid-filled sacs that cushion the knee. This can cause decreased range of motion in the knee and increased pain.

What Causes Iliotibial Band Syndrome?

ITBS is an overuse injury most commonly seen in patients between the ages of 15 and 50.

Any repetitive activity in which the leg turns inward can lead to this condition, as this type of motion causes the iliotibial band to tighten and rub against the bone. Due to anatomical differences in the knee and thigh, women are more likely than men to develop ITBS.

Cyclists, tennis players and athletes who regularly participate in aerobic activities are at an increased risk for IT band syndrome. However, long-distance runners are at greatest risk, however. Studies show that up to 7.5 percent of regular distance runners suffer from IT band syndrome.

ITBS is particularly prominent in runners who have poor running biometric or weak hip abductors, or those who frequently run on banked or downhill surfaces.

How Is Iliotibial Band Syndrome Treated?

Initial treatment for ITBS involves the R.I.C.E technique, or rest, ice, compression and elevation.

Sports medicine physicians recommend modifying your exercise regimen, begin a strengthening program to address weak gluteal or core muscles, and consider a video running gate analysis.

If symptoms fail to improve after several weeks, physical therapy may be advised. To reduce inflammation and pain, a corticosteroid may be injected into the irritated bursa.

For those patients who do not improve with more conservative treatment approaches, orthopedic surgery must be used to release the IT band.

Can ITBS Be Prevented?

Although no sports injury is entirely preventable, you can take steps to reduce your chances of developing ITBS.

If you experience any pain or swelling on the outside of the knee, take a few days off from running or your chosen sport. When you do run, choose your route carefully. Avoid concrete surfaces and stick to areas where the ground is flat and even. If you opt to run on a track, change directions frequently to avoid overstressing the IT band.

Finally, check your shoes. If they are worn along the outside edge, it’s time to invest in a new pair.

If the pain persists, make an appointment with an orthopedic surgeon or sports medicine specialist to avoid causing further damage.

Osteoarthritis (OA) is one of the most common forms of arthritis. The joint pain and stiffness caused by OA can make it difficult to work, play sports and perform daily activities.

Osteoarthritis is a condition of the bone or joint in which there is loss of cartilage (soft, spongy tissue covering the bone for protection) resulting in the release of inflammatory products causing irritation of the joint lining (synovium) leading to pain and swelling. As a result of continued joint impact, there may be an increase in bone formation leading to reduced joint range of motion.

How Patients Can Reduce the Painful Symptoms of OA

Weight Loss

For every additional pound of weight above ideal body weight (IBW), the knee or hip has four times  the additional force across the joint. For example, if you are 20 pounds over IBW, there is an additional 80 pounds of force across the joint (20 x 4). If you take an average of 5000 steps per day, then there will be 400,000 pounds of additional force every day on your joint.

What this means for you is that for every pound of weight lost, there is a four pound reduction in knee-joint load per step.

(Messier S, Gutekunst D, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee OA. ARTHRITIS & RHEUMATISM Vol. 52, No. 7, July 2005, pp 2026–2032.)

Motion is Lotion

Exercise is crucial if you have arthritis. Motion in the joint creates increased release of hyaluronic acid which helps to lubricate your joint. Your muscles act as “shock absorbers” for your joints, so increased strength = increased shock absorption.

Knowing just how much activity to do when you’re hurting can be tricky. After all, research has shown that moderate activity can help prevent the progression of arthritis and improve overall function. But while mild muscle soreness after a workout is normal, sharp pain during or immediately after can signal injury.

20- to 30-minute weight-training sessions two to three times a week are sufficient. You should start reaping noticeable benefits within four to 12 weeks, such as improved energy and muscle tone. Within six months, most people increase their strength 40 percent or more. Give your body at least one recovery day between sessions.

Tai Chi

The martial art of Tai Chi is all about slow, rhythmic, meditative movements designed to help you find peace and calm.

A study by Wang et al suggested that Tai Chi is a potentially effective treatment for pain associated with osteoarthritis of the knee. In a prospective, single-blind, randomized, controlled trial, 40 patients with symptomatic tibio-femoral osteoarthritis who performed 60 minutes of Tai Chi twice weekly for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent 12 weeks of wellness education and stretching. The Tai Chi cohort also had significantly better WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) physical function scores, patient and physician global visual analog scale scores, chair stand time, Center for Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical component summaries.

Glucosamine and Chondroitin

Glucosamine and Chondroitin are components of normal cartilage. In the body, they are the building blocks for cartilage and appear to stimulate the body to make more cartilage. There are conflicting studies on glucosamine and chondroitin, some demonstrating a beneficial effect on osteoarthritis pain, and others showing no benefit.

The supplements, which are available in pharmacies and health food stores without a prescription, are well-tolerated and appear to be safe. However, there are no long-term studies to confirm their long-term safety and effectiveness. Keep in mind that the U.S. Food and Drug Administration (FDA) regulates supplements, but treats them like food rather than drugs; supplement manufacturers are not required to prove their products are safe or effective before selling them in the marketplace.

Anti-Inflammatory Diet

This is not a diet in the popular sense. It is not intended as a weight-loss program (although people can and do lose weight on it), nor is it an eating plan to use for a limited period of time. Rather, it is way of selecting and preparing anti-inflammatory foods based on scientific knowledge of how they can help your body maintain optimum health.

Along with influencing inflammation, this natural anti-inflammatory diet will provide steady energy and ample vitamins, minerals, essential fatty acids dietary fiber, and protective phytonutrients.

  1. To get maximum natural protection against age-related diseases (including cardiovascular disease, cancer, and neurodegenerative disease) as well as against environmental toxicity, eat a variety of fruits, vegetables and mushrooms.
  2. Choose fruits and vegetables from all parts of the color spectrum, especially berries, tomatoes, orange and yellow fruits, and dark leafy greens.
  3. Choose organic produce whenever possible. Learn which conventionally grown crops are most likely to carry pesticide residues and avoid them.
  4. Eat cruciferous (cabbage-family) vegetables regularly.
  5. Include soy foods in your diet.
  6. Drink tea instead of coffee, especially good quality white, green or oolong tea.
  7. If you drink alcohol, use red wine preferentially.
  8. Enjoy plain dark chocolate in moderation (with a minimum cocoa content of 70 percent).

Anti-inflammatory Supplements

Tumeric: Traditionally used in Chinese and Indian Ayurvedic medicine to treat arthritis turmeric/curcumin blocks inflammatory cytokines and enzymes, including NFkB/Cox 1/Cox 2 resulting in reduced prostaglandins and leukotrienes. May take without similar adverse effects as NSAIDS (ibuprofen, Naprosyn, Mobic).

A systematic review and meta-analysis was conducted using data reported by RCTs. The primary efficacy measure was pain intensity or functional status. A total of eight RCTs met our inclusion criteria that included 606 randomized patients. Curcuminoids were found to significantly reduce pain (SMD: -0.57, 95% CI: -1.11 to -0.03, P = 0.04). This pain-relieving effect was found to be independent of administered dose and duration of treatment with curcuminoids, and was free from publication bias. Curcuminoids were safe and well tolerated in all evaluated RCTs.

(Sahebkar A, Henrotin Y. Analgesic Efficacy and Safety of Curcuminoids in Clinical Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med. 2016 Jun; 17(6): 1192-202). Recommended dose of 400-600mg TID. A quality supplement by New Chapter is Zyflamend. (http://www.newchapter.com/zyflamend/zyflamend-whole-body)

Green Tea: Its use in the treatment of arthritic disease as an anti-inflammatory agent has been recognized more recently. The constituents of green tea are polyphenolic compounds called catechins, and epigallocatechin- 3 galate is the most abundant catechin in green tea. Epigallocatechin-3 galate inhibits IL-1–induced proteoglycan release and Type 2 collagen degradation in cartilage explants. In human in-vitro models, it also suppresses IL-1β and attenuates activation of the transcription factor NF-κB. Green tea also inhibits the aggrecanases, which degrade cartilage.

The usual recommendation is 3 to 4 cups of tea a day. If the patient is taking green tea extract, a dosage of 300 to 400 mg is typical.

Omega-3: EFA, found in fish oil, can directly reduce the degenerative enzymes aggrecanase and matrix metalloproteinase, as well as IL-1, TNFα, and COX-2 to reduce the inflammation in synovial cartilage.

A recent study of 250 patients with cervical and lumbar disc disease who were taking NSAIDs revealed that 59% could substitute fish oil supplements as a natural anti-inflammatory agent for the NSAIDs. The recommended dosage is a total of 1.5 to 5 g of EPA and DHA per day, taken with meals. Typically, persons on a regimen of anticoagulant medications should not take omega-3 EFAs because of the possibility of increasing the bleeding potential.

Pycnogenol: Like white willow bark, this is a nutraceutical material that has been used since ancient times. Pycnogenol is derived from the bark of the maritime pine tree (Pinus maritima) and has been used for more than 2000 years. It contains a potent blend of active polyphenols that includes catechin, taxifolin, procyanidins, and phenolic acids. It is one of the most potent antioxidant compounds currently known.[120]

Pycnogenol inhibits TNFα-induced NF-κB activation as well as adhesion molecule expression in the endothelium. Vigorous sports activity dramatically increases oxygen consumption, by 10- to 20-fold over the resting state. Hence, an increased number of free radicals is generated during exhaustive exercise.

Pycnogenol is thought to counteract the deleterious effects of these free radicals and improve blood flow to muscle, as was demonstrated by Pavlovic in a double-blind cross-over study of 24 recreational athletes. A small 2007 University of Arizona study found pycnogenol reduced osteoarthritis pain by 43 percent and stiffness by 25 percent. Two 2008 studies showed significant improvements in joint pain, stiffness and function that persisted after the supplement was stopped. But a 2012 review concluded that these studies were poorly designed and underpowered.

How Doctors Can Help Reduce Symptoms of OA

Prescription or Over-the-Counter Analgesics or NSAIDs

Analgesics: Pain relievers, or analgesics, such as acetaminophen (e.g. Tylenol), or tramadol (e.g. Ultram) are used to relieve pain, but do not alleviate inflammation or swelling. Because they have few side effects, analgesics are recommended for patients experiencing mild to moderate pain.

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs):  This group includes such painkillers as aspirin, ibuprofen (e.g. Advil), naproxen (e.g. Aleve), cox-2 inhibitors) are used to reduce swelling and inflammation, and are recommended for patients experiencing moderate to severe pain.

Remember, OA joint pain is a chronic condition that may require long-term treatment. As with all NSAIDs, it’s important to use the lowest effective dose for the shortest time possible. You and your doctor can develop a treatment plan that’s right for you. Drug therapy is used to manage physical symptoms, with a focus on relieving pain and slowing progression of the disease.

Topical Analgesics: Topical analgesics are creams that can be applied directly to the skin over the affected area. The primary ingredients in these creams are usually counterirritants, such as wintergreen and eucalyptus, which stimulate the nerve endings and distract the brain from joint pain. Topical analgesics are available in most drug stores, and can be used in combination with most oral pain medications.

Voltaren® Gel is a nonsteroidal anti-inflammatory drug (NSAID) used for the relief of joint pain of osteoarthritis in the knees, ankles, feet, elbows, wrists, and hands. Voltaren® Gel has not been studied for use on the spine, hip, or shoulder.

Physical Therapy

Referral to a Physical Therapist to guide you in a strengthening and balance program. A literature review by Runhaar et al indicated that the mechanisms by which exercise reduces pain and improves function in cases of osteoarthritis may include the development of increased upper leg strength, the reduction of extension impairments, and the improvement of proprioception.

Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Certain studies also indicate that a home exercise program for patients with OA of the knee provides an important benefit

Guided Injections

Steroid Injections: Corticosteroids are medications that mimic the effects of the hormone cortisol, which is produced naturally by the adrenal glands. Cortisol affects many parts of the body, including the immune system. It helps lower levels of prostaglandins and downplays the interaction between certain white blood cells (T-cells and B-cells) involved in the immune response. Corticosteroids stimulate this effect to control inflammation.

Steroid injections are great for acute pain relief. Your physician may administer them every 3-6 months. They have the potential to transiently increase your blood glucose and may accelerate cartilage breakdown.

(Dragoo JL1, Danial CM, Braun HJ, Pouliot MA, Kim HJ. The chondrotoxicity of single-dose corticosteroids. Knee Surg Sports Traumatol Arthrosc. 2012 Sep;20(9):1809-14. doi: 10.1007/s00167-011-1820-6. Epub 2011 Dec 21.)

Visco-Supplementation:  EUFLEXXA is a hyaluronic acid (HA) product that is manufactured from a natural source of HA. HA is a natural substance that is found in the human body as well as in animals and bacteria. In the human knee, HA is a thick, slippery fluid that helps cushion, lubricate, and protect the bones and joint tissue.

In patients with OA of the knee or hip, the HA gets thinner over time and becomes less able to provide protection. EUFLEXXA is used to relieve OA knee pain in people who do not get enough relief from simple pain medications such as acetaminophen, ibuprofen, or naproxen or from exercise and physical therapy.

Do not take this product if you have had any previous allergic reaction to EUFLEXXA or hyaluronan products.

Platelet-Rich Plasma (PRP) Therapy: Sometimes called PRP therapy or autologous conditioned plasma (ACP) therapy, attempts to take advantage of the blood’s natural healing properties to repair damaged cartilage, tendons, ligaments, muscles, or even bone.

Although not considered standard practice, a growing number of people are turning to PRP injections to treat an expanding list of orthopedic conditions, including osteoarthritis. It is most commonly used for knee or hip osteoarthritis, but may be used on other joints or tendons as well. Platelet-rich plasma is derived from a sample of the patient’s own blood.

The therapeutic injections contain plasma with a higher concentration of platelets than is found in normal blood. Plasma is the liquid component of blood; it is the medium for red and white blood cells and other material traveling in the blood stream. Plasma is mostly water but also includes proteins, nutrients, glucose, and antibodies, among other components.

Like red and white blood cells, platelets are a normal component of blood. Platelets alone do not have any restorative or healing properties; rather, they secrete substances called growth factors and other proteins that regulate cell division, stimulate tissue regeneration, and promote healing. Platelets also help the blood to clot; a person with defective platelets or too few platelets will bleed excessively from a cut.

A 2016 study comparing PRP to visco-supplementation demonstrated improved pain score and function at the 12-month follow-up in the PRP group. Other WOMAC and SF-36 parameters improved only in the PRP group.

(Raeissadat SA1, Rayegani SM2, Hassanabadi H3, Fathi M4, Ghorbani E5, Babaee M5, Azma K6. Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial). Clin Med Insights Arthritis Musculoskelet Disord. 2015 Jan 7;8:1-8. doi: 10.4137/CMAMD.S17894. eCollection 2015)

Stem Cell Treatments: May be discussed during clinic visit and as detailed in a separate hand-out.

Referral to an Arthritis Specialist

Your primary care physician can refer you to a doctor with additional training in arthritis to help you explore the correct treatment course for you.