Most commonly, arthritis is a “wear and tear” process; once a joint shows signs of significant degeneration, the more stress it is subjected to, the more it degenerates. Let me use the analogy of a tire on a car. If the tread is thin and worn, it will not last very long driving the car back and forth daily on a long commute. On the other hand, putting the car up on blocks preserves the tires, but makes the car useless to you. As you can see, the appropriate amount of activity modification is a very individual decision based on common sense.
As a general guideline, low stress activities that are usually tolerated well are short distance walking, exercise bicycle, swimming and water aerobics. High stress activities (these are not advised) would include jumping, jogging, long distance walking (> 1 mile) or heavy lifting. However, I have operated on many patients who don’t meet the traditional requirements for activity limitation.
With the improvement of surgical techniques and implants, I now think it is reasonable to replace hips so active patients can return to high-level activity such as running. An individual must weigh the risks of surgery against his/her desire to participate in sports or heavy work.
Weight loss will also decrease the stress on a joint. Because of the muscles acting across the hip joint, normal walking causes a force across the hip approximately three to five times the body weight. Therefore, if you are 20 pounds overweight, the force across the hip is increased by 100 pounds. Even small amounts of weight loss will decrease the force about the hip, slow down the destruction of the hip joint and decrease pain.
Cane, Crutch, Walker
Another way to decrease the force is to use a cane or crutch in the opposite hand. This decreases the required muscle function about the hip during walking and reduces the force on the hip by several hundred pounds. Braces are not effective in the treatment of hip arthritis.
Exercise is useful mainly to maintain muscle tone and range of motion. Isometric exercises and gentle range of motion exercises should be sufficient. Because arthritis is often a problem of “wear and tear”, vigorous exercises and the use of weights only results in further deterioration of the joint. Vigorous physical therapy, aggressive stretching and chiropractic manipulation usually worsen the symptoms.
Heat is also helpful to decrease stiffness and relieve pain. Superficial heat, such as provided by liniments and ointments, etc., do not deliver heat deep enough to be beneficial. The best is a hot water bottle or hot packs because the temperature can be controlled and they deliver a significant amount of heat deep into the joint. Use of a heated whirlpool or spa may also be helpful. Use of a heating pad can be helpful, but care must be taken to avoid burning the skin.
Glucosamine, sometimes in combination with Chondroitin, is an over the counter remedy that may relieve the pain of mild arthritis. Large scientific studies have shown conflicting results when judging symptom relief. It is not effective for severe arthritis (bone on bone).
However, it is often advertised as a treatment to rebuild lost cartilage —there is no scientific evidence for this claim. It does take 2-3 months of regular use of this material before it “gets into your system” and relieves arthritis pain.
If you notice no improvement in your symptoms after 2-3 months, it is probably not worthwhile to continue using this supplement. The usual recommended dosage is 1500 milligrams per day.
Tylenol is a very effective and safe pain reliever for the treatment of arthritis. It may be taken in conjunction with anti-inflammatory medications for added benefit. If taken on a regular and prolonged basis, regular check ups and lab tests by your internist are recommended. The maximum daily dosage in healthy adults is 3000mg. If you drink more than 1-2 alcoholic drinks daily, you should use less to avoid injuring your liver.
Non-steroidal Anti-inflammatory Medications (NSAIDS)
The use of non-steroidal anti-inflammatory medications (NSAIDS) is also an important treatment. Aspirin is the most commonly used anti-inflammatory medication, but many people cannot take it because of either allergy or gastrointestinal difficulties. There are many aspirin substitutes that are currently on the market but are significantly more expensive than aspirin. None of them have been shown to work any better than aspirin but they do have less side effects and more convenient dosage frequencies.
There are probably 25-30 of these types of medication on the market today. Each company claims superior effectiveness of their own brand. Sometimes one brand, as opposed to another, may seem to work better for one individual. However, generally speaking, they are all equally effective. The newer brands are usually advertised more vigorously and carry a higher price tag.
The earlier brands (Ibuprofen, Naproxen) are no longer under patent and can be purchased much more inexpensively and often at lower doses as an over-the-counter formulation. Sometimes, for unclear reasons, one may work better for an individual. However, if you have tried 2-3 of these and have inadequate relief, there is no value in testing others. The most common side effects of these are gastrointestinal (GI) irritation and bleeding. Rarely kidney or liver damage can occur.
Celebrex is a unique “cox 2” inhibitor. Its efficacy in treating arthritis pain is no different than all of the other NSAIDS. However, this drug is much less likely to cause GI irritation or bleeding than the other NSAIDS. This drug also does not interfere with platelet clotting function and therefore can be safely taken by patients using anticoagulant medicines (blood thinners). It also does not interfere with the therapeutic anti-platelet action of aspirin like the other NSAIDS do. Therefore, patients who are taking aspirin to prevent heart attacks and strokes may be better off taking celebrex rather than other NSAIDS.
There were two other “cox2” inhibitors previously on the market, which were recalled by the FDA. Vioxx was found to have a higher rate of cardiac complications than other NSAIDS. Bextra rarely caused a severe skin reaction called Stevens-Johnson syndrome. Although Celebrex is also a “cox 2” inhibitor, it causes no more cardiac problems than other NSAIDS and may well be safer than other NSAIDS in patients who need to take aspirin for clot prevention.
Celebrex is still patented; therefore it costs much more (approximately $100 per month) than other NSAIDS. Despite its proven better safety, insurance companies often place pressure on patients to use a less safe option. If you can’t afford celebrex, Mobic is the closest substitute as a mixed cox1/cox2 inhibitor. It is available as a cheap generic.
Other combination medicines including an NSAID plus a stomach protector are now available. Another strategy is to use over-the-counter prilosec as a stomach protector.
Steroid injections into joints can give temporary relief. If the joint destruction is not too severe, several months of relief can sometimes be achieved. Hip injection is difficult and costly; it is done under x-ray control. A dose pack of oral steroid can also give temporary relief. But the side effects of long-term steroids are severe and therefore oral steroids are not advised for most arthritis patients.
Visco supplementation injections seem to have a similar effect as steroid injections, but they are much more expensive and often require multiple injections. The cost/benefit ratio is not appealing.
Platelet concentrate and marrow stem cell injections have shown similar results as steroid injection. They have not shown any evidence of joint preservation or cartilage regeneration. They are expensive.
Prolotherapy is expensive, illogical and has no scientific merit.
More powerful anti-rheumatoid medicines such as steroids, gold (oral or injection), methotrexate, embrel, or others are often used by rheumatology specialists to treat inflammatory arthritis such as rheumatoid arthritis. They have excellent proven benefits for the right patient. They do not work for osteoarthritis.
Unproven Alternative Treatments
Chiropractic manipulation may be helpful in alleviating back symptoms that are often confused as “hip pain”, but there is no role for this in the treatment of hip arthritis.
There are many unproven alternative treatments such as magnets, wraps, devices and herbs, prolotherapy, that may act on the basis of a placebo effect.