A Guide to Arthritis: How To Manage Pain by Body Part
BY KATHY KATELLA September 23, 2022
Anyone who struggles to button a shirt or get up from a chair because of arthritis knows how painful and limiting the condition can be. Symptoms worsen with age, but if you’re young and think you are still years away from experiencing them, you may be surprised to learn that although the onset of arthritis is typically after age 40, even people in their 20s can develop it.
There are more than 100 different types of arthritis, a general term for conditions that affect the joints, tissues around the joints, and other connective tissues. About 25% of adults in the U.S. have some form of arthritis.
The most common type, by far, is osteoarthritis (OA), a degenerative disease resulting from a breakdown of the cartilage that eases friction between the joints. Inflammatory joint diseases, like rheumatoid arthritis (RA) or psoriatic arthritis, are autoimmune conditions in which the body’s immune system attacks the joints, causing redness, stiffness, painful swelling, and deformity; they commonly begin in middle age. Yet another type is post-traumatic arthritis, which can occur years after an injury—even if the injury itself was successfully treated.
Whatever type of arthritis you may have, the one thing you should not do is ignore it.
“People with symptoms of arthritis should get evaluated early to find out if they have it and, if so, how far it has progressed, so they can make a plan for the future,” says David Gibson, MD, a Yale Medicine orthopaedic surgeon. “There are many medical and surgical treatments available that can ease pain and help with mobility.”
Depending on their type of arthritis, people may see a rheumatologist or an orthopaedic surgeon—or both—for care. “Rheumatologists have made advances in treating RA with disease-modifying, anti-rheumatic drugs that suppress inflammation, and with biologics that target specific molecules involved in the development of RA,” says Insoo Kang, MD, a rheumatologist who treats various forms of arthritis. “We treat RA with medications, but if your joints need to be surgically treated, we’ll refer you to our colleagues in orthopaedics.”
We spoke to Yale Medicine orthopaedists and rheumatologists about how to treat arthritis in four of the most common areas where it develops.
How it happens: The hip is a ball-and-socket joint that is padded and protected by smooth cartilage during movement. When that cartilage breaks down due to overuse, aging, stress on the body from obesity, and/or any number of other factors, bone rubs against bone, causing pain and other symptoms. It’s a common area for OA to develop. And, while RA usually starts in the smaller joints, it can show up in the hip as well.
“The hip really drives the boat,” says Dr. Gibson, who specializes in both hip and knee disorders. “If the hip isn’t working, the feet and ankles are under stress, and it becomes harder to move your knee. A person may notice a ’locking’ noise with movement, decreased range of motion, a limp, and/or pain in the groin that can move down the leg and up into the back. You might eventually start to walk with an altered gait.”
Self-care: Start an exercise program (or change the one you have to avoid high-impact sports, such as running or tennis), maintain a healthy diet, and lose weight, if needed.
Dr. Gibson suggests trying “a gentle cyclic loading program,” like walking or low-impact aerobics. These types of activities have been shown to be protective of joints. Talk to your doctor about taking an over-the-counter pain reliever, such as a non-steroidal anti-inflammatory drug (NSAID), but remember that these are intended for short-term use.
How a specialist can help: Consult a professional when your hip arthritis limits daily function or regular activities, Dr. Gibson says.
A specialist will start with noninvasive treatments, including physical therapy and oral medications. If these simple treatments don’t work, more invasive treatments, like corticosteroid hip injections, can minimize symptoms and preserve function. One caveat is that injections are “a double-edged sword” in that they relieve inflammation and provide acute pain relief, but they can be toxic to the areas where they are administered, Dr. Gibson says. “So, you don’t want to do too many—maybe two or three at most in a given year.”
If you’re considering surgery: Hip replacement is considered one of the most successful operations in orthopaedics, explains Dr. Gibson. It’s minimally invasive and can be done as an outpatient surgery in many cases. “It's really a dramatic, transformative operation—someone who was sedentary can get to a place where they can do pretty much everything again,” he says.
Replacement hips use implants—made of a combination of metal, plastic, and ceramic—that last decades. One operation, called the direct anterior approach, avoids cutting through muscle to replace a hip, and surgeons say that leads to easier rehabilitation.
Whatever approach a patient chooses, the key is to find a surgeon who has done a high volume of that particular operation and is comfortable performing it, Dr. Gibson adds.
Hand and base-of-the-thumb arthritis
How it happens: The small joints of the hands are a place where both OA and RA can develop. One difference with RA is that it typically develops on both sides of the body, whereas OA is less symmetrical. OA often starts in the most distal, or faraway, joint on an index finger. “But it hurts more at the base of the thumb, where it is incredibly common, especially in women, since they have looser joints, which is necessary for giving birth,” says Xuan Luo, MD, a Yale Medicine hand, shoulder, and elbow surgeon. “It also can be accelerated by very heavy manual labor—so it affects a high number of people who do work with their hands that requires a heavy grip, as in construction and woodworking.”
Self-care: Moving and exercising the affected joints can help, but the key is to avoid putting too much stress on the area. Find ways to adapt, such as buying clothes that don’t have buttons, snaps, or zippers. Talk to your doctor about taking NSAIDs for pain.
How a specialist can help: They can prescribe a brace (there are rigid ones for sleep and softer daytime ones that don’t restrict mobility).
“While it is very adaptable, the hand is prone to stiffness,” says Dr. Luo, adding that it can do more harm than good to wear a splint for too long. Corticosteroid (or cortisone) injections, which give relief from acute pain, can also provide temporary relief. “I will do injections for as long as they help to postpone a surgery that will potentially remove the joint.”
If you’re considering surgery: "There are three approaches," says Dr. Luo. "The first, done only at the base of the thumb, is called resection arthroplasty, and it removes the joint completely. While it’s highly successful, a full recovery takes up to two years." The second replaces the small joints in the fingers and may need to be redone in 8 to 11 years. The third, also in the fingers, is called joint fusion—while the joint will never move again, the fusion provides stability that relieves pain, he adds.
How it happens: The knee is the largest and strongest joint in the body. It includes three important bones that are covered with cartilage, which protects the knee as you bend or straighten it, and the meniscus—two pieces of cartilage that cushion the thigh and shin bones.
It’s a common area for OA to develop, and RA can sometimes show up in the knee as well. Sports injuries, motor vehicle accidents, or falls—even after they are treated with surgery—can also damage both cartilage and bone. These injuries can change the way a person moves their knee, which can lead to post-traumatic arthritis.
Self-care: Lose weight, if needed; switch from high-impact activities, like running, to low-impact ones, like walking or swimming; avoid movements, like lunges and squats, that could make the condition worse. Apply ice or heat for pain, and talk to a doctor about taking NSAIDs.
How a specialist can help: They can recommend specific exercises and/or physical therapy, and provide assistive devices like canes. They also prescribe oral and topical medications, as well as injections, starting with cortisone shots. "A second line of treatment is the injection of hyaluronic acid, a substance that occurs naturally in the joint and can add some temporary lubrication and cushioning in patients who have little or no swelling," Dr. Gibson says.
If you’re considering surgery: There are a variety of knee surgeries, including synovectomy, which replaces a joint lining damaged by RA, and cartilage grafting, which uses healthy tissue from another part of the knee to replace damaged cartilage. If a knee replacement is called for, it may be performed as a same-day surgery using materials (that are longer lasting than have been used in the past) for implants.
“We've become better with anesthesia and with pain control afterwards,” says Dr. Gibson. Anesthesiologists use nerve blocks, a type of pain relief that leaves people more comfortable in the day or two after surgery and can minimize or eliminate the need for opioid medicines.
Surgeons want patients to start moving soon after knee surgery to prevent scar tissue from developing. “You have to really get that motion early,” says Dr. Gibson.
Foot and ankle arthritis
How it happens: The foot hitting any surface (whether you are walking or running) puts a high degree of contact stress on arthritic joints—every step hurts. “The pain can be quite excruciating if a joint is damaged,” says Irvin Oh, MD, chief of Yale Medicine Orthopaedic Foot & Ankle Surgery. Range of motion becomes limited, and bone spurs can develop. Pain is common in the big toe, on the top of the foot, and in the ankle.
Self-care: Keep your weight under control, as being overweight or having obesity puts stress on the foot and ankle. Modify your activity if overuse seems to be exacerbating the pain, and try ice packs. Ankle-strengthening exercises (using a resistance band) and Achilles-stretching exercises can also help reduce pain. Talk to your doctor about using NSAIDs.
How a specialist can help: “We always have to think of evenly distributing mechanical load,” says Dr. Oh. He compares the foot and ankle to a tripod and says it must be well-balanced to be optimized for even the most basic functions, like taking a step. Some people with foot arthritis will compensate to avoid feeling pain and that can throw off the balance, he adds. Supportive shoes, an ankle brace, and orthotics may help.
If you’re considering surgery: Surgeons who have special training can address problems with biomechanics by surgically realigning the foot, ankle, and lower leg to “off-load” the area that is damaged by arthritis, Dr. Oh says. “I can remove bone spurs and clean up the joint using a minimally invasive technique or realign the ankle in a way that evenly redistributes the load, so that the stress to the impacted area is lessened.”
Replacing or fusing arthritic joints may also be recommended. "There are innovative joint replacement options for such surgical treatments as toe implants and total ankle replacements for people whose joints are severely damaged or who have no cartilage left," he says. “We always try to preserve native joints as much as possible.”
That’s important for young patients because while the materials used in replacements in the feet and toes are always improving, they have a limited lifespan.
Therefore, optimizing the balance of the foot and ankle is crucial for extending the longevity of those implants, he explains.
Should you get help for arthritis?
Whatever type of arthritis a person has, a key factor in determining when to treat it—and when to perform surgery—is how they tolerate pain, says Dr. Luo. There are people with mild arthritis who seek care early to avoid prolonged pain, while others don’t remark on their pain, even after an X-ray shows extensive damage, he explains. “Some have a lot of arthritis and never need treatment, while others have a lower level of arthritis and need surgery. Everyone is different,” he says.
"I think the time to seek out a specialist for arthritis is when it is affecting your daily life,” says Dr. Luo. “If it’s a minor inconvenience, it’s not worth getting injections, braces, or surgery. But if you can no longer do the things you normally do, a specialist can help.”