Many changes come along with aging. One of the most common complaints we hear from seniors is joint pain. Sometimes, it is a known issue to the elderly such as arthritis, or diagnosed osteoporosis. Other times, the pain seems to be triggered just by a change in the weather. Though it is true that muscle weakness, bone deterioration and balance problems aggravate with age; an aching back, creaking knees, and stiff ankles are not necessarily a natural part of aging. Underlying these symptoms might be a condition or risk that needs to be tended to medically.
Doctors refer to bone, joint and muscle conditions as musculoskeletal diseases. The musculoskeletal system, also called the locomotor system, includes all bones, joints, muscles, ligaments, tendons, cartilage and other connective tissues that work together to help maintain the body’s shape, stability and movement. According to WHO, musculoskeletal conditions affect 1.7 billion people worldwide, with higher incidents in countries with aging populations. In Singapore, musculoskeletal disorders are the third largest contributor to combined burden of early death and disability, such as in the case of falling that leads to bed ridden years. Understanding the risks of bone, joint and muscle conditions among the elderly and how to prevent them is therefore key in maintaining active and fulfilling golden years for all seniors.
In this article series about elderly’s joint and bone health, we discuss the most common joint and bone problems that affect seniors. For each condition, we define the ailments, their causes, symptoms, complications, treatments and management. Part 1 of this series will focus on inflammatory and wear & tear conditions of the joints and bones. One of the most common examples is rheumatoid arthritis. But we are also discussing very common complaints such as frozen shoulder and sacroiliac joint pain.
Musculoskeletal deterioration in the elderly with inflammatory conditions
Since we are talking about inflammation throughout the article, it is crucial to highlight what it is and how it works. Inflammation is a part of the body’s immune response to harmful agents or factors like viruses, bacteria, irritants or injuries. As such, inflammation is a useful healing process to keep us healthy. However, it also causes uncomfortable symptoms such as swelling, redness, and pain.
In some cases, inflammation is triggered by mistake, known as autoimmune disease. The body mistakenly perceives its own cells as harmful and launches a ‘self-attack’, causing damage to its own tissues. This can happen as a result of a glitch in the immune system or of wear and tear mechanisms. When inflammation by mistake happens repeatedly, it can cause damage throughout the body.
An example is a rheumatoid arthritis in the hands. According to a recent study, inflammation caused by rheumatoid arthritis does not only destroy the bone and joint tissues of the hands, causing hand deformity over time but also triggers changes and deformation in the musculoskeletal system, further contributing to worsening the symptoms. Thus, early management is critical in these ailments to maintain mobility and preserve the quality of life for our senior adults.
Let’s discuss in detail each of the common inflammatory joint diseases that affect the elderly.
1. Rheumatoid Arthritis (RA)
Before we discuss rheumatoid arthritis, let’s explain two related terms – arthritis and rheumatism.
Arthritis refers to any diseases featuring inflammation of the joints – or inflammation of the articulations in medical terms. Arthritis could happen due to extensive wear and tear, immune problems, or an infection. Regardless of the cause, it triggers pain, stiffness, and the progressive destruction of the joint. There are over 100 types of arthritis, the most common ones include rheumatoid arthritis and osteoarthritis which we will discuss in this article series.
Rheumatism is a term commonly used by the general public to refer to arthritis. However, when doctors say rheumatism, they often refer to ‘rheumatoid diseases’, which is the same as musculoskeletal diseases, or diseases of the bones, joints and muscles in general. Medically speaking, arthritis is a subset of rheumatoid diseases or rheumatism.
Rheumatoid arthritis (RA) is a prevalent type of arthritis associated with inflammation. It is in essence an autoimmune condition in which the body’s immune system goes overboard, causing an exaggerated response that destroys healthy joint tissues instead of protecting them. This autoimmune reaction causes joint inflammation, joint pain and overtime damages to joint tissues. In Singapore, rheumatoid arthritis is estimated to affect 0.5% to 1% of the population, two thirds of whom are women. Although it is more common among adults of 40 years and above, it can happen at any age.
Causes & Risk Factors
As an autoimmune condition, rheumatoid arthritis is believed to have several causes, including:
- Genetic factor: Studies suggest a number of genes might be associated with the occurrence of rheumatoid arthritis. The exact trigger mechanism is not fully understood. The disease is not confirmed to be hereditary, which means that individuals with parents suffering from RA do not necessarily develop the condition. However, it has been observed that having a close relative with rheumatoid arthritis increases your chance of having RA.
- Environmental factors: According to research, exposure pollution such as air pollution, occupational dust, and lifestyle factors such as smoking, obesity, a diet high in sodium and low in vitamin D, contribute to triggering rheumatoid arthritis.
For unknown reasons, gender is a risk factor for RA. Females are more likely to develop RA than males.
Patients report both gradual and sudden onset of symptoms, including:
- Stiff, painful and/or swollen joints, usually at the small joints first such as hands, wrists, ankles. Multiple joints can be affected at the same time, and typically on both sides of the body for the same joint.
- Stiffness in the morning after waking up or after a prolonged period of inactivity.
- Warm and red skin over the swollen joints.
- Fatigue or tiredness.
- Mild fever.
It is advisable to visit a doctor if above symptoms do not improve with over the counter patches and ointment in 4-6 weeks.
The most common complication in rheumatoid arthritis is a reduction in the patient’s quality of life. In addition to constant pain, joints and related soft tissues can be progressively destroyed as the disease worsens, resulting in deformity and loss of function most noticeable in the hands. This causes ‘crooked fingers’ or ‘crooked hands’ that are unable to perform simple daily tasks such as buttoning up shirts or holding items. Fortunately, this type of complication can be managed with early diagnosis and treatment.
RA patients also have a higher risk of:
- Carpal tunnel syndrome – a nerve syndrome characterised by pain, numbness and tingling sensation in the hands and wrists
- Inflammation spread out throughout the body. When this happens in the heart, lung, eyes or blood vessels, it can result in fibrosis – a medical term for tissue scarring and thickening – in the respective body parts, causing cardiovascular diseases, shortness of breath, lung diseases, dry and red eyes, reduced blood circulation and more.
- Rheumatoid nodules – moveable lumps formed under the skin, usually near the affected joints.
- Inactivity or reduced level of exercise due to pain. This can lead to overweight and increased risk of developing high cholesterol, cardiovascular conditions, diabetes, etc..
- Cardiovascular disease – individuals with RA have an increased risk of developing heart and other cardiovascular diseases, though the linkage is not fully understood.
Complications might exacerbate among elderlies who experience mobility issues, muscle weakness, and dependence on others to complete their daily activities. Joint pain and muscle weakness could increase the risk of falling or frequently dropping things, increasing the incidence of accidents in this group.
Diagnosis & Treatment
To confirm a rheumatoid arthritis case, the doctor will examine the patient’s joints and medical history. Blood tests will be ordered to check for inflammation markers and rheumatoid factor. Imaging tests such as X-ray, ultrasound or MRI scans are also needed to determine if joints and bones are eroded and the stage of the condition.
Treatments for rheumatoid arthritis aim to stop or reduce inflammation, control pain and other symptoms, prevent joint damage and complications, and improve mobility and functions for the affected part.
- Medical treatment often includes anti-inflammatory medications to relieve pains and steroids to prevent further harm by the immune system. Topical products are also prescribed to help with pain.
- Self care to relieve pain symptoms includes warm and cold compresses over the affected joints. Warm compresses help to improve blood circulation, soothe stiff joints while cold compresses help to reduce inflammation and swelling.
- Lifestyle changes: Managing rheumatoid arthritis is a life-long process, which means lifestyle changes are key in addition to medication. Joint pain makes exercising harder for rheumatoid arthritis patients. However, it is also essential to engage in light or moderate exercise regularly whenever possible and maintain a healthy and omega-3 rich diet. Research has shown beneficial effects of taking omega-3 fatty acid in treatment of RA. Talk to your doctor if you want to take supplements instead. Do not smoke and avoid inflammatory foods (processed foods and those with a high content of saturated fat). Staying positive and reducing stress also helps with your overall well-being.
- Physiotherapy is often prescribed for patients to regain their joint function. A combination of lifestyle factors, medical treatment, and physical therapy improves the quality of life in these patients.
- In severe cases or when nothing can be done, and the bone has deteriorated extensively, surgery is recommended to replace the joint with a prosthesis. This outcome is prevalent in cases affecting the knee and the hip.
If you have relatives diagnosed with rheumatoid arthritis, you can use the same recommendations for lifestyle changes above to prevent the disease. It is also important to visit a doctor as soon as you notice the early signs of the condition, as early diagnosis improves treatment results and gives you a higher chance of putting the disease in remission.
2. Osteoarthritis (OA) and Osteophytes (Bone Spurs)
OA is the most common type of arthritis due to wear and tear, globally as well as in Singapore. The impact of the condition is beyond statistics. According to a local survey, as many as half of those who suffer from knee pain choose to self medicate or suffer in silence, without knowing that the condition might deteriorate, requiring costly knee replacement or resulting in disability in the long run. The good news is that early diagnosis and treatment can slow down such progression and improve quality of life for patients.
OA happens when the cartilage that cushions the end of the bones suffers an accelerated breakdown. Unfortunately, cartilage can’t repair itself once damaged. As it wears out, the bone ends rub against each other without any cushioning layer, and their friction causes inflammation and pain. OA can happen at various joints, more commonly in the knees, hips, hands, thumps, big toes and spine.
Osteophytes (bone spurs) happen in most cases as a result of OA. When bone tissues are damaged, they try to repair themselves by increasing bone production. But sometimes, new bone creation is irregular, resulting in a roughened or bumpy surface that increases the wear and tear of the joints. Osteophytes are created this way, and they keep growing over time.
As wear and tear conditions, both OA and bone spurs are more common among the elderly. More wear and tear is accumulated as we age. However in Singapore, OA is also rising among younger adults, which could be due to a rising interest in sports among adults.
Causes & Risk Factors
The most common cause of OA is wear and tear. In other words, age is a risk factor. The older we are, the more wear and tear, and the higher the risk of developing osteoarthritis.
Other causes and risk factors include:
- Being overweight: This puts additional pressure on the joints and cartilage, requiring them to work harder, resulting in faster deterioration.
- Injuries, in particular those that alter the way the joints work after healing.
- Bone and joint abnormalities, such as a curved spine by birth, can cause pressure on the joints over the lifetime and result in OA.
- Movement or posture habits, such as poor posture, or a particular way a person walks, or excessive sports movement such as squatting or lifting, can also put unnecessary stress on the joints, contributing to osteoarthritis.
- Comorbidity: Other inflammation joint and bone conditions such as rheumatoid arthritis or other types of arthritis such as gout can also create damages to the cartilage. Diabetes Type 2 is also known to be associated with OA.
- Gender: Females are more likely to develop OA than males, especially after menopause when body production of estrogen – a hormone that protects bone and cartilage – drops.
- Genetic factor: Similar to RA, though not confirmed to be inheritable, OA risk is higher when you have a close family member with the condition.
The most common cause of bone spurs is osteoarthritis, as noted above. Another cause of bone spurs is ankylosing spondylitis. It is another type of arthritis, but this time occurring in the spine. In this case, osteophytes are formed in the vertebrae due to inflammation.
The symptoms of OA and bone spurs often overlap with those of RA. Sometimes, conditions can happen simultaneously, and these osteophytes worsen the symptoms of the underlying disease. It is recommended to consult specialists to be sure which type of condition is the underlying cause for the most optimal treatment.
The symptoms triggered or worsened by OA and bone spurs include:
- Painful and swollen joints
- Reduction of the range of motion
- Muscle weakness
- Bumpy areas in the affected joint
As they worsen, OA and bone spurs can cause compression on nearby nerves causing neuropathic pain or rub against tendons causing tendinitis and tendon tears. They could be very severe and restrict mobility in these patients.
Neuropathic pain is not relieved by over-the-counter painkillers and usually causes tingling, numbness, or a burning sensation in the skin.
The only way to take away OA and osteophytes is through surgery to replace the worn out joint, such as in the case of hip replacement or knee replacement. However, in most cases, it is not necessary to resort to such an invasive and costly procedure. The condition can be effectively managed, especially if detected early, with:
- Home remedies such as hot and cold compresses to reduce inflammation
- Pain relievers and resting the joints
- Cortisone and other steroids administered by your doctor, taken orally or through injection. A relatively new and potentially effective treatment is injection of hyaluronic acid into the joint to increase lubrication and reduce inflammation. Further research is being done in this area to create effective drugs using this method.
- Physical therapy with a combination of stretches and exercises
- Lifestyle changes in exercise habits, diet, weight management and stress management.
- Usage of supporting tools such as knee braces for the knees, canes for back support, ergonomic chairs to maintain good posture, or supportive shoes to reduce pressure on the affected joints.
Preventing OA and bone spurs works similarly to preventing rheumatoid arthritis and its complications. It is recommended to keep a healthy weight to reduce stress on your joints. A balanced diet and not smoking will reduce inflammation and prevent osteophyte growth. Maintaining good posture, engaging in appropriate workout exercises and a generally healthy lifestyle helps to delay and prevent developing these conditions even when you have risk factors.
3. Frozen Shoulders (Adhesive Capsulitis)
Frozen shoulder is a common problem in patients over 40 years, especially women with chronic conditions such as diabetes and thyroid problems. It features inflammation in the shoulder capsule – the connective tissue that surrounds the shoulder joint and helps to stabilize the shoulder. The medical name of the condition is adhesive capsulitis.
As the name implies, a frozen shoulder is a condition that makes the shoulder very difficult to move. The shoulder capsule becomes very thick and makes the shoulder joints tight and stiff. There is a reduction of synovial fluid in the joint, and adhesions start to develop. Ultimately, the patient becomes unable to move the joint.
The exact cause of adhesive capsulitis (frozen shoulder) is not entirely understood. However, we know that it is more common between 40 and 60 years old. It is more predominant in women, especially if they have metabolic problems such as diabetes or thyroid disease. Seniors with Parkinson’s disease are also at risk of developing a frozen shoulder.
Another cause is prolonged immobilization. For example, rest and immobilization are a part of the recovery after enduring a fracture or injury. But they can increase the risk of frozen shoulder if the patient lets the joint rest for too long.
Adhesive capsulitis develops progressively in different stages. Each one features its own signs and symptoms.
The initial phase is called the freezing stage, and it develops in a period of 6 weeks to a few months. During this time, patients feel progressive pain in the shoulder articulation. The range of motion is progressively reduced, too.
In the “frozen” phase, the range of motion is severely compromised. The joint is very stiff, and the patient may require help for his daily activities. It lasts 4 to 6 months in which pain comes and goes, but the stiffness stays the same or becomes worse.
This stage is followed by a resolution or thawing phase in which the shoulder articulation goes back to normal. This is a very slow process that takes a minimum of 6 months and up to 2 years.
Frozen shoulder is usually a self-resolving condition and does not have significant complications. Loss of function and reduced mobility affect the quality of life and the ability to look after themselves, especially in seniors.
In some cases, not moving the shoulder articulation causes muscle wasting, atrophy, or weakness that persists after a long time.
This ailment is rarely treated with surgery, but sometimes it can be useful to perform a shoulder arthroscopy to release the shoulder joint.
In most cases, the symptoms improve with conservative treatment, which includes:
- Over-the-counter painkillers: They are usually anti-inflammatory medications. They reduce swelling and improve pain symptoms.
- Steroid shots: They are only recommended in very advanced cases. These injections are administered directly on the affected articulation to reduce inflammation.
- Hydrodilatation: It is similar to steroid shots but uses sterile fluid without drugs. The purpose is to stretch and expand the capsule, releasing the tension and controlling the symptoms
- Physical therapy: It involves exercises and stretches to improve the range of motion, exercise the muscles, and loosen the articulation.
Studies show that the best approach should include several treatments, especially physical therapy in combination with analgesics.
Since the cause of adhesive capsulitis is not entirely understood, preventing this ailment is particularly difficult. However, it is essential to encourage early mobilisation and physical therapy of the shoulder in immobilised patients after surgery, bone fractures, or injuries.
4. Sacroiliac Joint Pain
Sacroiliac joint pain is also known as sacroiliac joint dysfunction or sacroiliitis. It is also an inflammatory disease, but this time limited to the sacroiliac joint. This joint is located at each side of the spine, attaching the pelvic bone to the sacrum. It causes low back pain, thigh pain, and tenderness in this area.
Sacroiliac joint pain is one of those conditions that scientists have not yet fully elucidated. Thus, diagnosing the disease is often difficult. Still, it is estimated that this ailment triggers a considerable number of cases of low back pain.
The exact cause of sacroiliac joint pain is often difficult to trace. However, arthritis is one of those reasons, especially ankylosing spondylitis which affects the spine. There’s inflammation of the sacroiliac joint, causing pain and stiffness in the lower back.
Other causes include pregnancy, trauma in the lower back, as in a car crash, or a side effect of spine surgery. Patients with an abnormal walking pattern may also develop sacroiliac joint pain. For example, a senior with foot pain may favour one leg over the other, creating an irregular walking pattern. This reflects on the sacroiliac joint, leading to sacroiliac joint pain.
Sacroiliac joint pain could be located on the lower back, the buttocks, or the thigh. The pain is triggered when the sacroiliac joint moves and the patient often feels tenderness in this area. Thus, sitting for a long time and climbing stairs could trigger a flare-up.
Other triggers include prolonged standing, running, large strides, turning in bed, and getting up from a chair.
Doctors often overlook sacroiliac joint pain, but it is a common cause of chronic back pain. These patients suffer from recurrent mobility issues and often develop an aberrant sacroiliac movement pattern. Such patterns cause balance problems that increase the risk of falling in older adults.
A recent review article was published in the Journal of the American Academy of Orthopedic Surgeons. The authors described different treatment options that relieve pain according to evidence. These patients usually find relief with over-the-counter painkillers. Anti-inflammatory drugs are recommended in patients with arthritis as an underlying disease. These patients often require muscle relaxants to relieve muscle spasms, and some of them may benefit from biological treatment, especially TNF inhibitors. In more severe cases, steroid shots may provide relief for a longer time.
Similar to other ailments described above, the sacroiliac joint disease usually improves with physical therapy. In this case, massage therapy, stretching, and light exercise can help patients increase their range of motion and stabilize their articulation. In some cases, body mechanics retraining can be helpful to learn how to move in your day-to-day activities if you want to avoid a flare-up.
Reducing inflammation, living an active life, and eating healthily could reduce the risk of sacroiliac joint dysfunction and prevent further flare-ups. Specific exercises and stretches have a protective effect on the sacroiliac joint.
For example, hip flexor stretches are recommended for patients who sit for a very long time. Another type of stretch is called sacroiliac joint stretch, which is an excellent treatment to release the joint and prevent symptoms in the future. Another exercise that releases the articulation is the leg bridge, which also activates and works out the glutes.
Continue to Part 2 of our Bone and Joint Article Series to learn about common bone-related conditions among elderlies including osteoporosis, osteomalacia, musculoskeletal tumour, bone fracture and degenerative disc disease.