Expert insight: Diagnosing joint pain

As well as causing discomfort, persistent joint pain can lead people to limit their physical activity in an attempt to rest the affect joint to allow for recovery. However, as highly respected consultant orthopaedic surgeon Mr Ansar Mahmood explains in this informative article, gentle and considered exercise can be very beneficial for some types of joint pain. The leading specialist also sheds light on how the cause of joint pain is diagnosed and the various surgical treatment options that may be considered in some cases.

What are the main causes of joint pain?

One of the main causes of joint pain is osteoarthritis. When we talk about arthritis, there are two broad categories to consider that exist within the condition. One is inflammatory arthritis, which many people call rheumatoid arthritis although there are many other types inflammatory arthritis. The second type is osteoarthritis, which people tend to differentiate as ‘wear and tear’ or degenerative arthritis.

Interestingly, both inflammatory arthritis and osteoarthritis have a biological process which causes the development of joint pain. However, with inflammatory arthritis, our own body attacks the joint causing inflammation. In contrast, osteoarthritis is less inflammatory and usually slower process that degrades your joint over time.

Although most often we see joint pain caused by osteoarthritis, there are lots of other possible causes, including damage to tissues and ligaments around the joint as well as ligaments within the joint.

As the knee is the highest load bearing joint, this is the joint where people most often experience pain. In fact, certain activities can generate five to seven times your body weight being transferred through your knee joint which can easily result in injury. Nonetheless, other joints are also susceptible to pain for other reasons.

How is the cause of joint pain diagnosed?

When you see an expert clinician like an orthopaedic surgeon or a musculoskeletal (MSK) specialist about joint pain, the first step in diagnosis is to take a history. In around half of all cases, a full history can help us to identify the cause of the problem. For instance, there are typical symptoms of joint pain which are characteristic of arthritis, such as:

• waking up with stiff joints
• stiffness on beginning to move which may not be present while at rest
• improving pain levels with movement as the joint becomes more agile and supple and the soft tissues recover

As the history in itself can be very important, we will ask a number of specific questions to establish if there is pain first thing in the morning, late at night, with activity or at rest.

Following a detailed history, we then examine the patient by observing their gait, how they walk, their pattern of movement, what they can and can’t do and any restrictions they are faced with as a result of their joint pain. If further information is needed, for instance to grade pathology, then we may also perform imaging, such as ultrasound or MRI scans, to give us more detail.

What can I do to relieve joint pain at home?

To effectively treat and relieve joint pain, you have to establish its cause. However, it’s important to remember that the best solution is not always intervention, such as injections or surgery, and simple measures like exercise can effectively resolve joint pain in some cases.

People with arthritis tend to do less exercise because it hurts but doing less exercise causes the muscles to degrade, creating a vicious cycle. The lower strength and weakness in the muscles causes an increase in the joint reaction force (JRF) when the person walk. This means that the forces travelling through the joint are actually higher than before and the joint struggles more because the patient has rested it.

Keeping your muscles and surrounding tissue in very good condition can reduce the joint reaction forces, keeping your pain improved and allowing the joint to function better. Therefore, exercise is very important and although high impact work may not be possible, cycling or exercising in water can be very beneficial.

If you have established that the cause of your joint pain is nothing to worry about but you are experiencing mild aching or early arthritis, the first thing to do is exercise and self-management. Another important step can be activity modification - low impact rather than high impact work. This could apply to making simple changes around the house, such as how and for how long you stand and sit, the positions you take or getting simple aids to help you.

Rather than requiring intervention for this type of joint pain, most people can effectively manage this at home with advice. We tend to see patients who have passed this stage and have also tried physiotherapy and rehabilitation without success. At that stage, patients need to see a specialist for advice and intervention. From the beginning, we always start treatment with minimally-invasive or non-invasive therapies, only escalating to further treatment or intervention when required.

When is surgery required for joint pain?

We are a joint preservation practice and so surgical treatment options are a last resort. Sometimes, however, surgery is the right answer for patients when all of the non-operative interventions and joint preservation options have been exhausted.

At the very lowest level, there are surgical options such as partial or full joint preservation through realignment surgery which changes the mechanics in the joint as opposed to replacing the joint itself. In the knee, for example, this could be performed with procedures such as high tibial osteotomy or distal femoral osteotomy, in which you maintain your own bones and joints.

In surgery of this type, a small controlled crack is made in the bone to allow the position of the joint to be changed very slightly so that the mechanical axis alters. This means that you are no longer walking on the bad painful arthritic surface.

One advantage of keeping your own joint surfaces as opposed to having them replaced is that most patients can usually maintain their regular activity levels. In fact, patients usually enjoy their ability to maintain higher activity levels for anywhere between five and fifteen years. This significantly delays the need for a total knee replacement although it may be required at some point in the future.

That brings us on to replacements, or what we call arthroplasty, which is where your joint is surgically excised and replaced with artificial metal or plastic implants. There are multiple variations of joint replacement surgery, including:

• partial knee replacement, also known as patellofemoral replacement, where only a portion of the knee is resurfaced (trochlea and patella)
• unicompartmental knee replacement, where intervention is only required on one side of the knee
• total knee replacement, where the entire joint is replaced

The expert opinion of a consultant orthopaedic surgeon will allow you to establish which options are available to you and help you to make a joint, informed choice about the best type of surgery for you.

If you are suffering from persistent joint pain and wish to schedule a consultation with Mr Mahmood, you can do so by visiting his Top Doctors profile.