Submitted by Tom Evans Krause, Puget Sound League President
One of our longtime players is an orthopedic surgeon who occasionally writes informative blogs for our membership. David ‘Doc’ Kuechle is also an excellent outfield/hitter and his teams have won several MSBL titles as well as a bunch of PSSBL divisional championships. Below is one of his most recent articles he supplied for our members. It addresses arthritic conditions and some methods of treatment. Enjoy!
David K. Kuechle, MD is a board-certified orthopedic surgeon at Edmonds Orthopedic Center and a member of the Smoky A’s and the Everest Monarchs.
April 5, 2018-Does your elbow not bend or straighten as far as it once did and does it hurt at the end of your range of motion? Does it feel like you pulled your groin 2 years ago and is it hard to get your foot up high enough to put on your shoes and socks? Have your knees become so bow-legged that your friends call you Cowboy Bob? If so, you probably have arthritis. In this blog post, I’m going to discuss arthritis – what it is and what can be done for it.
Technically, arthritis is inflammation of a joint. In practice, though, we use the term arthritis to specifically mean damage to the cartilage joint surface. The ends of our bones are covered with hyalin cartilage – a durable, smooth, white rubbery substance that cushions the bones that form the joint. Some joints, like the knee, also contain structures that contain another type of cartilage (fibrocartilage) such as the meniscus. The terminology can be a bit confusing. A “torn cartilage” refers to the meniscus, not the hyalin joint cartilage. The lining of the joint, called the synovium, makes a lubricating and cushioning fluid called, you guessed it, synovial fluid. Normal joints are amazingly durable and smooth. We’ve never been able to manufacture surfaces that come close to matching the low friction of healthy joints, even with advanced machining techniques and the best industrial lubricants.
A number of conditions can cause arthritis. The most common is called osteoarthritis and is basically wear and tear arthritis, although it also has a strong genetic component. If one or more of your parents have osteoarthritis, chances are, you do too (lucky you!). Trauma, such as fractures through the joint, especially if the bones heal in such a way that make the joint surfaces irregular, can also cause arthritis. A third group is inflammatory arthritis, which is associated with autoimmune conditions like psoriasis and rheumatoid arthritis.
In general, arthritic conditions tend to be slowly progressive because cartilage has limited ability to repair itself. Early symptoms tend to be episodic pain, stiffness and swelling. As time goes on, the symptoms become more constant and severe. The joint can change shape as bone spurs form at the margins of the joint, or the joint can become crooked as cartilage erodes from one side of the joint more than the other.
Treatment depends on the severity of the arthritic symptoms. Most of the non-surgicaloptions provide partial relief. However, if enough of the treatments are combined together, patients can sometimes enjoy significant relief of their pain. Over the counter medications like acetaminophen or anti-inflammatories like naproxen or ibuprofen can lessen pain and in the case of the anti-inflammatories, swelling as well. Ice can help too. Topical medications containing capsaicin or ingredients that cause local irritation can reduce perceived pain. Physical therapy can improve range of motion and strengthen muscles that cross joints and provide some shock absorbing function. The use of a brace is a bit of a double-edged sword because they do some of the work we want the muscles to do, potentially leading to weakness, but at the same time can support the joint and reduce pain. In the knee, there is a special type of brace, called an unloaded brace, that can dampen the stresses of weight bearing and thereby improve pain.
There are several injectable options. Cortisone reduces pain and inflammation, but doesn’t treat the underlying cartilage damage. A standard cortisone injection typically only lasts a few weeks. However, there is a brand new sustained-release version of cortisone that reportedly lasts 4 months or more. A potentially longer acting “gel shot” injection for the knee uses a synthetic version of one of the proteins found in normal synovial fluid (hyaluronate) in an attempt to reduce symptoms. A series of 3 or 4 injections performed a week apart can reduce pain for as much as 8 months to a year. Not all insurance companies cover this injection (notably Regence and Premera can be hit or miss) but fortunately most do. This injection doesn’t work in everyone, but many patients get at least a partial response. It can be done in joints other than the knee, but that would be considered an “off-label” use in the U.S. and would again not be covered by insurance.
Some of the newer injections attempt to address the underlying cartilage damage and perhaps promote some repair. Platelet rich plasma or PRP, entails taking a small blood sample from the patient, spinning it down and pulling off the platelet layer (cells involved in healing response), then injecting that into the joint. Again, this is considered experimental and has a significant out of pocket cost as most insurances don’t cover it. In my opinion, PRP has other uses for which it is better suited than the treatment of arthritis. Stem cell injections are another potentially reparative injection that’s received a fair amount of publicity lately. This technology uses immature cells from fat or bone marrow, then injects them into the arthritic joint. The idea is that immature cells can become whatever cell is found in the area where they are injected – in this case cartilage – and perhaps resurface the damaged area. This is a technology in its infancy as I don’t think we have all the details worked out yet as to how best to deliver it. Arthritic joints provide an inhospitable environment for tender stem cells to take root. There is also a lot of misinformation about this treatment and much direct to consumer advertising – again insurances don’t cover it and it costs thousands of dollars out of pocket. In my opinion, it’s not yet ready for prime time and I would advise you save your money for now until we learn more about how to best utilize this promising technology.
Finally, joint replacement is a technique that can be life-changing for people suffering with arthritic joint pain. Joint replacement can often restore motion and function, while reducing or eliminating pain. With newer techniques and prostheses, artificial joints can last decades, if patients are reasonable with their activity level afterwards. If patients are not reasonable, they can look forward to many repeat visits with their friendly orthopedic surgeon, while he frowns at their X-rays. The decision to undergo joint replacement is a personal one. I tell my patients that they generally will know when they’re ready for this option. I’ve also been surprised over the years at how often the severity of a patient’s arthritis on X-ray does not correlate to the intensity of their symptoms. There is basically one reason to have joint replacement surgery and that is pain.