Joint Pain

Myths in joint pain

R Gurumoorthi

There are many misbelieves (myths) regarding joint pain not only among the general population but also among the treating physicians. These myths are obstacles in the management of the joint pain. Understanding and accepting the facts help in the proper management of the joint pain.

Myth-1: Increasing age is the main factor in developing arthritis

Fact: Degenerative osteoarthritis is very common in increasing age and any arthritis occurring in younger age should be suspected for infective and inflammatory arthritis.

With increasing age, due to wear and tear of joint, they are prone to develop degenerative arthritis. Even in those patients, pain is not always directly related to actual joint damage. It is highly variable with patient with clinical sign of osteoarthritis will not have any pain. In case of younger age group, inflammatory arthritis should be considered.

Myth-2: Joint which is swollen, warm and red is infective.

Fact: Same signs/features can be seen in inflammatory arthropathy especially in gouty arthritis which can be monoarticular. Gouty arthritis is due to deposition of monosodium urate [MSD] crystals in joint. It triggers inflammation which can lead to painful, swollen, warm and red joint. In early gout, only 1 or 2 joints are usually involved. The most common sites of gouty arthritis are the great toe, ankle, wrist, finger joints, and knee. Gout attacks begin abruptly and typically reach maximum intensity within 8-12 hours. It is difficult to differentiate it from septic arthritis. In this case, joint fluid tap will help in differentiating both. Presence of negatively birefringence MSD crystals in polarized light with red filter will differentiate it from septic arthritis which has sensitivity of 84% and specificity of 100%.

Myth-3: Patient had been prescribed medicines for rheumatoid arthritis and patient came back to doctor stating that disease and pain is not getting down even after taking for 1 week.

Fact: Methotrexate is relatively rapid onset DMARD’s but it takes nearly 6-8 weeks for its action to be seen clinically.

Medicines should not be stopped at least for these periods to assess need of further dose increment. Two-thirds of patients develop some clinical improvement as a result of therapy with any of these agents, although the induction of true remissions is unusual. In addition to clinical improvement, there is frequently an improvement in serologic evidence of disease activity, and titers of rheumatoid factor and C-reactive protein and the ESR frequently decline.

Myth-4 Patient with shoulder pain or back pain with high serum uric acid should be treated for gouty arthritis

Fact: Shoulder and spine are very rarely involved in gouty arthritis and just elevated serum uric acid without clinical features need not to be treated.

Measurement of serum uric acid is the most misused test in the diagnosis of gout. Approximately 25% of the population has a history of elevated serum uric acid, but only a minority of patients with hyperuricemia develops gout. Thus, an abnormally high serum uric acid level does not indicate or predict gout. Asymptomatic hyperuricemia generally should not be treated. However, patients with levels higher than 11 mg/dL and overexcretion of uric acid are at increased risk for renal stones and renal impairment; therefore, renal function should be monitored in these individuals.

Myth-5: Topical application of NSAID is safer and doesn’t have any systemic side effects in arthritis.

Fact: Topical application of NSAID also will be absorbed systemically and can cause gastritis and renal damage.

It had been believed that when NSAID is applied topically will act only on that site and don’t be absorbed systemically thus no side effects. It had been proved that analgesic action due to topical NSAID is very minimal and most action is due to the placebo effect. It will be absorbed systemically and will cause gastritis and renal damage, though less intense than oral or systemic NSAID. It can also cause local skin damage and reaction.

Myth-6: Exercises have no role in pain relief

Fact: There is high-quality evidence that knee pain exercises reduce knee pain. Studies with other pain also have proved it. But exercise should not be done in the acute phase or when pain is severe or pain is associated with acute inflammation of joints.