Today’s guest post comes courtesy of physical therapist Dr. Michael Infantino, and covers a topic every human in the history of ever has had to deal with.
It’s good. You should read it.
Enjoy.
What Your Doctor Never Told You About Arthritis
Physician: “Welcome. Thanks for coming in for your appointment this morning. It says here that you are having shoulder pain. Is that correct?”
You: “Yes it is. I didn’t think anyone actually read that intake form. I am glad that I took the 30 minutes to fill it out in the waiting room. Also, thank you for taking me back only 45 minutes later than my scheduled appointment time. That’s way better than my previous appointments.” [In a sarcastic tone.]
Physician: “Well there could be a host of reasons that you are having shoulder pain. Did you fall recently? And how old are you? Did you know that most 40 year olds have arthritis?”
You: Inner dialogue, “No, I didn’t fall. Fall? What am I 90 years old?” “I exercise regularly Doc. It hurts sometimes when I am bench pressing or doing shoulder press. Can’t think of any specific incident when it first started hurting.”
Physician: “Did you ever consider not lifting weights? It may be rewarding to have those big muscles, but it could increase your risk of injury. Look at me. I do 20 minutes of stationary biking each day, no pain… try that.”
You: [Scratching your head] Again, inner dialogue, “He is kidding, right? I would rather beat my head into a wall than stationary bike for 20 minutes.”
Physician: “Ok, lets do some testing on you. (Three minutes later) Well, luckily I didn’t find anything that resembled a rotator cuff tear or instability. You also don’t seem to be missing much motion so we can throw a frozen shoulder diagnosis out the window. Why don’t we have an X-ray done?”
You: “Ok Doc. You are the boss… this should tell me what the problem is, right?”
Physician: “For the most part, yes. We can see if you have any bone spurs or arthritis. Remember what I said about old people right? They get arthritis.”
You: “Old? I am 40 bro!”
THE FINDINGS:
Physician: “It seems here that you have some arthritis in your shoulder. This explains your pain. You could try taking some anti-inflammatories. Exercise might help to. Here is a list of rotator strengthening exercises that we use. Have at it! If this doesn’t work come back in a few weeks and I can inject it with cortisone.”
You: You think to yourself, “Shoulder exercises? I work out my shoulders all the time. Is the Doc saying I am weak? Am I going to be popping anti-inflammatories my whole life?”
As doom sets in you start to think about all the moments you have taken for granted.
The joy you get from bench pressing and the euphoria that bicep curls provide. The ease in which you were once able to perform the perfect landmine press, never having to worry about your shoulder.
You start questioning past decisions. If I only would have strengthened my rotator cuff muscles earlier or just road the stationary bike like the DOC.
As you are drowning in self-pity the pause button is pressed, and some random guy pops out to provide what might seem like a cheesy infomercial.
Random Guy: “Hello! I am aware that your physician just made arthritis seem like the death sentence. Before you leave today demoralized, let me give you some facts about arthritis to ensure that you don’t sentence yourself to a lifetime of stationary biking. He tried that line on me once too.”
What is Arthritis and What Does This Mean For Me?
Osteoarthritis is the most commonly diagnosed form of arthritis. Referred to as the “wear and tear” arthritis.
This label holds some truth, but it does not tell the whole story. Living a life enriched by the joys of picking big things up and putting them down may lead to more arthritis than stationary biking.
Surprisingly this is not always the case. In another article, we talk about a study that showed a significantly higher rate of arthritis in a sedentary obese population compared to a lifetime recreational runner.
Osteoarthritis is actually the result of increased inflammation surrounding the joint.
Remember that inflammation is your body’s attempt at healing tissue.
Unfortunately, your joints and cartilage do not always allow for optimal blood flow. Instead of providing healing it just leads to some degeneration. What you need to understand is that many other factors can contribute to arthritis.
This includes:
- natural aging
- obesity
- diet
- gender
- previous injury
- your god given anatomy
Arthritis. “The Get Out of Jail Free Card.”
Arthritis seems to be that “get out of jail free card” for most clinicians.
You show up complaining of pain without any recent trauma. You don’t recall dropping a barbell on your chest or hearing a pop after throwing a no-hitter… for your co-ed softball league.
It seems like your rotator cuff and labrum are safe and sound.
We strive to avoid wrinkles like we strive to avoid arthritis.
So what usually happens next?
Your medical doc whips out the “big guns” of course.
In this case that would be an X-ray, MRI or ultrasound.
Come to find out you have a little bit of arthritis at the shoulder.
Lets stop for one second.
For some reason we imagine this life where we defeat the natural aging process. We strive to avoid wrinkles like we strive to avoid arthritis. Wrinkles may be a source of pain just as much as arthritis is.
More importantly, having arthritis does not necessarily mean you are going to have pain.
It wasn’t until some brilliant people started putting people without pain under X-ray that we realized something extraordinary.
They have arthritis too, but no pain!
One study found that arthritis and degeneration of the spine progressively increased with age. However, that is generally NOT true with pain. People also complain of back pain more frequently in their 40’s to early 50’s (Louw, 2017). From there it steadily declines despite the fact that arthritis steadily increases.
More than 90% of 60 year olds (without complaints of pain) will present with some form of degeneration around the spine (Brinjikji W. et al).
As much as we hate to hear it, we need to remember that inflammation does not create pain. It just warns the brain that we may have a problem.
The brain determines whether or not you feel pain.
People who have had limb amputations because of rheumatoid arthritis (another form of arthritis triggered by an autoimmune disease) continued to feel stiffness in a limb that was no longer there (Haigh et al).
Basically, phantom limb pain.
This reinforces the idea that part of your discomfort is also because of a sensitized central nervous system. Your brain and nerves get all hyped up the longer your pain lasts. This is why pain management and physical therapy are focusing on finding ways to desensitize your central nervous system. This includes things like graded motor imagery and helping people understand how pain really works.
It is Time To Do Your Best Sherlock Holmes Impersonation.
With what you know now, how terrible would it be if arthritis were blamed for your pain without considering other causes?
We may go through the rest of life thinking that nothing that can be done.
On top of that we think, “if I have arthritis now how bad will in be in ten years from now?”
You may even consider canceling your gym membership and living in a bubble. Before it gets to this point try to enhance your self-awareness. Consider what activities may be contributing to your pain. Poor programming, bad technique and lack of focus on mobility.
These are all low hanging fruit.
Other considerations for reducing inflammation:
- Diet
- Sleep
- Exercise
- Physical and Emotional Stress
Failing at any of the categories listed above can elevate local joint inflammation. Potentially leading to pain. People neglect the importance of a diet that minimizes inflammation. We have a general idea of the foods that cause more trouble (breads, pastas, dairy, sugar, red meats, and so on).
Losing weight, minimizing alcohol intake, not smoking, exercising and cleaning up your diet is usually sufficient for getting on the right path.
Many recommendations for herbal supplements and vitamins exist. But don’t think that taking some turmeric and fish oil will override the bowl of ice cream you take down every night.
Or the occasional soda with lunch.
We also know that being deficient in certain vitamins can result in increased levels of inflammation. In a study that looked at the relationship between knee pain and arthritis, “people with knee osteoarthritis who were obese but had healthy vitamin D levels were less disabled than people who were obese individuals but had insufficient vitamin D levels.”
Make sure you consult with your doctor before implementing any vitamin supplementation.
More is not always better.
Consuming too much of one vitamin could cause toxicity or alter the effectiveness of other vitamins (Glover et al).
If You Are Already Making All the Right Lifestyle Choices and Still Having Pain What Can We Do?
Muscle can often be the source of a lot of the aches and pains we experience. Inflammation at a joint or trigger points in a muscle both increase those danger signals back to the brain.
Our goal is to decrease those danger signals in as many ways as possible.
That could be treating the muscle, reducing stress, getting more sleep, improving our diet and so on.
To start moving in the right direction we can benefit heavily from seeing a professional.
Who exactly?
It really depends on your preference.
A lot of overlap exists between massage, physical therapy, chiropractic, acupuncture and so on these days. Many of these disciplines are using similar services when it comes to hands on treatment.
For example, cupping, joint mobilization, manipulation, soft tissue manipulation, instrumented assisted treatment, active release techniques and more. Other disciplines besides physical therapy are also using exercise. Doing your research, and finding out which provider specializes in your injury is more important than ever.
Been There, Done That and Still No Success?
This is when I would look to a medical doctor, preferably someone that specializes in orthopedics or sports medicine. Knowing that you have been through conservative care already they will most likely recommend an X-ray, ultrasound and/or MRI.
Caution: Ignorance is sometimes bliss. This is when you are going to see what your joint really looks like. It is not always pretty, and “degeneration,” “tears,” “bone spurs” are not always synonymous with pain. Do not let these findings immediately make you think that surgery is necessary.
- 2/3 people over the age of 70 have pain-free rotator cuff tears (Milgrom, Schaffler et al., 1995)
- 50% of people with knee arthritis have no reported pain (Bedson and Croft, 2008)
- 35% of collegiate basketball players without reported knee pain have notable abnormalities on MRI (Major and Helms, 2002)
The doc offered a cortisone injection… should I do it?
Cortisone tends to be used more commonly with knee and shoulder pathology. It has been shown to be effective at reducing pain. The goal is to reduce inflammation local to the joint.
“Yea, but isn’t inflammation a good thing?”
Great question.
Yes, it can be, but excessive inflammation can cause increased stress on a tissue, enhancing those danger signals. Ultimately resulting in more pain.
Could cortisone cause more damage?
It is possible that excessive use of cortisone can weaken tissues leading to possible tissue injury. What is “excessive use” defined as? That part varies depending on who you ask. Learn a little more about cortisone injections from the Cleveland Clinic.
Should I take Aspirin (anti-inflammatories)?
Anti-inflammatories may be effective as reducing local inflammation.
Some studies have shown that cortisone may be more effective, but not in all cases. Anti-inflammatories like aspirin are not meant for long-term use secondary to its harmful effects on the gastrointestinal system.
“Possible risks of all NSAIDs include: stomach problems (such as bleeding, ulcer, and stomach upset), kidney problems, high blood pressure or heart problems, fluid retention (causing swelling, such as around the lower legs, feet, ankles, and hands), rashes, or other allergic reactions.” (Rheumatology.org).
As always, consult with your physician.
The doctor gave me a home exercise plan for my shoulder. Will this work?
It depends.
As we mentioned earlier, exercise that does not increase pain can be beneficial.
To keep it simple, “motion is lotion.”
Movement also increases local blood flow, which can help reduce inflammation.
Cardiovascular exercise can reduce pain through endorphin release (self made pain killers). Keep in mind that working through pain on your generic rotator cuff strengthening program will get you no where. Not to say that working through a little pain is a bad thing. The assumption that a weak rotator cuff is the culprit is often misguided.
Interested in a FREE Shoulder Mobility Program to help reduce pain? Click here.
Overview
Arthritis is not a death sentence.
It also does not mean that you need to resort to stationary biking and aquatic therapy.
Arthritis is as normal as developing wrinkles when it comes to aging. Before you blame your pain on arthritis consider the low hanging fruit that you are not addressing. If you need a little boost get a second pair of eyes on you at the gym. Also consider seeing a medical provider that can do some soft tissue and joint mobilization.
Low Hanging Fruit:
- You weight
- Diet
- Sleep
- Exercise Routine (programming and technique)
- Self Care Practices (mobility work and rest)
- Stress (physical and emotional)
About the Author
Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.
References
Arroll, B., & Goodyear-Smith, F. (2005). Corticosteroid injections for painful shoulder: a meta-analysis. The British Journal of General Practice, 55(512), 224–228.
Bedson, J., & Croft, P. R. (2008). The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskeletal Disorders, 9, 116. http://doi.org/10.1186/1471-2474-9-116
Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.
Glover T, Goodin B, King C, Sibille K, Herbert M, Sotolongo A, Cruz-Almeida Y, Bartley E, Bulls H, Horgas A, Redden D, Riley J, Staud R, Fessler B, Bradley L, and Fillingim R. (2015). A cross-sectional examination of vitamin D, obesity, and measures of pain and function in middle-aged and older adults with knee osteoarthritis. Clin J Pain; 31 (12); 1060-67.
Haigh RC1, McCabe CS, Halligan PW, Blake DR. Joint stiffness in a phantom limb: evidence of central nervous system involvement in rheumatoid arthritis. Royal National Hospital for Rheumatic Diseases, and Department of Medical Sciences, University of Bath, UK.
Liu-Bryan R, Terkeltaub R. Emerging regulators of the inflammatory process in osteoarthritis. Nat Rev Rheumatol 2015; 11:35.
Louw, A., Zimney, K., Johnson, E.A. et al. Aging Clin Exp Res (2017) 29: 1261. https://doi.org/10.1007/s40520-017-0731-x
Loeser RF, Goldring SR, Scanzello CR, Goldring MB. Osteoarthritis: a disease of the joint as an organ. Arthritis Rheum 2012; 64:1697.
- Major and Clyde A. Helms. MR Imaging of the Knee: Findings in Asymptomatic Collegiate Basketball Players. American Journal of Roentgenology 2002 179:3, 641-644
Milgrom, Charles & MB, Schaffler & Gilbert, S & van Holsbeeck, Marnix. (1995). Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. The Journal of bone and joint surgery. British volume. 77. 296-8.
Serdar Kesikburun, MD, Arif Kenan Tan, MD, Bilge Yilmaz MD, Evren Yasar, MD, Kamil Yazicioglu, MD. Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial With 1-Year Follow-up
Up To Date: Pathogenesis of Osteoarthritis.
