TUESDAY, OCTOBER 20 , 2020. THE WASHINGTON POST EZ EE E5
joint healthAn array of strategies are avail-
able for treating joint pain, rang-
ing from physical therapy to pain
medications, injections and sur-
gery, but one of the most effective
ways to manage joint discomfort
is one that can seem counterintu-
itive: Keep moving.
If you’re feeling pain in your
joints, you might be inclined to
lay off them, but that’s one of the
worst things you can do, says A.
Lynn Millar, a physical therapist
and fellow emeritus at the Ameri-
can College of Sports Medicine.
It’s a vicious cycle — it hurts, so
you stop moving the area that’s
painful, but “immobilization ac-
tually causes deterioration in the
joints,” Millar says. Hence the
saying among physical thera-
pists, “Motion is lotion.” Move-
ment brings nutrients to the
joints and keeps them healthy,
Millar says. “Everyone wants a
magic bullet,” she says, and physi-
cal activity is the closest thing we
have.
Even if you’ve had an X-ray or
MRI that shows arthritic changes
in your joint, that shouldn’t dis-
suade you from exercising. “Your
structure isn’t your destiny,” says
Greg Lehman, a Toronto-based
physiotherapist, chiropractor
and clinical educator in physio-
therapy.
Turns out, the findings on an
imaging test aren’t a good indica-
tor of pain, he says. Imagine going
to a ski area and finding all the
people 50 and older who were
skiing around enjoying them-
selves. Lehman says that if you
gave these skiers a scan of their
knees and hips, the “vast majority
of them” would have structural
changes in their knee and hips
without even knowing about it.
For a 2012 study, researchers
took MRIs of the knees of 710
people 50 and older and found
that nearly 90 percent had at least
one feature of osteoarthritis on
the MRI, irrespective of whether
they had knee pain.
An X-ray or MRI is not a good
indicator of whether someone
has pain, Lehman says. “It’s not
that those changes you can see in
a joint or tendon or muscle are
irrelevant,” he says, but they are
not very good at predicting how
someone feels or what they can
do.
Joint pain is complicated, and
it’s not just about what’s going on
with your bones and ligaments,
but also how your nervous system
is interpreting the signals it’s
receiving.
Chemical mediators, such as
enzymes and neuropeptides, re-
leased into the joint when some-
one has arthritis can sensitize the
nerve endings around it to make
them more active than normal.
“These signals are translated by
the brain as pain,” McDougall
says.
Researchers are just starting to
characterize the different kinds
of chemical mediators that might
be involved in these pain signals,
he says.
Even when it hurts, “putting
JOINT PAIN FROM E1
more stress on the joint in the
form of physical activity does not
lead to more degeneration,” Leh-
man says. Moving the joints can
help by promoting blood flow to
deliver nutrients and the circula-
tion of synovial fluid, which can
act as a lubricant for the joint.
Most people with joint pain
respond well to physical therapy
and an activity program, Lehman
says, and studies have shown that
exercise programs can reduce
pain and increase physical func-
tion for people with osteoarthri-
tis in their hips.
Low impact activities such as
swimming, biking, walking or us-
ing an elliptical trainer can be
gentle ways to move your joints,
but even something as high im-
pact as running can be fine for
people who can tolerate it, Millar
says.
A study that followed nearly
500 runners over a period of 14
years found that “there was no
progressive increase in musculo-
skeletal pain in older adults who
participated in regular vigorous
exercise, including running, com-
pared with those who did not.”
Arthritis does not progress any
faster in people who run than in
people who don’t, Millar says, and
people with arthritis who are
regular runners report less pain
and maintain function longer
than people who don’t run.
Strength training can also help
by building up the muscles
around the joint so they’re better
able to deal with the force coming
through the joints. You don’t have
to lift heavy weights to reap ben-
efits, Millar says. Even doing
some simple leg lifts or bending
and straightening your legs can
yield benefits for your knees and
hips, for instance.If you’re carrying extra weight,
losing even as little as a single
pound can make a noticeable
difference.
Research has show that one
pound of weight on the body
equates to four pounds of weight
across your knee, says Antonia
Chen, an orthopedic surgeon at
Brigham and Women’s Hospital
in Boston. “I tell my patients to
celebrate losing one pound. Even
one pound is four pounds off your
joint and it will make you feel
better.”
Obesity is a well-known risk
factor for joint pain, and it’s not
just the added stress on joints
that comes with the extra weight.
Researchers are starting to see
that obesity can be associated
with changes in metabolism and
the microbiome that may be relat-
ed to chronic pain, McDougall
says.
“Bugs in our stomachs talk to
the nerves in our bodies,” McDou-
gall says. And research suggests
being overweight may also in-
crease inflammatory markers in
the blood that could make joint
inflammation worse, Millar says.Drug options
Nonsteroidal anti-inflammato-
ry drugs such as ibuprofen and
naproxen are the go-to medica-
tions for managing arthritic pain,
but they’re no panacea.
“Most of the time, they work
for a little bit, and then they stop
working,” says Ali Guermazi, a
professor of radiology and medi-
cine at Boston University School
of Medicine. They also have side
effects such as internal bleeding,
especially when taken long-term,
Guermazi says. For people who
cannot take NSAIDs because of
side effects, acetaminophen (Ty-lenol) can also be an option. In
severe cases, opioids may be used
short term, but they aren’t a great
option and should be carefully
managed because of addiction
risk, Guermazi says.
When pain meds aren’t help-
ing, corticosteroid injections to
the joint are sometimes used, but
they’re not without risks. Al-
though they can offer relief for
many patients, they can also dam-
age the cartilage in the joint,
Chen says. Guermazi’s research
has found that a small subset of
patients who receive corticoster-
oid injections for joint pain ex-
perience rapid bone degenera-
tion in the joint. “People are
taking steroids thinking it’s a
good treatment,” Guermazi says,
“but there is no study that I can
think of that is showing a long-
term pain relief from steroids. It’s
all temporary.”
A pain management specialist
might be needed for severe cases
where the pain isn’t responding
to any of these other treatments,
Chen says. Options include
numbing agents to block the
nerve or nerve ablation, a treat-
ment that uses heat or cold to
destroy nerve tissue that’s in-
volved in the pain.
With cannabis being legalized
in many parts of the country,
cannabinoids (compounds de-
rived from the cannabis plant)
are becoming another option for
treating pain. McDougall’s group
has studied the use of cannabi-
noids for controlling joint pain.
“We have found that they can be
highly effective and relatively
safe and well-tolerated by pa-
tients,” he says.
The nonintoxicating cannabis
derivative called cannabidiol, or
CBD, is one type to try for thosewith joint pain, McDougall says.
“CBD won’t make you high. It
might make some people feel a
little sleepy,” he says, adding that
drowsiness might be a good thing
for people who aren’t sleeping
well because of pain.
Tetrahydrocannabinol, or
THC, the cannabinoid responsi-
ble for marijuana’s famous high,
also has anti-inflammatory prop-
erties, studies have found.
Whether that’s an option depends
on legality in your state, and some
patients will tolerate THC and the
“high” it can produce better than
others, McDougall says. “It’s a
personal preference. The patient
should be driving what feels good
for them.”
When all else fails, joint re-
placement surgery is a final op-
tion.
“The recommendation is that
you should try to put it off as long
as possible,” McDougall says. Al-
though a joint replacement can
be life-changing in a good way for
some patients, it’s not a magical
cure. A small 2005 study involved
in-depth interviews with 25 peo-
ple who had undergone total
knee replacements and found
that most of them reported a
“good” outcome, but “further dis-
cussion revealed concern and dis-
comfort with continuing pain
and mobility difficulties,” the au-
thors wrote.
Chen says that it’s important to
have realistic expectations for the
surgery: “It’s not like you get the
joint replacement and you’re up
and jumping around. It can take
up to one full year to recover.”
Chen specifically doesn’t rec-
ommend to her patients several
popular treatments. One is a kind
of injection, called “gel shots,” or
viscosupplementation, where a
gel-like fluid is injected into the
joint to increase cushioning.
Chen says that this treatment has
“demonstrated minimal benefits”
and the injections are not sup-
ported by the American Academy
of Orthopaedic Surgeons (AAOS)
Glucosamine and chondroitin
sulfate supplements are another
popular joint pain treatment she
tells her patients to skip. The
evidence that they help is so slim,
she says, that in 2013 the AAOS
put out a statement that said,
“don’t use glucosamine and chon-
droitin to treat patients with
symptomatic osteoarthritis of the
knee.” The supplements “do not
provide relief for patients.”
There’s no way around it —
exercise remains the bedrock for
joint health. “If your knees are
sore, it doesn’t always mean you
should stop what you’re doing,”
Lehman says.
Doing the activities you love
can be therapeutic, not just me-
chanically and biologically for the
joint, he says, but because you’re
moving again and that can be
emotionally and psychologically
healing, too.
[email protected]Christie Aschwanden is author of
“Good to Go: What the Athlete in All
of Us Can Learn From the Strange
Science of Recovery.”Achy knees or neck? Keep moving to manage joint pain.
ISTOCKnose with your eyes closed, or
walk in a straight line without
looking down.
Proprioceptors are sensory
neurons found in muscles, ten-
dons and joints that instantly
shift the body in an unconscious,
instant course correction that
keeps it centered. It develops over
time, which is why toddlers learn-
ing to walk still often look at their
feet, and ebbs as you age, one
reason the elderly are susceptible
to falls.
“It’s your body’s internal GPS
system,” says Nicholas DiNubile, a
Havertown, Pa., o rthopedic sur-
geon and doctor for the Pennsyl-
vania Ballet. “Every joint has pro-
prioceptors, which are networks
of neurons. These are position
sensors. If you start to tilt, they
help you self-correct when you
veer off.”
Proprioception has an especial-
ly important role in weight-bear-
ing joints, such as the ankle.
When you sprain an ankle, pro -
prioceptors become damaged.
This impairs the body’s ability to
right itself, and makes it more
likely you will sprain that same
ankle again. What physicians of-
ten call a “floppy” or loose ankle —
which results from the initial
sprain — actually is a slowdown in
the feedback loop between the
nerves and the brain. The brain
cannot react quickly enough to
keep that ankle from turning
again.
If it’s a moderate or severe
ANKLE SPRAIN FROM E1 sprain, “the ligament is loose for
life,” unless you do exercises to
retrain these key nerves, DiNubile
says.
Before you start doing them,
however, you need to first treat
the sprain. “I have always be-
lieved that ankle sprains are the
most undertreated injury seen in
the emergency room,” says Shel-
don Laps, a D.C. podiatrist. “X-
rays are usually taken, and if they
are negative, patients are usually
sent home with crutches and ad-
vised to ice the area and stay off it
until they are able to walk on the
foot.”
He and other experts still rec-
ommend the old sports acronym
RICE: rest, ice, compression and
elevation. They advise that you
put ice on it — the sooner the
better — to reduce swelling (I
once sprained an ankle while out
running during the winter, and
stuck my foot in a nearby snow
bank for a few minutes before
hobbling home. I’m convinced it
shortened my recovery time.) Iceit for 15 to 30 minutes, then take a
15 to 30 minute break, and ice it
again. Do this as often as you can
the first day. Don’t use heat, which
worsens the swelling.
Some experts in recent years
have disparaged the RICE formu-
la, ice in particular, saying re-
search suggests it delays healing
and may make things worse. B ut
many still believe it can be a big
help immediately after an injury
occurs.
“Swelling after acute injury,
such as an ankle sprain, is the
body’s response to protect the
injured area and limit more dam-
age by preventing movement or
motion,” Laps says. “Ice causes
vasoconstriction, which narrows
the blood vessels and reduces fur-
ther swelling. I recommend ice
for acute injuries [and] for swell-
ing with chronic injuries. I don’t
believe that ice hampers or reduc-
es the inflammatory process or
delays healing when used im-
mediately post injury. My feeling
is based on treating athletes for
over 35 years.”
DiNubile agrees that ice is valu-
able in the hours immediately
following an injury to reduce
swelling and pain. But he suggests
skipping ice after several days in
favor of the remainder of the for-
mula — elevation, compression,
rest and/or gentle movement.
“We don’t necessarily believe
anymore that extended use of ice
is necessary, except after the ini-
tial injury, and could be counter-
productive,” he says.
Wrap your foot with an elasticbandage and elevate it — keep it
higher than your head, if possible,
but definitely above your heart.
This keeps blood from pooling in
the ankle, which also will increase
swelling. (If it is still swollen and
painful after a couple of days,
consider having an X-ray to rule
out a fracture.)
Laps tells his patients to avoid
exercise until they can walk brisk-
ly and pain-free on the ankle. He
also suggests wrapping the ankle
before exercising, and stretching
before and after. After exercise,
ice the ankle for five minutes if it
still tends to swell after a workout.
Runners especially should keep
their mileage and intensity low
when they start back, and run
alternate days on a flat surface,such as an outdoor track, before
resuming hard training or serious
competition, he says.
“I see quite a few injuries in
runners from repetitive stress of
running or working out every
day,” Laps says.
Once healed, it’s time to work
on that proprioception. Some of
the most effective exercises in-
clude sitting with your legs
crossed with a resistance band
around the injured foot. Bend
your foot up and outward, that is,
in the direction away from the big
toe. Do three sets of 15 repetitions
— as it gets easier, increase the
strength or the band and the
number of repetitions.
Also, try balancing on the leg
with the injured ankle. Stand onthe bad leg only, and try to bal-
ance on it for a minute. If that’s
easy, do it with your eyes closed. If
that’s also easy, stand on a pillow,
which is a mushier surface that
makes it more challenging. If
that’s easy, too, try it with your
eyes closed.
DiNubile also recommends the
yoga “tree” pose. “With your eyes
closed, stand up with your arms
straight out to the side and put the
heel of one foot to the inner side of
the knee so it looks like a letter P,”
he explains. “On the good leg, they
might be able to do it, hold it and
have no problem. On the bad side,
they’ll be wobbling all over the
place, ready to go over. If they
can’t do it with their eyes open, I
have them look in a mirror. Then,
I have them do it without a mirror,
then with their eyes closed.”
Finally, experts suggest per-
forming agility drills. These in-
volve such maneuvers as side-to-
side shuffling, backward walking
or running, figure-eight running,
and cone drills that involve run-
ning in a “box” shape or around
cones. Start with wide loops and
progress to tighter loops as the
ankle gets stronger.
If you are diligent about
strengthening that ankle after the
first sprain, you reduce your
chances of having another, DiNu-
bile says.
“An injury like an ankle sprain
can really compromise your prop-
rioception,” DiNubile says. “But
the good thing is that it can come
back.”
[email protected]The right exercises can help to avoid repeated sprains on the same ankle
ISTOCK
Once you’ve sprained an ankle, you are inclined to sprain it again.“I have always believedthat ankle sprains arethe most undertreatedinjury seen in theemergency room.”
Sheldon Laps, podiatrist“Immobilizationactually causesdeterioration in thejoints.”
A. Lynn Millar, physical therapist