MYTH: Having arthritis means guaranteed pain and decline over time. It's the beginning of the end!

Age related joint changes and arthritis are not the same thing. Just because your joints show signs of ageing, that does not guarantee that this will be painful - think of it like wrinkles on the inside.  

Arthritis specifically refers to when a joint is also inflamed and therefore painful, which is not guaranteed with joint changes alone. It is important to remember that because we are humans, and not objects, our joints are able to continue to adapt over time, even as we age - they do not simply ‘wear out’ over time (Anderson & Loeser, 2010). It is possible to be diagnosed with arthritis and never develop any further symptoms from it - it is not guaranteed to get worse. 

MYTH: High impact exercise like running and jumping causes arthritis 

This is a common misconception and so far has not been proven. Joint damage is a predictor of developing joint arthritis, for example tearing a meniscus or rupturing an ACL (Anderson & Loeser, 2010). General exercise, however, even more intense forms of exercise, do not specifically cause joint damage and therefore are not predictors of arthritis.  

Observational data on runners shows that recreational runners have lower rates of osteoarthritis than people who don't run (Dhillon et al., 2023). Of those who have arthritis and are runners, less runners progress to needing knee replacements than non-runners. Observational studies checking the progression of pre-existing joint conditions such as meniscus tears or cartilage damage in marathon runners show that there is no progression of these conditions over the course of training for a marathon (Dhillon et al., 2023). 

MYTH: Arthritis is wear and tear 

The idea that arthritis is 'wear and tear' of the joints is also not entirely accurate. In fact, it is thought that arthritic joints are actually working extra hard to repair themselves, and going overboard (Arthritis.org).

Arthritis is more recently being thought of more as a problem relating to the entire joint, meaning it affects the soft tissues surrounding the joint as well as the joint itself. It is thought that the main contributor to developing symptomatic osteoarthritis is the presence of chronic low grade inflammation, which can be exacerbated by both modifiable and non-modifiable factors (Terkawi et al., 2022). That is, you can reduce inflammation with a healthy diet, reducing alcohol and smoking, and doing regular exercise; however this is only part of the picture and some health conditions or genetic profiles are more predisposed to higher levels of inflammation. Current research suggests the contribution of genetics to the development of arthritis is at least 50% (Spector & MacGregor, 2004).

Again this is important to know, as people are often discouraged to continue movement and exercise, fearing that it will further wear out the joint. Conversely, exercise is a way to reduce inflammation in the long term. 

MYTH: Severity on imaging predicts symptoms 

There is absolutely a place for imaging in the management of arthritis, particularly to monitor a joint over time, however research indicates that symptoms only match imaging findings some of the time. A systematic review found that people with arthritis visible on an x-ray had pain between 15-81% of the time, showing just how unpredictable the relationship between imaging and symptoms can be (Bedson & Croft, 2008). Best practice guidelines suggest that imaging should not be used in isolation, and rather a combination of imaging findings alongside clinical presentation is necessary when determining a management plan (Anderson & Loeser, 2010).

No two people are the same, and so it is important to recognise that a particular severity of arthritis on imaging does not directly match to what treatment is likely to be needed. 

MYTH: Once you have “bone on bone” the only option is surgery 

This ties in to the point made in the prior paragraph. Though it may sound as though if you have 'bone on bone' there is no way forward, the human body is actually quite incredible and not everyone with bone on bone experiences severe symptoms.

In our classes, for example, there are a number of people who have been told they have bone on bone in their knees. They were told this at ages varying between 40 and 70. Their symptoms range from mild stiffness and occasional discomfort; to moderate stiffness and regular discomfort; to severe pain and significant discomfort. Treatments have varied from exercise, to arthroscopies, to joint injections, to surgery. The outcomes of each have also been diverse.  

It is not possible to predict one’s experience or future experience through another person’s, as there are so many factors influencing how each of us experience the same diagnosis. The language used by doctors and other clinicians can have a huge impact on patient perceptions and choices and as such i personally believe we should be very careful about the language we use - i personally try to stick with "normal joint related changes", "a little less cushioning than before", or "wrinkles on the inside" as opposed to saying things like bone on bone. 

Beliefs can significantly impact treatment trajectories, which is why the language around these sorts of things is so important. For example, someone with 'bone on bone' who believes surgery is the only option for them may be more likely to go straight to that option, without trying anything else. Someone who hates the idea of surgery and has a favourable history with exercise might be more inclined to try exercising as a way to manage their diagnosis. 

A large review of people with hip and knee osteoarthritis found that willingness to undergo surgery was the biggest predictor of one progressing to that option (Gustafsson et al., 2024). The same review also found that it was possible to delay or avoid joint replacement surgery all together for some people by taking part in a non-operative management plan consisting of lifestyle modifications and exercise. 

MYTH: Knee arthroscopies help clean out the joint and slow down joint damage 

Degenerative meniscus tears are very common. It has been explained to me by an orthopaedic surgeon to consider the meniscus like cushioning in a shoe. It gets thinner over time and may tear a little at the edges but it still works as a cushion and protects your foot from the ground. That is a great way, i believe, to think of our menisci over time. Once we are over 40, they will be a little thinner and a little less robust, but they can still do their job just fine. Going in and cutting it away causes trauma to the joint, and we know now that any joint trauma is likely to increase rates of arthritis later on. 

This was demonstrated in this study comparing arthroscopy surgery to sham surgery (as in they went in with surgical probes but didn’t actually do anything), which found that outcomes in the short term for arthroscopy vs. non-operative management was the about the same, but that rates of arthritis were higher in the knees that actually underwent surgery 5 years later (Sihvonen et al., 2020).  

I find myself saying often at work that things WILL get better if you just wait long enough (in most cases). Meniscus tears can be incredibly slow, but if you just wait it out, they generally get better on their own, it is just a matter of maintaining strength and function while they do. When i say 'get better', I mean the symptoms are likely to diminish; the tears don't generally heal on imaging. Again, the human body is great like this, there are likely lots of imperfections throughout your body that you are blissfully unaware of that don't hurt, so you don't know about them. 

TRUTH: For some people, joint replacements are the best option

Even if you do everything right, unfortunately, sometimes joint pathology progresses to the extent that means joint replacement is the best option. While it is probably not advisable to jump straight to this as a treatment option without trying any non-operative strategies first, it is important to recognise that for some people, this is a viable and successful option. Joint replacement surgeries are most common in the hip and knee. 

What can you do to help manage your symptoms of osteoarthritis? 

Generally, exercise helps to maintain joint health by maintaining movement, and the more global effects of exercise on health markers are likely to have a positive impact on arthritis. Exercise also helps with maintaining overall function and ability.

Exercise is the main treatment we suggest for those with osteoarthritis, and we do specialised programs for our patients with hip and knee arthritis that focus more on these areas, while also including general full body strength and bone density maintenance. Lifestyle factors can also play a significant role.

If you are interested in having an assessment to start regular exercise & have some tailored lifestyle advice to help manage your osteoarthritis, book an initial physiotherapy consultation here. 

References:

Anderson, S, Loeser RF. Why is osteoarthritis an age-related disease? Best Pract Res Clin Rheumatol. 2010 Feb;24(1):15-26. doi: 10.1016/j.berh.2009.08.006. PMID: 20129196; PMCID: PMC2818253. https://pmc.ncbi.nlm.nih.gov/articles/PMC2818253/

Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008 Sep 2;9:116. doi: 10.1186/1471-2474-9-116. PMID: 18764949; PMCID: PMC2542996. https://pmc.ncbi.nlm.nih.gov/articles/PMC2542996/

Dhillon J, Kraeutler MJ, Belk JW, Scillia AJ, McCarty EC, Ansah-Twum JK, McCulloch PC. Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-up. Orthop J Sports Med. 2023 Mar 1;11(3):23259671231152900. doi: 10.1177/23259671231152900. PMID: 36875337; PMCID: PMC9983113.

Gustafsson K, Cronström A, Rolfson O, Ageberg E, Jönsson T. Responders to first-line osteoarthritis treatment had reduced frequency of hip and knee joint replacements within 5 years: an observational register-based study of 44,311 patients. Acta Orthop. 2024 Jul 15;95:373-379. doi: 10.2340/17453674.2024.41011. PMID: 39007806; PMCID: PMC11249020.

Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Kalske J, Nurmi H, Kumm J, Sillanpää N, Kiekara T, Turkiewicz A, Toivonen P, Englund M, Taimela S, Järvinen TLN; FIDELITY (Finnish Degenerative Meniscus Lesion Study) Investigators. Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial. Br J Sports Med. 2020 Nov;54(22):1332-1339. doi: 10.1136/bjsports-2020-102813. Epub 2020 Aug 27. PMID: 32855201; PMCID: PMC7606577.

Terkawi MA, Ebata T, Yokota S, Takahashi D, Endo T, Matsumae G, Shimizu T, Kadoya K, Iwasaki N. Low-Grade Inflammation in the Pathogenesis of Osteoarthritis: Cellular and Molecular Mechanisms and Strategies for Future Therapeutic Intervention. Biomedicines. 2022 May 10;10(5):1109. doi: 10.3390/biomedicines10051109. PMID: 35625846; PMCID: PMC9139060.

Tim D. Spector, T, MacGregor, A. Risk factors for osteoarthritis: genetics11Supported by Procter & Gamble Pharmaceuticals, Mason, OH, Osteoarthritis and Cartilage,Volume 12, Supplement, 2004, Pages 39-44, ISSN 1063-4584, https://doi.org/10.1016/j.joca.2003.09.005.