Your questions on osteoarthritis and rheumatoid arthritis

Q) I'm 86 and have had osteoarthritis for many years. This has worsened during the past five years, with me requiring a walking stick and now a tri-wheel walker. The worst side effect is that I can't go down slopes and am nervous even with the help of the walker, feeling that I will fall over. Initially I believed that this was a psychological reaction, but I was assured that it was a symptom of the condition. Is this correct, please, and is there anything I can do about it?

Robert, via email - 2013

A) People with osteoarthritis of joints in the legs commonly complain of nervousness and fear of falling. I think the cause of this is not straightforward, but a result of many factors, all of which can contribute. In some people, especially those who have already fallen, psychology does play a part and it takes some time and effort to get their confidence back. Other factors are more directly related to arthritis. Muscles controlling joints weaken, thus increasing the chance that the joint will give way. At the same time, the mechanisms that the joint uses to judge balance and position also fail, increasing the chance of a fall. And pain in the joint causes people to trip and fall, especially if it is sudden and severe. The good news is that all these factors can be controlled with treatment – with drugs to control pain and exercises to increase strength and mobility. Most physiotherapy departments will also have balance and walking classes that you can attend. And finally, doesn't that walker of yours have brakes? It certainly should do!

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) Is there a link between osteoarthritis and osteoporosis? If you have one of these conditions, is there more chance that you may get the other? My mother had both. I had a hysterectomy at the age of 47, and was on HRT for five years. I recently had a DEXA scan and found that I have a condition called osteopenia.

Angela, Swindon, Wiltshire - 2008

A) For a long time rheumatologists have believed that there's an inverse relationship between osteoarthritis and osteoporosis – that people are unlikely to have both conditions at the same time. In fact, it was thought that having osteoporosis is protective against developing osteoarthritis. Now the facts don't quite fit with this theory, although some of the evidence is still compelling. We see people in everyday practice who present with a new hip joint (replaced because of osteoarthritis) and now have a fracture in another bone and osteoporosis, just like your mother. Osteopenia is used to describe bones that have lost calcium, but not severely enough to call it osteoporosis. Usually both these conditions are diagnosed after a DEXA (bone density) scan, which gives a more precise estimate of the amount of calcium in the bones.

This answer was provided by Dr Philip Helliwell in 2008, and was correct at the time of publication.

Q) I have a Baker's cyst on my right knee because of osteoarthritis. What am I to expect? How long will it last? Will I need a new knee eventually? I’ve already had two hip replacements, so I use a crutch when I walk outside.

Rowena - 2017

A) A Baker's cyst is a swelling that can develop behind the knee. It's filled with synovial fluid, which is the lubricating fluid that's usually found inside the knee joint. It most commonly occurs if there's an underlying problem with your knee, such as osteoarthritis. A Baker’s cyst often causes no symptoms, but some people can experience pain, swelling and tightness behind the knee.

Having a Baker’s cyst doesn’t necessarily mean you'll need a knee replacement. Often it'll get better on its own and the swelling goes away over time. In a small minority of people, they can split open (rupture) and the fluid inside can leak out into the calf muscle, which causes swelling, redness and itching. If anything like this happens, you should get it checked out by your GP, as they'll need to make sure that the symptoms are due to the Baker’s cyst and not a deep vein thrombosis (DVT), which can cause similar symptoms, but needs treatment. However, most people with a Baker’s cyst won’t experience this.

Your focus should be on maintaining the health of the knee and managing any other symptoms of osteoarthritis. Keep the joint moving, stay active and try to keep to a healthy weight. If there's a lot of swelling in the knee, then sometimes a joint injection to take out the fluid and put in some steroid medication can help.

This answer was provided by Dr Tom Margham in 2017, and was correct at the time of publication.

Q) I'm getting desperate. I suffer from both osteoarthritis and rheumatoid arthritis. My greatest problem is osteoarthritis in my cervical spine. For about five years I've been in constant pain, night and day. My rheumatologist can only suggest exercises, heat, a collar and painkillers (co-codamol), all to little effect. I heard of someone who has Botox injections three times a month, which brings great relief. Could you advise me on this or any other treatment you think would be successful? I'm reaching the end of my tether.

Patricia, Altrincham, Cheshire - 2011

A) I'm sorry to hear about this. Constant pain in the neck is one of the worst types of pain and I know from personal experience how disabling it can be. I've given Botox injections for neck conditions, but only if significant muscle spasm is present – this is sometimes referred to as spasmodic torticollis. Botox works by (temporarily) paralysing the muscles. It's a drug derived from the bacteria that cause botulism, where widespread muscle paralysis can occur. It sounds worse than it is and these injections have now been introduced widely in medicine. You've probably heard of their use in plastic surgery. The paralysis isn't permanent, but can last for a good while. Often the injections have to be repeated to maintain their benefit. In your case, it would be advisable to seek an opinion from someone who administers these treatments. Other injections, such as selective nerve blocks, are also a possibility.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) I suffer from mild rheumatoid arthritis which fortunately doesn't stop me from doing anything I did before. But I've noticed that when I catch a cold, it seems to be worse than before I was diagnosed. Is this me being ultra-sensitive to my body or does rheumatoid arthritis actually make common ailments worse?

Roena, via email - 2015

A) With rheumatoid arthritis, you have what could be described as an overactive, but misdirected, immune system. It's doing its job, but in the wrong places – against your own body, rather than materials from outside your body that might be a threat to health.

It's true that people with rheumatoid arthritis are more prone to infections and, as you describe, it possibly makes minor infections worse. This is partly due to your immune system not working properly and also because of the effects of the drugs used to treat rheumatoid arthritis, which work by damping down the immune system.

One of the most important things you can do is get a flu jab each year and a pneumococcal vaccine (usually only required once) to help stop you picking up flu, which is the most common cause of pneumonia. These are both 'inactivated' vaccines, so are safe for people with rheumatoid arthritis. You can read more about this in our vaccination and arthritis information.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) I've suffered from dry eyes for a long time. I suffer from rheumatoid arthritis and had a hip replacement in 2000. I've tried all the remedies the NHS has to offer and have been on sulfasalazine and methotrexate for three years. Does rheumatoid arthritis contribute to dry eyes? Can you suggest a cure or anything to relieve the symptoms?

Gordon, Shetland - 2010

A) Dry eyes are a recognised feature (extra-articular manifestation) of rheumatoid arthritis. The rheumatoid process can cause damage to the cells that produce the moisture for the eyes and mouth. This is called Sjögren’s syndrome (Sjögren was the Swedish eye physician who described a condition that primarily affects the moisture producing cells in the eyes and mouth). At its most severe, this condition can lead to damage of the surface of the eye and visual impairment, so it's important to seek help. Mostly, lubricant eye drops are used, but sometimes surgical solutions are necessary. These include putting a plug in the duct that drains the tears away. Lubricants can also be used for the mouth and a tablet called pilocarpine may help both eyes and mouth.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) I'm 63 and have suffered from osteoarthritis for around 10 years. I've recently been diagnosed with chronic inflammatory arthritis, at which time my consultant also used the words rheumatoid arthritis. Although the blood markers were negative, which he said applied to around 30 per cent of sufferers, an MRI showed inflammation and degeneration around the joints of my hands. He's prescribed methotrexate and folic acid. Are these conditions the same? I'd like to refer to my condition correctly.

Nigel, Horsham, East Sussex - 2011

A) People can unfortunately get two different forms of arthritis. If possible, we like to keep the diagnoses made for any one person to a minimum. This is known as Occams Razor. William of Ockham was a logician and philosopher who introduced the 'law of parsimony'. Essentially this suggests: 'why use two explanations when one will do'. So, if one diagnosis can explain all your symptoms, then this is the preferred assumption, and it does simplify treatment. However, having said all that, people with osteoarthritis can develop other types of arthritis. Chronic inflammatory arthritis is just a generic term to describe the condition and how it differs from osteoarthritis. In such cases, drugs like methotrexate are used. Rheumatoid arthritis is one form of chronic inflammatory arthritis, but there are other types, such as psoriatic arthritis and gout. If it's not clear exactly what the underlying condition is, then rheumatologists will often just call it chronic inflammatory arthritis.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) My son suffers from a serious back injury he sustained while serving in the army. He's had several operations and was told that, in the future, he may well suffer from arthritis in his spine as a result.

Is there an area of the country that has a lower incidence of the condition, or does climate and the environment have no bearing?

Susan - 2018

A) I’m sorry to hear about your son’s injury. The risk of osteoarthritis in a joint is increased when you have a history of injury to that joint, including the spine. Moving to a different location with a different climate won’t alter the risk of developing osteoarthritis or slow the progression of the condition.

The debate around whether warm climates improve symptoms of osteoarthritis, such as stiffness and pain, continues. Warm weather may have a small impact on improving symptoms, but unfortunately it doesn’t stop you from getting the condition.

This answer was provided by Dr Tom Margham in 2018, and was correct at the time of publication.

Q) I’m a male aged 61 and have just developed what appears to be osteoarthritis in my right ankle. I was very active as a young man and suffered a lot of ankle injuries and so osteoarthritis is probable. I await an MRI scan to confirm the diagnosis.

I’m physically very active and it’ll be devastating if I have to give up my hobby of mountaineering. Before considering treatment options, could you tell me what treatments are presently being developed? And what are the probable timescales to bring such treatments into production?

I accept I may have to wait a few years for an effective cure, but I consider it’d be better to delay surgery for a year or two in favour of a cure. I’m aware of research into gene therapy and the use of drugs to stimulate cartilage regrowth, but I imagine there are other possible therapies being investigated.

Are there any digests of present research available online?

Simon, via email - 2015

A) It‘s likely that the injuries you sustained as a younger man have impacted on the pain you’re experiencing in your ankle now. It’s good that you're having an MRI to establish a full diagnosis for your problem. An MRI will identify problems in the bones, joint surface, ligaments and tendons around the ankle joint. This will help to guide your treatment options.

I presume that you’ve damaged the ligaments that support the ankle joint as well as the nerve fibres that provide feedback to your brain about the position of your ankle joint. While you’re waiting for new treatments to become available, the mainstay of treatment is a mix of:

• tretching to maintain full joint range of movement
• resistance exercises to increase the strength and stability of the muscles and tendons around the ankle
• work to improve the sense of balance in the joint (this is called proprioception).

Our exercises for foot pain may be useful for you.

Footwear is incredibly important, particularly if you’re mountaineering. Boots that support your ankle and support the arch of your foot are most suitable – balancing stiffness and support with flexibility.

You might also find that treatments such as steroid joint injections to your ankle joint may help manage symptoms if you’re having a flare-up of pain. Topical creams such as non-steroidal anti-inflammatory drugs (NSAIDs) or capsaicin (chilli extract) may also help to manage pain.

In response to your request for digests of present research I would point you in the direction of what we're funding.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) I was diagnosed with osteoarthritis in my spine about 15 years ago. In 2000, I had Guillain-Barre syndrome and was treated with immunoglobulin. For many years my symptoms improved (plus I hadn’t had any colds or infections until the last two years.) I'm wondering if the immunoglobulin helped to keep the osteoarthritis at bay and if it's known that it does, why it isn’t offered as a treatment?

Janine, Hampshire - 2011

A) Immunoglobulin is used for various rheumatic diseases. Generally it's used for the connective tissue diseases, such as lupus, dermatomyositis (inflammation of skin and muscles) and sometimes as ‘emergency’ treatment where drugs which suppress the immune system can't be used. It's not known exactly how it works but it's probably by several different mechanisms acting on the immune cells which are causing the problem. Although low-grade inflammation is seen in most joints affected by osteoarthritis it is, on the whole, a non-inflammatory problem and immunosuppressive drugs are seldom used. However, some people with osteoarthritis feel improved when they take drugs such as steroids (cortisone) and I think it's for a similar reason that you felt better after these drugs. I'm assuming, however, that steroids weren't part of your treatment regime when you had Guillain-Barre syndrome.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) I'm 56 and have suffered from osteoarthritis since my 20s. One hip was resurfaced six years ago. I keep active by going to the gym twice weekly but am rarely completely free of pain in various joints. A recent tooth abscess and two weeks of antibiotics seemed to have the most welcome side-effect. While taking the course I awoke and remained pain-free throughout the day. Is there a link between osteoarthritis and infection?

Gill, West Midlands - 2010

A) The short answer is no. In fact the only evidence of a link between osteoarthritis and infection is that joints in which an infection has occurred often become severely and prematurely damaged by osteoarthritis at some point after the infection has cleared. In your case it's fascinating to hear of your improvement. I wonder if the antibiotic you were taking has some other pain-relieving or anti-inflammatory property? Could the improvement have resulted from all the additional painkillers you were taking for the tooth abscess?

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) My partner has just been diagnosed with adult-onset Still’s disease at the age of 36. I’m told this condition is quite rare. Can you tell me how and in what way this is different to rheumatoid arthritis and whether the drugs he'll be taking will be the same as those used in rheumatoid arthritis?

Jennifer, Norfolk - 2007

A) This is an uncommon condition and it often takes time for doctors to make the diagnosis. Still’s disease (named after George Frederick Still, an English paediatrician) usually occurs in children. It causes arthritis, fever, rash and inflammation of internal organs such as the liver, spleen and heart. Rarely, a similar condition occurs in adults but more often, in my experience, causes arthritis (although less severe than rheumatoid arthritis), fever and internal inflammation. In both conditions treatment has been with steroids and methotrexate, both drugs used in rheumatoid arthritis. Also, good results have recently been reported with the newer biological drugs acting against the chemical known as tumour necrosis factor, an important cause of inflammation in these conditions.

This answer was provided by Dr Philip Helliwell in 2007, and was correct at the time of publication.

Q) As a patient with rheumatoid arthritis I found leflunomide very effective but unfortunately I do have history of bronchiesctasis. It had been stable for more than 40 years but leflunomide has changed that. The lung infections are under control again but I can l no longer use that drug. Which leaves a problem: what do I take?

Mr S W, Kempston, Bedford, Beds - 2013

A) You ask an impossible question. What you take next for your rheumatoid arthritis depends very much on what you have already taken, the state of your arthritis and the other medical problems you have, such as bronchiectasis. Unfortunately, bronchiectasis is more common in people with rheumatoid arthritis. Bronchiectasis is a condition where the lungs are damaged. In the past measles was a common cause of this condition. It leads to repeated lung infections and progressive breathlessness. Treatment with immunosuppressive drugs can make the infections more frequent, and with bronchiectasis, finding the right treatment can be a challenge. I have used rituximab without causing the lungs to deteriorate but this does not mean it will be the right drug for you. Everyone is different.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) I'm 61 and I've had rheumatoid arthritis in both my hands for about five years.

At first I was in complete denial and refused to go onto any sort of medication, which, looking back on it, was extremely foolish.  Since then I've been on several types of medication, including methotrexate. I lasted precisely 11 weeks on it before developing nausea and shortness of breath. I consequently got very frightened and came off it immediately.

For the past 18 months, I've been on sulfasalazine, which, although is keeping it at bay, isn't preventing the damage to my joints. I've had several flare-ups, which have rendered me almost immobile at times.

My rheumatologist is now trying to persuade me to try methotrexate again, this time by injection, or biological medication, which will also be by injection.

I've got to the stage where I feel like coming off all drugs, as I feel that I keep taking all this awful, toxic medication yet nothing is working. My left hand is constantly swollen and my right hand is extremely disfigured. I don’t have much pain, which is a good thing, but my main concern is that nothing is ‘stopping’ the damage to my joints. 

I know I'm lucky that it's only in my hands but it really can render me useless at times. I'm afraid to pick up my grandson for fear of dropping him.

I'm at a loss as to what to do for the best. I just want something that works.

Rhona, via email - 2015

A) I’m sorry to hear that things aren’t going well. I can completely understand your reluctance to retry the methotrexate given your previous experience. That said, the swelling and flare-ups you're describing are signs of active and ongoing inflammation and therefore joint damage. It’s very important that efforts are made to bring this under control as soon as possible. Effective treatment should slow and in many cases stop ongoing damage to your joints.

Many people are willing to accept the balance of taking potentially ‘toxic’ medication against the benefit of reducing inflammation, reducing symptoms and preventing joint damage. However, the frustrating thing is not knowing at the outset which drug is going to help. We’re engaged in research that will try and predict which drugs will work best for which patient.

Methotrexate given by injections can often cause fewer side-effects. Your rheumatologist or specialist nurse should advise you on ways to reduce them, for example increasing the dose very slowly and using folic acid supplements.

Biological therapies, which have also been suggested by your rheumatologist, have proven to be revolutionary for many people with rheumatoid arthritis and other types of inflammatory arthritis. Don’t discount these treatments as they may be a very effective option for you.

I wish you all the best in whatever decision you make.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) I would be very grateful for any information regarding the possible link between the contraceptive pill and rheumatoid arthritis. I have suffered from rheumatoid arthritis for nearly 40 years but it is relatively well-controlled with quadruple therapy including anti-TNF. I have two daughters in their 20s and I am very worried about the possibility of the contraceptive pill triggering RA. I read about this possible link over 35 years ago and immediately stopped taking the pill myself. Has any progress been made in research since then? I am very worried as both my daughters have recently started taking the pill. I feel terrible that I had not warned them of a possible risk.

June, via email - 2013

A) There is a strong link between hormones and arthritis, and that includes both osteoarthritis and rheumatoid arthritis. Women, of course, have such dramatic surges (pregnancy) and ebbs (the menopause) in hormone concentrations and this may explain the common occurrence of arthritis starting after pregnancy and the menopause. And it may be linked to the fact that rheumatoid arthritis is more common in women than men. In fact it is now thought that taking the contraceptive pill may be protective against developing rheumatoid arthritis, although reports are conflicting. The use of oral contraceptives may also reduce the severity of rheumatoid arthritis once it has developed. So I would not spend time worrying about your daughters.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) I was very interested in the article about palindromic rheumatism and felt that after 25 years of pain, disability and frustration I was finally reading something which explained my symptoms.

I had two years of flare-ups in my joints before getting a positive rheumatoid arthritis blood test. Over the years I've had longer term swelling in joints which have led to damage. However, the pain and pattern is totally different to the original flare-ups.

Over the years I've continued to suffer the flare-ups regularly while blood tests show the rheumatoid arthritis to be largely under control with methotrexate. I spoke to my nurse about a diagnosis of palindromic rheumatism, but she told me that you can't have both.

I understand that the treatments are the same, but I've become frustrated with the rheumatologist describing these flare-ups as if they're nothing more than moans about normal everyday pains suffered by the general population. Can you have both? Does palindromic rheumatism continue alongside rheumatoid arthritis or morph into it?

Susan, via email - 2015

A) Really interesting question, thank you. Palindromic rheumatism is a challenging condition to live with and to diagnose. But from what you describe in your email it does sound as though you currently have rheumatoid arthritis with flare-ups, rather than palindromic rheumatism.

It's true that a small proportion of people with palindromic rheumatism go on to develop rheumatoid arthritis and it may be that this is what you had originally, as more people with palindromic rheumatism who have positive rheumatoid factor blood tests go on to develop rheumatoid arthritis.

But it may also be true that you have had rheumatoid arthritis all along but that it took longer for your rheumatoid factor blood tests to come up positive. Current thinking is that palindromic rheumatism can morph into rheumatoid arthritis, but it doesn't seem to continue alongside it. That said, it's true to say there's a lot we don't know about palindromic rheumatism, so it's not beyond the realms of possibility that the two conditions can coexist.

One of the big differences between the two conditions is that you don't usually see joint damage in palindromic rheumatism.

The second point you raise seems to be more about the relationship with you rheumatology team. It's unfortunate that you feel your flare-ups are being treated as nothing more than everyday moans. It sounds like perhaps your rheumatoid arthritis isn't being well enough controlled by the treatment you're taking currently, so it's worth further discussion with your rheumatology team.

If you feel you are being dismissed unsatisfactorily then you're within your rights to ask for a second opinion from another rheumatologist.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.