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Osteoarthritis and joint pain

Osteoarthritis pain does not always match what X-rays show, and joint replacement is not the only option — nor always the right one. Exercise and strength work are the foundation; targeted nerve procedures can reduce joint pain for people waiting for surgery, unsuitable for it, or still in pain after it.

Osteoarthritis is the most common joint disease, and the most common source of confusion about it is the X-ray. Joints that look severe can hurt little; joints that look mild can hurt a lot. Pain — not the picture — is what limits lives, and pain is what treatment should target.

The foundation is not procedural. The strongest evidence in osteoarthritis belongs to unglamorous things: graded exercise and strength work, weight management where relevant, activity pacing and education. These are first-line in every major guideline, they reduce pain as well as improving function, and nothing offered here replaces them. The role of a pain specialist is what to add when the foundation is not enough.

When the joint's nerves become the target. Joints signal pain through identifiable nerves, and those nerves can be blocked and treated. For the knee, genicular nerve blocks and radiofrequency can reduce osteoarthritis pain for months at a time — including pain that persists after knee replacement. For the hip, blocks and radiofrequency of the nerves supplying the joint offer similar logic, and for the shoulder, the suprascapular and axillary nerves are the targets. In each case a diagnostic block is commonly used first to establish whether those nerves are carrying the pain.

Who benefits most. Three groups, principally: people on long waiting lists for joint replacement who need the interim to be liveable; people for whom surgery is not appropriate — because of other health problems, age or preference; and people with persistent pain after a technically successful replacement, a recognised and frustrating outcome. For all three, reducing the pain signal can mean better sleep, more exercise — which itself treats the arthritis — and deferred or better-timed surgery.

Injections into the joint itself. Anti-inflammatory injections can settle a flared joint, with benefit that varies widely and is often measured in weeks to months. Platelet-rich plasma and hyaluronic acid are available in selected cases, with an honest caveat: the trial evidence is inconsistent, high-quality placebo-controlled studies — including Australian research in knee osteoarthritis — have found no benefit over placebo in some settings, and neither attracts a Medicare rebate. Dr Martin will tell you plainly whether he thinks either is worth your money in your situation.

When surgery is right. Joint replacement is an effective operation for the right joint at the right time, and part of good non-surgical care is saying when that time has come. Where it has, referral to an orthopaedic surgeon follows — with your pain properly characterised, which helps the surgical decision too.

Sources: Royal Australian College of General Practitioners — Guideline for the Management of Knee and Hip Osteoarthritis; Australian Commission on Safety and Quality in Health Care; Healthdirect Australia.