Ask the Doctors July 2011 Issue

Ask The Doctors: July 2011

I have rheumatoid arthritis. Although I’m fine when I go to bed, I always wake up extremely stiff. In fact, unless I go through a stretching routine for several minutes, I find I can hardly walk. What causes morning stiffness?

Morning stiffness is characteristic of patients with rheumatoid arthritis (RA). Some patients can be stiff for hours, even all day. The physiology of the stiffness is not entirely clear, but it is related to inflammation in the body’s soft tissues and joints, which may cause a feeling of tightness. If you have morning stiffness that persists for more than 30 minutes, it is usually a sign of joint inflammation (synovitis), especially when there is also swelling. The treatment is to use drugs that are commonly prescribed for RA. These include nonsteroidal anti-inflammatory drugs (NSAIDs), over-the-counter drugs such as Aleve and Advil, or prescription medications such as plaquenil, methotrexate, sulfasalazine, and leflunomide. For patients with persisting synovitis after these other medications, biologics (Enbrel, Humira, Remicade, Orencia) are recommended. These drugs all have side effects, so their use should be carefully monitored.



I have end-stage osteoarthritis in my right knee and am facing the prospect of a total knee replacement. I’m not eager to undergo surgery. How long can I postpone the operation without compromising its success?

Total knee replacement is elective surgery. With few exceptions, it is usually not urgent and can be scheduled around important life events. Occasionally, excessive delays can result in the loss of bone and tendon tissue, which can compromise the quality of the surgery and its results. Some studies have shown that patients with the worst function and pain at the time of surgery had comparatively worse function two years after surgery, and that performing knee replacement earlier in the course of functional decline may be associated with a more positive outcome. Better overall physical fitness will allow quicker recuperation and return to activity after surgery. Patients typically have the procedure when pain prevents them from taking part in activities they used to enjoy. When the basic activities of daily life—walking, shopping, or recreational pastimes—are inhibited by knee pain, it may be time to consider surgery.



I’ve had osteoarthritis in my lower spine for several years. I also have a heart condition. Are cortisone shots advisable?


Cortisone injections in the spine are usually given for two reasons. The first is spinal stenosis, a condition in which the nerves are compressed by bones, ligaments, and disc material. The second is for osteoarthritis (OA) of the facet joints—the joints that join each vertebral body together. These types of injections do not cause heart problems, other than the stress that having the shots might have on the heart.


My doctor says I have degenerative changes in my spine. What does that mean—is it arthritis?


Degenerative changes in the spine often refer to those that cause loss of normal structure or function. The intervertebral disk is one structure prone to degenerative change associated with the wear and tear that comes with aging. As we grow older, our intervertebral disks lose their flexibility, elasticity, and shock-absorbing characteristics. The fibrous outer portion of the disk becomes brittle and prone to tearing. At the same time, the soft gel-like center of the disk starts to dry out and shrink. The combination of damage to the intervertebral disks, the development of bone spurs, and the gradual thickening of the ligaments that support the spine can all contribute to degenerative arthritis of the spine.