HOW CAN X-RAY HELP DIAGNOSE ARTHRITIS?

According to the Arthritis Society of Canada, one in five Canadians live with arthritis every day. The term arthritis applies to over 100 diseases, which most often cause inflammation in the joints. Inflammation is redness and swelling which can cause pain and stiffness in the joints.

There are two main categories of arthritis conditions:

1. Osteoarthritis (OA) – This is the most common form of arthritis. It’s a disease of the whole joint that leads to the breakdown of joint cartilage and the underlying bone. In normal joints, cartilage – the tough elastic material that covers and protects the ends of bones – acts as a cushion and provides a smooth, gliding surface for joint motion. OA causes the cartilage to break down and over time, the cartilage wears away and bone rubs against bone.
2. Inflammatory arthritis – This category of arthritis includes everything except OA. For these conditions, the source of joint damage is from inflammation rather than deterioration of cartilage. Most conditions in this category are autoimmune diseases, where the immune system attacks normal joint lining.

For both categories of arthritis, the symptoms can include the following:

• Catching or locking of joint during movement.
• Decreased mobility in joints or spine.
• Joint pain or stiffness.
• Swelling, which can occur in the mornings or after activities.
• Tenderness and reddening of skin around a joint.

OA usually progresses slowly over months or years and early symptoms tend to come and go. It commonly affects the knees, hips, first toes, wrists, thumbs, fingers, and spine. As damage progresses, symptoms can become more constant, occurring at rest and disturbing sleep.

WHAT SIGNS OF ARTHRITIS CAN BE SEEN ON X-RAY?

Osteoarthritis is usually diagnosed through a clinical assessment based on your symptoms and a physical examination. X-ray may be ordered to confirm the diagnosis and establish the severity of your OA. For suspected inflammatory arthritis, you will be referred to a rheumatologist, but X-ray may also be ordered to look for signs of OA or to monitor the progression of the disease.

X-ray is often the first step for imaging to investigate arthritis because its inexpensive and readily accessible. On the X-ray image, the radiologist will look for:

• Bone damage, such as erosions.
• Bony growths called bone spurs or osteophytes.
• Cysts, fluid-filled spots that form in bone.
• Narrowing of the joint space, which occurs when the cartilage degrades and the bones in the joint get closer together.
• Thickening and hardening of the bone underneath the cartilage in a joint, called subchondral sclerosis.

Magnetic resonance imaging (MRI) may also be ordered when investigating arthritis. MRI can help provide information about cartilage, tendons, and other structures in the joint, as well as showing the presence of swelling caused by too much fluid in your tissue (edema).

WHAT ARE THE TREATMENT OPTIONS FOR ARTHRITIS?

For osteoarthritis, treatment options can vary depending on the stage of progression of the disease. Bracing and wraps to ensure joint stability may help at any stage. In the early stages, weight loss and exercise may be recommended to slow the progression of the disease, and oral nonsteriodal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen, may be ordered to help relieve pain and inflammation. Other options include:

• nSTRIDE autologous protein solution (APS) can help treat mild-moderate OA (stage 2-3) in the knee. The treatment involves a single injection of a protein liquid derived from your own blood. It’s drawn from an arm vein prior to the injection and centrifuged to remove unwanted blood components and then spun again to obtain the protein liquid. APS has proven to be a safe and effective treatment, which has been shown to reduce pain and protect cartilage by reducing further destruction. As a result, there is a decrease in pain and an improvement in joint function, often within a few weeks of the injection.
• Steroid injections may be an option for moderate OA (stage 3) where the bones show damage and the space between the bones begins to narrow. The procedure locally introduces a corticosteroid (an anti-inflammatory medication) to decrease inflammation and reduce pain. A small dose of steroids is injected into the joint under image guidance to keep potential side effects to a minimum. Results can last from weeks to months depending on the joint involved, severity of the arthritis, and the specific cause of pain. Some patients get complete relief after a single injection. Unfortunately, steroids may become less effective with repeated injections and may have effects on the rest of your body over time.
• Narcotics may be prescribed on a short-term basis to treat moderate to severe pain for stage 3 OA, but they are not recommended for long-term use due to the risk of increased tolerance and possible dependence. Side effects of these medicines include nausea, sleepiness, and fatigue.
• Viscosupplement injections may also be a treatment option for stages 2-4 OA. This procedure involves the injection of hyaluronic acid (HA) – a viscose substance normally present in healthy joints but decreased in OA. When injected into affected joints, these gel-like substances improve mobility, reduce pain, and lubricate the joint. They also have a mild anti-inflammatory effect. They are best performed under image guidance to ensure the solution is delivered exactly where you need it. The relief may take a few weeks. Occasionally, patients may experience a post-injection flare after HA with increased pain and stiffness. This could be due to the viscosity of the injection and settles with oral anti-inflammatories or a subsequent steroid injection.
• Surgery may be an option for severe OA (stage 4), such as joint fusion or, more commonly, joint replacement surgery. Steroid or HA injections may provide temporary symptom relief for patients awaiting surgery or can help manage symptoms longer term for those who decide against or cannot have surgery.

For inflammatory arthritis conditions, some of the initial treatment options are similar to those for OA, such as exercise and weight loss or diet changes. Other treatments can include anti-rheumatic and anti-inflammatory medication, as well as cortiocosteriod injections.

Arthritis conditions are chronic (long-term) and, although there is no cure, treatment can help reduce your symptoms and make it possible for you to lead a full and active life. Studies suggest treatment in early stages of the disease is the most effective way to prevent progression. In most cases, you can manage mild to moderate arthritis symptoms for many years with a treatment plan. It’s also important to thoroughly discuss all your options with your health care practitioner, especially in the later stages of the disease.

For more information on pain management injections, please speak to your health care practitioner.

REFERENCES

Arthritis Society Canada (2023) “What is arthritis?” www.arthritis.ca. Accessed July 12, 2023.

Bennington-Castro, J. (2023) “What Is Osteoarthritis? Symptoms, Causes, Diagnosis, Treatment, and Prevention.” www.everyday.health. Accessed July 12, 2023.

Frank, J. (2021) “Rheumatoid Arthritis (RA) Diagnosis.” www.arthritis-health.com. Accessed July 12, 2023.

Holland, K. (2023) “Stages of Osteoarthritis (OA) of the Knee.” www.healthline.com. Accessed July 12, 2023.

Johns Hopkins Arthritis Centre (2023) “Osteoarthritis: Signs and Symptoms.” www.hopkinsarthritis.org. Accessed July 12, 2023.