Ask the Expert: What is the Normal Progression of OA?
Dear Dr. Krant:
I am a 55 year-old man who has had osteoarthritis in my feet for 17 years. During the last 3 years it has spread throughout my spine, skull to tailbone, in the shoulders/hips/knees and hands, and nodes on fingers. I also have some difficulty walking. Is this a normal progression, or an extreme variation?
You have had osteoarthritis for almost twenty years, beginning in your early 30s. Many people develop aches and pains in the large weight-bearing joints relatively early, even in their twenties. X-ray evidence of joint space narrowing, loose bodies and asymmetry throughout the weight-bearing surfaces usually does not appear until the 40s, although certain people will develop abnormalities early on. This is particularly true when cartilage has been surgically removed from the knees, when work involves repetitive lifting, bending and weight-bearing heavy loads, and when there is a genetic link to an affected parent.
Nodes on the fingers (called Heberden’s nodes abutting the fingernails, or Bouchard’s nodes in the middle knuckle) frequently occur in the late 20s and later, signifying only a tendency toward more generalized osteoarthritis. These nodes are generally silent (non-painful). On occasion, nodes contain inflammatory fluid, are somewhat gelatinous and quite tender. Such changes are referred to as inflammatory nodulosis, and the involved nodes are difficult to treat. Local injection with steroids and lidocaine is painful, and surgical removal does not prevent recurrence.
The pattern of joint involvement you describe is quite typical in advancing osteoarthritis. Pain and tenderness in the large weight-bearing joints (hips, knees and ankles) is frequently observed first, with eventual bony overgrowth and asymmetry. Warmth, fluid accumulation and swelling can occur, particularly when loose bodies accumulate and interfere with the normal mechanics of joint movement. People frequently report pain at the base of the thumbs (first carpometacarpal joint), along with wrist pain in advancing osteoarthritis. Stiffness in the spine, extending from the neck to the tailbone is also quite common, particularly when there is a past history of injury (traumatic fall, motor vehicle accident). Plain films almost always confirm the clinical suspicion of spinal involvement, with irregularity of the vertebral endplates, narrowing of the interveterbral spaces and occasional forward protrusion of one vertebral body (spondylolisthesis). Numbness and weakness in an extremity suggests the possibility of a herniated disc in the spine; when these features arise, physicians will often request an MRI, looking for disc herniation with nerve root compression.
In summary, the extent of osteoarthritis burden you describe fits well with the natural history of this condition, with diffuse disease extending from the neck to the lumbar spine, with small and large weight-bearing joint involvement. Remember to speak with your primary doctor to discuss the specifics of your case and treatment options.
Jonathan D. Krant, M.D., directs the teaching service in Rheumatology at Berkshire Medical Center in Pittsfield, Massachussetts. A busy clinician, he oversees the care of 6,000 patients and runs the clinical investigation unit at Berkshire Rheumatology Associates, where he is employed as a staff rheumatologist. He wrote about osteoarthritis for HealthCentral.