Joint Pain: Non-Operative Ways to Manage Discomfort

Whether it’s a sore shoulder, stiff knees, or aching hips, many people experience joint pain as they age. The root cause is often years of accumulated strain and our body being imbalanced over time.

“Poor mechanics can really take a toll on a joint,” says Dr. Elan Goldwaser, a pediatric and adult sports medicine physician at NewYork-Presbyterian and Columbia.“ To reverse the damage, you have to fix the issues that were causing them in the first place.”

The good news is, there are more tools than ever to treat joint pain — from physical therapy and holistic remedies to effective medications and cutting-edge injections. Health Matters spoke to Dr. Goldwaser about what causes joint pain, the most affected areas, and the wide range of non-operative treatments available.

What causes joint pain?

Joint pain is largely due to overloading a joint with improper mechanics. If you’re trying to muscle through an activity or improperly use a specific joint for a task, you can mount stress in that joint because you’re putting the mechanical forces in the wrong spot. That wear and tear over time can become inflammation and conditions like arthritis, and the damage causes pain.

Sometimes joint pain is unavoidable, like you fell skiing and hurt your knee. However, the principles for treatment are the same, whether it’s rehab, calming inflammation, or regenerative medicines.

What are the most common joints where people have pain?

If we’re not talking about rheumatic conditions (which tend to affect the smaller joints), the most common are the load-bearing, bigger joints — meaning the knees, the hips, the shoulder joints. Those sustain injury over the long term.

How is joint pain diagnosed?

X-rays are the best way of diagnosing and quantifying the arthritis. MRIs show us the degree of inflammation inside the joint, not just the level of arthritis.

But everybody’s different, and you have to take into account the level of debility the patient has. Genetics is far and away the most important factor in determining how bad somebody’s pain will be. I’ve seen patients come in with rip-roaring bone-on-bone arthritis and they just have a little achiness. Then I see people come in and there’s very minimal degenerative change, and they’re in agony.

What are the non-surgical treatment options for joint pain?

There are many different tools in our toolbox. For my patients, I usually start off slow and conservative and build in intensity depending on the level of pain.

Physical Therapy: The best way to treat joint pain is to fix the underlying improper forces. Physical therapy (PT) helps bolster up the musculoskeletal structure, so you’re better aligned. Biomechanical forces are better withstood through different areas of a joint, and so alignment is a big factor in preventing joint pains. I hand out PT prescriptions to probably 90% of my patients, because PT at its core is the best way to correct a chronic biomechanical condition when there is no initial trauma to the area and is extremely beneficial for recovery after injury. PT is also critical for patients who are treating their pain with an injection.

It takes roughly four to six weeks of PT before you start to notice the gains, just like with anyone starting a work-out program. PT is a more focused form of personal training with someone with a degree and background in medicine.

Holistic Therapies: Vitamin D is fantastic. It acts almost like a hormone, with implications on not just bone health, but on tendon/ligament/connective tissue strength, muscle health, digestion, mood regulation, immunity, and so many other positive effects on the body. I always recommend everybody takes Vitamin D, it’s safe for all ages of all ages.

There is also evidence to show that supplements like turmeric and garlic have anti-inflammatory properties.

Supplements can help a lot of patients but always consult a doctor before you start taking them because they’re not FDA regulated.

Creams: If it’s a joint that’s more superficial and closer to the surface — like your wrist or ankle joint — a topical cream can provide some relief. There are many different kinds, including over-the-counter creams, anti-inflammatory gels, and herbal remedies, such as arnica gel and capsaicin creams which contain ingredients like chili pepper powder or tree bark or plants.

Medication: Medications to treat joint pain can include nonsteroidal anti-inflammatory drugs (NSAID) like ibuprofen (Advil, Motrin) and naproxen (Aleve), and acetaminophen (Tylenol). For patients with kidney issues who can’t take ibuprofen, Suzetrigine (Journavx) is a new non-opiate, pain-blocking medication that’s a step beyond Tylenol, but not quite at the level of other opiates. Patients respond better to some medications more than others, and I usually follow the patient’s lead in a thoughtful approach as to which one gives them the most relief.

Injections: With advances in science and better understanding of the biomechanical principles of what causes pain and inflammation inside joints, we have a range of injections we can use and many more coming down the pipe:

• Prolotherapy: The scientific principle with prolotherapy has been around for hundreds of years — you inject a substance into the joint that causes inflammation, and the body starts a healing response. Prolotherapy is the most basic injection, and it’s very gentle on the joint. The solution is often composed of sugar water (or dextrose and saline). Recent studies have shown that injecting a prolotherapy solutions month-by-month can produce a healing and a mild regenerative effect over time.
  
• Cortisone: Cortisone shots are commonly used, whether it’s athletes or people with arthritis. If a patient is in in tremendous pain, cortisone can be a great fire extinguisher. But it can weaken and degrade joints, so we have to be sparing with when and how often we use cortisone. The general rule of thumb is that cortisone shots should be spaced roughly 3-4 months apart when injecting the same joint. There are studies showing that joints can wear down when done in a tighter time interval than that over a couple years.
  
• Gel shots: These are also known as viscosupplementation or hyaluronic acid injections, and the substance is the same material that’s put into face moisturizers or fillers. It’s a very viscous substance material that can smooth over the lining of the cartilage. It carries a “cooling,” effect and can act as a lubricant on the joint to address stiffness and pain. The injections come as a single shot, or in a series, and people could potentially have relief for about six months on average (versus three months on average from a cortisone shot). The main problem with gel shots is that you can’t predict who they will work for.
  
• Platelet-rich plasma injection (PRP): With PRP, we draw blood from the patient, spin it down in a centrifuge, and extract the plasma layer from the blood. The plasma layer (also called the buffy coat layer) contains white blood cells, platelets, and proteins that signal the body to start the healing process. When you inject it into a joint, it superglues itself into areas of damage and inflammation. It acts like scaffolding, where proteins and growth factors can deploy and work to heal damage, similar to a construction crew working on the scaffolding on the side of a building.
  
  PRP has been cleared by the FDA for use in orthopedics for about 50 years, but it still has not achieved the full FDA approval. We now have larger studies that show that people with mild arthritic changes can get upwards of a year of relief with a single PRP injection, which is double the length of the hyaluronic acid or four times the length of a standard cortisone shot. Soft tissue injuries can be healed through the use of PRP.
  
• Microfragmented fat (mFat) / Bone Marrow Aspirate Concentrate (BMAC): I call this the last stop on the train to surgery.  If PRP is analogous to laying a fertilizer bed down in a joint space, using these materials would be considered the seeds. Microfragmented fat injections (or “adipose-derived mesenchymal signaling cells”) and BMAC are the pinnacle of FDA-cleared regenerative medicine treatments. You are injecting stem cells directly into the joint space to not just attempt to heal it, but more robustly reinforce it so it doesn’t break down in the future. These are excellent medium-to-long-term injection options.
  
  mFat and BMAC can be composed of a variety of different growth factors, proteins (like exosomes), and cells (like adipocytes or progenitor cells), all aimed to promote healing.  These products do contain Hematopoietic Stem Cells (HSCs) or Mesenchymal Stem Cells), but evidence shows stem cells are often not the only player in the healing process, and that there is a deep interplay between all the different components being injected to create what’s called an ‘immunomodulatory cascade’ for cellular migration to the injured area to start a healing response.  Basically, when injected, it’s like opening up a Lego set of healing materials into a joint space for the body to put together.
  
  While these methods are relatively new in the orthopedic literature, evidence is excellent for improved pain and function in medium- and long-term studies, as well as return to prior level of activity and faster than other interventional methods for most injury recoveries.

When should someone with joint pain consider surgery?

Surgery, I tell everybody, is a last resort. I always tell patients that surgery is reserved for when we can’t control their pain and restore their function. All these different injection options fill the orthopedic treatment gap between conservative measures and surgical ones. The list of available interventional options continues to grow, and it’s important to discuss these with a responsible medical professional who is well-versed in this new and exciting field of interventional orthopedics.