“I could sit maybe five minutes at the most,” says the 64-year-old Akron resident. “Then I’d have to get up and walk around.”
The retired speech language pathologist had tried gel injections in her knees, but improvements only lasted a few months. Pascu-Godwin also considered joint replacements, but the surgery, hospital stay, physical therapy and six-week recovery time made her wary.
So in July 2016, she opted for an outpatient procedure for her knees called bone marrow concentrate, which uses stem cells to help repair the damaged joint cartilage.
During the 1 1/2- to two-hour procedure, doctors extract bone marrow from the back of the hip to obtain the mesenchymal stem cells, which are separated and concentrated in the lab.
“Once they’re concentrated, they’re then injected into the exact areas that are injured to promote healing and regrow tissue,” says Dr. Melissa Tabor, an orthopedic sports medicine specialist at Regen Orthopedics.
To ensure precision — and because stem cells tend to stay in one place in the body — doctors use musculoskeletal ultrasound to pinpoint the injection sites.
With arthritis, for example, the cells are placed into the joint, around the capsule, the ligament and maybe even the tendon if an ultrasound spots micro-tears.
“Our belief is the whole joint needs to be stabilized, especially for arthritis, in order to help the pain,” Tabor says. “That’s been very successful for us.”
Pascu-Godwin’s chronic pain disappeared the same day as the procedure — even in her right knee, where the cartilage had almost entirely broken down and created bone-on-bone friction.
Months later, she gushes that she’s still feeling great. “My outcome far exceeded my expectations,” she says.
Although stem cell injections are still considered an experimental treatment for joint pain, it’s an emerging option for millions of Americans.
In 2006, a National Health Interview Survey found that approximately 30 percent of American adults reported having joint pain or stiffness in the preceding 30 days.
Osteoarthritis, a condition where joint cartilage degenerates, is a leading cause of achy knees, hips, shoulders or fingers. Yet people can develop joint pain for many reasons: a sports injury, a congenital condition or even just movement repetition. Although it’s normal for joints to incur wear and tear as people age, pain can strike at any time.
Zeroing in on the causes of joint pain is a crucial part of determining a treatment plan, says Dr. Robert Molloy, director of adult reconstruction in the department of orthopedic surgery at the Cleveland Clinic, which performs between 500 and 600 hip and knee replacements a year.
Knee pain might be tendonitis, for example, or it might be pain “referred” from the hip joint. “That’s where history and the physical exam are really critical to diagnosis,” he explains, “so that you know you’re treating the right problem.”
Once doctors know the underlying cause of the joint pain, they have myriad treatment options. In some cases, such as a torn anterior cruciate ligament or when knee cartilage has broken down so severely from arthritis that bones are rubbing together, the answer may be obvious: surgery. For other patients, the best treatment plan isn’t so cut and stitch.
“Everybody’s looking for the magic bullet,” says Dr. Kermit Fox, director of outpatient physical medicine and rehab at MetroHealth Medical Center.
But that’s the case for only about 10 to 20 percent of cases, he says. “For the rest of us, these are conditions that there is no quick fix,” he says. “It does take a multipronged approach.”
Physical therapy to increase flexibility and core strength, for example, is often paired with more involved treatment, including weight loss.
“For every one pound of body weight that someone is able to lose, on average, they’ll take about five pounds of pressure off of their hip with every step, just simply walking,” says Dr. Albert Dunn, an orthopedic surgeon at Chardon-based Precision Orthopaedic Specialties.
In fall 2016, Dunn also started having patients use a relatively new hip brace to combat pain from moderate arthritis. The device, which requires a fitting from a bracing specialist, resembles bicycle shorts with a series of compression straps that wrap around the pelvis at the thigh.
“It’s pretty low profile,” Dunn says. “You can wear it underneath normal pants.”
While pilot studies have produced positive results, it’s only a stopgap.
“The bracing buys you time,” he says. “Arthritis is a progressive disease. It will always progress, regardless of what we do.”
SHOTS AND MEDS
The unique nature of joint pain also poses challenges for doctors.
“What we found is the longer people have pain in a joint, the more the pain changes,” Fox says. “Different nerves start sending different signals. Medicines that normally work for acute pain and immediate pain don’t work so well in this chronic pain and vice versa.”
Some evidence shows membrane stabilizers such as Lyrica or Cymbalta, medicines often advertised as a treatment for fibromyalgia, can be an effective solution for chronic arthritic conditions.
Nonsteroidal anti-inflammatory drugs and cortical steroid injections are more common ways to combat joint pain, although these have their downsides. Prolonged use of certain anti-inflammatory drugs needs to be closely monitored by a doctor, since they can cause cardiovascular complications, while ongoing use of steroid shots can have unwanted side effects.
For some, these injections cease being effective. People who have undergone joint replacement surgery may not be a good candidate for shots in their joints, due to concerns over the hardware becoming infected.
In the latter case, a nonsteroidal option called radio frequency ablation, which uses heat to “knock out certain pain fibers to some of the joints in the spine,” says Fox, could be a boon.
By applying this same ablation technique to nerves connected to knee joints, he’s had some success in reducing pain.
“It’s been particularly helpful for the small percentage of patients who’ve had knee replacements and still have pain,” he says.
SURGERY
When treatment options have been exhausted to alleviate pain, surgical procedures such as joint replacement may be necessary.
“The Holy Grail for us is always to try and avoid joint replacement surgery,” says Dr. Michael Salata, director of University Hospitals’ Joint Preservation & Cartilage Restoration Center. “This has been an ongoing process throughout the history of orthopedics to try and figure out things that we can do from a biologic standpoint to avoid putting metal and plastic into people.”
Complications such as infection and the limited lifespan of artificial mechanical joints can be potential surgical downsides. Due to such risks and because of an aging population that’s remaining more active longer, doctors are increasingly turning to preventative care to delay joint pain or even slow degeneration before it begins.
“Joint preservation is a term you’re going to be hearing more and more in the future,” Fox says. “We’re trying to intervene earlier to preserve the cartilage, preserve whatever function we can in the joints, and stave off that wear and tear process that often ends up leading to a joint replacement.”
At University Hospitals, those methods include preventative surgical measures meant to stop hip osteoarthritis at the pass.
People with femoroacetabular impingement — a condition where the joint ball isn’t quite rounded enough and causes damage to the labrum and erodes cartilage over time — can opt for a minimally invasive procedure to repair the labrum, eliminate the impingement and stabilize the joint.
“Then we can reshape the ball to make it more round to prevent further damage,” Salata says.
Those with hip dysplasia, where the socket is shallow, are also in luck. University Hospitals is one of three hospitals in the Midwest offering a periacetabular osteotomy. The procedure combines the arthroscopic approach used to address femoroacetabular impingement with “an open surgery where you actually cut the socket free of the pelvis and rotate it to provide more coverage to cure the dysplasia,” Salata explains.
Cartilage restorative surgery can be an option for those who have developed osteochondritis dissecans, a disorder that occurs after the blood supply is cut off to a bone or cartilage. As a result, microfractures emerge in the cartilage, breaking down the surface and commonly leading to pain.
One of the more cutting-edge cartilage restorative techniques is matrix-induced autologous chondrocyte implantation. The two-stage procedure takes cartilage from a non-weight-bearing portion of the knee and then “amplifies” the person’s cartilage-producing cells, called chondrocytes, in a lab to create a kind of patch.
“You can place this patch into the defect,” Salata says. “It’s almost like filling a pothole.”
Many have found relief with a nonsurgical intervention for knees with degenerating cartilage using a gel shot called viscosupplementation. Comprised of synthetic cartilage (sometimes dubbed the “rooster shot” because the medication was derived from rooster combs), the injections provide much-needed cushioning that protects and lubricates the joint.
“There’s some evidence that it may actually delay progression of arthritis in joints,” Fox says.
According to Salata, studies have shown that another regenerative medicine-based procedure, platelet-rich plasma therapy, can be as effective as gel shots.
Similar to the stem cell-based procedures, it involves drawing blood rather than aspirating stem cells.
“You get an ultra-filtrate that has a plethora of healing factors within it,” Salata says. “It’s to try and stimulate the body’s healing response to an area of cartilage that’s damaged.”
WHAT'S NEXT
Joint replacement surgeries still require dedicated rehab for months after. However, these procedures aren’t quite as involved as they used to be.
Precision Orthopaedic Specialties’ Dunn trained on hip replacements at Yale University under Kristaps Juris Keggi, a pioneer in the modern version of a surgical technique known as the direct anterior approach.
“We don’t cut or detach any muscles or tendons,” Dunn says. “It does allow for a little easier recovery.”
Making surgery recovery easier on patients informs the mindset of Reuben Gobezie, the founder, director and chief of surgery at the Cleveland Shoulder Institute.
For the past 3 1/2 years, he’s done total shoulder replacements as a 35-minute outpatient procedure.
“That, from multiple angles, is a significant advantage to the patient,” he says. “I believe that type of health care delivery change will occur for hips, for knee replacements. A lot of the procedures we don’t currently think of as outpatient will start to become outpatient.”
With improvements in surgical techniques and treatment options, joint pain doesn’t have to be a daily torment.
“A lot of times, when people say there’s nothing that can be done, that’s not always the case,” says Salata.
When people are figuring out their options, it’s a measured process that includes the amount of pain, how it affects daily life, past treatments and what the patient hopes to accomplish with surgery, says Molloy, of the Cleveland Clinic.
Just because you have arthritis on an X-ray doesn’t mean you need a replacement, adds Dunn.
“You have to have the pain that interferes with your quality of life,” he says. “But if it’s interfering with quality of life, hip replacement surgery is one of the most successful surgeries in the history of medicine for improving quality of life.”
