DEAR MAYO CLINIC: I am 50 years old and live an active lifestyle. Recently, I started having more aches and pains, especially in my knees and hips. I wonder if I have arthritis. What are my treatment options?

ANSWER: Osteoarthritis, also known as mechanical arthritis or "wear-and-tear" arthritis, is the most common joint disorder in the U.S. This condition occurs when the protective cartilage lining the joints is lost, resulting in pain and impaired function. An estimated 20%-30% of adults older than 45 have evidence of hip or knee osteoarthritis on X-rays.

As a first step, it is important to establish a diagnosis for hip and knee pain. Through an appointment with primary care, or with a specialist such as an orthopedic surgeon, your doctor can perform a careful history, physical examination and obtain X-rays to confirm if you have osteoarthritis. This needs to be differentiated from other potential sources of hip and knee pain, such as referred pain from the back; soft tissue pain, like tendinitis or bursitis; and other joint pathologies, including osteonecrosis or inflammatory arthritis, such as rheumatoid arthritis. Once your health care professional diagnoses osteoarthritis and confirms the degree of severity, you and your health care team can discuss an appropriate treatment plan.

Generally, it is best to treat painful osteoarthritis with the most conservative and least invasive measures first, and then escalate as necessary to achieve tolerable pain and function. A three-tier framework can be helpful to understand the treatment ladder orthopedic surgeons use to manage osteoarthritis

The American Academy of Orthopaedic Surgeons publishes clinical practice guidelines for hip and knee osteoarthritis, as well as many other conditions.

The first-tier conservative regimens that have received the strongest evidence include:

• Modifying activities
  Shift to activities that cause less pain and avoid activities that are most aggravating.
• Exercise
  Exercise is one of the most effective interventions for hip and knee pain, but it may require you to modify prior routines and seek out lower-impact activities.
• Manage weight
  Under the guidance of a health care professional, lose weight if you are overweight.
• Gait aids and braces
  Offloading pressure from the joint with gait aids such as canes, crutches or walkers, or with braces of the knee, can help manage pain, especially for longer walks or when on uneven surfaces.
• Over-the-counter pain medication
  If you can safely tolerate medications such as acetaminophen or nonsteroidal antiinflammatory drugs, or NSAIDs, these can be effective first-line therapies for pain. Topical NSAIDs also are available that can be rubbed over the affected joint.

Many other conservative measures can be discussed and tried, but strong evidence of patient benefit has not been achieved. Narcotics should not be used for hip and knee osteoarthritis. While narcotics or opioids are helpful for some medical conditions, including managing pain after hip or knee surgery, they are inappropriate to use for osteoarthritis.

Injections are the second rung in the treatment ladder and may be considered when conservative measures fail.

Injections can include:

• Steroids
  Steroids have the highest recommendation for pain relief and may be used in conjunction with local anesthetics like you receive at the dentist. It is important to note that steroid injections do not work for all patients, only provide temporary relief and typically have decreased effectiveness with repeated use.
• Hyaluronic acid
  Certain injections use components of knee joint lubricating fluid to try to replenish it. Evidence for these injections is weaker than steroids, except in rare patients who do not respond to steroid injections. Note that not all insurance providers cover these types of injections.
• Regenerative medicine
  Many injections are marketed as regenerative medicine, including stem cells, platelet-rich plasma and acellular biologics. These injections are not recommended for hip and knee osteoarthritis, are usually expensive and are not covered by insurance.

The final option for treating hip and knee osteoarthritis is joint replacement surgery. These are the most common elective surgeries in the U.S. Although they are major procedures with risks to consider, they are also remarkably effective for most patients deemed candidates by their surgeon. Hip replacement and knee replacement are routinely rated as the first and second among all surgeries in medicine in a metric of health improvement known as quality added life years.

Not every patient is a candidate for hip or knee replacement, however. While joint replacement is effective for most patients, complications can occur. You should discuss risks with your surgeon to ensure an informed decision for surgery.

Also, patients need to be cleared for surgery based on lifestyle factors and health risks. For instance, many institutions have a cutoff for a body mass index of less than 40. Patients with diabetes need to demonstrate reasonable control with blood testing. If you are on immunosuppression or blood thinner medications, your surgeon and the doctor prescribing these medications will formulate a management plan.

If surgery is warranted, it is important to remember that recovery takes time.

Typically, we rely on the Rule of 3s:

• The first three days following surgery, the goal is to get up and around the house for basics while using a walker.
• In three weeks, most patients can get around town for light activities, usually with help from a family member or friend.
• After three months, most patients are at least 80% recovered and are back to all activities in a graduated fashion. Improvements continue through the first full year after surgery.

Hip and knee osteoarthritis can be extremely debilitating, but fortunately, there are many treatment options. Seek out a certified and skilled orthopedic specialist to confirm your diagnosis and develop the best treatment plan. Health care organizations that offer collaborative care can assist you in all elements of therapy, whether that includes medication therapy, weight loss, exercise or surgery. — Dr. Cody Wyles, Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

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