Hair loss Treatment Center

• Can cracking your knuckles cause arthritis?
• Is there a connection between arthritis and fibromyalgia?
• How effective are cortisone injections in treating osteoarthritis?

PARTICIPANTS Allan Gibofsky, MD, JD New York Presbyterian-Weill Cornell Hospital

Joining me to do that is Dr. Allan Gibofsky, Professor of Medicine and Public Health at Cornell, and a rheumatologist at the Hospital for Special Surgery. Thanks for helping us out.

Let's take the first question here. "Okay, it's time for the facts. I've always heard that popping your knuckles, neck, wrists, etc., will lead to arthritis. I've also heard lately that it's a myth. I would like to know if there are any direct connections, or if the actual effects of popping your bones can or cannot cause arthritis."

ALLAN GIBOFSKY, MD: First of all, the word arthritis is like the word automobile; what make, what model, what color, what options. There are a hundred different forms of joint disease that come under the title of arthritis as the lay person uses it.

The kind of arthritis that our questioner is asking about would be degenerative arthritis. The result of stressing your joints through an unusual arc of motion. Doing things like this on a repeated basis. There is really no good evidence that cracking ones knuckles leads to or causes arthritis or makes arthritis worse.

When one cracks ones knuckles, what is happening is that gas that is in the fluid of the joint is being rapidly released and popping against the closed container of the joint. When that happens, you hear that pop. Several minutes later, that gas goes back into the joint fluid, and that's why people can crack their knuckles again and again.

So no David, cracking ones knuckles does not cause arthritis, but it doesn't help it either.

DAVID MARKS, MD: Okay. You don't recommend it.

The next question is from Evelyn Barr. It's about fibromyalgia. "How is fibromyalgia and arthritis connected, and how can they be treated together?"

ALLAN GIBOFSKY, MD: As I indicated in response to the last question, there are a hundred different forms of arthritis, and fibromyalgia is a form of arthritis. Fibromyalgia refers to "achy-ness" of the fibrous tissue of the body. Because the term arthritis is used to refer to aches and pains, fibromyalgia is considered one of the arthritis conditions.

We don't really know what causes fibromyalgia. We're just beginning to learn more about its chemical effects in the body and certain kinds of treatment that may work. But just as every patient with arthritis is an individual, so too is every patient with fibromyalgia. The kinds of things that may cause fibromyalgia in one person may not be the kind of things that cause it in another. Consequently, the therapies for each patient may be different.

That's a long-winded way to say that there is no one treatment for fibromyalgia, just as there is no one treatment for arthritis.

DAVID MARKS, MD: Should a patient try to get his or her doctor to coordinate the care between arthritis and fibromyalgia, if it's possible?

ALLAN GIBOFSKY, MD: I would say that the best person to treat a patient with fibromyalgia is a rheumatologist, who is an internist who is particularly trained in the diagnosis and treatment of muscle, bone and joint diseases. So if a patient is having fibromyalgia, meaning achy-ness of the body, together with joint pain and inflammation, that patient is best seen by an arthritis specialist who can tease out what may be due to fibromyalgia and what may be due to other causes other than the fibromyalgia, which should not go undiagnosed.

DAVID MARKS, MD: Good. The next question says, "I have osteoarthritis, and my hands are getting very disfigured, stiff and sore. Would surgery help this? If so, would my fingers still be stiff and painful?"

ALLAN GIBOFSKY, MD: An excellent question. Again, it's difficult to answer without knowing the degree of disability. There are a variety of surgical techniques for the patient with osteoarthritis. The questioner hasn't told me whether it's osteoarthritis of the wrist, the thumbs, the fingers or what-have-you.

We have to carefully differentiate between the gnarled knuckles of our grandparents, which are cosmetically problematic, but not functionally problematic, and those joints which are a result of chronic wear and tear have become degenerative.

In some instances, we can replace certain of the finger joints. In other instances, the degeneration may not be advanced enough to require that kind of surgery. In other instances, the degeneration may be too far advanced to resort to surgery for any one joint. There are several dozen joints in the hand, and it would not be possible to replace or repair all of them.

DAVID MARKS, MD: But if a joint is replaced, will that joint be painful and stiff and sore?

ALLAN GIBOFSKY, MD: One thing we do know is that replacement of a joint takes away pain. You cannot have pain in a joint that's been replaced by a piece of plastic or two pieces of metal. As far as range of motion, that too may be improved, but depending upon the deformities in the other joints around the joint, it may not be possible to get back to regular function.

Let me give you one anecdote. I had a patient with severe rheumatoid arthritis, a condition different from what the questioner is talking about, who had very deformed hands. She worked as a typist. Because of the deformities in her hands, she had trained herself to hit the keys with fingers other than the ones we traditionally teach people to use.

When she came in and had her fingers repaired, she was no longer able to work as a typist because by realigning her fingers, she couldn't train herself, again, in enough time to hit the keys the right way. So sometimes we have to be aware that not everything we do has the desired outcome.

DAVID MARKS, MD: Very interesting. The next question says, "How do you treat moderate osteoarthritis of the knee? What about cortisone injections every three months?"

ALLAN GIBOFSKY, MD: Moderate osteoarthritis of the knees has a variety of therapies available to it. We try to use them all in a staged, sequential, but sometimes concurrent fashion. We may prescribe medications to relieve pain. We may prescribe medications to relieve swelling. Or, if there is acute swelling - meaning that the knee itself is blowing up and collecting fluid - we may put a needle in, drain the fluid that's connected, and leave behind a little bit of prednisone or cortisone, which is a very powerful antiinflammatory medication.

We don't like to do this more than three or four times per year, if that, because it is not a benign procedure. There is a risk of infection. There is a risk of leaving behind crystals which can cause further inflammation. So I think we try and tailor this to the individual. If an individual needs many more than three shots in their knee, it may well be time to see the orthopedic surgeon about removing or replacing that knee with a more appropriate structure and one that will be less painful.

DAVID MARKS, MD: The last question is "Why do they take a SAID rate with arthritis? Does it always prove or disprove you have arthritis?"

ALLAN GIBOFSKY, MD: The SAID rate, the erythrocyte sedimentation rate or ESR is a nonspecific index of inflammation. When it is elevated, when it is abnormal, we know that there is inflammation in the body. When it is not elevated, assuming that there are no things to falsely lower its value, we know that there is no inflammation in the body.

Merely that the SAID rate is elevated, that does not mean that the patient has arthritis. So it is not a diagnostic tool. The SAID rate can be elevated in anything from athlete's foot to terminal cancer. Indeed, there are studies that show that women at certain times in their normal menstrual cycle may have an elevated SAID rate.

We use the SAID rate as gauge, as a guide to how much inflammation there is, and whether the therapy we're prescribing is reducing that inflammation. We do not use it diagnostically because it cannot make the diagnosis for us.

DAVID MARKS, MD: So it's used as a guide for the physician?

ALLAN GIBOFSKY, MD: That's correct. It's an index of whether what we're giving is working, and it's also an index as to how much inflammation is going on in that patient. A patient who comes in with multiple complaints and a very high SAID rate, is a patient with something that that we need to look to find out further. A patient with multiple complaints and a normal SAID rate kind of sets the stage that we may have more time to watch something evolve if anything will evolve at all.

Thank you for your questions, and thank you for joining our webcast. I'm Dr. David Marks. Goodbye.