ASK THE PODIATRIST

--Dr. Jay C. Goldstein

Q: About eight months ago I developed pain on the top of my midfoot. My doctor told me to take ibuprofen. Initially it helped, but after a few months the pain began to increase. After six months I returned, and he informed me that I had osteoarthritis, that there was not much that could be done about it, and he increased the ibuprofen to 800 mgs. three times daily. After a month of taking the ibuprofen, I tried going without it, but soon began limping. I asked him how long I would have to take it, and the answer I got was something like: “Until something better comes along.” He also recommended that I stop exercising. I had already stopped running, and I am really reluctant to stop walking.

A: Your question has several implications, some of which I have previously addressed. The remainder that I cannot address today, I will answer in future issues.

WHAT IS OSTEOARTHRITIS?

Envision two bones joining together to form a joint. Since bones are hard and relatively dry, it would be very unpleasant to have the two bones rubbing against each other. Therefore, Mother Nature developed cartilage. Cartilage serves two purposes:

1. It is very smooth and slippery, thereby making it easy for one bone to move upon another.

2. It is resilient, thereby providing shock absorption between the two bones.

Osteoarthritis occurs when the cartilage erodes. Sometimes it may be accompanied by pain, swelling, limited motion, and/or redness. If it occurs without an injury or other specific cause (such as infection), it is referred to as primary osteoarthritis. If it occurs to a single joint in a case with an identifiable cause (such as an injury), it is referred to as secondary osteoarthritis, or sometimes as degenerative arthritis. Osteoarthritis affects tens of millions of people in the U.S.

WHAT ARE NSAIDs?

NSAID stands for non-steroidal anti-inflammatory drug. The prototype is aspirin, formally developed in 1899. In the 1960’s, indomethacin (Indocin) and ibuprofen (Motrin, Advil, Nuprin, etc.) were developed. Since then, many additional have been developed.

Let us compare NSAIDs to acetaminophen (Tylenol). Acetaminophen relieves pain and reduces fever. NSAIDs do two additional things:

1. They reduce inflammation.

2. With the possible exception of two new (Celebrex and Vioxx) they reduce clotting caused by platelets (making one more likely to bleed—sometimes good, sometimes bad).

NSAID SIDE EFFECTS

All medications have side effects. If people were forced to read the PDR (Physicians Desk Reference), we would all take fewer medications. While most of the side effects of this large group of medications are not much worse than the typical prescription medication, there are some side effects that disturb me:

1. Many people taking NSAIDs will develop ulcers (erosions) of the lining of their stomach and/or intestine. Some of those ulcers will become unpleasantly deep and bleed. Some of those people will die. Although people die from many different medications, in the case of NSAIDs we are talking about thousands of deaths a year. This statement needs to be weighed against the fact that there are millions of people taking NSAIDs, and that, in some cases, they are delivering a desired action. On the other hand, death is a fairly significant side effect.

2. Other significant side effects may include kidney problems and, in the case of people on blood pressure medication, aggravation (raising) of their blood pressure. Some studies have implicated chronic use with congestive heart failure.

3. One side effect that I think is less well known, and that I consider ironic, is that several NSAIDs, including aspirin, ibuprofen, and indomethacin, have been implicated in some studies to increase the destruction or loss of cartilage. Thus, one of the medications that we are using to treat joint pain may, with long-term use, INCREASE the likelihood of ARTHRITIS.

I think it is important to review the last few paragraphs. The development of NSAIDs provided a powerful tool to fight pain and inflammation. However, like all medications, they have side effects. (The side effects are usually worse with increasing duration and increasing dosage of the medication. The side effects listed above are not likely when taken in small amounts for brief periods of time.) It is up to each patient, usually with the help of his or her doctor, to be certain the tradeoff is worthwhile.

THE DIAGNOSIS

Now let us return to the specifics of this ODR reader. Assuming the description of your history is accurate, I am not sure that I feel completely comfortable that adequate time and effort have been invested in making an accurate diagnosis. In most cases, it is not wise to embark upon an extended treatment plan until the diagnosis is determined. Moreover:

1. Ibuprofen, like all of the NSAIDs, is an excellent pain reliever. Unfortunately, the pain relief may mask Mother Nature’s message that you should not be performing a certain activity at a given intensity.

2. You are taking a medication for an extended period of time that has been implicated in possible eventual loss of cartilage.

3. Have other options been explored, including biomechanically stable shoes, orthotic devices, and modification (not cessation) of your athletic activities?

4. Assuming that you do have osteoarthritis, I would encourage you to read about medications and supplements that may be more appropriate for long-term use, such as glucoasamine, chondroitin, and SAMe.

EXERCISE

Not all that long ago, people with osteoarthritis would have been advised by most of their physicians to become couch potatoes, which would be a prescription for becoming fat, hypertensive, and unhappy. Fortunately, several studies have demonstrated that moderate exercise is advantageous for osteoarthritis, but that will need to be the fodder for a future column.

Dr. Goldstein is board certified in Podiatric Surgery, Podiatric Orthopedics, and Podiatric Medicine. He has been running for many years, although sometimes he rests.