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Joint problems are extremely common and are the number-one cause of reduced activity as we get older. Joint problems are more difficult to identify and treat in older adults compared with younger people. The x-rays and blood tests used to diagnose joint problems often show changes that could be due to normal wear and tear on the joint. This means that sometimes changes seen on x-rays are not causing the current symptoms. In addition, older adults may have more than one condition in which the joints are affected, such as osteoarthritis and tendonitis. Older adults may also have medical or surgical complications that make treatment more difficult. However, maintaining a healthy lifestyle and receiving proper medical care can greatly reduce the disability that joint problems often cause in older adults.

Arthritis is the most common joint problem among older adults. Many factors contribute to osteoarthritis, including normal wear and tear, genetics, and joint vulnerability. It is a major cause of knee, hip, back, and joint pain. Osteoarthritis can also develop faster in people who are overweight or not physically active.

Symptoms usually begin as pain and joint stiffness, especially first thing in the morning, that progress gradually. Typically, joints of the thumbs, the end joints of the fingers, the hips, the knees, and the base of the big toe are involved. In people with osteoarthritis, these joints may be enlarged or their fingers or legs may appear deformed. Inherited osteoarthritis does not usually involve the wrists, elbows, shoulders, and ankles. Osteoarthritis in the ankles suggests that arthritis is secondary to another condition that involves the joint, such as fractures near or in the joint, repeated trauma, gout or pseudogout (see Foot Problems), rheumatoid arthritis, bleeding into the joint, or not enough blood supply to the bones in the joint.

Sometimes in osteoarthritis, the cartilage that normally cushions the joints and protects the ends of the bones is lost. In the early stages, the cartilage becomes dry and less elastic. The cartilage then wears away through repeated movement of the joints. Cartilage loss leads to changes in the bone, including formation of bony growths (called osteophytes), small holes in the bone near the joints, and damage to the underlying bone that supports the cartilage. This in turn causes small fractures in the bone, stretching of ligaments and the joint lining, and irritation of nerves that go along with the blood vessels underneath the cartilage. Over time, the muscles and tendons surrounding the joint can also become inflamed or weakened. This process accounts for the pain, inflammation, stiffness, and joint swelling seen in osteoarthritis.

In rheumatoid arthritis, small joints, usually on both sides of the body, become inflamed. The blood vessels, heart, lungs, and nerves can also be involved. Rheumatoid arthritis frequently begins between the ages of 30 and 50, but about 10% of cases begin after the age of 60. Women are affected more often than men.

Rheumatoid arthritis is an autoimmune disease. This means that the body's own immune system becomes confused and attacks the joints as if they were foreign material.

Rheumatoid arthritis causes inflammation that damages the joints and surrounding muscles, ligaments, tendons, and bones. In younger people, classic symptoms include progressive stiffness, swelling, and pain of the small joints of both hands, both wrists, both feet, and both ankles. However, in older adults, rheumatoid arthritis typically begins suddenly, involving the hip, knee, and shoulder. Weight loss, chest and abdominal pains, and a skin rash can also develop.

Rheumatoid arthritis is a serious and chronic disease, regardless of the age when it begins. It often progresses and can be debilitating. However, recent research suggests that older adults may have a somewhat milder form of the disease with less severe joint damage than younger adults.

Mechanical problems within a joint can be caused by trauma that tears cartilage or ligaments within the joint, or by changes in the bone. Generally, there is swelling around the joint, and pain with specific movements. For example, a torn cartilage in the knee may result in pain when the leg is straightened and slightly twisted. There are often periods without pain, followed by periods of pain and difficulty using the joint. Joints may sometimes "give way" or "lock" when bits of ligament or cartilage act as wedges that block joint movement. Mechanical problems do not generally cause any other symptoms, such as fever, weight loss, or change in appetite. If other symptoms develop in addition to sudden joint pain, then other conditions (such as joint infection or rheumatoid arthritis) need to be considered.

The hip joint is formed by the ball-shaped top of the thigh bone (the femur) and a socket made of bones in the pelvis. The hip is protected by the large muscles of the upper leg, but because of its deep location, hip pain can be felt in many areas, including the groin, outer thigh, or even down the leg to the knee (see Figure).

Any joint condition can affect the hip, including osteoarthritis, rheumatoid arthritis, and gout (see also Foot Problems). In addition, the ball of the thigh bone can wither if blood supply is reduced because of a break or other problem. The thigh bone can break relatively easily when older adults fall, especially if they have osteoporosis (see Osteoporosis). Medical attention should be sought immediately if there is fever, recent injury, difficulty walking, or severe pain, especially if the pain is felt at rest when not moving or bearing weight.

In osteoarthritis in the hip, pain gradually develops in the buttocks, groin, thigh, or knee. Early signs include being unable to cross legs, tie shoes, or bend at the waist. Pain is mainly due to placing weight on the hip, so sitting or lying down provides relief. Going up stairs or moving from a sitting to a standing position is difficult, because this requires the hip to bend.

The knee joint acts as a hinge. Normally, the knee "locks" into position when fully straightened. How stable the knee is depends on the strength of all structures involved in the joint, including the bones, muscles, ligaments, and cartilage.

Knee problems affect perhaps 5% of older adults. Knee problems can result in disability, especially in walking or using stairs, because there are few ways to "make up for" a loss of knee function. You should seek medical attention if you notice swelling, severe knee pain, or any knee instability. Seek medical attention immediately if you have a fever or if you cannot walk.

Any joint condition can affect the knee. Often, one of the earliest signs of a knee problem is becoming slightly bowlegged. Osteoarthritis of the knee can involve the kneecap and both the inner and outer portion of the knee (see Figure). The inner part of the knee is the area affected most often. Osteoarthritis in this area can make it painful to even bend the knee, making it difficult to straighten the leg or to shift weight from one position to another. Walking normally can be difficult and can place strain on the hip and back.

The pain caused by problems of the kneecap commonly develops over the top of the knee and travels down into the lower leg. Going down stairs is often painful, because this both bends and places weight on the knee. Going down stairs sideways or even backward can be less painful. The strain on tissues attached to the kneecap is made worse by weakening of the large muscles in the thigh. Osteoarthritis involving the kneecap can result in crepitus, which is a "crackling" or "popping" in the knee joint. You can usually feel crepitus by placing your hand on the kneecap as you straighten your knee.

The shoulder is a complex joint that has a wide range of motion. In fact, the shoulder joint allows the arm to have a wider range of motion than any other body part. The rotator cuff reinforces the attachment of the upper arm to the shoulder blade. It is formed by a series of tendons and muscles. The shoulder is also surrounded by many bursas, which are small pillow-like sacs that allow the joint to glide easily as it moves.

Shoulder problems are quite common, especially involving the rotator cuff muscles and tendons, one of the large bursas, and the area between the collar bone and the shoulder blade (see Figure). Any mechanical problem with these structures causes pain, which is usually felt in the upper part of the arm. The pain is often worse after exercise and at night.

You should seek medical attention for any severe shoulder problem, especially pain with fever, severe pain at rest, or not being able to move your arm straight out to the side. Ignoring the problem can lead to a shoulder joint that becomes stiff and limits arm movement.

Injuries to the rotator cuff muscles, tendons, or bursa are common. The limited blood supply to these structures increases the chances of inflammation and tears. Activities or motions that further pinch off the blood supply to the area, such as sleeping with an outstretched arm, can aggravate the problem even more.

Inflammation of either the rotator cuff tendons or the bursas usually causes a dull ache in the shoulder and upper arm. The pain is usually more severe at night or after reaching over your head (eg, putting on a coat). Similar symptoms are experienced if the muscles or tendons are torn. Tears may happen after a strain, collision, or fall. Tears are also common among people being treated for kidney failure or with high levels of corticosteroids.

The tendon attached to the shoulder blade from the large muscle in the upper arm (the biceps muscle) can become inflamed, causing pain along the side of the shoulder. If a part of the biceps muscle tears or ruptures, it forms a large bulge near the elbow, leaving a hollow space in the middle of the arm where the muscle should be. Surprisingly, these conditions do not have a major effect on arm or shoulder function, and usually only minimal treatment (eg, pain relievers) is needed.

In frozen shoulder, movement of the shoulder gradually becomes more restricted and painful. Aching in the shoulder region often travels down into the upper arm. The pain is usually worse with movement and at night. Although frozen shoulder sometimes follows an injury, usually no reason can be identified. The cause is unknown, but people with diabetes mellitus are at risk for its development. Recovery is slow, often taking many months to a few years, but chances for complete recovery are excellent.

The history of your condition is extremely important. For example, pain that gradually worsens, swelling, and morning stiffness in certain joints (eg, fingers) suggests osteoarthritis. Arthritis in joints that are not typically involved in osteoarthritis (eg, wrists or ankles) suggests rheumatoid arthritis. Your healthcare provider will examine your joints, muscles, and bones for swelling, stability, and range of motion. If the hips or legs are involved, your healthcare provider will probably also want to watch you walking and getting into and out of a chair (see also Walking Problems).

X-rays often provide useful information about joint problems. In arthritic joints, the amount of space in the joint usually appears narrower than usual and uneven from loss of cartilage. Other common arthritic changes include small holes in the bone and extra bone growth where two bony surfaces rub together. Although x-rays are very useful, it is important to remember that many joint changes seen on x-rays do not cause symptoms.

In certain situations, your healthcare provider may recommend a joint tap, a procedure in which a small amount of fluid is withdrawn from the joint. Normal joint fluid is clear and syrupy. The joint fluid becomes cloudy in infection, gout, or pseudogout. The joint fluid can be analyzed for the number of white blood cells it contains, which can indicate osteoarthritis, inflammation, infection, gout, or pseudogout.

Treatment for osteoarthritis or injury to soft tissues is aimed at reducing pain and stiffness, and improving the ability to move around. Ice packs applied once or twice a day can help reduce pain and swelling. Over-the-counter medications can also be very effective at relieving pain and improving the ability to move. Acetaminophen preparations are often a good choice, because they are gentler on the stomach than other pain relievers. If acetaminophen is not effective, buffered aspirin or another nonsteroidal anti-inflammatory drug (NSAID) such as naproxen sodium or ibuprofen can be tried. However, these latter medications should be used cautiously because of the potential for liver, kidney, or stomach problems with long-term use. In addition, moderate to heavy alcohol intake increases the risk of side effects.

Arthritis medications that belong to a class of drugs called COX-2 inhibitors can also reduce the inflammation and pain associated with arthritis. However, COX-2 inhibitors are not generally better at reducing inflammation or pain than than older NSAIDs. The only potential advantage of COX-2 inhibitors is a reduced risk of developing stomach ulcers. However, this benefit may be "canceled" when a COX-2 inhibitor is combined with low-dose aspirin, which is taken by many older adults to prevent stroke and heart attack. COX-2 inhibitors can cause problems with blood pressure, heart failure, and kidney disease at least as severe as those caused by older NSAIDs. Because of new evidence for increased risk of stroke and heart attack in older adults who take COX-2 inhibitors, some medications in this class have been removed from the market or are now subject to special warnings from the FDA to your healthcare provider. A COX-2 inhibitor may still be the best choice for certain older adults, but this choice should be made only after careful consultation with your physician.

Research suggests that the long-term use of dietary supplements containing glucosamine and chondroitin may improve symptoms and function in older adults with osteoarthritis. These two substances are important parts of healthy cartilage. Many over-the-counter preparations contain glucosamine and chondroitin (see Complementary and Alternative Medicine). However, the best dose for these supplements is unknown.

Other treatments for arthritis include injecting either corticosteroids or lubricating drugs into the joint. These treatments often provide short-term relief with relatively few side effects. Corticosteroids can also be injected into painful tendons or bursas, such as those involved in rotator cuff tendonitis.

NSAIDs are commonly used to control symptoms of rheumatoid arthritis. However, chronic use can have numerous side effects (eg, skin breakdown and bone problems). These side effects are minimized by using low dosages. Your healthcare provider can also show you other ways to prevent most of the side effects of corticosteroids. Be sure to ask your healthcare provider what is right for you.

Drugs that suppress the immune system and certain cancer chemotherapies have also been used to treat rheumatoid arthritis. Unlike traditional anti-inflammatory drugs that address only the symptoms, these drugs can actually change the course of this disease. Some of the drugs that can change the course of rheumatoid arthritis are well tolerated, while others require very close monitoring of blood tests by your healthcare provider to avoid problems. Unfortunately, some of these drugs can also have serious side effects, including liver failure, lymph cancer, and life-threatening infections.

All types of arthritis generally cause weakened muscles because of inflammation and lack of use. Early efforts to strengthen the muscles and improve joint motion are critical. Using pain relievers can allow physical therapy to be used effectively in managing arthritis long term.

Continuing to walk and exercise the joints, especially the knees, may result in better and better function with less pain. Weight loss can also help reduce pain and improve function, especially if the lower spine or weight-bearing joints are involved. Exercise programs should to be tailored to the specific problem and needs of the individual. Seeking advice from a physical therapist early in the course of arthritis can be very helpful. The physical therapist can evaluate your situation and give you a set of exercises to do every day at home.

In knee arthritis, special exercises can be recommended by your healthcare provider or physical therapist that strengthen the large thigh muscles without further irritating the knee. A good exercise to do is to sit on the edge of a high chair or table and gently kick one leg out as straight as possible, then hold the leg straight out without support for a count of five. This exercise can be done while watching television. One leg can be exercised during the first commercial, and the other leg exercised during the next commercial.

Swimming is an ideal exercise for people with hip arthritis, because it involves moving the hip without bearing weight. Exercises or activities that place a lot of weight on the hip (eg, walking for a long time or standing) should be avoided. Severe pain at night or pain that slowly worsens from day to day when you are exercising regularly may indicate that there has been too much activity during the day. Extra attention and consultation with your healthcare provider and physical therapist may be needed to find just the right set of exercises to be done at just the right level of intensity that works best for you. It is worth the effort, because properly done exercises can delay the need for arthritis surgery. At the worst, if arthritis surgery is ever required, you will have fewer complications and faster recovery because your muscles were in good shape before the surgery.

In hip arthritis, a cane or other device can help shift weight away from the bad hip (see also Rehabilitation). The cane should be used on your good side, so that the cane and the weak hip form an arch. When walking, the weight is carried by the shoulder, arm, and cane (as weight is shifted away from the painful leg).

Physical therapy can also be an important part of treatment for shoulder problems. Exercising the shoulder can help to keep it moving and prevent scarring of the shoulder capsule. Shoulder problems heal slowly, so therapy may be needed for several months.

A hip or a knee joint that has been destroyed by osteoarthritis can be replaced surgically. Surgical replacement of a joint can relieve pain and improve the ability to move around. Surgery is a major step but should be considered if you have a lot of pain at night, or so much pain that it is difficult to shift weight from side to side or to take short walks. Surgery should also be considered when major tears in rotator cuff tendons or muscles prevent being able to move the shoulder joint.

Bones and joints are surrounded by muscles, tendons, ligaments, bursas, and nerves that together make up the soft tissue. In addition to true arthritis, damage to soft tissue is common. Symptoms typically involve a region of the body rather than a specific joint. These soft-tissue injuries usually cause pain that is brought on by some movements but not others. Pain that worsens at night or that happens only in certain body positions suggests soft-tissue injuries. These problems do not typically cause morning stiffness. Other symptoms (eg, fever, chills, weight loss, or change in appetite) are not seen.

Generally, people with tendonitis or bursitis feel pain not at the joint, but beyond it (toward the arms or legs) when the joint is moving. This is common in shoulder problems.

Pain in a region of the body that cannot be linked to arthritis, tendonitis, bursitis, or nerve damage can be caused by muscle "trigger points." These are areas in the muscle that are tender and sometimes crackle when touched. Putting pressure on these trigger points brings on the pain. Trigger points are most common over the upper back, especially over the shoulder blades, and are sometimes found on the chest, lower back, and hips. The cause is not known. Treatment includes repeatedly applying ice packs to the trigger points or injecting the trigger points with local anesthetic, corticosteroids, or both.

Fibromyalgia causes pain in many muscles throughout the body. The average age of onset is around 45 years, but fibromyalgia affects people of all ages. Most cases are in women.

Fibromyalgia is not associated with damage to specific tissues, such as muscles, tendons, or nerves. Instead, it seems that the brain perceives or interprets the pain differently. For example, the brain seems to interpret normal sensations as painful. People who suffer from fibromyalgia often suffer from irritable bowel or chronic fatigue syndromes as well, suggesting that there may be a similar cause for these three conditions.

Although fibromyalgia can persist well past the age of 80, research suggests that symptoms decrease somewhat with age. Treatment consists of pain relievers occasionally when needed and reassurance that the condition is not life threatening and can improve. Exercise can help keep muscles in good condition. Antidepressants, muscle relaxers, or anti-anxiety drugs can provide relief in some cases.

The median nerve passes through the carpal tunnel of the wrist. Carpel tunnel syndrome develops when this nerve becomes pinched or compressed, usually by repeated trauma to the wrist, such as long periods of typing, computer work, or needlepoint. Symptoms can also be secondary to rheumatoid arthritis, gout, or pseudogout. Risk factors for carpal tunnel syndrome include an underactive thyroid gland and diabetes.

Carpal tunnel syndrome generally causes pain during the night, tingling, and numbness in the hand. In some cases, the pain travels from the wrist into the arm and shoulder.

Treatments include pain relievers, anti-inflammatory drugs, and correction of any underlying problems. Corticosteroids can be injected into the wrist to relieve symptoms. Wrist splints can also be used to protect the wrist during treatment. Surgery is sometimes needed.

Activities that involve repeated trauma should be stopped or done less. Isometric stretching exercises may help recovery and prevent the condition from coming back.

In elbow bursitis, the bursa (or sac) that cushions the elbow becomes inflamed and fills with fluid. It can be caused by gout, rheumatoid arthritis, or trauma to the elbow. However, it sometimes occurs for no apparent reason.

Fluid can be drawn out of the sac with a needle and analyzed to see if there is infection, gout, or some other cause for the inflammation. Specific drugs, such as antibiotics or anti-inflammatory agents, may be prescribed if indicated. Recovery can take several months, and relapses are common. Draining the fluid and padding the elbow can speed recovery.

Polymyositis is a combination of inflammatory diseases of muscle that can develop in both children and adults. Among adults, polymyositis affects women more often than men, and blacks more often than whites. In older adults, polymyositis may be complicated by respiratory failure and pneumonia. In some cases among older adults, there is underlying cancer.

The characteristic symptom of polymyositis is muscle weakness, which is most common in the upper arm and leg muscles. Deciding if there is a problem with fatigue or true weakness can be very difficult. Your healthcare provider can help determine if true weakness is present. The true weakness from polymyositis leads to a decreased ability to exercise or perform simple tasks, such as reaching above the head or going up stairs. Affected muscles are usually not painful. Sometimes, arthritis, rash, problems with heart rhythm, or problems with the esophagus can develop. The rash may involve specific areas (eg, the eyelids or nose) or may be spread more generally around the body. When rash is present, the condition is called dermatomyositis. Blood tests, biopsies, and other more specialized test are used for diagnosis. Anti-inflammatory medications, especially corticosteroids, can improve muscle function. Older adults are also usually evaluated for underlying cancer. Polymyositis usually improves when the underlying cancer is controlled.

Fractures in older adults are often caused by falling, especially when bones are weakened by osteoporosis or some other condition. Slowed reflexes, vision loss, and problems with coordinated movements make falls fairly common (see Falling).

Fractures are described by their location, by the type of break (across, at an angle, or spiral), and by how much the bone has separated or been fragmented (see Figure). Fractures often happen in areas of bone that have already been weakened by osteoporosis, cancer (see Cancer), arthritis, or some other disease. In these cases, pain in the area of the break often increases before the fracture occurs. This pain typically increases at night or when placing weight on the affected limb. Early examination and treatment of the pain can reduce the chances of a fracture and greatly improve treatment and results.

The hip, pelvis, leg, wrist, and vertebrae (back bones) are common fracture locations among older adults. Most hip, pelvis, arm, and wrist fractures are caused by falls. Hip fractures and fractures of the vertebrae are especially common among older adults compared with younger ones. These two types of fractures rarely happen before 50-70 years of age.

Hip fractures can happen with no or very little trauma, especially when the bone is weakened by osteoporosis or chronic arthritis (see Figure). In some cases, a lot of bleeding around the fracture can result in shock due to a drop in blood pressure.

Fractures of the vertebrae (back bones) are usually caused by activity that stresses the spine, such as lifting, bending forward, or missing a step while walking. In older adults, the bones are often already weakened by osteoporosis (see Osteoporosis). Many vertebral fractures happen without any symptoms and are found only on an x-ray. In other cases, back pain is severe and made worse by sitting or standing. The affected part of the spine may be very tender. There are rarely any problems with nerve function in the area. These fractures usually heal, even without much treatment, because the back bones are stable and usually keep the fracture from moving out of alignment. Back pain usually resolves in 6-12 weeks. Complete recovery is common, although the spine may curve forward, resulting in a loss of height.

The area of a fracture is usually painful, swollen, tender, and bruised. Some types of hip fracture may result only in groin pain when weight is placed on the hip, without bruising, swelling, or other obvious signs. X-rays are usually used to confirm the break and to determine the location of the bony pieces. Some types of hip fracture do not even show up on x-rays.

First the injured limb must be immobilized, or prevented from moving. This relieves pain and makes it easier to move someone who is injured. It also prevents the sharp ends of the break from moving, which can damage muscles, nerves, and blood vessels. Injuries near the elbow or knee can often be immobilized with splints. Slings or wraps can be used to immobilize most injuries of the shoulder, upper arm, and elbow. Hip fractures can be initially immobilized by careful positioning with pillows.

After these first efforts, the fracture must be kept stable for several weeks to prevent movement and get the best healing. Casts can immobilize the broken limb, but keeping the area from moving for a long time in older adults increases the risk of stiff joints and medical complications. So, fracture treatment in older adults emphasizes a rapid return to routine physical activities. This generally means surgery to stabilize the fracture, although short casts or splints can often stabilize wrist fractures without leading to immobility or needing bed rest.

Surgery is often the best approach for treating fractures, especially for hip fractures that would otherwise cause immobility and bed rest for a long time. In most circumstances, the risks of surgery are usually outweighed by the chances of complications from bed rest. However, surgery is generally postponed until other medical problems (eg, infection or severe osteoporosis) have been corrected or controlled. Surgery is needed immediately only for fractures that puncture the skin or that might threaten loss of the limb. In these fractures, antibiotic treatment and often drainage are needed because of the risk of infection.

Most hip fractures are stabilized with surgery, using special pins or screws. This allows someone to start moving and bearing weight immediately and prevents the ends of the fracture from separating. Hip fractures generally heal well as long as the head of the thigh bone (or femur) didn't separate too far out of the hip socket. When the head of the femur is far out of the socket, its blood supply can be reduced, which causes the bone to wither and die.

In these cases, surgery can be done to stabilize the joint with pins or screws, or the joint can be replaced with an artificial hip. Stabilizing the joint with pins or screws is usually done only in people younger than 80 years old who are otherwise active and in good health. These people can generally function reasonably well on crutches while the hip heals. However, sometimes complications develop, including poor healing or severe deformity (misshapenness) in the head of the femur, which can be painful and require a second surgery. Partial or complete hip replacement is often recommended initially because of these complications.

A nonsurgical approach may be best for people at high risk of developing major complications. This includes people in nursing homes who were not able to walk before the hip fracture, and people who are confined to bed for other reasons.

Beginning to move the affected limb as soon as possible is important to keep the joints from stiffening and to maintain good muscle tone. This is especially true for arm or wrist fractures to prevent a stiff shoulder from developing. Stiffened joints can cause severe pain and limit movement, which can lead to disability. Physical therapy is often extremely helpful. See also Rehabilitation.

Pain and weakness usually decrease gradually after a broken wrist is repaired, although full recovery can take 6-12 months. After an arm fracture, several months of rehabilitation may be needed before someone can easily perform tasks that involve lifting the arm over the head (eg, combing his or her hair). Physical therapy and various exercises help speed recovery.

After hip replacement, most people can begin bearing weight immediately with a walker for support. A walker is needed for 6-12 weeks before switching to a cane. Physical therapy helps increase range of motion and muscle tone. Most people can eventually walk independently. Fractures of the back bones are usually managed similarly.

When casts or splints are used to set fractures, swelling is always a risk. Swelling can block blood flow, which can cause tissue damage and further injury. If pain or numbness develops within or beyond (eg, fingers or toes) the cast or splint, the cast or splint should be immediately loosened or removed.

One of the most serious complications in leg fractures is the development of large blood clots in the veins of the leg and pelvis. These clots can break away and travel through the blood. A clot that lodges in a vessel and blocks blood supply to the lungs is potentially fatal. Major risk factors for blood clots include the following:

• advanced age
• obesity
• cancer
• trauma
• surgery involving the legs
• a history of having one or more blood clots
• prolonged bed rest