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CHAPTER 17: JOINTS, MUSCLES, AND BONES

Overview

Causes of Joint, Muscle, and Bone Problems

Symptoms

Neck Pain

Shoulder Pain

Back Pain

Hip Problems

Knee Problems

Foot Problems

Conditions

Gout

Pseudogout

Osteoarthritis

Rheumatoid Arthritis

Osteoporosis and Osteomalacia

Paget's Disease of Bone

Bone Fractures


Overview

Joint problems are extremely common and are the number-one cause of reduced activity as we get older. At least half of us will have joint conditions, but most of us are not bothered by our symptoms.

Joint problems in older people are more difficult to identify and treat than they are in younger people. The X rays and blood tests used to diagnose joint problems often show joint narrowing, bony changes, and other abnormalities that are unrelated to any symptoms. In addition, there may be more than one joint condition: osteoarthritis and rheumatoid arthritis, for example. Obviously, the presence of two or more forms of arthritis increases the chance of disability. Older people experience different types of joint problems, and conditions such as bursitis or tendinitis take longer to heal. Although there is less disk disease in older people, they experience more back pain caused by compression fractures (due to osteoporosis), unstable vertebrae, and cancer. Most people do not realize that rheumatoid arthritis occurs at a high rate among older people (about 3 in 100 women and 1 in 100 men). Moreover, rheumatoid arthritis involves different joints, has a different course, and requires different treatment in older people as compared with younger individuals. Other muscle and joint conditions such as polymyalgia rheumatica and pseudogout are seen primarily in older people. Each of these conditions is addressed later in this chapter.

Joint conditions are generally more difficult to manage in older people because of increased medicinal and surgical complications. However, despite these concerns, skillful professional care can substantially reduce the burden of disability that joint problems often cause for older people.

Causes of Joint, Muscle, and Bone Problems

Generally, joint problems fall into one of five categories (shown in Figure 16):

  • Problems around the joint
  • Mechanical problems with the joint
  • Sudden inflammatory arthritis
  • Smoldering inflammatory arthritis
  • Wear-and-tear arthritis, called osteoarthritis

Problems Around the Joint

The symptoms of conditions involving structures around the joints, such as tendons or bursae, usually consist of pain brought on by some movements but not others. Pain that worsens at night and pain that occurs only in certain body positions suggests problems around the joint. Conditions around the joint do not show more stiffness in the morning and are not accompanied by symptoms such as fever, chills, weight loss, or change in appetite. Generally, people with problems around the joint (usually tendinitis or bursitis) have pain that is felt not at the joint but beyond it (toward the extremities) when the joint is in motion. These conditions can also limit the movement of the joint. The physician will attempt to reproduce the pain of tendinitis by applying resistance during the active range of motion of the affected muscle. For example, pressing down on the arm as the person attempts to lift it may reproduce the pain associated with tendinitis around the shoulder.

Mechanical Problems with the Joint

Mechanical problems may be caused by trauma that tears a joint's cartilage (a little pad that cushions the joint) or ligament (a fibrous band that connects bones) or changes in the underlying bone. People with these mechanical joint conditions generally have painfree intervals with intermittent pain and dysfunction. The pain often occurs abruptly and the joints may frequently "give way" or "lock." There are no additional symptoms such as fever, weight loss, or change in appetite. People who have mechanical problems inside the joint generally have swelling around the joint and have pain with specific movements. For example, a torn cartilage in the knee may produce pain when the leg is straightened and slightly twisted.

Sudden Inflammatory Arthritis

With arthritis that occurs suddenly, people have an abrupt onset of joint pain and swelling, usually at its worst within 12 to 48 hours, accompanied by additional symptoms such as fever and chills. People usually cannot rest because of the pain, and will have a lot of fluid around the joint. These joints are not always warm, because active inflammation does not always produce an increase in skin temperature. People with this kind of active arthritis need to be evaluated immediately by a physician to check for infectious diseases, skin rashes, heart murmurs, and other evidence of underlying disease.

Chronic Inflammatory Arthritis

People with a chronic inflammatory arthritis such as rheumatoid arthritis have a slower onset of joint pain. Morning stiffness generally lasts more than an hour and involves the small joints such as the hands, wrists, ankles, and feet. This form of arthritis may be associated with weight loss, chest and abdominal pains, and skin rashes.

A careful physical examination provides the best way to determine the forms of chronic inflammatory arthritis. An older person may have painless loss of motion of the wrists or elbows and there may be early signs of thickening around the joint because of an increase in the synovium tissue that makes joint fluid. This synovium thickening may be seen along the knuckles of the hand, the wrists, the elbows, knees, and along the ball of the foot. Lymph gland enlargement in the armpit sometimes indicates joint inflammation in the arm. Severe deforming changes in the fingers can be seen in some forms of rheumatoid arthritis.

Osteoarthritis

People with osteoarthritis have a gradual progression of pain, pain that worsens with the use of the joint, and stiffness in the morning that lasts less than a half hour. People with osteoarthritis may have bony enlargements of the joints and deformities of their fingers or legs caused by an asymmetric loss of the cartilage. In the usual form of osteoarthritis the characteristic joints involved are the very end joints of the fingers, the thumb, the hips, knees, and the base of the big toe.

The physician's examination of a joint, muscle, or bone problem focuses on joint swelling, stability, and range of movement. A search for any difficulty in walking and getting in and out of a chair is usually undertaken if the hips or legs are involved.

The most helpful test for diagnosing these various joint conditions is an examination of the joint fluid. This test is absolutely essential in people with sudden-onset arthritis to look for infection and for crystals that would indicate gout or pseudogout. Normal joint fluid is a clear viscous fluid that looks like motor oil and contains up to 200 white blood cells per microliter. The number of white blood cells helps the physician identify the cause of the joint condition. White blood cell counts between 200 and 2,000 are generally seen in osteoarthritis; and counts above 5,000 prove there is joint inflammation. People with white blood cell counts in joint fluid of more than 50,000 generally have cloudy joint fluid caused by either an infection, gout, or pseudogout.

Based on the joints involved, the nature of the discomfort, the results of the physical examination, and the examination of the joint fluid, the physician may order other laboratory tests to determine the cause of the arthritis more precisely. X rays may be difficult to interpret in older people with joint complaints because most older people have joint abnormalities on X rays. But, there is very little relationship between the appearance of X rays and the presence of pain. Consequently, before recommending treatment most physicians make sure that the symptoms and physical features of the person's condition are consistent with the results of diagnostic X ray studies.

SYMPTOMS Neck Pain

Neck discomfort is very common, and the most frequent source is tension in the neck muscles. This discomfort usually improves on its own, but any pain that lasts more than a few weeks should be evaluated by a physician. Other warning symptoms are fever, arm weakness or numbness, and neck pain after a fall.

Causes of Neck Problems

Changes in the neck (cervical spine) due to normal wear and tear are seen on neck X rays in virtually everyone over the age of 65. Three conditions that can cause neck pain are the following (see Figure 17):

  • Compression of the spinal cord
  • Compression of a nerve root
  • Pressure from a slipped disk

Compression of the Spinal Cord in the Neck. Compression of the spinal cord in the neck by bony growths called osteophytes (see Osteoarthritis, later in this chapter) can produce weakness in the legs and an urgent and frequent need to urinate (see Figure 17). Because the course of this condition is variable, specific recommendations for management are difficult to make. Many people have a slow progression or even a stable course despite significant changes in the weak structures on X rays. Aggressive surgery is risky and the results are inconsistent. About half of the people undergoing surgery experience significant improvement. The decision to operate, therefore, depends greatly on the progression of symptoms and on the severity of impairment in the nervous system.

Compression of a Nerve Root. Pressure on a nerve root--causing a pinched nerve--in the neck can be caused by many things. There may be bony growths, osteophytes, pressing against the nerves where they exit from the spinal column or the nerve may be compressed by a slipped disk. Symptoms of a pinched nerve consist of pain, sometimes numbness and tingling, and sometimes changes of sensation occurring in bands (called dermatomes) along the neck, shoulders, upper chest, and arms. An illustration of dermatomes is shown in Figure 18. There may be weakness in the arms, hands, or fingers. These symptoms often resolve on their own in three to six weeks. If there is persistent or progressive arm weakness, one should seek medical attention.

Pressure from a Cervical Disk. Pressure from a ruptured disk in the neck (a cervical disk) produces pain in the neck, shoulder blades, and upper shoulders. The condition is sometimes confused with a muscle spasm. People with this condition have pain and limited motion on some, but not all neck movements. Cervical disk displacement can affect nerve roots, which in turn may affect the muscles associated with these nerves. A physician will examine carefully for such muscle involvement. Treatment of cervical disk displacement by immobilizing the neck with a soft foam rubber collar combined with intermittent cervical traction is a more logical approach than resorting to more aggressive neck braces and injections to the muscles. If left untreated, cervical disk displacement usually resolves itself in one to four weeks. If muscle weakness continues beyond four weeks, one should seek further, more extensive evaluation and treatment.

Shoulder Pain

Shoulder problems are quite common in older people. The shoulder structures are complex, consisting of three interrelated joints. A series of tendons and muscles around one of the joints form the rotator cuff, which reinforces the position of the upper arm to the shoulder blade. The muscles of the rotator cuff assist in moving the arm away from the body and reinforce the upper arm to hold the top portion of it in proper alignment with the other shoulder structures when the arm is lifted. The shoulder joint allows the arm to move more than any other body part. The shoulder is surrounded by many bursae, which are small pillowlike sacs that permit an easy gliding motion throughout joint movement.

Causes of Shoulder Problems

The most vulnerable structures in the shoulder (see Figure 19) are these:

  • Rotator cuff tendons
  • The tendon that attaches the biceps muscle to the shoulder blade
  • A large subacromial bursa that is between the large shoulder muscles and the upper part of the arm
  • The joint between the collar bone and the shoulder blade

Any mechanical problem with these structures causes pain, usually felt in the upper part of the arm. This type of pain often increases after exercise and worsens at night. Medical attention should be obtained for shoulder pain with fever, severe shoulder pain with no movement, or if the arm cannot be lifted straight out to the side. Shoulder injuries can cause the shoulder to stiffen, but specific exercises and treatments can help maintain and restore function.

Rotator Cuff Tendinitis and Bursitis

The rotator cuff tendons lie next to a large bursa called the subacromial bursa. Inflammation of either the rotator cuff tendons or the subacromial bursa produces similar pain. Because the treatment of rotator cuff tendinitis and subacromial bursitis is the same, we will consider them together.

At the very end of the rotator cuff tendons on the upper arm the blood supply is limited. As a result, this region is subject to inflammation, reduced delivery of oxygen and nutrients to the tissues, and small tears of the tendons. These factors appear to cause rotator cuff tendinitis and bursitis. Usually this discomfort begins with a dull ache that extends from the shoulder into the upper arm and worsens at night. The pain is made more severe by such movements as reaching over one's head or putting on a coat.

Evaluation of Rotator Cuff Tendinitis and Bursitis. The physician can usually tell the difference between rotator cuff tendinitis and subacromial bursitis by pushing against the arm to resist the range of motion. Pain with resistance is typical of tendinitis. If the pain does not increase when resistance is applied, then the condition is probably bursitis.

Treatment of Rotator Cuff Tendinitis and Bursitis. As mentioned earlier, small tears of the tendons are a predominant cause of rotator cuff tendinitis. These take longer to heal in older people; an 80-year-old suffering from such small tears might need from three to four months for full recovery. A 20-year-old by contrast usually heals in two or three weeks. Therapy consists of either anti-inflammatory drugs or injections of corticosteroids into the painful area. It is also important to gently exercise the shoulder per a doctor's directions to help maintain movement and prevent scarring of the shoulder capsule.

Rotator Cuff Tears

Rotator cuff tears are muscle or tendon injuries that usually occur in people over the age of 50. Those who are being treated with corticosteroids or who are receiving treatment for kidney failure tend to develop this problem.

Causes of Rotator Cuff Tears. Most people with rotator cuff tears resulting from these treatments have symptoms similar to those of rotator cuff tendinitis described above. In other cases, a tear may occur after a strain, collision, or fall.

Evaluation of Rotator Cuff Tears. A rotator cuff tear is identified during a physical examination by a physician. A person's inability to move the shoulder in the direction of the affected muscles (or tendons) indicates which muscle or tendon is torn. The confirmation of a suspected rotator cuff tear is often accomplished by special X ray studies.

Treatment of Rotator Cuff Tears. Treatment for complete rotator cuff tears is problematic. The only effective therapy is surgery to repair the torn muscle or tendon, but this goal is difficult to achieve in elderly people. Surgery should be carefully considered when a complete rupture prevents effective functioning.

Tendinitis of the Biceps Tendon

The tendon attached to the shoulder blade from the biceps muscle in the upper arm is frequently inflamed. When such inflammation occurs, pain is felt along the side of the shoulder. Sometimes, a portion of the biceps muscle fibers tears or ruptures, producing a large bulge near the elbow and a hollow space in the middle of the arm where the biceps muscle usually is. Fortunately, this condition does not significantly affect arm or shoulder function, and it often requires no therapy.

Frozen Shoulder

Frozen shoulder is a chronic condition characterized by a gradually progressive, painful restriction of shoulder movement. The cause of frozen shoulder is unknown. There is often a slow recovery in shoulder motion over a period ranging from months to years. In about 15 percent of people, both shoulders are involved.

People with a frozen shoulder experience aching in the shoulder region that often radiates to the upper arm. The pain is often worse at night and is aggravated by moving the affected arm. Although frozen shoulder sometimes follows an injury, it usually occurs without any clear precipitating event.

Evaluation of Frozen Shoulder. People with frozen shoulders lose shoulder motion in every direction, with the least ability to move the arm away from the body. Even though a frozen shoulder usually does not produce changes on an X ray of the shoulder, a physician may order an X ray to look for other possible causes, such as rheumatoid arthritis, bone deterioration caused by poor blood supply, and fractures of the upper arm.

Treatment of Frozen Shoulder. The natural untreated course of a frozen shoulder is an important consideration. Usually the painful phase lasts 2 to 4 months and is followed by a relatively stable period of immobility lasting 4 to 6 months. The full range of motion then gradually returns during the next 6 to 12 months. Regardless of the type (or lack) of treatment, the chance of a complete return of function is excellent. However, return of function may take up to two years.

A sensible approach to treatment, therefore, entails first understanding that the problem usually goes away without treatment or therapy. During the two to four months when there is shoulder pain, steroid injections or nonsteroidal anti-inflammatory drugs may provide relief. Once the pain has resolved, an active stretching program supervised by a physical therapist may be helpful, but it should be discontinued if it causes a recurrence or worsening of the pain. Active stretching programs usually yield the most improvement within the first three to four weeks of treatment. Aggressive therapies such as manipulation of the shoulder under anesthesia are not necessary.

Back Pain

Most of us will experience back pain--it is a chronic illness with a high likelihood of both recovery and recurrence. As with a number of other musculoskeletal or joint conditions, the cause, course, and evaluation of back pain in older people is quite different than in younger people. Changes in the lower back due to wear and tear constitute a normal feature of aging, and interestingly these changes by themselves do not cause back pain. In younger people, distortion of the gellike disks sandwiched between the vertebrae in the lower back is a common cause of back pain, but these disks lose much of their water content with age and are much less likely to become distorted (see Figure 17, page 242).

Causes of Back Pain

In older people, back pain can be produced by movement, disk compression of an already narrowed spinal canal with a displaced disk, and instability of the lower back vertebrae.

The range of causes in older people also includes an increased possibility of malignancy, infections, and abdominal aortic aneurysm (ballooning of a blood vessel wall described in more detail in Chapter 19).

Changes at one disk space in the lower back out of proportion to the rest of the spine can result in an unstable lower back spine. This instability sometimes pushes some of the vertebrae forward, which in turn pinch spinal nerves and cause severe pain in the back or down the back of the leg. This pain comes on suddenly, lasts a short period of time, and often recurs. It is frequently brought on by sudden movements. The person moves very carefully and has pain when moving from a flat to a sitting-up position. Sometimes a special corset with metal supports or abdominal-muscle strengthening exercises can help.

A backache caused by underlying diseases such as infections, aneurysms, and tumors usually has a distinct course that calls for prompt and vigorous investigation. Pain from a backache caused by an underlying disease gets steadily worse during a course of several days to weeks. The pain is not usually related to the person's position (lying or sitting) as it becomes more severe and persistent. Urgent warning signals that require immediate evaluation by a physician are pain in the upper to midback, fever, pain going down below the knee, difficulty walking, significant pain after a fall, and loss of bowel or bladder control. Because of the risk of spinal cord compression, a person with a known malignancy who experiences back pain should receive an emergency evaluation.

Evaluation of Back Pain

To determine the cause of most back pain, a physician needs to know how the condition started and its progress, the results of a physical examination, and a knowledge of applied anatomy. Sophisticated X ray imaging usually does not reveal the cause of a person's back pain.

Treatment of Back Pain

In older people, back pain is less likely to resolve without treatment and is more likely to require aggressive evaluation and treatment.

Because low back pain usually produces muscle spasms, the basic treatment consists of rest and pain relievers. Generally the pain resolves in a week; persistent pain should prompt additional medical evaluation. Surgery may be considered for severely pinched nerves, but it is not always helpful and failures are common. Backache produced by infections, tumors, or aneurysms is treated by addressing the specific cause.

Hip Problems

The hip joint is formed by the knob-shaped end of the femur (the thigh bone) and a socket made of bones in the pelvis (see Figure 20). The joint is located deep in the body and is protected by the large upper leg muscles. Because of its deep location, hip pain can be felt in many locations such as the groin, outer thigh, or even down the leg to the knee.

Causes of Hip Problems

Any of the common joint diseases mentioned in the introductory section on joint problems and specific conditions discussed later in this section can affect the hip, including osteoarthritis, rheumatoid arthritis, and gout. Structures around the hip such as bursae can become inflamed. In addition, if blood supply to the knob-shaped end of the femur is reduced, the bone will wither. The femur can break relatively easily if the older person falls or has extensive osteoporosis (these conditions are discussed later in this chapter).

Evaluation of Hip Problems

Hip pain usually requires a medical evaluation. Medical attention should be sought immediately if there is fever, recent injury, walking difficulty, pain with bearing weight, or severe pain with no movement or weight bearing. The physician will probably order X rays.

Treatment of Hip Problems

The treatment of hip pain depends on the results of the physician's evaluation. Surgery may be helpful in some circumstances to reduce pain and improve ambulation.

Osteoarthritis of the Hip

Osteoarthritis of the hip is characterized by the gradual development of pain in either the buttock, groin, thigh, or front of the knee.

Cause of Osteoarthritis of the Hip. The pain is directly related to bearing the weight of the body, thus it is relieved when the person sits or lies down. People find that going up stairs is difficult because this activity requires the hip to bend. They also have difficulty in moving from a sitting to a standing position, and they walk with a gait that appears painful, which is often characterized by a short stride and extended buttock.

Evaluation of Osteoarthritis of the Hip. The inability to cross legs, tie shoes, or bend at the waist is an early sign of osteoarthritis of the hip. Because hip disease sometimes produces pain in the back or the knee, the hip must be carefully examined when either back or knee complaints occur. A physician usually checks the movement of the hip with the person lying flat (first on the back, then lying prone). The leg is moved up and down and from side to side to check the hip movements.

Treatment of Osteoarthritis of the Hip. Treatment of osteoarthritis of the hip involves pain relievers, weight loss, limitation of weight-bearing activities, an exercise program, and the use of supportive devices such as a cane (see Chapter 8). The cane should be used on the person's good side so that the cane and the weak hip form an arch. When walking, the weight is borne by the shoulder, arm, and cane and is shifted away from the painful leg. When done appropriately, as much as 40 percent of the weight can be shifted off a painful hip.

For the person with osteoarthritis of the hip, activities that produce the pain should be avoided and exercise begun cautiously. Usually severe pain at night indicates that there has been too much activity during the day. Extensive inappropriate weight-bearing activity may speed up the need for joint replacement surgery. Because of this, prolonged standing and walking should be avoided. On the other hand, too much sitting or use of a wheel-chair can produce a stiff joint, so a balance between sitting, lying, and standing must be achieved to maximize function.

An exercise program usually performed under the supervision of a physical therapist can help to maintain the strength of the muscles around the joint to prevent deformity and maintain function. Exercises that stretch the joint or increase the range of motion are not likely to be helpful because the loss of range of motion is caused by loss of cartilage. Rather, a person with osteoarthritis should follow a regimen of exercises done while lying on the stomach and designed to prevent hip contractures. A swimming program to maintain the muscles around the joint without irritating the joint is also likely to help.

A decision to replace a hip joint destroyed by osteoarthritis is a major one. The primary reason for a hip replacement is the relief of pain. Surgery should be considered if the person has pain that makes transferring weight from side to side and short walks difficult, has significant pain at night, or pain that has a disabling impact on the person's lifestyle.

Knee Problems

Knee problems are very common, affecting about 5 percent of elderly people. Knee disorders can produce considerable disability, especially in walking or using stairs because there are few ways to compensate for impaired knee function.

The knee joint is a hinge that can move a little over 120 degrees. Normally the knee locks into position when fully straightened. Horses take advantage of this and are able to sleep while standing. Stability of the knee depends on the strength of the bones, muscles, and ligaments as well as the cartilage pad that sits in the joint.

Causes of Knee Problems

Any of the common joint diseases can affect the knee. Osteoarthritis is the most common and produces pain on standing (see page 253). Serious conditions such as infection and gout can also frequently produce swelling and knee pain.

Evaluation of Knee Problems

Because knee problems can result in significant walking difficulty, most people should seek medical attention if they notice swelling, severe knee pain, or any knee instability. Medical attention should be immediately sought if there is fever or if the person cannot walk.

Treatment of Knee Problems

The treatment of knee problems depends on the results of the physician's examination. Medications and physical therapy are often prescribed, and surgery may be appropriate for torn cartilages or severe deformity.

Osteoarthritis of the Knee

Osteoarthritis of the knee can involve three components of the knee: the kneecap, the inner (medial) portion of the knee, and the outer (lateral) portion (see Figure 21). Usually, a narrowing of the medial joint space, resulting in bowleggedness, is the earliest feature of the condition.

The pain produced by problems of the kneecap commonly occurs over the top surface of the knee and radiates down into the lower leg. Since bending the knee while bearing weight stretches this compartment, going down stairs often creates the pain. Many people compensate for this by going down stairs sideways or even backward. The strain on tissues attached to the kneecap is made worse by atrophy of the large muscles in the thigh. Osteoarthritis involving the kneecap can produce crepitus, a crackling and popping sound that can be produced by placing the hand on the kneecap as the person straightens the knee.

The medial component of the knee is the most commonly affected portion of the osteoarthritic knee--bending the knee will produce pain. The loss of the ability to straighten the knee makes the transfer of weight from one position to another difficult; there is also a strain on the hip and back during walking. A reasonable exercise program has three goals: strengthening the large thigh muscles as much as possible, avoiding any further irritation around the kneecap, and preventing knee stiffness and resistance to movement, called contractures. These aims can be achieved by sitting on the edge of a high chair or table and gently kicking one leg out as straight as possible, then holding the leg straight out without support for a count of five. This exercise can be built into the daily routine and done, for example, while watching television. One leg can be raised and held straight out for the duration of a television commercial then the opposite leg raised and held out for the duration of the next commercial and so on.

Foot Problems

Foot disorders almost always cause walking problems in older people. Close inspection of the feet often provides useful clues to the overall hygiene and health status of the individual. People with alcohol problems, for example, will often have feet that are not well cared for and that perspire freely.

Table 21. Causes of Foot Pain

Big toe deformities

Blood vessel disease

Congenital causes

Gout

Ill-fitting shoes

Neurologic disease

Plantar warts

Rheumatoid arthritis

Stress fractures

Trauma

Thumors

Causes of Foot Problems

A lifetime of habitual foot activity and the use of ill-fitting footwear can produce a number of foot deformities including bony growths called exostoses. These bone growths may lead to foot distortions, swelling over the exostoses, skin growth over the protuberance (commonly called a corn), and a need for therapeutically designed footwear. Foot pain can result from a variety of conditions, as listed in Table 21.

Treatment of Foot Problems

The first step in treatment involves modifying the footwear to accommodate the changes in the foot. This may mean stretching the current shoes, buying new shoes, or having specially designed shoes made to accommodate the foot abnormality. Treatment of corns with corn plasters may reduce the pressure on the affected area. Sometimes weight-bearing activities must be stopped for a few days to control the symptoms. Nonweight-bearing exercises should be done during this time to maintain strength and movement. Nonsteroidal anti-inflammatory drugs may provide some pain relief, especially when minor swelling and redness are present. When the symptoms of foot disorders limit one's activity and do not get better, a visit to the physician or a podiatrist is in order.

While surgical procedures to correct foot problems are sometimes successful, these procedures involve substantial discomfort and limit standing and walking for weeks to months. People recovering from foot surgery must be sure to maintain their muscle strength during convalescence.

Pain in the Ball of the Foot

Pain in the ball of the foot (called metatarsalgia) is one of the most common foot problems seen in older people.

Causes of Pain in the Ball of the Foot. The condition appears to be more common in women than in men and may be caused by wearing pointed-toe shoes and by a number of disorders that distort the metatarsal joints.

A bunion, sometimes called hallux valgus, is a condition in which the big toe turns sideways, almost pointing directly toward the little toe on the same foot (see Figure 22). This produces a protrusion and sometimes bony growth at the joint at the base of the large toe. A bunion can also be a consequence of rheumatoid arthritis or osteoarthritis. As the large toe turns to the side, the second toe may overlap it and develop corns on its top surface caused by friction with the shoe. Occasionally, small branches of the nerves in the foot are compressed, producing tenderness and tingling in the areas around the toes and just behind the toes.

Morton's neuroma, a benign small nerve growth, can form on any of the small nerves of the foot but usually involves the third toe. Early on, the growth produces a mild ache in the area of the ball of the foot that is sometimes accompanied by a mild burning sensation. The pain can be reproduced by pushing on the space at the base of the third or fourth toe.

Causalgia, a type of reflex in the nervous system that follows an injury to a large (trunk) nerve, produces a severe burning pain in the foot.

Tarsal tunnel syndrome is caused by trauma (especially a fracture), foot deformity, or excessive movement in the foot and ankle. The nerve supplying sensation to the foot, called the posterior tibial nerve, is compressed near the ankle, resulting in numbness, tingling, burning pain, and other changes of sensation in the toes and soles of the feet. Sometimes the person cannot feel the prick of a pin in these areas. Ankle, foot, and leg movements may relieve the pain in tarsal tunnel syndrome. The condition is similar to the carpal tunnel syndrome that can involve the hands.

Plantar warts resemble corns and callouses and are flat and surrounded by extra skin growth. They can be extremely tender and may appear anywhere on the sole of the foot.

Treatment of Pain in the Ball of the Foot. Usually, the initial treatment for metatarsalgia is conservative, consisting of weight loss for people who are overweight and choosing appropriate footwear. Physical therapy and anti-inflammatory medication are often helpful. Custom-made shoes are usually not necessary and most people can be treated initially with simple soft pads in their shoes designed to transfer weight-bearing to areas of the foot that are not painful. If such adaptations of footwear do not work, then it may be necessary to obtain special devices. As mentioned earlier, surgery should be considered only when less invasive measures for correcting foot problems have failed.

Heel Pain

Older people frequently have heel pain that begins immediately upon walking and lessens as walking continues. In most situations, however, the pain is felt at the base of the heel most when the person is standing.

The most common cause of such heel pain is a bone spur that presses into the heel area. Placing a pad or special insert into the person's shoe to decrease weight on the heel may relieve the pain. Footwear that provides maximum cushioning such as shoes with rubber soles is helpful. Sometimes it is necessary for a physician to inject the area with a corticosteroid, which often provides relief for many weeks. Surgical treatment is rarely necessary.

Haglund's deformity (sometimes known as the "pump bump") appears to arise from pressure on the back of the heel where a bursa may become irritated by pressure from a shoe. This condition may respond to NSAIDs or a corticosteroid injection. Heel lifts that raise the heel above the shoe top can also help in reducing pain and discomfort. If these efforts do not work, surgical removal of the bursa may be necessary.

Miscellaneous Foot Disorders

Itching of the feet is common in older people and may simply be due to dry, scaly skin. Contact dermatitis and fungal disease such as athlete's foot are also common causes of itching. A moisturizing cream may help reduce the itching problem. For seriously irritated feet, it may be necessary to apply a cream or lotion containing a small amount of corticosteroids. A skin condition called contact dermatitis can result from an allergic reaction to shoes or other footwear: Sometimes a change in footwear relieves this condition. Athlete's foot is identified by the presence of small blisters, cracks, or fissures in the skin. The most common site for these conditions is between the toes. Older people may be predisposed to develop other complications, especially if they have poor circulation to the feet. Treatment of athlete's foot includes soaking the feet with Epsom salts and applying topical antifungal creams. Close examination of the area between the toes is especially important in any older person since this is one of the most common sites from which serious infection (such as cellulitis) can spread to the legs.

Corns and calluses result from friction around bony prominences and are particularly associated with shoes that do not fit correctly. Corns are especially common over bunions or other abnormalities in the feet. If corns and calluses are causing problems a physician or nurse can trim them or provide padding to the shoe to relieve pressure and to reduce friction.

CONDITIONS Gout

Although gout most frequently develops in middle-aged men, it can occur at any age. In women, gout most often appears after menopause. Development of a sudden painful large joint in the foot or lower leg suggests the condition.

Causes of Gout

Gout is a disease usually associated with a high uric acid level in the blood and the deposition of uric acid crystals in body tissue. Uric acid comes from the chemical breakdown of purines--one of the building blocks of DNA. Alcohol use may increase the chance of getting gout. People taking diuretic medication, alcohol, or who have recently had a serious illness or surgery also have an increased likelihood for gout. Gout tends to be episodic and recurring.

Evaluation of Gout

Although elevated uric acid in the blood is often present, a doctor usually bases a diagnosis of gout on the results of a microscopic examination of fluid drawn from the affected joint with a needle. Characteristically, the examination will reveal needle-shaped uric acid crystals.

Treatment of Gout

There are many effective methods of treating acute gout. High doses of nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in most cases. Colchicine, a drug that can be given intravenously, is also an effective medication for flare-ups. Oral colchicine once or twice a day can also act as an effective preventative measure against recurrent attacks of gout. The high oral doses of colchicine required for treating an acute attack almost always cause diarrhea and do not appear to be as effective as NSAIDs or intravenous colchicine.

A high uric acid itself does not need to be treated unless the person is having recurrent symptoms of gout, or has kidney stones caused by high uric acid. Some people undergoing cancer treatment by chemotherapy receive treatment to lower uric acid because chemotherapy can produce extremely elevated uric acid levels in the blood. The use of uric acid-lowering drugs has no role in the management of a sudden gout attack, but can be useful in some people to prevent attacks.

Pseudogout

Pseudogout, also known as calcium pyrophosphate deposition disease (CPPD), is a common cause of joint pain in older people. The average age of onset is the late fifties. It is called pseudogout because it resembles acute attacks of gout and may be difficult to distinguish clinically.

Cause of Pseudogout

Pseudogout is characterized by calcium deposits in the joints and the presence of crystals of calcium pyrophosphate in the joint fluid seen under a microscope.

Evaluation of Pseudogout

There are many forms of pseudogout and any joint can be affected, although it most often involves the knees and wrists. In addition, as in authentic gout, pseudogout can be provoked by severe illness, injury, or surgery; attacks are often accompanied by fever.

One form of pseudogout resembles rheumatoid arthritis. People with this form have chronic discomfort that lasts from weeks to months, and may have very stiff joints in the morning. A useful clue is wrist and knee involvement without the involvement of any other small or large joints. Some people experience a progressive destruction of many joints with pseudogout, which may indicate another underlying problem. Although X ray evidence of calcium in the joint can help a physician diagnose pseudogout, this finding by itself does not indicate the cause of pain, because over 25 percent of older people (most of them pain-free) have calcium in their joints.

Treatment of Pseudogout

Usually the treatment of pseudogout consists of NSAIDs for abrupt attacks, although low-dose colchicine may also decrease the frequency of attacks. In people with only one affected joint, draining the inflamed fluid from the joint and injecting corticosteroids can be helpful.

Osteoarthritis

Osteoarthritis is a slowly progressive disorder principally affecting the hands, hips, and knees. (See the sections on hip and knee problems for more information.)

Cause of Osteoarthritis

Loss of cartilage, the normal cushion of the joint, is the main feature of osteoarthritis. This loss causes bone changes: formation of bony growths called osteophytes, small holes (cysts) in the bone near the joints, and changes below the cartilage in the bone that supports the joint. Normal cartilage is made of chemical building blocks that have water-absorbing and elastic properties. The earliest signs of osteoarthritis are changes in some of these building blocks, resulting in less water absorption and reduced elasticity within the cartilage. Pain and dysfunction are the major problems associated with osteoarthritis. The pain itself is probably not due to the changes in the cartilage (cartilage does not contain nerve fibers), but most likely results from small fractures around the joint, stretching of the joint lining, or irritation of nerves that accompany the blood vessels below the cartilage. These mechanical problems can cause pain and swelling in the joints.

X rays show a characteristic, asymmetric joint space narrowing, reflecting loss of cartilage. X rays also reveal bone cysts and extra bone growth where two bony surfaces touch or rub each other. Osteoarthritis can also result as a by-product of fractures, repeated trauma, diseases such as gout and pseudogout, bleeding in the joint, and inadequate blood supply to the bones that make up the joint.

Evaluation of Osteoarthritis

The most common form of osteoarthritis is seen in postmenopausal women. The first clue is usually a bony enlargement of the end joints of the fingers; however, other finger joints and the base of the thumb can be affected. Other joints frequently involved include the hips, knees, and the base of the big toe. Lack of involvement in the wrist, elbow, and ankle helps to differentiate this condition from arthritis caused by gout, pseudogout, and other inflammatory conditions. People who have bony enlargement of the joints generally maintain complete functioning of these joints. Stiffness and aching, however, can develop in the early years of the condition. Even so, most people with osteoarthritis can use their hands with little discomfort over long periods of time.

Treatment for Osteoarthritis

Ice packs applied once or twice a day can be quite helpful for reducing the pain around an osteoarthritic joint. Injection of corticosteroids into irritated bursae or ligaments can often relieve discomfort. Generally, for additional pain relief acetaminophen should be tried first. If this is not effective, a trial of low-dose aspirin (4 to 6 tablets per day) is often recommended as the next best medication for people who can take aspirin. If these two simple regimens do not work, a physician should be seen for additional evaluation and guidance.

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic systemic disease characterized by inflammation of small joints, usually symmetrically (on both sides of the body). Other body organs such as the blood vessels, heart, lungs, and nerves can be involved.

Cause of Rheumatoid Arthritis

The cause of rheumatoid arthritis is not known. The joint lining (synovium) grows and thickens, which starts an inflammatory reaction that chemically destroys the cartilage, ligaments, tendons, and bones, ultimately affecting the joints. Rheumatoid arthritis occurs in about 3 percent of elderly women and 1 percent of elderly men. While the peak onset of rheumatoid arthritis is usually in the thirties or forties, it starts after the age of 60 in at least 10 percent of people. Women, whether young or old, are more commonly affected. Many elderly people with rheumatoid arthritis have antibodies in their blood called rheumatoid factors.

The classical features of rheumatoid arthritis include stiffness, swelling, and pain of the small joints of both hands, both wrists, both feet, and both ankles. The course of the illness is often progressive and destructive. This classical pattern is seen in older as well as younger people.

A second pattern of the disease is more characteristically seen in people who develop rheumatoid arthritis at an older age. Typically there is an abrupt onset of the disease, with involvement of large joints such as the shoulder, hip, and knee. More men have this type than women and rheumatoid factors are often not elevated in the blood. There is a reasonable chance of spontaneous remission within a year. The large joint involvement often makes this condition difficult to distinguish from other arthritis.

Evaluation of Rheumatoid Arthritis

Rheumatoid arthritis is usually diagnosed through a physical examination. The presence of swelling of the joints in the hands, ankles, and elbows as well as loss of motion of the wrist, shoulders, and hips points to inflammatory arthritis. Laboratory tests have a limited role in making the diagnosis because an abnormal result is not very specific for rheumatoid arthritis. A key to the identification of this condition in older people is the presence of joint inflammation in joints not involved with general wear-and-tear osteoarthritis. An increased number of white blood cells in the joint fluid is a good indicator of an inflammatory arthritis.

Treatment of Rheumatoid Arthritis

Nonsteroidal anti-inflammatory drugs are used cautiously in treating rheumatoid arthritis because of the potential gastrointestinal, kidney, heart, and other complications. Short courses of low doses of corticosteroids can be helpful in some older people (for example, 10 milligrams of prednisone a day). Long-term use of high doses (more than 10 milligrams of prednisone a day) can produce devastating side effects such as bone fractures, tendon ruptures, infections, and skin breakdown. High doses of corticosteroids are used only if the disease is not responding to other measures.

Osteoporosis and Osteomalacia

Osteoporosis and osteomalacia are both diseases producing a lack of bone. However, osteoporosis and osteomalacia differ: In osteoporosis the bone is normal in its mineral composition but is decreased in amount, whereas osteomalacia is characterized by having decreased bone mineralization (see Figure 23).

Osteoporosis

Under the microscope, osteoporosis is defined as a decrease in the amount of bone, with the remaining bone appearing normal. A useful, clinical definition of osteoporosis is less clear. A panel of experts convened by the National Institutes of Health defined osteoporosis as "an age-related disorder characterized by decreased bone mass and increased susceptibility to fracture in the absence of other recognizable causes of bone loss." To some extent osteoporosis is part of normal aging. The challenging task is distinguishing between the amount of bone loss that is normal for a person's age and that which should be considered abnormal. It seems clear that with decreasing amounts of bone that the likelihood of fractures goes up, but even at the lowest levels of bone density, some people do not experience fractures.

For white women over the age of 65 the lifetime risk of hip fracture is about 15 percent, vertebral fracture 30 percent, and forearm fracture 10 percent. African-American women have about one-third the risk of fracture of white women. White men have a 6 percent risk of hip fracture compared with a 3 percent risk in African-American men. The lifetime risk of hip fracture remains stable from the ages of 60 to 90. The estimates for vertebral crush fractures are more difficult to determine because many do not cause symptoms. Most fractures occurring in vertebrae happen in the middle and lower back. The principal problems include decreased height, stooped posture, possible back pain, and a significant amount of psychologic distress. Wrist fractures, the third most common type of fracture associated with osteoporosis, are relatively benign but cause significant transient disability.

Causes of Osteoporosis. The fundamental causes of osteoporosis are considered to be related to the menopause and to age. For other causes the mechanisms appear to be complex and are not well understood. A simple classification is shown in Table 22.

Table 22. Causes of Osteoporosis

Aging

Alcohol

Cigarettes

Disuse (immobilization)

Drugs

Hormone changes (estrogen, diabetes mellitus, thyroid disease, others)

Malignancy (multiple myeloma, leukemia, lymphoma)

Because women have so many more fractures of the hip, wrist, and vertebrae than men, estrogen deficiency is thought to be a cause of osteoporosis. Women who take estrogen have about half the number of hip fractures than women not taking estrogen have. Estrogen replacement corrects poor absorption of dietary calcium in postmenopausal women. Bone density is maintained in women treated with estrogens as compared with women not so treated. Estrogen also has an effect on vitamin D and parathyroid hormone levels, two compounds intimately related to bone growth and bone loss.

A relative deficiency of calcium has also been suggested as a cause of both postmenopausal and age-related osteoporosis. The age-related decrease in calcium absorption by the intestine may be due to problems with vitamin D activation by the kidney. Another factor is that lack of exercise or activity may cause the bones to release calcium.

Additional evidence for calcium's role in the development of osteoporosis comes from studies looking at the amount of calcium in the diet. Studies suggest that a high level of calcium intake through life may decrease the risk of fracture and help maintain overall bone density. Other studies have suggested that people with osteoporosis have had lower calcium intake than people who do not have osteoporosis.

Decreased calcium absorption from the intestine is at least partially responsible for the calcium loss that occurs when someone is completely immobilized in bed, and conversely, calcium absorption increases with physical activity. These changes are consistent with the observations that immobility causes bone loss while exercise may have a protective effect against osteoporosis. Exercise may also have a beneficial effect in preventing osteoporosis by directly increasing bone density.

Symptoms and Manifestations of Osteoporosis. A fracture due to little or no apparent trauma may be the first indication of osteoporosis. Sometimes incidental fractures in the vertebrae are seen on chest or spine X rays. Common situations include back pain with vertebral compression fractures, pain due to a hip fracture following a fall, and fracture of the wrist after falling on outstretched hands. Because of an increased awareness of the occurrence and importance of osteoporosis, many women now seek an assessment of their risk.

Evaluation of Osteoporosis. In general, the physician's evaluation includes a complete physical examination and blood tests to look for possible causes such as thyroid gland abnormalities, diabetes mellitus, various malignant diseases, and liver and kidney disease.

Estimates of fracture risk depend on several clinical factors: racial and genetic background, diet, medications, smoking history, exercise, and body size and weight. However, even when used in combination, these clinical factors cannot adequately predict bone density in an individual person and cannot be recommended as a way to reliably determine the chance of a fracture.

To provide more accurate estimates of the risk of fractures, a special technique called bone densitometry has been developed to measure bone density. This technique uses a low-level X ray source to determine the amount of bone density. The person puts his arm in a box and the bone is scanned in a few moments. Bone density measures can predict the likelihood of fractures up to seven years in advance. The lower the amount of bone density the higher the fracture rate. Bone densities of women under age 60 have been predictive of vertebral fractures, while bone densities of women older than 60 on average have been predictive of hip fractures. Although this predictive capability is impressive, it's still not reliable enough for general application. Bone density screening programs are not recommended at this time.

Treatment and Prevention of Osteoporosis. The treatment for established osteoporosis remains experimental. Sodium fluoride is a recognized treatment, yet its safety and efficacy are still being determined. Fluoride increases bone mineral density, but the resulting bone may be brittle (like porcelain) and fractures may actually be more common during fluoride treatment.

Calcitonin is a hormone that has not yet been shown to reduce fractures, although it is approved for treatment of osteoporosis. It appears to increase bone density up to 8.5 percent over a year. However, this increase in density tends to plateau at about 18 months. Calcitonin is expensive and generally must be used as an injection. However, a nasal spray has been developed and if proved effective may become the preferred mode of administration. Strategies are being developed to try to overcome the plateau effect.

In spite of the progress made in the treatment of osteoporosis, prevention continues to be the main way to address this condition. Men and women should increase their intake of calcium since agerelated decreases in calcium absorption occur in both sexes. Good calcium intake early in life can increase the peak of skeletal bone mass. This increased peak can help as bone is slowly lost throughout life. For postmenopausal women, the intake of calcium should be 1,500 milligrams per day, and for elderly men it should be at least 1,000 milligrams per day. Because older men and women have increased requirements for vitamin D, they should take between 600 and 800 international units (IU) of this vitamin. (Two regular multivitamins usually provide 800 IU.) Older people with a history of kidney stones should not take extra calcium or vitamin D.

Weight-bearing exercise should be used as a preventive measure in both men and women throughout life. Exercise three times a week helps maintain bone mass and may reduce the risk of fractures.

Estrogens reduce postmenopausal osteoporosis. There is a 50 percent reduction in the risk of hip and wrist fractures in women who use estrogen.

In addition to providing a substantial benefit of hip fracture prevention, estrogen may also prevent heart attacks. Several studies suggest a 50 to 60 percent reduction of the risk of heart disease, which has led many people to conclude that the benefits far outweigh the risks of estrogens. (See Chapter 25 for more on estrogenreplacement therapy.)

The decision to use estrogens, however, to prevent osteoporosis must be based on an analysis of the benefits versus the risks. If estrogen is used by itself, there is a small increase in the risk of endometrial cancer. The risk of developing endometrial cancer can be avoided by adding progestin, another female hormone, to produce menstrual cycling. The effect of this combination on breast tissue is not known. Using estrogen alone for up to 15 years does not appear to increase the risk of breast cancer; using estrogen and progestin together may increase the risk. Another concern is that adding progestin may change the levels of cholesterol in the blood and reduce some of the potential cardiovascular benefits of estrogen therapy.

It is not clear if a woman is ever too old to begin estrogen replacement therapy (ERT). The rate of bone loss is reduced in women who begin to use estrogen in their eighties, but this may not really reduce their risk of fracture. Some experts have suggested that ERT should begin at menopause and should be stopped at the age of 65. The rationale for this is that it may take approximately 20 years after the menopause for fractures due to osteoporosis to occur. Because of this 20-year interval it is believed that taking estrogen until the age of 65 would delay the onset of hip fractures until the age of 85. However, since this rationale pertains only to the use of estrogen for the prevention of fractures due to osteoporosis, this strategy does not take into account a continued use of estrogen for the potential prevention of cardiovascular disease.

Osteomalacia

Osteomalacia can be confusing because it may refer to a variety of things, including several symptoms indicating an underlying condition, a specific disease, and a particular, microscopically observed deterioration of bone structure. As a specific disease, osteomalacia is caused by vitamin D deficiency.

Causes of Osteomalacia. The causes of osteomalacia are shown in Table 23. Problems with vitamin D regulation, ultimately, are the common cause of osteomalacia. To understand these causes it is important for us to review how vitamin D is used in the body.

Vitamin D is a naturally occurring constituent of a few foods such as cod liver oil, swordfish, and eggs. It is also made in the skin in the presence of sunlight exposure. A chemically synthesized version of vitamin D is commonly added to milk and other foods. These dietary and skin sources of vitamin D are modified by the liver and in the kidney to more active forms.

Vitamin D has many functions including the regulation of calcium and phosphorus absorption in the intestine, the release of calcium from the bone to regulate calcium levels in the blood, maintaining phosphate balance, and a role in helping bone to mineralize, which is not completely understood. Vitamin D deficiency results in decreased calcium absorption from food, stimulation of parathyroid hormone, decreased phosphorus in the blood, and later on, decreased calcium in the blood.

Table 23. Causes of Osteomalacia

VITAMIN D DEFICIENCY
Anticonvulsant therapy
These drugs stimulate liver metabolism of vitamin D to inactive metabolites
Chronic severe liver disease
Chronic kidney disease
Due to impaired formation of active vitamin D by kidneys and to circulating inhibitors of bone mineralization found in kidney failure
Dietary lack, especially in alcoholism
Gut malabsorption
Vitamin D is a fat-soluble vitamin and fat malabsorption (steatorrhea) leads to vitamin D deficiency
Poor sunlight exposure
Vitamin D-dependent osteomalacia
Type I inherited deficiency of the enzyme necessary for activating vitamin D; Type II inherited inability of target organs to respond to vitamin D
LOW PHOSPHORUS IN THE BLOOD
Excess ingestion of aluminum hydroxide gels, which decrease phosphate absorption
Hereditary hypophosphatemia
Inherited phosphate-transport abnormality, with renal phosphate wasting
Tumor osteomalacia
Some tumors produce a humoral factor that causes renal phosphate wasting
Other renal disorders

Use of anticonvulsants, chronic severe liver disease, and primary biliary cirrhosis may also be associated with low-turnover osteoporosis.

Source: Adapted from Mundy GR. Osteopenia. Disease of the Mouth. 1987;33:537. Reprinted with permission.

Any cause of vitamin D deficiency (from poor nutrition to problems in the liver or kidney) disturbs body calcium levels and bone mineralization. There are additional distinct mechanisms that can inhibit bone mineralization and cause osteomalacia. If the level of phosphorus in the blood is persistently low, for example, osteomalacia occurs despite the high levels of active vitamin D. Other causes of osteomalacia appear to exert their effects directly by inhibiting bone mineralization through as yet unknown mechanisms.

Deficiencies of vitamin D, calcium, and phosphorus affect muscles and other biochemical processes as well as bone formation. Vitamin D may be necessary for normal muscles to function. Low calcium levels in the blood can produce numbness or tingling in the hands and feet, muscle cramps, and muscle contractions. Low phosphorus levels in the blood can cause muscle, blood, and heart disorders.

Who Is at Risk for Osteomalacia? Age-related changes in nutrition and body functions place older people at higher risk for vitamin D deficiency. The amount of vitamin D in the diet is generally low because of voluntary avoidance of milk products and foods rich in vitamin D. In addition there is decreased vitamin D absorption by the intestine. Because of these factors vitamin D levels in older people depend more on the amount of sunlight they are exposed to than on the amount they get from food. Therefore, older people who live in northern climates and those who are institutionalized or house-bound are at higher risk for osteomalacia from vitamin D deficiency. Clearly an important contributing role may also be played by the chronic diseases that led to the person being house-bound or institutionalized.

Symptoms and Evaluation of Osteomalacia. Osteomalacia in older adults produces bone pain, especially in the lower spine, ribs, pelvis, and legs; muscle weakness in the thighs and shoulders; and cramps or involuntary muscle contractions if blood calcium is low. Fractures of the hip, spine, ribs, and pelvis also are part of the osteomalacia syndrome. Studies of the bone condition in older people who have had hip fractures suggest that as many as one-quarter have osteomalacia.

Wide-scale screening programs for osteomalacia are currently not being recommended because of the limited knowledge of the extent of osteomalacia and the poor understanding of its relationship to subsequent events such as fractures. However, people who have conditions that are associated with changes in vitamin D or phosphorus as listed in Table 23 should consider an evaluation for osteomalacia. Generally, this can be started by having blood tests for calcium, phosphorus, vitamin D levels, and parathyroid hormone levels. A complete evaluation would include bone X rays.

Treatment and Prevention of Osteomalacia. For all age groups, the standard dose of vitamin D to treat documented vitamin D deficiency is 10,000 International Units (IU). Intermittent larger doses can also be used but are associated with increased risk of developing a dangerously high calcium level in the blood. Two to three grams of calcium is usually taken each day to prevent the low calcium in the blood that may occur as bone is actively being mineralized. For osteomalacia caused by changes in the gastrointestinal tract or liver, or by kidney disease, the treatment must be tailored to the specific cause.

Although the recommended daily allowance for vitamin D for all ages is only 400 IU, the amount needed to maintain bone health in older people is higher. This is due to the previously described changes related to aging. Except for people with a history of kidney stones, the safe alternative is 800 IU per day. This amount can be easily supplemented by taking two multivitamins a day. An alternative method is a single 10,000 IU, high-dose vitamin D supplementation once every six months when the risk of osteomalacia is high and the person's compliance with daily medications is doubtful.

Paget's Disease of Bone

In Paget's disease of bone (named for the 19th-century English surgeon Sir James Paget), the affected bones are larger than normal, are often deformed, and have an increased blood supply. Under the microscope, the bone looks very disorganized, with increased activity of cells. Bone turnover seems to be rapidly accelerated, with increased bone destruction followed by excessive bone growth. Eventually the bone loses its rich blood supply and develops scar tissue in the bone marrow space.

Causes of Paget's Disease of Bone

The exact cause of Paget's disease of bone has not yet been determined. Some evidence suggests a virus as the cause, though so far no virus has been isolated. Other factors such as repeated trauma and a strong family history may play a role in the development of the disease. The prevalence of Paget's disease of bone increases with age and has a peculiar geographic distribution. In the United States, it is seen more commonly in northern rather than southern states, and in Europe it is more commonly seen in England and France than in Sweden and Denmark.

Evaluation for Paget's Disease

Paget's disease is sometimes obvious if the skull or a superficial bone is involved because the bones appear much larger than normal and are deformed. For most people, Paget's disease is discovered accidentally when tests are done for other reasons. Bone changes revealed in X rays show characteristic features of the disease. Blood tests reflect the increased bone turnover. Bone pain, the most common symptom of Paget's disease, results either from the disease or its complications. The pain is generally worse at night, especially if the person is lying in a warm bed. Severe unrelenting pain that occurs suddenly and is resistant to treatment suggests the development of a malignant tumor and is more likely to affect the bones of the upper arms and the skull.

The features and complications of this disorder depend upon which bones are affected. Long bones such as those in the legs tend to bend along the lines of least resistance. For example, the bone in the lower leg, called the tibia or shinbone, bows out to the front or the long bone in the thigh, the femur, may bow out sideways. Other bones commonly affected include the pelvis, skull, and the vertebrae. Nerve compression can occur. In the skull Paget's disease can cause blindness and deafness in some cases (Beethoven's deafness may have been caused by Paget's disease).

Fractures that commonly occur in Paget's disease may happen spontaneously or be caused by trauma. The fractures often have multiple breaks and are difficult to repair. The difficulty in management is due to the increased blood flow and the brittleness of the bone. In addition, even if a support is properly placed around the fracture site, the surrounding bone is weak and may not be able to hold its position.

Additional complications of Paget's disease include an increased level of calcium in the blood caused by the person's reduced mobility and the development of a malignant tumor called osteogenic sarcoma. Osteogenic sarcoma is a rare complication of Paget's disease occurring in less than 1 percent of people with the disease. In rare cases, people with Paget's disease develop high blood pressure, irregular heartbeat, and changes in the heart valves, especially if bone involvement is extensive.

Treatment of Paget's Disease

The treatment of Paget's disease is aimed at relieving pain, avoiding complications, relieving any nerve compressions, and maintaining skeletal function, while minimizing treatment side effects. Specific therapy must be individualized. Since most people do not have any symptoms, they do not require specific treatment. The main reasons for specific treatment include pain that does not respond to mild pain relievers, fractures, and neurologic complications. Some orthopedic surgeons also prefer specific treatment before they operate on an involved bone to reduce its overly rich blood vessel supply.

Traditionally, a hormone called calcitonin that specifically inhibits the cells that normally destroy bone has been used to control the activity of Paget's disease. This hormone is given by nasal spray or by injection. Side effects include nausea and flushing; both tend to disappear over time. The administration of calcitonin usually results in a sharp decline in the biochemical changes in the blood that reflect rapid bone loss and replacement. In most cases, treatment leads to improvement in the bone structure and in the appearance of the bones on X ray.

There are now, however, other medications--diphosphonates and their derivatives--that have largely replaced calcitonin in the treatment and management of Paget's disease. They are easy to take and have relatively few side effects if given in low doses. The remission induced by these compounds appears to be longer lasting than that induced by calcitonin. Diphosphonates are usually taken on an empty stomach since food interferes with their absorption. Some diphosphonates can be given as a single injection and have produced remissions lasting over a year. Because diphosphonates are excreted in the urine, the dose must be reduced in people who have kidney problems.

Bone Fractures

Fractures in the elderly usually result from low-energy injuries and involve bones that have been weakened by osteoporosis or some other disease process. Certain types of fractures happen more frequently among older people. Vertebral compression fractures and hip fractures are relatively rare until the fifth and sixth decades of life, after which they increase significantly. Other common fractures in old age include those of the wrist, leg, and pelvis.

Causes of Fractures

Most hip, arm, and pelvic fractures in older people are the result of a fall. The older person's ability to ward off the impact of a fall may be reduced by slowed reflexes, decreased muscle strength, and impaired coordination. In fact, most fractures are the result of relatively low-energy trauma caused by a fall on level ground.

Evaluation and Description of Fractures

Fractures are described in terms of their location, the orientation of the break (across, at an angle, or spiral), and the degree of bone fragmentation, called comminution (see Figure 24). If the bone has protruded through the skin it is called an open break, if it is not so exposed, it is a closed break. Another consideration is fracture alignment, referring to the relative position of the broken segments and the orientation of these segments. Finally, the broken ends themselves are identified as overriding, displaced, or impacted (pushed together).

The term "pathologic fracture" refers to any break that occurs in an abnormal bone. The abnormal bone may be weakened by an underlying cancer in the bone, a benign bone tumor, a metabolic disorder, an infection, or osteoarthritis. A person who has a fracture after minimal trauma very likely has had a pathologic fracture. In such cases, the person may have experienced increasing pain in the area of the break before the fracture occurred, pain that is especially noticeable at night and with bearing of body weight. Awareness of any such pain prior to a fracture is important to share with a physician because it can greatly alter the choice of treatment and the likelihood of healing.

Sometimes, a person with a pathologic fracture that has not yet entirely broken through the bone notices pain in the affected area associated with the use of the limb. For example, getting out of a chair can cause thigh pain in a person who has a problem with the large bone in the upper leg (femur). Fixing these partial fractures is often recommended to prevent displacement of the bone sections, provide pain relief, and permit the person to maintain function. Otherwise, if the impending fracture breaks through completely and becomes displaced the treatment becomes considerably more difficult, with increased disability and less chance of an effective bone repair and healing.

Spread of cancer from other places to the bone accounts for the great majority of bone malignancies. The most common spread occurs from breast, lung, prostate, gastrointestinal, kidney, and thyroid cancers. Multiple myeloma and lymphoma can also produce bony abnormalities in older people. (These bone marrow and lymph gland malignancies are covered in Chapter 20.)

How Fractures Heal

The repair process can be divided into three overlapping chronological phases: inflammation, repair, and remodeling. The inflammatory phase usually lasts several days and constitutes the body's initial response to injury. The trauma that breaks the bone also injures surrounding blood vessels, muscles, and other soft tissues. Bones are well supplied with blood and bleeding around the fracture site forms a large clot (hematoma). The bony fragments at the fracture site produce an immediate and intense inflammatory reaction, making the area swollen and tender. The repair stage begins within 24 hours after the injury and reaches peak activity after one to two weeks. During this time, fractures of the bone that are not rigidly stabilized heal by rapid formation around the fracture site of new bone, called external callus. This callus is not visible on the X ray until three to six weeks after the injury. Until enough callus forms to provide stability, collapse and displacement of the fracture can occur. This repair process can take up to several months for a long bone fracture such as in the leg. Fractures at the ends of bones tend to heal faster. During the remodeling phase, the initial callus, which was laid down relatively rapidly, is slowly reabsorbed and replaced by stronger bone. This process may proceed slowly in older people and may account for symptoms of discomfort that last for many months after a fracture.

Principles of Treating Fractures

The outlook for fracture healing in older people differs from that for younger people since there is a greater chance that joints will stiffen as a result of immobilization and there is a higher risk of medical complications with bed rest. The death rate for people during their first year after a hip fracture is 10 to 20 percent higher than for people of the same age and sex who have not had a hip fracture. In addition, 15 to 25 percent of those people who lived at home and were functionally independent before their fracture required nursing home care for more than a year. An additional 25 to 35 percent became dependent on various mechanical aids or help from others.

To avoid these complications, the goals of treatment emphasize a rapid return to the physical activities necessary to maintain independent living. Older people generally place less stress on their musculoskeletal system, so that alignments of bones or prosthetic replacements of joints that would not be suitable for a younger population often work well for this age group.

The injured limb must be properly immobilized to prevent further damage. The movement of sharp fracture ends can cause serious damage to soft tissues, arteries, veins, and nerves. In addition, the skin can be punctured, converting a closed injury into an open one, increasing the likelihood of infection. Immobilization makes it easier to transport the injured person and also relieves pain. Initially, injuries located near or beyond the elbow or knee can often be immobilized with splints. All splints are best fitted by holding the injured part with a gentle, longitudinal traction while someone else applies the splint. A sling can be effective in immobilizing most injuries of the shoulder, upper arm, and elbow. If further restraint is required, the arm can be kept close to the body by adding various wraps. Hip fractures can be treated initially by careful positioning with pillows.

Surgery to stabilize fractures offers compelling benefits for older people, especially when they have hip fractures for which nonsurgical treatment would involve prolonged immobility and bed rest. In these circumstances, the risks of surgery are usually outweighed by the likelihood of complications resulting from the bed rest.

Despite these advantages, surgical treatment of most fractures should be postponed until the correction of any acute medical problems has been achieved. Only those fractures that are associated with limb-threatening conditions or open fractures require urgent surgical treatment. There are some situations in which surgery generally should not be performed. For example, the presence of a blood infection prohibits the use of pins or other metal implants. In addition, bones severely affected by osteoporosis or Paget's disease may have poor mechanical properties and the surgeon may be unable to fix the hardware securely to the bone. (Osteoporosis and Paget's disease are discussed elsewhere in this chapter.)

Complications of Fractures

Swelling of injured muscle within a confined space surrounded by a cast or other unyielding constraint can lead to increased pressures that can block the normal circulation. The resulting tissue damage in turn leads to further injury, swelling, and higher pressures. The only solution to this ever-intensifying cycle is to completely remove all of the confining elements around the swollen muscles. This means all casts, splints, and dressings must be loosened immediately if a person complains of increasing pain or numbness in an immobilized limb. Emergency surgery is sometimes necessary to open up the muscle compartment.

The development of large blood clots in the legs and pelvic veins is another complication of fractures. Before the advent of specific treatment to prevent blood clots, deep vein clots developed in about half of people with hip fractures. These clots can be serious because they can dislodge and travel to the lungs causing a "pulmonary embolus," a potentially fatal event. Death caused by such blood clots was once the most frequent fatal complication resulting from lower leg trauma. The major factors that predispose a person to have such blood clots in the legs are advanced age, trauma or surgery involving the legs, a previous history of having one or more blood clots, being immobilized through bed rest, having a malignancy, and being overweight. These blood clots are hard to detect without specialized testing.

The majority of episodes of deep venous blood clots that occur in the hospital are preventable. Thinning of the blood with heparin is necessary for people undergoing hip replacement surgery or who have hip fractures. Treatment to thin the blood before and after surgery has greatly reduced the chance of having deep venous blood clots. Nonetheless, blood clots are still a matter for significant concern when fractures occur in the leg and pelvic areas.

Specific Fractures

Fractures of the Upper Arm. This injury is most commonly the result of a fall on an outstretched hand. People with this fracture have intense shoulder pain, inability to move the arm, considerable swelling, and discoloration of the lower arm. Fortunately, about 80 percent of these fractures do not have the fractured ends displaced.

The treatment and outlook depend upon the number and extent of the fracture fragments. If the alignment and position of the fragments are satisfactory, the arm may be immobilized in a sling. If not, an orthopedic surgeon may be able to realign the fragments by manipulating them without surgery. If a satisfactory alignment cannot be achieved by manipulation, then surgery is necessary to restore the appropriate alignment.

It is very important to begin simple movement exercises as soon as possible, because the most common complication results from the irritated surfaces of the joint capsule in the shoulder sticking together. This can cause severe pain as well as disability due to restricted motion. Physical therapy is often extremely helpful in these situations. It may take several months to regain the ability to perform over-the-head tasks, such as combing the hair.

Wrist Fractures. As with upper arm fractures, wrist fractures are usually the result of a fall on an outstretched hand. The fracture causes pain, tenderness, and swelling of the wrist.

For people with minimally displaced fractures or with low functional demands, the treatment may consist only of a short arm cast or splint. For displaced fractures, the physician may have to manipulate the bone pieces. This can be painful and some form of anesthesia is usually necessary. More severe fractures may require extensive casting.

Because the most frequent complication of a wrist fracture is stiffness of the fingers and shoulder, active motion of the shoulder, elbow, and fingers is usually strongly encouraged. To prevent swelling in the hand, it is important to hold it elevated above the heart. Immobilization of the wrist by a cast is usually maintained for three to eight weeks depending on the nature of the break. The person can expect gradually diminishing pain and weakness in the wrist to last for 6 to 12 months after the injury. Physical therapy and various exercises help to speed the recovery, and most people eventually regain satisfactory, pain-free function.

Hip Fractures. Two common forms of hip fracture involve either the femoral neck or the area between two trochanters (see Figure 25). Femoral neck fractures can be classified as either occult (invisible on ordinary X ray), impacted (wedged together), nondisplaced, or displaced. Elderly people with an occult fracture may have experienced minimal or even no apparent trauma. They typically complain of persistent groin pain with weight bearing, but X rays of the hip reveal no fracture. A bone scan may show the fracture. Weight bearing must be avoided because the crack can extend across the bone, causing complete displacement.

People with impacted and nondisplaced femoral neck fractures can also have groin pain and no deformity on physical examination. These fractures are visible on X rays and are classified according to the disruption of the blood supply to the head of the femur. The classification is very important in determining the treatment and outcome.

Occult, impacted, and nondisplaced femoral neck fractures are usually treated with surgery by using special pins. The stabilization allows older people to begin movement and weight bearing immediately and prevents displaced fractures. These fractures heal well because the blood supply to the femoral head is not disrupted.

A displaced fracture severely reduces the blood supply to the femoral head. While a displaced fracture can heal if it is securely stabilized, the chance of complications is considerable because of the poor blood supply. In 15 to 20 percent of people who have suffered a displaced fracture, there is no healing, and severe deformity of the femoral head occurs in another 15 to 30 percent.

People with displaced fractures have two treatment options--surgery to stabilize the joint or a hip joint replacement. Surgical treatment with no prosthetic replacement is usually reserved for vigorous people who are under the age of 70 and can tolerate a postoperative treatment of protected, crutch-associated weight bearing. This treatment preserves the femoral head and, if successful healing occurs, makes for a nearly normal hip. However, if the fracture does not mend properly, the joint will become very painful and a second operation will be required.

Partial or complete hip replacement is often recommended as an initial treatment because of the high likelihood of poor healing and deformity of the femoral head. In partial replacement the femoral head fragment is removed and replaced with a prosthesis. A prosthetic hip replacement may be the best choice for those over 70 because it permits immediate full weight bearing and a faster return to independent functioning.

In the group of people who are at highest risk for major complications, such as people from nursing homes who were not able to walk prior to their fracture, nonsurgical therapy may be appropriate. Conservative nonsurgical approach may also be appropriate for people who are confined to bed.

Hip fractures occurring between the two trochanters of the femur, called intertrochanteric fractures, are usually caused by a fall, often on level ground. Bleeding around the site can be significant and can cause shock due to a decrease in blood pressure.

Intertrochanteric hip fractures are treated by surgery unless there is a serious medical reason not to. This is because healing with traction instead of surgery usually requires four to eight weeks and exposes the person to all the hazards of immobilization in bed. Furthermore, healing in traction is often incomplete, as it does not allow for adequate control of the powerful muscles around the hip. The leg can become shortened and be turned slightly to the side, making it difficult to walk. After surgery, on the other hand, most people can begin immediate full weight bearing with a walker for support. Usually 6 to 12 weeks of walker use are required before they are able to switch to a cane and then walk independently.

Compression Fractures in the Vertebrae. In older people, this type of fracture is usually caused by some activity that increases compression stress on the spine such as lifting, bending forward, or missing a step while walking. Usually the person has severe pain that is made worse by sitting or standing, and there is a very specific point of tenderness over the affected part of the spine. There are rarely any neurological problems.

Initially, hospitalization for a short course of bed rest and pain relief may be necessary. As soon as possible, the person should be encouraged to sit up and walk for short periods. It may require a week or longer for independent walking. The person may have significant back pain for 6 to 12 weeks thereafter. As the healing progresses, the pain frequently shifts from the site of the original fracture to a higher or lower location. This is probably due to altered mechanical stresses caused by the deformity.

Back braces, which probably do little to prevent deformity, are only useful in the lower back because adequate support cannot be achieved above this level. Braces sometimes can help to relieve pain and permit a more rapid return to activities. The most effective in providing mechanical support, however, are not necessarily the most comfortable.

Many vertebral body fractures occur without any symptoms in older people, and are only revealed on an X ray. Osteoporosis weakens the vertebral bodies, which are then compressed by excessive stress on the back. This can result in a stooped posture as the fronts of vertebral bones crush in on themselves.

Vertebral body compression fractures always heal since the bone is really just compressed onto itself. The blood supply is not impaired, and neurological problems due to pinching nerves are not common. In addition, these fractures are generally stable because the back components of these vertebrae remain in place. The long-term result is a progressive forward curvature of the spine, due to wedging of these vertebrae, and a loss of height.




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