DEAR DR. ROACH: I'm a 60-year-old healthy man. I am very active as a team roper. My arthritis bothers me every day, every waking hour. We ride two or three days a week. I take a tramadol with acetaminophen (37.5/325) and a 500-mg acetaminophen in the mornings. This works well during the day. But if I take it at night, it keeps me from sleeping. Would 150 mg of diclofenac be safe to take before bed? I've had two surgeries for bone spurs: in my right elbow and left shoulder. What causes bone spurs? -- T.H.
ANSWER: It seems you have osteoarthritis, the most common type of arthritis. Osteoarthritis affects all parts of the joint. There is damage to and progressive destruction of the articular cartilage, which is the smooth load-bearing portion of the joint. Loss of cartilage and joint space, especially in the knee, is one of the primary ways we establish severity of osteoarthritis.
The bone is also affected, when collagen on the bone around the margins of the joint turns bony. This is called osteophytes or "bone spurs." It's not the cause of the inflammation, but rather a result of the inflammation in the joint affected by osteoarthritis. Damage to the ligaments and tendons are also common in joints affected by osteoarthritis.
Rodeo roping is a high-impact activity. Damage to the joint, such as a ligament, from trauma can start the process of osteoarthritis. When I see a person with only one joint affected by osteoarthritis, I wonder if it's this post-traumatic osteoarthritis, as opposed to people with many joints, where age, gender, joint anatomy and being overweight are major risk factors.
Exercise for osteoarthritis is one of the first-line treatments for most people. Weightbearing exercise with minimal trauma, such as walking, is ideal. For people with more severe disease, less weightbearing movements, such as swimming, is a good choice.
Team roping wouldn't be my first choice, as this activity certainly has the potential to worsen your symptoms. Further injury could even worsen the progression of the osteoarthritis. At some point, you would be wise to give this up. I never lightly suggest a person give up their exercise, because many people are passionate about what they do, and in some cases, it helps define a person's identity.
Medication is another part of treatment. Tramadol is an opioid drug that has other effects, and it's not usually a first-line treatment. It has potential for side effects and even potential for misuse and overdose. Acetaminophen (Tylenol) can be taken by itself, but it is also offered in combination with other medicines, such as the combination you are taking. This has only mild benefit for most people. Everyone must carefully count all the acetaminophen they take from all sources.
Anti-inflammatories like diclofenac (over-the-counter alternatives include ibuprofen and naproxen) are the usual first-line treatment for those who need additional pain relief. There is no value taking anti-inflammatories if there isn't pain, since these medicines do not slow or stop progression of arthritis.
Surgery is not usually used for osteoarthritis. It may be necessary for joint replacement or to repair soft tissue damage like rotator cuff or labral tears, especially in people with a history of trauma.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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