COMMON SKELETAL SYSTEM DISORDERS

A number of disorders affect the skeletal system, including bone fractures and bone cancers. However, the two most common disorders of the skeletal system are osteoporosis and osteoarthritis. At least ten million people in the United States have osteoporosis, and more than eight million of them are women. Osteoarthritis is even more common, affecting almost 1.4 million people in Canada, and 1 in 4 women over the age of 50. Because osteoporosis and osteoarthritis are so common, they are the focus of this section. These two disorders are also good examples to illustrate the structure and function of the skeletal system.

Osteoporosis is an age-related disorder in which bones lose mass, weaken, and break more easily than normal bones. Bones may weaken so much that a fracture can occur with minor stress — or even spontaneously, without any stress at all. Osteoporosis is the most common cause of broken bones in the elderly, but until a bone fracture occurs, it typically causes no symptoms. The bones that break most often include those in the wrist, hip, shoulder, and spine. When the thoracic vertebrae are affected, there can be a gradual collapse of the vertebrae due to compression fractures, as shown in Figure 11.7.2. This is what causes kyphosis, as pictured above in Figure 6.36.

CHANGES IN BONE MASS WITH AGE

As shown in the Figure 6.37, bone mass in both males and females generally peaks when people are in their thirties, with males typically attaining a higher peak mass than females. In both sexes, bone mass usually decreases after that, and this tends to occur more rapidly in females, especially after menopause. The greater decrease in females is generally attributable to low levels of estrogen in the post-menopausal years.

WHAT CAUSES OSTEOPOROSIS?

The underlying mechanism in all cases of osteoporosis is an imbalance between bone formation by osteoblasts and bone resorption by osteoclasts. Normally, bones are constantly being remodeled by these two processes, with up to ten per cent of all bone mass undergoing remodeling at any point in time. As long as these two processes are in balance, no net loss of bone occurs. There are three main ways that an imbalance between bone formation and bone resorption can occur and lead to a net loss of bone. All three ways may occur in the same individual. The three ways are described below:

1.  An individual never develops normal peak bone mass during the young adult years: If the peak level is lower than normal, then there is less bone mass to begin with, making osteoporosis more likely to develop.
2. There is greater than normal bone resorption: Bone resorption normally increases after peak bone mass is reached, but age-related bone resorption may be greater than normal for a variety of reasons. One possible reason is calcium or vitamin D deficiency, which causes the parathyroid gland to release PTH, the hormone that promotes resorption by osteoclasts.
3. There is inadequate formation of new bone by osteoblasts during remodeling: Lack of estrogen may decrease the normal deposition of new bone. Inadequate levels of calcium and vitamin D also lead to impaired bone formation by osteoblasts.

An imbalance between bone building and bone destruction leading to bone loss may also occur as a side effect of other disorders. For example, people with alcoholism, anorexia nervosa, or hyperthyroidism have an increased rate of bone loss. Some medications — including anti-seizure medications, chemotherapy drugs, steroid medications, and some antidepressants — also increase the rate of bone loss.

DIAGNOSING OSTEOPOROSIS

Osteoporosis is diagnosed by measuring a patient’s bone density and comparing it with the normal level of peak bone density in a young adult reference population of the same sex as the patient. If the patient’s bone density is too far below the normal peak level (as measured by a statistic called a T-score), then osteoporosis is diagnosed. Bone density is usually measured by a type of X-ray called dual-energy X-ray absorptiometry (or DEXA), an example of which is shown in Figure 6.38. Typically, the density is measured at the hip. Sometimes, other areas are also measured, because there may be variation in bone density in different parts of the skeleton. Osteoporosis Canada  recommends that all women 65 years of age and older be screened with DEXA for bone density. Screening may be recommended at younger ages in people with risk factors for osteoporosis (see Risk Factors for Osteoporosis below).

OSTEOPOROTIC FRACTURES

Fractures are the most dangerous aspect of osteoporosis, and osteoporosis is responsible for millions of fractures annually. Debilitating pain among the elderly is often caused by fractures from osteoporosis, and it can lead to further disability and early mortality. Fractures of the long bones (such as the femur) can impair mobility and may require surgery. Hip fracture usually requires immediate surgery, as well. The immobility associated with fractures — especially of the hip — increases the risk of deep vein thrombosis, pulmonary embolism, and pneumonia. Osteoporosis is rarely fatal, but these complications of fractures often are. Older people tend to have more falls than younger people, due to such factors as poor eyesight and balance problems, increasing their risk of fractures even more. The likelihood of falls can be reduced by removing obstacles and loose carpets or rugs in the living environment.

RISK FACTORS FOR OSTEOPOROSIS

There are a number of factors that increase the risk of osteoporosis. Eleven of them are listed below. The first five factors cannot be controlled, but the remaining factors generally can be controlled by changing behaviors.

1. Older age
2. Female sex
3. European or Asian ancestry
4. Family history of osteoporosis
5. Short stature and small bones
6. Smoking
7. Alcohol consumption
8. Lack of exercise
9. Vitamin D deficiency
10. Poor nutrition
11. Consumption of soft drinks

TREATMENT AND PREVENTION OF OSTEOPOROSIS

Osteoporosis is often treated with medications that may slow or even reverse bone loss. Medications called bisphosphonates, for example, are commonly prescribed. Bisphosphonates slow down the breakdown of bone, allowing bone rebuilding during remodeling to keep pace. This helps maintain bone density and decreases the risk of fractures. The medications may be more effective in patients who have already broken bones than in those who have not, significantly reducing their risk of another fracture. Generally, patients are not recommended to stay on bisphosphonates for more than three or four years. There is no evidence for continued benefit after this time — in fact, there is a potential for adverse side effects.

Preventing osteoporosis includes eliminating any risk factors that can be controlled through changes of behavior. If you smoke, stop. If you drink, reduce your alcohol consumption — or cut it out altogether. Eat a nutritious diet and make sure you are getting adequate amounts of vitamin D. You should also avoid drinking carbonated beverages.

If you’re a couch potato, get involved in regular exercise. Aerobic, weight-bearing, and resistance exercises can all help maintain or increase bone mineral density (for example hiking as in Figure 6.39). Exercise puts stress on bones, which stimulates bone building. Good weight-bearing exercises for bone building include weight training, dancing, stair climbing, running, and hiking (see Figure 11.7.5). Biking and swimming are less beneficial, because they don’t stress the bones. Ideally, you should exercise for at least 30 minutes a day most days of the week.

Osteoarthritis

Osteoarthritis (OA) is a joint disease that results from the breakdown of joint cartilage and bone. The most common symptoms are joint pain and stiffness. Other symptoms may include joint swelling and decreased range of motion. Initially, symptoms may occur only after exercise or prolonged activity, but over time, they may become constant, negatively affecting work and normal daily activities. As shown in Figure 6.40, the most commonly involved joints are those near the ends of the fingers, at the bases of the thumbs, and in the neck, lower back, hips, and knees. Often, joints on one side of the body are affected more than those on the other side.

WHAT CAUSES OSTEOARTHRITIS?

OA is thought to be caused by mechanical stress on the joints with insufficient self-repair of cartilage. The stress may be exacerbated by low-grade inflammation of the joints, as cells lining the joint attempt to remove breakdown products from cartilage in the synovial space. OA develops over decades as stress and inflammation cause increasing loss of articular cartilage. Eventually, bones may have no cartilage to separate them, so bones rub against one another at joints. This damages the articular surfaces of the bones and contributes to the pain and other symptoms of OA. Because of the pain, movement may be curtailed, leading to loss of muscle, as well.

DIAGNOSING OSTEOARTHRITIS

Diagnosis of OA is typically made on the basis of signs and symptoms. Signs include joint deformities, such as bony nodules on the finger joints or bunions on the feet (as illustrated in Figure 6.41). Symptoms include joint pain and stiffness. The pain is usually described as a sharp ache or burning sensation, which may be in the muscles and tendons around the affected joints, as well as in the joints themselves. The pain is usually made worse by prolonged activity, and it typically improves with rest. Stiffness is most common when first arising in the morning, and it usually improves quickly as daily activities are undertaken.

X-rays or other tests are sometimes used to either support the diagnosis of OA or to rule out other disorders. Blood tests might be done, for example, to look for factors that indicate rheumatoid arthritis (RA), an autoimmune disease in which the immune system attacks the body’s joints. If these factors are not present in the blood, then RA is unlikely, and a diagnosis of OA is more likely to be correct.

RISK FACTORS FOR OSTEOARTHRITIS

Age is the chief risk factor for osteoarthritis. By age 65, as many as 80 per cent of all people have evidence of osteoarthritis. However, people are more likely to develop OA — especially at younger ages — if they have had a joint injury. A high school football player might have a bad knee injury that damages the joint, leading to OA in the knee by the time he is in his thirties. If people have joints that are misaligned due to congenital malformations or disease, they are also more likely to develop OA. Excess body weight is another factor that increases the risk of OA, because of the added stress it places on weight-bearing joints.

Researchers have found that people with a family history of OA have a heightened risk of developing the disorder, which suggests that genetic factors are also involved in OA. It is likely that many different genes are needed for normal cartilage and cartilage repair. If such genes are defective and cartilage is abnormal or not normally repaired, OA is more likely to result.

TREATMENT AND PREVENTION OF OSTEOARTHRITIS

OA cannot be cured, but the symptoms — especially the pain — can often be treated successfully to maintain good quality of life for people with OA. Treatments include exercise, efforts to decrease stress on joints, pain medications, and surgery.

Exercise

Exercise helps maintain joint mobility and also increases muscle strength. Stronger muscles may help keep the bones in joints correctly aligned, and this can reduce joint stress. Good exercises for OA include swimming, water aerobics (see Figure 6.42 below), and biking. These activities are recommended for OA, because they put relatively little stress on the joints.

De-stressing Joints

Efforts to decrease stress on joints include resting and using mobility devices such as canes, which reduce the weight placed on weight-bearing joints and also improve stability. In people who are overweight, losing weight may also reduce joint stress.

Pain Medications

The first type of pain medication likely to be prescribed for OA is acetaminophen (e.g., Tylenol). When taken as prescribed, it has a relatively low risk of serious side effects. If this medication is inadequate to relieve the pain, non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen) may be prescribed. NSAIDs, however, are more likely to cause serious side effects, such as gastrointestinal bleeding, elevated blood pressure, and increased risk of stroke. Opioids usually are reserved for patients who have suffered serious side effects or for whom other medications have failed to relieve pain. Due to the risk of addiction, only short-term use of opioids is generally recommended.

Surgery

Joint-replacement surgery is the most common treatment for serious OA in the knee or hip. In fact, knee and hip replacement surgeries are among the most common of all surgeries. Although they require a long period of healing and physical rehabilitation, the results are usually worth it. The replacement “parts” are usually pain-free and fully functional for at least a couple of decades. Quality, durability, and customization of artificial joints are constantly improving.

Prevention

1. Maintain a normal, healthy weight. The more you weigh, the more force you exert on your joints. When you walk, each knee has to bear a force equal to as much as six times your body weight. If a person weighs 200 pounds, each knee bears more than half a ton of weight with every step. Seven in ten knee replacement surgeries for osteoarthritis can be attributed to obesity.
2. Avoid too much high-impact exercise. Examples of high-impact activities include volleyball, basketball, and tennis. These activities generally involve running or jumping on hard surfaces, which puts tremendous stress on weight-bearing joints, especially the knees. Replace some or all of your high-impact activities with low-impact activities, such as biking, swimming, yoga, or lifting light weights.
3. Reduce your risk of injury. Don’t be a weekend warrior, sitting at a desk all week and then crowding all your physical activity into two days. Get involved in a regular, daily exercise routine that keeps your body fit and your muscles toned. Building up muscles will make your joints more stable, allowing stress to spread across them. Be sure to do some stretching every day to keep the muscles around joints flexible and less prone to injury.
4. Distribute work over your body, and use your largest, strongest joints. Use your shoulder, elbow, and wrist to lift heavy objects — not just your fingers. Hold small items in the palm of your hand, rather than by the fingers. Carry heavy items in a backpack, rather than in your hands. Hold weighty objects close to your body, instead of at arms’ length. Lift with your hips and knees, not your back.
5. Respect pain. If it hurts, stop doing it. Take a break from the activity — at least until the pain stops. Try to use joints only to the point of mild fatigue, not pain.

Feature: Myth vs. Reality

About one out of every 5 adults in Canada suffer from osteoarthritis. The more you know about this disease, the more you can do to avoid it or slow its progression. That means knowing the facts, rather than believing the myths about osteoarthritis.

Review

1. Create a brochure or poster about osteoporosis to educate others about this disease.  Include information about:
   1. A definition of osteoporosis
   2. Causes
   3. Dangers of living with the disease
   4. Canadian osteoporosis statistics
   5. Risk factors
   6. Diagnosis
   7. Treatment
2. Why is it important to build sufficient bone mass in your young adult years?
3. Explain the difference in cause between rheumatoid arthritis and osteoarthritis.
4. Debunk the myth: Osteoarthritis is caused by physical activity, so people who are equally active are equally susceptible to it.
5. Explain how we know that estrogen generally promotes production of new bone.

Kevin Stone: The bio-future of joint replacement, TED, 2010.

Sophia loves wearing high heels when she goes out at night. She knows they are not the most practical shoes, but she likes how they look.

Lately, she has been experiencing pain in the balls of her feet — the area just behind the toes. Even when she trades her heels for comfortable sneakers, it still hurts when she stands or walks.

What could be going on? She searches online to try to find some answers. She finds a reputable source for foot pain information — a website from a professional organization of physicians that peer reviews the content by experts in the field. There, she reads about a condition called metatarsalgia, which produces pain in the ball of the foot that sounds very similar to what she is experiencing.

She learns that a common cause of metatarsalgia is the wearing of high heels. Shoes like this push the foot into an abnormal position, resulting in excessive pressure being placed on the ball of the foot. Looking at the photograph above (Figure 11.1.1), you can imagine how much of the woman’s body weight is focused on the ball of her foot, because of the shape of her high heels. If she were not wearing high heels, her weight would be more evenly distributed across her foot.

As she reads more about the hazards of high heels, Sophia learns that they can also cause foot deformities, such as hammertoes, bunions, and small cracks in bone called stress fractures. High heels may even contribute to the development of osteoarthritis of the knees at an early age.

Think about the following questions:

1. Sophia suspects she has a condition called metatarsalgia. This term is related to the term “metatarsals.” What are metatarsals, where are they located, and how do you think they are related to metatarsalgia?
2. High heels can cause stress fractures, which are small cracks in bone that usually appear after repeated mechanical stress, instead of after a significant acute injury. What other condition described in this chapter involves a similar process?
3. What are bunions and osteoarthritis of the knee? Why do you think they can be caused by wearing high heels?

As Sophia discovered in the beginning of the chapter, wearing high heels can result in a condition called metatarsalgia. Metatarsalgia is named for the metatarsal bones, which are the five bones that run through the ball of the foot just behind the toes (highlighted in Figures 6.43 and 6.44). Wearing high heels causes excessive pressure on the ball of the foot, as described in the beginning of this chapter. Additionally, the toes are forced to pull upward in high heels, which moves the fleshy padding away from the ball of the foot and adds to the overall pressure placed on this region. Over time, this can cause inflammation and direct stress on the bones, resulting in the pain in the ball of the foot known as metatarsalgia. The pain occurs especially in weight-bearing positions, such as standing, walking, or running — which is what Sophia was experiencing. There may also be pain, numbness, or tingling in the toes associated with metatarsalgia.

Wearing high heels can also cause stress fractures in the feet, which are tiny breaks in bone that occur due to repeated mechanical stress. This is caused by the excessive pressure that high heels put on some of the bones of the feet. These fractures are somewhat similar to what occurs in osteoporosis when the bone mass decreases to the point where bones can fracture easily as a person goes about their daily activities. In both cases, a major noticeable injury is not necessary to create the tiny fractures.

Don’t think you are immune to stress fractures just because you don’t wear high heels! This injury also commonly occurs in people who participate in sports involving repetitive striking of the foot on the ground, such as running, tennis, basketball, or gymnastics. They may be avoided by taking preventative measures. You should ramp up any increase in activity slowly, cross-train by engaging in a variety of different sports or activities, rest if you experience pain, and wear well-cushioned and supportive running shoes.  It is important to know that your cardiovascular and muscular systems adapt to an increase in physical activity much more quickly than the skeletal system.

Sophia learned through her online research that wearing high heels can also lead to foot deformities, such as bunions and hammertoes. As you learned in an earlier chapter, a bunion is a protrusion on the side of the foot, most often at the base of the big toe. It can be caused by wearing shoes with a narrow, pointed toe box — a common shape for high heels. The pressure of the shoes on the side of the foot causes an enlargement of bone or inflammation of other tissues in the region, which pushes the big toe toward the other toes.

Hammertoes are an abnormal bend in the middle joint of the second, third, or fourth toe (with the big toe being the first toe), causing the toe to be shaped similarly to a hammer. The narrow, pointed toe box of many high heels, combined with the way the toes are squished into the front of the shoe as a result of the height of the heel, can cause the toes to become deformed this way. Treatments for bunions and hammertoe include wearing shoes with a roomy toe box, padding or taping the toes, and toe exercises and stretches. If the bunion or hammertoe does not respond to these treatments, surgery may be necessary to correct the deformity.

Because the bones of the skeleton are connected and work together with other systems to support the body, wearing high heels can also cause physical problems in areas other than the feet. Wearing high heels shifts a person’s posture and alignment, and can put strain on tendons, muscles, and other joints in the body. Research published in 2014 from a team at Stanford University suggests that wearing high heels, particularly if the person is overweight or the heels are very high, may increase the risk of osteoarthritis (OA) in the knee, due to added stress on the knee joint as the person walks. As you have learned, OA results from the breakdown of cartilage and bone at the joint. Because it can only be treated to minimize symptoms — and not for a cure — OA could be an unfortunate long-term consequence of wearing high heels.

Sophia has decided that wearing high heels regularly is not worth the pain and potential long-term damage to her body. After consulting with her doctor, who confirmed she had metatarsalgia, she was able to successfully treat it with ice, rest, and wearing comfortable, supportive shoes instead of heels.

High heels are not the only kind of shoes that can cause problems. Flip-flops, worn-out sneakers, and shoes that are too tight can all cause foot issues. To prevent future problems from her shoe choices, Sophia is following guidelines recommended by medical experts. The guidelines include:

• Wearing shoes that fit well, have plenty of room in the toes, are supportive, and are comfortable right away. There should be no “break-in” period needed for shoes.
• Avoiding high heels, especially those with heels over two inches high, or those that have narrow, pointed toe boxes or very thin heels.
• If high heels must be worn, it should only be for a limited period of time.

As you have learned in this chapter, your skeletal system carries out a variety of important functions in your body, including physical support. But even though it is strong, your skeletal system can become damaged and deformed — even through such a seemingly innocuous act as wearing a certain type of shoe. Taking good care of your skeletal system is necessary to help it continue to take good care of the rest of you.