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Q1: I am no longer able to make a fist due to arthritis of the middle joints of my fingers. Are there surgical options for fingers as there are for hip replacements? They are very painful and apart from Difene or Voltoral type gel rubs are there any stronger pain relief remedies? R Smith, Dublin

A: The reader hasn't told us his or her age nor whether the arthritis is the result of rheumatoid arthritis or osteoarthritis.

I would guess that the reader's troubles are the result of osteoarthritis as the middle and the terminal joints in the fingers are the ones more likely to be affected in osteoarthritis than are the first joints of the fingers. In rheumatoid arthritis it is usually the proximal finger joints between the fingers and the hands and those of the wrists that suffer most. Furthermore you have made no mention of troubles elsewhere in your body, and usually in rheumatoid arthritis the joint involvement is more widespread and doesn't often, for example, only affect the hands, feet or knees as it may do in osteoarthritis in which a joint may be subjected to some specific prolonged overuse or trauma.

Surgery is always an option but the rule is this should only be considered to relieve pain. Hip replacements when successful offer complete pain relief in well over 90 per cent of cases. Likewise knee joint replacements are usually successful in achieving this. Techniques for knee replacement are improving almost by the month. The first joint in the fingers, that between the hand and the fingers, are being successfully replaced in some cases with a plastic implant, but the decision to do this would have to be reached by your surgeon and rheumatologist. I would expect that they would be reluctant to undertake surgery in cases of osteoarthritis unless the pain couldn't be controlled by other means.

I have never been hugely enthusiastic about trying to achieve pain relief by rubbing in analgesic anti-inflammatory creams and balms and have preferred anti-inflammatory drugs taken by mouth. The problem with these NSAIDs drugs is that in older people, or those with a history of indigestion or dyspepsia, there is much higher incidence of gastro intestinal bleeding than is realised. The COX II inhibitors are excellent at relieving pain, less likely to cause gastro intestinal bleeding (that is occasionally fatal) but there is strong evidence that some of them may increase fractionally the chances of having an acute heart problem. Despite this when I have an acute attack of gout I take Arcoxia, a COX 2 inhibitor that so far has a clean bill of health as regards side effects but I wouldn't even recommend taking this COX 2 inhibitor permanently. My favourite NSAIDs is Arthrotec as it includes a constituent that is alleged to reduce the risk of gut haemorrhage or perforation.

The disadvantage of all joint replacements is that not only may they become loose and painful so that in time they inevitably fail but there is always the danger of infection. Finger replacements that I have seen carried out successfully have usually been done because of rheumatoid rather than osteo-arthritis.

Q2: I have suffered a stiff neck for over six months and with no history of trauma my doctor simply advised exercise. However my neck has not improved and no solution is forthcoming, any advice? Name and address withheld

A: As always it is impossible to comment on an individual case without seeing the patient. I have no doubt that the reader has seen his or her own GP and they will know far more about this person's neck than I do.

However when there isn't some obvious cause for neck pain I would always arrange for my patients to have their necks X-rayed and if there was persistent pain and stiffness would order an MRI scan of it as well. I would want to know the condition of the joints between the cervical vertebrae and whether any of the nerves leaving the spine are being touched or nipped - trapped - by osteoarthritis. Although an X-ray gives a good impression of the state of the neck in general an MRI scan gives a much better view of the relationship of the nerves leading from the spine and the neck bones and joints.

Q3: About four or five years ago I started taking two 750 mg tablets of Glucosomine Sulphate daily to treat arthritis in my knee and had wonderful results - all the pain disappeared completely after about a month. A few months ago a new product was introduced, Optiflex Glucosomine HCl, and I changed to this as it was reported to be superior. However, during the past month or so the discomfort in my knee has gradually started to return. I would be grateful for any suggestions of alternative products which might help me now. I have heard that a combination of glucosomine and chondroitin is thought by some to be very good. Gill Mitchell, North Yorkshire

A: Glucosamine is an interesting substance as for many years it was condemned as being useless by traditional doctors. Rather to the medical profession's, and my, surprise carefully conducted research within the last few years has shown that it does in fact exert a helpful influence on joints. There is also a suggestion, as the reader discovered, that the combination of glucosamine and chondroitin is better than glucosamine alone. I have the impression that our reader doesn't want to take a non-steroidal anti-inflammatory agent (NSAIDs) such as Arthrotec, possibly for the very good reason of their age or the state of their gastro-intestinal lining. I have been quite impressed by the evidence advanced for the rosehip preparation LitoZin. Some Scandinavian doctors have shown that it is helpful in moderate cases of osteoarthritis, but I wouldn't have thought it would be strong enough to deal with, for example, rheumatoid arthritis. LitoZin takes some weeks, even two or three months, before it's effects become manifest.

In all osteoarthritis cases the first choice of treatment, coupled with lifestyle changes such as weight loss, heat treatment, hydrotherapy etc. is pain relief. Once pain and stiffness reach a point that they are interfering with a patient's professional or domestic life, the latter includes pursuit of valued hobbies, surgery should be considered. It should also be an option that is discussed if a patient is deprived of sleep because of pain.

Q4: Having had polymyalgia for two years, after one year it was brought down to zero steroid, but it recurred and 15mg steroid was re-started. It is now back down to zero, since which more pains have occurred in places which had not been affected before. My ESR is now low and these pains in the upper legs are more noticable when getting up from a sitting position after about half an hour. The pains in my upper arm muscles are continuous and the pain in my knuckles is more noticable in the mornings but there is no obvious swelling in those areas. I am told by my doctor that steroids only mask the pain. Is there any treatment, either medical or dietary which will help? My current exercise level is about 10 miles a week walking. Because the ESR is low, what would this current pain be called? Name and address withheld

A: Polymyalgia rheumatica is essentially an arteritis that usually affects the muscles of the shoulder girdle and, slightly less often, those of the pelvic girdle. The muscles of the chest and upper arm and thighs and waist become extremely tender and painful with associated stiffness and weakness in the relevant joints. Standing up from a bed or sofa is notoriously difficult. The blood test known as the ESR, that is a measure of any inflammatory process taking place in the body, is considerably raised.

Polymyalgia rheumatica usually has a rapid onset. It normally affects people over fifty, most often between sixty and seventy, and women more often than men. Associated with the arteritis is a low grade fever and one way or another the patient feels rotten has a marked loss of weight, loss of appetite and such a general feeling of being unwell that doctors always worry in case they have missed some concealed tumour. Fortunately, although polymyalgia is a most unpleasant but relatively common problem in older age, once the patient is given steroids the rapidity of the response is remarkable. Usually after a good response has been achieved the dose is very gradually reduced over many months. Most patients should expect to have to take a maintenance dose for two or three years but some have to stay on steroids for much longer.

There is some evidence that the onset of osteoarthritis may be hastened by an attack of polymyalgia rheumatica, or possibly its treatment, but it is likely that the symptoms of osteoarthritis have only become apparent because both conditions affect the same age group. Furthermore a period of inactivity followed by resumption of exercise may exacerbate any underlying joint condition.

I expect that the reader's doctor has told the patient all about temporal arteritis, a similar inflammatory condition that affects the arteries leading to the eye and is also associated with polymyalgia. For this reason it is essential that a close check is kept on the reader's condition and if the reader suffers any tenderness over the temporal or scalp region, hair brushing or combing may become suddenly and unexpectedly painful, or has any sudden blurring of vision then they should immediately take a large dose of prednisilone steroid and see their doctor. Temporal arteritis causing blindness is one of the medical emergencies where sudden treatment may be sight-saving.

Q5: I am a 64-year-old lady who luckily is very fit, and I play a lot of sport. Unfortunately I have arthritis in my wrists and neck. Regular visits to an osteopath keep the neck and head pains at bay, and I can cope with the wrist pain. My problem is that I cannot take glucosamine, chondroitin or anti-inflammatories in any form as they upset my stomach. I wonder if you can give me any information about rose hips which I understand is effective. I also cannot take anything in capsule form. I am concerned that as I am not now taking glucosamine, my arthritis will worsen. Or is there anything else that might help? Name and address withheld

A: I am afraid that the long term result of being an active sports man or woman is osteoarthritis. I assume that our reader doesn't want to take non-steroidal anti-inflammatory agents (NSAIDs) for the pain. She may want treatment that she considers to have a more natural basis. There is evidence that LitoZin, carefully extracted from the hips of one of the species of wild rose, has an anti-inflammatory action on joints. It takes some weeks before an effect will become apparent. It is also been shown that fish oil has an anti-inflammatory action, hence the use of cod liver oil or, preferably, fish oil rich in Omega 3 supplements for people with arthritis. Another so-called natural product is that of the green lipped mussel. All of these have anti-inflammatory properties but are not as powerful, of course, as the NSAIDs out of a chemist's bottle. Unfortunately NSAIDs have an appreciable adverse side effect profile so that care is needed. Rosehips LitoZin may be taken with NSAIDs

Q6: I'm 55 and broke my ankle quite badly three years ago. I had to have a metal plate and nine screws inserted but they've since been removed. I was told at the time that I'd almost certainly develop arthritis in this joint. Why is this? Is it inevitable that anyone who suffers a serious joint injury will develop arthritis and can anything be done to prevent this? I've been very lucky so far - I didn't suffer the nerve damage that the consultant predicted and only have a slight stiffness in this ankle for the first five minutes after I get up in the morning. Janice, Leeds

A: I am afraid that when fractures involve joint surfaces this hastens the advent of arthritis. Everyone sooner or later suffers osteoarthritis, the wearing out of joints because of destruction of the cartilage in joints that coats the bony surfaces and acts as a washer between the ends of the bones in the joints. Age is not the only factor that determines when osteoarthritis starts. The tendency to develop it early runs in families so there is also a genetic component. Likewise the amount of wear is subjected to is also relevant to when osteoarthritis becomes a nuisance and hence the problems that sportsmen and women suffer. Any abnormality of the skeletal structure of the body so that the wear on the joints is irregular makes the problem worse as does trauma to the joint whether accidents or injuries. Surgery interrupts or interferes, even if possibly only temporarily, with the blood supply to the cartilage which has very rudimentary circulation, if any, and is therefore more likely to suffer problems. The hope is that the reader will have many years before her troubles return.

Q7: My husband fell hard on his knee whilst chasing our three-year-old a few months ago. Since then, he has had mild pain and his knee feels as though there are bits of something floating in it. His GP felt it and said it was normal gristle but I am concerned that it has not been investigated thoroughly and may lead to osteoarthritis in the future. I thought his GP would refer him for futher investigations. Should we be pushing for this? My husband is 36 years old and says the injury is preventing him from running at the present time. Marie

A: This is a most unpleasant and painful condition that may affect people who have banged their knee and have damaged their knee caps. For a time after the injury the knee may be exquisitely painful every time a person kneels on it or over-exercises. The patient then feels as if there are sharp needles pricking the inside of the joint. Whether a specialist opinion is called for is a matter for any patient to discuss with their GP and the people involved. I usually had my patients knees looked at by a consultant orthopaedic surgeon but when I had a similar injury myself I waited for time to achieve a cure and within 18 months the knee had returned to normal.

Q8: I have calcific tendonitis and bursitis in my right shoulder. It is not responding well to cortisone injections (four injections over the last 10 months) and I have been using painkiller and anti-inflammatory drugs to keep the pain regulated. Should I consider an operation to alleviate the symptoms? What are the advantages and disadvantages of such an operation and the prognosis of recovery? Shane Darcy

A: This is a matter for the reader's orthopaedic surgeon and GP. MRI scans have revolutionised shoulder treatment. We, the doctors, now know what we are treating and how severe the condition is and can therefore give a better opinion on the treatment needed. Surgery to the shoulder is far more effective than it used to be. There is only one proviso. Surgery does not always produce a miraculous cure. It may take a little time, perhaps a matter of a month or two, before the advantages of the surgery become apparent.

Q9: What causes arthritis and is lifestyle beneficial? After having a range of symptoms over the last five years varying from swollen joints, aching muscles and varying degrees of tiredness, can lifestyle improve it or is it a case of of what might work for one doesn't work for another? What part does the immune system play in our future state of health? Stephen, Carlisle

A: Arthritis is a description of the symptom of a painful, inflamed stiff joint. The job of the doctor is to determine the type of arthritis and its likely cause. An arthritic joint may be the result of rheumatoid arthritis, osteoarthritis, gout or one of the rarer more exotic causes of inflamed joints including allergic phenomena. The causes and therefore treatment vary. Persistent or worsening arthritic conditions should always be seen by a rheumatologist.

Rheumatoid arthritis is an auto-immune disease so the immune system obviously plays a large part in its aetiology. Whether osteoarthritis is mainly the result of age, wear and tear or the type of use or injury the joint has had to put up with depends on each individual case.