Arthritis of the fingers can leave a person helpless

Arthritis is an inflammatory disease of the joints, accompanied by severe pain, which is quite difficult to get rid of. Unfortunately, they are widespread in society. According to statistics, every tenth person on the planet suffers from arthritis of the fingers or toes.

Medicine distinguishes one hundred and fifty types of this disease. Arthritis of the finger joints can develop over years, deforming and thinning the cartilage tissue. This makes life much more difficult for many people affected by this disease.

General information about the disease

Arthritis of the fingers is an inflammation of the metacarpophalangeal and interphalangeal joints of the fingers. The disease occurs quite often at any age. According to statistics, women over 40 years of age are more affected by it. This is explained by the fact that, compared to men, women have a greater load on their hands and fingers. ICD-10 code for finger arthritis of unspecified origin M13.

Depending on the cause that caused it, the disease can occur only in small joints of the fingers, or can be combined with damage to large joints. The onset of the disease can be acute, subacute and chronic, but then the course in most cases becomes protracted or chronic. The exception is post-traumatic arthritis of the fingers: with proper treatment, it ends in complete recovery. But if treatment was not prescribed on time, it also takes a chronic course.

Methods for treating joints:

• Undergoing physical therapy.

It can be of several types:

1. Warm water. Here you need to do exercises in warm water with sufficient depth. For example, in the pool. The liquid will support your weight, reducing stress on your muscles and joints.
2. Physical therapy. A special set of exercises has been prepared here, based on the individual needs of the patient. Sometimes combined with pain-relieving procedures.

• Ultrasound treatment.

The body is exposed to high frequency ultrasonic waves. Thanks to this, it is possible to reduce pain. Also thanks to it, medications penetrate into the deeper layer of the epidermis.

Causes of inflammation in the joints of the fingers

The causes of the disease can be different. Most often, the small joints of the fingers are affected by rheumatoid arthritis, an autoimmune (allergy to the patient’s own tissues) disease, which is based on a hereditary predisposition. The starting point for the onset of the disease is usually some kind of infection. After some time, genetically predisposed individuals develop arthritis of the fingers. In the future, other, larger joints may be affected.

Another common cause of inflammation in the small joints of the hands is psoriatic arthritis. It is also an autoimmune hereditary disease that mainly affects the joints of the fingertips (distal) with simultaneous characteristic lesions of the nails. This usually occurs against the background of existing skin manifestations of psoriasis, but sometimes symptoms of arthritis in the joints of the fingers appear first.

Quite often, arthritis of the finger joints develops with gout. The disease has a metabolic (metabolic) origin - the metabolism of uric acid salts is disrupted, they are deposited in the articular and periarticular tissues, causing an inflammatory process.

Post-traumatic arthritis of the finger joints is sometimes of an occupational nature. It develops with constant minor trauma to the hands of jewelers, seamstresses, hairdressers, etc. The inflammatory process is constantly supported by additional trauma and becomes chronic. After acute (sports, household) injuries, acute arthritis can develop, which then completely disappears.

Other types of arthritis rarely cause damage to small joints. Provoking factors that contribute to the development of arthritis in the small joints of the hands are hormonal changes (adolescence, pregnancy, menopause), stress, frequent colds and allergies, bad habits, and professional activities.

How to treat when the joints on your fingers hurt?

Therapy for this ailment helps eliminate both the unpleasant sensations themselves and the causes of their occurrence. Thus, for inflammatory processes, non-steroidal or hormonal anti-inflammatory drugs are prescribed, as well as antibiotics in case of infection. In case of dystrophic damage, the task of treatment is to restore cartilage tissue with the help of chondroprotectors, physiotherapy and massage. Performing special exercises also helps restore finger mobility.

The most effective way to restore the functionality of small joints is physical therapy: magnetic resonance therapy, electrophoresis with novocaine, electrosleep and some other procedures. During the period of remission, sanatorium-resort treatment using hydrogen sulfide and radon sources is recommended. Therapeutic nutrition for joint pathologies:

• seafood and fish - contain calcium, iron and phosphorus;
• apple cider vinegar – helps rid the body of toxins;
• flaxseed oil, fish oil - contain fatty acids, help restore fat metabolism.

In addition, it is advisable to include lettuce, radishes, nuts, currants, pomegranate, figs, and ginger in your diet. Limit your consumption of fatty dairy products, mayonnaise, sweets, baked goods, spicy foods and smoked foods.

Symptoms of arthritis in the fingers

Symptoms can be different, they depend on the nature of the inflammatory process (acute, subacute, chronic), as well as on the clinical form of the underlying disease.

First signs

Swelling and aching pain are the first signs of hand arthritis

The onset of the disease is slow in most cases. There are aching pains in the hands and stiffness of movements in the morning. At first, this symptom lasts on average no more than half an hour, and then goes away. The pain is aching, constant, and its intensity increases slowly.

Less often the onset is acute. Pain appears in one or more small finger joints, accompanied by redness and swelling of the surrounding tissues. The function of the joint is impaired: it is difficult to bend and unbend, sometimes it is impossible to do this due to pain.

With the acute onset of the disease, the patient’s general condition often suffers: fever, malaise, and headache appear. If the process develops subacutely or chronically, there may be no general manifestations; changes in the affected joints may also not be too pronounced.

The most important thing to do if you experience symptoms of arthritis is to seek medical help. The sooner this happens, the greater the chance of stopping the inflammatory process at the very beginning.

Obvious symptoms

Obvious signs of chronic hand arthritis include the appearance of swelling and redness of the tissues around the affected areas of the hands, as well as the involvement of other joints in the pathological process on the same or another hand. The appearance of new foci of inflammation may be accompanied by a slight rise in body temperature, increased pain and dysfunction of the affected joints. But more often, rheumatoid exacerbations occur without general manifestations.

After some time, the inflammatory process may somewhat reduce intensity, local inflammation and general symptoms decrease. After this, the process becomes chronic. Morning stiffness of movement appears, patients note the feeling of tight gloves on their hands, which do not allow them to move. Some time after getting up in the morning and starting physical activity, this feeling decreases or even disappears. The appearance of crepitus (friction and clicking) in the affected articular joints is also characteristic.

When the patient does not receive treatment for arthritis, there is an alternation of exacerbations and remissions with constant pain and rapid formation of joint deformation (with rheumatoid arthritis) or melting of the fingertips with their shortening (with psoriatic arthritis). Arthritis of the thumb most often develops with gout, occurs with severe pain, swelling, redness, then goes away without a trace, but with frequent relapses, deformation and loss of function of the joint also develops.

Dangerous symptoms

Emergency medical attention is required if the following symptoms of finger arthritis appear:

• high body temperature (38 - 39°) for 5 or more days;
• a sharp rise in temperature, increased inflammation and pain in the joint with an already existing inflammatory process - may indicate the onset of suppuration;
• involvement of new small or large joints in the pathological process;
• the appearance of blackened tissue on the fingertips (necrosis) in psoriatic arthritis.

If such symptoms appear, you should immediately consult a doctor.

Orthotics - hand brace

A rigid bandage can support the injured joint and relieve pain. For rhizarthrosis, the most convenient option is an individual orthosis made directly to the arm. It limits painful movements of the thumb while still keeping the wrist joint free.

You can wear the retainer during the day, put it on while working, or vice versa only at night. Its main functions:

• Pain relief
• Correct positioning of the injured joint during work
• Rest for the joint

How dangerous is the disease?

The main danger of any type of chronic arthritis is the progression of the inflammatory process, which over time becomes degenerative-dystrophic with deformation of the limbs and disability. The longer arthritis lasts, the higher the risk of complications.

Stages of the disease

Any form of arthritis has serious complications, so you should not delay treatment.
See how easily the disease can be cured in 10-12 sessions.

Arthritis of the joints of the fingers has 4 stages of development depending on the degree of joint damage detected during instrumental examination:

1. Initial stage
   . If there are pronounced or minor clinical signs of inflammation, an x-ray can show signs of inflammation in the form of widening of the joint space. An ultrasound can show the presence of an increased volume of joint fluid. Symptoms can be pronounced or almost absent in the chronic course of the disease.
2. Progressive inflammation.
   Signs of inflammation are clearly visible on x-rays and ultrasound. Articular cartilage is destroyed, and in its place loose connective tissue - pannus - is formed. The process takes on a wave-like (exacerbation-remission) or constantly progressive course. Pain and stiffness of movement increase.
3. Connective tissue ankylosis.
   The connective tissue of the pannus becomes rough, it grows and connects the joint-forming bone surfaces with each other, as a result of which movement in the joint is limited. Fingers become deformed.
4. Bone ankylosis.
   Instead of connective tissue, bone tissue grows in the joint, which leads to complete immobility of the joint and loss of its function.

Possible complications

If arthritis of the hands and fingers is not treated, the disease will progress. The following complications are also possible:

• development of a purulent inflammatory process with transition to the tissue surrounding the joint, development of abscesses, phlegmon and sepsis;
• necrosis of the fingertips, their shortening and inflammation of the soft tissues;
• subluxations and dislocations of small joints;
• various types of joint deformities;
• complete loss of function of the fingers and hands.

What to do during an exacerbation

You can get rid of pain from arthritis of the hands with the help of drugs from the group of non-steroidal anti-inflammatory drugs

When arthritis worsens, the joints become sharply painful, the skin over them turns red, swells, and movements in the fingers become impossible due to pain. To reduce suffering you need to:

• give your hands a slightly elevated position - this will reduce swelling;
• take any medicine from the group of non-steroidal anti-inflammatory drugs (NSAIDs) - Diclofenac, Nise, Indomethacin, Ibuprofen; this will reduce pain and inflammation;
• apply any external agent from the NSAID group - gel or ointment - to the skin over the diseased joint; emulgel Voltaren helps a lot;
• consult a doctor or call him at home.

During an exacerbation, you cannot delay visiting a doctor; it is urgent to suppress the progression of the disease. It is impossible to do this on your own.

Injections

• Glucocorticoids (diprospan) are powerful anti-inflammatory drugs that provide quick but short-term relief from pain. I use them as a test or as an emergency treatment to relieve severe pain.
• Hyaluronic acid preparations (Fermatron) are a gel-like substance that improves the rheological properties of synovial fluid and the transport of nutrients. The administration of such drugs is carried out in a course, the effect of which can last longer than a year. Further destruction of the joint is somewhat slowed down.

How does arthritis of the fingers proceed in different clinical forms of the disease?

The symptoms of hand arthritis and the nature of its course depend on the disease that led to its development. Damage to small joints of the hands is most often found in rheumatoid, psoriatic and gouty arthritis. But it can also occur in other clinical forms of arthritis.

Rheumatoid arthritis

In most cases, arthritis begins slowly and unnoticeably. Aching pain appears in the fingers. The nature of the pain is constant, aching, exhausting. In the morning after sleep, stiffness of movement appears, which can last up to 30 minutes or more.

After some time, the patient notices that the fingers begin to swell in the joints. Most often, the metacarpophalangeal and overlying interphalangeal joints of the 2nd and 3rd fingers are affected. The lesion is symmetrical on both hands. Pain of varying degrees of intensity is constant. Over time, characteristic spindle-shaped finger deformations appear

Small, painless subcutaneous rheumatoid nodules appear on the skin of the fingers and in the elbow area. The course of the disease is slow, steadily progressing, accompanied by constant debilitating pain, deformities and loss of joint function.

Psoriatic arthritis

Pictured is rheumatoid and psoriatic arthritis of the hands

With this disease, arthritis develops in the distal (end) interphalangeal finger joints against the background of existing skin manifestations of psoriasis. But sometimes joint symptoms appear before skin symptoms or simultaneously with them. The disease in most cases begins acutely or subacutely with the appearance of redness, swelling and pain in the small finger joints. The lesion is usually asymmetrical, with the fingers resembling sausages.

The disease occurs with severe exacerbations and remissions. Nail plates are almost always involved in the pathological process. Over time, deformation of the fingertips occurs, they thicken, the nails become thinner and also deformed, and a symptom of a thimble appears - pinpoint depressions on the nail plates.

With a long course of the disease, dislocations and subluxations of small distal joints develop, as well as lysis (melting) of the bones of the fingertips (radiological sign) and shortening of the fingers.

Chondroprotectors: what are they, how to choose, how effective are they?

Joint pain at rest

Gouty arthritis

An attack of gout begins acutely, with the appearance of severe pain, swelling and redness in the affected joints. Small joints are often involved. Typically, inflammation begins with the metacarpophalangeal joint of the 1st finger, and then can spread to the metacarpophalangeal and interphalangeal joints of other fingers.

The pain is very severe, the attack can last from several hours to several weeks, and then everything goes away. But with frequent attacks affecting the same joints, their function is impaired.

Post-traumatic arthritis

This type of arthritis of the fingers can develop against the background of an acute domestic, industrial or sports injury, occur acutely with subsequent complete recovery, or (in the absence of the necessary help) be complicated by the addition of a purulent infection. Sometimes such an inflammatory process can become chronic with subsequent deformation of the affected joints.

Initially, post-traumatic arthritis of the fingers takes a chronic course with constant minor unnoticeable injury to the fingers. Most often this occurs among people in certain professions who perform minor work. Arthritis develops slowly, affecting the joints that are most injured during work. If you do not change jobs, a permanent deformity develops with impaired finger function.

Other types of arthritis

With such types of arthritis as reactive, infectious, idiopathic, damage to the small joints of the fingers practically does not occur.

How to do preventive hand massage

With simple movements you can independently relieve tension and eliminate muscle spasms in your hands. Massage is necessary to improve blood circulation and normalize metabolism in the joints.

• First, warm your palms by rubbing them together.
• Using the thumb and index finger of one hand, rub each finger on the other hand in turn: from the base to the nail, and then back.
• Wrap your hand around your finger and rotate as if sharpening a pencil.
• Bend and straighten your fingers at a fast pace, without clenching them into a fist, 15-20 times.

Massaging your fingers only takes a few minutes

Diagnostics

The diagnosis is established based on the characteristic symptoms of the disease and is confirmed by examination data:

• laboratory tests - detect the presence of an inflammatory process, the presence or absence of infection, antibodies to infectious agents, rheumatoid factor;
• X-ray – reveals bone changes in joints;
• Ultrasound - the presence of an increased volume of exudate in the joint cavity is a sign of an active inflammatory process;
• MRI – changes in soft articular and periarticular tissues.

Without additional examination methods, it is impossible to establish the correct diagnosis (and therefore prescribe adequate treatment). Therefore, if you experience pain in the small joints of your fingers, you should consult a doctor as soon as possible.

Methods for treating joints

After passing a clinical examination and collecting anamnesis, a diagnosis is made. Pathological changes are confirmed by X-ray diagnostics. The most typical changes are a narrowing of the space in the joints, subchondral sclerosis (an increase in bone density occurs around the joint), the appearance of the same cyst and osteophytes.

There is no direct treatment for these diseases. They are both irreversible processes that occur due to age. However, it is possible to control its progress, reducing pain and destruction of cartilage tissue and improving the patient’s well-being.

Treatment of arthritis of the fingers

After a final diagnosis has been established, treatment for arthritis of the fingers is prescribed, which is carried out by a rheumatologist (sometimes together with other specialists - a surgeon, a dermatovenerologist). It should be comprehensive, aimed at suppressing the progression of the pathological process and preventing disorders of joint function. The complex treatment includes:

• drug therapy;
• physiotherapeutic procedures;
• therapeutic exercises and massage;
• reflexology courses;
• folk remedies.

Drug therapy

The primary goal of drug therapy is to alleviate the condition of a sick person. For this purpose, NSAID medications are prescribed to relieve pain, inflammation and tissue swelling. Depending on the degree of activity of the inflammatory process, these drugs are prescribed in the form of injections (shots) or tablets for oral administration. In addition, drugs in this group are prescribed externally in the form of gels, ointments and creams.

The most effective NSAID is Diclofenac, but it has an irritating effect on the walls of the gastrointestinal tract, so it cannot be taken for a long time. Instead of Diclofenac, more modern drugs of the NSAID group are prescribed - Nise, Celebrex, etc. Such products as Pentalgin gel and Diclofencac ointment are used externally. The best ointment for arthritis of the fingers is Voltaren emulgel. The use of NSAIDs can bring significant relief to the patient.

Drugs for the treatment of hand arthritis

Sometimes the inflammatory process is so severe that it cannot be relieved with NSAID medications. In this case, glucocorticoid hormones are used - Prednisolone, Dexamethasone, etc. in the form of injections, orally in tablets or externally in the form of ointments. Intra-articular injection of hormones into small joints is rarely practiced.

To suppress autoimmune processes, basic group drugs are prescribed - Methotrexate, Sulfasalazine, Leflunomide and biological agents (MabThera, Redditux). These drugs are selected by a rheumatologist and prescribed according to a special regimen in long courses.

To restore joint function, chondroprotectors are prescribed - medications that restore the cartilage tissue of joints (Dona, Structum, etc.). They are also prescribed in long courses.

Agents that improve blood circulation and metabolism in tissues - Pentoxifylline, Actovegin, etc. help restore tissue trophism.

Vitamins and minerals are prescribed as general tonics, improving metabolism and helping to restore overall balance in the body.

Physiotherapeutic procedures

The complex treatment of arthritis of the fingers necessarily includes physiotherapeutic procedures. They, just like medications, are selected individually depending on the clinical form and activity of the pathological process. This can be electrophoresis with Hydrocortisone, UHF, laser or magnetic therapy, etc.

Crunching in joints - when to worry

Intra-articular injections of hyaluronic acid

Massage and exercise therapy

Courses of massage and therapeutic exercises are prescribed during the period of subsidence of the inflammatory process. They help improve blood circulation and metabolism in tissues, restore the function of small joints. At home, you can do the following physical exercises to improve mobility:

• roll a small elastic ball on the table surface with your finger surfaces for a minute, actively involving the affected finger joints in the process;
• with the fingertips of one hand, touch the pad of the 1st finger of the opposite hand; start with the little finger and end with the index finger; repeat the exercise 10 times;
• position your hands so that your fingertips are slightly bent and touch the surface of the table; bend each finger in turn and hit the table with it (like the keys of a piano);
• repeat three times.

Such exercises should be done daily, gradually increasing the number of approaches.

Folk remedies

A doctor should tell you how to treat arthritis of the fingers with folk remedies. He also selects the most suitable method. You can use both herbal decoctions and infusions for oral administration and external agents:

• a compress of kefir mixed with crushed chalk at the rate of 50 g of chalk per 75 - 100 ml of kefir; You should get a thick mixture that needs to be applied once a day at night; to do this, you need to apply it on a cotton napkin, apply it to the sore spot, and put polyethylene and insulation on top; leave it like that all night; perfectly relieves swelling and pain;
• infusion of celery roots; Place 20 g of crushed raw materials (dry or fresh) in a thermos overnight, pour 200 ml of boiling water; the next day, drink 3 to 4 times before meals; course of treatment – ​​2 weeks; relieves pain and swelling well.

Surgery

This type of treatment for arthritis of small joints is rarely used. In cases of severe arthritis that cannot be treated conservatively, a synovectomy is sometimes performed - removal of part of the synovial membrane that produces a large volume of exudate.

In some cases, the joint is replaced with an artificial one, but this is a fairly rare operation.

Modern treatment strategy for rheumatoid arthritis in this article.

Surgically

In cases of severe arthrosis, which is accompanied by rapid destruction of cartilage tissue, surgical intervention (arthroplasty) is used. The most common procedures are hip or knee replacements. Previously, most of the operations were performed on elderly people, whose age was 60 years or older. However, with the development of technology, artificially produced implants have become much better, and therefore young patients also undergo similar operations. However, another procedure in the form of revision surgery has been prepared for them in the future. Therefore, it is important to understand this before undergoing surgery.

Approach to the treatment of arthritis of the fingers at the Paramita clinic

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In our clinic, the patient is thoroughly examined using the latest laboratory and instrumental methods, including MRI, and only after that is treatment individually selected for each patient prescribed.

A special feature of treatment in our clinic is that complex therapy includes:

• modern Western methods of treatment
  , allowing to eliminate the main manifestations of arthritis of the fingers;
• traditional oriental methods of treating diseases
  , allowing to restore balance in the body, establish the relationship of all organs and systems; this leads to the elimination of inflammation, swelling and pain in the joints and suppresses the progression of the disease.

The combination of Western and Eastern techniques makes it possible to quickly and painlessly relieve our patients of pain, and then effectively restore the function of damaged joints. The specialists at the Paramita Clinic have extensive experience in treating arthritis of the fingers. You can find out more about treatment methods in our clinic on our website.

We combine proven techniques of the East and innovative methods of Western medicine.
Read more about our unique method of treating arthritis

Glucosamine

It acts as an amino sugar, which gives a “start” to the biochemical synthesis of glycosylated proteins. It is also a structural component of cartilage tissue. Thanks to glucosamine, the body receives “natural” materials for the development, repair and support of tendons, ligaments and other tissues. With age, the body produces less of this substance, which leads to deterioration of the musculoskeletal system.

Rheumatologists say that taking a glucosamine supplement can reduce pain and the destruction of cartilage tissue. More than 18 studies that served as the basis for the 2005 review clinically supported the substance's effectiveness and beneficial effects on osteoarthritis.

The norm for patients is 700 mg/day. If necessary, the dosage can be increased to 1500 mg.

General clinical recommendations

For patients suffering from arthritis of the fingers, it is recommended:

• lead a healthy lifestyle, toughen up;
• be treated in a timely manner, eliminate all foci of infection that may become a trigger in the development of exacerbations of arthritis;
• get rid of bad habits;
• eat right, regulate sleep and wakefulness;
• if arthritis worsens, do not put stress on your fingers, do not do housework, including washing dishes;
• during remission, do physical exercises for your arms at home; classes should be held daily;
• completely abandon self-medication and adhere to the doctor’s recommendations in everything.

Prevention of arthritis of the fingers

Preventing arthritis is especially important for people who have a genetic predisposition to this disease (close relatives with this pathology). In order to maintain health, they need to adhere to the following recommendations:

• you should not overload your hands with heavy physical or long-term painstaking work, including at home;
• you should not overcool, you should avoid overcooling your hands;
• lead a healthy lifestyle, eat right, toughen up;
• engage in feasible sports, conduct daily training;
• avoid prolonged stress.

Diet

Special nutrition is required only for gouty arthritis of the fingers. The diet of such patients should not contain strong broths, offal, meat of young animals, alcohol, sorrel, lettuce, strong tea, coffee, or chocolate.

If you have gouty arthritis, you should follow a diet

In other cases, it is enough to adhere to the principles of a healthy diet: eat lean meat and dairy products, fish (fatty sea fish is healthy), grains, cereals, vegetables, and fruits. High-calorie foods, sweets, baked goods, spicy seasonings, fried and smoked foods should be avoided. Meals should be regular.

There are 3 main factors as the cause of the disease (rheumatological triad)

1. Genetic predisposition
   Hereditary tendency to autoimmune reactions
2. More common in carriers of a certain MHC II class antigen: HLA - DR1, DR4
3. Infectious factor
   paramyxoviruses - mumps, measles, respiratory syncytial infection viruses
4. hepatoviruses - hepatitis B virus
5. herpes viruses - herpes simplex viruses, herpes zoster, Cytomegalovirus, Epstein-Barr virus
6. retroviruses - T-lymphotropic virus
7. Triggering factor (hypothermia, hyperinsolation, intoxication, mutagenic medications, endocrinopathies, stress, etc.). For women, breastfeeding for a longer period of time reduces the likelihood of developing RA. Breastfeeding for 24 months or longer reduces the risk of developing RA by half.

Frequently asked questions about the disease

Which doctor should I see for arthritis of the fingers?

It is better to immediately see a rheumatologist; if necessary, he will refer you for consultation to another specialist.

Can folk remedies be used for treatment?

You can, but not on your own, but only as prescribed by a doctor.

Rheumatologists often prescribe hormonal drugs; are they harmful?

Hormones are prescribed in short courses to eliminate pain and swelling. Such treatment cannot harm.

Arthritis of the fingers often develops unnoticed. It is very important to pay attention to aching pain in your fingers in a timely manner and consult a doctor in a timely manner. But even if you have missed time and obvious signs of arthritis appear, do not despair: you can help at any stage. It is difficult to completely cure a chronic disease, but it is quite possible to stop its progression, relieve you of pain and improve your quality of life. Doctors at the Paramita clinic (Moscow) know how to do this.

Literature:

1. Zabolotnykh, I.I. Diseases of the joints / I.I. Zabolotnykh. - M.: SpetsLit, 2009. - 256 p.
2. Velyaminov, N.A. The doctrine of joint diseases from a clinical point of view / N.A. Velyaminov. - M.: State Publishing House, 2011. - 434 p.
3. Shostak N. A. Psoriatic arthritis: new approaches to treatment // Clinician. 2008. No. 2. P. 41–45.

Themes

Arthritis, Joints, Pain, Treatment without surgery Date of publication: 11/13/2020 Date of update: 04/03/2021

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