Joint Pain in the Younger Population

Joint pain in the younger population, young adults from their teens to about 40, is driven mainly by four things: overuse injuries from sport and physical activity, a sedentary screen-bound lifestyle with the weight gain that follows, autoimmune or inflammatory disease such as rheumatoid arthritis, and nutritional gaps in vitamin D, calcium, magnesium and protein. Early diagnosis is crucial to prevent chronic damage to the joints.

Dr. Rakesh Mahajan, Vice Chairman & HOD - Orthopedics, BLK-Max Super Speciality Hospital, New Delhi, India, describes this group as the common population an orthopaedic surgeon comes across. His central point is that the first weeks of a joint problem decide whether it is treated simply or becomes chronic. This guide sets out the causes he sees, the symptoms that should prompt assessment, the step-by-step treatment pathway he follows and the diagnostic reasoning behind it, illustrated by a case discussed with doctors during the session.

Two companion articles go deeper. One covers preventing joint pain in young adults through nutrition and safe weight training: vitamin D, calcium, magnesium, protein and how to build strength without injuring the joints. The other covers joint pain treatment in young adults, from physiotherapy and NSAIDs to steroid injections, PRP and GFC.

Joint pain in the younger population: who it affects

Dr. Mahajan defines the younger population as people from their teens to 40 years of age. It is, in his words, the common population an orthopaedic surgeon comes across, and it behaves differently from older patients in three ways that shape care:

• They are active and energetic. They take part in sport, dance and many other demanding activities.
• They are informed. Most arrive having read about their condition online, and they want better treatment.
• They seek care themselves. Unlike many elderly patients, they do not wait for a relative to bring them to a doctor.

The reason this group matters is that early diagnosis is crucial to prevent chronic damage to the joints. A problem that persists for months becomes chronic, and the line of treatment changes.

Causes of joint pain in young adults

Dr. Mahajan groups the causes of joint pain in young adults into four clusters: overuse and physical strain, a sedentary life with poor posture and weight gain, autoimmune and inflammatory disease, and gaps in nutrition.

1. Overuse and physical strain

Active young people take part in sport, dance and a wide range of physical activities, and the repetitive load produces four main injuries. The distinctions matter, because each is treated differently:

• Sprain: an injury to a ligament, the band of tissue that connects bone to bone. Ankle, wrist, elbow and knee sprains are the most familiar, and one or several ligaments can be involved. The knee alone depends on the medial and lateral collateral ligaments and the anterior and posterior cruciate ligaments; the wrist, hip and shoulder each have their own sets.
• Strain: a muscle pulled by overuse or overstretching. One muscle or a whole group can be affected.
• Tendinitis: inflammation of a tendon, the structure through which a muscle attaches to bone. Common sites include the rotator cuff tendons of the shoulder (supraspinatus, infraspinatus and subscapularis), the Achilles tendon and the hamstring tendons (semitendinosus and semimembranosus).
• Bursitis: inflammation of a bursa, a small fluid-filled cushion that the body places around joints to absorb shock and prevent friction. Overuse inflames it. Typical sites include the bursae around the greater trochanter of the hip, the ischium and the biceps tendon at the shoulder.

The injury pattern follows the sport. Dr. Mahajan's map of where he sees the damage:

2. Sedentary life, posture and weight

The second cluster is the opposite of the first. Many young people work at desks, laptops and computers, and spend two or three hours at a stretch looking at a screen or a mobile phone. The fixed posture places unusual strain on the anti-gravity muscles of the neck and the dorsal (upper back) spine. Those muscles weaken, become stressed and then painful. Stiffness affects the neck, the dorsal spine and even the lumbar spine.

A sedentary life also leads to overweight and obesity, which Dr. Mahajan describes as a major issue worldwide. Rising incomes, more fast food and less time for activity are driving obesity among young people, and excess weight adds load to every weight-bearing joint.

3. Autoimmune and inflammatory disease

The third cluster is inflammatory joint disease: rheumatoid arthritis, ankylosing spondylitis, juvenile idiopathic arthritis and thyroid-related joint problems. Rheumatoid arthritis, an autoimmune disease in which the immune system attacks the joint lining, illustrates the pattern Dr. Mahajan sees:

• swelling, redness and difficulty moving the joint, with morning stiffness that can leave the patient uncomfortable through the day;
• a course that moves through stages (early, active, passive or advanced);
• muscle spasm around the inflamed joint, which in time can produce joint deformity;
• weakening of the muscles around the joint, so the young patient is not fully mobile.

He describes what follows as a vicious cycle. Reduced movement weakens the bones, beginning with early osteoporosis (thinning of the bone that makes it fragile). Many patients with rheumatoid arthritis are also treated with steroids, which weaken bone further, producing steroid-induced osteopenia (bone density below normal, short of osteoporosis) or osteoporosis. Each problem worsens the others.

4. The nutrition gap

The fourth cluster underlies the other three. Vitamin D deficiency is among the most common nutritional deficiencies worldwide, most diets contain little vitamin D, and many young people spend little time outdoors. Low calcium and magnesium are linked to night cramps, and too little protein erodes muscle and bone. Dr. Mahajan's view is that attention to vitamin D, calcium and magnesium in the diet takes good care of the muscles, joints and bones. The companion article on prevention sets out what he recommends.

When to see a doctor: symptoms of joint pain that need assessment

Most young patients present with some combination of:

• stiffness;
• swelling;
• warmth and redness over the joint;
• persistent pain;
• a reduced range of motion;
• joint pain accompanied by fatigue.

Warmth, redness and morning stiffness point towards an inflammatory cause. Pain tied to a sport or a specific movement points towards overuse. In either case, Dr. Mahajan's message is the same: assess early, because the treatment that works in the first weeks is not the treatment that works at three months.

How joint pain in young adults is treated

Dr. Mahajan's treatment follows a ladder of six steps, and time is the main factor that moves a patient from one rung to the next.

1. Lifestyle adjustment. Swap high-impact activity for regular low-impact exercise, such as yoga-type routines, if the patient is prone to injury, and correct nutritional deficits.
2. Physiotherapy. Ultrasonic therapy, shortwave diathermy, interferential therapy and TENS (transcutaneous electrical nerve stimulation), chosen by the depth of the injured tissue, with targeted exercises.
3. Medicines. A short course of non-steroidal anti-inflammatory drugs (NSAIDs), usually two to three weeks; nutraceuticals such as collagen; and disease-modifying anti-rheumatic drugs (DMARDs) for inflammatory arthritis.
4. Steroid injection. Triamcinolone or methylprednisolone, considered when pain keeps rising despite about three weeks of conservative treatment.
5. Regenerative therapy. Platelet-rich plasma (PRP) or growth factor concentrate (GFC) for partial tears and problems that have become chronic, which he labels at three months.
6. Surgery. Ligament reconstruction for complete tears, or arthroscopy (keyhole surgery) when injection and physiotherapy fail.

He is explicit that the rungs are not interchangeable. A steroid suppresses inflammation; PRP and GFC aim at regeneration of tissue that has stopped healing. Using regenerative therapy too early, or alongside a steroid, misreads the stage of the problem. The companion treatment article explains each rung, including how PRP and GFC compare.

Bilateral shoulder pain in a young adult: how the diagnosis is built

A case presented by a doctor during the session shows the diagnostic sequence in practice. A man in his mid-thirties had pain in both shoulders for six months, worse over the previous month, with a limited range of movement. He had no diabetes and no known inflammatory condition.

Dr. Mahajan's reasoning, step by step:

1. Ask about diabetes and thyroid disease first. Shoulder problems of this kind are very common in these patients. In his practice, he estimates that around 30% of patients with diabetes or thyroid disease have this problem, so he always asks whether the patient has taken any medicine for blood sugar or thyroid.
2. Ask about work and load. If the answer is no, the next question is whether the patient does manual work or heavy lifting that loads the shoulders.
3. Get plain X-rays. If there is no such history, X-rays rule out narrowing of the joint space and calcium deposits in the tendons (calcific tendinitis).
4. Start conservative treatment for three weeks. If the X-rays are normal, he begins physiotherapy (ultrasonic therapy, TENS, cold packs and shoulder exercises) with an anti-inflammatory, and watches the response.
5. Ultrasound if there is no response. If the patient has not improved within three weeks, an ultrasound of both shoulders shows whether the subacromial bursa (the cushion beneath the bony roof of the shoulder) is inflamed and impinging on the tendons, the very common picture called impingement syndrome. It also rules out a partial tear or tendinitis of the supraspinatus or infraspinatus.

In this patient, further results changed the picture. The rheumatoid factor was positive, the antinuclear antibody (ANA) test negative and uric acid normal, and MRI showed likely chronic partial-thickness tears of both supraspinatus tendons at their attachment to bone, with subacromial bursitis. With a positive rheumatoid history and inflammation of both the joints and the bursa, Dr. Mahajan's plan combines four elements:

• anti-inflammatory drugs;
• anti-rheumatoid drugs;
• a steroid (triamcinolone) injection into the subacromial bursa;
• physiotherapy.

The injection should not be repeated before three months. If the patient still does not respond, the next step is shoulder arthroscopy: the bursa is completely debrided (cleared of inflamed tissue), the acromioclavicular (AC) joint is assessed and the supraspinatus and infraspinatus are inspected for tears.

The case captures his method: history before investigation, the simplest test first, a defined trial of conservative care, then imaging and escalation only when the response falls short. Shoulder surgery itself, including rotator cuff repair, is covered in depth in Dr. Vipin Maheshwari's guide to knee and shoulder arthroscopy.

When to get an X-ray, ultrasound or MRI for joint pain

In Dr. Mahajan's approach, investigations escalate step by step. Plain X-rays come early and rule out joint space narrowing and calcium deposits. Ultrasound is the next step for shoulder problems that fail to settle after three weeks of conservative treatment. For a ligament injury such as a chronic ankle sprain, he is clear that MRI should not be held back: when in doubt, get the MRI, because it distinguishes a complete tear, which needs reconstruction, from a partial tear, which can be treated with PRP or GFC.

Acute or chronic joint pain: the clock that drives treatment

Across the session, Dr. Mahajan returned to one organising idea: the duration of the problem decides the treatment.

• Within the first days to weeks, the problem is treated as acute inflammation: cold packs, a support such as a tennis elbow band, physiotherapy and a short course of anti-inflammatories.
• Between about 6 and 12 weeks, chronicity sets in. Most patients who reach him have already seen several consultants and taken many treatments, and they arrive beyond six weeks.
• At three months, he labels the problem chronic. At that point it is no longer driven by inflammation but by tissue that has failed to heal, and the line of treatment changes towards regenerative therapy or surgery.

The practical consequence is that a problem seen in its first weeks is treated conservatively, while one that has lasted beyond three months needs a different line of treatment.

Related masterclasses on joint replacement and arthritis

Dr. Mahajan's other masterclasses cover the end of the spectrum that this one aims to prevent: robotic knee replacement and complex total hip arthroplasty. For established arthritis in older patients, Dr. Mannu Bhatia's guide to joint arthritis diagnosis and management covers the full pathway to joint replacement, and Dr. Rohit Lamba's guide to the spectrum of orthopaedic disorders covers knee and hip arthritis, non-union and bone infection. Related articles are grouped in the orthopaedics and rheumatology specialty hubs. The questions doctors raised in this session, including the shoulder case above, are collected in the Live Discussion for this masterclass.