Hip and knee arthritis treatment in Hawai‘i: arthritis is a spectrum — your treatment should be too

Hip and knee arthritis treatment is a ladder, not a switch: strengthening and weight optimization first, then medication, injections, biologics and nerve treatments, and joint replacement only when the joint is bone-on-bone and pain is stealing your life. Dr. Paul Morton, a fellowship-trained hip and knee surgeon in Honolulu, stages every joint with standing X-rays and an honest exam — and most of his arthritis patients never need surgery.

A joint is simply the connection between two bones, and healthy cartilage is the smooth bearing surface that lets those bones glide past each other without friction. Arthritis means that cartilage is wearing away. As it thins, bone begins to grind against bone — and a joint that once moved silently starts to ache, stiffen, and swell. The two joints most often affected are the ones that carry you: the knee (between the femur and tibia) and the hip (between the pelvis and the femur).

It's also far more common — and more costly — than most people realize:

Osteoarthritis — by far the most common — is mechanical wear over decades. Rheumatoid arthritis and its inflammatory relatives are immune-driven and co-managed with rheumatology (which specialist you need). Gout is a crystal disease of uric-acid metabolism. Post-traumatic arthritis follows old injuries, often decades later. And septic arthritis is joint damage left behind by infection. All five roads can end at the same place — bone on bone — but the pace, the pain pattern, and above all the treatment options differ. Getting the label right is the first job of the first visit.

Osteoarthritis (OA) is not the same thing as "old age" — plenty of people live long, active lives with pain-free joints. OA develops when cartilage cells become damaged and lose the ability to rebuild. Enzymes released from those damaged cells break down collagen and proteoglycan — the structural building blocks of cartilage — faster than the joint can replace them. Age, genetics, excess weight, prior surgery, and a history of injury all tilt the balance toward breakdown.

As cartilage disappears, the bone beneath it hardens (sclerosis), the joint edges sprout new bone (bone spurs), and fluid-filled pockets called subchondral cysts form in the deteriorating bone. Eventually the joint wears through entirely — the "bone-on-bone" appearance on an X-ray.

The five stages of osteoarthritis

How osteoarthritis is diagnosed

There is no blood test for OA — labs are used only to rule out inflammatory causes like rheumatoid arthritis. Standing (weight-bearing) X-rays show the cartilage loss and bone spurs directly, and stage the disease in a single visit. An MRI is rarely required; it's reserved for complex cases where soft-tissue detail changes the plan.

Rheumatoid arthritis (RA) is a chronic autoimmune disease: the body's own immune system attacks the synovium, the soft-tissue lining that produces the fluid nourishing and lubricating the joint. As the synovium is destroyed, the cartilage and bone beneath it deteriorate, and movement becomes painful. Unlike osteoarthritis, RA can strike at any age, and it can involve far more than joints — skin, lungs, heart, and eyes. The exact cause is still unknown, but identified genetic markers raise the risk roughly fivefold.

The four stages of rheumatoid arthritis

• Stage 1 — Mild: the synovium is inflamed and the joint hurts, but the bones are not yet damaged.
• Stage 2 — Moderate: inflammation begins destroying cartilage; range of motion narrows and movement becomes painful.
• Stage 3 — Severe: bone itself erodes; with the cushion gone, bones rub and wear against each other, and muscle weakness sets in.
• Stage 4 — End-stage: the inflammation may finally burn out, but the joint no longer functions — extreme pain, stiffness, and swelling, and the bones may even fuse together (ankylosis).

How rheumatoid arthritis is diagnosed

Early RA is genuinely hard to pin down — no single finding or lab confirms it. The diagnosis combines the exam with inflammation markers (ESR and CRP), confirmatory antibodies (rheumatoid factor and anti-CCP), and imaging: X-rays to track progression, MRI and ultrasound to gauge severity. Because modern disease-modifying medications have been genuine game-changers, Dr. Morton co-manages inflammatory arthritis with rheumatology — medical control of the disease first, surgery only for the joints already destroyed.

Gout is a disorder of uric-acid (urate) metabolism. Uric acid is a normal byproduct of purine breakdown; trouble starts when the body makes too much of it (metabolic disorders, dehydration) or can't excrete enough (kidney or thyroid problems, inherited conditions). Once blood and tissues are saturated, urate precipitates into hard, needle-like crystals — favoring the cooler, more acidic environment of peripheral joints — that physically grind away at cartilage and bone with every movement.

The attacks are unmistakable: sudden, severe episodes of pain, swelling, redness, and tenderness — classically waking you in the middle of the night with the sensation that your big toe is on fire. Long-standing gout can also deposit visible crystal lumps under the skin, called tophi.

Diagnosis is definitive: fluid is drawn from the joint with a needle (arthrocentesis) and examined under a microscope for urate crystals. Treatment works: urate-lowering medications (allopurinol, febuxostat, probenecid), medications to prevent flares, and dietary changes — cutting back on red meat, organ meats, sugary drinks, and fructose-heavy foods that raise uric acid.

Post-traumatic arthritis

Post-traumatic arthritis develops when a joint that once sustained a physical injury — a car accident, a fall, a sports or military injury — wears out ahead of schedule. The original trauma damages bone and cartilage and deranges the joint's mechanics, so it grinds where it used to glide; excess body weight accelerates the process further. These joints are often the most complex to treat: deformity, retained surgical hardware, and prior operations can make both the arthritis pattern and the eventual surgery more demanding than routine osteoarthritis. X-rays tell most of the story; a CT scan or MRI is added when planning requires it.

Septic arthritis

Septic arthritis is joint inflammation caused by infection — usually bacterial, most often staphylococcus. Bacteria reach the joint through the bloodstream, a penetrating injury, or an infection in nearby bone or soft tissue, and joints with pre-existing arthritis are especially vulnerable. The immune system's battle against the bacteria damages the cartilage itself, so even a cured infection can leave a permanently arthritic joint. Diagnosis rests on lab markers (ESR, CRP) and aspirating joint fluid to test for bacteria. This history matters enormously for later care: patients who have had a joint infection carry a higher risk of chronic pain, and joint replacement after septic arthritis has an elevated risk of failure and re-infection — which makes experienced surgical planning essential.

Treatment escalates only as needed:

Treatment for hip and knee arthritis begins without a scalpel — and there is a good chance your pain improves without ever needing one. Here is the full nonsurgical toolkit Dr. Morton draws from:

Hawai‘i patients often ask about complementary treatments — and Dr. Morton welcomes the conversation rather than dismissing it. The goal is that you understand what each option involves, what the evidence actually shows, and what it costs, before you spend money on it. Treatments patients commonly ask about include:

• Platelet-rich plasma (PRP) injections — offered in-office where the evidence supports them
• Stem-cell and bone marrow concentrate (BMAC) injections
• Cannabidiol (CBD) and medical marijuana
• Acupuncture
• Chiropractic manipulation
• Massage therapy
• Homeopathy and naturopathic medicine
• Kava (‘awa)
• Turmeric (‘ōlena)
• Glucosamine and chondroitin

Some of these help some patients modestly; none of them regrows cartilage. Bring whatever you're using — or considering — to your visit, and you'll get a straight answer about it.

Half wait too long — grinding through years of shrinking life while the joint (and the muscles around it) deteriorate, making eventual surgery harder. The other half jump too fast, replacing joints that injections and strengthening could have managed for another decade. The antidote to both is staging: standing X-rays, an honest exam, and a surgeon who profits nothing from steering you wrong. Dr. Morton's practice is deliberately built on the whole ladder, so the recommendation matches the joint — not the business model.

The page's own criteria, turned into a checklist. Neither list is a diagnosis; both are settled by standing X-rays and an exam in a single visit.

Three signs, together, usually mean it's time: bone-on-bone imaging, failed conservative care done properly, and — most important — pain that's stealing your life. Dr. Morton puts it to patients in concrete terms: he considers surgery when conservative treatment has failed and pain is limiting one or more of four areas of life.

• Your ability to work — when pain keeps you from your job, even on light-duty tasks.
• Activities of daily living — when the grocery store, or simply moving around your own house, has become an ordeal.
• Relationships with family — when constant pain makes you short-tempered, or keeps you from playing with your grandchildren.
• The activities you love — when golf, tennis, biking, or beach walks are off the table. In his words: "Life is not worth living if you cannot enjoy the things you like to do."

When those align, modern hip replacement and knee replacement are a remarkably good trade: robotic precision (Dr. Morton is certified on all four major platforms — ROSA, Mako, CORI, and VELYS), muscle-sparing approaches, same-day discharge, and implants that commonly last 20+ years; individual results vary. Until they align, every other rung gets used first.

Not sure which rung you're on? An exam and weight-bearing X-rays settle it in one visit — book a consultation or call (808) 439-6201; clinics in Honolulu (Ala Moana), Kunia, Hilo and Kona, with most new patients seen within one to two weeks. Bring a photo ID, your insurance card, a medication list, and any prior imaging; managed-care and Medicaid/Quest plans need a referral from your primary care physician, which the office helps arrange. Telehealth works for staging when an in-person visit isn't practical, with standing X-rays taken near home.