Download 2. Osteoarthritis

Osteoarthritis
Objectives
Describe prevalence, etiology & pathogenesis of ( O.A. ) .
Take proper history, considering Pt.'s ICE.
List the risk factors for developing O.A.
Conduct knee examination .
Describe the radiological findings .
Identify different modalities of management for O.A.
Recommend lifestyle changes & educational strategies as
part of treatment .
Case Scenario
- Saied, healthy & active 54 years old carpenter.
- C/O: Bilateral knee pain . He used Acetaminophen & local
diclofenac gel. He had partial relief .
- He is unable to do his job comfortably .He does his
prayers sitting on a chair.
- PMH: GERD & hernia repair 10 years ago.
- O/E: BP = 130/85 mmHg , Temp. 36.5 °C.
- Weight = 98 Kg, Height = 175 cm
- Knees Examination:
- X-Rays of both knees:
Definition
 OA refers to a clinical syndrome of joint pain accompanied by
varying degrees of functional limitation and reduced quality of
life.
 OA is a common degenerative disorder of the articular
cartilage associated with hypertrophic bone changes.
 It is characterised pathologically by localised loss of
cartilage, remodelling of adjacent bone and associated
inflammation.
 It is the most common form of arthritis, and one of the leading
causes of pain and disability worldwide.
 The most commonly affected peripheral joints are the knees,
hips and small hand joints.
The pathogenesis of joint damage
Articular cartilage.
molecular level
gradual proteolytic degradation of the matrix
increased synthesis of the matrix components by the
chondrocytes
morphological changes
cartilage surface fibrillation
cleft formation
loss of cartilage volume
The pathogenesis of joint damage
Bone :less well understood,
development of osteophytes at the joint margin
ossification of cartilage outgrowths
major changes in the vascularity and turnover of the
subchondral bone.
Cytokines and other signalling molecules released from
the cartilage, synovium, and bone affect chondrocyte
function.
Role for inflammation in O.A. , at least in some patients
and in some phases of the disease.
Differential diagnosis
Condition
Differentiating Differentiating
signs/symptoms Investigations
Gout
More acute onset(few Hours),
the affected joint is usually
red, hot, and acutely tender.
Commonly involves the
(MTP) joint
Joint fluid analysis shows
leukocytes >2000, and the
presence of sodium
monourate crystals.
RA
symmetrical small joint in the
hands, the MCP joints and
sparing the DIP joints. More
prolong morning stiffness
than OA. Patients feel
generally unwell, with fatigue
and low mood.
In RA, ESR and CRP are
abnormal and RF is positive.
Typical RA erosive changes
are seen on x-ray, MRI, or
ultrasound.
Condition
Psoriatic Arthritis
Avascular Necrosis
Differentiating
signs/symptoms
Differentiating
Investigations
often affects the DIP joints.
In psoriatic arthritis, the joint
involvement is usually
asymmetrical
x-ray shows typical erosive
changes.
This is common in the hip and
knee joints. The onset is
subacute and there is usually
a risk factor such as
corticosteroid use.
MRI is the most sensitive test
in AVN. In the early stages,
localised subchondral
oedema is characteristic. In
50% of all cases,
accompanying joint effusion
may be found.
Common clinical Features that allow
Bedside Diagnosis
Increased age
Pain
Stiffness
Reduces movement
Swelling &
Crepitus
Diagnosis
 The diagnosis is based on a history of joint pain worsened
by movement, which can lead to disability in activities of
daily living.
 Plain radiography may help in the diagnosis, but
laboratory testing usually does not.
Finding in Plain X-ray
 Mnemonic
L: loss of joint space
O: osteophytes
S: subchondral cysts
S: subchondral sclerosis
 Osteophyte is the most specific radiographic marker for
OA although it is indicative of relatively advanced disease.
Diagnosis
differentiation from
1. referred pain
2. periarticular (soft-tissue) conditions
3. somatisation (regional pain in the absence of any local
pathological cause)
Diagnosis
Diagnose osteoarthritis clinically without investigations if
a person:
 Is 45 or over and
 Has activity-related joint pain and
 Has either no morning joint-related stiffness or morning
stiffness that lasts no longer than 30minutes,unlike
rheumatoid arthritis, which causes stiffness for 45 minutes
or more.
Risk Factors

Genetics,
 Female sex,
 Past trauma,
 Advancing age, and
 Obesity.
Involve Joints
 The joints most commonly
affected are
 The hands,
 Knees,
 Hips, and
 Spine,
- But almost any joint can be
involved.
The pathogenesis of joint pain
Synovitis
Subchondral bone changes
Peripheral pain sensitisation
Central pain sensitisation
 Finally, the experience of pain will be modulated by
psychological, social, and other contextual factors
Signs and Symptoms of OA
 Hand
Pain on range of motion
Hypertrophic changes at distal and proximal
interphalangeal joints (Heberden nodes and Bouchard
nodes)
Tenderness over carpometacarpal joint of thumb
Typical findings
 Heberden’s nodes
1
2
2
 Bouchard’s nodes
Hand affected by osteoarthritis.
(1) Heberden nodes. (2) Bouchard
nodes.
Radiograph of a hand
affected by OA
(1) joint space narrowing,
(2) osteophytes, and (3)
joint destruction. Also
note changes at
carpometacarpal joint (4),
which are very common
in osteoarthritis.
2
3
1
4
Shoulder
Pain on range of motion
Limitation of range of motion, especially external rotation
Crepitus on range of motion
Knee
Pain on range of motion
Joint effusion
Crepitus on range of motion
Presence of popliteal cyst (Baker cyst)
Lateral instability
Valgus or varus deformity
KNEE/(1) joint space narrowing and (2) osteophyte formation.
Hip
Pain on range of motion
Pain in buttock
Limitation of range of motion, especially internal rotation
Radiograph of the hips showing (1) joint space narrowing
and (2) osteophyte formation.
Foot
Pain on ambulation, especially at first metatarsophalangeal
joint
Limited range of motion of first metatarsophalangeal joint,
hallux rigidus
Hallux valgus deformity
Spine
Pain on range of motion
Limitation of range of motion
Lower extremity sensory loss, reflex loss, motor weakness
caused by nerve root impingement
Pseudoclaudication caused by spinal stenosis
Physical examination
 Important in making the diagnosis.
 Pain and limitation of range of motion are common
 Each joint has unique physical examination findings
Laboratory testing
Usually is not required to make the diagnosis.
 ESR & CRP are typically normal.
 Immunologic tests, such as ANA & RF (only if evidence
of joint inflammation or synovitis)
 uric acid level (only if gout is suspected).
Holistic approach to OA assessment
and management
 Offer advice on the following core treatments to all
people with clinical osteoarthritis.
 Access to appropriate information.
 Activity and exercise.
 Interventions to achieve weight loss if the person is
overweight or obese
Treatment
Treatment
Four main categories:
Nonpharmacologic,
 Pharmacologic,
 Complementary and alternative, and
 Surgical.
Begin with the safest and least invasive therapies
All patients with OA should receive at least some
treatment from the first two categories.
NONPHARMACOLOGIC
 Exercise: Muscle strengthening and range-of-motion
exercises.
Thermotherapy: local heat or cold should be considered as
an adjunct to core treatments.
Swimming, elliptical training, and cycling are exercise
options for patients with osteoarthritis in weight-bearing
joints.
Weight reduction
Bracing and splinting to help support painful or unstable
joints.
PHARMACOLOGIC
Acetaminophen
NSAIDs
Opoids
Intra-articular injections of corticosteroids or hyaluronic
acid
combination of glucosamine and chondroitin
COMPLEMENTARY AND
ALTERNATIVE MEDICINE
Acupuncture – LBP
glucosamine and chondroitin (GAIT).
Balneotherapy (spa therapy or mineral baths).
Capsaicin cream
S-adenosylmethionine (SAM-e)
SURGICAL
Indication is continued pain and disability despite
conservative treatment.
The most effective is total joint replacement.
Excellent outcomes for hip, knee, and shoulder.
Follow-up and review
Monitoring the symptoms and the ongoing impact of the
condition on everyday activities and quality of life.
Monitoring the long-term course of the condition
Discussing person's knowledge & concerns
Personal preferences and ability to access services
Reviewing effectiveness & tolerability of all treatments
Support for self-management.
Annual Review
 For any person with one or more of the following:
troublesome joint pain
more than one joint with symptoms
more than one comorbidity
taking regular medication for their osteoarthritis.