History

Fact Explanation
Joint Pain Joint pain is usually slow in onset, with gradual and intermittent increase. It can be diffuse/ sharp and stabbing in character which is initially relieved by rest but later on disturbs sleep. Vigorous activity may cause pain to flare up. Distribution is often asymmetric. Pain is more on weight bearing due to stress on the synovial membrane & later on due to bone surface,which are rich in nerve endings coming in contact. Muscle spasms add to the pain. [1,2,3,4]
Joint stiffness Pain and stiffness after periods of inactivity passes over approximately 30 min of using joint again. This is more common just after getting out of bed in the morning. (ie. morning stiffness) As the disease progresses, prolonged joint stiffness can occur. [1,2]
Restricted movement Restricted movements of the affected joints may be due to either capsular thickening and bony changes, painful muscle spasm or soft tissue contractures. Patients may complain of joint locking. [1,2,3]
Joint deformity Affected joint may look swollen. The swelling may be hard (caused by osteophytes) or soft (caused by synovial thickening and joint effusion). Osteophytes are bony projections that form along joint margins formed due to deformed repair process of the bone. [1,2,4]
Joint instability Sometimes joints may feel like give way as the supporting muscles have weakened and joint structure has become less stable. [1]
Crepitus Crepitus is referred to the grating or grinding sensation when the joint moves.It can be palpated/heard.This occurs due to due to flaked cartilage & abnormally replaced bone ends. [1,2]
Secondary osteoarthritis Although usually occurring as a primary disorder owing to heredity and environmental causes, osteoarthritis can occur secondary to other processes which is named as secondary osteoarthritis. Such causes are namely : Calcium deposition, Congenital or developmental causes, Endocrine disorders such as diabetes, genetic defects such as Marfan's syndrome. septic arthritis, metabolic disorders such as hemochromatosis and wilson's disease should be considered. Post-traumatic Injury to joints or ligaments as a result of an accident or orthopedic operations and rheumatologic diseases other than primary osteoarthritis are also among secondary etiologies. [1]
References
  1. SINUSAS,K. Osteoarthritis: Diagnosis and Treatment, Am Fam Physician[online]. 2012,85(1),49-56. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2012/0101/p49.html
  2. FELSON,D.T. Developments in the clinical understanding of osteoarthritis,Arthritis Research & Therapy[online],2009, 11,203 [viewed 2 May 2014]. Available from:doi:10.1186/ar2531
  3. RALPH,H, R.L.MOODY, A.W.DAVIS, THOMAS, S.F,Osteoarthritis: Diagnosis and Therapeutic Considerations,Am Fam Physician[online].2002,65,841-8.[viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2002/0301/p841.html
  4. RINGDAHL,E , S.PANDIT.Treatment of Knee Osteoarthritis, Am Fam Physician[online]. 2011,83(11),1287-1292. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2011/0601/p1287.html

Examination

Fact Explanation
Crepitus Crepitus is a palpable or audible crunching or popping sound of the joint specially during movements. It is a late presentation of osteoarthritis. [1,2,4]
Restricted movements Capsular thickening, bony changes, painful muscle spasm or soft tissue contractures can cause reduced range of movements of hand,shoulder, knee, hip, foot or spine. [1,2,3,4]
Joint line tenderness Palpation causes pain when the bone surface exposes after the degeneration of the articular cartilage ,which are rich in nerve endings coming in contact. [1,4]
Bony swelling The swelling may be hard (caused by osteophytes) or soft (caused by synovial thickening and joint effusion).[1,2,4]
Soft tissue swelling Due to surrounding imflammation.[1,2]
Deformity Abnormal bone formations cause deformities due to misalignment. Varus deformity of the knee is formed when the tibia is turned inward in relation to the femur, resulting in a bow legged deformity. Hallux valgus deformity or bunion is caused by either due to the swollen bursal sac or an osseous anomaly on the metatarsophalangeal joint. [1,2,3]
Muscle wasting Muscles waste due to disuse atrophy. [1,2,3,4]
Heberden nodes and Bouchard nodes Hypertrophic changes at distal (Heberden nodes) and proximal interphalangeal joints (Bouchard nodes). Heberden nodes are more common in women [3,4]
Popliteal cyst (Baker's cysts) It is a benign inflammatory swelling of the semimembranous or more rarely some other synovial bursa found behind the knee joint. [2,3,4]
Pseudoclaudication This is caused by spinal stenosis due to osteoarthritis of the spine. [1,2,4]
References
  1. SINUSAS,K. Osteoarthritis: Diagnosis and Treatment, Am Fam Physician[online]. 2012,85(1),49-56. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2012/0101/p49.html
  2. FELSON,D.T. Developments in the clinical understanding of osteoarthritis,Arthritis Research & Therapy[online],2009, 11,203 [viewed 2 May 2014]. Available from:doi:10.1186/ar2531
  3. RALPH,H, R.L.MOODY, A.W.DAVIS, THOMAS, S.F,Osteoarthritis: Diagnosis and Therapeutic Considerations,Am Fam Physician[online].2002,65,841-8.[viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2002/0301/p841.html
  4. RINGDAHL,E , S.PANDIT.Treatment of Knee Osteoarthritis, Am Fam Physician[online]. 2011,83(11),1287-1292. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2011/0601/p1287.html

Differential Diagnoses

Fact Explanation
Rheumatoid Arthritis Chronic symmetrical inflammatory polyarthritis affecting small and large joints including hand, knee, wrist, ankle and neck. Deformity may vary depending on the joint affected in hand. These include ulnar deviation, boutonniere deformity, swan neck deformity and Z-thumb (hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint). There are extra articular manifestations such as subcutaneous nodules and carpal tunnel syndrome. More common in females. [1]
Avascular Necrosis Avascular necrosis can affect any bone , but the classical site is head of femur. The pain most commonly be localized to the groin or in the ipsilateral buttock, knee, or greater trochanteric region. Pain is exacerbated with weight bearing. [1]
Ankylosing Spondylitis Chronic symmetrical inflammatory polyarthritis affecting large joints and axial skeleton. Ankylosing spondylitis characteristically affects spine and is manifested as an insidiously onset inflammatory back pain. There are extra articular manifestations such as Iritis, tendonitis and aortic insufficiency. [1]
Fibromyalgia Chronic symmetrical non-inflammatory polyarthritis affecting diffusely involving the axial skeleton as well. Fibromyalgia is a disorder that causes muscle pain and fatigue. Patients may complain of "tender points" on the body. Tender points are specific places on the neck, shoulders, back, hips, arms, and legs. There are many other complains such as disturbed sleeping, morning stiffness, headaches and painful menstrual periods in women. Females are affected more commonly. [1]
Gout Recurrent attack of acute inflammatory arthritis.Metatarsal-phalangeal joint at the base of the big toe is affected most often. Heels, knees, wrists and fingers, may also be affected. [2]
Psoriatic arthritis Usually psoriasis appears to precede the onset of psoriatic arthritis. Psoriatic arthritis is accompanied with enthesitis and dactylitis. Psoriatic skin lesions are characterized with scaly, erythematous plaques. Psoriatic nail changes like leukonychia, onycholysis, subungual hyperkeratosismay will also be evident. [1]
References
  1. RICHIE, A.M, M.L.FRANCIS,Diagnostic Approach to Polyarticular Joint Pain, Am Fam Physician[online]. 2003 Sep, 15,68(6),1151-1160. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2003/0915/p1151.html
  2. EGGEBEEN,A.T, Gout: An Update,Am Fam Physician[online]. 2007 Sep,15,76(6),801-808. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2007/0915/p801.html

Investigations - for Diagnosis

Fact Explanation
Erythrocyte sedimentation rate (ESR) usually is not required to make the diagnosis. ESR is typically normal except during a flare up. [1]
Immunologic tests (eg- antinuclear antibodies and rheumatoid factor) Only done when autoimmune arthritis is considered as a differential diagnosis. [1]
Serum uric acid level Only done when gout is considered as a differential diagnosis. [1]
Plain radiography Non uniformal joint space narrowing is the earliest evidence. Other radiographic hallmarks of primary osteoarthritis include osteophyte formation, cyst formation and subchondral sclerosis. Plain film radiographs are adequate for initial confirmation the diagnosis or assess the severity. But presence of radiographic changes in the absence of symptoms should not lead to the diagnosis of osteoarthritis. [1,2]
Computed tomography (CT) Rarely needed unless the diagnosis is in doubt and there is a strong suspicion for another etiology, such as a meniscal injury. [1,2,3]
Magnetic resonance imaging (MRI) Rarely needed unless the diagnosis is in doubt and there is a strong suspicion for another etiology, such as a meniscal injury. [1,2,3]
References
  1. SWAGERTY, D.L.D,E. HELLINGER,Radiographic Assessment of Osteoarthritis, Am Fam Physician[online], 2001,64,279-86. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2001/0715/p279.html
  2. SINUSAS,K. Osteoarthritis: Diagnosis and Treatment, Am Fam Physician[online]. 2012,85(1),49-56. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2012/0101/p49.html
  3. RALPH,H, R.L.MOODY, A.W.DAVIS, THOMAS, S.F,Osteoarthritis: Diagnosis and Therapeutic Considerations,Am Fam Physician[online].2002,65,841-8.[viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2002/0301/p841.html

Investigations - Followup

Fact Explanation
Plain radiography Follow-up radiographs can be helpful, especially if surgical intervention is planned or a fracture is suspected. [1]
References
  1. FRANKLIN,J. et al. Natural history of radiographic hip osteoarthritis: A retrospective cohort study with 11-28 years of followup, Arthritis Care Res (Hoboken) [online]. 2011 May,63(5),689-95. [viewed 2 May 2014]. Available from: doi: 10.1002/acr.20412.

Management - General Measures

Fact Explanation
Education Symptoms may cause the patient to feel frustrated, dependent upon others for help, and even depressed. These factors may reduce patients motivation and compliance to the treatment. So It is important to discuss the options for the treatment, the effects of the disease on daily activities, and the strategies for coping with the limitations. Some studies suggest that psychosocial support may be as effective as drug therapy for reducing the symptoms. [1,3,8]
Physiotherapy Physiotherapy interventions can reduce knee pain and improve function in those with knee osteoarthritis. It helps to dissipate knee joint load, alter lower limb alignment, improve range of motion and restore normal neuromuscular function. [1,2,8]
Exercise program Regular exercise appears to be safe and effective in managing the symptoms and disability. Exercises encourage full range low impact movements. (eg- swimming, cycling) But prolonged loading activities that cause pain, contact sports and high impact sports such as running should be avoided. Quadriceps exercises are of proven value for pain relief and improving function in patients with knee osteoarthritis. [1,3,5]
Aids and appliances Braces / splints, special shoes/insoles dressing, reaching, tap openers, kitchen aids Use of a cane, stick or other walking aid reduce the loading on the joints can improve symptoms. Special shoes and insoles are used to reduce impact and loading on lower limb joints. Modern sports shoes (‘trainers’) often have appropriate insoles. Alternatively, special heel or shoe insoles of sorbithane or viscoelastic materials can be used. [1,2,3]
Heat Some benefit from heat locally over the affected joint. Heat may work by improving circulation and relaxing muscles.Heat can be applied to the joints with hot packs, hot water bottles, heating pads, or electrically heated mittens.[4,8]
Ice Provides local vasoconstrictive and analgesic effects. Cold may numb the pain, decrease swelling, constrict blood vessels and block nerve impulses to the joint.Ice massage showed a significant benefit in improving range of movements and function. [4]
Transcutaneous nerve stimulation (TENS) Use of transcutaneous nerve stimulation (TENS) as an adjunct to other therapy for pain relief at the knee joint. [1,2,3]
Weight loss mechanical forces and inflammation are predisposing for osteoarthritis development. Dietary weight loss and exercise in obese persons with osteoarthritis have shown clinically significant improvements in symptoms. Studies have shown that pain, physical function, and walking distance improve with short-term exercise. [6,8]
Dietary supplements Glucosamine-containing supplements are among the most commonly used products for osteoarthritis.They are required for synthesis of glycoproteins and glycosaminoglycans, which are found in synovial fluid and ligaments. Glucosamine is available in hydrochlorides and sulfates. It has been found that glucosamine can improve symptoms of pain and slow disease progression. Chondroitin sulfate also has been found to reduce symptoms. It is an endogenous glycosaminoglycan, which helps in formation of the joint matrix structures. S-adenosylmethionine, methylsulfonylmethane, Harpagophytum procumbens (devil’s claw), Curcuma longa (turmeric), and Zingiber officinale (ginger) are other supplements. [7]
References
  1. SINUSAS,K. Osteoarthritis: Diagnosis and Treatment, Am Fam Physician[online]. 2012,85(1),49-56. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2012/0101/p49.html
  2. PAGE,C.J., R.S.HINMAN, K.L.BENNELL. Physiotherapy management of knee osteoarthritis, Int J Rheum Dis[online], 2011 May,14(2),145-51. [viewed 2 May 2014]. Available from:http://onlinelibrary.wiley.com/doi/10.1111/j.1756-185X.2011.01612.x/pdf
  3. FELSON,D.T. Developments in the clinical understanding of osteoarthritis,Arthritis Research & Therapy[online],2009, 11,203 [viewed 2 May 2014]. Available from:doi:10.1186/ar2531
  4. BROSSEAU, L. et al. Thermotherapy for treatment of osteoarthritis, Cochrane Database Syst Rev[online]. 2003,(4),CD004522.[viewed 2 May 2014]. Available from: DOI: 10.1002/14651858.
  5. RALPH,H, R.L.MOODY, A.W.DAVIS, THOMAS, S.F,Osteoarthritis: Diagnosis and Therapeutic Considerations,Am Fam Physician[online].2002,65,841-8.[viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2002/0301/p841.html
  6. MESSIER,S.P. Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management.Rheum Dis Clin North Am[online], 2008 August , 34(3), 713–729.[viewed 2 May 2014]. Available from: doi:10.1016/j.rdc.2008.04.007.
  7. GREGORY,P.J, M.SPERRY, A.F.WILSON, Dietary Supplements for Osteoarthritis,Am Fam Physician[online].2008.77(2),177-184.[viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2008/0115/p177.html
  8. RINGDAHL,E , S.PANDIT.Treatment of Knee Osteoarthritis, Am Fam Physician[online]. 2011,83(11),1287-1292. [viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2011/0601/p1287.html

Management - Specific Treatments

Fact Explanation
Acetaminophen Acetaminophen can relieve mild to moderate arthritis pain. To avoid the serious but rare ranal and hepatic side effects, it is important to follow dosing instructions and to avoid drinking excessive amounts of alcohol. Acetaminophen, in a dosage of 1 g four times daily, is considered an initial drug of choice. [1,4,6]
Nonsteroidal anti-inflammatory drugs (NSAIDs) The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's. [1,4,6]
Codeine Acute severe arthritis exacerbation may require treatment with narcotic analgesics which should be taken for only short periods of time because they can be addictive. [1,4]
Cyclooxygenase inhibitors celecoxib and rofecoxib cause fewer gastrointestinal side effects compared to NSAIDs can be considered for use in patients with a history of gastrointestinal bleeding or those who may be on certain medications such as warfarin and oral steroids. [1,4,5]
Corticosteroid injections Anti inflammatory effect of intra-atricular glucocorticoids can relieve pain. Glucocorticoid injections may be recommended for patients who still have pain despite the use of NSAIDs. Sometimes corticosteroid are injected along with a local anesthetic, such as lidocaine .The immediate relief of lidocaine confirms that the medication was injected into the correct area. Some people experience a brief flare of symptoms after an injection. This is followed by an improvement from baseline at 48 hours. Usual practice is limited to four injections annually. [1,4,6]
Hyaluronic acid injections Intra-articular hyaluronic acid injections are also called as viscosupplementation. It has been found to have effective for treating knee osteoarthritis. [1,4,5]
Capsaicin Some patients have got pain relief as they apply creams containing capsaicin, the active substance in hot chili peppers. Capsaicin acts on nerve endings and lessens the arthritis pain. [1,5]
Joint replacement. Surgery may be used to replace a damaged joint with an artificial joint. This is Indicated when pain affects work, sleep, walking and leisure activities despite of medical treatment. Joint replacement surgery dramatically relieves pain in people with severe arthritis of the hip or knee, and this benefit appears to last for at least three years. [1,3,7]
Arthroscopy and joint irrigation During joint irrigation, the joint is injected with normal saline and joint fluid is drained out of the joint. This is repeated several times. Irrigation is done to remove the joint of debris. It decreases inflammation and joint pain in return. But the effectiveness of joint lavage has been questioned and studied.[2,7]
Osteotomy This is done in patients with severe symptoms. The joints are realigned by removing wedge of bones near damaged joints. This shifts weight from an area where there is damaged cartilage to an area where there is more or healthier cartilage. [7]
References
  1. SINUSAS,K. Osteoarthritis: Diagnosis and Treatment, Am Fam Physician[online]. 2012,85(1),49-56. [viewed 2 May 2014]. Available from:http://www.aafp.org/afp/2012/0101/p49.html
  2. MARX,R.G. Arthroscopic Surgery for Osteoarthritis of the Knee?,N Engl J Med [online].2008,359,1169-1170. [viewed 2 May 2014]. Available from: DOI: 10.1056/NEJMx080035
  3. KUO,A, K.A.EAAET, S. PATIL, C.W. COLWELL, Total Hip Arthroplasty in Rapidly Destructive Osteoarthritis of the Hip: A Case Series, HSSJ[online],2009, 5, 117–119.[viewed 2 May 2014]. Available from: DOI 10.1007/s11420-009-9112-0
  4. RINGDAHL,E , S.PANDIT.Treatment of Knee Osteoarthritis, Am Fam Physician[online]. 2011,83(11),1287-1292. [viewed 2 May 2014]. Available from:
  5. MORELLI,V, N.CHRISTOPHER, V.WEAVER, Alternative Therapies for Traditional Disease States: Osteoarthritis, Am Fam Physician[online]. 2003,67,339-44.[viewed 2 May 2014]. Available from:
  6. RALPH,H, R.L.MOODY, A.W.DAVIS, THOMAS, S.F,Osteoarthritis: Diagnosis and Therapeutic Considerations,Am Fam Physician[online].2002,65,841-8.[viewed 2 May 2014]. Available from: http://www.aafp.org/afp/2002/0301/p841.html
  7. JEFFREY,N.K., B.E.EARP,A.H. GOMOLL, Surgical Management of Osteoarthritis, Arthritis Care Res (Hoboken)[online].2010 Sep,62(9),1220-8. [viewed 2 May 2014] doi: 10.1002/acr.20231.