X-rays are confirmatory and not useful for following pts
because there is a poor relationship between X-ray
OSTEOARTHRITIS findings and symptoms.
Acquired, noninflammatory, MS disorder that results
from slow progressive loss of articular cartilage Management:
without adequate regeneration. Prevention: ID and modification of risk factors for
Prevalence: 90% of the U.S. population > 65 yo has occupational and athletic joint injury, such as
radiographic evidence of dz. repetitive, unsupported motion, poor conditioning,
and poor technique.
Etiology and pathophysiology Cognitive and Behavioral Control of Arthritis Pain:
Risk factors Highly motivated pts and those w/favorable rational
1) Age: predominant risk factor for all sites of OA thinking indices have significantly levels of pain
2) Obesity: for weight-bearing joints, such as the knee and psychological distress, and better overall health.
and hip. Added mechanical stress on the joints. Psycho-educational interventions are effective in pain,
3) Previous joint damage from trauma/infection: esp. disability, and medication and health resource
at the DIP and PIP joints of the hand and, to a lesser utilization.
extent, at the knee. Causes stiffness of the Biomechanical Factors
subchondral bone excessive wear of overlying
joint loading on weight-bearing joints: weight loss or
cartilage. Also involving the articular surface, or s/p the use of aids, such as a cane in the contralateral
hand, crutches, or appliances such as heel or insole
4) Congenital defective joints: mechanical incongruity wedges, as indicated.
Weight loss: modest loss can dramatically joint-
5) Family History: Particularly in PIP’s/DIP’s and hip.
Normal: Cartilage remodeling equilibrium between
cartilage matrix degradation & chondrocyte-
mediated synthesis of type II collagen and
Exercise regimens in patients with OA have discernible
Cartilage degradation exceeds its regeneration Fitness walking pain and disability over the short term
progressive erosion and fissuring of cartilaginous Continued exercise in people with mild to moderate OA
joint surfaces. does not damage cartilage and may in fact slow the
Insult release of enzymes from chondrocytes progression of disease.
degrade collagen and proteoglycans repartive Acute MS pain cold applied to the joint may
process w/ bone formation.
Subacute pain heat applied superficially or deeply, is
Clinical Features: preferable to pain threshold muscle relaxation.
AM stiffness generally short in duration < 30 min.
Pain: Progressive. “Deep ache.” Made worse by Medical Management:
movement, especially movement and weight
bearing. Made better with rest. Prolonged AM Analgesics
stiffness. Acetaminophen: First-line therapy. Up to 4 gm/day for
No systemic symptoms OA of the hip and knee. Same efficacy as NSAIDs
Crepitus w/ SE. Acts centrally pain threshold. It has
Deformity: Joint enlargement. Also varus or valgus no anti-inflammatory properties at therapeutic
bowing of knee. doses.
Limited ROM Opioids: can be added to analgesic regimens in OA for
Joint contraction short periods.
NSAIDS, Including Cox-2 Inhibitors
Need to distinguish between OA (involving facet joints)
and degenerative disk disease with disk space Exert their anti-inflammatory and SE through
narrowing and osteophytes on vertebrae. cyclooxygenase (COX) inhibition.
Hips: Earliest abnormality restricted ROM, w/limited Similar efficacy among the different agents in this class.
internal rotation (<35*) and abduction (<45*) Pain.
Symptoms are aggravated by excessive weight Toxicity
bearing and prolonged immobility. Gastropathy: most common complication. Dyspepsia,
Knees: Pain on weight bearing, descending stairs more ulceration, or perforation of GI tract. Elderly are
so than by climbing stairs, rising from a sitting more prone to NSAID-induced GI ulceration, and
position. endoscopic evidence of this complication is seen in
Spine: Lower C and L spine. Pain is often poorly up to 20% of users.
localized. Muscle spasm and stiffness often Aspirin: more ulcerogenic than other NSAIDs.
accompany it, and restricted ROM develops with Platelet dysfunction: All NSAIDs inhibit platelet
progression of dz. . adhesion potentiate GI bleeding and perforation.
Neck: Limited extension and lateral bending and Misoprostol w/NSAIDs may GI bleeding, but
rotation are the first motions. may not reduce other GI symptoms.
Hand: Small joints. Pain aching and stiffness of Acute renal insufficiency: more commonly seen in the
fingers, worsened by repetitive finger use elderly
Heberden Nodes: DIP CNS: Indomethacin mental confusion, HA.
Bouchard’s Nodes: PIP Hepatotoxicity: diclofenac.
Wrist, elbow, shoulder and ankle are usually spared. Aseptic meningitis: Very rare toxicity of all NSAID’s.
Others: Skin reactions, CNS disturbances, and
Diagnosis interference with diuretics and antihypertensive..
Clinical findings confirmed by x-ray changes w/typical
features of localized narrowing of the joint space. COX-2: GI ulceration vs. conventional NSAID.
X-ray features that must all be present for diagnosis:
Early unequal joint space narrowing (<4 mm in the hip)
Osteophytes Documented symptomatic benefit for knees. Benefit to
Juxta-articular sclerosis ("eburnation") other joints unknown.
Subchondral bone cysts. Glucosamine: may provide pain relief, reduce
tenderness, and improve mobilityimprovement is
generally delayed compared vs. conventional OA
Chondroitin sulfate:OTC med. Preparations have
variable amounts of Chondroitin. May slow or
prevent tissue damage in the joint in addition to
Intra-articular steroid injection:
Short term relief of symptoms.
inflamed Heberden's nodes.
large, painful, inflammatory effusions of
osteoarthritic knees arthrocentesis steroid
injection and topical anesthetic agents effective in
Pt should minimize joint loading for some period after
injection longer period of improvement
Should not be repeated > 3 to 4 x/yr in any given joint
because of the possibility of steroids potentiating
rapidly progressive joint failure.
Hyaluronic acid: prototype glycosaminoglycan that is
normally produced by chondrocytes and synoviocytes.
Sustained pain relief, comparable w/naproxen, w/ SE
Onset of pain relief less rapid than intra-articular steroid
Duration of pain relief may be much longer.
Used in pts who fail non-drug management and
Arthroscopy: Surgical removal of loose bodies and
Osteotomy: Tibial osteotomy symptomatic relief in
pts w/varus angulation < 10* and good ligamentous
Considered with severe pain and end-stage
Better results if profound muscle weakness has not
set in so that postop rehab is possible.
Pain relief is achieved in > 90% who undergo total
joint replacement of the knee or hip.