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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
in the clinic
Osteoarthritis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the major risk factors for OA?
 Older age
 Genetic inheritance
 Race and ethnicity
 Similar rates hand, knee OA in Europeans and Americans
 Lower rates hip OA in African blacks, Asian Indians, and
Chinese persons from Beijing and Hong Kong
 Higher rates knee OA among older Chinese women in
Beijing than white women in the Framingham study
 Being female
 Local mechanical factors
 Malalignment, muscle weakness, internal derangements
 Excessive joint loading
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Should diet and physical activity be
modified to prevent knee OA?
 Obesity: most important modifiable risk factor
 Counsel overweight and obese patients to lose weight
 Encourage physical activity
 Conditioning programs, graduated training schedules
 Muscle strengthening for quadriceps
 But avoid intense loading of previously injured joints
 Contact sports increase risk of knee injuries
 Meniscal tears and cruiciate ligament injuries predispose
patients to OA regardless of surgical repair
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
CLINICAL BOTTOM LINE: Prevention…
 Obesity is most important modifiable risk factor for knee OA
 Encourage exercise to maintain quadriceps strength
 If participating in sports, advise proper training and
conditioning to avoid injury
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the characteristic symptoms of OA?
 Pain
 Activity-related or mechanical
 Exacerbated by use and alleviated by rest
 Usually insidious in onset; nocturnal in advanced disease
 Morning stiffness of brief duration
 Reduced range of motion and crepitus
 Absence of systemic features (e.g., fever)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the characteristic physical
examination features?
 Crepitus
 Audible, palpable grating quality when the knee is flexed
and extended
 Bony prominence
 Particularly finger joints: Heberden and Bouchard nodes
 Squaring of joint contour: 1st carpometacarpal articulation
 Malalignment
 Use goniometer to visually bisect thigh and lower leg
 Remember: back and hip disorders can refer pain to knee
 Evaluate both anatomical sites to isolate the origin of pain
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should imaging studies be ordered?
 Diagnose OA on the basis of history and physical exam
 Radiographs are insensitive to early pathologic features
 Radiograph findings correlate poorly with symptoms
 Plain-film radiography can confirm clinical suspicion
 Joint space narrowing
 Osteophyte (or spur) formation at the joint margin
 Cortical bone thickening (or eburnation)
 Formation of subchondral cysts
 MRI useful to evaluate for internal derangement of knee
or early osteonecrosis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Should other diagnostic studies be
pursued in suspected cases?
 For diagnosis, lab testing is not helpful
 OA is relatively noninflammatory
 CBC & acute-phase reactants should be normal
 Before NSAIDs: test creatinine level + liver function tests
 Especially in elderly and in those with comorbid conditions
 Establishes a baseline if iatrogenic features develop
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What are the diagnostic criteria?
 Knee OA
 Use criteria from American College of Rheumatology
 Based on clinical, radiologic, & synovial fluid analysis data
 Hip OA and hand OA
 American College of Rheumatology Criteria also valuable
for classifying OA of the hip and hand joints
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Are there distinct subsets?
 Generalized OA
 Affects multiple joints in appendicular and axial skeleton
 Secondary OA
 Result of well-defined cause (e.g., injury, endocrinopathy)
 Previous damage from infection or an underlying
inflammatory arthropathy
 Erosive OA
 Involves hand joints and predominantly affects women
 Flares cause erythema, swelling, severe pain
 arosion of affected joints and osteophytes and ankylosis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the differential diagnosis?
 Primary OA
 Anserine bursitis
 Hemochromatosis
 De Quervain tenosynovitis
 Ochronosis
 Meniscal tear
 Multiple epiphyseal and
spondyloepiphyseal
dysplasia
 Osteonecrosis
 Calcium pyrophosphate
deposition disease
 Neuropathic (Charcot) joint
 Acromegaly
 Inflammatory (erosive) OA
 Rheumatoid arthritis
 OA due to trauma or
mechanical factors
 Psoriatic arthritis
 Trochanteric bursitis
 Gout
 Nodal generalized OA
 OA of 1st carpometacarpal
joint
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should clinicians consult a
rheumatologist or an orthopedist?
 If the pattern of joint involvement is atypical
 If symptoms suggest inflammatory arthropathy
 If manifestations are severe
 If features suggest a periarticular source of pain
 Such as pes anserine bursitis or trochanteric bursitis
 If joint is red, hot, and swollen
 Aspiration is needed right away
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Diagnose OA on the basis of history and physical exam
 Use plain-film radiographs for diagnostic confirmation
 In atypical cases, perform diagnostic joint aspiration
 Confirm suspicion of OA
 Exclude other diagnoses (gout, pseudogout, septic arthritis)
 Reserve MRI to evaluate for internal derangement
 Joint locking or giving way
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the overall therapeutic approach
to OA?
 Tailor management to the individual patient
 Diminish joint pain, enhance functional capacity
 Don’t define treatment rigidly by radiographic findings
 Modify treatment according to responses to therapy
 Begin with nonpharmacologic, nonsurgical strategies
 Including PT, OT, nutritionist
 Offer pharmacologic agents if conservative efforts don’t
improve function
 Use surgery as a a last resort
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
How does education fit into the patientphysician discussion?
 Encourage participation in self-management programs
 Information about the natural history of disease
 Resources for social support
 Instructions on coping skills
 Support undertaking a new diet or exercise program
 Patient education interventions show therapeutic benefit
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Is weight loss part of the treatment plan
for knee OA?
 Absolutely!
 Encourage weight loss through diet and exercise
 Can help alleviate OA symptoms if overweight or obese
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the role of exercise in the
management of OA of the knee or hip?
 Increases aerobic capacity, muscle strength, endurance
 Facilitates weight loss
 Individualize exercise programs
 To improve adherence, seek an exercise the patient enjoys
 Encourage low-impact aerobic exercise (walking, biking)
 Discourage high velocity / high impact exercise (running)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should clinicians prescribe physical
and occupational therapy?
 PT can improve joint biomechanics with knee or hip OA
 Active and passive ROM exercise
 Muscle strengthening
 Improve alignment
 Joint-protection principles
 OT is a key resource in management of OA of the hand
 ROM exercises
 Joint protection instruction
 Splinting of the first carpometacarpal joint
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Is there a role for assistive devices?
 For knee or hip OA
 Cane or walker can improve gait & mobility, diminish pain
 Cane transfers body weight away from the structurally
compromised osteoarthritic limb
 Instruction in proper use of a cane is warranted
 For hand OA
 Large-grip utensils, writing instruments, key holders
 Reduce force across arthritic fingers and base of thumb
 Enhance the gripping motion and reduce pain
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the role of lateral-wedge insoles?
 Knee OA with predominant unilateral involvement
 Consider an unloading brace and lateral shoe wedges
 Transfers load from the narrowed to the more open knee
compartment
 Alleviates knee pain
 But evidence for these measures is conflicting
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
Which analgesic agents should clinicians
prescribe first?
 Acetaminophen in doses up to 4 g/day
 Comparable efficacy to NSAIDs but with safer GI profile
 Add NSAIDs or substitute with them if response is
inadequate
 NSAIDs
 Common 1st-line Rx, but routine use has disadvantages
 Significant potential toxicity, particularly in the elderly
 Toxicity contributes to hospitalizations and deaths
 Prescribe COX-2-selective and nonselective NSAIDs with
caution in light of concern regarding CV risk
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When are topical analgesics useful?
 Topical NSAIDs
 Maximizes local delivery and minimizes systemic toxicity
 Good first-line agent to avoid systemic therapy
 Minimal side effects (local rash, itching, burning)
 Topical capsaicin
 Active ingredient of chili peppers
 Modulates nociceptive fibers
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When are intra-articular glucocorticoids or
hyaluronic acid indicated?
 Knee OA
 Improve pain and function in the context of knee OA
 Benefit is short-term (about 1 wk)
 Intra-articular steroids
 Don’t use more than once every 4 months
 Repeated use can cause cartilage and joint damage
 Hyaluronic acid injection
 High-molecular-weight polysaccharide in the
extracellular matrix of connective tissue
 Symptomatic benefit equivalent to arthrocentesis
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
What is the role of glucosamine-chondroitin
and acupuncture?
 Glucosamine and chondroitin
 Symptom-modifying effect is similar to placebo
 Potential structure-modifying benefits are uncertain
 Acupuncture
 May relieve pain and improve function
 But data are equivocal
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
When should clinicians consider joint
lavage, debridement, or joint replacement?
 When symptoms are refractory to medical therapy
 Debilitating pain
 Major functional limitations (walking, working, sleeping)
 Joint lavage or arthroscopic debridement
 No role in OA
 Joint replacement
 No clear standards for who gets joint replacement
 Consider for patients with moderate to severe symptoms
after adequate trial of conservative therapy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment…
 Goal: alleviate pain and improve functional capacity
 Nonpharmacologic treatments
 Weight loss and exercise
 Physical therapy, occupational therapy
 Pharmaceutical options
 If conservative efforts dont improve function
 First-line: acetaminophen for mild pain
 NSAIDs: use caution due to potential side effects
 Surgery
 Reserve for advanced disease
 When symptoms don’t respond to medical therapy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (1): ITC1-1.