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14 Articles in Volume 15, Issue #6
Antihistamine for G-CSF–Induced Bone Pain
Book Review: Advanced Headache Therapy
Brain Drain: Lymphatic Drainage System Discovered in the Brain
Case History of Chronic Migraine: Update 2015 Part 2
Disturbed Sleep: Causes and Treatments
Is Topical Ketamine Ready For Prime Time?
Letters to the Editor: Central Sensitization, Microglia Modulators, Supplements
New App Helps Interpret Urine Drug Test Results
Osteoarthritis Update: 2015
Pain Catastrophizing: What Clinicians Need to Know
PPM Editorial Board: Tips for Treating Osteoarthritis
Practical Overview of Osteoarthritis
Status Report on Role of Stimulants in Chronic Pain Management
Treatment of Osteoarthritis

Practical Overview of Osteoarthritis

Symptoms and diagnosis of osteoarthritis (OA) of the spine, hand, hip, knee, and ankle.

Osteoarthritis (OA) is a common cause of pain and disability in adults. Approximately 27 million Americans have clinical OA, which translates to nearly 14% of those over age 25 and 33% of those over 65 years of age.1 OA is a disease of the entire joint involving the cartilage, joint lining, ligaments, and underlying bone.2 The breakdown of these tissues eventually leads to pain and joint stiffness. The joints most commonly affected are the knees, hips, and those in the hands (Table 1).3

The specific causes of OA are unknown but it is believed to result from both mechanical (overuse and wear and tear) and molecular events in the affected joint. Recent studies linked an increased risk of OA with higher levels of C-reactive protein and erythrocyte sedimentation rate, as well as higher prevalence of metabolic syndrome4

There is a highly heritable component associated with OA.5,6 In fact, there is a genetic contribution to OA for 60% of women.7 Among the genes that have been linked to OA are several that are involved in the development and maintenance of joint shape, including members of the Wingless and bone morphogenetic protein families. Important genetic markers for the development and progression of the disease are under research.7

OA impacts quality of life and increases health-related expenditures. For example, OA of the knee is one of the 5 leading causes of disability among non-institutionalized adults.8 About 80% of patients with OA have some degree of movement limitation and 25% cannot perform major activities of daily living; 11% of adults with knee OA need help with personal care and 14% require help with routine needs. About 40% of adults with knee OA report their health as “poor” or “fair.”8

According to the Centers for Disease Control and Prevention, OA costs $3.4 to $13 billion per year.9 The average direct cost of OA per patient is $2,600 per year,10 and the total annual cost is $5,700 per person.11

Treatment for OA focuses on relieving symptoms and improving function, and can include a combination of patient education, physical therapy, weight control, medications, and, perhaps eventually, total joint replacement. Hospital expenditures for total knee and hip joint replacements in 2009 were estimated to be $28.5 billion and $13.7 billion, respectively.12

This article aims to review the suspected causes and risk factors for OA (Table 2)4-6,9,13 and its symptoms, and to outline the appropriate diagnostic approach for the various types of OA.

Spinal OA (Spondylosis)

Spinal OA, or spondylosis, can occur anywhere along the spine, but most commonly affects the cervical spine (neck) and lumbar spine (low back).14 Like other types of OA, spondylosis is a degenerative disorder. In the normal spine, the vertebrae and cartilage, which cushions the bones as they move, are healthy and in alignment. Every vertebra has two sets of joints called facet joints that help facilitate movement.

Through use (and especially through overuse), cartilage can start to wear down, affecting movement and causing pain. When the cartilage on the facet joints starts to wear down, the bones can start to rub together. In an effort to stop this painful movement, the bones may create bone spurs. This is the body’s attempt to stabilize the joint, but unfortunately, these bone spurs can make movement more difficult. They also can pinch nerves in the spine, causing more pain.

As patients grow older,9 the discs between the vertebrae that cushion the spine’s movement and help it bend and twist can start to wear out—this is called degenerative disc disease. It is a separate spinal condition from spondylosis, but they are closely linked. If, for example, a disc between the vertebrae starts to thin, it can change the way facet joints work—causing the cartilage to wear out and leading to spondylosis. In addition to age, other risk factors that can contribute to degeneration include:

  • Occupations that excessively strain the spine
  • Past neck or spine injury
  • Ruptured or slipped disc
  • Being overweight and not exercising (Note: the literature is undecided on this point, but it is important to encourage patients to lose weight and exercise)
  • Small fractures to the spine caused by osteoporosis
  • A family history of spondylosis

Symptoms of spondylosis tend to come on gradually as the spine changes. Patients may notice that movement has become more difficult or painful. Patients may feel “stiff,” especially in the morning or after sitting for a while. If a bone spur is pressing on a nerve, the patient may have pain that travels away from the spine. For example, if a bone spur is pinching a nerve in the neck, pain may radiate down the arm. Symptom of spondylosis in the neck include:

  • Neck pain and stiffness, which may get worse with activity
  • Weakness and numbness in the arms, hands and fingers
  • Muscle spasms in neck and shoulders
  • Headaches
  • Grinding and popping sound/feeling in the neck when you move

Hand OA

The hand is one of the parts of the body most frequently affected by OA.15 OA can occur in many areas of the hand and wrist. In a healthy hand, a joint is made of 2 smooth bone surfaces covered in cartilage, a slippery tissue that provides a smooth gliding surface and allows the bone surfaces to fit well together. If the cartilage wears away, the sensitive underlying bone can become exposed. The result is bone-on-bone contact, which leads to pain, stiffness, and difficulty using the hand.

OA of the hand is most likely to develop between the ages of 40 and 70. In people under 40, OA of the hand is usually caused by an injury to the affected joint. For most people, however, the most significant risk factor is age. Other risk factors include having a job or hobby that involves repeated hand motions, being female,13 having a family history of hand OA, and obesity.

The 3 most frequent sites of OA of the hand include:

  • The base of the thumb, where the thumb and wrist come together
  • The joint closest to the fingertip
  • At the middle joint of a finger

An early symptom of hand OA is joint pain. It may produce a burning or a dull sensation. A person often feels the pain after heavy gripping or grasping. The pain may occur hours later, or even the next day. In advanced stages, the pain may wake a person up. Other symptoms include:

  • Morning pain and stiffness in the hand
  • Increased joint pain in rainy weather
  • Difficulty with daily activities such as opening a jar or starting the car
  • Swelling of the affected joint
  • Warmth in the affected joint, due to inflammation
  • A sensation of grating or grinding in the affected joint, caused by damaged cartilage surfaces rubbing against each other

Having arthritis in the hands means the patient is at higher risk for developing arthritis in the knees.

OA of the Hips

The hips often are one of the first joints to develop OA.16 Many middle-aged and older adults experience minor inflammation, pain, and stiffness as the cartilage in the hip wears away. However, for some OA patients, the inflammation progresses and the pain can become severe. A strong family history is a risk factor for the development of hip OA, but much like the knee, an injury to the joint, type of work, over exercise, and obesity also increases the risk of hip OA.

The first symptom of OA is usually a small twinge of stiffness in the hip. But as the OA evolves, the hip may become rigid and painful. Patients may have a harder time doing everyday activities, such as taking a short walk, bending over to tie their shoes, or getting up from a chair. The pain usually develops slowly and gradually gets worse. The pain and stiffness may be worse in the morning, or after prolonged sitting or resting. Pain is often experienced in the thigh and buttock, and can mislead patients into thinking they have a muscle strain in that area.

In patients with suspected OA of the hip, look for signs such as tenderness in the hip, reduced range of motion in the hip, a grating sensation inside the joint when it is moved, pain when pressure is placed on the hip, and problems with the way the patient walks. An x-ray can show whether there is a narrowing of the joint space, changes in the bone, and whether there are bone spurs.

Knee OA

During a lifetime, knees go through considerable wear and tear. As these joint are the center of motion for the legs, and can experience 3 to 5 times a person’s body weight during activities such as descending stairs and running, they are highly susceptible to injury. Over time, this natural wear-and-tear process can lead to OA in the knees. As OA develops, the top layer of cartilage around the joints starts to break down and erode, causing pain, swelling, and loss of movement in the joint.17 As more time passes, the joint affected by OA may lose its normal shape and may develop bone spurs on the edges of the joint. Bits of bone and/or cartilage can break off, then “float” in the joint space—causing more damage and pain,17 as well as sometimes a feeling that the knee is “locking up.”

Currently, researchers don’t understand the exact cause of knee OA. Many factors can lead to the degeneration of the knee cartilage, including overuse and injury. But sometimes, knees can develop OA without a clear cause.

The symptoms of knee OA usually develop gradually. This is because it takes time for the cartilage to wear down and change the way the joints work. However, sudden onset of symptoms is possible—but not as common.

The following symptoms are commonly seen in OA of the knee:

  • Stiffness and swelling: Feeling that it’s tough to move the knee(s) when first getting up in the morning or after sitting down for a while is an OA symptom. The swelling makes it hard to bend or straighten the knee. Pain and stiffness often are worse in the morning or after being inactive, whereas swelling usually occurs after a long period of excessive activity.
  • Changes in the weather: When it’s rainy and/or cold can make the pain and other OA symptoms in the knee feel worse.
  • Pain can be worse in the morning or after a lack of activity. Patients also may notice more pain after certain activities—walking or climbing stairs, for example.
  • Limited movement: The pain, stiffness, and swelling can make it harder to sit down, stand up, or walk.
  • Warmth in the knee joint: The knee joint can become inflamed, and warmth around the joint is a sign of that inflammation.

Ankle OA

As one ages, it’s common to feel pain and stiffness in the feet and ankles. A sudden injury to the ankle, such as a broken bone, torn ligament, or moderate ankle sprain, can increase the risk for developing OA, even years later. Obesity and a family history of OA also can increase the risk.18

Severe arthritis of the ankle can reduce mobility, but proper treatment can slow the development of arthritis and improve quality of life. The symptoms of ankle arthritis are similar to those of OA in other sites and can include: pain and tenderness, stiffness, reduce motion, swelling, and difficulty walking.

Diagnosing OA

Diagnosing OA requires a detailed medical history of current and past symptoms, including a history of other illnesses or injuries.19 It is possible for a patient to have more than one form of arthritis at the same time.

Questions should include when the pain started, how often and for how long it hurts, whether anything makes it better or worse, and whether the patient has ever been treated for the pain.

To diagnose OA, all that is needed is a thorough history and examination, and simple x-rays. A thorough physical examination should include testing strength, touch sensation, reflexes, blood flow, flexibility, and, if relevant, gait. Blood tests can exclude other conditions such as rheumatoid arthritis. In spinal arthritis, CT scans, MRI, electromyography, and myelograms are sometimes used if the condition is advanced and there are signs of nerve or spinal cord impingement.

Last updated on: August 23, 2017
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Treatment of Osteoarthritis

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