Background Information

Risk Factors

• Genetic contribution (independent of known environmental or demographic confounding factors)

• Biological factors
  • Increasing age (typically >45 y/o)
  • Women
  • Overweight / obesity
  • Low bone density

• Physical / biomechanical factors (causes of joint injury and damage)
  • Joint laxity
  • Reduced muscle strength
  • Joint malalignment
  • Exercise stresses
  • Occupational stresses

Clinical Features

General Examination Findings

Possible findings include:

Findings in Knee OA

Typically bilateral and symmetrical.

Associated features:

• Giving way
• Locking
• Crepitus and tenderness along the joint line
• Restricted range of movement

Features seen in advanced disease:

• Bony swelling of the femoral condyles and lateral tibial plateau
• Varus deformity (more common than valgus)
• Antalgic gait

Findings in Hip OA

• May present with deep pain in the anterior groin on walking or climbing stairs
• Painful restriction of internal rotation with the hip flexed

Features seen in advanced disease:

• Trendelenburg gait
• Fixed flexion external rotation deformity with compensatory lumbar lordosis and pelvic tilt

Findings in Hand OA

Typical joint involvement:

• 1st CMC joint
• PIP joint
• DIP joint

Other findings:

• Fixed flexion deformity of the CMC joint with hyperextension of the distal joints
• Squaring of the thumb

• Bouchard’s nodes (bony nodules next to the PIP joint)
• Heberden’s nodes (bony nodules next to the DIP joint)

X-ray in OA

Do NOT routinely use imaging to diagnose OA unless there are atypical features or features that suggest an alternative or additional diagnosis.

Typical radiological features of OA: (LOSS)

• Loss of joint space (or narrowing)
• Osteophyte formation
• Subchondral sclerosis
• Subchondral cysts

Complications

• Chronic pain
• Joint deformity
• Functional limitations
• Psychosocial impact

Guidelines

Investigation and Diagnosis

Clinical diagnosis of OA can be made if ALL of the following are present:

• ≥45 y/o, and
• Activity-related joint pain, and
• Morning joint stiffness lasting <30 min

Management

General Advice / Conservative Management

Offer:

• Weight management – if the patient is overweight / obese
  • Advise that any amount of weight loss is beneficial but losing 10% is likely better than 5%
• Therapeutic exercise tailored to patients (e.g. local muscle strengthening, general aerobic fitness)

Consider:

• Manual therapy in hip / knee OA alongside therapeutic exercise
• Walking aids if there is lower limb OA

Do not routinely offer an aid or device (insoles / braces / tape / splints / supports), unless there is:

• Joint instability or abnormal biomechanical loading AND
• Therapeutic exercise is ineffective or unsuitable without it AND
• The addition of it is likely to improve movement and function

Pharmacological Management

Pharmacological management should always be used alongside non-pharmacological options and at the lowest effective dose for the shortest possible time:

• 1st line: topical NSAID (useful for knee OA, but maybe less effective for other OAs)
• 2nd line: oral NSAID with gastroprotection
• 3rd line: paracetamol or weak opioid for short-term pain relief and infrequent use only
• 4th line: intra-articular corticosteroid injections (explain that it only provides 2-10 weeks of pain relief)

Surgical Management – Joint Replacement

Consider referring patients with knee / hip / shoulder OA for shoulder replacement if:

• Symptoms are substantially impacting quality of life, AND
• Non-surgical management is ineffective / unsuitable

References