A COMMON JOINT DISEASE

OSTEOARTHRITIS
-Osteoarthritis is one of the most common degenerative joint disease causing pain in certain large joints of the body, like shoulder, elbow, wrist, hip, knee, ankle.
it is a condition of synovial joint (the joint containing synovial fluid), however" INFLAMMATION is NOT a PROMINENT FEATURE" of the condition.
-The condition of osteoarthritis results in symptomatic joint failure. 

 EPIDEMIOLOGY:

-The condition rises in prevalence from the age of 30. 
-Most commonly occurring in the age of 30 and above.
-The joints which are more prone to the disease are the hip and the knee joints.
-Women are affected more as compared to men. (Hip joint equally affected in men and women).
-occupational risk factors also play an important role in the occurrence, such as farmers are more prone to hip OA, football players are more prone to knee OA.

ETIOLOGY:

-Mechanical factors
-Metabolic factors
-Trauma
-Obesity
-Smoking
-Gender
-Genetics
-Usage
-Occupation

CLASSIFICATION:


PRIMARY OA:
Occurs in old age, largely affecting the weight bearing joints (hip and knee), the condition is more common.
SECONDARY OA:
Occurs as a result of an underlying primary condition of the joint leading to degenerative changes in the joint, it may occur at any age after adolescence, hip joint is more affected.

PATHOLOGY:

  • ·  The degenerative changes affects the articular cartilage. 
·     -   There is an enzymatic degradation of the major structural components.
·       - There is an increase in the water content and depletion of the proteoglycans from the cartilage matrix.
·   -     The chondrocytes increases their production of matrix components and divide to produce metabolically active clones of chondrocytes.
 -With an increase in the turnover of the aggrecan, the concentration decreases, decreased size of aggrecan molecules causes increased water concentration which is the first change occurring at the joint.
-Repeated weight bearing on such joint causes fibrillation. 
-The degeneration of the articular cartilage begins and there is:
-Fibrillation of the cartilage,
-Focal loss of the cartilage,
- Thinning of the cartilage,
-Damage to the cartilage abraded by the grinding mechanism at the points of contact between the articular surfaces until the underlying bone is exposed.
-The bone at the margins of the joint hypertrophies and forms a rim of projecting spurs known as osteophytes
-Formation of subchondral cysts occurs along with sclerosis.
- At joint capsule, there is thickening leading to joint stiffness.

CLINICAL FEATURES:

  • PAIN (VARIABLE AND INTERMITTENT)
  • FUNCTIONAL DISABILITY
  • RESTRICTED ROM (TERMINAL MILITATION)
  • SWELLING
  • TENDERNESS
  • STIFFNESS
  • MUSCLE WEAKNESS
  • MUSCLE WASTING (QUADRICEPS FEMORIS)
  • CREPITUS ON MOVEMENT
  • DEFORMITY: VARUS OF KNEE, FLEXION- ADDUCTION-EXTERNAL ROTATION OF HIP.
  • IRREGULAR AND ENLARGED JOINTS

TYPES:

  • NODAL OA:

- Polyarticular Finger Interphallangeal Joint OA, 
- Fingers are affected
-Heberden's node formation
-Marked female predisposition
-Peak onset in middle age
-Pre disposition to other joints
Sstrong genetic pre disposition
-Lateral deviation of fingers
-Involvement of first carpometacarpal joint
-Thumb base OA occurs

  • KNEE OA:

-Targets patello-femoral joint and medial tibio-femoral joint of knee.
-Etiology: trauma, gender, obesity, smoking, occupation.
-In men the condition is unilateral
-In women the conditon is bilateral and symetrical
-Pain in anterior and medial aspect
-Pain worsens on climbing stairs
-Posteriorly pain occurs in the popliteal fossa due to formation of popliteal cyst.
-Symptoms:
-Difficulty in walking, climbing stairs, rising from chair, bending.
·         on local examination
-Jerky, Asymmetrical 'Antalgic Gait'.
-Fixed Flexion deformity.
-Swelling
-Tenderness.
-Restricted Rom (flexion/extension)
-Crepitus

  • HIP OA:

Targets superior aspect of the hip joint.
-Pain in anterior groin, radiating to buttock, anterior thigh, knee, shin.
-Pain increases on lying.
 On local examination:
-Antalgic Gait.
-Tenderness over Greater tronchanter.
-Anterior groin tenderness.
-Ipsilateral leg shortening.
-weakness of muscle. (Quadriceps and gluteal)

INVESTIGATION:

Radiological examination
The image has been taken from a real case study

  • Narrowing of joint spaces.
  • Subchondral Sclerosis: dense bone under the articular surfaces
  • subchondral  cysts
  • osteophyte formation
  • deformity of joint

MANAGEMENT:

·         PATIENT EDUCATION:

-Full explanation to the patient about the nature of the disease. Explaining the patient about the treatment protocol and awareness of  the risk factors, aggravating factors.

·         ADVICE AND INSTRUCTIONS:

-patient is advised to avoid the climbing of stairs, prolonged sitting, and prolonged walking.
-the active movements of the joints to maintain ROM
-strengthening of the muscles with the help of resistance,
Resistance can be in the form of weight cuffs, dumbbells, therabands.
-Closed chain exercises: squatting, planks, pushups.
-Quadriceps table
-Cycling (static and dynamic)

·         DRUGS:

-Analgesics used to suppress pain.
-Initial trial of pracetamol.
-NSAIDs
-Steroids

·         REDUCTION OF ADVERSE MECHANICAL FACTORS:

-wearing shock absorbing footwear.
-weight reduction.
-use of walking sticks.
-avoiding stress and strain.

·         SURGERY:

-osteotomy: brings relief in symptoms.
-joint replacement: for cases crippled with advanced damage.
-joint debridement: the affected joint is opened and the cartilage is smoothened, the osteophytes and the hypertrophied synovium is excised.
-arthroscopy: removal of loose bodies, meniscal tears.

·   PHYSIOTHERAPY:

-hot fomentation.
-IFT to reduce pain
-ultrasonic therapy to localized tenderness.
-active/passive movements to maintain full ROM
-STENGTHENING EXERCISES:
·         KNEE: (EACH MOVEMENT WITH 10 REPEATITIONS)
 Knee isometric exercises:
-keep a towel roll or a pillow under the knee and press and hold for 10 seconds and release.
-keep the towel roll or pillow under the heel and press and count 10 and release.
-Keep the pillow or the towel roll between both the knees and press and count 10.
-straight leg raise: raise the leg at an angle of approximately 45 degrees and count 10.
Bend the knee and straighten.
In a high sitting position (on a chair, couch) straighten your leg and count 10 and release.
·         HIP: (EACH MOVEMENT WITH 10 REPEATITIONS)
-straight leg raise: raise the leg at an angle of approximately 45 degrees and count 10.
-in a side lying position, lift the leg and count 10 and release.
-in supine lying position, take the leg out of the couch and count 10 and release.
(The same movements can be done with weights added).
-stretching of the tightened muscles.

References:
Essential Orthopaedics, j. Maheshwari, 3rd edition (revised).
Davidson's Principles and practice of Medicine, 19th Edition, edited b Christopher Haslett, Edwin R. Chilvers, Nicholas Boon, Nicki R. Colledge, International editor John A.A. Hunter.

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