Osteoarthritis

• Osteoarthritis

  Described as "wear and tear" in the joints, occurs in synovial joints, results from genetic factors, overuse, and injury, thought to result from an imbalance between cartilage damage and the chondrocyte response
• Risk factors for osteoarthritis

  • Obesity
  • Age
  • Occupation
  • Trauma
  • Being female
  • Family history
• Commonly affected joints in osteoarthritis

  • Hips
  • Knees
  • Distal interphalangeal (DIP) joints in the hands
  • Carpometacarpal (CMC) joint at the base of the thumb
  • Lumbar spine
  • Cervical spine (cervical spondylosis)
• Four key x-ray changes in osteoarthritis

  • Loss of joint space
  • Osteophytes (bone spurs)
  • Subarticular sclerosis (increased density of the bone along the joint line)
  • Subchondral cysts (fluid-filled holes in the bone)
• 1. ray reports might describe findings of osteoarthritis as degenerative changes
• 1. ray changes do not necessarily correlate with symptoms
• Osteoarthritis presents with joint pain and stiffness, worsens with activity and at the end of the day
• Osteoarthritis leads to deformity, instability, and reduced function of the joint
• General signs of osteoarthritis

  • Bulky, bony enlargement of the joint
  • Restricted range of motion
  • Crepitus on movement
  • Effusions (fluid) around the joint
• Signs in the Hands in osteoarthritis

  • Heberden’s nodes (in the DIP joints)
  • Bouchard’s nodes (in the PIP joints)
  • Squaring at the base of the thumb (CMC joint)
  • Weak grip
  • Reduced range of motion
• The carpometacarpal joint at the base of the thumb is a saddle joint, prone to wear
• Patients may present with referred pain, particularly in adjacent joints
• Consider osteoarthritis in the hip in patients presenting with lower back or knee pain
• The NICE guidelines (2022) suggest that a diagnosis can be made without any investigations if the patient is
• Patients may present with referred pain, particularly in the adjacent joints
• Example of referred pain

  • Osteoarthritis in the hip in patients presenting with lower back or knee pain
• The NICE guidelines (2022) suggest that a diagnosis can be made without any investigations if the patient is over 45, has typical pain associated with activity, and has no morning stiffness (or stiffness lasting under 30 minutes)
• Non-pharmacological management

  1. Patient education

  2. Lifestyle changes

  3. Therapeutic exercise to improve strength and function and reduce pain

  4. Weight loss if overweight to reduce the load on the joint

  5. Occupational therapy to support activities and function (e.g., walking aids and adaptations to the home)
• Pharmacological management recommended by NICE guidelines (2022)

  1. Topical NSAIDs first-line for knee osteoarthritis

  2. Oral NSAIDs where required and suitable (co-prescribed with a proton pump inhibitor for gastroprotection)

  3. Weak opiates and paracetamol are only recommended for short-term, infrequent use

  4. NICE (2022) recommend against using any strong opiates for osteoarthritis

  5. Intra-articular steroid injections may temporarily improve symptoms (NICE say up to 10 weeks)

  6. Joint replacement may be used in severe cases, with hips and knees being the most commonly replaced joints
• NSAIDs (e.g., ibuprofen or naproxen) are very effective for musculoskeletal pain but must be used cautiously, particularly in older patients and those on anticoagulants like aspirin or DOACs. They are best used intermittently, only for a short time during flares
• Adverse effects of NSAIDs

  • Gastrointestinal side effects such as gastritis and peptic ulcers (leading to upper gastrointestinal bleeding)
  • Renal side effects such as acute kidney injury (e.g., acute tubular necrosis) and chronic kidney disease
  • Cardiovascular side effects such as hypertension, heart failure, myocardial infarction, and stroke
  • Exacerbating asthma
• Opiates are not helpful with chronic pain, associated with side effects, risks, tolerance, dependence, and withdrawal. They often result in dependence without any objective benefits
• The WHO pain ladder is not helpful in chronic pain. Paracetamol and opiates are not recommended for regular use in osteoarthritis. NSAIDs cause hypertension by blocking prostaglandins (prostaglandins cause vasodilation) and should be used very cautiously with a history of high blood pressure
• Last updated

  August 2023