Lesson

Osteoarthritis

History

As discussed earlier, patients with a chondral injury or osteoarthritis (OA) generally present with activity-related pain and swelling. This is typically localised to the compartment that is predominantly affected. Swelling is also a common complaint. Symptoms are often improved with rest. There may be a past history of joint trauma or surgery – especially an ACL reconstruction or meniscal debridement. There is also a strong association with increased body weight.

 

Examination

The patient may present with an antalgic gait. There can be a “bulky” appearance to the joint, an effusion and a loss of movement. Localised tenderness is a common finding – for more superficial joints like the ankle and knee.

 

Investigation

Plain films are typically the only investigation that is needed. Findings may include joint space narrowing, subchondral sclerosis (and cysts) and osteophyte formation. It is important to realise that while a patient may have radiological evidence of OA – this may be asymptomatic.

Click on the following images to see some examples of osteoarthritis affecting the hip, knee and big toe.

  • Left hip OA

    Note the loss of joint space and marginal osteophytes.

  • Subchondral cysts

    Note the subchondral cysts

  • Medial compartment narrowing

    medial joint narrowing and marginal spurring.

  • MTPJ OA

    Post-traumatic changes following an earlier partial medial meniscectomy.

Treatment

As the radiologic evidence of OA show no symptoms for many people, it is important to treat the patient – and not their XR.

The following tabs outline some of the treatment options for patients with osteoarthritis.

Education and activity
Education is a key component of successful treatment. Encouraging patients to remain physically active and to lose weight are critical components.13, 14 Patients may need to reduce the amount of weight-bearing exercise and substitute with other modalities like swimming and cycling. Remaining active is better for the affected joint – and for their overall well-being. Finding types of activity that the patient likes and enjoys is critical. Walking football has been promoted as an activity that can be useful in this patient group.
Analgesia
Simple analgesia (like paracetamol) can be very effective for joint pain – as can non-steroidal anti-inflammatory medications. Patients should be encouraged to use the lowest effective dose. Paracetamol is the best initial treatment, as it is almost as effective as NSAID and has substantially fewer side effects.
Braces and orthotics
There may be a role for these devices in some situations. A laterally posted orthotic has been shown to improve pain in those with medial compartment OA in the knee. Valgus producing medial knee braces have also been demonstrated to have some value in this patient group. The effectiveness of these interventions can be quite variable.
Joint injections
Steroid injections have been used widely for knee OA for a number of decades. In general terms these are not effective. Studies have shown that they can provide three months of symptomatic relief. As a result they can be useful for short-lived flares of pain. Injectable hyaluronic acid has also been used to treat joint pain. These have been shown to produce an improvement in symptoms for approximately 12 months – and can be repeated. More recently platelet rich plasma (PRP) has been promoted as an alternative treatment. This treatment has shown some promise.19
Surgery
A number of procedures are described to treat osteoarthritis. Arthroscopies are widely performed for patients with knee arthritis – despite there being no evidence for their efficacy. When there is established joint-space narrowing on XR, there is no real role for this procedure. Some patients have a short-term benefit, some have no effect and some are made worse. The only real exception to this is when the patient is having mechanical symptoms or instability. In this setting, removing a loose body or unstable cartilage flaps can be helpful (although there are also comparable results with non-surgical treatment in this patient population).

In some situations (for example uni-compartmental OA in the knee), an osteotomy can provide a temporary improvement in pain and function. This can be a good option in younger patients to help delay a joint replacement.

When patients have ongoing symptoms and have failed non-surgical treatment, a joint replacement may be considered. This gives good pain relief and restores function. It does not provide the patient with a “normal joint”.

While it is tempting to progress to more invasive treatments when a patient is not improving, it is important to make sure that the simple things are being done well. Weight loss and maintaining some form of physical activity is essential – and is the best validated treatment.

Dr Mark Fulcher

Sports and Exercise Physician