Osteoarthritis
Valgus Knees
Valgus Knees
Flat Foot
Flat Foot
Knee Osteoarthritis
Knee Osteoarthritis
Hand Osteoarthritis
Hand Osteoarthritis
Osteoarthritis (OA) affects about 4-6% of adult population and is mentioned as one of the top 5 chronic diseases in India. It is a common, age-related, chronic and slowly progressive joint disorder which ultimately leads to joint failure. Most common joints involved in osteoarthritic process are those which overwork during entire life viz. knees, neck, low back and small hand joints at your finger-tips. It is a disease of cartilage – a smooth rubbery cushion which covers the surfaces of bones of the joint. It contains few cells which secrete a complex matrix made up of proteoglycans and hyaluronic acid. Worn out matrix components are regularly replaced during life although cartilage has very limited ability to repair and adapt. Cartilage break down in OA is associated with damage to menisci and other joint components as well as with remodeling of bone. It is not a disease of aging because about 45% people above 100 years do not have any pain due to OA. Half of elderly patients with knee pain have normal knee X-rays. OA is currently considered as a disease caused by dynamic reaction of joint to a variety of biomechanical and biochemical factors. It occurs when degradation of cartilage exceeds repair. The ligaments surrounding the joint become lax, joint capsule thickens, joint fluid becomes less viscous, muscle undergo wasting and become weak. These changes ultimately lead to joint failure - a condition akin to heart failure or kidney failure. Cartilage has no pain sensation. Pain in OA arises from bone and other structures within and around the joint. Crystals and swelling inside the joint are important causes of pain in OA.

Causes

Age (weakness, joint laxity, decreased sensory capacities), female sex (after menopause - especially if uterus is surgically removed) and being overweight are risk factors for development of OA. There is a direct correlation between obesity and osteoarthritis due to certain chemicals (adipokines) secreted by cells of fatty tissues. OA is also known to run in some families. Although heredity plays a very small role in OA, involvements of small hand joints and onset at younger age are common features in such patients. Certain mechanical factors such as joint hypermobility, previous surgery or injury, repetitive joint use (occupational-farmers and porters) and joint deformities (congenital or disease-related) also lead to early OA.
Indian habits of squatting, kneeling and sitting cross-legged probably accelerate OA process in knees due to mechanical factors. Secondary OA can develop in diseases such as diabetes and leprosy (neuropathic joint – Charcot’s). Other congenital, metabolic and endocrine diseases can also lead to secondary OA. Secondary OA usually involves atypical joints.

Features
Pain in the involved joint especially after activity is the main feature of OA. There may be some stiffness associated. Morning stiffness does not last for more than half an hour and stiffness after rest (gelling) lasts for just a few minutes. Pain increases in cold and damp weather in some patients.

Pain usually waxes and wanes in early stages. There may be intermittent inflammatory flares with severe pain and swelling. Night pain and crepitus (creaking in the joint) are some of the later features. There may be difficulty in walking upstairs or downstairs, standing for long time, doing household tasks, getting in or out of an autorikshaw or a car and getting up from sitting when knees are affected. Hand OA leads to difficulty in opening lid of a container, writing with a pen, holding or lifting a utensil and operating door handle or latch-keys. Joints become unstable with progression of disease; movements get restricted along with wasting of muscles. Locking and buckling are other mechanical features. Hands become square shaped in hand OA whereas gait changes due to hip or knee OA. Knee OA can complicate with swellings around the joints (Baker’s cyst, anserine bursitis).

Bakers CystBaker’s cyst can rupture and cause a painful swelling of entire leg. OA of spine (spondylosis) commonly affects neck and low back regions. Pain on movement especially after day-long work is an important feature. Bony overgrowths and changes in disc dimensions can cause pressure on outgoing nerve roots and lead to tingling, numbness, pain and weakness of hands and legs in cases of cervical (neck) and lumbar (low back) spondylosis respectively.

Forms
OA is probably not a single disease. It can involve a single joint like knee hip being uncommon in India) or multiple joints. Generalized OA involves more than 3 joints usually those of hand. Localized OA manifests as small nodules (Heberden’s nodes) around joints near fingertips. OA can be erosive too with intermittent painful flares. About 15% of such patients evolve in to rheumatoid arthritis.

Investigations

 X-Ray KneeAnkle OsteoarthritisNo laboratory tests are required for diagnosis of OA. The diagnosis can be easily reached from patient history and clinical examination. X-Rays of involved joints can be helpful in grading severity of joint involvement. Medical treatment can be planned on the basis of severity of OA. New laboratory tests are being developed as research tool for early diagnosis of cartilage degradation. OA disease scores (which measure pain, stiffness and physical function through a questionnaire) have been developed and are useful in following disease progression and response to therapy

Therapy
Non-drug therapy is important in OA management. All patients must learn more about their disease and try to live with it as there is no cure for this chronic disease. Lifestyle changes (pacing of activities-intermittent rest), avoidance of squatting, kneeling or sitting cross-legged, exercise (both aerobic as well as joint strengthening – under guidance of a physiotherapist) and weight reduction are essential for control of OA pain. It is estimated that 10% weight loss reduces OA pain by about 50%. Exercise reduces pain and improves joint function. Regular Yoga practice also helps in various ways. Some patients may require assistive devices such as stick (hold in opposite hand) and walkers (if both knees are affected) for unloading. Knee cap stabilizes knee and corrects mild deformities. Appropriate footwear should be used after assessment from an occupational therapist. Some patients benefit from heat, ice-packs and local ointments/liniments. Capsaicin has shown some benefit on regular local application for over 2 months.

Pain management can be done with paracetamol (up to 4 grams per day). Combination of tramadol with paracetamol gives better pain relief. Nonsteroidal anti-inflammatory drugs (ibuprofen, piroxicam, diclofenac, etc) should be used during inflammatory flares for short period under medical supervision. These drugs should be used in lowest possible dose to avoid possible adverse effects. Patients may adjust doses themselves in accordance with need for adequate pain control. Severe pain nonresponsive to oral drugs responds well to steroid injection in joint. This simple, safe and effective procedure relieves pain for 3-4 or more months especially if extra joint-fluid is also removed simultaneously. Diacerine, glucosamine and chondroitin are disease modifying drugs (efficacy questionable) available for treatment in early OA. They should not be continued for more than 3-6 months if there is no apparent response.

Knowledge about disease, regular exercise, healthy diet and adequate sleep are essential elements of OA management. One must learn to protect joints by avoiding overuse while remaining active. A positive approach towards life and support from family and friends help in coping with this disease.
Surgery
Joint replacement surgery is usually undertaken as a last resort and is expensive. Surgery should be considered in all patients with inadequate pain control and functional improvement despite rigorous drug- and nondrug- therapy. A successful surgery offers excellent pain relief and should not be delayed whenever indicated.
Related Publications   (Marathi)
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