Osteoarthritis: Clinical sciences

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Introduction0:00–0:47

Osteoarthritis is a degenerative disease of the joints, characterized by mechanical wear and tear injury to articular cartilage, resulting in bony and synovial damage.
This chronic inflammatory process is mediated by cytokines, such as interleukin-1 and tumor necrosis factor-ɑ, and can affect any joint, but it most commonly affects the knees, hips, hands, and feet!
Important risk factors for osteoarthritis include age, being biologically female, obesity, and joint injury. Now, in most cases, osteoarthritis is a clinical diagnosis, but sometimes, imaging with X-ray might be needed if the diagnosis is not clear.
Now, if your patient presents with signs and symptoms suggestive of osteoarthritis, first you should perform a focused history and physical examination.

History and Physical0:47–2:30

The patient will typically have a history of joint pain that began in an isolated joint, such as the knee; hand, like the interphalangeal joints; wrist; or feet, like the metatarsophalangeal joints.
Also, your patient may describe joint pain that is worse with activity and have limited joint range of motion. They may also have minimal morning stiffness that typically lasts less than 30 minutes before improving.
Now, here’s a clinical pearl to keep in mind! If your patient has morning stiffness that lasts longer than 30 minutes, then consider inflammatory arthritis, such as rheumatoid arthritis instead.
Another way to distinguish between the two is by the pattern of affected joints. Rheumatoid arthritis tends to be symmetric, meaning that joints on both sides of the body are equally affected, whereas patients with osteoarthritis are more likely to have asymmetric joint involvement.
On the other hand, the physical exam may reveal tenderness along the joint line, and crepitus, which is a grating sound or sensation when the joint moves.
Your patient may also have pain with range of motion testing of the joint, a limited range of motion, as well as bony enlargement of the interphalangeal joints.
Bony enlargement at the distal interphalangeal or DIP joints, is called Heberden nodes, whereas enlargement at the proximal interphalangeal PIP joints, is called Bouchard nodes.If the history and physical exam findings are consistent with osteoarthritis, then no further testing is needed and you can diagnose osteoarthritis.

X-ray, alternative diagnosis2:30–3:35

But if the diagnosis is not clear, you should order an x-ray of the affected joint. If the X-ray findings are not consistent with osteoarthritis, you should consider an alternative diagnosis.
But if the x-ray shows joint space narrowing, osteophytes, and subchondral sclerosis, you can diagnose the patient with osteoarthritis.Here’s a clinical pearl to keep in mind!
X-ray findings don’t always correlate with symptoms in patients with osteoarthritis. For example, the X-ray could show severe joint damage, but the patient may have only mild symptoms.
Now, once you have diagnosed osteoarthritis, the next step is to determine which joints are affected. The treatment options differ based on which joints are involved.Alright, let’s say your patient has osteoarthritis of the knee or hip.

Knee and/or hip - Nonpharmacologic management3:35–4:37

The first step is to begin non-pharmacologic management. First, encourage exercise and physical activity to reduce pain by increasing muscle strength and improving the range of motion in the affected joints.
Second, recommend weight loss, especially if your patient has a BMI greater than 25. Weight loss relieves stress on weight-bearing joints, meaning many patients see significant pain relief and improvement in mobility.
Third, recommend Tai chi to your patients, which is a traditional Chinese mind-body practice that can improve strength and balance, and help relieve pain.
Finally, patients with knee or hip osteoarthritis have difficulty walking, so they might benefit from using assistive devices such as a cane or knee brace, as well as foot orthoses.

Assess response - First line pharmacologic management4:37–5:55

After trying one or more non-pharmacologic therapies, you should assess your patient’s response. If your patient has an adequate response, meaning they have significant pain relief and improved function, then continue non-pharmacologic management.
However, if there is an inadequate response, continue the current therapy, and consider starting pharmacologic management.
If your patient has osteoarthritis of the knee, prescribe a topical NSAID for pain reduction. Topical NSAIDs have similar efficacy to oral NSAIDs but don’t carry the same risk of side effects.
Keep in mind topical NSAIDS are not effective in people with hip osteoarthritis due to the location and depth of the joint.
So in this case, your patient can try oral NSAIDs, but remember, this has a higher risk of adverse effects in patients with chronic kidney disease, or cardiovascular disease.
In addition, be cautious in using NSAIDs in patients with peptic ulcer disease or a history of GI bleeding, as NSAIDs can worsen these conditions.
Finally, another option is oral duloxetine which is a Serotonin reuptake inhibitor. Ok, so after a trial of first-line pharmacologic management, you should again assess the patient’s response.

Assess response - Second line pharmacologic management5:55–7:06

If your patient has an adequate response, continue the current management. On the other hand, if there is an inadequate response, consider starting second-line pharmacologic management with intra-articular glucocorticoids or hyaluronic acid, which are injected directly into the affected joints.
Intra-articular glucocorticoids address inflammation and can temporarily reduce pain and improve joint function, but they’re being used less frequently as newer evidence shows they may negatively affect the joint hyaline cartilage.
In contrast, intra-articular hyaluronic acid acts as a cushion to lubricate the joint. Here’s a clinical pearl to keep in mind!
Glucocorticoids can temporarily increase blood glucose levels, so advise your diabetic patients to monitor their blood glucose levels carefully for several days after receiving intra-articular glucocorticoids.

Assess response - Surgical consultation7:06–7:30

Next, give your patient some time and again assess their response to treatment. If the patient has an adequate response, continue current management.
However, if their joint function still doesn't improve, refer the patient for surgical consultation for possible joint replacement.
Ok, now that we’ve reviewed what to do for knees and hips, let’s switch our focus to osteoarthritis of the hands. If your patient presents with osteoarthritis of the hand, your first step is to begin non-pharmacologic management.

Hand - Nonpharmacologic management7:30–8:16

Just like those with osteoarthritis in the knees and hips, patients with hand osteoarthritis benefit from exercise that strengthens the muscles and improves joint mobility.
Consider referring the patient to an occupational therapist to supervise their exercise program. Additionally, if your patient has osteoarthritis of the first carpometacarpal joint, or base of the thumb, try a hand orthotic to help stabilize the joint and improve grip strength.
Again, don’t forget to assess the patient’s response. If the patient has an adequate response, then continue the current management.

Assess response - Pharmacologic management8:16–8:54

However, if there is an inadequate response, then continue the current therapy and start pharmacologic management with a topical NSAID, oral NSAID, or oral duloxetine.
Again, be mindful of possible contraindications to NSAID use, such as chronic kidney disease, cardiovascular disease, peptic ulcer disease, or history of GI bleeding.

Review8:54–9:47

Alright, as a quick recap… Osteoarthritis is a degenerative disease of the joints, characterized by mechanical wear and tear injury to articular cartilage, resulting in bony and synovial damage.
Diagnosis is made clinically based on joint pain with stiffness lasting less than 30 minutes. Physical exam typically reveals tenderness along the joint line, crepitus, limited range of joint motion, and bony enlargement.
This should be enough to diagnose osteoarthritis, but if you are still not sure, order an X-ray to confirm the diagnosis.
You’ll then want to start treatment with nonpharmacologic management, including exercises and supportive devices. If the patient is not responding, consider pharmacological therapy.
For larger joints, if none of these interventions work, you should then consider surgical consultation for joint replacement.