Osteoarthritis

Contributor: Janine Evans, MD

CASE 1

A 63 year-old healthy secretary presents complaining of hand and wrist pain. While the pain is bilateral, it is more problematic in her dominant hand. It was initially intermittent but she now notices it on a daily basis. She relates that she has stiffness in her hands in the morning lasting for about 15 minutes. The pain is in her finger joints but spares the MCPs. In the wrist, she points to pain at the base of her thumb rather than the wrist itself. This area is particularly painful when she grips things with her thumb such as turning her key in her car ignition or picking up a stack of files. She denies any joint swelling but admits that her fingers are getting "knobbier". She relates her mother also had very crooked fingers and complained of arthritis. She denies any other joint complaints.

On examination of the hands, she has bony enlargement with tenderness in multiple distal interphalangeal joints (DIP) and proximal interphalangeal joints (PIP). There is also increased pain at both the carpometacarpal joint and metacarpophalangeal joint (MCP) of the thumb. The other metacarpophalangeal joints and the wrist are normal. There is no synovitis. The appearance is similar to that in the attached picture.

Findings on radiograph are attached.

This patient has osteoarthritis (OA) of her hands.

CASE 2

A 55 year-old man with a history of RA is seen for pain in both knees with recurrent swelling of the right knee for the past 6 months. He has been seen twice at a walk-in clinic and has had the fluid drained. Each time the fluid has re-accumulated. He has tried increasing his oral prednisone from 5 mg to 20 mg a day without improvement in either the pain or the swelling. He is stiff for 10 minutes in the morning and is stiff when he arises from a chair. Walking is limited because of the pain. Because of the knee problems, he was not able to continue working and has been unemployed for the past 6 months. He denies any other joint pain on the 20 mg of prednisone.

He relates a 15 year history of RA. He was doing well on methotrexate 15 mg weekly, prednisone 5 mg a day and etanercept 50 mg weekly but had quit taking all but the prednisone roughly one year prior because he thought he was doing well.

His examination is notable for difficulty arising from the chair secondary to knee pain and stiffness. He walks with the aid of a cane. There are synovial effusions in both knees, larger on the right. No warmth is noted. Valgus deformity is present on the right. There is pain, stiffness and coarse crepitance with range of motion of both knees, more pronounced on the right. In the hands there is ulnar deviation and subluxation of the MCPs with swan-neck deformities in multiple fingers, but no synovitis. Both wrists demonstrate widening and subluxation with some loss of flexion and extension but no warmth, swelling or pain. There is a nodule at the left olecranon. The feet also show old deformities consistent with RA with subluxation of the metatarsal heads but no tenderness.

Patient Care

  1. List the joints most commonly involved in primary osteoarthritis (OA) and compare the joint distribution with that of rheumatoid arthritis (RA).
  2. List commonly described features of the pain associated with OA.
  3. Review the physical exam changes characteristic of OA and be able to identify these changes on patient examination (1, 2, 3).
  4. Recognize the classification criteria for OA of the hand, hip, and knee.
  5. Identify the radiographic findings which are characteristic of OA (1, 2, 3).
  6. Summarize the results of blood and joint fluid analysis typical of OA and contrast with that expected with an inflammatory joint process.
  7. Review and demonstrate appropriate utilization of the pharmacological treatment options (see links: 1, 2) for OA. Recognize oral therapies (acetaminophen, non-steroidal anti-inflammatory agents and analgesics/narcotics), topical agents and inter-articular options and include a discussion of the appropriate indications, anticipated benefit, cost and potential risks associated with each agent.
  8. Locate and employ a patient narcotic use contract.
  9. Review and demonstrate appropriate utilization of non-pharmacological therapies including patient education, exercise, physical therapy, occupational therapy and prosthetics.
  10. Identify the indications and options for the surgical interventions commonly employed including joint replacement.

Medical Knowledge

  1. Review the cartilage changes which occur in OA (see images: 1, 2, 3).
  2. Describe the epidemiology of OA Distinguish localized and generalized OA.
  3. Review the common risk factors for the development of primary OA.
  4. Identify and review conditions and disorders associated with secondary OA [including, but not limited to trauma, avascular necrosis, chondrocalcinosis (see images: 1, 2), hemochromatosis (see images: 1, 2) and acromegaly (see images: 1, 2)] and identify any differences in joint disease distribution which may be characteristic of each condition.
  5. Review inflammatory (erosive) OA and describe its characteristic findings (see images: 1, 2).
  6. Review diffuse idiopathic skeletal hyperostosis (DISH) as a distinct subset of OA (see images: 1, 2, 3).

Interpersonal Communication

  1. Explain the diagnosis and the anticipated course of the disease in a way that incorporates patients' perspectives.
  2. Provide reassurance regarding long term outcomes and help establish practical, patient-oriented long-term goals.
  3. Advise on the choices of therapy and the rationale for each, including the potential risks and benefits.
  4. Review life style modification which may provide long term benefit.
  5. Acknowledge and include family and social support as designated by the patient.
  6. Provide reassurance and adequate time and accessibility to address patient concerns.

Professionalism

  1. Display integrity and honesty in discussing patient care issues and management.
  2. Insure patient privacy.
  3. Promote patient autonomy in clinical and therapeutic decisions.
  4. Communicate in a timely fashion regarding study results.
  5. Communicate in a timely fashion with the other members of the patient's health care team including the primary care physician.
  6. Serve as the patient's advocate.

Practice-Based Learning

  1. Utilize web-based resources to supplement and update current knowledge base and to explore patient-specific problems.
  2. Incorporate evaluation and feedback into practice and management.
  3. Utilize errors and complications to improve understanding and future management.
  4. Set learning goals in diagnostic strategies and management of OA.

Systems-Based Practice

  1. Identify barriers to accessing optimal medical care for each individual patient and utilize alternative resources when available to overcome these barriers.
  2. Engage and incorporate the input of all medical providers including other physicians, the nursing staff, and physical and occupational therapists as necessary.
  3. Serve as a source of learning and education for other members of the health care team for the patient.
  4. Utilize the existing health care system to support established patient care goals.
  5. Incorporate considerations of cost and risk-to-benefit ratios in clinical evaluations, monitoring and therapeutic decisions for individual patients.
  6. Recognize the impact of both diagnostic and therapeutic interventions on the health care system locally and globally.

References

Questions

(Answer questions 1 – 5 on a piece a paper. Find Answer Key at the bottom on the page.)

CASE 1

1) What are the key points in her history that suggest OA?

2) What findings on physical exam support a diagnosis of osteoarthritis? Which findings help distinguish it from an inflammatory arthropathy?

3) What features on her hand X-ray are characteristic of hand OA and was the radiograph really necessary in making this diagnosis?

4) What laboratory studies are indicated?

5) What other therapeutic options could be considered in the future?

CASE 2

1) In this patient with RA, what would be the differential for knee pain and swelling disproportionate to the arthritis activity in the other joints?

2) What work-up would best help determine the cause of the knee problems?

3) What features of the joint fluid analysis support a diagnosis of OA?

4) What features on the knee X-ray are most characteristic of OA?

5) What evidenced-based data is there regarding joint injections, oral medications and joint replacement for OA of the knee?

Answers

CASE 1

1) The most characteristic clinical complaints for OA of the hands are the short duration of morning stiffness, and the distribution of joints involved: the distal finger joints and base of the thumb, with sparing of the MCPs.

2) The key distinguishing feature of OA is the lack of synovitis. Bony joint enlargement is characteristic of OA. The distribution again is more characteristic of OA than rheumatoid arthritis (RA).

3) Radiographs were not necessary in order to make the diagnosis. Joint space narrowing with osteophyte formation is characteristic for OA.

4) No laboratory studies are indicated for making a diagnosis of OA, unless other diagnoses are in your differential. Baseline laboratory measurement of blood counts, and liver and kidney function should be considered depending on what medications are instituted as therapy.

The patient is begun on daily acetaminophen and referred to occupational therapy for evaluation both for hand exercise and adaptive equipment. She is also given a splint for the carpometacarpal joint of the thumb of the dominant hand.

5) Other oral medications that could be tried include non-steroidal anti-inflammatory drugs (NSAIDs) and pain medications. Some patients respond to local injections to the thumb joints. Rarely is surgical intervention warranted.

CASE 2

1) Secondary osteoarthritis is dominant in the differential. Other considerations would include infection, crystal disease and active RA.

2) Joint aspiration of the involved knee for fluid analysis would be the most helpful.

  • Sterile joint aspiration of the right knee is performed and 35 cc of yellow fluid is obtained. Analysis of the fluid demonstrates a white blood cell (wbc) count of 750/cu mm and only 50 rbc/cu mm. Crystal examination, gram stain and culture are all negative. Radiographs of the knee demonstrate marked narrowing of the medial joint space with moderate sclerosis of the adjacent bony margins on the right knee and lateral joint space loss with bony sclerosis in the left knee. A diagnosis of secondary OA is made.
  • For treatment, he is given an intra-articular injection of steroids and started on a daily non-steroidal anti-inflammatory along with a proton-pump inhibitor for gastric protection and referred to physical therapy for quadriceps strengthening. His prednisone dose is decreased to 5 mg a day. Over the next month, he notes marginal improvement in the pain and swelling. He continues to have a significant functional loss related to problems with the right knee and is unable to return to work. A referral to orthopedics is made for consideration of a right knee replacement.

3) The joint fluid is non-inflammatory, with a low total wbc. In general, wbc counts less than 3000/cu mm in synovial fluid are considered non-inflammatory.

4) Asymmetrical joint space narrowing, along with bony sclerosis are characteristic of OA. Other characteristic findings include osteophytes.

5) Joint injections with both depot corticosteroid and hyaluronate preparations have been shown to be beneficial. Oral therapies including acetaminophen and several NSAIDs have demonstrated benefit. It is not possible to have a study comparing joint replacement with a sham operation but surgical intervention in those patients who have failed all alternative treatments is generally acknowledged as providing improved mobility and pain relief.

Last updated February 2015.