OSTEOARTHRITIS I.

Definition Osteoarthritis is a form of arthritis that features the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a "cushion" between the bones of the joints. Among the over 100 different types of arthritis conditions, osteoarthritis is the most common, affecting over 25 million people in the United States. Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After 55 years of age, it occurs more frequently in females. In the United States, all races appear equally affected. A higher incidence of osteoarthritis exists in the Japanese population, while South-African blacks, East Indians, and Southern Chinese have lower rates. Osteoarthritis is abbreviated as OA or referred to as degenerative arthritis or degenerative joint disease (DJD). Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Osteoarthritis usually has no known cause and is referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary II. Cause Primary osteoarthritis, osteoarthritis not resulting from injury or disease, is mostly a result of natural aging of the joint. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. In advanced osteoarthritis, there is a total loss of the cartilage cushion between the bones of the joints. Repetitive use of the worn joints over the years can irritate and inflame the cartilage, causing joint pain and swelling. Loss of the cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths (spurs, also referred to as osteophytes) to form around the joints. Osteoarthritis occasionally can develop in multiple members of the same family, implying a hereditary (genetic) basis for this condition.

Secondary osteoarthritis is a form of osteoarthritis that is caused by another disease or condition. Conditions that can lead to secondary osteoarthritis include obesity, repeated trauma or surgery to the joint structures, abnormal joints at birth (congenital abnormalities), gout, diabetes, and other hormone disorders.

Obesity causes osteoarthritis by increasing the mechanical stress on the joint and therefore on the cartilage. In fact, next to aging, obesity is the most significant risk factor for osteoarthritis of the knees. The early development of osteoarthritis of the knees among weight lifters is believed to be in part due to their high body weight. Repeated trauma to joint tissues (ligaments, bones, and cartilage) is believed to lead to early osteoarthritis of the knees in soccer players and army military personnel. Interestingly, studies have not found an increased risk of osteoarthritis in long-distance runners. Crystal deposits in the cartilage can cause cartilage degeneration and osteoarthritis. Uric acid crystals cause arthritis in gout, while calcium pyrophosphate crystals cause arthritis in pseudogout. Some people are born with abnormally formed joints (congenital abnormalities) that are vulnerable to mechanical wear, causing early degeneration and loss of joint cartilage. Osteoarthritis of the hip joints is commonly related to structural abnormalities of these joints that had been present since birth. Hormone disturbances, such as diabetes and growth hormone disorders, are also associated with early cartilage wear and secondary osteoarthritis.

III. Pathophysiology

IV. Signs and Symptoms Osteoarthritis is a disease of the joints. Unlike many other forms of arthritis that are systemic illnesses (conditions that affect multiple areas of the body or the entire body), such as rheumatoid arthritis and systemic lupus, osteoarthritis does not affect other organs of the body. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. Joint pain of osteoarthritis is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long periods of inactivity (for example, sitting in a theater). In severe osteoarthritis, complete loss of the cartilage cushion causes friction between bones, causing pain even at rest or pain with limited motion. Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can be debilitated by their symptoms. On the other hand, others may have remarkably few symptoms in spite of dramatic degeneration of the joints apparent on X-rays. Symptoms also can be intermittent. It is not unusual for patients with osteoarthritis of the finger joints of the hands and knees to have years of pain-free intervals between symptoms. Osteoarthritis of the knees is often associated with excess upper body weight, with obesity, or a history of repeated injury and/or joint surgery. Progressive cartilage degeneration of the knee joints can lead to deformity and outward curvature of the knees, which is referred to as being "bowlegged." People with osteoarthritis of the weight-bearing joints (such as the knees) can develop a limp. The limping can worsen as more cartilage degenerates. In some patients, the pain, limping, and joint dysfunction may not respond to medications or other conservative measures. Therefore, severe osteoarthritis of the knees is one of the most common reasons for total knee replacement surgical procedures in the United States. Osteoarthritis of the cervical spine or lumbar spine causes pain in the neck or low back. Bony spurs, called osteophytes, that form along the arthritic spine can irritate spinal nerves, causing severe pain that can radiate from the spine as well as numbness and tingling of the affected parts of the body. Osteoarthritis causes the formation of hard, bony enlargements of the small joints of the fingers. Classic bony enlargement of the small joint at the end of the fingers is called a Heberden's node, named after a famous British doctor. The bony deformity is a result of the bone spurs from the osteoarthritis in that joint. Another common bony knob (node) occurs at the middle joint of the fingers in many patients with osteoarthritis and is called a Bouchard's node. Dr. Bouchard was a famous French doctor who also studied arthritis patients in the late 1800s. Heberden's and Bouchard's nodes may not be painful, but they are often associated with limitation of motion of the joint. The characteristic appearances of these finger nodes can be helpful in diagnosing osteoarthritis. Osteoarthritis of the joint at the base of the big toe of the foot leads to the formation of a bunion. Osteoarthritis of the fingers and the toes may have a genetic basis and can be found in numerous female members of some families.

V. Diagnostic exams There is no blood test for the diagnosis of osteoarthritis. Blood tests are performed to exclude diseases that can cause secondary osteoarthritis, as well as to exclude other arthritis conditions that can mimic osteoarthritis. X-rays of the affected joints can be used to diagnose osteoarthritis. The common X-ray findings of osteoarthritis include loss of joint cartilage, narrowing of the joint space between adjacent bones, and bone spur formation. Simple X-ray testing can also be very helpful to exclude other causes of pain in a particular joint as well as assisting the decision-making as to when surgical intervention might be considered. Arthrocentesis is a procedure to remove joint fluid that is often performed in the doctor's office. During arthrocentesis, a sterile needle is used to remove joint fluid for analysis. Joint fluid analysis is useful in excluding gout, infection, and other causes of arthritis. Removal of joint fluid and injection of corticosteroids into the joints during arthrocentesis can help relieve pain, swelling, and inflammation. Arthroscopy is a surgical technique whereby a doctor inserts a viewing tube into the joint space. Abnormalities of and damage to the cartilage and ligaments can be detected and sometimes repaired through the arthroscope. If successful, patients can recover from the arthroscopic surgery much more quickly than from open joint surgery. Finally, a careful analysis of the location, duration, and character of the joint symptoms and the appearance of the joints helps the doctor in diagnosing osteoarthritis. Bony enlargement of the joints from spur formations is characteristic of osteoarthritis. Therefore, the presence of Heberden's nodes, Bouchard's nodes, and bunions of the feet can indicate to the doctor a diagnosis of osteoarthritis. VI. Treatment There's no known cure for osteoarthritis, but treatments can help to reduce pain and maintain joint movement. Medications Acetaminophen. Acetaminophen (Tylenol, others) can relieve pain, but doesn't reduce inflammation. It has been shown to be effective for people with osteoarthritis who have mild to moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage. Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce inflammation and relieve pain. Over-thecounter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others). Stronger NSAIDs are available by prescription. NSAIDs can cause stomach upset, ringing in your ears, cardiovascular problems, bleeding problems, and liver and kidney damage. Older people are at highest risk of complications. Narcotics. These types of prescription medication typically contain ingredients similar to codeine and may provide relief from more severe osteoarthritis pain. These stronger medications carry a risk of dependence, though that risk is thought to be small in people who have severe pain. Side effects may include nausea, constipation and sleepiness.

Therapy Work with a physical therapist. Ask your doctor for a referral to a physical therapist. The physical therapist can work with you to create an individualized exercise regimen that will strengthen the muscles around your joint, increase the range of motion in your joint and reduce your pain. Find ways to avoid stressing your joints. Find ways to go about your day without stressing your joints. An occupational therapist can help you discover ways to do everyday tasks or do your job without putting extra stress on your already painful joint. For instance, a toothbrush with a large grip could make brushing your teeth easier if you have finger osteoarthritis. A bench in your shower could help relieve the pain of standing if you have knee osteoarthritis. Try braces or shoe inserts. Consider trying splints, braces, shoe inserts or other medical devices that can help reduce your pain. These devices can immobilize or support your joint to help you keep pressure off it. Take a chronic pain class. The Arthritis Foundation and some medical centers have classes for people with osteoarthritis or chronic pain. Ask your doctor about classes in your area or check with the Arthritis Foundation. These classes teach skills that help you manage your osteoarthritis pain. And you'll meet other people with osteoarthritis and learn their tips and tricks for reducing and coping with joint pain. Surgical and other procedures Cortisone shots. Injections of corticosteroid medications may relieve pain in your joint. During this procedure your doctor numbs the area around your joint, and then inserts a needle into the space within your joint and injects medication. The number of cortisone shots you can receive each year is limited, because the medication can cause joint damage. Lubrication injections. Injections of hyaluronic acid derivatives (Hyalgan, Synvisc) may offer pain relief by providing some cushioning in your knee. These treatments are made of rooster combs and are similar to a component normally found in your joint fluid. Realigning bones. During a surgical procedure called an osteotomy, the surgeon cuts across the bone either above or below the knee to realign the leg. Osteotomy can reduce knee pain by shifting your body weight away from the worn-out part of your knee. Joint replacement. In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint surfaces and replaces them with plastic and metal devices called prostheses. The hip and knee joints are the most commonly replaced joints. Surgical risks include infections and blood clots. Artificial joints can wear out or come loose and may need to eventually be replaced. VII. Health Teachings Rest. If you're experiencing pain or inflammation in your joint, rest it for 12 to 24 hours. Find activities that don't require you to use your joint repetitively. Exercise. Exercise can increase your endurance and strengthen the muscles around your joint, making your joint more stable. Stick to gentle exercises, such as walking, biking or swimming. If you feel new joint pain, stop. New pain that lasts for hours after you exercise probably means you've overdone it.

Lose weight. Being overweight or obese increases the stress on your weight-bearing joints, such as your knees and your hips. Even a small amount of weight loss can relieve some pressure and reduce your pain. Talk to your doctor about healthy ways to lose weight. Most people combine changes in their diet with increased exercise. Use heat and cold to manage pain. Both heat and cold can relieve pain in your joint. Heat also relieves stiffness and cold can relieve muscle spasms. Apply over-the-counter pain creams. Creams and gels available at the drugstore may provide temporary relief from osteoarthritis pain. Some creams numb the pain by creating a hot or cool sensation. Other creams contain medications, such as aspirin-like compounds, that are absorbed into your skin. Pain creams work best on joints that are close to the surface of your skin, such as your knees and fingers. Use assistive devices. Assistive devices can make it easier to go about your day without stressing your painful joint. A cane may take weight off your knee or hip as you walk. Gripping and grabbing tools may make it easier to work in the kitchen if you have osteoarthritis in your fingers. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful to you. Catalogs and medical supply stores also may be places to look for ideas.