Osteoarthritis

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving degradation of joints,including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causes—hereditary, developmental, metabolic, and mechanical deficits—may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax.

Treatment generally involves a combination of exercise, lifestyle modification, and analgesics. If pain becomes debilitating, joint replacement surgery may be used to improve the quality of life. OA is the most common form of arthritis, and the leading cause of chronic disability in the United States. It affects about 1.9 million people in Australia, 8 million people in the United Kingdom and nearly 27 million people in the United States.

MRI of osteoarthritis in the knee, with characteristic narrowing of the joint space.

ICD-10 M15-M19, M47

ICD-9 715

OMIM 165720

DiseasesDB 9313

MedlinePlus 000423

eMedicine med/1682 orthoped/427 pmr/93 radio/492

MeSH D010003

Signs and symptoms

Bouchard's nodes and Heberden's nodes may form in osteoarthritis

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp ache or a burning sensation in the associated muscles and tendons. OA can cause a crackling noise (called "crepitus") when the affected joint is moved or touched and people may experience muscle spasms and contractions in the tendons. Occasionally, the joints may also be filled with fluid.[6] Some people report increased pain associated with cold temperature, high humidity, and/or a drop in barometric pressure, but studies have had mixed results.

OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel better with gentle use but worse with excessive or prolonged use, thus distinguishing it from rheumatoid arthritis.

In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen. Some people notice these physical changes before they experience any pain.

OA is the most common cause of a joint effusion of the knee.

Causes

Damage from mechanical stress with insufficient self repair by joints is believed to be the primary cause of osteoarthritis. Sources of this stress may include: misalignments of bones caused by congenital or pathogenic causes; mechanical injury; excess body weight; loss of strength in the muscles supporting a joint; and impairment of peripheral nerves, leading to sudden or uncoordinated movements.However exercise, including running in the absence of injury, has not been found to increase the risk.Nor has cracking one's knuckles been found to play a role.

Primary

Primary osteoarthritis of the left knee. Note the osteophytes, narrowing of the joint space (arrow), and increased subchondral bone density (arrow).

A number of studies have shown that there is a greater prevalence of the disease among siblings and especially identical twins, indicating a hereditary basis. Although a single factor is not generally sufficient to cause the disease, about half of the variation in susceptibility has been assigned to genetic factors.

As early human ancestors evolved into bipeds, changes occurred in the pelvis, hip joint and spine which increased the risk of osteoarthritis.Additionally genetic variations that increase the risk were likely not selected against because usually problems only occur after reproductive success.

The development of OA is correlated with a history of previous joint injury and with obesity, especially with respect to knees.Since the correlation with obesity has been observed not only for knees but also for non-weight bearing joints and the loss of body fat is more closely related to symptom relief than the loss of body weight, it has been suggested that there may be a metabolic link to body fat as opposed to just mechanical loading.

Changes in sex hormone levels may play a role in the development of OA as it is more prevalent among post-menopausal women than among men of the same age.A study of mice found natural female hormones to be protective while injections of the male hormone dihydrotestosterone reduced protection.

Secondary

This type of OA is caused by other factors but the resulting pathology is the same as for primary OA:

Alkaptonuria

Congenital disorders of joints

Diabetes

Ehlers-Danlos Syndrome

Hemochromatosis and Wilson's disease

Inflammatory diseases (such as Perthes' disease), (Lyme disease), and all chronic forms of arthritis (e.g. costochondritis, gout, and rheumatoid arthritis). In gout, uric acid crystals cause the cartilage to degenerate at a faster pace.

Injury to joints or ligaments (such as the ACL), as a result of an accident or orthopedic operations.

Ligamentous deterioration or instability may be a factor.

Marfan syndrome

Obesity

Septic arthritis (infection of a joint)

Pathophysiology

Primary OA is a chronic degenerative disorder related to but not caused by aging, as there are people well into their nineties who have no clinical or functional signs of the disease. As a person ages, the water content of the cartilage decreases better source needed] as a result of a reduced proteoglycan content, thus causing the cartilage to be less resilient. The water content of healthy cartilage is finely balanced by compressive force driving water out & swelling pressure drawing water in. Collagen fibres exert the compressive force, whereas the Gibbs-Donnan effect & cartilage proteoglycans create osmotic pressure which tends to draw water in. However during onset of OA there is an increase in cartilage water content.

This increase occurs because whilst there is an overall loss of proteoglycans, it is outweighed by a loss of collagen.Without the protective effects of the proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also occur, though often mild (compared to what occurs in rheumatoid arthritis). This can happen as breakdown products from the cartilage are released into the synovial space, and the cells lining the joint attempt to remove them. New bone outgrowths, called "spurs" or osteophytes, can form on the margins of the joints, possibly in an attempt to improve the congruence of the articular cartilage surfaces. These bone changes, together with the inflammation, can be both painful and debilitating.

Diagnosis

Diagnosis is made with reasonable certainty based on history and clinical examination. X-rays may confirm the diagnosis. The typical changes seen on X-ray include: joint space narrowing, subchondral sclerosis (increased bone formation around the joint), subchondral cyst formation, and osteophytes.Plain films may not correlate with the findings on physical examination or with the degree of pain. Usually other imaging techniques are not necessary to clinically diagnose OA.

In 1990, the American College of Rheumatology, using data from a multi-center study, developed a set of criteria for the diagnosis of hand OA based on hard tissue enlargement and swelling of certain joints.[33] These criteria were found to be 92% sensitive and 98% specific for hand OA versus other entities such as rheumatoid arthritis and spondyloarthropathies.

Related pathologies whose names may be confused with OA include pseudo-arthrosis. This is derived from the Greek words pseudo, meaning "false", and arthrosis, meaning "joint." Radiographic diagnosis results in diagnosis of a fracture within a joint, which is not to be confused with OA which is a degenerative pathology affecting a high incidence of distal phalangeal joints of female patients. A polished ivory-like appearance may also develop on the bones of the affected joints, reflecting a change called eburnation.

Classification

OA can be classified into either primary or secondary depending on whether or not there is an identifiable underlying cause.

Both primary generalized nodal OA and erosive OA (EOA, also called inflammatory OA) are sub-sets of primary OA. EOA is a much less common, and more aggressive inflammatory form of OA which often affects the distal interphalangeal joints of the hand and has characteristic articular erosive changes on x-ray.

Management

Lifestyle modification (such as weight loss and exercise) and analgesics are the mainstay of treatment. Acetaminophen ( also known as paracetamol) is recommended first line with NSAIDs being used as add on therapy only if pain relief is not sufficient.This is due to the relative greater safety of acetaminophen.

Lifestyle modification

For overweight people, weight loss may be an important factor. Patient education has been shown to be helpful in the self-management of arthritis. It decreases pain, improves function, reduces stiffness and fatigue, and reduces medical usage.[38] Patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip OA.

Physical measures

Moderate exercise is beneficial with respect to pain and function in those with osteoathritis of the knee and possibly hip.While some evidence supports certain physical therapies evidence for a combined program is limited.There is not enough evidence to determine the effectiveness of massage therapy.

The use of orthoses (which include splints, braces or insoles) have been studied. Lateral wedge insoles do not appear to be useful in osteoarthritis of the knee. Knee braces may be useful.

The evidence for manual therapy is inconclusive. Functional, gait, and balance training has been recommended to address impairments of position sense, balance, and strength in individuals with lower extremity arthritis as these can contribute to higher falls in older individuals.

Medication

The analgesic acetaminophen is the first line treatment for OA.For mild to moderate symptoms effectiveness is similar to non-steroidal anti-inflammatory drugs (NSAIDs), though for more severe symptoms NSAIDs may be more effective. NSAIDs such as naproxen while more effective in severe cases are associated with greater side effects such as gastrointestinal bleeding.Another class of NSAIDs, COX-2 selective inhibitors (such as celecoxib) are equally effective to NSAIDs with lower rates of adverse gastrointestinal effects but higher rates of cardiovascular disease such as myocardial infarction.[48] They are also much more expensive. Oral steroids are not recommended in the treatment of OA because of their modest benefit and high rate of adverse effects.

There are several NSAIDs available for topical use including diclofenac. They have fewer systemic side-effects and at least some therapeutic effect.A Cochrane review concluded that opioid analgesics such as morphine and fentanyl reduce pain, but this benefit is outweighed by frequent adverse events and thus they should not routinely be used.[50] Topical capsaicin is controversial with some reviews finding benefit and others not.

Injection of glucocorticoids (such as hydrocortisone) leads to short term pain relief that may last between a few weeks and a few months. Joint injections of hyaluronic acid have not been found to lead to significant improvement. Hyaluronic acid injects have been associated with significant harm. Nevertheless another study about hyaluronic acid injections says efficacy on pain and function, and no adverse effect when compared to saline injections.

Surgery

If disability is significant and more conservative management is ineffective, joint replacement surgery or resurfacing may be recommended. Evidence supports joint replacement for both knees and hips.[56] For the knee it improves both pain and functioning.[57] Arthroscopic surgical intervention for OA of the knee however has been found to be no better than placebo at relieving symptoms.

Alternative medicine

Dietary supplements

Many dietary supplements are sold as treatments for OA and some of them have been found to be effective. Phytodolor, SAMe, and SKI 306X (a Chinese herbal mixture) may be effective in improving pain, and there is some evidence to support the use of cat's claw as an anti-inflammatory.There is tentative evidence to support avocado/soybean unsaponifiables, Boswellia serrata extracts (frankincense),MSM and rose hip.

The effectiveness of glucosamine is controversial. Most recent reviews found it to be equal to or only slight better than placebo. A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not.The Osteoarthritis Research Society International recommends that glucosamine be discontinued if no effect is observed after six months] and the National Institute of Clinical Excellence no longer recommends its use.Despite the difficulty in determining the efficacy of glucosamine, it remains a viable treatment option.

There is little evidence supporting benefits for some supplements, including: the Ayurvedic herbal preparations with brand names Articulin F and Eazmov, collagen, devil’s claw, Duhuo Jisheng Wan (a Chinese herbal preparation), fish liver oil, ginger, the herbal preparation Gitadyl, glucosamine, hyaluronic acid, omega-3 fatty acids, the brand-name product Reumalax, stinging nettle, turmeric, vitamins A, C, and E in combination, vitamin E alone, vitamin K and willow bark. There is insufficient evidence to make a recommendation about the safety and efficacy of these treatments.Chondroitin is not recommended as a treatment for OA.

Manual therapies

While acupuncture leads to a statistically significant improvement in pain relief, this improvement is small and may be of questionable clinical significance. Waiting list-controlled trials for peripheral joint osteoarthritis do show clinically relevant benefits, but these may be due to placebo effects.Acupuncture does not seem to produce long-term benefits.While electrostimulation techniques such as TENS have been used for twenty years to treat osteoarthritis in the knee, there is no conclusive evidence to show that it reduces pain or disability.

Epidemiology

Disability-adjusted life year for OA per 100,000 inhabitants in 2004.

no data

= 200

200–220

220–240

240–260

260–280

280–300

300–320

320–340

340–360

360–380

380–400

= 400

Globally approximately 250 million people have osteoarthritis of the knee (3.6% of the population). OA affects nearly 27 million people in the United States, accounting for 25% of visits to primary care physicians, and half of all NSAID prescriptions. It is estimated that 80% of the population have radiographic evidence of OA by age 65, although only 60% of those will have symptoms. In the United States, hospitalizations for OA increased from 322,000 in 1993 to 735,000 in 2006.

Globally OA causes moderate to severe disability in 43.4 million people as of 2004.

In the United States, there were approximately 964,000 hospitalizations for osteoarthritis in 2011, a rate of 31 stays per 10,000 population. With an aggregate cost of $14.8 billion ($15,400 per stay), it was the second-most expensive condition seen in U.S. hospital stays in 2011. By payer, it was the second-most costly condition billed to Medicare and private insurance.

Etymology

OA is derived from the Greek word part osteo-, meaning "of the bone", combined with arthritis: arthr-, meaning "joint", and -itis, the meaning of which has come to be associated with inflammation. The -itis of OA could be considered misleading as inflammation is not a conspicuous feature. Some clinicians refer to this condition as osteoarthosis to signify the lack of inflammatory response.

History

Evidence for OA found in the fossil record is studied by paleopathologists, specialists in ancient disease and injury. OA has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis.

Plica of the knee - the great mimic

"A young soccer player finds himself frustrated, unable to find out what is wrong with his knee. After submitting to extensive physiotherapy and two lots of surgery he finds out that his symptoms are due to a thickened plica." - case presentation by Dr Angus Strover.

footballer

J.L. is a 16 year old schoolboy. He is a talented sportsman, playing soccer, tennis, squash and running to keep fit.

About 18 months ago he tried to get fit enough to compete in middle distance athletics but had to give it up because he developed pain in his right knee which developed after running. The pain was quite severe and was situated above the knee cap and on the inner side of the knee. The pain was aggravated by going downstairs but not by going up. He was unaware of any swelling, but said that the knee felt hot on occasion. The pain was associated with a regular click under the kneecap. He noticed the clicking more in the morning on first getting up and going downstairs to the bathroom. Besides the pain and clicking, J.L. noticed that his knee became stiff and ached when he sat in one position for any length of time.

Struggling for a diagnosis

J.L. sought treatment from the club physiotherapist (PT) who taped the kneecap and gave him V.M.O exercises (vastus medialis obliquus - ie the inner quads muscle). Although this seemed to help in the first instance, as time went on the exercises made the pain worse and his physio suggested that he sought advice from a podiatrist as J.L. had pronated (flat) feet which is known to often aggravate knee pain. The physio felt that the problem might be corrected by appropriate inserts into his footware.

J.L. spent £300 (about $500) on inserts for his shoes and trainers but his knee pain got worse until he noticed that he could only run about a mile or play soccer for about 20 minutes before the pain stopped him from continuing the exercise. Pain on stairs was becoming an everyday occurrence and J.L. stopped playing soccer and stopped jogging.

He sought advice from his G.P. (primary care practitioner) who did some blood tests and prescribed anti-inflammatory tablets, rest and ice. The pain and clicking settled down during this period, but immediately returned when he went back to sporting activities. He asked for a referral to an orthopaedic surgeon with an interest in sports medicine.

Surgery fails to reveal diagnosis

This orthopaedic surgeon examined J.L.'s knee and suspected chondromalacia and maltracking of the patella, or else some damage to his joint surface or his meniscal cartilages. He ordered an X-ray, which was normal, and an M.R.I. scan which was also reported as normal. He decided to do an arthroscopy as a day case.

The arthroscopy showed normal appearances to the meniscal cartilages, ligaments and joint surfaces, but the surgeon took photographs and kept a video of the procedure. He also did a biopsy of the synovial membrane.

The biopsy showed 'non-specific synovitis' (inflammation without obvious cause) and the surgeon advised that a steroid injection into the joint might help.

The injection into the knee did help for about 6 weeks, but then the symptoms came back.

More rehab but still no diagnosis

The surgeon sent J.L. to another physiotherapist, who decided to do an isokinetic test. This tests the muscles working the joint at maximum strength at a pre-determined speed through a full range of movements. The test was painful and the physio asked J.L. to score the pain on a scale of 1 to 10. J.L. said that at its worst the pain was about 5 out of 10.

Again he was given quadriceps exercises, but J.L.'s pain returned when he went back to playing squash and running.

Ah-haa!

Finally J.L. was referred to another surgeon who felt that the story was typical of 'the plica syndrome'. He explained that a synovial plica is a fold of the synovial membrane - the inner lining of the knee joint. These folds are normal structures which develop in the first eight weeks of a pregnancy when the embryo's joints are developing in its limbs. In most people synovial plicae (plural of plica) do not give problems. But in some people, often following a minor injury such as a direct blow on the knee, a synovial plica becomes inflamed and loses its normal elastic compliant nature. It then forms scar tissue which clicks as it slides across the surfaces of the joint and with exercise the plica becomes painful and inflamed. The process is on-going and progressively becomes worse with time especially after sporting activities.

The surgeon explained that a plica can be missed during arthroscopy if the knee was not examined from above. He also explained that it is frequently unreported on MRI scan as a plica is generally considered a normal finding. But in his own clinical experience it is a frequent cause of problems.

J.L. was persuaded to have another arthroscopy during which this surgeon inspected the joint from an entry portal (small surgical cut) above the kneecap. A thickened plica was found and a video showed the entrapment of the plica between the patella and the femur whilst the knee was being bent to 90 degrees.

The plica was completely removed during the surgery.

After the operation J.L.'s knee was swollen for four weeks and he was given gentle mobilisation, anti-inflammatory tablets and ice on the knee. During the next three months the knee became stronger, the swelling went completely, the clicking diminished and was not painful and, finally, at six months after the operation J.L. returned to soccer, running and squash. Stairs are now no problem and J.L is delighted with the complete absence of any pain in his knee.

Osteoarthritis

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or a disease of the joints, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone . Symptoms may include joint pain, stiffness, locking, and sometimes an effusion. A variety of hereditary causes, development, metabolic and mechanical deficits may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of the decrease of the secondary movement pain, regional muscles may atrophy, and ligaments can become lax.

Treatment usually involves a combination of exercise, lifestyle modification, and analgesics. If the pain becomes debilitating, joint replacement surgery can be used to improve the quality of life. Osteoarthritis is the most common form of arthritis, and the leading cause of chronic disability in the United States. It affects about 1.9 million people in Australia 8 million people in the United Kingdom and nearly 27 million people in the United States.

MRI of osteoarthritis of the knee, with a characteristic narrowing of the joint space.

ICD-10 M15-M19, M47

ICD-9715

OMIM 165720

DiseasesDB 9313

MedlinePlus 000423

eMedicine med/1682 orthoped/427 pmr/93 radio/492

MeSH D010003

Signs and symptoms

The Bouchard's nodes and Heberden's nodes may form in osteoarthritis

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp pain or a burning sensation in the associated muscles and tendons. OA can cause a crackling noise (called "crackling") when the affected joint is moved or touched and people may experience muscle spasm and contractions in the tendons. Sometimes the joints may also be filled with fluid. [6] Some people report increased pain associated with cold, high humidity and / or a decrease in barometric pressure, but studies have had mixed results.

OA commonly affects the hands, feet, spine, and large weight-bearing joints such as hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints are larger, are stiff and painful, and usually feel better to use gentle but worse with excessive or prolonged use, thus distinguishing it from rheumatoid arthritis.

In small joints such as the fingers, hard bony enlargements, called Heberden nodes (on IPD) and / or Bouchard's nodes (on the proximal interphalangeal joints), may form, and if they are not necessarily painful, they limit movement of the fingers significantly. OA at the toes leads to the formation of onions, making them red or swollen. Some people notice these physical changes before they suffer no pain.

Osteoarthritis is the most common knee joint effusion cause.

Causes

Damage caused by mechanical stress with insufficient self repair joints is considered the main cause of osteoarthritis. Sources of this stress may include: inadequacy of bones caused by congenital or pathogenic causes; mechanical injury, excess weight, loss of strength in the muscles supporting a gasket, and impairment of peripheral nerves, leading to stroke or uncoordinated movements.However exercise, including running in the absence of injury, has not been found to increase risk.Nor a cracking his joints were found to play a role.

Primary

Primary osteoarthritis of the left knee. Note the osteophytes, narrowing of the joint space (arrow), and the density of subchondral bone increased (arrow).

A number of studies have shown that there is a greater prevalence of the disease in siblings and especially identical twins, indicating a hereditary basis. Although only one factor is generally not sufficient to cause the disease, about half of the variation of the sensitivity was attributed to genetic factors.

As our human ancestors evolved into bipeds start, changes in the pelvis, hip and spine increased the risk of genetic variations that increase the risk osteoarthritis.Additionally probably was not chosen because usually against the problems occur after the success of reproduction.

The development of osteoarthritis is correlated with a history of joint injury and obesity, in particular as regards the knees.Since correlation with obesity was observed not only for the knees, but also for non-joint bearing and loss of body fat is more closely related to relieve the symptoms of loss of body weight, it was suggested that there could be a metabolic link to body fat, as opposed to just a mechanical loading.

Changes in levels of sex hormones may play a role in the development of osteoarthritis as it is more common in postmenopausal women than men in the same study found age.A mouse natural female hormones to be protection while injections of the male hormone dihydrotestosterone reduced protection.

Secondary

This type of OA is caused by other factors, but the resulting pathology is the same as for primary osteoarthritis:

AKU

Congenital abnormalities of joints

Diabetes

Ehlers-Danlos

Hemochromatosis and Wilson's disease

Inflammatory diseases (such as Perthes disease), (Lyme disease), and all forms of chronic arthritis (e.g. costochondritis, gout and rheumatoid arthritis). In gout, uric acid crystals cause the cartilage degenerates at a faster pace.

Injuries to joints or ligaments (such as ACL), following an accident or orthopedic operations.

Ligament deterioration or instability may be a factor.

Marfan syndrome

Obesity

Septic arthritis (joint infections)

Pathophysiology

Primary OA is a chronic degenerative disease related to, but not caused by aging, as there are people well into their nineties who have no clinical or functional signs of the disease. As a person ages, the water content of the cartilage decreases better source needed] as a result of a reduced proteoglycan content, thus causing the cartilage to be less elastic. The water content of healthy cartilage is finely balanced by a force of water swelling and compression chasing draw water in. collagen fibers carry the force of compression pressure, while the Gibbs-Donnan effect and cartilage proteoglycan create a osmotic pressure which tends to draw water in. However during the development of osteoarthritis, there is an increase in the water content of the cartilage.

This increase occurs because while there is an overall loss of proteoglycans, it is offset by a loss of collagen.Without The protective effects of the proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also occur, though often mild (compared to what happens in rheumatoid arthritis). This can happen as breakdown products of cartilage are released into the synovial space, and the cells lining the joint attempt to remove them. New bone outgrowths, called "spurs" or osteophytes, can form on the margins of the joints, possibly in an attempt to improve the congruence of the articular cartilage surfaces. These changes in the bone, as well as inflammation, can be both painful and debilitating.

Diagnosis

The diagnosis is made with reasonable certainty based on history and clinical examination. X-rays can confirm the diagnosis. The typical changes seen on X-ray include: joint space narrowing of the space, subchondral sclerosis (increased bone formation around the joint), the formation of subchondral cysts, osteophytes and movies. level may not correlate with the results of the physical examination or with the degree of pain. Usually other imaging techniques are not needed to diagnose clinically OA.

In 1990, the American College of Rheumatology, using data from a multi-center study, developed a set of criteria for the diagnosis of hand osteoarthritis based on hard tissue enlargement and swelling of certain joints. [33] These criteria were considered 92% sensitive and 98% specific for hand OA compared to other entities such as rheumatoid arthritis and spondyloarthritis.

Related pathologies whose name may be confused with osteoarthritis include pseudo-arthrosis. It is derived from Greek words nickname, which means "false", and arthrosis, meaning "common." Results diagnostic radiography in the diagnosis of a fracture in a joint, which should not be confused with osteoarthritis which is a degenerative disease affecting a high incidence of distal phalangeal joints of female patients. One aspect of the ivory polite can also develop on the bones of the joints affected, reflecting a change called éburnation.

Classification

OA can be classified as primary or secondary depending on whether or not there is an identifiable underlying cause.

For both the nodal and generalized osteoarthritis erosive osteoarthritis (EOA, also called inflammatory osteoarthritis) are subsets of primary osteoarthritis. EOA is a much less common inflammatory form, more aggressive Osteoarthritis commonly affects the distal interphalangeal joints of the hand and erosive joint changes characteristic x-ray.

Management

lifestyle modification (such as weight loss and exercise) and analgesics are the mainstay of treatment. Acetaminophen (also known as paracetamol) is recommended first line with NSAIDs used as add on treatment only if the pain is not sufficient.This is due to the greater relative safety of acetaminophen.

modification of lifestyle

For overweight people, weight loss may be an important factor. Patient education has been shown to be useful in self-management of arthritis. It reduces pain, improves function, reduces stiffness and fatigue, and reduces medical consumption. [38] Patient education can provide 20% more than average relief of pain compared to NSAIDs alone in patients with osteoarthritis of the hip.

Physical measurements

Moderate exercise is beneficial with respect to pain and function in people osteoathritis knee and perhaps hip.While evidence supports some evidence of physical therapy for a combined program limited.There is not enough evidence to determining the effectiveness of massage therapy.

The use of orthotics (which include splints, braces or insoles) were studied. Lateral wedge insoles do not seem to be useful in osteoarthritis of the knee. knee may be helpful.

Evidence of manual therapy is not conclusive. Functional, gait, and balance has been recommended for treatment of impairment of position sense, balance and strength in individuals with arthritis of the lower end of these can contribute to falls higher among the elderly.

Drug

Acetaminophen is the analgesic first-line treatment for mild to moderate symptoms OA.For efficiency is similar to anti-inflammatory drugs (NSAIDs), although for more severe symptoms NSAIDs may be more effective. NSAIDs such as naproxen, while effective in severe cases are associated with more serious side effects such as gastrointestinal bleeding.Another class of NSAIDs, COX-2 selective inhibitors such as celecoxib () are also effective for NSAIDs with lower rates of gastrointestinal side effects, but higher rates of cardiovascular diseases such as myocardial infarction. [48] ??They are also much more costly. Oral steroids are not recommended in the treatment of OA because of their modest benefit and high rate of adverse effects.

There are several NSAIDs available for topical use including diclofenac. They have fewer systemic side effects and at least one Cochrane review concluded that therapeutic effect.A opioid analgesics such as morphine and fentanyl reduce pain, but this advantage is offset by the common side effects and therefore should not be systematically used. [50] Capsaicin is controversial with some comments find advantage and others do not.

Injection of glucocorticoids (such as hydrocortisone) leads to relieve short-term pain that can last from several weeks to several months. Intra-articular injections of hyaluronic acid have not been found to lead to a significant improvement. Injected hyaluronic were associated with significant acid damage. However another study on hyaluronic acid injections said efficacy on pain and function, and no adverse effects compared with saline injections.

Surgery

If the disability is important and conservative treatment is ineffective, surgery or resurfacing joint replacement may be recommended. Evidence supports joint replacement for knees and hips. [56] For the knee, it improves both pain and function. [57] Arthroscopic surgery for osteoarthritis of the knee but was not considered better than placebo in relieving symptoms.

Alternative medicine

Dietary supplements

Many dietary supplements are sold as treatments for osteoarthritis and some of them have been found to be effective. Phytodolor, SAMe, and SKI 306x (a Chinese herbal mixture) can be effective in improving pain, and there is some evidence to support the use of cat's claw as an anti-inflammatory.There is proof of principle to support unsaponifiable avocado / soybean extract Boswellia serrata (frankincense), MSM and rose hip.

The effectiveness of glucosamine is controversial. Most recent comments have shown that it is better than placebo at or only slightly. A difference may exist between glucosamine sulfate and glucosamine hydrochloride, glucosamine sulfate showing a benefit and glucosamine hydrochloride not.The Osteoarthritis Research Society International recommends that glucosamine be discontinued if no effect is observed after six months ] and the National Institute of Clinical Excellence recommends its use.Despite more difficult to determine the effectiveness of glucosamine, it remains a viable treatment option.

There is little evidence to support benefits for some supplements, including: preparations Ayurvedic herbal with brand names and Eazmov Articulin F, collagen, devil's claw, Duhuo Jisheng Wan (a preparation Chinese plants), liver oil, fish, ginger, preparation based Gitadyl plants, glucosamine, hyaluronic acid, omega-3 fatty acids, the product brand Reumalax, nettle, turmeric, vitamins A, C, and E in combination, the only vitamin E, vitamin K and willow bark. There is insufficient evidence to make a recommendation on the safety and efficacy of these treatments.Chondroitin is not recommended in the treatment of osteoarthritis.

Manual therapies

While acupuncture causes a statistically significant improvement in pain, this improvement is small and may be of questionable clinical significance. Pending list controlled trials for osteoarthritis peripheral joints have not clinically relevant advantages, but these may be due to a placebo does not appear to produce effects.Acupuncture techniques electrostimulation benefits.While such long term dozens have been used for twenty years to treat osteoarthritis in the knee, there is no conclusive evidence to show that it reduces pain and disability.

Epidemiology

Disability-adjusted life year for osteoarthritis per 100,000 inhabitants in 2004.

no data

= 200

200-220

220-240

240-260

260-280

280-300

300-320

320-340

340-360

360-380

380-400

= 400

Overall about 250 million people suffer from osteoarthritis of the knee (3.6% of the population). OA affects nearly 27 million people in the United States, which represents 25% of visits to primary care physicians, and half of all NSAID prescriptions. It is estimated that 80% of the population have radiographic evidence of osteoarthritis at age 65, although only 60% of those who have symptoms. In the United States, hospitalizations for osteoarthritis increased by 322,000 in 1993 to 735,000 in 2006.

Overall OA causes moderate to severe disability in 43.4 million people in 2004.

In the United States, there were about 964,000 hospitalizations for osteoarthritis in 2011, a rate of 31 stays per 10,000 inhabitants. With a total cost of $ 14.8 billion ($ 15,400 per stay), it was the second most expensive given the state hospital stays in the United States in 2011. By payer, it was the second most expensive condition billed to Medicare and private insurance.

Etymology

OA is derived from the Greek word part arthrosis, meaning "bone", combined with arthritis: arthr, which means "common", and-itis, whose meaning has come to be associated with inflammation. The-ite of osteoarthritis could be considered misleading as inflammation is not an outstanding feature. Some clinicians refer to this condition as osteoarthosis to signify the absence of inflammatory reaction.

History

Evidence of osteoarthritis found in the fossil record is studied by paleopathologists, disease specialists and old injuries. OA has been reported in fossils of dinosaur Allosaurus fragilis large carnivores.

Seven ways of treating arthritis

There are many ways to treat severe arthritis. As used to treat arthritis symptoms and may depend on the type of arthritis affecting the person.

i) drugs - Most people who suffer from severe arthritis normally see a doctor for medication to relieve and reduce the pain of arthritis. Doctors usually prescribe an NSAID (non-steroidal anti-inflammatory drugs) to reduce inflammation and swelling. These NSAIDs may be beneficial in treating the symptoms and short-term assistance to those suffering from severe arthritis. Some commonly used NSAIDs include aspirin, ibuprofen and naproxen. You should also be aware that these NSAIDs can cause side effects such as stroke, heart attack, stomach ulcers and kidney. Given this, these drugs can be used to relieve pain in the short term.

ii) Physical Therapy - With medication, physiotherapy plays an important role in the management of arthritis pain. It can help you maintain independence through improved power, mobility and flexibility. Physiotherapists examine muscles, posture and the way you walk and it includes activities that cause you pain. They will design a personalized treatment plan that may include hydrotherapy, massage and techniques of pain relief.

iii) Surgery - For people with arthritis progresses, medications will no longer be an option. They will go to surgery for relief of arthritis pain. Operations may include

a) replace a severely damaged joint

b) release of trapped nerves

c) removing the wall of the cavity of the articular inflammation

d) removal of the bone to relieve pain

e) the repair of damaged tendons

In most cases surgery successfully restore the knee joints and significantly reduce pain. The disadvantage is that the surgery is expensive and there are cases where surgery does not manage to restore the knee joint.

iv) Exercise - For osteoarthritis, exercise may be the preferred option. Exercise can help relieve stiffness, reduce pain and swelling and also improve muscle and bone strength. Exercise programs may include

a) low-impact aerobic activity

b) exercise range of motion for flexibility

c) strength training for muscle tone

v) weight management - Losing weight is another way that can significantly reduce the pain of the knee joint. When a person is overweight, the extra weight will normally add additional pressure on the knee joint which aggravates the pain of arthritis. Young adults who are classified as obese should try to lose weight that will delay the onset of getting arthritis and joint pain. Another thing about maintaining the right weight is that you have less health problems as you age.

vi) changes in lifestyle - People who suffer from arthritis should participate in stress reduction activities such as meditation, yoga or tai chi.We can improve the strength and flexibility of joints practicing certain yoga postures. These postures are warrior pose, tree pose, Triangle pose, posture and Bridge corpse pose. If you practice yoga regularly using good posture associated with meditation, you can get relief from the pain of arthritis.

vii) Health and balanced diet - Eat a healthy diet rich in fruits and vegetables, which contain important vitamins and minerals, especially vitamin E. Eat foods rich in omega-3 fatty acids, such as cold water fish (salmon, mackerel and herring), flaxseed, rapeseed (canola) oil.

You can treat the pain of arthritis you suffer from any of the ways mentioned above. You should carefully consider your circumstances and the situation you are in before deciding which approach will yield the desired result.

Is there an allergy arthritis connection?

Arthritis is one of the most debilitating diseases in the United States and a major cause of missed work. Unfortunately, conventional treatments are limited and almost exclusively focused on anti- inflammatory drugs , not the elimination of the original trigger of this inflammation .

What is " arthritis " means ?

The word "arthritis " simply means " joint inflammation ." There are basically two types: osteoarthritis and rheumatoid arthritis.

Osteoarthritis is an inflammation caused by the degeneration of the joint and is due to chronic wear and tear. Osteoarthritis is most commonly found in the knees.

Rheumatoid arthritis ( RA) is a more common term for inflammation , pain and swelling of joints. Rheumatoid arthritis is often seen in the hands , although it can affect any part of the body .

The traditional approach of arthritis

Rheumatoid arthritis is considered by an unknown cause autoimmune disease . This belief ignores a large body of scientific evidence showing food allergies as a major cause of arthritis. The correlation between arthritis and allergies proves quite significant .

Dr. Theron G. Randolph Illinois was the founder of environmental medicine . During his research, he has tested more than 1,000 patients with rheumatoid commonly eaten foods and chemicals . He tested substances from natural gas, automobile exhaust , paint , perfume, hair spray , insecticides , tobacco smoke which of these substances caused their symptoms.

Several other studies have shown that many foods , food additives , as well as foreign invaders such as protozoa, bacteria , yeasts, fungi and can trigger or worsen arthritic symptoms . In the case of food allergies , eating too much of certain foods too often is another problem. " Most people eat the same few foods over and over again , sometimes literally " ad nauseam , "wrote Dr. Randolph .

In addition , Dr. Marshall Mandell, author , book Allergy- Mr. Mandell recipes , tested over 6000 patients. He found that foods, chemicals, grass , pollen , mold and other airborne substances caused allergic reactions in joints nearly 85 % of arthritic it tested .

The medical community has focused almost exclusively on the treatment of arthritis with anti -inflammatory medications , either prescription or nonprescription . These medications provide only temporary relief of pain and swelling, but they never cure arthritis . In the long term , this type of treatment also comes with a host of side effects.

Is it possible to eliminate inflammation without drugs?

Very often it is possible to eliminate the cause of the inflammation without the use of drugs to suppress . Inflammation is caused by the immune system . The important question is : "Why the immune system creates inflammation " ?

What triggers the immune system to create inflammation? Â ? ¨

Anything that triggers an immune response also triggers inflammation. These include allergies , foods that are incorrectly identified by the immune system as not belonging to the body . Thus , an allergic reaction to a food can result in inflammation of the joints and pain .

What foods cause arthritis ?

The body may be allergic to food , therefore, any food allergy is able to cause inflammation and arthritis. This includes RA , juvenile arthritis , and joint pain defined.

That is why it can be so hard for one to recognize the relationship between their diet and their symptoms. Many times there is a delay between eating the suspect food and the associated pain.

What to do?

If we can remove the defective programming and replace it with a program that does not create inflammation, reduce pain and in many cases disappear completely.

Programs like NAET were very effective in the treatment of joint pain and allergies. And if you do not have the time or money to investigate this very successful removal treatment of allergy.

Plica Syndrome

What is a Plica?

A plica is a fold of synovial membrane most commonly in the anteromedial aspect of the knee. Plica are present in about 50% of the population and are thought to be the remnants of embryonic connective tissue that failed to fully resorb during your foetal development. Luckily, most plicae are asymptomatic.

While your knee potentially has four plica it is the medial plica that is most likely to be symptomatic (Dupont 1997). It runs parallel to your medial patella just below your medial retinaculum and inserts into your fat pad.

What is Plica Syndrome?

Plica syndrome is essentially an inflammed plica. Your plica can catch during:

repetitive knee straightening and bending,

blunt trauma or knee twisting,

fat pad irritation,

altered knee motion,

internal knee derangements eg meniscal tears. (Schindler 2004)

This is particularly the case if you have experienced persistent pain and weakness in the quadriceps muscles. Plica syndrome often does not always occur in isolation, but concurrently with other knee conditions such as meniscal injuries, patellar tendonitis and Osgood-Schlatter’s Disease.

What are the Symptoms of Plica Syndrome?

Plica syndrome can be suspected when you have:

Anteromedial knee pain - esp medial femoral condyle.

Visible and palpably tender plica.

Audible clicking or snap during knee motion - painful arc 30 to 60 degrees. (Dupont 1997).

Positive Duvet test: pain eased by using a duvet between your knees to ease pain in bed.

Pain with activities: ascending and descending stairs, squatting, rising from a chair and/or sitting for extended periods. (Shetty et al 2007).

Quadriceps atrophy is common on chronic cases.

How is Plica Syndrome Diagnosed?

Your physiotherapist will be able to clinically diagnose plica syndrome. It is more important that you have your knee thoroughly assessed by a physiotherapist or sports doctor to exclude other knee pathologies, in particular meniscal injuries.

X-ray may be useful to rule out other associated pathologies but will not identify a plica. MRIs can identify plica inflammation. However, MRI is more useful for diagnosing other pathologies that may be related to the plica irritation. A comprehensive examination by your physiotherapist or sports physician is preferable.

Plica Syndrome Treatment

Studies show that about 60% of patients with plica syndrome will settle successfully with conservative physiotherapy treatment within 6 to 8 weeks. (Lu et al 2010).

Your physiotherapy treatment will aim to:

Reduce pain and inflammation.

Improve patellofemoral (knee cap) alignment via taping, bracing and exercises.

Normalise your muscle lengths.

Strengthen your knee: esp quadriceps (esp VMO) starting with closed-chain exercises and eventually progressing to open-chain exercises

Strengthen your hip and lower limb muscles.

Address foot biomechanics issues.

Improve your proprioception, agility and balance.

Improve your lower limb function and quality of movement eg walking, running, squatting, hopping and landing.

Minimise your chance of re-aggravating your plica syndrome.

We strongly suggest that you discuss your knee injury after a thorough examination from a knee specialist such as a sports physiotherapist, sports physician or knee surgeon.

Plica Surgery

Should your symptoms persist beyond 3 to 6 months, arthroscopic knee surgery for a plica syndrome may be considered. The most successful surgery involves lateral retinacular release to allow the patella to track more medially and thereby alleviate plica irritation as it rolls over the medial femoral condyle. Success rates exceed 85%. (Gerbino et al 2007).

How to Prevent Plica Syndrome?

Since plica syndrome usually occurs concomitantly with other knee conditions, it is important to be proactive in managing your other knee injuries. This involves maintaining normal knee joint alignment, adequate strength and flexibility in the muscles around the knee joint plus the rest of the lower limb.

Ensuring that you wear adequate footwear that supports your foot biomechanics. Also, weight-management can play a role in the pressure exerted on lower limb joints, and thus should be something considered as a long-term preventative measure.

For more advice, please consult your physiotherapist.

Braces for Plica Irritation

Many patients will try a knee brace. Brace that improve patellofemoral joint alignment seem to be the most effective to ease plica-related pain.

Patellofemoral Brace

An effective patellofemoral brace can be useful as an alternative to kneecap taping.

Proteins Provide Amino Acid Building Blocks For Growth and Repair

Proteins are extremely important because they constitute the majority of the structural tissue in your body, such as bone and connective tissues that provide the shape and form to which your cells attach. Proteins are involved in just about every function in the body as well since enzymes are proteins, and enzymes are the molecules in the body that do much of the work, like building new tissue or removing damaged tissue. Proteins are also message carriers in your body, transporting hormones from one place to another, and transporting signals across your cell membranes to your DNA.

Your body is constantly making new proteins to replenish what's lost from tissue damage or to provide for growth. Enzymes are continually being produced anew to replace older, less functional enzymes. Therefore, to maintain optimal health, your body needs a continuous supply of the nutrients to support protein production.

Proteins are made up of smaller molecules called amino acids that are strung together by chemical bonds like beads on a chain. To become an active, functional protein, this string of amino acids folds in on itself forming a twisted and entwined, three-dimensional structure. An individual protein molecule can be as small as 200 to as large as 5,000 amino acids strung together.