Osteoarthritis Case Study

Osteoarthritis is a leading cause of disability in older adults in the United States.^1-3Approximately 33% of American adults report some kind of arthritis or chronic joint symptoms.³ The incidence increases with age and is higher in women than in men.³

More than 5 million adults report having osteoarthritis in a knee joint, with pain, swelling, and stiffness, and >75% of these people are women.^4-7 In 1999, osteoarthritis of the knee accounted for nearly 4 million physician office visits, > 150,000 hospital outpatient visits, and >400,000 hospital inpatient stays.⁴Approximately half of the inpatient stays were for primary total knee replacement surgery.⁴

Osteoarthritis of the knee has a tremendous impact on a person’s ability to function and to perform everyday activities. Between 25% and 50% of people with osteoarthritis of the knee experience — at best — significant difficulty with walking, carrying items, or stooping, while 20% either cannot perform or have difficulty performing chores around the house.⁴ This disease takes a severe emotional toll on its victims, as well. People with osteoarthritis of the knee report higher degrees of emotional distress than those without it, and many consider themselves as having poor or fair health.⁴ Patients with osteoarthritis lose more work than their healthy colleagues and spend more time confined to bed.⁴

Patients can now be treated with an array of nonpharmacologic, pharmacologic, and surgical interventions. The following report summarizes a case presented at a sports medicine clinic in New York, illustrating the importance of individualizing treatment based on the age of the patient, the level of symptoms, risk factors and comorbidities, and impact on quality of life.

Case Presentation

Mrs Jones (not her real name), 55 years old, came to a musculoskeletal specialist seeking advice for a 3-year history of progressively worsening pain in both knees. Her knees were stiff for about 20 minutes when she arose in the morning and for a few minutes after getting up from a chair during the day. She had difficulty walking > 30 minutes because of pain, and her symptoms were exacerbated by kneeling, squatting, or descending stairs. Although sitting, resting, and reclining relieved her pain, she became stiff if she stayed in one position for too long. Her symptoms were worse on humid or cold days, and she occasionally felt as if one of her knees would “give out.”

Mrs Jones was slightly obese, and physical examination of the lower extremities revealed mild genu varum, which suggested medial compartment involvement. Her gait was mildly antalgic, and passive range of motion of both knees indicated palpable crepitus. She was unable to flex or extend her knees completely. While a physically active osteoarthritis patient commonly has a maximum flexion < 130° (compared with a normal maximum flexion of 140° to 150°), this patient’s was < 120°. In addition, in patients with severe osteoarthritis, it is not uncommon to have a partial (<'10°) loss of extension. Mrs Jones had 8° loss of extension.

Patellar facet tenderness was determined by palpation. There was tenderness over the joint line and patellofemoral crepitus, which is common in patients with osteoarthritis of the knee. There was moderate warmth and soft-tissue swelling. Patellar tilt was determined clinically and, with the knee in full extension, patellar glide was measured by assessing how far the patella translated medially and laterally. Mrs Jones exhibited moderately severe decreased patellar glide both medially and laterally.

Knee stability was determined in the coronal (varus/valgus) and sagittal (anteroposterior) planes. Patients with medial inflammation and a varus deformity commonly have medial pseudolaxity, which is a sensation of valgus laxity as the varus deformity is manually corrected with the patient supine and the leg extended. As expected, Mrs Jones presented with medial pseudolaxity with mild instability. In addition, patients may have increased tibial translation on both Lachman’s testing and anterior drawer testing, and a positive pivot shift maneuver, indicating a chronic anterior cruciate ligament insufficiency, which can lead to osteoarthritis. However, the examination indicated that this patient had none of these findings.

Examination of Mrs Jones’s hands revealed enlargement of some of the proximal interphalangeal joints (Bouchard’s nodes) and some of the distal interphalangeal joints (Heberden’s nodes). There was a squaring at the bases of both thumbs at the carpometacarpal joints. The feet demonstrated similar deformities, with enlargement and reduced dorsiflexion of the first metatarsophalangeal joints. Upon further questioning, the patient admitted experiencing occasional pain and stiffness in these joints.

Because of the prevalence of atherosclerosis in the older population, a thorough neurovascular examination was performed on this patient. Her distal pulses were intact, as was sensation, and there was no evidence of cyanosis, clubbing, or edema. The examination showed no signs of neurovascular compromise. Had any of these findings been evident, a complete vascular workup would have been obtained, including blood work, to look for indications of a hypercoaguable state. If either neurovascular compromise or evidence of coronary artery disease had been found, then the risk-benefit ratio of prescribing a cyclooxygenase (COX)-2 inhibitor would have been weighed.

Mrs Jones’s hip and back were examined thoroughly, as well, to rule out any contribution to the knee symptoms. She had full range of motion (ROM) of the lumbosacral, and all motions were pain free. Her hip examination showed decreased internal ROM, but motions were pain free and symmetric. These findings indicate that neither hips nor back was contributing to this patient’s symptoms. However, she had a leg length discrepancy, with her right leg being 0.5 cm shorter than her left. Leg length discrepancy can contribute to a patient’s symptoms and affect the treatment plan.

In cases where such a discrepancy is contributing to a patient’s symptoms, both surgical and nonsurgical interventions can be considered. With Mrs Jones, the difference was < 5 cm, so correction was not necessary. Radiographs showed osteophytes, joint space narrowing, and subchondral bone sclerosis in both of her knees.

Treatment: Nonpharmacologic Interventions
Mrs Jones had moderate bilateral knee osteoarthritis. She was given educational material regarding her condition and informed of further resources, including the Internet and the Arthritis Foundation. The specialist discussed with Mrs Jones various pharmacologic and nonpharmacologic treatment options and lifestyle modifications that may result in better control of her osteoarthritis pain and increase her ability to function.

She was advised that weight loss has been shown to decrease joint stress and pain and to improve ability to exercise.^8,9 Data have shown that a 12-lb weight loss can decrease the chance of developing osteoarthritis in women by 50%. In addition, Mrs Jones was cautioned to avoid high-impact activities like running and jumping, and encouraged to take up low-impact activities such as swimming and bicycling, which have been proven most beneficial for the arthritic knee.

Because she had significant patello-femoral disease, she was counseled to avoid activities that load the patellofemoral joint, such as squatting and ascending and descending stairs. The importance of maintaining a regular exercise program to maximize aerobic conditioning and increase caloric expenditure was stressed. It has been demonstrated that supervised walking programs increase functional status without increasing symptoms.¹⁰

Physical therapy. A program of physical therapy was recommended, with the goal of increasing ROM and flexibility, especially in the hamstrings. Muscle strength training for both quadriceps and hamstrings was suggested, as was proprioceptive retraining. The importance of stretching all major muscle groups that cross the joint to maintain range of motion was stressed. Tight hamstrings in particular can exacerbate knee pain, and Mrs Jones showed evidence of this. She was advised to strengthen her quadriceps, as weak quadriceps correlate with pain severity in osteoarthritis,¹¹ and there is evidence that quadricep strengthening improves functioning and knee pain.^12-14

Quadricep sets and isometric strengthening exercise, such as straight-leg raises, were recommended as an initial program. She was advised that, as her strength improved, she should try closed-kinetic-chain strengthening of both quadriceps and hamstrings. This exercise leads to the co-contraction of the hamstrings and quadricep muscles, which results in decreases in patellofemoral joint forces, anterior cruciate ligament strain, and tibial translation. Proprioceptive retraining was prescribed as well, as this can decrease joint stress, and Mrs Jones was encouraged to use a knee sleeve during physical therapy to help her regain a sense of stability. Patellar taping was recommended as well, as this may reduce patellar facet impact on the femoral condyle.

Although Mrs Jones had been active several years prior to her visit to our clinic, her symptoms had increased in both intensity and frequency in recent years, which limited her activity. Therefore, she was advised to implement this exercise program gradually, as increasing the intensity of the program too quickly can exacerbate symptoms in osteoarthritis patients.

Bracing. A knee unloader brace was prescribed to relieve some of Mrs Jones’s symptoms. Knee bracing has been found to provide significant pain relief.^15,16 In a trial of 20 patients with severe medial osteoarthritis of the knee, 19 experienced significant pain relief, and quadriceps muscle strength increased in 17 patients, declined in 2, and remained the same in 1.¹⁵

Another trial, in which 119 patients with varus gonarthrosis were randomized to an unloader brace, a neoprene sleeve, or standard medical treatment (control group), found that patients benefited significantly from the use of a knee brace in addition to standard medical treatment.¹⁶ At the 6-month evaluation, patients assigned to the unloader brace group had significantly less pain than those in the neoprene-sleeve group after both the 6-minute walking test and the 30-second stair-climbing test, although both the neoprene sleeve and the unloader brace were associated with significant improvement in quality of life and function compared with the control group.¹⁶

Occupational therapy. Although Mrs Jones was retired, she enjoyed a number of recreational activities, and her osteoarthritis symptoms were interfering with her ability to participate in them. She attended occupational therapy for training in activities of daily life. Such training can help patients by providing an individual functional assessment and joint protective strategies to be used during activities of daily life.¹⁷ Energy conservation and joint protection principles and stress management techniques are taught so that fatigue can be minimized and pain and stress on joints reduced, with the goal of increasing performance of activities of daily life and preventing loss of function.¹⁷

The use of adaptive equipment and alternative methods may enable patients to carry out daily tasks. For instance, simple placement of grab rails by the bathtub and raising the toilet seat may dramatically improve the home environment for patients with osteoarthritis and promote independent functioning, allowing patients to take care of their personal hygiene.¹⁷ A raised toilet seat decreases the required range of motion and force placed on the hip and knee joints.¹⁷ The use of ice or heat before exercise may alleviate pain and thus encourage activity.¹⁷

Treatment: Pharmacologic Therapy
Mrs Jones was started on 325 mg of acetaminophen three times a day, but it did not alleviate her pain. Six weeks later, she was switched to 500 mg of naproxen twice a day, which improved her symptoms by about 50%. Tramadol, one to two 50-mg tablets every 6 hours as needed, was prescribed for breakthrough pain, and a proton pump inhibitor was added to the regimen to prevent gastric discomfort. Mrs Jones’s symptoms also improved with physiotherapy.

However, over the next several years her symptoms worsened, and she was given a narcotic to take for episodes of severe pain. After experiencing a severe effusion to her right knee with an inflammatory component, Mrs Jones opted to have intra-articular steroid injections. She received 3 injections spaced about 3 months apart and, each time, this provided about 3 months of relief. However, when the pain returned following the third injection, she elected to have hyaluronic acid G-F 20 injections. The first treatment was given in a series of 3 injections. Viscosupplementation with hyaluronic acid provided 18 months of relief, and the patient opted to repeat the hyaluronic acid injections when the symptoms returned.

Discussion

Mrs Jones responded well to the management program. She lost 15 lb initially and managed to maintain her new weight. The prescribed exercise program proved successful, and she gained strength in her quadriceps as well as functional ROM, while her overall pain decreased. Mrs Jones initially responded to the nonsteroidal anti-inflammatory drugs (NSAIDs). However, because of the side effects including peptic ulcer associated with these agents, we recommend that patients be prescribed the lowest effective dose, take the drug with food, and use it for the shortest time possible. We usually start a patient on an over-the-counter agent, such as ibuprofen. Selective COX-2 inhibitors should be used only in patients with renal or gastrointestinal risk factors.

As Mrs Jones’s condition deteriorated, painkillers were no longer enough to control her symptoms, and we used an intra-articular corticosteroid injection. We find this helpful for patients who no longer respond to NSAIDs and in those for whom NSAIDs are contraindicated. We do not usually aspirate the knee unless there is a tense effusion present. If aspiration is necessary, however, then the fluid is sent for the appropriate studies. If there are no signs of hemarthrosis or infection, the knee joint can be injected with corticosteroid. In patients without an effusion, a cortisone injection may be indicated if there are signs of inflammation such as synovial thickening, nocturnal or diffuse pain, or pain that is felt when the patient is at rest. Localized knee pain that is felt only with weight bearing is less likely to respond to cortisone injection. The solution — 1% lidocaine (3 mL) and triamcinolone (40 mg), or betamethasone sodium phosphate (6 mg) — is injected into the anterolateral soft spot under sterile conditions.

We have found the duration of the effects of this injection to be variable, lasting from a few days to >6 months. In Mrs Jones’s case, the effects lasted 3 months. As the injections are less effective with each successive course, we limit corticosteroid injections to 3 or 4 treatments a year. After the initial injection, we considered viscosupplementation in this patient.

Although surgical interventions including a tibial osteotomy and a total knee replacement were discussed when Mrs Jones’s condition worsened, the patient elected to pursue the more conservative course with viscosupplementation. Viscosupplementation may postpone the need for surgical intervention, and studies have suggested that it may delay structural progression of the disease. Injections provide relief for 6 months to 1 year and can be repeated every 4 to 6 months.

Mrs Jones is still receiving conservative care and is doing well. She is able to participate in recreational activities and continues with a strengthening program. The conservative interventions have allowed her to go back to her hobbies, including gardening, golfing, and shopping, with minimal side effects. She continues to take tramadol intermittently for breakthrough pain, but she takes an NSAID along with a proton pump inhibitor only for flareups. Her use of pain medication, including both opioids and NSAIDs, has decreased significantly since she received viscosupplementation.

Conservative management. This patient’s case illustrates how a conservative management strategy can help maintain patient functioning and quality of life while minimizing side effects and avoiding major surgical trauma to the patient.

Tibial osteotomy is an option for patients such as Mrs Jones, who have varus angulation < 10° and stable ligamentous support, and it can reduce symptoms and stimulate formation of a new articular surface.⁴ However, after discussing this intervention with the musculoskeletal specialist, Mrs Jones decided not to pursue it. With surgery there is always some risk of infection or complication from anesthesia, as well as risk of blood clots, nerve damage, or circulatory problems.⁴ Furthermore, it is highly probable that a total knee replacement would be needed at some time in the future, as long-term follow-up of patients treated in this manner indicates that clinical results deteriorate over time.⁴ Previous tibial osteotomy makes knee replacement more technically challenging.⁴

Although surgical procedures remain an option for this patient should the situation deteriorate, by postponing or avoiding surgery in a relatively young patient such as Mrs Jones, the need for multiple knee replacements may be averted. The lifespan of a total knee replacement is not known, but it is believed that as the surgery is performed in younger people, an increasing number of these patients may live long enough to see the failure of their knee prostheses.⁴ Performing such surgery in middle-aged patients increases the likelihood that it will have to be repeated, with all the costs and risks inherent to major surgery.

Mrs Jones’s response to viscosupplementation was excellent. She achieved 18 months of relief from her symptoms and was able to reduce the use of both NSAIDs and breakthrough medication by about 75% during this time. She still takes it, but intermittently.

Although the medical community generally considers NSAIDs safe, more than 16,500 Americans die and 103,000 are hospitalized each year as the result of anti-inflammatory drug use.¹⁸ In contrast, use of viscosupplementation is associated with a low incidence of local adverse events, which consist of local inflammation and effusion.¹⁹ Adverse events typically occur within 48 hours of injection and rarely after the first injection of a first course of therapy, and usually resolve spontaneously or respond well to conservative symptomatic treatment.^19,20

To avoid such reactions, patients are told to rest and apply an ice pack for 2 to 3 hours after the injection and avoid strenuous activities until after the course of therapy is completed.¹⁹ Mrs Jones was instructed to apply the ice pack and avoid strenuous activity and did not experience any injection reaction during either of her treatment courses.

Although a first course of viscosupplementation provides relief from pain for up to 6 months in patients with osteoarthritis, a second course also has been shown to reduce pain significantly and improve physical functioning for up to 6 months.²⁰ Mrs Jones’s experience with viscosupplementation is similar to that found in a recent clinical trial in 71 patients, where the mean interval between first- and second-course treatments was >18 months.²⁰ Other studies have shown that deterioration in structural parameters is less in the group using viscosupplementation than in control groups.²¹

Conclusion

The pain and disability associated with osteoarthritis have a serious impact on the lives of patients, yet conservative treatment in many patients can reduce pain, improve performance, and forestall invasive surgical procedures. A management strategy combining nonpharmacologic treatments such as strength training, appropriate exercise, weight loss, orthotics, and physical therapy with pain medication can be successful in many patients.

When disease progression demands more aggressive treatment, the use of techniques such as viscosupplementation may obviate surgical procedures and achieve good clinical results, allowing patients to return to their everyday activities and more productive lives. It is essential, however, to determine treatment strategies based on individual patient characteristics such as age, comorbidities, symptoms, and risk factors for other diseases. In this way, we can maximize our patients’ quality of life while ensuring that they receive the best possible care.

References

Gelber AC, Hochberg MC, Mead LA, Wang N-Y, Wigley FM. Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med. 2000; 133:321-328.
Yelin EH, Felts WR. A summary of the impact of musculoskeletal conditions in the United States. Arthritis Rheum. 1990; 33:750-755.
Centers for Disease Control. Prevalence of arthritis-United States, 1997. MMWR. 2001; 50:334-336.
American Academy of Orthopaedic Surgeons. Osteoarthritis of the knee fact sheets. Avail-able at: http://www3.aaos.org/research/imca/OakneeContents/osteoarthritis_knee_m2_2.htm. Accessed September 22, 2004.
Behavioral Risk Factor Surveillance System (2000). National Center for Health Statistics. Osteoarthritis (unspecified) Group.
National Health and Nutrition Examination Survey III-Adult (1988-1994). National Center for Health Statistics. Osteoarthritis of the Knee Group.
National Health Interview Survey-Sample Adult (1999). National Center for Health Statistics. Osteoarthritis of the Knee Group.
Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med. 1992; 116:535-539.
Toda Y, Toda T, Takemura S, Wada T, Morimoto T, Ogawa R. Change in body fat, but not body weight or metabolic correlates of obesity, is related to symptomatic relief of obese patients with knee osteoarthritis after a weight control program. J Rheumatol. 1998; 25:2181-2186.
Kovar PA, Allegrante JP, MacKenzie CR, Peterson MG, Gutin B, Charlson ME. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized controlled trial. Ann Intern Med. 1992; 116:529-534.
Felson DT. Nonmedicinal therapies for osteoarthritis. Bull Rheum Dis. 1998; 47:5-7
Gur H, Cakin N, Akova B, Okay E, Kucukoglu S. Concentric versus combined concentric-eccentric isokinetic training: effects on functional capacity and symptoms in patients with osteoarthrosis of the knee. Arch Phys Med Rehabil. 2002; 83:308-316.
Rogind H, Bibow-Nielsen B, Jensen B, Moller HC, Frimodt-Moller H, Bliddal H. The effects of a physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil. 1998; 79:1421-1427.
Jan MH, Lai JS, Tsauo JY, Lien IN. Isokinetic study of muscle strength in osteoarthritis knees of females. J Formos Med Assoc. 1990; 89:873-879.
Matsuno H, Kadowaki KM, Tsuji H. Generation II knee bracing for severe medial compartment osteoarthritis of the the knee. Arch Phys Med Rehabil. 1997; 78:745-749.
Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am. 1999; 81:539-548.
Clark BM. Rheumatology: 9. Physical and occupational therapy in the management of arthritis. CMAJ. 2000; 163:999-1005.
Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999; 340:1888-1899.
Waddell DD. The tolerability of viscosupplementation: low incidence and clinical management of local adverse events. Curr Med Res Opin. 2003; 19:P1-P6.
Waddell DD, Cefalu CA, DeWayne CB. An open-label study of a second course of hylan G-F 20 for the treatment of pain associated wit knee osteoarthritis. Curr Med Res Opin. 2003; 19:499-507.
Listrat V, Ayral X, Patarnello F, Bonvarlet JP, Simonnet J, Amor B, Dougados M. Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee. Osteoarthritis Cartilage. 1997; 5:153-160.

Authors

From the Hospital for Special Surgery, New York, NY