- Osteoarthritis is a degenerative joint disease affecting cartilage that commonly occurs in weight-bearing joints like the knee. It can be primary with no underlying cause or secondary to other joint issues. - Symptoms include joint pain that worsens with use and improves with rest, morning stiffness, and crepitus. Conservative treatment focuses on lifestyle changes, physical therapy including exercises, bracing, and medications like acetaminophen, NSAIDs, or injections. Surgery is considered if conservative options provide insufficient relief.

1. OSTEOARTHRITIS – KNEE
PRESENTED BY:
• Dr Joe Antony
JR1
DEPT OF PMR
KGMU
MODERATOR:
• Dr Sanjai singh
Assisstant prof
DEPT OF PMR
KGMU
1

2. Contents
• Introduction
• Types
• Pathology
• Symptoms and signs
• Radiological approach
• Treatment
• Conservative
• Surgical
2

3. Introduction
• Definition- nonerosive, noninflammatory progressive disorder of the joints
leading to deterioration of the articular cartilage and new bone formation at
the joint surfaces and margins.
• Among the chronic rheumatic diseases, hip and knee osteoarthritis (OA) is
the most prevalent and is a leading cause of pain and disability in most
countries worldwide.
• Overall prevalence of knee OA was found to be 28.7% in india is
Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian
journal of orthopaedics. 2016 Oct;50(5):518-22. 3

4. Types of Osteoarthritis
1. Primary Osteoarthritis
• occurs in a joint de novo.
• It occurs in old age, mainly in the weight bearing joints (knee and hip).
• In a generalised variety, the trapezio-metacarpal joint of the thumb and the
distal inter-phalangeal joints of the fingers are also affected.
• Primary OA is commoner than secondary OA
2. Secondary Osteoarthritis
• there is an underlying primary disease of the joint which leads to
degeneration of the joint
4

5. 3. Diffuse idiopathic skeletal hyperostosis (DISH)
• Variant form of primary OA degenerative arthritis typically characterized by ossification of
spinal ligaments
• Osteophytes extending to the length of the spine leading to spinal fusion typically in the
thoracic or thoracolumbar spine.
• Commonly asymmetric with predilection for the right side of the thoracic spine.
• Hallmark - ossification spanning three or more intervertebral discs.
• Ossification of the anterior longitudinal ligament, separated from vertebral body by
radiolucent line.
5

6. DISH (contd)
• More prevalent in white males above the age of 60.
• Multisystem disorder associated with:
Diabetes mellitus (DM), obesity, hypertension, coronary artery disease
Stiffness in the morning or evening
Dysphagia if cervical involvement
NOT associated with sacroiliitis, apophyseal joint ankylosis, or HLA-B27 positivity
(distinguishes from ankylosing spondylitis)
6

7. Causes of secondary osteoarthritis knee
• Congenital maldevelopment
• Irregularity of the joint surfaces from previous trauma
• previous disease producing a damaged articular surface
• internal derangement , such as a loose body
• mal-alignment
• obesity and excessive weight.
7

8. Pathology
• Osteoarthritis is a degenerative condition primarily affecting the articular
cartilage.
• The first change - increase in water content and depletion of proteoglycans from
the cartilage matrix.
• Repeated weight bearing on such a cartilage leads to its fibrillation.
• cartilage gets abraded by the grinding mechanism at work at the points of contact
between apposing articular surfaces, until eventually underlying bone is exposed.
• With further ‘rubbing’, subchondral bone becomes hard and glossy (eburnated).
• Meanwhile, the bone at the margins of joint hypertrophies to form a rim of
projecting spurs known as osteophytes.
• similar mechanism results in the formation of subchondral cysts and sclerosis
8

9. 9

10. Symptoms
• Dull aching pain increased with activity, relieved by rest.
• Later pain occurs at rest.
• Joint stiffness for <30 minutes; becomes worse as the day goes on.
• Joint giving away.
• Articular gelling- stiffness after immobility lasting short periods and dissipating after brief period of
movement.
• Crepitus on ROM.
• Deformities in later stages
10

11. Signs
• Mono- or pauciarticular; shows no obvious joint pattern.
• Localized tenderness of joints.
• Pain and crepitus of involved joints.
• Enlargement of the joint - changes in the cartilage and bone secondary to proliferation of synovial
fluid and synovitis.
11

12. Radiological approach to OA
Melnic CM, Gordon J, Courtney PM, Sheth NP. A Systematic Approach to Evaluating Knee
Radiographs with a Focus on Osteoarthritis. J Orthopedics Rheumatol. 2014;2(1): 6.
12

13. Recommended views
1) weight bearing anteroposterior 2) weight bearing 45 degree
posteroanterior (PA) (Rosenberg view)
Melnic CM, Gordon J, Courtney PM, Sheth NP. A Systematic Approach to Evaluating
Knee Radiographs with a Focus on Osteoarthritis. J Orthopedics Rheumatol. 2014;2(1):
13

14. 3) The lateral view 4) Merchant view
14

15. Kellgren-Lawrence (K&L) grading scale
• Grade 0 - indicates no radiographic evidence of OA.
• Grade 1- Osteophytes are present
• Grade 2- Joint space loss .
• Grade 3- Subchondral sclerosis,
• grade 4- More severe joint space narrowing and sclerosis with bony deformity.
Delisa physical medicine and rehabilitation 15

17. OUTLINE OF TREATMENT OF OA KNEE
17
OA KNEE
TREATMENT
CONSERVATIVE
NON
PHARMACOLOGICAL
LIFESTYLE
MODIFICATION
PHYSICAL
MODALITIES
PHYSICAL THERAPY
STRENGTHENING
STRETCHING
PROPIOCEPTION
JOINT PROTECTION
TECHNIQUE
AEROBIC
CONDITIONING AND
AQUATIC THERAPY
ORTHOTICS
ASSISTIVE DEVICES
OCCUPATIONAL
THERAPY
PHARMACOLOGICAL
SURGICAL

18. Non pharmacological management
• Initial counseling should include a discussion of the etiology,
natural history, and prognosis of OA
• In the home,
• raised toilet seats,
• grab rails,
• walk-in showers,
• higher seating surfaces
• Ramps instead of steps
18

19. Weight loss
• Weight loss is recommended for all individuals who are overweight or obese,
• Those with a healthy body weight should be encouraged to maintain their weight.
• Weight loss has been shown to improve pain and disability related to OA.
• Some may require referral to a nutritionist or weight loss clinic for assistance.
• Most effective nonpharmacologic weight loss interventions combine
• Fat and caloric restriction,
• Increased physical activity,
• Behavioral reinforcement,
• Extended weight maintenance program, with support from the physician and weight-loss support
groups
19

20. Physical therapy
• An individualized program is important for
adherence to and maintenance of an
exercise program.
• Low-impact exercises are often better
tolerated as well as shorter bouts of
exercise.
20
PHYSICAL THERAPY
STRENGTHENING
STRETCHING
PROPIOCEPTION
JOINT PROTECTION
TECHNIQUE
AEROBIC
CONDITIONING AND
AQUATIC THERAPY

21. STRETCHING EXERCISES
• Knee OA classically involves extension lag, but flexion may also be limited.
• The pathophysiology of ROM deficits is probably multifactorial, including
articular changes within the joint as well as shortening of myotendinous
structures in areas of pain and/ or weakness.
• Decreased ROM is often found not only at the OA joint but also at other
joints within the same lower limb and even in the contralateral lower limb.
• When muscles are shorter than their ideal length, they are at a
biomechanical disadvantage when they are required to generate force.
• Thus, a stretching program to address inflexibilities should probably be
incorporated early in an exercise program for OA patients.
21

22. STRETCHING PROGRAM- FLEXIBILITY
PROGRAM
GENTLE ROM
EXERCISES
STRETCING TO
REVERSE SOME
OF LOST ROM
• Slow, gentle, and sustained
stretching.
• Sustained stretching generally
involves holding the stretch for
at least 20 to 40 seconds, and
perhaps longer, before relaxing
and then repeating the stretch.
• Sudden, jerky or ballistic
stretching should be avoided
since it may cause exacerbation
of the OA
22

23. STRENGTHENING EXERCISES
• Quadriceps weakness is a better indicator of functional limitation
than pain
• Preferred strengthening technique in OA knee
• Closed chain kinetic exercises
• Initially- Isometric
• Benefits limited
• Goal- isotonic exercise in pain free ROM of mixed program of closed and open
chain exercises
23

24. Balance and proprioceptive training
• If lower extremity proprioception is suboptimal, the force of impact
transmitted up to the hip and knee will be increased during weight-
bearing activities
• Repetitively, such forces may promote progression of OA and the
associated symptoms.
• Hence , propioception and balance training must be included in OA
knee Physical therapy program
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25. Joint protection
• Joint protection is one goal of exercise in a patient with OA.
• Flexibility, strength, and proprioception are optimized in hopes of
reducing joint stresses, decreasing shock impacts to the joint, and
maximizing joint movement and alignment.
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26. Aerobic conditioning and aquatic therapy
• Aerobic exercise for OA patients commonly includes a daily walking
program since physical activity levels are often reduced.
• Using the guideline of 30 minutes of accumulated of moderate activity on
most days is an excellent goal for those patients whose lifestyles are
sedentary
• Aquatic therapy
• increased sensory input, relaxation from warm water, and decreased joint
compression often allow individuals to move with less significant pain.
26

27. Modalities
• Heat – hydrotherapy , hydrocollator packs, Pulse diathermy
• Improve myotendinous flexibility, help in stretching and flexibility, there by improve pain
also
• Cold- Ice packs/massage
• Improved muscle strength and ROM or decreased swelling, good analgesia
• Electrical- high-intensity burst modes and acupuncture-like
transcutaneous electrical nerve stimulation (TENS)-
• Especially in acute exacerbation
• No evidence for use of routine use of electrical stimulation,
iontophoresis, or ultrasound in OA
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28. Orthotics
• Pain relief and joint protection via structural support and realignment
are principle benefits that can be realized by the OA patient from the
use of orthotic devices.
• Pain reduction is achieved by,
• supporting the affected joint,
• reducing the muscular force needed to stabilize the joint,
• redirecting axial loads, which lead to intra-articular bone-on-bone force
28

29. • Canadian Arthritis Research Symposium—University of British
Columbia knee orthosis (CARS UBC)- 1975
• comprised of plastic thigh and calf shells,
• utilized universal hinges
• a telescoping tube assembly,
• a waistband for suspension.
29

30. Unloading braces
• bracing for medial compartment gonarthrosis currently involves
application of a three-point force system across the coronal plane of
the knee joint
• valgus bracing that “unloads” the medial compartment
30

31. • a simple knee sleeve for those patients who present with mild OA-
related knee pain but without any significant angular deformity
• No structural advantage
• Improvement in proprioception- pain relief
31

32. Foot orthotics
• Knee varus/ medial compartment involvement
• lateral wedge heel &sole insole or sole rise
• Knee valgus/ lateral compartment involvement
• Medial wedge heel &sole insole or sole rise
• Viscoelastic shoe inserts provide shock absorption at the knee and
provide pain relief
32

33. Orthotics in patello femoral OA
• neoprene-sleeve patellar stabilizing brace consists of a patellar cutout
and force inducing buttress pads around the inferior and lateral
aspects of the patella.
• The brace has two circumferentially wrapped rubber straps that apply
dynamic tension to a crescent-shaped lateral patellar pad
33

34. Assistive devices
• Utilizing a cane in the contralateral hand can reduce pain and improve function in
hip and knee OA.
• For those concerned about the appearance of a cane, a good alternative is a
walking stick.
• If there is not sufficient joint offloading with a cane or in the presence of bilateral
OA, a walker can be used.
34

35. Pharmacological
management
European Society for Clinical and
Economic Aspects of Osteoporosis and
Osteoarthritis (ESCEO) algorithm for the
management of knee osteoarthritis
35

36. • The medications most commonly used to reduce OA pain include acetaminophen
and NSAIDs
• Commonly recommended analgesic medications are not intended for long-term
use and have the potential for negative health effects with prolonged use.
• Patients should be encouraged to take the medications on an as needed basis
rather than scheduled.
• An individual’s medical comorbidities must also be taken into account when
determining the most appropriate treatments.
• If a medication is ineffective, an alternative medication should be trialed;
• if it is partially effective, a second medication can be added.
36

37. Summary of drugs used in symptomatic OA
knee
• Acetaminophen- First line drug
• NSAIDS
• Weak opiods
• Adjuants
• SSRIs, SNRIs- Duloxetine
• Steriods
• Anti epileptics- BZDs
37

38. Acetaminophen (paracetamol)
• Most guidelines recommend acetaminophen (paracetamol) as first-line therapy for managing
pain related to OA.
• However, recent reviews have raised concerns about the efficacy and safety of acetaminophen
with potential risk for gastrointestinal (GI), hepatic, and cardiovascular (CV) adverse effects
• It remains a good option for analgesia when used within new dosing guidelines of up to 3 g/d on
an as needed basis.
38

39. Non steroidal anti inflammatory drugs
• NSAIDs are available in both oral and topical formulations.
• Diclofenac is the only CDC approved topical NSAID
• While the various NSAIDs have been shown to provide equivalent benefit, some
individuals may benefit more from one NSAID compared to others.
• Therefore, if one is ineffective, others can be considered.
39

40. • NSAIDs carry risk of GI, CV, and renal adverse effects.
• Topical NSAIDs have little systemic absorption and therefore less GI and CV risk
compared to oral formulations .
• However, they have limited penetration and therefore cannot be used for deeper joints
such as the hip; but they can be used for the knee, ankle, and foot.
• The guidelines differ with regard to their recommendations for NSAIDs; several
recommend topical NSAIDs over oral NSAIDs due to their improved safety profile,
whereas others do not differentiate between the two.
• Oral NSAIDs should be avoided in individuals with known CV disease or GI ulcer or
bleeding if possible
40

41. Other analgesics
• When there is insufficient pain relief with acetaminophen or NSAIDs, or those medications
cannot be used due to contraindications, tramadol or opioids can be considered.
• These medications can be used in combination with acetaminophen or NSAIDs for
synergistic effect.
• Caution must be used when prescribing opioids given risk for possible serious adverse
events.
• Lastly, recent studies of duloxetine, a serotonin and norepinephrine reuptake inhibitor
(SNRI), have shown benefit for chronic pain related to OA.
41

42. Nutraceuticals
• Glucosamine and chondroitin, normal components of the extracellular matrix of articular
cartilage, are available as supplements, but the evidence supporting their benefit for pain
relief and slowing disease progression is poor.
• In studies that have shown more benefit, the study medications were prescription-grade
crystalline glucosamine sulfate and chondroitin sulfate .
• The published guidelines vary from recommending glucosamine and chondroitin as first-
line treatment to stating that there is either uncertain or no benefit.
• Overall, these supplements are safe and well tolerated and can be considered for a 3- to
6- month trial and continued long term if beneficial.
42

43. Injectables
• In addition to oral and topical medications, there are injectable medications utilized in the
setting of OA. The primary medications are corticosteroids and HA, a component of
synovial fluid and cartilage.
• Corticosteroids are anti-inflammatories and have generally shown benefit for short-term
pain relief in the hips, knees, ankles, and feet.
• Most guidelines recommend use of intra-articular steroids for flares of pain or when other
treatments have not provided sufficient pain relief. Injections can be performed up to four
times per year.
43

44. • HA is approved as a biologic for use in the knees only.
• HA has limited evidence for efficacy, and many of the guidelines now do
not recommend the use of HA.
• If used and the patient has good relief of symptoms, injections can be
repeated every 6 months
44

45. • Studies are being conducted on use of PRP, Autologous blood and stem cells for
OA, but there is not enough evidence at this time to recommend for or against
the use of these treatments.
• PRP- stimulates cell proliferation and superficial zone protein secretion by
articular cartilage and synovium of the human knee joint
45

46. Prolotherapy
• Mechanism of action
• Stimulate low grade inflammation
• Activates fibroblast
• Secondary GFs produced locally
• Connective tissue repair and mature collagen deposit in articular cartilage
46

47. Solutions used
• Hypertonic dextrose- 12.5%, 15%, 25%
• Safest solution
• Create osmotic gradient- dessicate local connective tissue- injury &
inflammatory cascade- cell fluid dilute dextrose- inflammation ceases itself
• Local anesthetic- lidocaine,procaine
• Saline based solutions ( instead of dextrose)
• Non inflammatory dextrose ( <10 percentage)
• Phenol containing solutions- P2G ( phenol glycerine and dextrose)
47

48. Genicular nerves- LA block or radiofrequency
ablation
• Indicated for pain management when
• Patient is awaiting for surgical fitness
• Peri op pain management
• Bed ridden patients for palliation
• Nerves blocked- inferior medial, superior medial, superior lateral
genicular nerves
• Inferior lateral genicular nerve is avoided- Due to proximity to
Common peroneal nerve
48

49. Surgical treatments
• When nonoperative treatments have failed and the patient has pain that is limiting function and
producing a negative impact on quality of life, surgery can be considered.
• The primary surgery for OA is joint arthroplasty.
• In loose bodies , joint arthroscopy can be performed.
• Additionally, in individuals with mechanical symptoms of joint locking or instability in the setting of a
meniscus tear with OA, arthroscopy can be considered.
• However, in the absence of mechanical symptoms, arthroscopy is not generally recommended as it
does not have a positive long-term benefit.
• Lastly, arthroscopy is not recommended solely for the treatment of OA
49

50. • Total knee replacement is the final treatment option for OA knee
• Then, Post Knee replacement rehabilitation
50

51. Thank you
• References
• Braddoms 6th edition
• Delisas physical medicine and rehabilitaion
• Essentials of orthopedics- Maheswari
• European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis
(ESCEO) algorithm for the management of knee osteoarthritis
• A Systematic Approach to Evaluating Knee Radiographs with a Focus on Osteoarthritis-
Christopher M Melnic
• Genicular Nerve Blocks- NYSORA
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