Osteoarthritis

History Taking

Chief Complaint:

• Patient complains of joint pain and stiffness, particularly in the knees, hips, or small joints of the hand.

• Patient may report joint pain that gets worse with activity and improves with rest.

• Patient may express concerns about decreasing mobility and difficulty with tasks of daily living.

History of Presenting Complaint:

• Pain is often described as a deep, "grating" pain, and patients may note that it worsens with weight-bearing activities.

• Patient may describe morning stiffness lasting less than 30 minutes.

• The patient might describe gradual onset of symptoms over years.

• Patient may report no apparent injury or trauma to the affected joints.

• The patient may report "cracking" or "creaking" sounds (crepitus) with joint movement.

• Patient may report joint swelling or warmth.

System Review:

• Musculoskeletal: Patient may report pain or stiffness in multiple joints, decreased range of motion.

• Neurological: Patient may report numbness or tingling if osteoarthritis affects the spine and compresses nerves.

Past Medical History:

• Patient might have a history of joint injuries or repetitive strain on the joints (e.g., due to certain sports or occupations).

• History of other conditions that may lead to secondary osteoarthritis, such as gout, rheumatoid arthritis, or septic arthritis.

• Obesity, as it places extra strain on weight-bearing joints.

Past Surgical History:

• History of joint surgery, such as meniscus repair in the knee or shoulder arthroscopy, which can increase the risk of osteoarthritis in the joint.

Drug History:

• Over-the-counter pain relievers such as acetaminophen (paracetamol) or NSAIDs for joint pain, which can hint at a self-management attempt.

• Use of dietary supplements for joint health, such as glucosamine or chondroitin.

Family History:

• Family history of osteoarthritis or other degenerative joint diseases, as osteoarthritis can have a genetic component.

• Family history of genetic disorders that affect the joints, such as Ehlers-Danlos syndrome or Stickler syndrome.

Social History:

• Occupation involving repetitive joint use or high-impact activities (e.g., construction worker, professional athlete).

• Sedentary lifestyle, which can contribute to obesity and weak musculature, both risk factors for osteoarthritis.

• Tobacco use, which is associated with a higher risk of osteoarthritis.

• Alcohol consumption history as excessive use can be associated with higher risk of osteoarthritis.

Personal History:

• Personal habits related to physical activity and diet, as these can impact weight and overall joint health.

• Non-compliance with prescribed exercises or physical therapy for joint health.

Physical Examination

General Examination:

• Reduced body mass index (BMI) or muscle wasting may indicate chronic illness or reduced activity due to pain.

• An obese physique, as obesity is a risk factor for osteoarthritis.

Examination of Hands and Arms:

• Bony enlargements of the distal interphalangeal joints (Heberden's nodes) or proximal interphalangeal joints (Bouchard's nodes).

• Crepitus (a grinding noise or sensation) may be detected on joint movement.

• Limited range of motion or deformities of the affected joints.

• Tenderness on palpation of the affected joints.

Cardiac Examination:

• Generally not relevant unless there are specific complaints, comorbid conditions, or medications with potential cardiac side effects.

Respiratory Examination:

• Generally not relevant unless there are specific complaints, comorbid conditions, or medications with potential respiratory side effects.

Abdominal Examination:

• Generally not relevant unless there are specific complaints, comorbid conditions, or medications with potential gastrointestinal side effects.

Neurological Examination:

• General assessment of reflexes and sensation should be normal unless osteoarthritis is severe enough to impinge on nerves (as may occur in the spine).

Additional Examination (if required):

• Examination of the lower limbs for signs of osteoarthritis, including swelling, crepitus, joint line tenderness, and reduced range of motion.

• Gait analysis may show an antalgic gait (a gait that develops as a way to avoid pain while walking) if the knee, hip, or ankle joints are affected.

• Assessment of the spine for reduced flexibility, tenderness, or nerve impingement if there are signs of osteoarthritis in the spine.

Investigations

Laboratory Investigations:

• Complete blood count (CBC), renal function, liver function tests, and inflammatory markers (CRP, ESR) to rule out systemic inflammatory conditions like rheumatoid arthritis.

• Serum uric acid level, to rule out gout which can mimic or coexist with osteoarthritis.

• Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies to rule out rheumatoid arthritis.

Imaging Investigations:

• Plain X-rays of affected joints, which can show joint space narrowing, subchondral sclerosis (increased bone density), osteophytes (bony outgrowths), and subchondral cysts.

• MRI may be useful in cases where more detail is needed, such as suspected meniscal tears in the knee, or to assess the spine for osteoarthritis.

Invasive Investigations:

• Joint aspiration and analysis if there is an effusion, to rule out septic arthritis or gout. The synovial fluid in osteoarthritis is usually clear and viscous with a low cell count.

• Arthroscopy can be performed for a more direct view of joint damage, particularly in cases where surgery may be considered.

Other Tests:

• Functional assessments such as the Western Ontario and McMaster Universities Arthritis Index (WOMAC) or the Health Assessment Questionnaire (HAQ) to assess how osteoarthritis is affecting the patient's quality of life and ability to perform daily activities. These assessments can be useful in guiding treatment decisions.

• Gait analysis if lower extremity joints are affected to assess for antalgic gait or other alterations due to pain.

Management

General Management:

• Patient education: Inform about the chronic nature of the condition, importance of self-care, weight management and exercise.

• Physiotherapy: Improve joint function and decrease pain through targeted exercises.

• Occupational therapy: To assist in maintaining daily activities and independence.

• Weight management: Reduction of body weight if overweight or obese can significantly reduce stress on weight-bearing joints.

Medical Management:

• Pain control: Start with paracetamol, if ineffective, consider non-steroidal anti-inflammatory drugs (NSAIDs).

• Topical treatments: Topical NSAIDs, capsaicin cream for localized pain.

• Intra-articular injections: Corticosteroids for acute exacerbations, hyaluronic acid for longer-term symptom relief.

• Opioids: Only in severe cases where other treatments are ineffective or contraindicated.

Surgical Management:

• Arthroscopy: For meniscal tears or loose body removal.

• Osteotomy: To correct joint alignment and offload the affected area, typically used in younger patients.

• Joint replacement: Total hip or knee arthroplasty is a common procedure in severe disease when conservative treatments fail.

Other Management:

• Use of assistive devices: Canes, walkers, orthotics, or braces to improve mobility and reduce pain.

• Complementary therapies: Acupuncture, massage, heat or cold therapy as adjuncts to core treatments.

• Nutritional supplements: Glucosamine and chondroitin, although evidence for their effectiveness is mixed.