Osteoarthritis

Pathology, Diagnosis, and Treatment Options

Benjamin Abramoff, MD, MS, Franklin E. Caldera, DO, MBA*

KEYWORDS
 Osteoarthritis  Arthralgia  Arthritis  Degenerative joint disease

KEY POINTS
 There are many modifiable and nonmodifiable risk factors for osteoarthritis (OA): genetic
predisposition, increasing age, obesity, metabolic syndrome, previous injury, lifestyle fac-
tors, and female gender.
 Progressive pain is the most prominent symptom in OA, although mechanical symptoms
may also be present. Systemic symptoms should be absent and their presence should
cause investigation into other pathologies.
 Plain radiographs, diagnostic ultrasound, and MRI are tools that can help diagnose OA
and guide treatment recommendations. Radiographic findings include joint space narrow-
ing, osteophytosis, subchondral sclerosis, and cyst formation.
 Traditional treatment options include lifestyle modification, physical therapy, oral medica-
tions, injections, physical modalities, and surgery. Numerous novel treatments are being
investigated, such as nerve blocks, mesenchymal stem cell injections, platelet-rich
plasma injections, and strontium ranelate.

INTRODUCTION

Osteoarthritis (OA) is endemic throughout the world. An estimated 30.8 million adults
in the United States and 300 million individuals worldwide are living with OA.1,2 It is the
leading cause of disability in older adults and leads to pain, loss of function, and
decreased quality of life (QOL).3,4
On a societal scale, OA is estimated to cost $303 billion dollars
annually in medical costs and lost earnings.5 Continued efforts are needed to
reduce the occurrence, pain, and loss of function from this chronic, debilitating
disease. This article is a review of OA—pathology, diagnosis, and treatment
options.

Department of PM&R, University of Pennsylvania, Penn Medicine Rittenhouse, 1800 Lombard

Street, Philadelphia, PA 19146, USA
* Corresponding author.
E-mail address: [email protected]

Med Clin N Am - (2019) -–-

https://doi.org/10.1016/j.mcna.2019.10.007 medical.theclinics.com
0025-7125/19/ª 2019 Elsevier Inc. All rights reserved.
2 Abramoff & Caldera

PATHOLOGY

Previously, OA was thought to be a simply a disease of “wear and tear.” Chronic over-
load and impaired biomechanics on the joint were thought to lead to destruction of the
joint’s articular cartilage and resultant inflammation. This subsequently led to stiffness,
swelling, and loss of mobility. It is now known that OA is a much more complex pro-
cess composed of inflammatory and metabolic factors.6,7
OA is most notable for its effect on articular cartilage, which gets severely degraded
over the course of the disease. Articular cartilage is the smooth cartilage at the end of
long bones and within the intervertebral discs. It provides a low friction surface for
articulation while being able to transmit heavy loads. Although the half-life of the
collagen within the cartilage is long, it heals very slowly if at all, even with minor in-
juries. Although the cartilage has the most notable changes, the entire joint is affected,
including the synovium, joint ligaments, and subchondral bone.7
Inflammation including active synovitis and systemic inflammation play a key role in
the pathogenesis of OA. One potential explanation is that degraded cartilage induces
a foreign body reaction within the synovial cells. This may lead to production of metal-
loproteases, synovial angiogenesis, and production of inflammatory cytokines, which
leads to further cartilage destruction. Other theories propose a central role of activated
synovial macrophages and the innate immune system in the progression of OA.8
Systemic inflammation may also play a role in the pathogenesis of OA. A study by
Yusuf and colleagues9 (2010) found that body weight was a strong risk factor for
developing hand OA. This suggests other consequences of obesity may be at play
beyond body-weight and joint mechanics. This study and others suggest that sys-
temic factors related to obesity, metabolic syndrome, and atherosclerosis likely play
a systemic role in the development of OA, possibly through leptin and other adipo-
kines. Direct effects of aging on cartilage (due to chondrocyte senescence, DNA dam-
age, aging of the cartilage matrix, oxidative stress, mitochondrial dysfunction, and
autophagy) as well as the effect of the endocrine system and estrogen on joint health
are also being investigated.8,10

RISK FACTORS

OA is a complex disease with many elements that potentially may lead to its presen-
tation and progression (Fig. 1). OA can be broadly classified into 2 types:
Primary OA—no known cause
Secondary OA—caused by other conditions such as trauma, obesity, or disease

Fig. 1. Risk factors that lead to the development of OA. (From Musumeci G, Aiello FC., Szy-
chlinska MA, et al. Osteoarthritis in the XXIst century: Risk factors and behaviours that influ-
ence disease onset and progression. Int J Mol Sci 2015;16(3):6096; with permission.)
 Osteoarthritis 3

This section discusses some of the known modifiable and nonmodifiable risk factors
for OA.

Age
Although prevalence numbers vary, particularly due to varying definitions of OA, it is
conclusive that aging is the single greatest risk factor for the development of OA.
The presence of both radiographic and symptomatic OA increases over the human
lifespan. Increased rates with aging have been noted in the knee, hip, and hand.11
Worldwide estimates are that 9.6% of men and 18% of women older than 60 years
have symptomatic OA.12 The Framingham Osteoarthritis study found that 27% of
those aged 63 to 70 years had radiographic evidence of knee OA, increasing to
44% in the age group older than 80 years.13

Genetic and Epigenetic Predisposition

Susceptibility to OA is considered polygenetic in nature; there are more than 80 genes
that have been implicated in the pathogenesis. Some of these genes are for vitamin D
receptors and insulin-like growth factor 1. OA has also been associated with a single-
nucleotide polymorphism in the growth and differentiation factor 5 gene, which is
involved in the development of healthy bone and cartilage.6 Epigenetic mechanisms
including DNA methylation, histone modification, and microRNAs are currently being
investigated for their role in the development of OA.14

Obesity/Metabolic Syndrome
Obesity and metabolic syndrome are also strong risk factors for the development of
OA. A meta-analysis found that the odds ratio (OR) for having OA in obese or over-
weight individuals compared with normal-weight individuals was 2.96.15 Evidence is
accumulating that prove that dyslipidemia and type 2 diabetes are risk factors for
OA independent of obesity.16

Endocrine
There is a 3 times higher risk of progression of knee OA in patients with low levels of
vitamin C or D.13 Despite being postulated, increasing bone density has not been
shown to lead to increased risk of OA.17

Gender
Most studies suggest that women are more likely to develop symptomatic knee prob-
lems compared with men (with analysis demonstrating a pooled OR of 1.84).15 A large
study of Spanish patients by Prieto-Alhambra and colleagues18 (2013) found that the
relative risk of OA in the hands, knee, and hip were 1.52 times greater in women than in
men. This difference was more pronounced in the hip/hand (relative risk [RR] 2.50)
compared with the knee (RR 1.19). These differences peaked at 70 to 75 years of
age for the knee and hip. Interestingly, the sex difference for hand OA peaked at 50
to 55 years of age. Despite this overall trend, OA is more prevalent in men than women
under the age of 50 years. This prevalence changes over the age of 50 years where OA
risk is higher in women than men.13

Previous Injury
Posttraumatic OA may be caused by any inciting event leading to damage to the joint,
including fractures, cartilage damage, ligamentous injury, or meniscal injuries. A 2006
study by Brown and colleagues19 estimated that 12% of all OA is posttraumatic in
4 Abramoff & Caldera

nature. Prevalence of previous injury varies by joint; posttraumatic OA accounts for

20% to 78% of cases of ankle OA, 10% of knee OA, and 2% of hip OA.20

Occupation
There is some evidence that excessive kneeling, squatting, jumping, bending, and lift-
ing can lead to knee OA.21,22 Construction workers, forestry workers, and farmers
have been found to be at particular high risk.23 Military populations also have been
found to have much higher rates of OA than the general population.24
An association between the increasing use of technology, computers, and smart-
phones and hand OA has yet to be proved but is a common concern that requires
further investigation, as these technologies have become increasingly prevalent in
our lives.6

Sports
Joint degeneration can also occur in athletes and younger individuals through damage
to the articular cartilage from repetitive impact and loading. Sports like football and
soccer account for the most impact damage secondary to direct blunt trauma. It
has been shown that more than 80% of American football players with a history of
knee injuries had evidence of OA 10 to 30 years after competing.25

Ethnicity
There is some evidence that race and ethnicity play a role in the prevalence of OA in
different populations. OA is more common in Europeans than in Asians, Africans, and
Jamaicans.13 Also, OA is more prevalent in Europe and the United States than in other
parts of the world.26 There may even be differences between joints, for example, there
is evidence that Chinese individuals may have lower risk for hand and hip OA while
concurrently having a higher risk of knee OA. Severity, gender predication, and spe-
cific OA features may also differ by ethnicity.27

Joint Shape and Dysplasia

Congenital abnormalities of joints, such as acetabular dysplasia, slipped capital
femoral epiphysis, hallux valgus, and valgus/valgus joint alignment likely play a role
in the development and progression of OA.27,28

SYMPTOMS

Pain is the most prominent symptom in patients with OA. A 2008 study by Hawker and
colleagues of the pain experience of those with OA found that pain tends to come in 2
forms, a constant background aching pain and intermittent intense pain. Pain with OA
is also noted to slowly and insidiously progress with time. Early in the course, the pain
is predictable and caused by specific (often high-impact) activities. Over time, pain
and other joint symptoms become less predictable and more constant, with daily ac-
tivities beginning to become affected. In advanced stages, constant dull and aching
pain is accompanied by unpredictable, intense, severe pain, which leads to avoidance
of certain activities.29 A full list of patient-reported symptoms and their frequency are
noted in Table 1.
It is worth noting that the degree of structural pathology noted on imaging and the
degree of pain are not always concordant with the symptoms of OA. Some individuals
with severe pain have a paucity of findings on imaging and vice versa. Elements such
as prior pain experiences, treatment expectations, psychological factors, and socio-
cultural environment all potentially play a role in the individual’s experience of pain.30
 Osteoarthritis 5

Table 1
Frequency of pain complaints in osteoarthritis

Frequency Distress (/6) Points (/10) Mean ± SD

Rank Feature N (%) Mean ± SD (Range) (Range)
1 Sharp pain 65 (71.4) 4.2  1.4 (1–6) 2.8  2.1 (0–9)
2 Limitation of 63 (69.2) 4.1  1.3. (0–6) 2.6  2.1 (0–10)
activities
3 Ache/dull 60 (65.9) 3.6  1.6 (0–6) 2.4  2.1 (0–10)
4 Triggered by 46 (50.5) 4.2  1.3 (1–6) 3.0  2.1 (0–10)
activity
5 Stiffness 24 (26.4) 4.0  1.2 (2–6) 2.9  2.7 (0–10)
6 Unpredictability 23 (25.3) 3.4  1.6 (1–6) 1.4  1.5 (0–6)
7 Constant 21 (23.1) 3.9  1.5 (1–6) 2.1  1.4 (0–5)
8 Unstable 20 (22.0) 4.3  1.6 (1–6) 2.2  1.5 (0–5)
9 Night pain/impact 16 (17.6) 3.9  1.4 (1–6) 2.9  1.4 (1–5)
on sleep
10 Mood 16 (17.6) 3.8  1.5 (1–6) 1.6  1.7 (0–5)
11 Swelling 14 (15.4) 3.9  1.8 (0–6) 1.6  1.2 (0–4)
12 Grating 12 (13.2) 4.3  1.3 (2–6) 1.8  1.3 (0–4)
13 Inactivity 12 (13.2) 3.5  1.2 (1–5) 2.0  1.0 (0–3)
14 Burning pain 6 (6.6) 4.2  2.3 (0–6) 3.7  1.4 (2–6)
15 Weakness 6 (6.6) 2.5  1.9 (0–5) 2.2  0.8 (1–3)
16 Fear 6 (6.6) 4.0  2.0 (L-6) 2.0  1.7 (0–4)
17 Use of medication/ 5 (5.5) 4.2  1.3 (3–6) 1.4  1.1 (0–3)
devices
18 Numbness 4 (4.4) 3.5  2.1 (1–6) 1.5  1.9 (0–4)
19 Locking 4 (4.4) 4.5  1.3 (3–6) 2.3  1.3. (1–4)
20 Cramping/muscle 3 (3.3) 4.7  0.6 (4–5) 2.3  2.3 (1–5)
spasms
21 Clicking/cracking 3 (33) 3.0  0.0 (3) 2.0  2.7 (0–5)
22 Radiating pain 1 (1.1) 6 (6) 1 (1)

From Hawker GA, Stewart L, French MR, et al. Understanding the pain experience in hip and
knee osteoarthritis–an OARSI/OMERACT initiative. Osteoarthritis Cartilage 2008;16(4):420; with
permission.

Other nonpain symptoms of OA include joint swelling, clicking, locking, grating,

crepitus, cramping, reduced range of motion, and deformity. Also described are
symptoms of instability, buckling, or “giving way.” Patients with OA complain of morn-
ing stiffness that improves in 30 minutes. This is unlike in rheumatoid arthritis, which
typically last longer. The pain of OA also increases throughout the day and with
increased activity.
Systemic symptoms should be absent. This includes fever, weight loss, or abnormal
blood test. The presence of such symptoms would alert the physician to other disease
processes such as infection or malignancy.31
The symptoms of OA have been noted to lead to a loss of independence and
impaired ability for individuals to do the activities that they enjoy.29 A large study of
10,000 patients by Fautrel and colleagues (2005) found that 81.5% of patients with
OA reported limitations in their activities of daily living; 61.1% reported limited mobility
6 Abramoff & Caldera

outside the home and 12.8% in the home (compared with 10.2% and 2.8% in the gen-
eral population, respectively). Patients with OA also noted significantly more impair-
ment that the general population in grocery shopping, house cleaning, and
dressing. Leisure activities including sports and gardening were also significantly
affected. Individuals with OA also missed more work compared with a control
population.32
Overall, quality of life (QOL) is significantly affected by OA in multiple domains.
Although clearly there is a diminished QOL in terms of physical functioning, adverse
effects on mental health have been noted as well.33

EXAMINATION FINDINGS

Typical joints affected by OA include the knee, hip, distal and proximal interphalangeal
joints, first trapeziometacarpal (carpometacarpal) joints, the first metatarsophalangeal
joint, and the facet joints of the spine. Other joints including the elbow, wrist, shoulder,
and ankle are less common.
There are many clinical features seen in patients with OA that may be due to synovial
fluid accumulation, active inflammation, or bony deformity of the joints. Some com-
mon clinical findings include joint line tenderness, reduced range of both passive
and active movement, crepitus, joint effusion, and bony swelling and deformity. These
findings can be localized to one joint or polyarticular in nature. Heberden and Bou-
chard nodes (swelling at the distal and proximal interphalangeal joints, respectively)
are also commonly noted.
The presence of a popliteal cyst is often the sequela of OA of the knee. One may also
see valgus or varus deformity. In the hip, limited internal rotation is commonly seen on
examination. Crepitus and decrease in range of motion, especially external rotation, is
often seen on physical examination of the shoulder.
In OA of the foot, pain may be seen in the first metatarsophalangeal joint with limited
range of motion of the first metatarsophalangeal joint. One may also see hallux valgus
deformity on physical examination.

IMAGING

OA is primarily a clinical diagnosis. However, plain radiography can be helpful in con-

firming the diagnosis and ruling out other pathology.34 MRI and computed tomogra-
phy are rarely needed.
There are certain plain radiographic findings characteristic of OA. OA often demon-
strates joint space narrowing, osteophyte formation, subchondral sclerosis, and cysts
(Figs. 2–5).
The knee joint is typically evaluated by using extended knee radiographs,
while the patient is weight bearing. Flexed knee radiographs are also used to
improve intraarticular visualization. There are multiple grading schemes used for
evaluation of joint space narrowing or osteophyte formation.35 One of the most
common grading schemes used in OA is the Kellgren-Lawrence classification
system.
Radiographic features of OA described by Kellgren and Lawrence include evalua-
tion of the following: formation of osteophytes on joint margins or on tibial spines, peri-
articular ossicles (distal or proximal interphalangeal joints), narrowing of joint cartilage
associated with sclerosis of subchondral bone, small pseudocystic areas with scle-
rotic walls situated in the subchondral bone, and altered shape of bone ends, partic-
ularly in the head of the femur:
 Osteoarthritis 7

Fig. 2. Severe left narrowing of the hip joint space (arrow).

Grade 0: demonstrated no joint space narrowing or reactive changes.

Grade 1: doubtful joint space narrowing, possible osteophytic lipping.
Grade 2: definitive osteophytes, possible joint space narrowing.
Grade 3: moderate osteophytes, definite joint space narrowing and possible bone
end deformity.
Grade 4: large osteophytes, marked joint space narrowing, severe sclerosis, definite
bone end deformity.36
Recently, additional modalities such as MRI, ultrasound, and optical coherence to-
mography have enhanced OA diagnosis and management.

Fig. 3. Moderate marginal osteophytes of the fifth DIP joint (arrow). DIP, distal interphalan-
geal joint.
8 Abramoff & Caldera

Fig. 4. Severe joint space narrowing of shoulder, subchondral sclerosis, subchondral cyst,
and osteophyte formation (arrow).

Degeneration of articular cartilage is a sign of progression of OA. Plain radiographs

cannot detect early chondral damage. Instead, MRI can provide information about
size and structural integrity of cartilage. This can be extremely useful in identifying
full or partial thickness changes of articular cartilage in OA.37 MRI can also be used
to identify predisposing factors for OA such a meniscal and anterior cruciate ligament
injuries (Fig. 6).38,39
Ultrasound can also assess the synovium for hypertrophy and inflammation. The
Rheumatoid Arthritis Clinical Trials Ultrasonography Taskforce defines ultrasound-
detected synovial hypertrophy as “abnormal hypoechoic intraarticular tissue that is,
nondisplaceable and poorly compressible and which may exhibit Doppler signal.”40
Ultrasound technology offers many advantages, including low cost, lack of ionizing ra-
diation, ability to image structure dynamically, and can be used for interventional pro-
cedures. MRI can be used to detect OA in deeper joints such as the hip and shoulder
that ultrasound cannot assess.

Fig. 5. Severe narrowing of the medial compartment (arrow).

 Osteoarthritis 9

Fig. 6. Medial meniscus. Degenerative oblique tear of the posterior horn (arrow).

LABORATORY FINDINGS

Laboratory test results are usually normal in patients with OA, although they may be
useful for narrowing the differential diagnoses when the diagnosis is uncertain.
C-reactive protein levels and erythrocyte sedimentation rate can be useful to evaluate
for systemic inflammatory conditions and autoimmune disorders. A uric acid level may
help evaluate for the presence of gout. Clinical guidelines established by the American
College of Rheumatology recommend against routine ordering of arthritis panels for
patients with joint problems.41

DIFFERENTIAL DIAGNOSIS

It is important in the diagnosis and treatment of OA to consider a broad differential.

Important alterative diagnoses and differentiating features are identified in Table 2.
Examination, imaging, laboratory workup, and history can help distinguish these
cases when initial evaluation is uncertain.

TREATMENT

There is no current cure for OA. Treatment can be broadly classified into reduction
of modifiable risk factors, intraarticular therapy, physical modalities, alternative
therapies, and surgical treatments (Table 3). There is also emerging evidence for
several novel treatments. Early on in the course of OA the treatment is focused
on the reduction of pain and stiffness. Later, treatment focuses on maintaining
physical functioning.

Nonpharmacologic Treatment
Reduction of modifiable risk factors
Obesity may be the strongest modifiable risk factor. A randomized trial by Messier and
colleagues (2011) demonstrated that a 10% reduction in body weight significantly
decreased the load in knee joints.42 Another study demonstrated that the risk of symp-
tomatic knee OA in women decreases by 50% by losing 5 kg of weight.43 Recent
studies also showed structural improvement of cartilage and positive changes in bio-
markers of cartilage and bone with weight loss.44
 10
Abramoff & Caldera
Table 2
Differential diagnosis for osteoarthritis

Knee OA Hip OA Shoulder OA Hand OA Multiple Joint OA

Pes anserine bursitis Aortoiliac insufficiency Rotator cuff impingement, Trigger finger (stenosis Referred pain from another
tendinopathy, tears flexor tenosynovitis) joint or radicular pain
Patellar tendinosis Referred visceral pain Labral tear Ganglion cyst Osteochondritis dissecans
Patellofemoral pain Sacroiliac neuropathy Adhesvie capsulitis Dupuytren contracture Pigmented villonodular synovitis
syndrome
Prepatellar bursitis Lateral femoral cutaneous nerve Glenohumeral joint or Carpal tunnel syndrome Avascular necrosis
syndrome scapular instability
Semimembranous bursitis Acetabular labral tear Biceps tendinopathy Mallet finger Gout
Iliotibial band syndrome Femoroacetabular impingement Scapulothoracic weakness Pseudogout
Medial plica syndrome Greater trochanteric pain Subscapular bursitis Septic arthritis
syndrome (trochanteric bursitis)
Popliteal cyst, popliteus Snapping hip Distal clavicular osteolysis Traumatic ligamentous or bony
tendinopathy injury
Quadriceps tendonosis Piriformis syndrome AC joint sprain Systemic rheumatologic disease:
rheumatoid arthritis, psoriatic
arthritis, reactive arthritis,
hemochromatosis
Popliteal artery aneurysm Osteitis pubis Sternoclavicular joint Stress and osteoporotic fracture
or entrapment subluxation/dislocation
Saphenous nerve Sacroiliac joint pain Bone tumors
entrapment
Hoffa fat pad syndrome

Data from Refs.45–49

 Osteoarthritis 11

Table 3
Treatment options for osteoarthritis with Osteoarthritis Research Society International
guidelines (if available)

OARSI Guidelines
Treatment Recommendation
Reduction in Weight loss Appropriate
modifiable Exercise Appropriate: both land and water
risk factor based, including strengthening
Bracing and Cane Appropriate for knee-only OA
physical Crutches Uncertain
modalities Biomechanical interventions Appropriate
Alternative T’ai Chi No recommendation
therapies Acupuncture Uncertain
Balneotherapy/spa Appropriate with individuals with
multiple joint OA
Uncertain with knee-only OA
NMES Not appropriate
Self-management and education Appropriate
Cognitive behavioral therapy No recommendation
TENS Uncertain in knee-only OA,
otherwise inappropriate
Ultrasound Uncertain in knee-only OA,
otherwise inappropriate
Laser therapy No recommendation
Electromagnetic field therapy No recommendation
Pharmacologic Acetaminophen Appropriate depending on
(oral) comorbidities
Avocado soybean unsaponfiables Uncertain
Chondroitin/glucosamine Uncertain for symptom relief, not
appropriate for disease
modification
Diacerein Uncertain
Duloxetine Appropriate with multijoint OA,
uncertain in knee-only OA
NSAIDs Appropriate in those without
significant comorbidities
Opioids Uncertain
Risedronate Not appropriate
Rosehip Uncertain
Pharmacologic Capsaicin Appropriate in knee-only OA
(topical) NSAIDs Appropriate in knee-only OA,
uncertain in multijoint OA
Tramadol No recommendation
Opioids Uncertain
Topical NSAIDs No recommendation
Pharmacologic Corticosteroids Appropriate
(intraarticular) Hyaluronic acid Uncertain in knee-only OA, not
appropriate in multijoint OA

Data from Rannou F, Poiraudeau S, Beaudreuil J. Role of bracing in the management of knee oste-
oarthritis. Curr Opin Rheumatol 2010;22(2):218–222.

Exercise has also been investigated as a treatment modality for OA. A network
meta-analysis of 60 randomized control studies by Uthman and colleagues (2013)
found that exercise improved pain and function in individuals with OA. This study
also suggested interventions that combined strengthening, flexibility, and aerobic ex-
ercise.45 Aquatic exercise may also be effective.46
12 Abramoff & Caldera

A Cochrane review of knee arthritis found that exercise led to decreased pain,
improved physical function, and mildly improved QOL. The improvement noted was
similar to previous studies evaluating nonsteroidal antiinflammatory drugs (NSAIDs).47
Most patients would likely benefit from a guided therapy program with a certified
physical or occupational therapist before initiating a home exercise program. This
allows the patient to have onsite direction and equipment, which may help with
program adherence and outcomes. There is limited information to guide specific
recommendations in terms of dosing and specific types of exercise.48,49 Specific
therapy techniques that are used include passive stretching, soft tissue mobiliza-
tion, active range of motion exercises, and progressive muscle strengthening.
Specific goals (such as increasing strength, flexibility, and range of motion) are
generally progressed with time in a physical therapy program. Specific
exercises and techniques for knee OA are outlined in the article by Deyle and
colleagues (2005), although similar techniques would be used for other joint
locations.

Physical modalities
Although more research is needed, bracing may be effective in treating knee OA.
Unloading knee braces may provide some symptomatic relief in medial and lateral
knee OA. For patellar OA, sleeves with a peripatellar device or taping may be help-
ful. For multicompartmental knee braces, neutral knee braces may be effective.
Knee sleeves may provide some warmth and relief. Lateral and medial wedge in-
soles may also be effective in the treatment of OA.50 For carpometacarpal OA
thumb base semirigid and rigid splints can be used to immobilize the joint.

Alternative therapies
Alternative therapies have also been investigated for OA. Study results have been
mixed with little definitive support for acupuncture in high-quality studies.51–55 Despite
this, there does not seem to be significant risk associated with knee acupuncture and
may prove useful for some patients.56
Self-management and education is another potential approach to treat the pain of
OA. Self-management is the concept of putting the management of symptoms and
consequences of the disease in the hands of the patient. Specific concepts include
the following:
 Self-efficacy building
 Self-monitoring
 Goal setting and action planning
 Decision-making
 Problem solving
 Self-tailoring
 Partnership between the views of patients and health professionals
Arthritis self-management programs have been shown to be beneficial and improve
pain and disability.57
Increased pain with OA has been associated with psychological dysfunction,
depression, anxiety, pain catastrophizing, social isolation, and poor coping
strategies. Cognitive behavioral therapy, psychotherapy using structured sessions
to help individuals identify and modify negative thinking and behaviors, has also
been used in the treatment of OA. Studies of CBT have shown mixed
outcomes for OA.58
 Osteoarthritis 13

Other treatments used such as lasers, transcutaneous electrical nerve stimulation,

ultrasound, and electromagnetic field therapy are commonly used but evidence is
poor on their effectiveness.59,60

Pharmacologic Treatment
NSAIDs and acetaminophen are generally considered first-line therapies in the treat-
ment of OA. NSAIDs are effective for overall pain from OA.61 There is no strong evi-
dence of benefit of any particular NSAID over another. NSAIDS should be used with
caution in those with gastrointestinal disease including selective cox-2 inhibitors or
nonselective NSAIDs with the addition of a gastroprotective agent.62
Acetaminophen has been found to be effective in the treatment of OA, although
modestly. They are also less effective than NSAIDs. Acetaminophen is generally
safe and may be preferable when NSAIDs are contraindicated.61 Topical options
such as capsaicin and topical NSAIDs are also available and effective.
Other treatments include serotonin-norepinephrine reuptake inhibitors. Recent evi-
dence has implicated central sensitization as an important factor in pain in OA. There is
a theory that limited efficacy by NSAID or acetaminophen occurs because the pain
may be central in origin. Both noradrenergic and serotonergic neurons modulate the
spinal cord and periaqueductal gray area in the spinal cord. Chapell and colleagues
(2011) performed the first randomized controlled trial comparing duloxetine with a pla-
cebo. In this trial the patient treated with duloxetine exhibited significant improve-
ments in average pain scores.63 Another study showed that duloxetine along with
an NSAID was more effective than an NSAID alone for pain in OA. This study led to
the Food and Drug Administration (FDA) approving duloxetine for the treatment of
chronic knee OA.64
The use of stronger medications, such as weak opioids and narcotic analgesics, can
be considered when other medications have failed or are contraindicated.65 Physi-
cians should adhere to the new opioid guidelines issued by Center for Disease Control
and Prevention in 2016 when treating patients.66
Avocado soybean unsaponifiables, glucosamine sulfate, chondroitin sulfate, hyal-
uronic acid, and diacerein, have also been used by patients for OA with uncertain
efficacy.

Intraarticular Treatments
Intraarticular injection of steroids is an option in the treatment of inflammatory flares of
OA, although efficacy is limited and short-lived.62 Viscosupplements such as hyal-
uronic acid have uncertain effects when used intraarticulately for the treatment of
OA in the knee. Although possibly less effective in the short term, they may provide
longer-lasting treatment in OA.67

Novel Treatments
Recent improvements in the understanding of the pathophysiology of the disease
have led to novel treatments.
Strontium ranelate inhibits subchondral bone resorption by regulating the activity of
osteoprotegerin, RANK ligand, and matrix metalloproteinases produced by osteo-
blasts. Strontium may have a direct effect on cartilage; this is supported by the obser-
vation that it promotes proteoglycan synthesis, which stimulates cartilage matrix
formation in vitro.68
Nerve growth factor (NGF) is postulated to modulate signals that control expression
of peripheral and central pain substances and sensitizes adjacent nociceptive neurons
in response to stimulation. Tanezumab is a highly selective immunoglobulin G2
14 Abramoff & Caldera

antibody against NGF. Several studies have shown that in patients with moderate to
severe knee OA tanezumab results in greater improvement in knee pain, stiffness,
and increase function compared with placebo. However, side effects include osteo-
necrosis leading to the medication being placed on hold by the FDA.69
Regenerative therapy has been one the latest rapidly growing strategies to treat OA.
Platelet-rich plasma, which is harvested from a patient’s blood with the theory that it
will provide important growth factors, has been investigated. A systematic review
found that platelet-rich plasma resulted in clinical improvement up to 12 months
following injection.70
Mesenchymal stem cells (MSCs) are a cell source that can be easily obtained from a
variety of tissues such as bone marrow, adipose tissue, and synovium. The stem cells
are capable of rapid proliferation, chondro-differentiation and immunosuppression.
One study showed mild improvements in pain for 5 years after injection of MSCs
into the knee joint.71,72
Another area of investigation is the use of radiofrequency ablation in the treatment of
knee OA. These procedures thermally lesion sensory nerves, which include the supe-
rior lateral and medial and inferior medial genicular nerves of the anterior joint capsule
of the knee, in order to decrease pain. To date, results are promising for improvement
in pain and reducing disability.73
Other novel approaches being investigated include cryotherapy and geniculate
arterial embolization.

SURGICAL TREATMENTS

Total joint arthroplasty is the gold standard treatment of patients with severe OA who
failed to respond to conservative treatment or pain is severely affecting their QOL. It
can provide marked pain relief and functional improvement in patients with severe
hip or knee OA. One study found after 12 months surgically treated patients had
greater pain relief and improvement in QOL than conservative treatment.74
With contemporary techniques, patients are typically allowed to weight bear as
tolerated on the affected limb immediately after surgery. Pain control is important
and accomplished by a multimodal approach. NSAIDS, analgesics, and narcotics
may be used. Patients typical stay in the hospital for 2 or 3 days, although more pa-
tients are leaving sooner after surgery.
Prevention of complications early after surgery is critical. Early complications
include infections, failed prosthesis, wound dehiscence, and deep vein thrombosis.
Pneumonia or atelectasis can be prevented with an incentive spirometer. Thrombotic
events are prevented by compression stocking and/or chemical prophylaxis. Active
exercises with early and frequent ambulation can also help to prevent thrombosis.
Early mobilization on the day of surgery helped to improve outcomes and decrease
hospital length of stay.75
In order to prevent hip dislocation following total hip arthroplasty (THA), patients are
placed on hip precautions. Precautions from a THA done from a direct anterior
approach include avoidance of hyperextension, adduction, and external rotation of
the hip. For surgery done from a posterior approach the patient should avoid hyper-
flexion, adduction, and internal rotation of the hip.
There is no clear consensus regarding optimal frequency, duration, or intensity of
physical rehabilitation following joint replacement surgery. A well-structured therapy
program that includes range of motion, gait training, quadriceps strengthening, and
training in activities of daily living is an important component of the rehabilitation pro-
cess following surgery.
 Osteoarthritis 15

Patients are discharged to home, a skilled nursing facility, or an acute inpatient reha-
bilitation hospital. Medicare standards currently allow acute rehabilitation for patients
with bilateral total joint arthroplasty, morbid obesity, or age greater than 85 years.
Close communication and coordination between hospital facility and the acute reha-
bilitation hospital is crucial to prevent complications or readmissions.
THA patients make most functional gains in the first 6 months, and total knee
replacement (TKR) can take up to 1 year. Quadriceps strength can be reduced up
to 60% after TKR, which can be mitigated by strengthening exercises.76 These exer-
cises will help increase a patient’s stair climbing ability, gait speed, and coordination,
all of which are crucial for independent living at home. After a TKR, the expected
range of motion of the knee is full extension to 90 of flexion. This is the minimum
required to be able to perform activities of daily living. Many patients will achieve
up to 115% degrees or more. It is not atypical to have swelling and pain up to
1 year after surgery.

SUMMARY

OA is a widespread and devastating condition that leads to pain, diminished QOL, and
high health care costs. Because increasing emphasis is being placed on cost-efficient
treatment (including increasing use of bundled payments), further work is needed to
understand the costs and cost-savings of accurate diagnosis and treatments
before surgery and the efficacy of novel treatment options. As we are learning more
everyday about the pathogenesis of OA, and that it is not just “wear and tear,” it is
opening the door to new treatment avenues. Given the multiple pathways involved
in the disorder, a multidisciplinary approach to treatment and prevention is likely the
future treatment of OA.

DISCLOSURE

The authors have nothing to disclose.

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