QuestionSBA
QuestionChoice
Intra-articular corticosteroid injections are used to deliver a high dose of corticosteroids directly to the joint to reduce inflammation and provide short-term pain relief. They are used in managing acute flares of joint pain rather than the initial treatment of osteoarthritis.
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d
Intra-articular corticosteroid
QuestionChoice
Diclofenac is tyically given topically and is the most appropriate initial management option for this patient's knee pain. Osteoarthritis (OA) is the most likely diagnosis, based on her clinical presentation and examination findings. OA is a degenerative joint disease that results in the erosion of cartilage in the intra-articular joints, causing joint pain and stiffness. Topical NSAIDs are the the first-line treatment for mild to moderate OA. It is effective in reducing pain and improving function in people with OA.
62328
a
Topical diclofenac
QuestionChoice
Allopurinol is used in gout prophylaxis. It decreases the production of uric acid and reduces the risk of kidney damage caused by high uric acid levels in the blood. Allopurinol is not used in the treatment of osteoarthritis.
62332
e
Allopurinol
QuestionChoice
Naproxen is a non-steroidal anti-inflammatory drug (NSAID) that is highly effective in treating osteoarthritis. However, oral NSAIDs are considered second-line agents in OA if both paracetamol and topical NSAIDs are ineffective.
62329
b
Oral naproxen
QuestionChoice
There is no role for oral corticosteroids in the management of osteoarthritis. Corticosteroids are potent anti-inflammatory medications that are used to treat a variety of autoimmune conditions, but they are not recommended for the treatment of OA due to the potential for serious side effects and the limited effectiveness in relieving OA symptoms.
62330
c
Oral corticosteroid
QuestionComment
literally says in the notes that NSAIDs are preffered over paracetamol in knee OA
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QuestionComment
For Knee^
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Intravenous Prone
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Hematoma Hereditary
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Chapter
# Summary

Osteoarthritis (OA) is a chronic, degenerative joint disease characterised by loss of articular cartilage, remodelling of bone with osteophyte formation and mild synovitis. The main risk factor is older age, although obesity, joint injury and genetics also contribute. Presentation is with gradual onset pain that is worse with activity, with associated functional limitations. The most commonly affected joints are the knees, hips and small joints of the hands. Diagnosis is clinical, and severity of disease on X-ray does not correlate well with severity of symptoms. Management should be individualised, with important components being exercise, simple analgesia and optimisation of risk factors (such as maintaining a healthy weight). Where there is ongoing pain and disability, options include intra-articular steroid injections and surgical intervention (such as joint replacement).

# Definition

Osteoarthritis (OA) is the commonest form of arthritis, which is characterised by degenerative changes affecting the entirety of joints affected. Cartilage is lost, the subchondral bone becomes sclerosed with formation of osteophytes and subchondral cysts and there is inflammation of the synovial membrane lining the joint capsule (synovitis). 

# Epidemiology

- Approximately 10 million people in the UK have osteoarthritis
- More women than men are affected
- Average age of onset is 55 
- The commonest joint affected is the knee, followed by the hip then the hand

# Aetiology

Osteoarthritis develops due to a combination of factors, with important contributors including:

- Older age
- Female sex
- Overweight or obesity
- Family history of OA
- Previous joint injury
- Joint damage due to inflammation (e.g. in patients with inflammatory arthritis)
- Physical inactivity and reduced muscle strength
- Low bone density 
- Deformities such as development dysplasia of the hip or leg length discrepancy
- Stresses on joints due to occupational factors (e.g. repetitive squatting or kneeling) or exercise

# Signs and Symptoms

Key symptoms include:

- Pain in the affected joint exacerbated by use
- Pain may radiate e.g to the thigh, knee and ankle in hip OA, or to the wrist in hand OA
- Joints may feel stiff (although prolonged morning stiffness is suggestive of inflammatory arthritis)
- Functional limitations such as difficulty opening jars (hand OA) or mobilising (knee or hip OA)
- Locking or giving way of the knee

Examination findings include:

- Restricted and painful range of motion (e.g. in hip OA internal rotation with the hip flexed is particularly painful)
- Crepitus (friction between bone and cartilage) 
- Affected joints may appear swollen or enlarged
- A small effusion may form, especially when the knee is affected
- Synovitis may present with mild soft tissue swelling, tenderness and warmth
- Muscle wasting and weakness can result from disuse atrophy
- Joint instability
- An antalgic gait ("limping") in knee OA
- Trendelenburg gait in hip OA (due to weak abductors patients lurch towards the affected hip)
- Deformities, including:
- Heberden's nodes (bony nodules over the distal interphalangeal joints) 
- Bouchard's nodes (bony nodules over the proximal interphalangeal joints) 
- Fixed flexion of the first carpometacarpal joint with hyperextension of the distal joints
- This may lead to squaring of the joint with subluxation and remodelling
- Ulnar or radial deviation of joints in the hand may occur
- In severe hip OA the leg may be shortened due to fixed flexion and external rotation
- Varus (most commonly) or valgus deformities of the knees 

# Differential Diagnosis

- **Inflammatory arthritis** such as rheumatoid arthritis, ankylosing spondylitis; pain that improves with activity and morning stiffness lasting over 30 minutes are differentiating factors, systemic symptoms such as malaise and weight loss may be present
- **Septic arthritis** is an important differential for all patients presenting with an acutely painful swollen joint (which may occur in an acute flare of osteoarthritis); patients may be systemically unwell with fevers
- **Fracture** e.g. of the tibial plateau may mimic OA symptoms of pain and limited mobility; usually the patient is unable to weight bear with swelling of the affected area; a history of trauma should be elicited
- **Malignancy** including bone metastases, multiple myeloma or sarcoma may cause mechanical pain leading to functional limitations; red flags include weight loss, night sweats, persistent pain not relieved by rest and night pain
- **Greater trochanteric pain syndrome** most commonly occurs in middle-aged women and causes lateral hip pain and tenderness worsened by activity; it may also radiate to the lateral knee
- **Iliotibial band syndrome** presents with lateral knee pain worse with activity, which is often accompanied by clicking or clunking sounds when the knee is moved; occurs most commonly due to repetitive knee flexion e.g. cyclists or runners 
- **Meniscal tear** may occur after an injury involving a twisting or pivoting movement; similar symptoms of pain, swelling, locking and giving way of the knee and range of motion may be limited on examination
- **Trigger thumb** may mimic OA of the hand with pain, clicking and catching when the thumb is flexed; a nodule may be palpable in the tendon
- **Ganglion cysts** occur more commonly in people with OA and present as soft tissue swellings e.g. at the base of the thumb; often asymptomatic but may cause pain and limit movement of the joint

# Investigations

Diagnosis of OA is clinical and can be made without any investigations in a patient of 45 or older if there are no features suggesting another underlying cause of symptoms.

If there is diagnostic uncertainty or a rapid deterioration in symptoms, **X-rays** of affected joints may be of use. Typical findings can be remembered with the mnemonic "LOSS":

- **L**oss or narrowing of joint space due to thinning of cartilage
- **O**steophytes i.e. formation of new bony spurs at the joint margins
- **S**ubchondral sclerosis i.e. increased bone density beneath the cartilage
- **S**ubchondral cysts which are fluid-filled sacs in the subchondral bone

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However, severity of OA features on X-ray may not correlate well with severity of clinical disease.

Other investigations if the diagnosis is in doubt should be targeted to the differential suspected, and may include:

- Further imaging such as MRI to look for ligament or cartilage damage (e.g. a meniscal tear)
- Joint aspiration with synovial fluid analysis to exclude septic arthritis or crystal arthritis
- Blood tests for inflammatory markers, rheumatoid factor and anti-CCP (for example) if rheumatoid arthritis is suspected

Baseline bloods for renal function and full blood count should be considered in all patients starting NSAID treatment, especially older patients who are at higher risk of adverse effects.

# Management

**Conservative management:**

- Patient education and advice on self-care e.g. appropriate footwear
- Weight loss advice and signposting to services in patients with excess body weight
- Exercise has many benefits including strengthening muscles, improving fitness, reducing pain and improving function
- Options include online fitness programmes designed for people with arthritis, physiotherapy and supervised exercise sessions
- Physiotherapy services may also be able to offer manual therapies and joint supports such as braces or splints to reduce load and improve instability
- Occupational health input may be needed in patients with functional impairment to assess their working environment and suggest adaptations
- Patients should be asked about psychosocial stressors and support offered e.g. for associated depression and anxiety
- Occupational therapy input may be helpful to advise on aids and devices to assist with activities of daily living (e.g. walking sticks, sock aids, grab rails, tap turners)
- Podiatry input may be useful to assess the biomechanics of joint pain and advise on orthotic devices such as insoles
- Referral to a pain management service may be appropriate for patients who have not responded to maximal medical (and if appropriate, surgical) management of OA
- Assess falls risk and consider referral to specialist services for patients at risk (e.g. those with abnormal gait or balance, or who have had a fall in the last year)

**Medical management:**

- First-line analgesia is with topical NSAIDs (such as ibuprofen gel) - patients should be made aware that some systemic absorption may occur
- If this is ineffective or unsuitable, oral NSAIDs should be considered (with a PPI for gastroprotection if there are risk factors for gastrointestinal side effects)
- Paracetamol or weak opioids (e.g. codeine) may also be used in the short-term
- Topical capsaicin is another option, especially for knee OA
- Intra-articular steroid injections may be considered if other treatments are not effective, and/or to enable therapeutic exercise

**Surgical management:**

- Patients with OA of the hip, knee or shoulder who have symptoms significantly impacting quality of life despite optimal medical management should be considered for orthopaedic referral
- The usual operation offered is an arthroplasty (joint replacement)
- Rehabilitation before and after surgery is key to optimising outcomes

# Complications

- Joint deformities (as above)
- Increased risk of falls
- Functional limitations, e.g. hand OA may making writing, turning keys or fasting buttons challenging
- Reduced mobility 
- Sleep difficulties
- Low mood and anxiety
- Chronic pain

# Prognosis

- Not all cases of OA are progressive and the disease course is variable
- OA of the hands generally has a good prognosis, especially interphalangeal joint involvement
- Hip OA has a poorer prognosis with many patients requiring arthroplasty
- Knee arthroplasties for OA are also common however many patients' symptoms improve or remain stable with time 
- Intermittent flares of OA may occur, where symptoms increase in intensity suddenly
- Flares tend to last for a few days before improving

# NICE Guidelines

[NICE CKS - Osteoarthritis](https://cks.nice.org.uk/topics/osteoarthritis)

[NICE - Osteoarthritis in over 16s: diagnosis and management](https://www.nice.org.uk/guidance/ng226/)

# References

[WHO fact sheet - Osteoarthritis](https://www.who.int/news-room/fact-sheets/detail/osteoarthritis)

[BNF Treatment Summaries - Osteoarthritis](https://bnf.nice.org.uk/treatment-summaries/osteoarthritis/)

[Patient UK - Osteoarthritis](https://patient.info/doctor/osteoarthritis-pro)
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Heberden's nodes.
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Osteoarthritis of the knees.
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Osteoarthritis
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Orthopaedics
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A 60-year-old woman with a history of type 2 diabetes mellitus and hyperlipidaemia presents to the GP with worsening pain in both knees over the past year. The pain is exacerbated by walking and relieved by rest, and warm compresses have provided temporary relief in the past. On examination, a "crepitus" is heard while palpating over the knee joints bilaterally. Her body mass index is 32kgm<sup>2</sup>.

What is the most appropriate initial treatment for her condition?
a