THERAPEUTIC MANAGEMENT OF

KNEE OSTEOARTHRITIS

BY
PT H N ABDULLATEEF
 OUTLINE
 Introduction  Assessment

 Epidemiology & economic  Therapeutic exercises

importance  Management
 Relevant anatomy  Case study 1
 Pathophysiology  Case study 2
 Classification  Conclusion
 Aetiology & Risk factors  Recommendation
 Clinical presentation  References
 Differentials
 Introduction
• The name osteoarthritis(OA) is a Greek word, osteo, arthro
and itis. It is characterized by age related degenerative
changes of cartilage and its underlying bone within a joint as
well as bony overgrowth.

• Osteoarthritis(OA) is a condition that is associated with pain

and inflammation of the joint capsule (Naredo et al,2005),
impaired muscular/ligament stabilization (Brandt et al, 2000),
reduced range of motion (Steultjens et al,2000) and disability
over time.
 Cont…
• Knee osteoarthritis (OA) is the most common type of
OA.( Andrianakos et al,2003) and its prevalence is rising
in parallel with the increasing age of the population.
(Felson et al,2005)

• Knee OA is one of the most chronic and degenerative

joint diseases and a major cause of pain and joint
stiffness in the elderly (Doherty, 2002)
 Cont..
• It is also one of the most common musculoskeletal
conditions resulting in disability (Mody & Woolf, 2003).

• The specific causes of OA are unknown, but are believed to

be as a result of both mechanical and molecular events in
the affected joint. The disease onset is gradual and usually
begins after the age of 40 years (Centers for Disease
Control and Prevention, 2009).
 Cont…
• Knee OA results in persistent pain and limited
function (Guccione et al., 1994) and substantially
reduces life expectancy by 12% when occurring as a
co morbidity with obesity (Warner, 2011).

• The management of knee OA is focused on

optimizing the patient’s quality of life by decreasing
pain and improving function (Hunter & Felson, 2006).
 Cont….

• Treatment of knee OA is also focused on

preventing/reducing joint stiffness, and
improving muscular/ligament stabilization and
joint mobility (Zhang et al,2008).
 Epidemiology and Economic
Importance.
• Osteoarthritis is the most prevalent form of arthritis and

occurs especially in the knee joint.

• It affects nearly 6% of all adults

• The burden of knee OA alone is particularly high and is on the

rise. (Cram et al., 2010)

• According to data from 2003 to 2005, at least 27 million

Americans have OA. ( Lawrence et al.,2008).

• Health impact, and economic consequences of OA, are

largely due to the aging of the US population and the

obesity epidemic ( CDC,2010)

• At least two hospital-based studies have shown that OA

is common in Nigeria (Akinpelu et al., 2007; Ogunlade,

Alonge, Omololu & Adekolujo, 2005).

• About 10% of people with the age of 55yrs or above

(and 50% of 65+) are having knee OA, of whom a

quarter are severely disabled.

• Although OA occurs all over the world, there are

ethnic differences in its prevalence (Mody & Woolf,

2003).
• Approximately 10% of men and 18% of women suffer

symptomatic OA (Woolf & Pfleger, 2003) with

radiological evidence in more than 50% of people

over 65 years of age (Royal Australian College of

General Practitioners, 2009).

• Akinpelu et al.,(2007) documented that

osteoarthritis is more common in females than males

(3.5:1) and that the knee joint is most frequently

affected.

• Reported to substantially reduce life expectancy by

12% when occurring as a co morbidity with obesity

(Warner, 2011).
According to American Academy of Orthopedic Surgeons
(2008)

• Approximately 60 000 primary total knee arthroplasty

(TKA) procedures, a common procedure in patients
with severe knee OA, are performed annually in the
United States.
• TKA volume increased to 161.5% in the US Medicare

population between 1991 and 2010.

• Furthermore, in 2006, 496 000 hospital admission,

and $19 billion in hospital charges were due to knee

OA.
 INCIDENCE OF OA KNEE IN NOH-DALA (JULY, 2018-
JUNE, 2019)
MONTH AFFECTED SIDE TOTAL
LEFT RIGHT BILATERAL
M F M F M F M F
JULY 2 2 2 1 - 3 4 6
AUGUST 2 - 1 - 1 1 4 1
SEPTEMBER - - 1 1 1 1 2 2
OCTOBER 1 1 - 1 1 2 2 4
NOVEMBER - 1 1 1 1 2 2 4
DECEMBER - 2 1 1 1 2 2 5
JANUARY - 1 2 2 1 - 3 2
FEBRUARY 2 1 - 2 2 2 4 5
MARCH 1 2 1 1 3 3 5 6
APRIL 1 1 1 - 1 3 3 4
MAY - 1 1 2 1 1 2 4
JUNE 1 - 1 2 2 2 4 4
TOTAL 10 12 12 14 15 22 37 48
ECONOMIC IMPORTANCE OF OA KNEE
IN NOH-DALA (JULY,18-NOV, 2018)

• From above statistic, a total of 85 knee OA patients

comprising of 37 males and 48 females presented for

treatment in ten month.

• Each attending twice/week, 8 times/month

• An individual patient would have incurred the sum of

#5000 for five physiotherapy sessions.

RELEVANT ANATOMY OF THE KNEE
• The knee is composed of
two joints, the
tibiofemoral and the
patellofemoral.
• It is an articulation
between the distal
condyle of femur and the
proximal surface of tibia
and the articulation
between the femur as
well as the patella.
 OSTEOLOGY
The bones that form
the joint are;
• Femur
• Tibia
• Patella
 MUSCULATURE
ANTERIOR MUSCLE
GROUP
• Muscles acting on the
patellofemoral joint are
the quadriceps muscles:
• Rectus femoris,
• Vastus medialis,
• Vastus lateralis,
• Vastus intermedius.
(Kenhub, 2014).
POSTERIOR MUSCLE
GROUP
• Hamstrings muscles
• Calf muscles
LATERAL MUSCLE GROUP
• Hamstring tendon
• Iliotibial band
OTHER SOFT
TISSUES
• Ligaments &
• Cartilages
 INNERVATION
• Innervation: branches
of the femoral,
obturator, tibial and
common peroneal
nerves (Hamilton,
1987).
 VASCULAR SUPPLY
• Blood supplies:
popliteal arteries
through a bout of
anastomosis from
superior and inferior,
medial and lateral and
descending genicular
arteries and the
anterior tibia recurrent
artery (Hamilton, 1987).
 PATHOPHYSIOLOGY
• The pathogenesis of knee OA have been linked to

biomechanical and biochemical changes in the articular

cartilage of the knee joint.

• The key functional feature of OA is that the articular cartilage

can no longer act as a shock absorber because its extracellular

matrix has been destroyed by the repetitive wear and tear

from the frictional forces and/or other predisposing factors.

• Degradation of matrix components corresponds to failure

of the articular cartilage to withstand cyclic loading,

which, in turn, accelerates its further degradation

especially in the load-bearing regions.

• Molecular events simultaneously taking place, will

further help in the destruction of the articular surfaces.

• Early stages of the condition are characterized by

changes in cartilage thickness, which in turn are

associated with an imbalance between cartilage

breakdown and repair.

• The cartilage eventually becomes softened and

roughened.
• Over time the cartilage wears away, and the

subchondral bone, deprived of its protective cover,

attempts to regenerate the destroyed tissue,

resulting in increased bone density (sclerosis) at the

site of damage and an uneven remodeling of the

surface of the joint.

• This is followed by the destruction of other joint

tissues, such as the subchondral bone, the synovial

capsule.

• Destroyed/exposed subchondral bone subsequently

develop cracks and some small fluid filled bone lesions

called the bone cyst

• Thick bony outgrowths (osteophytes) subsequently

develop, from the deposits calcium of the degraded

articular surface and thickened synovium.

• Joint space narrowing becomes significant.

• Articulation of the joint becomes difficult.

RADIOGRAPHIC CHANGES
 CLASSIFICATION
• OA is classified into two groups according to its
etiology: primary (idiopathic or non-traumatic) and
secondary (usually due to trauma or mechanical
misalignment).

• The severity of the disease can also be graded

according to the radiographical findings by the
Kellgren–Lawrence (KL) system described in 1957.
The Kellgren and Lawrence system is a method of classifying

the severity of knee osteoarthritis (OA) using five grades:

• Grade 0: no radiographic and symptomatic features of OA

are present, healthy joint.

• Grade 1: doubtful joint space narrowing (JSN) and possible

osteophytic lipping, with no pain or loss of function.

• Grade 2: definite osteophytes and possible JSN on anteroposterior

weight-bearing radiograph, symptoms begin to appear.

• Grade 3: multiple osteophytes, definite JSN, sclerosis, possible bony

deformity, obvious cartilage damage and more frequent symptoms.

• Grade 4: large osteophytes, marked JSN, severe sclerosis, complete

severe cartilage loss, mal alignment and definite bony deformity

with persisting symptoms.

 RISK FACTORS
• Age
• Gender
• Obesity
• Previous knee injury
• Occupation
• Smoking
• Joint hypermobility or instability
• Peripheral neuropathy
• History of prolong immobilisation
• Family history
(Coleman et al., 2012)
 CLINICAL PRESENTATION

• Pains/inflammation

• Loss of function

• Decrease in joint ROM

• Crepitation
• Joint stiffness

• Muscle atrophy

• Joint deformity (varus/valgus)

• Bony hypertrophy

• Elevated sensitivity (esp. COLD)

 DIFFERENTIALS
• Meniscal pathology
• Ligamentum and/or soft tissue pathology
• Bursitis
• Chondromalacia patellae
• Other arthritic conditions
Etc
 ASSESSMENT
• Subjective Evaluation:

- Relevant clinical history

- Mechanism of injury (when, where/ how)

- Aggravating factors/relieving factors

-Previous history of trauma/infection

11/8/2019 45
• O/E

Observation; gait, erythyema, temperature,

swelling, atrophy, deformity, bony contour

Body physique/body build

• Palpation;

pain/ tenderness, tonicity, soft or bony enlargement

• Joint rom/integrity- PROM/AROM- goniometry

• Crepitus associated with movement

11/8/2019 47
• Muscle power grading

• Ligament status assessment

• Functional ability/limitations

• Radiological/laboratory investigations
 Aims of management
• To relieve pain
• To improve/maintain ROM
• To strengthen mms
• To improve functional abilities
• To improve the quality of life
 MANAGEMENT

• The management of knee OA is multi-disciplinary,

involve;

– Pharmacological therapy

– Physiotherapy

– Surgery

11/8/2019 51
 Physiotherapy Treatment
It may comprise:

• Cryotherapy

• Thermotherapy

• Therapeutic Exercise

– Strengthening exercise

– Open chain /Closed chain

kinetic Exs

– Free resistance exercise

Bicycle Ergometer And Electrical
Muscle Stimulator
 Physiotherapy mgt contd
• Soft tissue manipulation

• The use of walking aids

• Joint mobilization

• Activity modification

• Biomechanical correction

(e.g. the prescription of

orthotics)
 Therapeutic Exercise
• Physical therapy and Exercises are important
components in the management of knee OA
and can help patient achieve and maintain
optimal mobility.
• Exercise helps to:
• Increase flexibility
• Maintain range of motion
• Strengthen surrounding muscles
• Decrease associated inflammation
• Improve overall fitness
• Exercise is recommended as a first-line conservative

intervention approach for knee (OA).

• Exercise included aerobic or endurance activities (eg,

walking and cycling), strength training with and

without weights, and balance training.

• Evidence supports both aerobic exercise (land-based

or water-based) and progressive strengthening

exercises reducing pain and improving physical

function in patients with mild to moderate knee OA.

• Therapeutic exercises have been found to have

effects on the followings;

• Pain

• Stiffness

• Range of movement

• Muscle strength

• Position sense
Hamstring stretch and calf stretch
Straight leg raise and quad set
seated Hip march and pillow squeze
Heel raise and side leg raise
Sit to stand and one leg balance
Steps up and walking
Low impact activities and water
aerobics
• Other exercises that are
easy on the knees
include biking,
swimming, and water
aerobics. Water exercise
takes weight off painful
joints.
 Exercise Prescription
- Frequency

- Intensity

- Mode

- Duration

- Progression

- All these have to be considered based on the assessment

and findings of the patients conditions.

 OUTCOME MEASURES

• IKHOAM

• Numeric pain rating scale

• Goniometer

• WOMAC
REVIEW OF STUDIES ON THERAPEUTIC
EXERCISES
• An overview of systematic reviews of physiotherapy

interventions for patients with OA of the knee

demonstrates that exercise can reduce pain and

improve function in patients with knee OA (Jamtvedt

et al., 2008).
• According to OA Research Society International

(OARSI) , patients with symptomatic knee OA may

benefit from appropriate exercises to reduce pain

and improve functional capacity.

• In OARSI guideline ( Zhang et al, 2007), patients with

knee OA should be encouraged to undertake and

continue regular aerobic, muscle strengthening, and

range-of motion exercises.

• In a research done by Egwu, et al, (2015)on the

comparative efficacy of self management education

(sme) and quadriceps strengthening exercises (qse)

on 79 knee OA patients .

• Result established significant reduction in pain

intensity in quadriceps strengthening group.

 Case study: 1
• Name: A.B
• ADDRESS: kano
• AGE: 48
• SEX: male
• P/C: left knee pain x 5/12

• H/X : patient developed insidious onset of intermittent left

knee pain 5/12 ago, pain was more at night and relieved on
sitting but worsened early in the morning and subsides later
in the day. He found it difficult to walk fast as a result of the
pain, he has been on pain reliever with mild relief later
decided to visit NOHD after a relative advised him to do so.
Was referred from SOPD 2/12 ago prior to presentation to
commence physiotherapy management.

• PMHX: HTNO, DMO, TraumaO, SCDO .

 Cont…
• DHX: currently on pain reliever
• FSHX: married with three children, a police officer,
physically active who enjoys playing football, AlcoholO, kola
nutO, smokingO

• O/E: an apparently healthy looking man, who walked into

physiotherapy outpatient treatment unit on a normal gait.
Not in obvious pain distress, afebrile to touch, anicteric,
and acynosed.

• CNS: well oriented in TPP, conscious and alert.

• Vital Sign: B/P: 110/80 mmHg
• PR: 78bpm
• RR: 20cpm.
• BMI: 20kg/m2 (weight 65kg, height 1.77m)
 Functional Assessment
• Lower Limb Assessment
• Right Lower Limb Apparently Normal

• Left Lower Limb (knee)

• ROM: full and painful in both active and passive range
of motion
• GMP: 4
• Deformity: mild valgus deformity present
• Tenderness: 1
• Atrophy: nil
• Swelling: mild swelling observed at the lateral aspect
of the knee.
 Special Test
• Goniometric measurement
• flexion 0-135o Extension 0o
• Valgus Stress Test: +ve Varus Stress Test: -ve
• Anterior and posterior drawer’s test: -ve
• Patella apprehension test: -ve
• Patella mobility test: mobile
• Patella grinding test: +ve
• Crepitus: present
• Apley’s Test : -ve

• Pain assessment
• Numerical Pain Rating Scale (NPRS)= 6/10
• Nature of pain: dull and intermittent
• Site of pain: lateral aspect of the knee
X-RAY
• Functional Abilities And Limitations
• Pain on long distance walk
• Unable to carry load
• Independent on activities of daily living (ADL)

• Impression: Reduced musculoskeletal function

of the left knee 2o to osteoarthritis (grade 2)
 Management
• Aim of management
• To relieve pain
• To improve function
• To prevent complication
• To improve the Quality of life

• Plan of management
• Cryotherapy/Thermotherapy
• Manual therapy
• Strengthening and flexibility exercise
• Open chain kinetic exercise
• Knee support
• Home program
 Review
• Findings after 6 sessions
• GMP 5
• Swelling subsided
• NPRS reduced to 2/10
 case study 2
• Name: U F
• Gender: Female
• Address: Kano
• Age: 61Years

• P/C: bilateral knee pain x 2years

• Hx: patient developed right knee pain 2years ago, 2/12 later
the pain transferred to the left knee, patient reported early
morning stiffness of which pain subsided during the day. Pt
found it difficult to stand after a prolonged sitting however,
resorted to self medication with mild relief and the swelling
was controlled. Upon visit back to kano, she decided to come
to NOHD and thus was referred to physiotherapy through the
SOPD to commence management.
• PMHX: HTNO, DMO, TraumaO, SCDO.
• DHX: currently on pain reliever

• FSHX: A widow, blessed with 7 children, a trader who

lives in a bungalow, AlcoholO, kola nutO, smokingO

• O/E: An apparently elderly woman, walked into

physiotherapy outpatient unit on an antalgic gait.
Afebrile to touch, anicteric and acyanosed. On obvious
pain distress.
• CNS: conscious and well oriented in TPP.
• Vital sign: BP: 140/90 mmHg
PR: 80 bpm
RR: 21cpm
BMI: 22kg/m2 (weight 60kg, height 1.65m)

• Pain Assessment
• Numeric Pain Rating Scale (NPRS): right 7/10 and left
5/10
• Nature Of Pain: dull and intermittent
• Site Of Pain: lateral aspect of both knee
 Both Knee Functional Assessment
Right Left
Muscle Strength Grading
Flexors 4 4
Extensors 3 4
Range Of Movement
Active : limited and painful Limited and painful
Passive: limited and painful Full and painful
Swelling: mild Nil
Stiffness: present Absent
Tenderness: 2 2
Deformity: Mild valgus deformity Nil
Warmth: Nil Nil
 Special Test
• Right • left
• Goniometry Assessment: • 0-90 o and 0o
Flexion: 0-100 o Extension: 0 o
• Crepitus: present • Present
• Anterior Drawers Test: +ve • +ve
• Posterior Drawers Test: -ve • -ve
• Valgus Stress Test: +ve • -ve
• Varus Stress Test: -ve • -ve
• Apley’s Test: -ve • -ve
• Patella Apprehension Test: +ve • +ve
• Patella Grinding Test: +ve • +ve
• Patella Mobility Test: Not mobile • Not mobile
Cont….
X-ray
• Functional Activities And Limitations
• Difficulty sitting for a long time (5 mins)
• Lying relieves pain
• Walking elicited mild pain.

• Impression: limited functional ability of the both knee

2o to osteoarthritis (grade 3)

• Aims Of Management
• To relieve pain on both knee
• To improve and maintain function
• Prevent complication
• Improve the quality of life
• Plan Of Management
• Cryotherapy/Thermotherapy
• Manual therapy
• Strengthening and flexibility exercise
• Open kinetic chain exercises
• Knee support
• Home program
 Review
• Findings After 8 Sessions
• Swelling subsided
• GMP: improved to 4/5 bilaterally
• Range of motion improved 110o respectively
• NPRS reduced to 4/10 for right and 2/10
respectively
• Valgus test: –ve bilaterally
 CONCLUSION

• OA is a common disease of the ageing population,

showing its inevitability and of economic importance.

• Pain and associated disability of the knee are

common symptoms of OA. Exercises and physical

activity have been proven to provide relief in patient

with knee OA.

 Recommendation

• Exercises due to its effectiveness, and its

availability is recommended in the

management of Knee OA.

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