Osteoarthritis

History taking

Aim: Identify 3 clinical triads- Pain, deformity, stiffness

1. Age- young age knee pain due to sport injury, elderly OA

2. Complain (Pain) mostly orthopedic complaints are pain

3. Analyse complain (to know 3 triads of OA)

● Pain- mechanical pain, occur at early phase of motion(start up pain-wake up

from sleep, wake up from sitting), pain relieve by continue moving

● Stiffness- can do squatting? Toileting? Praying?how is the praying done?(fully

bend to floor or how? Must describe details the step of praying patient can do)

● Deformity- any progressive bowing of knee? Inwards or outwards? Any

shortening of leg?

**OA=varus defromity **Rheumatoid arthritis 2o OA = valgus deformity

**shortening in unilateral OA

4. Differential diagnosis

Five causes in orthopedics pain

● Trauma- if no trauma must say specific- no trauma to KNEE

● Infection (2 types)- Bacteria and TB (TB must separate out due to endemic)

Any infection history- fever? Discharge coming out (pus/abscess), prolong

admission to ward for antibiotics? recurrent admission to ward due to lung
infection? **speak this all out show examiner pt not immunocompromise. Say all
these 4 questions is negative if patient say don’t have.

TB infection- Haemoptysis, Fever at night? Night sweat? LOA LOW? Contact

with PTB? Even if all is negative say it out.
● Tumour- Nocturnal pain? Pain score very severe need to be relieve by
morphine? Pain not relieve by normal analgesics? Resting pain-not related to
movement? LOW, LOA

● Degenerative (OA, lumbar spondylosis) - Pain is mechanical type, occur at

early phase of movement (start up pain- wake up from sleep, wake up from
sitting), pain reduced by movement (after 15-30 min of walking).

● Inflammatory- 5 diseases( RA, ankylosing spondylitis, gouty arthritis,

psoariatic arthritis, reitter’s syndrome)

Rheumatoid arthritis-

- pain& stiffness of small joints of hand(fingers) last for >1hr >2weeks: must be
symmetrical (bilateral).

- early morning pain & stiffness of small joints

- pain is symmetrical

- nodules? **Bouchard nodule at PIP and elbow in RA

**Heberden nodule at DIP in Primary OA

Ankylosing spondylitis- More common in male. hx of lower back pain, pain

aggravated by resting (sleep), relieve by exercise, SOB due to chest expansion
limited, anterior uveitis(blurring of vision, redness of eyeball)

Gout- acute pain/inflammation at 1st metatarsal phalangeal joint at big toe (podagra
joint), any treatment receive for gout?

Psoariatic arthritis- scaly skin before?

Reitter’s syndrome- TRIAD: conjunctivitis (redness, blurring of vision), joint pain,

urethritis( dysuria), more common in male patients.
Clinical examination

1. Inspection

2. Palpation

3. Movement

4. Special test

1. Inspection (gait, general, local)

Exposure from umbilicus & below

● Ask patient to walk (must take off shoes)- heel strike, stance and swing

- short stance phase= antalgic gait >>know pain

- shoulder of affected site drop because of varus of knee = short limb gait
>>deformity

● Ask patient to squad, cannot squad >>stiffness

● Ask patient stand again with both foot together-inspect from front, side, back

Infront- see knee varus deformity and gap between knee (measure the gap from
medial condyle with measuring tape).

Side- hyperextension/ fixed flexion deformity

Back- baker cyst at popliteal fossa

**if see baker cyst, diagnosis straight OA, baker cyst is complication of OA

● Then lie the patient

General inspection-hand any nodules at PIP & DIP and elbow, palm, eyes,
temporal muscle wasting etc.

Specific inspection- inspect from top (above knee) to down

⮚ Above knee: Look for vastus medialis oblique, if wasted (flattening of

muscle), normal (bulging)

⮚ Knee: Medial parapatella gutter, if not seen (effusion) **OA normally seen. If
no gutter then do fluid shift test.0
⮚ Below knee: Gastronecmius (media) and peronous (lateral) muscle atrophy

⮚ Scars? Can cause 20 OA

surgical scar-linear and suture line

open wound- irregular shape, sign of contracture

2. Palpation

Superficial and deep palpation

Superfical for temperature and soft tissue, deep for bone. Suprapatellar, patellar
and infrapatellar region.

Superficial palpation: soft tissue

⮚ Palpate normal site first, not raise in temperature **degenerative not

inflammatory

⮚ Palpate the 3 muscles- VMO, gastronecmius, peroneus , if flabbing, soft=

wasted

(Palpate by grasping the muscle by whole hand)

Deep palpation: bone

(sit on patient foot, knee flexed 90o) 4 fingers behind, thumb center.

Start from tibia crest, use 2 thumbs palpate tibia crest from distal to proximal until
reach tibia tuberosity( eyes at pt face), > at level of tibial tuberosity- right thumb
palpate medially til pes anserinus (gracilis, semitendinous, sartorius) look for
tenderness (if tender=RA and AS) > back to tibia tuberiosity> left thumb move
laterally reach fibulla head for tenderness(if tender=RA) > back to tibia
tuberiosity> move up from tibia tuberiosity to soft tissue( patella tendon) > palpate
medial and lateral side will be soft ( area of joint line) then keep palpating to
medial and lateral will feel something hard which is the collateral ligmaments.

right thumb move medially from soft tissue til hard (collateral ligamament)
(usually OA tender at medial joint space)> back to centre> left thumb moves
laterally to collateral ligaments> go up to patella to feel for patella

expect to see tenderness around the joint line.

*** tenderness other than joint line is RA

3. Movement

Active first, then passive

Passive is start from the point that patient cannot do further active movement, (OA
cannot flexed)

- Ask patient to flex and extend the knee.

*OA fixed flexion is due to soft tissue, so passive movement can further flexed.
Thickened knee capsule (soft tissue not bone) - stiffness, so cannot flex actively
but can flex further passively because the capsule is soft.

*If cannot fuether flexed by passive, due to knee ankylosis secondary to septic
arthritis (bone issue)

* not important to measure by goniometer

4. Special test (only do at the affected side), supine, bring foot together.

● Shortening and gap (knee in full extension)

Bring the foot together, check got gap, Use both thumbs dorsiflex the foot

Look the heel, if heel lower/ higher means shortening. If got shortening on the heel,
do galleazi test. Flex knee 90 degree. Put ruler on knee See from tibia side if got
shortening then it means tibia shortening. See from femur side, if got shortening
from that side means it’s a femur shortening.

● Fluid shift (knee in full extension)- do only if medial gutter swollen

Left hand push from suprapatellar (block the space, don’t release hand), left thumb
place on lateral joint space

Right hand shift fluid from medial to lateral. Lift right hand first. Will see a
depression. shift the fluid again from lateral to medial with your thumb.

Eyes look at medial joint space for bulging

Patellar tap- done when the patellar is hugely swollen. Not done in OA.

● Patella grinding test- supine or sitting.( knee in full extension and sitting)
Supine: Passive grinding test- palm push on patella, elbow extended, move patella
in circular motion.

Sitting: knee is flexed 90 degerees. palm push patella, elbow extended. Other hand
extend and flex knee. Can also feel for crepitus.

** positive will be pain

(in sitting position)

Left hand hold ankle, right hand press patella, left hand extend& flexed legs

** felt for crepitus

● Hook test – palpation of under surface of patella: (knee in full extension):

supine position

Left hand push patella to medial side

Right hand hook to palpate patella undersurface at medial side

Look patient face

Lateral repeat the samething

** tender for patella femoral OA

*******do not do drawer, valgus, varus test in OA*******

Not important in OA, important in malunion and non union

Gallaezzi test (knee in 900 flexed)

See from front, put phone above suprapatella, if tilted= tibia shortening

See from above, put phone above infrapatella, if tilted= femur shortening
Investigation

1. Laboratory- routine blood test ( FBC, LFT, RP, FBS only in older people) ,
Inflammatory markers ( tro infection and tumor: ESR, CRP-crp more important
and sensitive), tumour markers ( not imp in OA)

2. Imaging-

● Xray of knee AP, lateral in standing position (4+1 features) Calgrins and
Lawrence classifcation. Calgrins type 4 is with deformity and reduced joint
space. Type 3: reduced joint space. Type 1: Only pain. no reduced joint space
and no osteophyte. Type 2: got osteophyte.

⮚ Narrow joint space

⮚ Subchondral sclerosis

⮚ Subchondral cyst

⮚ Osteophyte

⮚ Foreign bodies/ loose bodies at lateral view

● Ultrasound- do only if fluid shift positive. Only do if got effusion.

● CT, MRI not done in OA

Treatment

Non operative

1. Medical- analgesic given in OA

- muscle relaxant(myonil) not given in OA

- nerve tonic( neurobion) not given in OA

 - antibiotics not given in OA

2. Physiotherapy- Quadricep and hamstring muscle strengthening: for

improving ROM

- LTENS( transelectrical nerve stimulation)

- Ultrasound wave

- Heat therapy

- Shock wave diathomy for pain relieve

: for pain relief

3. Immobilization- knee guard/ knee brace

4. Injection- intraarticular injection hyaluronic acid

Operative

3 types- Arthroscopy knee washout for young patient

- Total knee replacement

- Arthrodesis (knee fusion)