OSTEOARTHRITIS

4.1 PERSONAL INFORMATION

 NAME OF THE PATIENT :
 AGE
 GREEN CARD NO
 DEPARTMENT
 PHYSICIAN IN CHARGE :
 MEDICAL DIAGNOSIS
Mrs. Seithum beebi
: 64 years
: 3777/15
: Department of Rheumatology and
Rehabilitation (General) , NHSL.
Dr .Lalith S. Wijeyaratne
(MBBS, MD, FRCP.)
: Osteoarthritis of both knee joint

4.2 SOCIAL HISTORY

 OCCUPATION : Retired
 POSITION IN THE FAMILY : Mother of three children

4.3 HISTORY OF PRESENT COMPLAINS

 This patient was pain in on and off form and identified
swelling at both knee joints.
 At initial stage, those signs were neglected. Gradually that
signs were increased, and there was as difficulty in walking.
On 02nd March 2015 she came to National Hospital of Sri
Lanka for treatment.
 Then she was referred to Department of Rheumatology and
Rehabilitation (General) later she was referred for
Physiotherapy.

4.4 PRESENT COMPLAINS

 She complained about severe pain in the both knee joints. In
the night, pain is increased
 when she was walking long distances and standing in
prolonged periods she got pain severely
 slight stiffness in the morning and it remains only for few
minutes

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 Cracking sound produces in the right knee joint more than

left, when she was moving the leg.
 Mild Swelling around the both knees
 Some movements were limited

0 1 2 3 4 5 6 7 8 9 10

Numerical scales for measuring the pain

4.5 EXAMINATION
 OBSERVATION
 The patient was somewhat obese
 No mark skin alternation from the left knee joint
 Slight thickening around the right knee joint
comparative to the left one
 Mild swelling over right knee compared to the left
 Patient can maintain erect posture but she had
abnormal gait
 There was an audible crepitation in right knee joint

 PALPATION
 No temperature increased over both knee joint
 When pressed the margin of the right knee joint
complained about pain

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 TESTS
Table 4.1 active and passive joint ranges of lower limbs
Left Joint Action Right
Active Active
110 Hip flexion 110

15 Hip Extension 15

40 Hip internal rotation 40

43 Hip eternal rotation 43

43 Hip abduction 44

24 Hip adduction 23

110 Knee flexion 90

2 Knee extension 2

30 Knee internal rotation 23

35 Knee eternal rotation 31

26 Ankle Dorsi flexion 24

46 Ankle plantar flexion 48

32 Foot inversion 30

12 Foot Eversion 13

 Active and passive joint range of the knee together with those
of hip and ankle joint (Reading in degrees)

 Muscle girth taken from the above to base of the patella

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Left Level Right

49 10cm above 48

53 15cm above 51

Table 4.2 Girth of muscles above the knee level in ‘cm’

 Active power of muscle group of lower limbs

Table 4.3 Muscle power of the lower limb of MRC scale.
Left Muscle group Right
4 Hip Flexors 4

4 Hip Extensors 4

4 Hip Internal rotators 4

4 Hip Eternal rotators 4

4 Hip Abductors 4

5 Hip Adductors 5

3 Knee Flexors *

4 Knee Extensors *

3 Knee Internal rotators *

3 Knee external rotators *

4 Ankle Dorsi Flexors 4

4 Ankle Plantar flexors 3

3 Foot Invertors 3

3 Foot Evertors 3

* Movement can take against gravity, but not in full range

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4.6 ANALYSIS OF THE FINDING OF EXAMINATION

There was two type of Osteoarthritis

1. Primary osteoarthritis
2. secondary osteoarthritis
 Primary osteoarthritis
There is no obvious cause
 Secondary osteoarthritis
This arise as a consequence of other condition such as

Normal joint Osteoarthritis joint

Table 4.4 possible causes for secondary osteoarthritis

Possible causes for secondary osteoarthritis
a) Trauma after severe injury, resulting in fractures of the
joint surface
b) Dislocations
c) Infection e.g. Tuberculosis
d) Deformity
e) Obesity
f) Hemophilia

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g) Acromegaly
h) Hyperthyroidism

 The cause is unknown

Table 4.5 predisposing factors

Predisposing factor

i. Condition already mentioned in mentioned to secondary

arthritis
ii. Hereditary
iii. Poor posture
iv. The ageing process in joint cartilage
v. Climate has not been shown to be related to the
pathological change but pain is greater in cold, damp
climates
vi. Defective lubricating mechanism and uneven nutrition of
the articular cartilage
vii. Crystals (Calcium pyrophosphate and hydroxyl apatite)
associated with synovitis in osteoarthritis joints

 The articular cartilage is slowly worn away (progressive

destruction of articular cartilage).

 Then the subchondral bone is exposed. So the underlying

bone becomes hard and glossy. Also bony margins produce a
ring of spurs known as Osteophytes.

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Table 4.6 clinical features

Clinical features

 More frequently affected fat middle aged female

 Gradual onset
 Pain in the affected joint
 Restriction of movements
 Joint enlargement
 Crepitation in the affected joint
 Muscle wasting and weakness

 This patient was having some cardinal signs of an

inflammation at the both knee region because of that, the
patient was unable to take full functions of the joint.

 Power of muscles around the affected knees joint became

weak and it lead to reduction of the muscle girth.

 Then if the condition neglect and keep as it is the patient may

develop the instability of the knee.

 She had an Antalgic gait due to pain and protective muscle

spasm.

4.7 PHYSIOTHERAPY DIAGNOSIS

Painful knee joint with reduced functions.

4.8 PLAN OF TREATMENT

 SHORT TERM GOALS
 Reassure the patient
 Reduce joint pain
 Reduce swelling
 Reduce muscle spasm around the joint

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 LONG TERM GOALS

 Restore fu mobility of the joint
 Increase the power of muscles around the knee joint
 Re-educate the gait
 Improve co-ordination
 Educate the patient about home management
 TOOLS OF MEASUREMENTS
A Goniometer, to check joint ranges

 SELECTED PHYSIOTHERAPY INTERVENTION

 Local heat therapy given to reduce pain and muscle

pain
 Accessory movements to reduce pain and increase
mobility of joint
 Increase joint range of knee joint with mobilization
exercises
 Increase the power of muscle around the knee with
static and dynamic strengthening exercises
 Gait reeducation program included management of
stairs, slope, standing to sitting and etc.
 Same strengthening program for the sound limb
 Educate the patient about home management program

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Table 4 .7 Treatment procedure

Treatment Procedure Duration Frequency
Patient  Explained the patient about
education her condition
 Gave little description about
this condition and how to
overcome the problem
 Gave the advice to rest and
educate about bad postures
and movements (Close kinetic
movements prevented))

 Patient was half lying position 20 three

Heat therapy with semi-flex knee minutes times per
 Use short wave diathermy week
continuous mode with space
electrode

Accessory  Position supine position 10 times Three

movement  Grade 4 accessory movements times per
perform in Antero-posterior, week
Postero-anterior, Inferio-
superior and superior inferior
directions to the right both
knee joints.
 Grade 4 Accessory movements
for mobilize the patella

 Positioned in side lying on her 10 times three

Mobilization left side times per
exercises  Placed pillow between two day
lower limbs

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 Asked her to bend and extend

the knee joint within pain free
range

Strengthenin 1st exercise 10 times three

g exercise Static quadriceps exercise times per

 Small sand bag is placed under day

right knee joint. Then advised

to compress the sand bag for
10 seconds and then relax for
the both knees. At the same
time toes and ankle contracted
towards the head
2nd exercise
Dynamic quadriceps exercise
 Patient was in sitting position
15 times three
((90 90 sitting)
times per
 Do extension of the knee joint
day
last few degrees are very
essential because it for
strengthen the vastus medialis

 Patient was advised to use a

Re- educate walking stick to left hand.
the gait Then she was trained to walk
with a stick properly include
stairs, slopes, standing to
sitting
 Use a walking stick to relieve
pain and stress and help to
balance

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 Rest 5-10 minutes every hour

Advices but avoid being in one
position for longer than half
an hour
 Do exercises daily
 Keep body weight under
control
 Before the exercises, to do hot
water fomentation

4.9 OUTCOME OF THE TREATMENT PROGRAMME

 Reduction of oedema was visible

 Muscle girth above base of the patella at different levels

Table 4.8 Girth of muscles above the knee level in ‘cm’

Left Level Right

50 10cm above 49

53 15cm above 52.5

 Pain was reduced according to numerical pain scale

Numerical scales for measuring the pain

0 1 2 3 4 5 6 7 8 9 10

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 Active and passive joint range of lower limb after treatments

Table 4.9 active and passive joint ranges of lower limbs after treatments

Left Joint Action Right

Active Active
115 Hip flexion 115
17 Hip Extension 17
43 Hip internal rotation 43
43 Hip eternal rotation 43
45 Hip abduction 45
25 Hip adduction 25
130 Knee flexion 128
2 Knee extension 2
30 Knee internal rotation 28
37 Knee eternal rotation 35
28 Ankle Dorsi flexion 27
50 Ankle plantar flexion 50
35 Foot inversion 35
15 Foot Eversion 13

 Active power of muscle group of lower limb, after treatments

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Table 2.10 Muscle power of the lower limb of MRC scale.

Left Muscle group Right
5 Hip Flexors 5
5 Hip Extensors 5
5 Hip Internal rotators 5
5 Hip Eternal rotators 5
4 Hip Abductors 4
5 Hip Adductors 5
4 Knee Flexors *
5 Knee Extensors *
4 Knee Internal rotators *
4 Knee external rotators *
5 Ankle Dorsi Flexors 4
5 Ankle Plantar flexors 4
4 Foot Invertors 4
4 Foot Evertors 4

* Movement can take against gravity, but not in full range

 Patient was in good understanding about home management

4.10 DISCUSSION
The blood circulation increases by using heat therapy. Therefore
it removes the irritants from the area, reduce pain and muscle
pain also reduce the local oedema. (Downie P.A 1993)

As the pain and swelling reduce, patient can take the movements
with less restriction so increases the joint mobility.

Strengthening the quadriceps muscle helps to maintain knee

joint stability. As the arthritic changes of joints are irreversible.

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That’s why Strengthening program is very important to make

stability of the joint (Adam and Hamblen 2003)

How much that we can do within the hospital is not enough for
patient, therefore home managements have to be taught to the
patient.

REFERENCES
o ADAMS J.C., HAMBLEN D.L., (2003): outline of orthopedics, 13th
edition, Elsevier séance, China.
o DOWNIE, P.A., (1993) cash’s text book of general medical and
surgical condition for physiotherapist, 4th edition, P.L. printer,
Delhi.

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