SEMINAR PRESENTATION

ON

MANAGEMENT OF KNEE JOINT ARTHRITIS

BY

AGHACHI RAPTURE CHINECHEREM

(ORTHOPEDICS UNIT)

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 OUTLINE
 Introduction
 Epidemiology
 Etiology
 Relevant Anatomy
 Pathophysiology
 Risk factors
 Clinical signs and symptoms
 Diagnoses
 Outcome measure
 Management
 Prognosis
 Case presentation
 Conclusion
 References 2
Introduction

 Osteoarthritis (OA) also known as a

degenerative joint disease, is typically the
wear and tear and progressive loss of
articular cartilage.
 OA is the commonest form of arthritis
globally with the most affected joints being
the large weight bearing joints such as, the
hip and knee.
 Knee osteoarthritis (OA), is a progressive
disease caused by inflammation and
degeneration of the structures around the
knee joint.
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Epidemiology
 OA is the most common disease of joints worldwide, with the knee joint being mostly
affected.
 The global prevalence of symptomatic OA is 9.6% among men and 18% among women.
(Mody and Woolf, 2003). Due to the higher prevalence of asymptomatic OA, it is estimated
that 250 million people all over the world suffer from OA.
 In Nigeria, an article by Akinpelu et al., 2007, stated that OA is more common in females
than in males in the ratio 5:3 and the knee is the most frequently affected joint. Knee OA
can lead to activity limitations, particularly walking, and also affects participation and quality
of life.
 In Physiotherapy department of the University of Uyo Teaching Hospital, one hundred and
seventy three (173) cases of knee OA has been recorded in the last four years which consist
of 110 females and 63 males.

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Etiology

 Primary knee OA: this is articular degeneration without any known cause.
 Secondary knee OA: articular degeneration of a known cause.
 Obesity
 Joint hyper mobility or instability
 Malpositioning of the joint e.g valgus/varus posture.
 Congenital defects
 Immobilization and loss of mobility
 Family history
 Metabolic causes e.g. ricket
 Scoliosis

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Relevant Anatomy

 The knee is the largest joint in the body. It is

a compound synovial joint that consists of
the tibio-femoral joint and the patello-
femoral joint.
 The four (4) main stabilizing ligaments of
the knee are: the anterior cruciate ligament
(ACL), Posterior cruciate Ligament (PCL),
Medial collateral Ligaments (MCL), and
Lateral collateral ligaments (LCL).

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Pathophysiology

 The pathogenesis of OA involves the

following:
 Degradation of cartilage and
remodelling of bone.
 The release of enzymes
 Break down of collagen and
proteoglycans,
 Destruction of articular cartilage
 Exposure of the underlying
subchondral bone
 Formation of osteophytes and bone
cysts.
 Progressive reduction in joint space.
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Pathophysiology

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Clinical features of knee OA

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Risk Factors of Knee OA

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Diagnosis of Knee OA

 Diagnosis of Knee OA can be gotten

through the following:  Objective Assessment

 A detailed History ( Subjective and  Observation of the knee

objective).  Range of motion (ROM) testing

 X-ray  Palpation
 MRI (Magnetic Resonance Imaging).  Muscle strength
 CT Scan  Balance
 Reflex testing
 Subjective Assessment
 A detailed history is obtained using the
OLDCART ( Onset, Location, Duration,
Character of pain, Aggravating factor,
Relieving factor and Time). 11
 DIAGNOSIS

 Radiological findings of OA
Diagnosis

Special Test
• Patellar Apprehension (patella
instability)
• McMurray test (medial and lateral
meniscus tear)
• Anterior Drawer’s test (Anterior
Cruciate ligament (ACL) injury)
• Valgus stress test (Medial collateral
ligament (MCL) injury)
• Varus stress test (Lateral collateral
ligament (LCL) injury)
• Lachman test (ACL)
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Differential Diagnosis

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 OUTCOME MEASURE

 The Knee Injury and Osteoarthritis Outcome Score (KOOS)

 The Western Ontario and McMaster Universities Arthritis Index (WOMAC)

 IKHOAM (Ibadan Knee/Hip osteoarthritis outcome measure)

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Management of Knee OA

 Conservative management ( Physiotherapy)

 Pharmacological management
 Surgical management

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Management

pharmacological management
 Acetaminophen
 Nonsteroidal anti-inflammatory drugs
(NSAIDs)
 COX-2 inhibitors
 Glucosamine and chondroitin sulfate
 Corticosteroid injections
 Hyaluronic acid (HA)

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Management

Surgical management
 Arthroscopy
 Tibial Osteotomy
 Patellofemoral joint arthroplasty
 Unicompartmental Knee arthroplasty
 Total knee replacement

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Physiotherapy Management

 The physiotherapeutic management for knee OA begins with obtaining a detailed history and
carrying out physical examination that will aid diagnoses and effective management of
patients’ symptoms. (Hay et al., 2006).

Roles of Physiotherapy
• To educate the patient
• To reduce knee pain and inflammation.
 To normalize knee joint range
 Improves proprioception, agility and balance.
 To strengthen weak muscles
 Promotes physical function.

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Physiotherapy Intervention

Heat Therapy

Techniques for heat therapy include the

application of hot packs, paraffin wax, infra-red

and short wave diarthermy.

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Physiotherapy Intervention

 Cryotherapy  Soft Tissue Mobilization (STM)

 Techniques for cryotherapy include  Transcutanous Electric Nerve

application of cold or ice packs. Stimulation (TENS)

 Ultrasound therapy

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Physiotherapy Intervention

Strengthening Exercises
 Static quad set in extension
 Standing terminal extension
 Seated leg presses
 Partial squats
 Straight leg raise

Stretching Exercises
 Standing calf stretch
 Supine hamstring muscle stretch
 Prone quadriceps muscle stretch

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Physiotherapy Intervention

ROM Exercises
 Active and passive knee flexion & extension
 Use of Bicycle ergometer

Aerobic Exercises
 Walking
 Cycling
 Swimming

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External Aids for Knee OA

 Knee Braces
 Walking Aids
 Foot Insoles (orthopedic insoles)

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Prognoses

Prognoses of Knee Osteoarthritis

Knee osteoarthritis is a progressive condition and cannot be reversed. However, treatments are
available which helps to slow down the progression and manage the associated symptoms. Early
management and lifestyle modification of the modifiable risk factors will help in managing and
slowing progression of the associated symptoms.
The course of functional decline is generally one of stability or slowly deteriorating function, but
on an individual level, many patients maintain function or improve during the first three years of
follow-up.
Physical activity has a substantial protective impact on future osteoarthritis-related disability.
(Suri et al., 2012).

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CASE PRESENTATION

Name: Mrs. E
Age: 71 years old
Sex: Female

Chief Compliant.: Bilateral knee pain.

History; Patient was apparently well until 9/12 prior to presentation when she started feeling
pains on the bilateral knee joint. She reported that there was no history of a fall or trauma prior to
the incidence. She also reported that nothing relieves or aggravates the pain. The pain is constant
round- the-clock.
However, she was given some ‘over-the-counter’ analgesics which she reported no relieve until
she then visited UUTH and was subsequently referred to physiotherapy for expert management.
PDHX: Antihypertensive drugs
PsHX: Apendisectomy

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 CASE PRESENTATION

F&SHX: A 71 year-old Farmer, married in a monogamous setting and blessed with 4 children. She
does not smoke, drink or take any form of tobacco. She lives in a bungalow.
O/E: A healthy looking aged woman walked into the treatment cubicle with an antalgic gait, well
oriented in TPP, afebrile to touch, acyanosed, anicteric and in no obvious respiratory distress.
Vitals: BP: 145/80mmHg
 Pulse: 85bpm
 Weight: 92kg
 Pain: 8/10 on Visual Analogue Scale
Segmental Examination
Head & Neck: Monocular Vision
Back & Spine: NAD
Thorax & Abdomen: NAD
Pelvic & Perineum: NAD
Upper Limb: NAD 27
CASE PRESENTATION
Lower Limb Right Left
 AROM (knee flexion) Limited and painful Limited & painful
(0-99 degrees) (0-100 degrees)
 PROM (knee flexion) Limited & painful Limited & painful
(0-108 degrees) (0-115 degrees)
•Patella mobile mobile

 Muscle tone normal normal

 Crepitation present present
 Swelling present present
 Tenderness present present
 Muscle bulk preserved preserved
 Differential warmthpresent present
 GMP (knee flexors)3/5 3/5
 (knee extensors) 4/5 28 4/5
CASE PRESENTATION

Special Tests right left

Valgus test +ve +ve
Varus test +ve +ve
Patella apprehension test +ve +ve
Ant.Drawer’s test +ve +ve
Post. Drawer’s test +ve +ve
Lachman test +ve +ve

Functional Assessment
 Patient cannot stand for a long time.
 Difficulty in walking and climbing stairs.
 Standing up from a chair is difficult.
 Difficulty in carrying out her farm work.
 Patient cannot carry out ADL maximally. 29
CASE PRESENTATION

Physical diagnosis
 Motion impairment: Limited ROM in both flexion and extension on the bilateral knee joint.
 Tenderness on palpation of the bilateral knee joints.
 Muscle impairment: Weakness of flexors and extensors of both knees.
 Mild swelling at the bilateral knee joints.
 Pain at the bilateral knee joint. (VAS: 8/10)
 Ligamentous injuries as reported by special tests
 Functional disability

Diagnosis: Bilateral Knee Pain secondary to Knee Osteoarthritis.

Aims of Treatment (Short term)

 Patient education.
 To relieve pain at the bilateral knee joints.
 To reduce swelling at the bilateral knee joints.
 To improve strength of the weak knee flexors and extensors. 30
CASE PRESENTATION

Aim of treatment (long term)

 To prevent further deformities.
 To improve ROM at the bilateral knee joints.
 To improve function.
Means of Treatment
 Short wave diathermy (SWD) to the bilateral knee joints.
 TENS to the bilateral knee joint.
 Soft tissue mobilization (STM)
 Free active exercises (FAEXs) and Resisted active exercises (RAEXs) to the bilateral lower
limb.
 Isometric muscle contraction exercises (quadriceps & hamstring stretch).
 Bicycle Ergometer.
 Patient education and home program. 31
CASE PRESENTATION

Review after six treatment session

After these six (6) sessions, patient has reported improvement in pain and activities of daily
living.
 Reduced pain at the bilateral knee joint (VAS: 5/10).
 Reduced swelling
 Improved muscle strength (knee flexors 4/5; knee extensors 4/5).
 Improved ROM right left
AROM (knee flexion) 0-110 degrees (0-120) degrees
PROM (knee flexion) 0-115 degrees (0-125)degrees

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CASE PRESENTATION

Conclusion

Knee osteoarthritis is a degenerative joint disease that is posing a serious public health problem
for the global economy. Physiotherapy intervention in conjunction with other non physical means
of management have been proven to be efficient in the management of knee OA, as they help to
slow down the progression of the condition, improve patient’s symptoms, prevent further
deformities and improve the overall quality of life of the patient.

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 REFERENCE

Akinpelu, A., Alonge, T., Adekanla, B. and Odole, A. (2009). Prevalence and Pattern of
Symptomatic Knee Osteoarthritis in Nigeria: A Community-Based Study. Internet Journal of Allied
Health Sciences and Practice. doi:https://doi.org/10.46743/1540-580x/2009.1254.
 
Aweid, O., Haider, Z., Saed, A. and Kalairajah, Y. (2018). Treatment modalities for hip and knee
osteoarthritis: A systematic review of safety. Journal of Orthopaedic Surgery, 26(3),
p.230949901880866. doi:https://doi.org/10.1177/2309499018808669.
 
Ayhan, E. and Kesmezacar, H. (2014). A clinical perspective of IL-1β as the gatekeeper of
inflammation. European Journal of Immunology, 41(5), pp.1203–1217.
doi:https://doi.org/10.1002/eji.201141550.

Brosseau, L., Yonge, K., Welch, V., Marchand, S., Judd, M., Wells, G.A. and Tugwell, P. (2003).
Thermotherapy for treatment of osteoarthritis. Cochrane Database of Systematic Reviews.
doi:https://doi.org/10.1002/14651858.cd004522.
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