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Second Line
- Topical capsaicin is an adjunct therapy for knee and hand OA; may cause local burning
- Topical NSAIDs (e.g., diclofenac gel) can lower gastric and renal risks associated with oral NSAIDs.
- Rubefacients (e.g., oil of wintergreen) are not recommended.
- Physical therapy: Core strengthening for hip OA and knee muscle strengthening for knee OA decrease joint reactive forces on the affected joint and can relieve pain.
- Bracing; Medial and lateral unloader braces are effective; long leg alignment x-rays can help determine the appropriate brace (1).
Third Line
- Intra-articular corticosteroid injections can be used for acute flares and for patients failing first- and second-line treatments. Minimize injections (<2/joint/year).
- Current recommendations do not support the use of viscosupplementation injections for OA.
- Platelet-rich plasma (PRP) is more effective than HA injections for early stage knee OA (2).
- PRP injections appear to be more effective for early OA when done in a series of three (3).
- Glenohumeral joint OA managed with HA injections and corticosteroid injection have similar outcomes (4).
- TENS is effective for pain relief in large joint OA.
- Ultrasound improves injection accuracy.
ADDITIONAL THERAPIES
Address psychosocial factors (i.e., self-efficacy, coping skills). Screen for and appropriately treat anxiety and depression. Improve social support. ‚
SURGERY/OTHER PROCEDURES
Surgery (e.g., osteotomy, debridement, removal of loose bodies, joint replacement, fusion) may be indicated in advanced disease. ‚
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Nutritional supplements (glucosamine and chondroitin sulfate) may benefit some patients and have low toxicity. There is lack of standardized outcome assessments. Trial results using glucosamine and chondroitin have been mixed. If no response is apparent within 6 months, treatment should be discontinued.
- TENS units and acupuncture have shown benefit.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Regularly assess joint range of motion and functional status.
- Monitor for GI blood loss, cardiac, renal, and mental status in older patients on NSAIDs or aspirin.
- Periodic CBC, renal function tests, stool for occult blood in patients on chronic NSAID therapy
PATIENT EDUCATION
- American College of Rheumatology: http://www.rheumatology.org/public/factsheets/index.asp?aud=pat
- Arthritis Foundation: http://www.arthritis.org
PROGNOSIS
- Progressive disease: early in course, pain relieved by rest; later, pain may persist at rest and at night.
- Joint effusions and enlargement may occur (especially in knees), as disease progresses.
- Osteophyte (spur) formation, especially at joint margins
- Advanced stage with full-thickness loss of cartilage at which point joint replacement is a consideration
COMPLICATIONS
- Leading cause of musculoskeletal pain and disability
- Decompensated CHF, GI bleeding, decreased renal function on chronic NSAID or aspirin therapy
REFERENCES
11 Dessery ‚ Y, Belzile ‚ EL, Turmel ‚ S, et al. Comparison of three knee braces in the treatment of medial knee osteoarthritis. Knee. 2014;21(6):1107 " “1114.22 Guler ‚ O, Mutlu ‚ S, Isyar ‚ M, et al. Comparison of short-term results of intraarticular platelet-rich plasma (PRP) and hyaluronic acid treatments in early-stage gonarthosis patients. Eur J Orthop Surg Traumatol. 2015;25(3):509 " “513.33 G ƒ ¶rmeli ‚ G, G ƒ ¶rmeli ‚ CA, Ataoglu ‚ B, et al. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial [published online ahead of print August 2, 2015]. Knee Surg Sports Traumatol Arthrosc.44 Colen ‚ S, Geervliet ‚ P, Haverkamp ‚ D, et al. Intra-articular infiltration therapy for patients with glenohumeral osteoarthritis: a systematic review of the literature. Int J Shoulder Surg. 2014;8(4):114 " “121.
ADDITIONAL READING
- Chen ‚ WL, Hsu ‚ WC, Lin ‚ YJ, et al. Comparison of intra-articular hyaluronic acid injections with transcutaneous electric nerve stimulation for the management of knee osteoarthritis: a randomized controlled trial. Arch Phys Med Rehabil. 2013;94(8):1482 " “1489.
- Jiang ‚ L, Tian ‚ W, Wang ‚ Y, et al. Body mass index and susceptibility to knee osteoarthritis: a systematic review and meta-analysis. Joint Bone Spine. 2012;79(3):291 " “297.
- Shimizu ‚ M, Higuchi ‚ H, Takagishi ‚ K, et al. Clinical and biochemical characteristics after intra-articular injection for the treatment of osteoarthritis of the knee: prospective randomized study of sodium hyaluronate and corticosteroid. J Orthop Sci. 2010;15(1):51 " “56.
CODES
ICD10
- M19.90 Unspecified osteoarthritis, unspecified site
- M19.91 Primary osteoarthritis, unspecified site
- M19.93 Secondary osteoarthritis, unspecified site
- M19.92 Post-traumatic osteoarthritis, unspecified site
ICD9
- 715.90 Osteoarthrosis, unspecified whether generalized or localized, site unspecified
- 715.10 Osteoarthrosis, localized, primary, site unspecified
- 715.20 Osteoarthrosis, localized, secondary, site unspecified
SNOMED
- 396275006 Osteoarthritis (disorder)
- 239862000 Idiopathic osteoarthritis
- 443524000 Secondary osteoarthritis
- 699262001 Post traumatic osteoarthritis (disorder)
- 201826000 Erosive osteoarthrosis (disorder)
CLINICAL PEARLS
- Patients with OA typically have morning stiffness lasting for <15 minutes.
- OA most commonly affects the hips, knees, and hands (PIP and DIP joints).
- Intra-articular steroid injections should be limited to no more than 2 per joint per year (if used at all).
- Consider PRP for early stage knee OA.
- American Academy of Orthopaedic Surgeons (AAOS) recommends against the use of HA injections for OA.
- Long-term therapy should be based on individual patient goals and expectations, particularly regarding pain management and activity level.