OSTEOARTHRITIS OF THE HIP AND KNEE – PART 1
Updated: Nov 2
Hip and knee osteoarthritis (OA) are two of the most common musculoskeletal conditions in our clinical practice. Considering its high prevalence in our society, it is not surprising that OA is the leading cause of disability in our aging population. Up to 40% of the population suffers from OA between the ages of 45-55, and by the time we reach the age of 75, over 80% of the population has OA. (1)
On a personal level, OA of the hip is something I have a lot of experience with; over three years ago, I had my right hip replaced. It was not a fun experience going through all that pain, but it taught me a lot about what it takes to address this condition and get back to a fully functional life again.
Although OA is not a condition that reduces life span, it significantly affects the quality of an individual’s life. Fortunately, manual therapy and exercise can dramatically influence this condition by slowing its progression, reducing or eliminating pain, and improving overall function (3, 17, 21, 22). In some cases, such as mine, surgery is necessary to regain full function, but that is not always the case.
WHAT IS OSTEOARTHRITIS?
OA is a degenerative disorder resulting from the breakdown of cartilage (articular cartilage) in synovial joints. In addition to breaking down cartilage, OA also affects the underlying bone (subchondral bone) and the connective tissue that lines the inside of the joint capsule (synovium).
Damage caused by OA occurs at a faster rate than the body can repair itself, resulting in ongoing degeneration. At a cellular level, several pathomechanical stresses occur (proteoglycan loss and death of chondrocytes.) (3) "Patho" means related to disease, and "mechanical" in this context refers to damage relating to a process that involves purely physical factors.
RISK FACTORS FOR OSTEOARTHRITIS
The causes of OA can be multi-factorial, covering everything from genetic causes to trauma-induced injuries. The following are some of the common risk factors for osteoarthritis:
Age – With the normal aging process, there is a decrease in overall cartilage volume in joints, decreased proteoglycans, and decreased vascularization (blood flow). All of which can lead to cartilage degeneration and OA.
Diabetes – There is increasing evidence that people with diabetes have alterations in fat (lipid) metabolism and that hyperglycemia (excessive glucose levels in the bloodstream) could directly influence cartilage health and subchondral bone. Damage to these structures could contribute to the development or progression of OA. (11, 24)
Genetics - Family history of arthritis.
Muscle Weakness - This is a significant factor since inactivity can accelerate the process of osteoarthritis. OA is a problem with joint degeneration, but the state of the surrounding soft tissue is just as important. For example, strength has been shown to directly impact the progression of knee OA. (10).
Obesity - The relationship between OA and obesity is very clear. Increased weight increases the mechanical stress on weight-bearing joints. Obesity also increases the inflammatory risk for OA since the adipose tissue cytokines promote low-grade inflammation. (8). Weight loss can substantially decrease stress and OA for both the hip and knee joints. (13)
Previous case of Inflammatory arthritis (IA)– IA is joint inflammation caused by an overactive immune system.
Previous surgical procedures can create compensations leading to increased stress, friction, and breakdown of cartilage.
Repetitive motion – causes increased mechanical stress on the joints and further inflames the occurrence of OA (9)
Trauma - Previous trauma substantially increases the risk factor for OA by as much as 20 times. (12, 24)
A FEW MYTHS ABOUT OSTEOARTHRITIS
There are some MYTHS than need to be considered when discussing the topic of OA:
Worsening of OA is inevitable – This just NOT true. Having mild to moderate OA does not mean it will always progress into severe debilitating OA. (2)
There is nothing I can do for my OA – Again, this is NOT true. It is true that there is no cure for OA. That being said, manual therapy and exercise can decrease pain, increase function, and decrease the overall risk factors associated with the progression of OA. (3)
The best way to treat OA is to just leave it alone and rest – Actually NO this is not true, not managing or poorly managing OA can lead to chronic pain, disability, and a cascade of cellular events that could have been prevented. (4)
Avoid sports at all costs, it will definitely lead to OA – The good news is that participating in sports, exercising, and physical activity in general is not associated with the progression of OA. In fact, research is demonstrating it can be protective in nature. (5,6). Even continuing to run is not bad for you, unless you already have severe OA before you begin running.
HALLMARKS OF KNEE & HIP OA
The hallmarks of hip and knee osteoarthritis are limited range-of-motion (ROM), crepitus during active motion, increased sensitivity during palpation, deformity, and swelling of the bone. The American College of Rheumatology (ACR) uses the following criteria: (15,16)
Pain for longer than one month.
Stiffness in the morning for less than 30 minutes.
Joint tenderness on palpation.
Pain for longer than one month.
Hip flexion that is less than 115 degrees, and internal hip rotation that is less than 15 degrees.
Stiffness in the morning for less than 60 minutes.
Patient is usually 50 years and older.
PROGRESSION OF OSTEOARTHRITIS
The symptomatic progression of OA can be divided into three symptomatic stages.
Stage One – Early OA
Occasional episodes of sharp joint pain with certain activities.
Over all function is not limited, except on high impact activities.
Stage Two – Mild OA
Increased frequency and duration of joint pain.
Some patients complain about the joint giving away or locking.
Pain is now affecting activities of daily living. Pain is especially noticeable after getting out of bed and after sitting for long periods of time.
Stage Three - Severe or Advanced OA
The pain is often constant.
Pain can vary in intensity from an aching dull pain to severe pain.
This stage of severe or advanced OA is characterized by a high level of functional limitations.
It should be noted that there is a high degree of inconsistency in correlating radiographic evidence against pain intensity, symptoms and functional limitations. The results also vary greatly between individual cases. Some patients show significant radiographic evidence of OA but NO symptoms, others patient will have no radiographic evidence but significant symptoms. (14)
EXAMINATION AND DIAGNOSIS OF HIP & KNEE OSTEOARTHRITIS
A comprehensive orthopedic and neurological assessment (plus indicated imaging) should be performed on every patient with hip or knee OA to assess the degree of degeneration that has already occurred.
Note: This section is technical and is written for practitioners, feel free to skip this section and go directly to Part 2.
Standard x-rays (anterior, posterior, and lateral views) are very cost-effective and provide valuable information in the diagnosis of OA.
Magnetic Resonance Imaging (MRI) does provide effective soft-tissue and osseous information that cannot be achieved through standard X-rays. However, MRIs are very expensive, and not available to everyone.
Ultrasound has the advantage of not involving radiation but is usually used for the assessment of muscles and tendon pathology. Ultrasound is not used for joint assessment.
Orthopedic & Neurological Testing
The first step in doing an assessment for OA is to rule out red flags (non-musculoskeletal causes of pain). This is often achieved by taking a comprehensive history, followed by an appropriate orthopedic and neurological examination. The following are some of the common tests we would perform an evaluation of both the hip and knee.
Hip Examinations should include:
Straight Leg Raise Test to rule out discogenic radiculopathy (sensitivity 91-92). (25)
Fulcrum test to check for fracture/stress fracture of hip (sensitivity 88-93). (26, 27)
Thigh Thrust Test to evaluate pelvic girdle related pain (sensitivity 88). (28)
FADDIR Test to evaluate flexion, adduction, and internal rotation (sensitivity 99). (29)
Hip Examination - Orthopaedic Testing
This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopaedic examination of the Hip region. This video is a summation of Parts 1 to 5 of the Hip Examination Process.
Knee Examination - Effective Orthopaedic Testing - Knee Examination
This video demonstrates some of the common orthopaedic tests we use to exam our patients knees. (available for the public June 3rd/2022)
Lower Limb Neuro Examination
The lower limb neurological examination is part of the over all neurological examination process, and is used to assess the motor and sensory neurons which supply the lower limbs. This assessment helps to detect any impairment of the nervous system. It is used both as a screening and an investigative tool. (Available for the public Nov. 11/2022)
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is a valuable tool used for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video we go over some of the common procedures we perform in daily clinical practice. This video is available for the public on November 14/2022.
RECOMMENDED ORTHOPAEDIC REFERENCE BOOKS
Orthopaedic Physical Assessment – David J. Magee https://amzn.to/3zgu0za
Dutton'sOrthopaedic: Examination, Evaluation and Intervention, Fifth Edition https://amzn.to/3st1AOv
DIFFERENTIAL DIAGNOSIS - CONSIDER THE POSSIBILITIES
It is important to remember that a diagnosis of Osteoarthritis is always a “working diagnosis”. No diagnosis is completely definitive, it’s always the practitioner’s best guess based on history, examination findings, imaging, and other diagnostic criterion. With osteoarthritis, keep in mind some other possible differentials, such as:
Lumbar Radiculopathy – Referred pain from the lumbar spine.
Avascular Necrosis – This refers to death of bone tissue due to a lack of blood supply. Possible causes include excessive alcohol use, blood clotting disorders and chronic steroid usage. A standard X-ray would be useful to help to rule out these other conditions.
Gout – with cases of gout, the joint and surrounding areas are usually hot to touch and extremely painful on palpation.
Rheumatoid arthritis (inflammatory arthritis) – In these cases, the joint is also usually hot. A lab test can be used to rule out the Rheumatoid arthritis factor. High levels of rheumatoid factor in the blood are most often associated with autoimmune diseases.
In cases of knee pain, it is important to consider referred pain caused by hip osteoarthritis, bursitis, ITBS, ligamentous injury, and osteochondritis in younger patients.
In part two of “Osteoarthritis of the Hip and Knee” we will discuss using manual therapy techniques with video demonstrations showing both joint mobilization and soft tissue techniques that we use. In part two, we provide video demonstrations showing treatments and common exercises that we prescribe to our patients with hip and knee OA.
Note: References are at the end of Part 2
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.
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