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Unraveling Hip & Knee Osteoarthritis: Part 1 – Intro & Diagnosis

Updated: Jun 17


Man Holding His Knee

Hip and knee osteoarthritis (OA) is a prevalent musculoskeletal condition, becoming a significant cause of disability, especially among the elderly. Studies indicate that the disease affects over 40% of individuals between 45 and 55 years and surges to more than 80% by the age of 75 (1). Personally, I've faced the challenges of hip OA, having undergone a right hip replacement. While the journey was marked by substantial pain, it offered me invaluable insights into managing OA and regaining full functionality.


Though OA doesn't reduce life expectancy, its influence on one's quality of life is profound. Manual therapy and exercise can profoundly impact OA management, slowing its progression, reducing pain, and improving functionality (3, 17, 21, 22). In certain cases, like mine, surgery is necessary for full restoration, but it isn't always the required course of action.


Article Index


Introduction


Examination & Diagnosis


Conclusion Part 1


Note: Part 2 of this series covers manual therapy and exercise.

 

Osteoarthritic Hip Joint

What is Osteoarthritis


OA is a degenerative disorder resulting from the wear and tear of articular cartilage in synovial joints. It doesn't just affect the cartilage, the subchondral bone beneath it, and the synovium lining the joint capsule.


The rate of degeneration surpasses the body's ability to repair itself, causing sustained damage. At a microscopic level, OA induces pathomechanical stresses, such as the loss of proteoglycans and the death of chondrocytes.


In this terminology, "patho" refers to factors related to the disease, whereas "mechanical" signifies physical elements contributing to the damage (3).


 


Man Grabbing His Belly Fat

Risk Factors


Several factors can increase an individual's risk of developing osteoarthritis (OA). These include:


  • 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 altered fat (lipid) metabolism, and 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: A family history of arthritis can also increase an individual's risk for developing OA.

  • 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 clear. Increased weight increases the mechanical stress on weight-bearing joints. Obesity also increases the inflammatory risk for OA since adipose tissue cytokines promote low-grade inflammation. (8) Weight loss can substantially decrease stress and OA for hip and knee joints. (13)

  • A previous case of Inflammatory Arthritis (IA) is joint inflammation caused by an overactive immune system.

  • Previous surgical procedures: These can create compensations leading to increased stress, friction, and breakdown of cartilage.

  • Repetitive motion: This 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)


 

Truth Bowling Ball Hitting The Myth Pins

Myths


Osteoarthritis (OA) is a common condition affecting millions worldwide. Despite its prevalence, several myths surrounding the topic of OA need to be addressed.


These include:

  • Worsening of OA is inevitable: This is not true. Having mild to moderate OA does not mean it will always progress into severe, debilitating OA. (2)

  • I can do nothing about my OA: This is also not true. While there is no cure for OA, 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. This is not true either. 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 Osteoarthritis


Hip and knee osteoarthritis are widespread musculoskeletal disorders with significant discomfort and impaired function. Key features include limited joint range of motion, crepitus (an audible or palpable grinding sensation within the joint during active motion), heightened sensitivity upon palpation, joint deformity, and bone swelling at the joint site, all of which reflect the ongoing inflammation and tissue damage within the joint (15,16).


X-ray of Osteoarthritic Knee

Knee Osteoarthritis Characteristics:

  • Persistence of pain exceeding a month.

  • Morning stiffness lasting less than half an hour.

  • Presence of crepitus during active range-of-motion (AROM).

  • Tenderness of the joint upon palpation.

  • Enlargement of the bone at the joint site.


Hip Osteoarthritis Features:

  • Experiencing pain for a duration extending beyond one month.

  • Hip flexion is limited to less than 115 degrees, and internal hip rotation is restricted to less than 15 degrees.

  • Morning stiffness persists for less than 60 minutes.

  • Typically observed in individuals aged 50 and above.


 

Man Holding His Knee

Stages of Progression


The symptomatic progression of osteoarthritis (OA) can be divided into three stages:


Stage One - Early OA

  • Occasional episodes of sharp joint pain with certain activities.

  • Overall 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 daily activities.

  • Pain is especially noticeable after getting out of bed and sitting for long periods.


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, while others may have no radiographic evidence but significant symptoms. (14)


By understanding the symptomatic progression of OA, healthcare professionals can tailor treatment plans to the specific needs of their patients. This can help reduce symptoms, increase function, and improve the overall quality of life.


 

Examination and Diagnosis


A comprehensive orthopedic and neurological examination, supplemented with necessary imaging, is recommended for an accurate appraisal of the existing degree of degeneration in individuals with hip or knee osteoarthritis (OA). This all-inclusive evaluation equips healthcare providers with a detailed understanding of the disease's progression, thereby facilitating the formulation of customized treatment strategies aligned with each patient's specific needs.


MRI of the Knee

Imaging


Imaging is crucial in diagnosing and managing osteoarthritis (OA). It allows healthcare professionals to visualize and assess the degree of joint degradation, thereby guiding therapeutic interventions and monitoring disease progression.


OA Imaging Modalities Several imaging modalities are available for OA, each with unique benefits and limitations. These include:


  1. Conventional Radiography: Standard radiographs, including anterior, posterior, and lateral views, are economical and essential for OA diagnosis. They can detect changes in bone architecture, such as osteophyte formation, joint space narrowing, and subchondral sclerosis.

  2. Magnetic Resonance Imaging (MRI): MRI effectively evaluates both soft tissue and bone structures, which are unattainable with conventional radiographs. It can identify subtle changes in cartilage, ligaments, and other soft tissues that are often unnoticed on X-rays. However, MRIs are expensive and may not be available to all.

  3. Ultrasound: Ultrasound is a safe non-radiative imaging option. While typically used for muscle and tendon pathologies, it isn't routinely utilized for joint evaluations.


Orthopedic & Neurological Assessment


When evaluating a patient for OA, it's vital to exclude any red flags or non-musculoskeletal causes of pain. Typically, a comprehensive patient history precedes a thorough orthopedic and neurological examination. Various standard tests on the hip and knee can help determine the presence and extent of joint degradation. This information can guide treatment decisions and contribute to devising patient-specific care plans.


Hip Examination - Orthopaedic Testing

This video covers inspection and observation, palpation, Active and Passive Ranges of motion, and orthopedic examination of the Hip region. It sums up Parts 1 to 5 of the Hip Examination Process.



Knee Examination - Effective Orthopaedic Testing

This video demonstrates some of the common orthopedic tests we use to examine our patient's knees.





Lower Limb Neuro Examination

The lower limb neurological examination is part of the overall 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.


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.



 

Differential Diagnosis Image

Differential Diagnosis


It is imperative to perceive that a diagnosis of osteoarthritis (OA) fundamentally constitutes an "evolving diagnostic hypothesis." Every diagnostic conclusion hinges on the healthcare provider's clinical acumen, incorporating the patient's comprehensive medical history, clinical examination findings, radiological evidence, and other pertinent diagnostic parameters. It is of utmost importance to incorporate potential differential diagnoses when formulating an OA diagnosis, encompassing:


  • Lumbar Radiculopathy – A scenario characterized by pain originating from the lumbar spine, often due to nerve root impingement.

  • Avascular Necrosis – This pathology is typified by the necrosis of bone tissue due to insufficient blood supply, possibly instigated by factors such as chronic alcohol abuse, coagulopathy, and long-term steroid administration. Conventional radiography can be a valuable tool in differentiating these conditions.

  • Gout – Characterized by an inflamed joint that is typically warm to the touch and elicits severe pain on palpation, often due to the deposition of monosodium urate crystals within the joint space.

  • Rheumatoid Arthritis (RA) – Inflammatory arthritis where the joint is frequently warm. Laboratory investigations to evaluate Rheumatoid Factor (RF) could aid in excluding RA. Elevated serum RF levels are predominantly associated with autoimmune diseases.


In knee-related discomfort, it's vital to consider referred pain potentially attributable to hip osteoarthritis, bursitis, Iliotibial Band Syndrome (ITBS), ligamentous injury, or osteochondritis in pediatric and adolescent patient populations.


 

Conclusion


Hip and knee osteoarthritis (OA) is a prevalent musculoskeletal condition that significantly contributes to disability, particularly among the elderly. Studies indicate that over 40% of individuals aged between 45 and 55 are affected, with prevalence surging to more than 80% by the age of 75. Personally, having faced the challenges of hip OA and undergone a right hip replacement, I can attest to the substantial pain and the journey toward regaining full functionality. This experience has provided invaluable insights into effectively managing OA.


While OA does not reduce life expectancy, its impact on the quality of life is profound. Manual therapy and exercise have proven to be highly effective in managing OA, slowing its progression, reducing pain, and improving functionality. Although surgery may be necessary for full restoration in some cases, it is not always the required course of action. By integrating manual therapy and exercise routines specifically designed for individual needs, most patients experience significant improvements, leading to a better quality of life and enhanced daily functioning. This holistic approach emphasizes the importance of proactive management and personalized treatment strategies to combat the debilitating effects of OA.


Note: References are at the end of Part 2



 

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DR. BRIAN ABELSON, DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.



 


MSR Instructor Mike Burton Smiling

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