- Dr. Brian Abelson
OSTEOARTHRITIS OF THE HIP AND KNEE – PART 1
Updated: Mar 12
Osteoarthritis (OA) of the hip and knee is a common musculoskeletal disorder seen in clinical practice. OA has grown to be a significant contributor to disability among the older population due to its high prevalence in society. A little over 40% of people between the ages of 45 and 55 have OA, and by the time they are 75, this percentage rises to over 80%. (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 characterized as a degenerative condition that stems from the breakdown of articular cartilage in synovial joints. It affects not only the cartilage but also the underlying subchondral bone and synovium that lines the joint capsule.
The degeneration occurs at a faster rate than the body's repair mechanisms can compensate, leading to ongoing damage. At a cellular level, OA results in pathomechanical stresses such as proteoglycan loss and chondrocyte death.
In this context, "patho" refers to disease-related factors, while "mechanical" pertains to physical factors that lead to damage. (3)
RISK FACTORS FOR OSTEOARTHRITIS
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 alterations in 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 both the hip and knee joints. (13)
A previous case of Inflammatory Arthritis (IA): 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)
A FEW MYTHS ABOUT OSTEOARTHRITIS
Osteoarthritis (OA) is a common condition that affects millions of people worldwide. Despite its prevalence, there are several myths surrounding the topic of OA that need to be addressed.
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)
There is nothing I can do 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 KNEE & HIP OA
Hip and knee osteoarthritis are common musculoskeletal conditions that can cause significant pain and disability. The hallmark features of hip and knee osteoarthritis include limited range of motion, crepitus during active motion, increased sensitivity during palpation, deformity, and swelling of the bone.: (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 osteoarthritis (OA) can be divided into three stages:
H1: Stage One - Early OA
Occasional episodes of sharp joint pain with certain activities.
Overall function is not limited, except on high-impact activities.
H1: 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.
H1: 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, which can help to reduce symptoms, increase function, and improve the overall quality of life.
EXAMINATION AND DIAGNOSIS OF HIP & KNEE OSTEOARTHRITIS
To accurately assess the degree of degeneration that has already occurred in patients with hip or knee osteoarthritis (OA), a thorough orthopedic and neurological assessment, along with any indicated imaging, should be performed. This comprehensive evaluation can provide healthcare professionals with a clear understanding of the extent of the condition, enabling them to develop tailored treatment plans that are most appropriate for the individual patient's needs.
Note: This section is technical and is written for practitioners, feel free to skip this section and go directly to Part 2.
Imaging is a crucial component in the diagnosis and management of osteoarthritis (OA). It enables healthcare professionals to visualize and assess the degree of joint degeneration, helping to guide treatment decisions and monitor the progression of the condition.
Imaging Options for OA
There are several imaging options available for OA, each with its own benefits and drawbacks. These include:
Standard x-rays, including anterior, posterior, and lateral views, are cost-effective and provide valuable information in the diagnosis of OA. They can detect changes in bone structure, such as osteophytes (bone spurs), joint space narrowing, and subchondral sclerosis (hardening of the bone beneath the cartilage).
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging (MRI) provides effective soft-tissue and osseous information that cannot be achieved through standard x-rays. It can detect subtle changes in the cartilage, ligaments, and other soft tissues that may not be visible on x-rays. However, MRIs are very expensive, and not available to everyone.
Ultrasound has the advantage of not involving radiation, making it a safe option for imaging. However, it is usually used for the assessment of muscles and tendon pathology and is not commonly used for joint assessment.
By using imaging to assess the degree of joint degeneration, healthcare professionals can develop a more comprehensive treatment plan that addresses the specific needs of each patient. Imaging can also help to monitor the progression of the condition and adjust treatment plans as necessary.
Orthopedic & Neurological Testing
It's crucial to rule out any warning signs or non-musculoskeletal pain reasons when a patient is being evaluated for osteoarthritis (OA). Usually, a detailed patient history is obtained before an extensive orthopedic and neurological examination is conducted. Many routine tests can be run on the hip and knee to assist determine the existence and degree of joint deterioration. These tests can offer useful data that can be used to advise treatment choices and create unique care plans for every patient.
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.
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.
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.
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's essential to keep in mind that an osteoarthritis (OA) diagnosis remains a "working diagnostic." Each diagnosis is based on the healthcare practitioner's professional judgement and always considers the patient's history, examination findings, imaging findings, and other diagnostic criteria. It's important to consider other possible differentials into account when diagnosing OA, 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 the second part of "Osteoarthritis of the Hip and Knee," we will delve into using manual therapy techniques. We will also provide video demonstrations that showcase both joint mobilization and soft tissue techniques that we use in our practice. Additionally, part two will offer video demonstrations of treatments and common exercises that we recommend to our patients who are suffering from hip and knee OA. By providing these practical resources, we aim to empower patients with the knowledge and tools they need to effectively manage their condition and improve their overall quality of life.
Note: References are at the end of Part 2
OSTEOARTHRITIS OF THE HIP AND KNEE – PART 2
DR. BRIAN ABELSON DC.
Dr. Abelson is committed to running an evidence-based practice (EBP) that incorporates the most up-to-date research evidence available. He combines his clinical expertise with the specific values and needs of each patient to deliver personalized care that is both effective and patient-centered.
As the developer of Motion Specific Release (MSR) Treatment Systems, Dr. Abelson operates a clinical practice in Calgary, Alberta, under the name Kinetic Health. He has authored ten publications to date and continues to offer online courses, in addition to his live programs, to healthcare professionals seeking to expand their knowledge and skills in treating patients with musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.
We Look Forward to Seeing You
We are excited to welcome you to Kinetic Health, our clinic located in NW Calgary, Alberta. Our dedicated team is committed to providing exceptional care and personalized treatment plans to help you achieve optimal health and wellness.
To schedule an appointment with our incredible team, please call us at 403-241-3772 or click on the MSR logo to the right. We are eager to assist you and look forward to helping you feel your best.
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