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

Updated: Jan 14


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.

 

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).


 


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 impact the progression of knee OA directly. (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) 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)


 

Myths


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.

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)

  • 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 Osteoarthritis


Hip and knee osteoarthritis are widespread musculoskeletal disorders characterized by 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).


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 limited to less than 115 degrees, and internal hip rotation restricted to less than 15 degrees.

  • Morning stiffness persisting for less than 60 minutes.

  • Typically observed in individuals aged 50 and above.


 

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 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, 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


For an accurate appraisal of the existing degree of degeneration in individuals with hip or knee osteoarthritis (OA), a comprehensive orthopedic and neurological examination, supplemented with necessary imaging, is recommended. 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 the specific needs of each patient.


Imaging


Imaging serves a crucial function 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: Economical and essential for OA diagnosis, standard radiographs, including anterior, posterior, and lateral views, can detect changes in bone architecture, such as osteophyte formation, joint space narrowing, and subchondral sclerosis.

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

  3. Ultrasound: As a non-radiative imaging option, ultrasound is safe. 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 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


This video demonstrates some of the common orthopaedic tests we use to exam our patients knees.



Neurological/Vascular Tests

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.


 

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 touch and elicits severe pain on palpation, often due to 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 instances of 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 paediatric and adolescent patient populations.


 

Conclusion


In the next part of "Osteoarthritis of the Hip and Knee," we're going to dive into the world of manual therapy techniques. We're excited to share video tutorials that show you exactly how we do joint mobilization and soft tissue procedures in our clinic. But that's not all! We're also going to provide video guides that demonstrate the therapeutic exercises and interventions we recommend to our patients with hip and knee OA.


Our aim is to make these practical resources available so that you have the knowledge and tools you need to confidently manage your condition and boost your overall health. We're right here with you on this journey, and we can't wait to get started!


Note: References are at the end of Part 2



 

DR. BRIAN ABELSON DC. - The Author


Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.

 


Revolutionize Your Practice with Motion Specific Release (MSR)!


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Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!

 

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