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U N I T 1 2
Musculoskeletal Function
changes in the synovium that occur in OA are not as
pronounced, nor do they occur as early.
In secondary forms of OA, repetitive impact load-
ing contributes to joint failure, accounting for the high
prevalence of OA specific to vocational or avocational
sites, such as the shoulders and elbows of baseball pitch-
ers, ankles of ballet dancers, and knees of basketball
players. Immobilization also can produce degenerative
changes in articular cartilage. Cartilage degeneration
due to immobility may result from loss of the pumping
action of lubrication that occurs with joint movement.
These changes are more marked and appear earlier in
areas of contact, but also occur in areas not subject to
mechanical compression. Although cartilage atrophy is
rapidly reversible with activity after a period of immo-
bilization, impact exercise during the period of remobi-
lization can prevent reversal of the atrophy. Therefore,
slow and gradual remobilization may be important in
preventing cartilage injury. Clinically, this has implica-
tions for instructions concerning the recommended level
of physical activity after removal of a cast.
Clinical Features
Typically, OA presents with joint pain.
60,61
Initially, pain
may be described as aching and may be somewhat dif-
ficult to localize. It usually worsens with use or activity
and is relieved by rest. A common phenomenon, often
referred to as “gelling,” involves difficulty initiating joint
movement after inactivity, epitomized by the problems
older people with OA have in “getting started” after sit-
ting down for a while. In later stages of disease activ-
ity, night pain may be experienced during rest. Cracking
of joints (audible crepitus) and joint locking may occur
when the joint is moved. As the disease advances, even
minimal activity may cause pain.
The most frequently affected joints are the hips, knees,
lumbar and cervical spine, proximal and distal joints
of the hands, the first carpometacarpal joint, and the
first metatarsophalangeal joints of the feet. Table 44-1
identifies the joints that commonly are affected by OA
and the common clinical features correlated with the dis-
ease activity of each particular joint. A single joint or sev-
eral may be affected. Although a single weight-bearing
joint may be involved initially, other joints often become
affected because of the additional stress placed on them
while trying to protect the initial joint. It is not unusual
for a person having a knee replacement to discover soon
after the surgery is done that the second knee also needs
to be replaced. Other clinical features are limitations
of joint motion and joint instability. Joint enlargement
usually results from new bone formation; the joint feels
hard, in contrast to the soft, spongy feeling characteristic
of the joint in RA. Sometimes, mild synovitis or increased
synovial fluid can cause joint enlargement.
Diagnosis and Treatment.
The diagnosis of OA usu-
ally is determined by history and physical examination,
x-ray studies, and laboratory findings that exclude other
diseases.
60–62
Although OA often is contrasted with RA
for diagnostic purposes, the differences are not always
readily apparent. Other rheumatic diseases may be
superimposed on OA. Psychological factors, severity of
joint disease, and educational level affect the expression
of symptoms.
Because there is no cure, the treatment of OA is
symptomatic and includes physical rehabilitative, phar-
macologic, and surgical measures. Physical measures
are aimed at improving the supporting structures of
the joint and strengthening opposing muscle groups
involved in cushioning weight-bearing forces. This
includes a balance of rest and exercise, use of splints to
protect and rest the joint, use of heat and cold to relieve
pain and muscle spasm, and adjusting the activities of
daily living. Weight reduction is helpful when the knee
is involved. The involved joint should not be further
abused, and steps should be taken to protect and rest
it. These include weight reduction (when weight-bearing
surfaces are involved) and the use of a cane or walker if
TABLE 44-1
Clinical Features of Osteoarthritis
Joint
Clinical Features
Cervical spine
Localized stiffness; radicular or nonradicular pain; posterior osteophyte formation may cause
vascular compression
Lumbar spine
Low back pain and stiffness; muscle spasm; decreased back motion; nerve root compression
causing radicular pain; spinal stenosis
Hip
Most common in older men; characterized by insidious onset of pain, localized to groin
region or inner aspect of the thigh; may be referred to buttocks, sciatic region, or knee;
reduced hip motion; leg may be held in external rotation with hip flexed and adducted;
limp or shuffling gait; difficulty getting in and out of chairs
Knee
Localized discomfort with pain on motion; limitation of motion; crepitus; quadriceps atrophy
due to lack of use; joint instability; genu varus or valgus; joint effusion
First carpometacarpal joint
Tenderness at base of thumb; squared appearance to joint
Proximal interphalangeal joint—
Bouchard nodes
Same as for distal interphalangeal joint disease
Distal interphalangeal joint
(DIP)—Heberden nodes
Occurs more frequently in women; usually involves multiple DIPs, lateral flexor deviation of
joint, spur formation at joint margins, pain and discomfort after joint use
First metatarsophalangeal joint
Insidious onset; irregular joint contour; pain and swelling aggravated by tight shoes
