Authors:

Michael McGalliard, PT, SCD, COMT

Mark Dutton, PT
Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA
Anna Shovestul Grieder, PT, DPT, OCS
Bryan W. Kist, PT, DPT, OCS
Michele Roy, B.Sc. P.T., F.C.A.M.P.T
Ashraf Moharram, MD, M.B.B.Ch, F.R.C.S.Ed
Michael McGalliard, PT, ScD, COMT
Phillip S. Sizer Jr, PT, PhD, OCS, FAAOMPT
Dean Ezell, MD

Degenerative: Inflammatory: Infectious: Metabolic

• Osteoarthrits • Rheumatoid • Osteomyelitis Osteoporosis
(OA) arthritis (RA)
• Systemic lupus • Septic
• Post-traumatic erythromatosis arthritis
arthritis (SLE) • Tuberculous
• Osteochondor • Ankylosing arthritis
itis dissicans Spondylitis (AS)
• Gout
• Psoriatic
arthritis

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A number of conditions can affect the musculoskeletal system, frequently producing pain. These
include infections (e.g., osteomyelitis), inflammatory disorders, neoplasms, and metabolic
disorders. Several findings are helpful in diagnosing such pathologic processes. These findings
may include:

► severe and unrelenting pain.

► the presence of a fever.
► bone tenderness.
► unexplained weight loss.
Inflammatory disorders

Perhaps, the most common inflammatory disorders of the musculoskeletal system are rheumatoid
diseases.
Rheumatoid Arthritis.
Rheumatoid arthritis (RA) can be defined as a chronic, progressive, systemic, inflammatory
disease of connective tissue, characterized by spontaneous remissions and exacerbations (flare-
ups). It is the second most common rheumatic disease after osteoarthritis (OA), but it is the most
destructive to synovial joints. Unlike OA, RA involves primary tissue inflammation rather than
joint degeneration. Although most individuals who develop RA do so in their early-to-middle
adulthood, some experience a late-onset RA in their older years.

Rheumatoid disease typically begins in the joints of the arm or hand. The individual complains
of joint stiffness lasting longer than 30 minutes on awakening, pain, swelling, and heat
(synovitis). Unlike with OA, the distal interphalangeal joints of the fingers usually are not
involved in RA.

The signs and symptoms of RA vary among individuals, depending on the rate of progress of the
disease. A complete musculoskeletal examination helps diagnose the disease. Clinical
manifestations include both joint involvement and systemic problems; some are associated with
the early stages of RA, whereas others are seen later in advanced disease.

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 Complaints of fatigue, anorexia, low-grade fever, and mild weight loss are commonly associated
with RA. As the disease worsens, joints become deformed, and secondary osteoporosis can result
in fractures, especially in older adults. Hand and finger deformities are typical in the advanced
stages of the disease. Palpable subcutaneous nodules, often appearing on the ulnar surface of the
arm, are associated with a severe, destructive disease pattern. As the disease progresses over the
years, systemic manifestations increase, and potentially life-threatening organ involvement
begins. Cardiac problems, such as pericarditis and myocarditis, and respiratory complications,
such as pleurisy, pulmonary fibrosis, and pneumonitis, are common.

RA can affect body image, self-esteem, and sexuality in older adults. The person with RA loses
control over body changes, is chronically fatigued, and eventually may lose independence in
activities of daily living (ADLs). As a reaction to these losses, individuals may display the phases
of the grieving process, such as anger or denial. Some people become depressed, feeling helpless
and hopeless, because no cure presently exists for the condition. Chronic pain and suffering
interfere with quality of life.
The physical therapy examination of the patient with RA involves

► measurement of independence with functional activities.

► measurement of joint inflammation.
► measurement of joint range of motion.
► determination of limiting factors including pain, weakness, and fatigue.

Juvenile Arthritis.
The descriptive term juvenile idiopathic arthritis was adopted as an umbrella term to indicate
disease of childhood onset, characterized primarily by arthritis of no known etiology persisting
for at least 6 weeks. Juvenile RA (JRA) is the most prevalent pediatric rheumatic diagnosis
among children in the United States. Substantial evidence points to autoimmune pathogenesis.69
JRA is not a single disease. Rather, it is a group of diseases of unknown etiology, which are
manifested by chronic joint inflammation. JRA is classified as systemic, pauci-articular, or
polyarticular disease, according to onset within the first 6 months. General history of JRA
includes the following:
► Disease onset is either insidious or abrupt, with morning stiffness and arthralgia during the
day.

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. Individuals with JRA may have a school history of absences, and their abilities to participate in
physical education classes may reflect severity of the disease.

. Limping may be observed in individuals with more severe JRA; however, the presence of
limping also raises the possibility of trauma or another orthopaedic problem. Very severe
joint pain raises the possibility of acute rheumatic fever

► Weight loss without diarrhea may be observed in individuals with active JRA and is
sometimes associated with anorexia. This symptom is also observed in individuals with acute
lymphocytic leukemia with other obvious findings (e.g., severe bone pain).

► Arthralgia is often present. Frank joint swelling is atypical; arthritis may not occur for months
following onset, making diagnosis difficult.
. Pauciarticular disease is characterized by arthritis affecting four or fewer joints.

Typically, larger joints (e.g., knees, ankles, and wrists) are affected.
Monoarticular arthritis in a hip is highly unusual. When the knee is affected, limping may
be noted, particularly in the mornings.
. Polyarticular disease affects at least five joints.

Both large and small joints can be involved, often in symmetric bilateral distribution.
Severe limitations in motion are usually accompanied by weakness and decreased physical
function.

► Some children may have a generalized myalgia.

. Localization to proximal muscles raises the possibility of a myositis.
. Consider Legg–Calve´–Perthes disease, toxic synovitis of the hip, septic arthritis,
osteomyelitis, or, in an older child, slipped capital femoral epiphysis or chondrolysis of
the hip.

Chronic involvement can result in atrophy of extensor muscles in the thigh, tight hamstring
muscles, and knee flexion contractures.

Gout.
Gout is the most common form of inflammatory arthritis in men older than 40 years of age and
appears to be on the increase.70 High blood levels of uric acid leads to inflammation, joint

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swelling, and severe pain. Symptoms are caused by deposits of sodium urate or calcium
pyrophosphate crystals in joints and periarticular tissues. Several factors have been identified as
predisposing a person to gout, including lifestyle elements of obesity, high-purine diet, and
habitual alcohol ingestion.

Onset is usually sudden, often during the night or early morning. The classic finding of gouty
arthritis (gout) is warmth, swelling, cutaneous erythema, and severe pain of the first
metatarsophalangeal (MTP) joint. However, other joints may also be involved. These include
the shoulder, knee, wrist, ankle, elbow, or fingers. Fever, chills, and malaise accompany an
episode of gout. As the condition becomes chronic, the patient may report morning stiffness and
joint deformity, progressive loss of function or disability. Chronic gouty nephropathy may
occur.
Differential diagnosis includes cellulitis, septic arthritis, RA, bursitis related to bunion,
sarcoidosis, multiple myeloma, and hyperparathyroidism.

Ankylosing Spondylitis.
Ankylosing spondylitis (AS, also known as Bekhterev’s or Marie–Stru¨mpell disease) is a
chronic rheumatoid disorder that affects 1–3 per 1000 people. Thoracic involvement in AS occurs
almost universally. The patient is usually between 15 and 40 years of age. There is a 10–20%
risk that offspring of patients with the disease will later develop it.73 Although males are affected
more frequently than females, mild courses of AS are more common in the latter.74

A human leukocyte antigen (HLA) haplotype association (HLA-B27) has been found with
ankylosing spondylitis and remains one of the strongest known associations of disease with HLA-
B27, but other diseases are also associated with the antigen. The disease includes involvement of
the anterior longitudinal ligament and ossification of the intervertebral disk, thoracic
zygapophysial joints, costovertebral joints, and manubrio-sternal joint. This multijoint
involvement of the thoracic spine makes the checking of chest expansion measurements a
required test in this region.

In time, AS progresses to involve the whole spine and results in spinal deformities, including
flattening of the lumbar lordosis, kyphosis of the thoracic spine, and hyperextension of the

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 cervical spine. These changes, in turn, result in flexion contractures of the hips and knees, with
significant morbidity and disability.74

The most characteristic feature of the back pain associated with AS is pain at night.75 Patients
often awaken in the early morning (between 2 and 5 am) with back pain and stiffness and usually
either take a shower or exercise before returning to sleep.74 Back ache during the day is typically
intermittent, irrespective of exertion or rest.74
Calin and colleagues76 describe five screening questions for AS:

1. Is there morning stiffness?

2. Is there improvement in discomfort with exercise?
3. Was the onset of back pain before age 40 years?
4. Did the problem begin slowly?
5. Has the pain persisted for at least 3 months?
Using at least four positive answers to define a “positive” result, the sensitivity of these questions
was 0.95 and specificity, 0.85.76

Inspection usually reveals a flat lumbar spine and gross limitation of side bending in both
directions. Mobility loss tends to be bilateral and symmetric. There is loss of spinal elongation
on flexion (Schober’s test), although this can occur in patients with chronic LBP or spinal tumors
and is thus not specific for inflammatory spondylopathies.80 The patient may relate a history of
costochondritis, and, upon examination, rib springing may give a hard end-feel. Basal rib
expansion often decreases. The glides of the costotransverse joints and distraction of the
sternoclavicular joints are decreased, and the lumbar spine exhibits a capsular pattern.

As the disease progresses, the pain and stiffness can spread up the entire spine, pulling it into
forward flexion, so that the patient adopts the typical stooped-over position. The patient gazes
downward, the entire back is rounded, the hips and knees are semi-flexed, and the arms cannot
be raised beyond a limited amount at the shoulders.81

Longitudinal studies in patients with AS have revealed that deformities and disability occur
within the first 10 years of disease.78 Most of the loss of function occurs during the first 10 years
and correlates significantly with the occurrence of peripheral arthritis, radiographic changes of

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AS in the spine, and the development of the so-called bamboo spine (figure 11.1).

Figure11.1 Bamboo spine

Psoriatic Arthritis.
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. It affects men and
women with equal frequency.79 Its peak onset is in the fourth decade of life, although it may
occur in children and in older adults. Psoriatic arthritis can manifest in one of a number of
patterns, including distal joint disease (affecting the distal interphalangeal joints of the hands
and feet), asymmetric oligoarthritis, polyarthritis (which tends to be asymmetric in half the
cases), and arthritis mutilans (a severe destructive form of arthritis and the spondyloarthropathy
that occurs in 40% of patients, but most commonly in the presence of one of the peripheral
patterns).79 Patients with psoriatic arthritis have less tenderness over both affected joints and
tender points than patients with RA.83

The spondyloarthropathy of psoriatic arthritis may be distinguished from AS by the pattern of

the sacroiliitis.84 Whereas sacroiliitis in AS tends to be symmetric, affecting both sacroiliac
joints to the same degree, it tends to be asymmetric in psoriatic arthritis,79 and patients with
psoriatic arthritis do not have as severe a spondyloarthropathy as patients with AS.73

Metabolic Disorders
Osteoporosis. Osteoporosis can result from insufficient bone formation, excessive bone
resorption, or a combination of these two phenomena. The result is decreased bone mineral
density (BMD) and a progressive loss of trabecular connectivity that is irreversible and
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 diminishes the bone quality in terms of its mechanical resistance to deformity under loading.94
Osteoporosis causes fractures of the vertebrae and fractures of other bones such as the proximal
humerus, distal forearm, proximal femur (hip), and pelvis.

Osteoporosis has been classified into two broad general types: type 1 (postmenopausal) and type
2 (involutional).95 Type 2 osteoporosis generally is seen in the older age population and has
been referred to as senile osteoporosis.95

Clinical Pearl
Women are more prone to develop osteoporosis because
of the contribution of the loss of estrogen to accelerated
bone loss in the postmenopausal female population.

It has been estimated that 15% of postmenopausal Caucasian women in the United States and 35%
of women older than 65 years have osteoporosis.95 Further, 50% of women older than 50 years
have osteopenia of the femoral neck, and 20% have osteoporosis at this site.96 The incidence of
hip fracture rises dramatically with age, to 3.4 per 100 in the 65–74-year- old age group and 9.4
per 100 in those older than 85 years.94 The presence of a significant vertebral fracture is associated
with increased mortality.96a Patients with these fractures have a relative risk of death that is 9
times greater than healthy counterparts.96b Approximately 20% of women with vertebral
fractures have another fracture of a different bone within a year.96

Numerous risk factors have been identified as contributing to the likelihood that an individual will
develop bone loss. Genetics plays a major role, and female gender, positive family history, and
racial characteristics associated with Caucasian, Asian, or Hispanic background increase the risk
of osteoporosis.97 Low body weight (less than 85% ideal body weight, or less than 127 lb) has
also been correlated with the development of osteoporosis.95

Modifiable risk factors associated with osteoporosis include early or iatrogenic menopause,
pregnancy at an early age, smoking, sedentary lifestyle, alcoholism, low body fat, low calcium
intake, high caffeine intake, prolonged bed rest, and anorexia.95,98,99 Medications such as
corticosteroids, some diuretics, and thyroid hormone preparations can also increase bone loss and
the risk of osteoporosis significantly.100,101

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 In addition to risk factors for the disease, there are independent risk factors for fractures,
including use of medications in elderly patients with CNS side effects, balance problems, poor
muscle strength, visual impairment, home environmental factors such as stairs, and medical
comorbidities that increase the likelihood of falls.94,98

The diagnosis of osteoporosis often is first established by the presence of an osteoporotic fracture.
However, a physical therapist may treat a patient with an undiagnosed low BMD. These patients
have a lowered fracture threshold. It is important to be able to identify this patient type, so that
safer choices can be made with regard to the types of intervention. At present, the only diagnostic
tool available that is within the scope of practice of the physical therapist is the identification of
those risk factors previously mentioned.102
The specific effects of physical activity on bone health have been investigated in several
studies.99,100,102–106 The conclusions drawn from these studies suggest that there is

► strong evidence that physical activity early in life contributes to higher peak bone mass105.

► some evidence that resistance and high-impact exercise are likely the most beneficial.

► some evidence that high-intensity aerobic exercise (70–90% of maximal heart rate) may
reverse or attenuate BMD loss.

► some evidence that high-load low-repetition routines are more effective at increasing BMD
than low-load high- repetition regimens.

Exercise during the middle years of life has numerous health benefits, but there are few studies
on the effects of exercise on BMD.105 Exercise during the later years, in the presence of adequate
calcium and vitamin D intake, probably has a modest effect on slowing the decline in BMD, but
it is clear that exercise late in life, even beyond age 90 years, can increase muscle mass and
strength twofold or more in frail persons.105

Randomized clinical trials of exercise have been shown to reduce the risk of falls by
approximately 25%,107,108 but there is no experimental evidence that exercise affects fracture
rates.105 It also is possible that regular exercisers might fall differently, thereby reducing the risk
of fracture caused by falls, but this hypothesis requires testing.105

The availability of new, effective drug therapies in the past decade has revolutionized the

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 intervention for osteoporosis, and it is important that clinicians at least be aware of the
intervention options. Many hormonals and hormone replacement therapies are also available,
including raloxifene (Evista), calcitonin (Miacalcin), Estradiol (Estrace, Vivelle, Climara,
Estraderm, Esclim, Alora), alendronate (Fosamax), ibandronate (BONIVA), etidronate
(Didronel), and risedronate (Actonel). Experimental evidence indicates that slow-release sodium
fluoride and low- dose parathyroid hormone (PTH) are capable of increasing bone formation
and thus preventing bone loss in women who are estrogen deficient.108a

Diagnostic tools have focused on bone density. New minimally invasive procedures are finding
a place among interventions for patients with osteoporotic fractures. The use of injected
hydroxyapatite cements into distal radius fractures for percutaneous stabilization has shown
efficacy as an intervention for patients with these fractures.10

What we know about prevention is that a key factor in the development of osteoporosis in later
life is a deficient level of peak bone mass at physical maturity110 and that physical activity and
calcium intake play substantial roles in the development of bone mass during these
developmental years.111

Clinical Pearl
It should be the responsibility of the health-care
providers to educate their young female patients
about the benefits of sufficient exercise and the
recommended dietary calcium intake to build
healthy bone.

Bone and joint infection

Definition: Infection is a condition in which pathogenic organisms multiply and spread within
the body tissues which gives rise to an inflammatory reaction (acute or chronic). Inflammation is
the body's way of combating the invaders.

Route: Micro-organisms may reach the bones and joints either:

- directly through a break in the skin (a wound, an open fracture or an operation) or
- indirectly via the blood stream from a distant site such as the nose or mouth, the
respiratory tract or the genitourinary tract.

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Outcome of Micro-organism reaching the bones and joints:
- A minor inflammatory reaction that resolves without significant pus or granuloma
formation
- a pyogenic osteomyelitis or arthritis (pus formation),
- -a chronic granulomatous reaction (as in tuberculosis), or an indolent response to an
unusual organism (e.g. a fungal infection).
-
Acute pyogenic infections are characterized by the formation of pus - a concentrate of dead and
dying bacteria, leucocytes and tissue debris - which is often localized in an abscess. Pressure
builds up within the abscess and infection may then extends:

• directly along the tissue planes

• via lymphatics (causing lymphangitis and lymphadenopa-thy) or
• via the bloodstream (bacteraemia and septicaemia).
The accompanying systemic reaction varies from a vague feeling of lassitude with mild fever to
severe illness, toxaemia and shock. The generalized effects are due to the release of bacterial
enzymes and endotoxins as well as cellular breakdown products from the host tissues.

Bone, which consists of a collection of rigid compartments, is more susceptible than soft tissues
to vascular damage and cell death from the build-up of pressure in acute inflammation;

Unless it is rapidly controlled, bone infection will inevitably lead to necrosis. Bone structure - a
honeycomb of inaccessible spaces - also makes it very difficult to eradicate infection once it is
established.

Acute haematogenous (pyogenic) osteomyelitis

Patient: Acute osteomyelitis is mainly a disease of children.
When adults are affected it may be because their resistance is lowered by debility, disease (as
diabetes) or drugs (as immunosuppressive drugs).
-Trauma may determine the site of infection, possibly by causing a small haematoma or fluid
collection in a bone.

The causative organism is usually Staphylococcus aureus, less often one of the other Gram-
positive cocci, such as Streptococcus pyogenes or S. pneumoniae. In children under 4 years of age
the Gram-negative Haemophilus influenzae is a fairly common pathogen.
Other Gram-negative organisms (e.g. Escherichia coli, Pseudomonas aeruginosa, and the
anaerobic Bacteroides fragilis} occasionally cause acute bone infection.

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Source: The blood stream is invaded, perhaps from a minor skin abrasion, a boil, a septic tooth or
- in the newborn - from an infected umbilical cord. In adults the source of infection may be a
urethral catheter, an indwelling arterial line or a dirty needle and syringe.
Site:
Organisms usually settle in the metaphysis, most often in the proximal tibia or in the distal and
proximal ends of the femur.
unless it is rapidly controlled, bone infection will inevitably lead to necrosis. Bone structure - a
honeycomb of inaccessible spaces - also makes it very difficult to eradicate infection once it is
established.
• In young infants, it is more common in the epiphysis in whom there is still a free
anastomosis between metaphyseal and epiphyseal blood vessels.
• In adults, haematogenous infection is more common in the vertebrae than in the long bones.

Pathology:
The pathological picture shows a characteristic pattern marked by inflammation, suppuration,
necrosis, reactive new bone formation and, ultimately, resolution and healing. Figure 11.2

Figure 11.2 Pathological cascades in osteomyelitis

Clinical features:
Symptoms:
✓ Usually a child,

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 ✓ There may be a recent history of infection - a septic toe, a boil, a sore throat or a discharge
from the ear.
✓ Malaise and a fever; in neglected cases, toxaemia may be marked.
✓ Severe pain and Loss of function. The parents will have noticed that the child refuses to
use one limb or to allow it to be handled or even touched.

Signs:
✓ Typically, the child looks ill and feverish; the pulse rate is likely to be over 100 and the
temperature is raised.
✓ Loss of function and loss of range of motion of the limb; The limb is held still and even
the gentlest manipulation is extremely painful.
✓ -There is severe tenderness near one of the larger joints (e.g. above or below the knee, in
the popliteal fossa or in the groin).
✓ -Local redness, swelling, warmth and oedema are later signs and signify that pus has
escaped from the interior of the bone.
✓ -Lymphadenopathy is common but non-specific.
It is important to remember that all these features may be attenuated if antibiotics have been
administered.

Diagnostic imaging: Plain x-ray, ultrasound, Radioscintigraphy, and MRI

Differential diagnosis:
CELLULITIS: Skin infections were there is widespread superficial redness and lymphangitis.
There is no boney involvement. The organism is usually staphylococcus or streptococcus.

ACUTE SUPPURATIVE ARTHRITIS: Tenderness is diffuse, and all movement at the joint is
abolished by muscle spasm. In infants the distinction between osteomyelitis and septic arthritis is
somewhat theoretical, as both usually coexist.

ACUTE RHEUMATISM: The pain is less severe, and it tends to flit from one joint to another,
and there may be carditis, rheumatic nodules or erythema marginatum.

STREPTOCOCCAL NECROTIZING MYOSITIS: A rare condition were group A Beta-

haemolytic streptococci (the same organisms which are responsible for the common 'sore throat')
occasionally invade muscles and cause an acute myositis which, in its early stages, may be
mistaken for cellulitis or osteomyelitis

Complications:
Metastatic infection
Suppurative arthritis

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 Chronic osteomyelitis
Altered bone growth

Degenerative joint diseases

Hip osteoarthrosis (coxarthrosis):
Hip pain associated with OA is the most common cause of hip pain in older adults. Prevalence
studies have shown that the rates for adult hip OA range from 0.4% to 27%. Early articular
changes observed on imaging may help identify individuals who have not been clinically
diagnosed with hip OA. In patients with hip pain, there is some evidence that the presence of
acetabular retroversion is related to the development of hip OA.

Primary coxarthrosis usually occurs in patients older than 40, whereas secondary coxarthrosis
is most often seen in patients older than 25. The primary disorder can occur unilaterally as well
as bilaterally and is seen more often in females.151-153 Moreover, the progression of
coxarthrosis in women is usually much more severe. Whereas the pain described by these
patients with coxarthrosis is similar to that of patients with synovitis, the pain itself and the
progression of the condition may be due to changes in the subchondral bone.154

Early stages of the disorder may produce pain only during weightbearing activities with
progression to constant pain even at rest. As the disorder progresses, pain can subside, and
progressive movement limitations then prevail. Once again, the limitation resembles a capsular
pattern that can be minimal, moderate, or severe, depending on the severity of the disorder

Clinical prediction rule for diagnosis of hip OA

Presence of at least 3 out of 5 of the following predictors increased the
likelihood that a patient has hip OA

Clinical Pearl • Squatting as an aggravating factor

• Active hip flexion causes lateral hip pain
• Scour test with adduction causes lateral hip or groin pain
• Active hip extension causes pain
• Passive internal rotation of ≤ to 25°

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 Diagnosis of hip osteoarthrosis:
Moderate lateral or anterior hip pain during weight bearing, in adults over the age of 50 years,
with morning stiffness less than 1 hour, with limited hip IR and hip flexion by more than 15°,
and when comparing the painful to the nonpainful side constitute useful clinical findings to
classify a patient with hip pain into the International Statistical Classification of Diseases and
Related Health Problems (ICD) category of unilateral coxarthrosis and the associated
International Classification of Functioning, Disability and Health (ICF) impairment-based
category of hip pain

Diagnosis of hip OA: (based on strong evidence) Level of evidence: A

Adults > 50 years can be classified as having coxarthrosis/ hip osteoarthritis (hip
pain and mobility deficits) when they have:
Clinical Pearl • Moderate anterior or lateral hip pain during weight-bearing activities,
• Morning stiffness less than 1 hour in duration after wakening,
• Hip internal rotation range of motion <24° or internal rotation and hip
flexion 15° less than the nonpainful side,
• And/or increased hip pain associated with passive hip internal rotation

Knee osteoarthritis
Osteoarthritis (OA) of the knee joint is a common problem after 60 years of age. Osteoarthrosis
is a common degenerative disorder of the articular cartilage associated with hypertrophic
changes in the bone. Risk factors include genetics, female sex, past trauma, advanced age, and
obesity.
The patient presents with knee pain that is aggravated by weight-bearing activities and relieved
by rest.15 The patient has no systemic symptoms but usually awakens with morning stiffness
that dissipates somewhat with activity. In addition to chronic joint stiffness and pain, the patient
may report episodes of acute synovitis.

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The most common symptom of osteoarthrosis is joint pain. The pain tends to worsen with
activity, especially following a period of rest. Osteoarthrosis can cause
morning stiffness, but it usually lasts for less than 30 minutes, unlike
rheumatoid arthritis, which causes stiffness for 45 minutes or more.
Patients may report joint locking or joint instability. These symptoms
result in loss of function, with patients limiting their activities of daily
living because of pain and stiffness.

The joints most commonly affected are the hands (figure 11.3), knees,
hips, and spine, but almost any joint can be involved. Osteoarthrosis is
often asymmetric. A patient may have severe, debilitating osteoarthrosis of
one knee with almost normal function of the opposite leg. Figure 11.3 Hand affected by
osteoarthrosis. (1) Heberden nodes. (2)
Bouchard nodes.
Clinical Pearl
Cardinal signs of OA:
• Joint space narrowing (asymmetrical)
• Marginal osteophytes and/or spiking of tibial spine.
• Subchondral bone sclerosis
• Subchondral bone cyst

Findings on physical examination include decreased range of motion, crepitus, a mild joint
effusion, and palpable osteophytic changes at the knee joint. When osteoarthritis is suspected,
recommended Diagnostic clusters are available (table 11.1).

Table 11.1 Criteria for Diagnosis of Osteoarthritis Based on Three Sets of Criteria477,483,484
SET ONE (CLINICAL AND SET TWO (CLINICAL FINDINGS) SET THREE (CLINICAL AND
RADIOLOGICAL LABORATORY FINDINGS):
FINDINGS)
• Osteophytes • At least 3 of the following: • At least 5 of 9 of the following:
• At least 1 of 3 of the ° >50 years of age ° >50 years of age
following: ° Stiffness <30 min ° Stiffness <30 min
° >50 years of age ° Crepitus ° Crepitus
° Crepitus ° Bony tenderness ° Bony tenderness
° Morning stiffness ≤30 min ° Bony enlargement ° Bony enlargement

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° Female ° No palpable warmth ° No palpable warmth
° Overweight ° Female ° Female
° Overweight ° Overweight
° ESR <40 mm/h
° Rheumatoid factor titer <1:40
° Synovial fluid clear, viscous with
leukocyte count <2 × 109
cells/L

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