OSTEOARTHRITIS
OR
O = Old age,
A = Arthritis
By:
Dr. P. Ratan Khuman (PT)
M.P.T., (Ortho & Sports)
Sr. Lecturer C.U. Shah Physiotherapy College

Introduction
 OA is one of the most common condition treated by
the Physiotherapist.
 Osteoarthritis is the most common form of arthritis
worldwide..
 It can occur in any synovial joint; the commonest
sites being the knees, hips & small hand joints.
 Consequences of OA include pain, reduced function,
& restriction in daily activities.
 Management is made complex because structural
changes can occur without the patient displaying any
symptoms.
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introduction cont…
3
 The word "arthritis," meaning "inflammation of a
joint," is a misnomer.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Definition
4
 Carol David, 1999 Definition of OA vary, but
considered to be a chronic degenerative &
progressive condition affecting synovial joint.
 John Ebnezar, 2003 It is a degenerative, non-
inflammatory joint disease characterized by
destruction of articular cartilage & formation of
new bone at the joint surface & margins.
 Royal College of Physician, 2008 OA refers to a
clinical syndrome of joint pain accompanied by
varying degrees of functional limitation & reduced
quality of life.
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classification
5
 According to number of joint involved –
 Mono articular
 Oligo or Poly articular
 According to type of OA described –
 Inflammatory
 Erosive OA
 Generalized OA (GOA)
 Other classifications –
 Primary idiopathic OA
 Secondary OA
 Endemic OA
Cooper, 1994
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Primary (idiopathic) oa
6
1. Localized - hands and feet, knee, hip, spine or
other joint
2. Generalized - three or more joint areas
 It occurs in old age, mainly in weight bearing joints
(Hip, knee)
 It is more common than secondary OA.
M. Sofue, N. Endo, 2007
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Secondary oa
7
 There is an underlying primary disease of the joint
which leads to degeneration of the joint.
 It can occur at any age after adolescence.
 The predisposing factors are –
 Congenital mal development of joint
 Irregularity of joint surface from previous trauma
 Previous disease producing a damage to articular
cartilage
 Internal derangement of the knee
 Obesity & excessive weight
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Examples of secondary oa
8
 Developmental  Trauma (acute or chronic)
 Congenital hip dislocation  Accidental
 Legg-Calves-Perthes disease  Sports injury
 Congenital hip dislocation  Occupational
 Epiphyseal dysplasias  Iatrogenic (post-surgical)
 Mechanical  Metabolic
 Hypermobility syndromes  Hemachromatosis
 Leg length discrepancy  Mucopolysaccharidoses
 Mal-alignment  Gout
 Pseudogout
 Calcium crystal deposition
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9
 Endocrine  Miscellaneous
 Acromegaly  Hemophilias
 Hyperparathyroidism  Paget’s disease
 Hypothyroidism  Osteonecrosis
 Inflammatory  Neuropathic
 Any systemic arthropathy
rheumatic disease
 Septic arthritis
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Endemic oa
10
 Only found in a certain population or in a certain
region
(M. Sofue, N. Endo, 2007)
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Pathology of oa
11
 OA is a multi-factorial, metabolically active
process usually begins in middle age.
 It was thought to be only degenerative, but it have
reparative features.
 The activity & behavior of chondrocytes provides
the key to progressive nature of joint degeneration.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Patho-mechanics
12
 Increased in water content in articular cartilage
 Changes in quality of collagen fibers, which
increased in diameter & disrupt collagen bundle.
 At molecular level – loss of proteoglycans in
cartilage & severity of lesions appear to be
proportional. (Lotts et al., 1987)
 Repeated weight bearing on such cartilage leads to
fibrillation.
 Cartilage gets abraded by the grinding mechanism
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Patho-mechanics cont…
13
 Further rubbing – subchondral bone become hard
& glossy (eburnated)
 The bone at the margins of the joints hypertrophies
to form a rim of projecting spurs known as
osteophytes.
 The loose flakes of cartilage incite synovial
inflammation & thickening of capsule.
 These leads to stiffness & deformities of the joint.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Incidence
14
 Affected 44% - 70% of population of age 55years.
 Symptomatic OA increased with age & weight
 Weight bearing joints are more affected.
 Relationship between osteoporosis & OA is largely
increasing.
 Athletes involves in running does not reduce the
incidence of OA.
 Age, genetic & presence of other local articular
pathology affect the biomechanical structure of joint.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

How common is arthritis?
15
 1 in 8 people have osteoporosis.
 1 in 10 people have osteoarthritis.
 1 in 33 people have fibromyalgia.
 1 in 100 people have rheumatoid arthritis.
 1 in 1,000 children have juvenile chronic arthritis.
 1 in 1,000 people have ankylosing spondylitis.
 1 in 2,000 people have systemic lupus erythematosus.
 1 in 10,000 people have scleroderma.
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Tissue involved in OA
Cartilage Focal softening and loss
Bone Osteophyte, sclerosis, but subchondral osteopenia
Capsule Thickening
Synovium Thickening and modest inflammation
Muscle Atrophy and weakness
Ligaments Degeneration
Bursae Secondary bursitis
Angiogenesis (formation of new blood vessels),
Vessels
avascular necrosis, venous hypertension
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Clinical features
17
 Pain
 Muscle spasm
 Stiffness
 Inflammation
 Loss of ROM
 Capsular pattern
 Muscular inhibition & atrophy
 Joint instability
 Crepitus
 Deformities
 Reduce function
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

pain
18
 It is often most immediate importance to the patient
 Worsen at night – due to raised pressure in subchondral bone
(Pinals, 1996)
 Often raised with movement & relive with rest.
 Many structure may give rise to pain in OA
 Periarticular soft tissue – capsular/ligament strain
 Periosteal elevation secondary to raised intraosseous pressure
 Muscular pain & weakness
 Inflamed & overstretched synovium
 Refer pain from spine
 Inability to cope
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Muscle spasm
19
 It is a protective mechanism
 Movement cause pain so the body attempts to stop
movement
 But prolong spasm cause pain due to metabolic
accumulation & fatigue.
 Adaptive shortening may also occur in muscles.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

stiffness
20
 Probably deprivation of normal movement
 Subchondral micro-fractures heal & callus forms,
this cause loss of joint mobility & stiffness
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Inflammation & effusion
21
 It is not always present unless the joint is
underwent over activity
 Sign & symptoms includes are –
 Heat
 Erythema
 Tenderness
 Effusion
 Discomfort &
 Pain.
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Loss of Range of motion
22
 Combination of joint pain, stiffness & possible
effusion will often cause limitation of end ROM
 Certain joint may develop capsular pattern with
restriction in certain ROM
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23
CAPSULAR PATTENS
Hip Adduction contracture – due to increase force in lateral margin of acetabulum
Knee Flexion contracture. 75% medial compartment, 25% lateral, 48% PF
Ankle Increase valgus force – limited inversion & supination
Great toe Hallux valgus – restricted abduction
Shoulder Adhesive capsulitis may develop – restricted abduction, lateral & medial rotation
Hands The small joints of fingers are often involved.
DIP Typically Heberden’s nodes – in 70% of OA hand
PIP Bouchard’s nodes – in 35% of patients
MCP In 10% of patients
CMC In 60% of patients
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Muscle inhibition & atrophy
24
 Effusion will inhibit surrounding muscle of joint.
 This may be a safety mechanism as the intra
articular pressure becomes relatively positive.
 E.g.quadriceps contraction may lead to rupture of
knee joint capsule (Bland, 1994).
 Chronic muscle inhibition is often linked to chronic
pain & will lead to atrophy & ensuring weakness.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

crepitus
25
 The flaked cartilage & eburnated bone end grate
against each other characterized sound.
 Mild creaking – indicate synovitis
 Loud cracking – indicate advance disease
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Joint instability
26
 Surrounding muscle weaken & imbalance
 Pain episodes are unpredictable causing joint to give
away.
 These process together with chronic stretch of soft
tissue will alter joint alignment.
 These will lead to instability & possibly subluxation
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deformities
27
 Osteophyte development reduce joint instability by
increasing the peripheral articular surface area.
 Such deformities are more profound in established
OA but may not developed equally on medial &
lateral.
 This may contribute to varus & valgus deformities
 Together with the soft tissue laxity, it will alter
normal joint biomechanics.
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Radiographic finding
28
 X-ray changes –
 Loss of joint space
 Sclerosis
 Altered bone end shape
 Osteophytes
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Kellgren & Lawrence grading system for osteoarthritis
Grade 0 Normal
Grade 1 Doubtful narrowing of joint space, possible osteophyte
Grade 2 Definite osteophyte, possible narrowing
Moderate multiple osteophytes, definite narrowing, some
Grade 3
sclerosis, possible deformity of bone ends
Large osteophytes, marked narrowing, severe sclerosis,
Grade 4
definite deformity of bone ends
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Reduce function
31
 All the clinical features described above can result
in functional difficulty.
 Often described problems are – walking a distance,
climbing stairs, getting out of chair, writing,
opening jars etc.
 But most patients compensate by alternative ways
of achieving the task.
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Inter-relationship of symptoms & sign in OA
Inflammation Effusion
Pain
Loss of ROM
Muscle
Instability Muscle atrophy Inhibition
Reduce Function
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ROLE OF KNEE LOADING IN Oa
33
 Knee loading plays a major role in OA knee
development and progression.
 During the stance phase of gait, high loads are applied
to knee in both sagittal and frontal planes.
 The most relevant load is the external knee adduction
moment (AM) in the frontal plane generated because
the ground reaction force vector (GRFv) passes medial
to the joint center.
 This moment forces the knee laterally into varus & is
resisted by an internal abduction moment, resulting in
compression of the medial joint compartment &
stretching of the lateral structures.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

ROLE OF KNEE LOADING IN Oa
34
 The AM influences the load distribution between
the medial & lateral plateaus.
 The higher the AM the greater the load on the
medial plateau relative to the lateral plateau.
 Importantly, the AM during gait is a factors known
to predict OA progression in humans.
 A 20 to 30% increase in the AM is associated with a
2.8 to 6.5 time increase in the risk of progression.
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35 P.R.Khuman MPT, Ortho & Sports 19-Jun-12

LOCAL MECHANICAL FACTORS Influencing KNEE
LOADING & PHYSICAL THERAPY OUTCOMES
36
 The effectiveness of physical therapy interventions
in knee OA is likely to differ depending on local
mechanical factors.
 The main local mechanical factors are –
 Mal-alignment
 Laxity.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Mal-alignment
37
 The mechanical alignment of LL influences
distribution of loads across the medial and lateral knee
joint compartments.
 Pre-existing mal-alignment - contribute development
of OA
 Or mal-alignment may arise - consequence of OA
process due to cartilage loss, bony attrition, and
meniscal damage.
 Mal-alignment has been shown to be mediator for the
effects of other factors (such as obesity) on disease
progression.
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38
 GRFv –
 In Neutrally Aligned Knee – passes slightly medial to
knee joint
 In Varus Knee – displaced more medially to knee
 In Valgus Knee – passes more laterally to knee
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Laxity
39
 Passive knee laxity refers to abnormal motion of
tibia with respect to femur in unloaded state.
 It is determined by ligaments, joint capsule, other
soft tissues, and the joint surfaces.
 Varus-valgus laxity has been found to be greater in
people with knee OA.
 Dynamic stability relies on integrity of passive
structures with the coordinated activity of muscles
around the knee joint.
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40
 Declines in joint stability can lead to a change in
load distribution.
 The cartilage may then be less able to withstand
applied loads and this may lead to degeneration.
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Diagnostic Approach to Joint
41
Pain & OA
 Diagnosis of OA is made clinically based on –
 History
 Physicalexamination
 Laboratory and radiologic investigations
 To exclude inflammatory arthritis, secondary osteoarthritis,
and non-articular causes of joint pain.
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42
 A practical diagnostic approach to a patient
presenting with joint pain, which is suspected to be
due to osteoarthritis is to ask 3 questions:
1. Is the source of pain articular or non-articular?
2. If articular, is the pathology osteoarthritis?
3. If osteoarthritis, is the pathogenesis idiopathic
(primary) or secondary?
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Is it articular or non-
43
articular pain?
Palpation is key in evaluation. Non-articular sources of joint pain include:
 Peri-articular soft tissue pain:  Referred pain:, e.g. knee
 Ligament (tear/strain) pain due to:
 Tendon (tendonitis, enthesitis)  Hip pathology
 Muscle (myositis, myofascial pain, disuse  Myofascial piriformis pain
atrophy, tight  Prolapsed lumbar disc with
 hamstrings) sciatica.
 Fascia (fasciitis, iliotibial band syndrome)  Central pain:
 Bursa (bursitis)  Fibromyalgia
 Plica  Restless Leg Syndrome
 Fat pad (Hoffa’s syndrome)  Complex regional pain
 Blood vessel (aneurysm, varicose veins) syndrome (Sudeck’s
 Bone (avascular necrosis, tumour) dystrophy).
 Nerve (neuroma).
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Is it osteoarthritis ?
44
 As osteoarthritis has no specific clinical
characteristic or diagnostic laboratory test, and
radiographic findings may not correlate with
clinical severity, the diagnosis is made clinically
based on history and physical examination, with
laboratory and radiologic tests selectively
undertaken to exclude inflammatory arthritis,
secondary osteoarthritis, and non-articular causes
of joint pain.
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“red-flags” to alert diagnosis of oa
45
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Is it primary or secondary oa?
46
 Primary/idiopathic OA has a symmetrical predilection
for joints of fingers, hips, knees & spine.
 Involvement of other joints should prompt an evaluation
for secondary causes of osteoarthritis:
 Trauma, Charcot’s (neuropathic) joint, Avascular necrosis
 Inflammatory arthritis
 Crystal arthropathy
 Rheumatoid arthritis
 Septic arthritis
 Congenital/developmental
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

pattern of joint involvement
47
 Primary OA can be further
subdivided into localized or
generalized (involving 3 or more
sets of joints)
 The more common joints
involved in OA are shown
shaded in the figure:
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

48 Management of Oa
 Pharmacological
 Conservative
 Surgical
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Pharmacologic Rx of OA
49
 Acetaminophen
 NSAIDs
 Non-selectiveNSAID
 COX-2 selective
 Tramadol, opioids
 Joint injection
 Supplements
 Glucosamine
 Chondroitin sulfate etc.
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50
PHYSICAL THERAPY
INTERVENTIONS FOR KNEE OA
―Those who think they have not time
for bodily exercise will sooner or later
have to find time for illness‖
—Edward Stanley,
British Prime Minister (1799-1869)
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Aims of physical therapy
51
 To educate the patient
 To reduce pain, inflammation & stiffness
 To eliminate aggravating factors
 To maintain or improvement of ROM
 To maintain or improvement, of muscle strength
 To restore muscle balance
 To reduce stress on the involved joints
 To retrain gait
 To maintain or improvement in functional
independence, including participation in a vocational
activities
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Patient Education
52
 A major objective of education is to improve patient
knowledge in order to integrate him or her into the
decision-making team.
 Content should include information concerning OA
pathophysiology, clinical presentations, how the
disease is assessed, its natural course & the indications
and expected results of various Rx modalities.
 The route of administration include discussions with
health professionals, group discussion or self-reviewed
materials (e.g., booklets, web sites).
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Exercise
53
 Goal of exercise –
 To prevent or delay disability.
 An exercise program should incorporate –
 To lessen pain during activity
 To increase or maintain joint ROM,
 To strength muscle,
 To stabilize joint &
 To improve aerobic capacity or level of conditioning.
 Exercise in OA should be adapted according to the
presence and severity of pain.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

exercise cont…
54
 In painful episodes –
 Isometric
exercise
 Non weight-bearing exercise (OCK)
 e.g., biking, rowing with adapted tools or
 Partial weight-bearing exercises (CKC)
 e.g., aquatic exercises should be recommended.
 In painless (or less painful) periods –
 The exercise program may include progressive muscle
performance exercises.
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Strengthening Specific Muscles
55
 Quadriceps Muscle Strengthening –
 A possible role for quadriceps-strengthening ex in
slowing disease progression was first explored in 1999.
 Muscle weakness (particularly quadriceps) is a well-
recognized impairment in people with knee OA.
 It has been associated with increased pain & a greater
deterioration in function over time.
 Quadriceps strengthening has formed the cornerstone
of traditional OA exercise therapy.
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Strengthening Specific
56
Muscles cont…
 Quadriceps Muscle Strengthening – cont…
 Quadriceps strengthening ex have consistently found
significant reductions in pain & improvements in
physical function.
 Stronger quadriceps muscles reduced the risk of
developing radiographic knee OA.
 Quadriceps muscles play a large role in resisting the
abduction moment (AM).
 Women with a moderate to high isokinetic quadriceps
strength had respectively a 55% - 64% reduced risk of
developing hip or knee OA.
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Strengthening Specific
57
muscles cont…
 Hamstring Muscle Strengthening –
 Weakness of the hamstring muscles has been found in
patients with knee OA.
 Control of varus-valgus laxity is largely produced by
co-contraction of the quadriceps & hamstring muscles.
 An increase in hamstring strength was associated with
less deterioration in function in people with knee OA.
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Strengthening Specific
58
muscles cont…
 Hip Abductor Strengthening (Frontal plane mover)–
 Strengthening the hip abd muscles controlling pelvic
position in frontal plane may reduce knee loads and
slow disease progression.
 Weakness of hip abductor –
 Drop in the level of the pelvis,
 Shifting the center of mass (COM) and
 Increasing the knee AM.
 Strengthening abductor muscles could reduce knee
load by increasing toe-out during gait
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Strengthening Specific
59
muscles cont…
 Hip adductor muscles (Frontal plane mover) –
 Assist in resisting the knee AM – particularly in a
varus mal-aligned knee.
 Eccentrically restrain the tendency of the femur to
move into further varus
 Knee OA had stronger hip adductors compared with
age-matched controls group.
 Hip strengthening could be a novel intervention for
rehabilitation of knee OA patients.
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Fig: Hip adductor muscles reduce knee varus by their distal
attachment to the proximal femur.
60 P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Strengthening Specific
61
muscles cont…
 Strengthening of hip extensor (Sagittal plane mover) –
 Hip extensor muscle play an important role in
dynamically stabilizing hip & pelvic in sagittal plane.
 The gluteus maximus act as a restraint for forward
progression during gait.
 It also helps to minimize deformity in sagittal plane.
 E.g. hip & knee flexion deformity
 Strengthening should consider both short & long lever
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Exercise – stretching
62
 Stretching ex for hip flexor, hamstring & calf
musculature helps improving ROM, pain &
flexibility of knee OA.
 It should be made as a routine part of Rx.
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Recommendations for
63
musculoskeletal flexibility
 Mode: Gentle static stretching
 Frequency: Minimum 2–3 days/week
 Intensity: Stretch to a position of mild
tension/discomfort
 Duration: Hold position for 10–30 seconds
 Repetitions: 3–4 repetitions for each stretch
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Muscles imbalance in bow-leg
64
Tight or Short Muscles Weak or Elongated Muscles
 Hip –  Hip –
 Abductors
 Flexors
 Extensors
 Knee –  Knee –
 Medial hamstring  Lateral hamstring
 Q,ceps  Q,ceps (VMO)
 Ankle –  Ankle –
 Gastrocnemius (lateral
 Gastrocnemius (medial head)
head)
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Muscles imbalance in knock -knee
65
Tight or Short Muscles Weak or Elongated Muscles
 Hip –  Hip –
 Flexors  Abductors
 Adductors  Extensors
 Knee –  Knee –
 Lateral hamstring  Medial hamstring
 Q,ceps  Q,ceps (VMO)
 Ankle –  Ankle –
 Gastrocnemius (lateral  Gastrocnemius (medial
head) head)
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Gait Retraining
66
 Gait patterns can influence loading at the knee joint,
and thus changing them through gait retraining could
slow disease progression.
 Parameters altering include – toe-out angle, walking
speed & location of loading under foot during stance.
 Although patients may be able to alter their gait pattern
when instructed in clinic, use of biofeedback devices,
leg/foot taping, or other strategies may be necessary to
allow the pattern to become habitual.
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Gait retraining cont…
67
 Degree of toe-out
 It represents the angle of foot placement (FP)
 It is the measure of angle formed by each foot’s line of
progression & a line intersecting the center of the heel
and the 2nd toe.
 Normal angle for male 70
 The degree of toe-out decreases as the speed of walking
increases in normal men.
 Toe-out angle –
 There was 10% reduction in odds of structural
disease progression per additional 10 of toe-out angle.
 Thus, small alterations in toe-out angle may have
clinically relevant effects.
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Gait Retraining cont…
68
 Walking speed –
 Itis another factor associated with knee load, with
faster walking speeds increasing all knee loads
(including the knee AM).
 Indeed, people with knee OA often walk more slowly
than the average, which is thought to be an adaptive
mechanism in reducing knee loads.
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Aerobic Exercise
69
 Aerobic exercise – including cycling, swimming,
and walking has been found to be effective for
relieving symptoms in knee OA.
 Such exercise could also have benefits for longer-
term joint health by assisting with weight
reduction.
 the combination of dietary weight loss and exercise
(including both aerobic and resistance components)
was more effective in improving function and pain
in people with knee OA
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Orthoses/ knee bracing
70
 Supports, braces & corrective devices may assist in
relieving pain & improving function of affected
joints.
 They are used –
 To reduce vertical forces applied to skeleton at heel
strike
 Realign unstable or structurally deficient joints with
restoration of normal force distribution
 Improve proprioception; and improve stability and
patient perception of instability.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Patellofemoral joint brace Unloader knee brace
71 P.R.Khuman MPT, Ortho & Sports 19-Jun-12

FOOTWEAR AND INSOLES
72
 Lateral Wedges (LW) –
 Wedged insoles were first proposed as a treatment for
knee OA in the 1980s by Japanese researchers.
 Wedged insoles exert a mechanical effect on the lower
limb by altering the magnitude, temporal pattern, and
plantar location of GRFv acting on the foot during gait.
 LW increase the subtalar joint valgus moment thereby
reducing the moment arm of the knee AM arm in the
frontal plane.
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73 P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Shock-absorbing Insoles
74
 Viscoelastic materials used in footwear or in insoles
augment body tissues (particularly the heel pad) in
reducing the magnitude of the heel-strike transient.
 With age, heel pad structure alters and results in a
loss of shock absorbing capacity.
 Viscoelastic insoles can attenuate transient forces
incurred during walking, running, stair climbing,
and jumping activities.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Electrotherapy for pain
75
 Electrotherapeutic modalities are widely used in PT
departments to decrease pain associated with OA.
 Popular Rx include - US, IFT, SWD, LASER &
TENS.
 The proposed physiological effects of these
modalities include deep heating, increased blood
flow, reduced muscle-spasm, promotion of
inflammatory response, and pain relief.
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76
 There are many laboratory-based studies that
demonstrate the physiological effects of electrotherapy
modalities that should theoretically produce therapeutic
effects.
 Until clinical trials replicate laboratory findings,
electrotherapy cannot be considered an efficacious,
cost-effective, evidence-based intervention for OA.
 However, it should be noted that patients generally like
electrotherapy Rx & considerable placebo effects could
be used to enhance other aspects of a Rx package.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Thermotherapy
77
 Heat applied through various heated packs, relieves
pain
 Heat ‘close the pain gate’, improved local circulation,
increased collagen extensibility, reduced muscle spasm,
and improved ROM.
 Similarly, cold therapy applied through ice packs or
baths may relieve pain via the ‘pain-gate’ mechanism,
reduced peripheral nerve excitability, and reduction in
joint effusions and oedema.
 Thermotherapy appears to be a simple, cost-effective,
means of assisting pain control & therefore is an
appropriate tool in patient self-management regimes.
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78 P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Ultrasound (US)
79
 Ultrasound (US) is probably the most commonly
used electrotherapy modality, especially for hip,
knee, and vertebral OA.
 It is claimed to alters cell function, vascularity, and
collagen extensibility, resulting in a
proinflammatory effect.
 A meta-analysis of US in musculoskeletal
conditions concluded that it has no role in the relief
of pain.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Transcutaneous electrical
80
nerve stimulation (TENS)
 TENS receives widespread use in many acute &
chronic pain conditions.
 The main theoretical rationale for pain relief is that
electrical stimulation of large diameter neural fibres
‘closes the pain gate’.
 Alternatively, counter-irritant stimulation may
facilitate release of endogenous opioid substances.
 TENS can effect pain relief when used at high
frequency or strong burst mode for more than four
weeks.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Interferential therapy (IFT)
81
 Physiological effects of this modality differ according to
level of stimulation & type of nerves fibres stimulated.
 Stimulation of motor nerves – Leads to muscle
contraction, as a result increases circulation in the area.
 This is of limited use in OA where active exercise is of
proven benefit
 Sensory nerve stimulation – Facilitating opioid
production and ‘closing the pain-gate’.
 However, there is no evidence for its benefit in
stimulating healing & only limited evidence supporting
analgesic effects.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

SWD
82
 SWD have been used in a variety of orthopaedic
and musculoskeletal conditions with varied
success.
 Pulsed or continuous delivery results in tissue
heating and subsequent increased circulation of
treated area.
 Cell membrane potentials may also be effected
although this theory remains contentious.
 Study suggested that pulsed Rx relieved pain in
subjects with knee OA.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Low-level laser therapy (LLLT)
83
 LLLT has evolved as a therapeutic intervention for
OA over the last decade.
 Therapeutic doses are too low to induce thermal
effects within the tissues and the physiological
benefits are thought to derive from photochemical
reactions at cellular level, which produce an anti-
inflammatory effect.
 A recent review failed to conclude whether LLLT
was beneficial in Rx of OA.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Balneotherapy (hydrotherapy
or spa therapy)
84
 Balneotherapy is one of the oldest recorded
treatments for rheumatic conditions.
 It utilizes buoyancy—the assistant and resistant
properties offered by water- in combination with
the ‘healing’ effects of warm, mineral rich waters.
 The aim is to relieve muscle spasm, increase joint
ROM and muscle strength, with subsequent
improvement in function.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Spa Therapy
85
 Spa Therapy is normally delivered on a 2–3 week
residential basis at spa resorts.
 It consists of daily thermal bathing, exercise
sessions, mudpacks, and jet massage.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Hydrotherapy
86
 Hydrotherapy consisting of heated pool is popular with
patients, and effective in relieving pain, improving
joint ROM & patient function & quality of life.
 Due to demand and limited resources, Rx are normally
of short duration with little possibility of follow-up Rx.
 Patients with a variety of rheumatic conditions benefit
from balneotherapy, with reductions in pain and muscle
spasm, and accompanying improvements in functional
activities.
 At present it is an expensive intervention based on
scientific evidence.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Walking aids
87
 Sticks & crutches are supplied to reduce the stress
applied to weight bearing joints and to improve
patient stability during ambulation.
 Unfortunately, walking aids are not always popular
with patients, who perceive them as being for the
elderly and infirm.
 They can also be impractical when performing
other functional activities.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Walking aids cont…
88
 Historically, patients have been encouraged to use
walking aids on the contralateral side to the
problematic joint, thus encouraging improved
weight distribution, and an energy efficient gait
pattern.
 For knee patients walking aids function as a
vertical load-sharing implement and cannot effect
forces in the frontal plane.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Manual therapy
89
 Physiotherapists, osteopaths and chiropractors use
manual techniques, to reduce joint pain and
stiffness, and increase ROM.
 Manual therapy applied to knee together with an ex
programme may be used to improve knee function
& pain relief for patients with OA of the knee.
 Manipulation often gain short-term benefit.
 Studies suggest minimal efficacy in relieving pain,
improving ROM and function.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Joint mobilization cont…
90
 Despite, it is still commonly used in outpatient
departments in conjunction with other modalities
such as electrotherapy and exercise.
 Further work is necessary to determine the efficacy
of these interventions especially at different stages
of disease progression, as there is a possibility that
benefits will differ accordingly.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Massage
91
 Patients frequently report that rubbing or massaging a
joint temporarily relieves pain, probably because the
mechanical stimulus excites large diameter nerve fibres
closing the pain gate.
 The additional application of topical agents may
enhance the benefits of massage.
 However, one back pain study reported that massage
was no better than manipulation, but was inferior to
TENS, in relieving pain.
 Massage is likely to be used by patients and
encouraged by practitioners.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Patellar taping
92
 Aim is to control patellar tracking and minimize
contact stress
 Most common method is medially directed taping
to offload lateral compartment of PFJ
 Significant improvements in pain and physical
function
 Direct effect on pain not attributable to placebo or
cutaneous stimulation
 No research on long-term effects of taping or role
in disease pathogenesis
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Physical activity
93
recommendations for health
 Activity: Daily activity (walking, yard work, etc.)
 Frequency: Most days of the week
 Intensity: Moderate; 55–70% of age-predicted
maximal heart rate; RPE 2–4
 Duration: Accumulate at least 30 minutes of
activity (e.g., three 10-minute bouts)
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Recommendations for
94
physical fitness (cv fitness)
 Mode: Rhythmic, aerobic exercise (walking,
jogging, cycling, swimming, etc.)
 Frequency: 3–5 days/week
 Intensity: 70–85% age-predicted maximal heart
rate; RPE 4–5
 Duration: 20–30 minutes continuous
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

Recommendations for physical
fitness (muscular fitness)
95
 Mode: Dynamic, resistance exercise for major
muscle groups
 Frequency: 2–3 days/week on alternate days
 Volume:
 8–10 exercises; resistance adequate to induce
moderate, volitional fatigue after 8–12 repetitions.
 If the subject is more than 50–60 years of age or frail,
or the primary goal is to improve endurance, choose a
level of resistance that will produce moderate fatigue
after 10–15 repetitions.
P.R.Khuman MPT, Ortho & Sports 19-Jun-12

references
96
 M. Sofue, N. Endo, Treatment of Osteoarthritic
Change in the Hip Joint Preservation or Joint
Replacement?, 2007
 J. Maheshwari, Essential Orthopaedics, 3rd edition,
2008
 John Ebnezar, Essential of Orthopaedics for
Physiotherapists, 1st edition, 2003
 Carol David, Jtll Lloyd, Rheumatological
Physiotherapy, 1999
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97
 Dr Marwan Bukhari, The NICE guideline on
osteoarthritis: treatment and management in primary
care, 2008
 ROYAL COLLEGE OF PHYSICIANS,
OSTEOARTHRITIS National Clinical Guideline For
Care & Management In Adults, 2008
P.R.Khuman MPT, Ortho & Sports 19-Jun-12