Dr F PatoMay 2011

01-03-2011 69yr African female painful and swollen right

ankle 2yrs Associated with swelling

of feet at times. Difficulty in sleep Occasional paraesthesia Tiredness Radiates to the hip joint.

Walks with aid (easy mobilization and balance)

limping gait Weight transferred to

the left side of the body.

She has been seen with this complaint by GP.

Patient is also having bilateral flank pain.

Prev medical history: hypertension, rheumatoid arthritis, dermatitis

Prev surgical history: sterilisation

Medication: antihypertensive

Allergies: Unknown Family history:

Hypertension Social: Pensioner, non-

smoking, non-alcohol user, lives with grandchildren en looks after them.

On Examination Overweight Oedema of the ankles and knees Cardiovascular: intact Respiratory: intact Abdomen: central obesity Skin: Dermatitis

Ankle joint: Range of movement decreased in all

directions. Passive and active

Pain with inversion of right ankle Rest of movement not painful, active en

passive. No notable deformities from rheumatoid

arthritis.

3point assessment: Subjective: Pain hinders with the level of

daily function, that is: playing with the children and taking care of the house and yard. She wants pain relief

Objective: Rheumatoid arthritis of ankle and knee joints, osteoarthritis

Contextual: osteoarthritis secondary to rheumatoid arthritis and obesity.

Assessment: rheumatoid arthritis, osteoarthritis, obesity, urinary tract infection.

Plan: urine dipstix, x-ray X-ray: decreased joint space and

osteophyte formation at the margin plus bone cysts. No signs of previous injury.

Advise exercise and weight reduction to relieve pressure applied to the joints

Exercises prescribed: walking, squats, dorsiflexion, eversion and inversion, heel raisers. Help with strengthening of the muscles around the joints and maintainance of movement.

Range of movement better. Pain improving. Swelling less. On examination: Swelling subsided. Still walking with aid Less antalgic. Range of movement improved. Patient to continue with exercise at

home. Review in 1 month.

Definition Rheumatological condition Synovial inflammatory

response Imbalance in joint tissue

breakdown and repair 3 Subchondral bone sclerosis Erosion of articular cartilage Deposition of osteophytes Structural and functional

failure of synovial joints3

Epidemiology6% above 30yrs (2006), 13% >60

(1998)Depends on method used to classifyRadiographs or self report

Risk factorsAge, gender, diet, family history,

obesity, joint injury, endocrine, occupational

BonesTibiaFibulaTalus

Ligamnets Lateral

Ant talofibular Post talofibular Calcaneofibula

r Medial

Ant tibiotalar Tibionavicular Tibiocalcaneal Post tibial part

Weight reduction not costly reduces joint load

Compliance with dietNot guaranteed to help

Exercise increases mobility Symptomatic relief only

Simple analgesiaSafe, cheap, relieve mechanical pain Often incomplete control of symptoms

NSAIDSReduce pain and

inflammation

Side effects ? chondrodestructive

OsteotomyRelieves painful movementIncreases joint mobility

Limited success rate

Intra articular steroidsTemporary decrease in stiffnessand inflammantion

May cause joint degradation side effects

ArthroplastyRelieves painful movementIncreases joint mobility

CostProsthesis lifespan and failure

Exercise prescription3 Weight loss Joint range of motion preserved Functional performance improvement Strength improvement Symptom reduction

Start with isometric then move to isotonic resistance as tolerated

Promotion of low-impact exercise Encourages exercise benefits Avoids potential damaging effects of high-

impact activities

Favourable dGEMRIC index (Delayed Gadolinium Enhanced MRI of cartilage) Compared sedentary vs exercise intervention Increased proteoglycan Cross sectional study (2004)

OA risk increased by activity of high impact and high stress to the joint, increased by the presence of previous injury to the specific joint

Overexercise leads to glycosaminoglycan depletion

Lack of mechanical stimulation leads to cratilage atrophy

? cartilage transplants

Human cartilage recovers within 90 min after loading

Appeared to deform a little in the 1st few minutes under high loads

Very little deformation shown Increased loading not associated with

articular thickening Deformation is dependent on biochemical

composition of tissue Aid in designing of artificial cartilage

Deformation difficult to assess during loading Age results in linear decrease in cartilage

thickness with or without OA Cartilage thickness is genetically determined Different genes responsible for different joints

Study comparing siblings and twins

Prevention of further degradation and maintaining functionality of joint is important

1. Clinical sports medicine revised third edition, P Brukner, K Khan

2. Clinically orientated anatomy fourth edition. K I Moore and A F Dalley

3. David J. Hunter. Felix Eckstein. Exercise and osteoarthritis, Journal of Anatomy2009.214(2):197-207

4. Lecture notes, D Whitelaw, osteoarthritis lecture notes, 2005

5. F. Eckstein, M. Huldelmaier, R. Putz. Effects of exercise on human articular cartilage, Journal of Anatomy2006.208:491-512