DEFINITION:

Other names includes: Degenerative joint disease (DJD), Hypertrophic arthritis, Degenerative disc disease (DDD in the spine), Generalized osteoarthritis or Kellgren’s syndrome.

Marked by two localized, pathological features, the progressive destruction of articular cartilage and the formation of bone at the margins of the joint (Sullivan)

Most common type of arthritis is an asymmetrical non-inflammatory disease that has no systemic component. (De Lisa)

In OA, there are differences in the water content ratio of certain cartilage constituent. And an increase in degradative enzyme activity compared with in non – osteoarthritis joint. (Braddom)

Most common form of arthritis, is a primarily a disease of cartilage, not of the synovium. In the upper limb, it most commonly involves the CMC joint of the thumb. A thumb spica hand – based or forearm – based splint can be prescribed for CMC joint OA by limiting motion at the base of the thumb, the splint decrease pain, especially with pinching – type activity. (Braddom)

Characterized by degenerative changes in articular cartilage and bony overgrowth at the joint margin (Shunts)

It is a group of diseases and mechanical abnormalities entailing degradation of joints, including articular cartilage and the subchondral bone next to it.

Osteoarthritis is a type of arthritis that is caused by the breakdown and eventual loss of the cartilage of one or more joints.

Classification of Osteoarthritis

OA is often graded on radiographs according to the criteria of Kellgren and Lawrence using an ordinal scale of five levels:

Grade 0 – normal radiograph

Grade 1 – doubtful narrowing of the joint space and possible osteophytes

Grade 2 – definite osteophytes and absent or questionable narrowing of the joint space

Grade 3 – moderate osteophytes and joint space narrowing, some sclerosis and possible

deformity

Grade 4 – large osteophytes, marked narrowing of joint space, severe sclerosis and

definite deformity.

General Criteria of OA

1. Pain on motion relieve by rest.

2. Aching pain and stiffness in joint after prolonged rest especially in early morning hour relieve in less than 30 minutes with mild exercise.

3. Restraining of cartilage or loss of joint space seen X- ray examination.

4. Increase density of subchondral bone.

5. There is reactive bone overgrowth at margin of joint.

Clinical classification criteria for knee and hip osteoarthritis

Knee osteoarthritis

1. Knee pain

2. Joint stiffness < 30 minutes

3. Crepitus

4. Bony enlargement

5. Bony tenderness

6. No palpable warmth

Hip osteoarthritis

1. Hip internal rotation > 15 degrees with pain, morning stiffness < 60 minutes, and age > 50 years old, or

2. Hip internal rotation < 15 degrees and hip flexion < 155 degrees

Two main types of arthritis

I. Inflammatory arthritis fall into four groups:

1. Inflammatory connective tissue disease (RA, JRA, SLE, DM-PM, mixed connective tissue disease)

2. Inflammatory crystal induced disease (Gout , pseudogout)

3. Inflammation induced by infectious agent (Bacterial, viral, tuberculosis & fungal arthritis)

4. Seronegative spondyloarthropathies (AS, Psoriatic Arthritis[PSA],Reiter’s disease, Inflammatory bowel disease[BD])

II. Non – inflammatory arthritis

1. Degenerative (OA, Postraumatizing aseptic necrosis[AN])

2. Metabolic (Lipid storage disease, Hemochromatosis, Ochronosis, Hypogammaglobulinemia, Hemoglobinopathies)

RELATED ANATOMY:

JOINT

Also called an articulation or arthrosis, is a point of contact between two bones, between the bone and cartilage.

The structural classification of joints is based on two criteria.

1. Presence or absence of a space between the articulating bones, called synovial cavity.

2. Type of connective tissue that binds the bones together.

Structurally

Fibrous joints- bones re held together by fibrous connective tissue that is rich in collagen fibers; they lack a synovial cavity.

Cartilaginous joints- bones are held together by cartilage; they lack a synovial cavity. The articulating bones are tightly connected by either Hyaline Cartilage (reduce friction, shock absorber).

Synovial joints- bones forming the joint have a synovial cavity and are united by the dense irregular connective tissue of an articular capsule, and often by accessory ligaments.

Functionally

Synarthrosis- immovable joint

Amphiarthrosis- slightly movable joint

Diarthrosis- a freely movable joint

Synovial Cavity - this allows a joint to be freely movable.

Synovial fluid -reduce friction by lubricating the joint and supplying nutrients to and removing metabolic wastes from the chondrocytes within the articular cartilage.

Joint capsule - a tough membrane sac that encloses all the bones and other joint parts.

Synovium - a thin membrane inside the joint capsule that secretes synovial fluid.

Cartilage- covers the articulating surface of the bones with a smooth, slippery surface but does not bind them together.

Subchondral bone - layer of bone in which is just below the cartilage.

Osteophytes-typically develop as a reparative response by the remaining cartilage.

Back Anatomy

The Spinal Column:

The spinal column (also called the vertebral column) contains and protects the spinal cord and supports the body and head. The spinal column is flexible to allow movement of the body.

The spinal column is comprised of a column of small bones called vertebrae.

Shock absorbing discs separate the vertebrae.

Vertebrae:

The 24 vertebrae are named according to their location along the spine. We start out with 33 vertebrae but the lowest nine fuses together to form single bones- 5 fused vertebrae form the sacrum and 4 tiny fused vertebrae form the coccyx (tailbone).

The 24 True or Movable Vertebrae: Cervical spine (neck area) with 7 vertebrae (labeled C1 - C7) Thoracic spine (chest area) with 12 vertebrae (labeled T1 - T12) Lumbar spine (lower back) with 5 vertebrae (labeled L1 - L5)

Fused Vertebrae (Below the lumbar spine):

Sacrum: a triangular shaped solid base with 5 fused vertebrae - connects with the pelvis

Coccyx: (the tailbone) with 4 very small fused vertebrae.

Main Parts of a Vertebra:

- The two main parts of the vertebra are the vertebral body and the vertebral arch.

Vertebral Body: The anterior segment and largest part of a vertebra, basically cylindrical in shape.

Vertebral Arch: The posterior part of a vertebra; the vertebral arch has several processes (bony projections).

Processes (bony projections) of the Vertebral Arch:

Spinous process - projecting from the center of the vertebral arch. and serve as attachments for the muscles and ligaments.

Transverse processes - projecting from either side of the vertebral arch and serve as attachments for the muscles and ligaments.

Articular processes meet and interlock at the facet joints to link one vertebra with the next. Each vertebra arch has four (two superior and two inferior) articular processes.

Intervertebral Foramen (plural: intervertebral foramina):

The opening formed between adjacent vertebrae from which the spinal nerves exit. There is an opening on each side.

Facet Joints:

Facet joints (commonly called spinal joints) join adjacent vertebrae. Facet joints are hinge-like and allow adjacent vertebrae to move on one another to allow bending and twisting and also keep the spine within a normal range of motion. The surfaces of the bones that make up the facet joints are coated with smooth cartilage that allows the bones to glide smoothly against each other. Muscles, ligaments and discs support the joints of the spine.

Discs:

The vertebral bodies are separated by shock absorbing intervertebral discs. Theses discs have a tough outer coating with and contain a jelly-like substance.

Spinal Cord:

A part of the central nervous system, the spinal cord transmits messages from the brain to other parts of the body and vice versa.The spinal cord begins at the brain and runs down to the level of the second lumbar vertebrae. Three meninges (membranes) cover the spinal cord. Spinal nerves branch out form the spinal cord.

Meninges:

The three membranes enclosing the spinal cord and brain - the pia mater, arachnoid, and dura mater. The dura mater is the outermost and toughest of the three meninges.

Spinal Canal:

Spinal Canal (also called vertebral canal) is the large canal in the center of the spinal column that contains the spinal cord and its membranes.

Ligaments:

Ligaments are tough bands of connective tissue that connect the vertebrae. Facet joints and ligaments help protect the spine by limiting how far the spine can bend or twist.

Muscles:

Muscles support the spine and allow movement. Muscles of the back, abdomen and buttocks stabilize the spine and maintain proper posture. Muscles protect the spine by absorbing shock before it reaches the discs and facet joints.

Hand Anatomy

Bones and Joints

There are 27 bones within the wrist and hand. The wrist itself contains eight small bones, called carpals. The carpals join with the two forearm bones, the radius and ulna, forming the wrist joint. Further into the palm, the carpals connect to the metacarpals. There are five metacarpals forming the palm of the hand. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb.

The main knuckle joints are formed by the connections of the phalanges to the metacarpals. These joints are called the metacarpophalangeal joints (MCP joints). The MCP joints work like a hinge when you bend and straighten your fingers and thumb.

The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the

proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb phalanges. The IP joints of the digits also work like hinges when you bend and straighten your fingers and thumb.

The joints of the hand, fingers, and thumb are covered on the ends with articular cartilage. This white, shiny material has a rubbery consistency. The function of articular cartilage is to absorb shock and provide an extremely smooth surface tofacilitate motion. There is articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Ligaments and Tendons

Ligaments are tough bands of tissue that connect bones together. Two important structures, called collateral ligaments, are found on either side of each finger and thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each joint.

In the PIP joint (the middle joint between the main knuckle and the DIP joint), the strongest ligament is the volar plate. This ligament connects the proximal phalanxto the middle phalanx on the palm side of the joint. The ligament tightens as the joint is

straightened and keeps the PIP joint from bending back too far (hyperextending). Finger deformities can occur when the volar plate loosens from disease or injury.

The tendons that allow each finger joint to straighten are called the extensor tendons. The extensor tendons of the fingers begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where theyeventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger.

The place where the extensor tendon attaches to the middle phalanx is called the central slip. When the extensor muscles contract, they tug on the extensor tendon and straighten the finger. Problems occur when the central slip is damaged, as can happen with a tear.

Hip Anatomy

The bones of the hip region are the hip bone and the femur (or thigh bone).

Prominent palpable bony structures of the hip bone include the iliac crest, the anterior superior (ASIS) and posterior superior iliac spines (PSIS), the posterior inferior iliac spine (PIIS), the five or so tubercles and the lower lateral borders of the sacrum, and the ischial tuberosity ("sitting bone")

Proximally the femur is largely covered by muscles and, as a consequence, the greater trochanter is often the only palpable bony structure.

The hip joint is a synovial joint formed by the articulation of the rounded head of the femur and the cup-like acetabulum of the pelvis. It forms the primary connection between the bones of the lower limb and the axial skeleton of the trunk and pelvis. Both joint surfaces are covered with a strong but lubricated layer called articular hyaline cartilage. The cuplike acetabulum forms at the union of three pelvic bones — the ilium, pubis, and ischium.

It is a special type of spheroidal or ball and socket joint where the roughly spherical femoral head is largely contained within the acetabulum and has an average radius of curvature of 2.5 cm. The acetabulum grasps almost half the femoral ball, a grip augmented by a ring-shaped fibrocartilaginous lip, the acetabular labrum, which extends the joint beyond the equator.] The head of the femur is attached to the shaft by a thin neck region

The acetabulum is oriented inferiorly, laterally and anteriorly, while the femoral neck is directed superiorly, medially, and anteriorly.

The extracapsular ligaments are the iliofemoral, ischiofemoral, and pubofemoral ligaments attached to the bones of the pelvis (the ilium, pubis, and ischium respectively). All three strengthen the capsule and prevent an excessive range of movement in the joint.

The intracapsular ligament, the ligamentum teres, is attached to a depression in the acetabulum (the acetabular notch) and a depression on the femoral head (the fovea of the head)

Knee Anatomy

The knee is essentially made up of four bones. The femur, which is the large bone in your thigh, attaches by ligaments and a capsule to your tibia. Just below and next to the tibia is the fibula, which runs parallel to the tibia. The patella or what we call the knee cap, rides on the knee joint as the knee bends.

When the knee moves, it does not just bend and straighten, or, as it is medically termed, flex and extend. There is also a slight rotational component in this motion. The knee muscles which go across the knee joint are the quadriceps and the hamstrings. The ligaments are equally important in the knee joint because they hold the joint together. The bones support the knee and provide the rigid structure of the joint, the muscles move the joint, and the ligaments stabilize the joint.

Anterior Cruciate Ligament- Extends posteriorly and laterally from a point anterior to the intercondylar area of the tibia to the posterior part of the medial surface of the lateral condyle of the femur. This limits hyperextension of the knee and prevents the anterior sliding of the tibia in the femur.

Posterior Cruciate Ligament-Extends anteriorly and medially from a depression from the posterior intercondylar area of the tibia and lateral meniscus to the anterior part of the

lateral surface of the medial condyle of femur.Prevents posteriorsliding of the tibia when the knee is flexed.

The knee joint also has a structure made of cartilage, which is called the meniscus or meniscal cartilage. The meniscus is a C-shaped piece of tissue which fits into the joint between the tibia and the femur. It helps to protect the joint and allows the bones to slide freely on each other. There is also a bursa around the knee joint. A bursa is a little fluid sac that helps the muscles and tendons slide freely as the knee moves.

Feet Anatomy

Bones and Joints

The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint.

The mortise and tenon structure is well known to carpenters and craftsmen who use this joint in the construction of everything from furniture to large buildings. The arrangement is very stable.

The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heelbone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side.

Just down the foot from the ankle is a set of five bones called tarsal bones that work together as a group. These bones are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by

the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting.

The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints.

Finally, there are the bones of the toes, the phalanges. The joint between the metatarsals and the first phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern.

Not much motion occurs at the joints between the bones of the toes. The big toe, or hallux, is the most important toe for walking, and the first MTP joint is a common area for problems in the foot.

Ligaments and Tendons

Ligaments are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. Ligaments and tendons come in many different sizes, and like rope, are made up of many smaller fibers. The thicker the ligament (or tendon) the stronger the ligament (or tendon) is.

The large Achilles tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to raise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. The toes have tendons attached that bend the toes down (on the bottom of the toes) and straighten the toes (on the top of the toes). The anterior tibial tendon allows

us to raise the foot. Two tendons run behind the outer bump of the ankle (called the lateral malleolus) and help turn the foot outward.

Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

EPIDEMIOLOGY:

Most common form of arthritis

Extremely common condition after 40 years of age

It is estimated that 80% of the population will have radiographic evidence of OA by age 65

Widespread in adults older than 65 years old

Men > women before the age of 45 but reverses after age 45.

Women experience greater severity of symptoms and report more problems with morning stiffness, joint swelling and night pain.

Its prevalence increase with age 7% of men and 8% of women 18 – 24 years of age showed evidence of OA. By 75 to 79 years of age all had evidence of OA.

Women more commonly have OA of the DIP, PIP, CMC and MTP; 65 -74 years of age men more often have hip involvement than women; Knee involvement is seen in two genders from 55-64 years of age.

The pervasiveness of osteoarthritis, as well as its conditions, makes arthritis the leading cause of disability, impairment and job loss among adults and limits everyday activities

ETIOLOGY:

Cartilage degeneration is the hallmark of the disease. The cause of the degeneration is unknown, but the possibilities include collagen framework damage secondary to fatigue or abrasion, changes in the synthesis of proteoglycan or its degradation, and defects in synovial fluid and chondrocyte function.

Degenerative changes in articular cartilage are more common and more severe with advancing age, in the weight bearing joints and in joints that have become incongruent or have been used abnormally. The fact that osteoarthritic changes are

often localized to only part of a single joint suggests that there are causative factors other than age and attrition. Mechanical injury, which may consist of a single major trauma or repeated minor traumas, may cause intra-articular changes that act as a predisposing or aggravating cause. In people over 45 years of age whose parents have suffered from arthritis late in life, there is a greater succeptibility than in those who have no family history of arthritis. Thus there may be genetically determined chemical differences in the cartilage of some individuals that predispose it to early degeneration.

Primary osteoarthritis – used to designate cases in which no underlying cause for the joint disease is clearly apparent. It may be localized (confined to one or two joints) or generalized (present in three or more joints).

Secondary osteoarthritis – in which an antecedent disease or injury is believed to be related to the arthritis, may result from any condition that disturbs normal joint function, including burnt-out rheumatoid arthritis, repeated trauma, malalignment as a result of fractures, congenital subluxation of the hips and a host of others. It is frequently seen in the younger age range.

PATHOPHYSIOLOGY:

The first osteoarthritic change in articular cartilage, w/c has been confirmed in humans is an increase in water content. This increase suggests that the proteoglycan have been allowed to swell with water far beyond normal, although the mechanism by w/c this occurs is unknown. Additionally there are changes in the composition of newly synthesized proteoglycan. In later stages of disease progression, proteoglycans are lost, articular cartilage loses its compressive stiffness and elasticity, which in turn result in the transformation of compressive forces to underlying bone. Changes in cartilage proteoglycans will also negatively affect the ability of the cartilage to form a squeeze film over its surface during joint loading. Collagen synthesis is increased initially, although there is a shift from type II collagen fibers to a larger proportion of type I collagen, the kind found in skin and fibrous tissues. As the articular cartilage is destroyed the joint space narrows.

One of the first noticeable changes in cartilage is the mild “fraying” or “flaking” of superficial collagen fibers. Deeper fraying or fibrillation of the upper third of the cartilage follows and occurs in areas of greater weight bearing. The cartilage may degenerate to the point that subcondral bone is expose. Subchondral bone in turn can then become sclerotic and stiffer than normal bone. These changes in cartilage and bone result in increase friction, decrease shock absorption and greater impact loading of the joint. The traditional view of OA is that the disease process starts with an unpaired injury to articular cartilage; however, there is also evidence that reduced compliance in bone and periarticular structure may initiate the degenerative process.

The process of osteophyte formation in OA is not well unerdstood, current hypothesis have implicated increase vascularity in degenerated cartilage venous congestion from subchondral cyst and thickened subchondral trabeculae, and the

continued sloughing of articular cartilage. Each of these hypotheses may explain how this bony growth contributes to the pain and loss of motion that accompany by OA.

OSTEOARTHRITIS OF THE SPINE

Extremely common Seen often in stocky and obese Male > female; person over 40y/o Observed in lumbar and cervical levels Constant use of back are probably an important causative factor

Pathology

Pathological changes are take place in the spinal diarthrodial (apophyseal) and in the intervertebral joints. Spur formation may occur about the articular facets. Thinning of the intervertebral disk and spur formation at the anterolateral margin of the of the vertebral bodies result from disk degeneration and reactive bone formation, changes often termed spondylosis or spondylophytosis, usually accompany OA of the facet joints, they may be represent a related but distinct degenerative process.

In later stages the vertebral bodies becomes flattened and much new bone develops about their margin, producing so called bridging and leaf formation. Ultimately there are frequently develops so much disk space narrowing and osteophyte formation that is stiffened but very stable and relatively painless articulation result. Roentgenograms are present to some degree in a high percentage of old people who have never had significant backpain; this true of heavy individuals.

Clinical features

Morning stiffness

Radiating pain around toward the chest or abdomen or down the legs or arm.

Radiating pain is particularly common in the lumboscaral joints and of the intervertebral foramina of the cervical spine

Deformity of the lumbar spine (lateral curvature and decrease normal lordosis may develop).

Attacks tend to occur less frequently when the spine becomes more stable.

Treatment

Rest and restriction of activity.

Salicylates for relieving discomfort. Hot packs and the use of massage. Thomas collar may be very effective in the management of neck pain Surgical treatment when there are sign of nerve root or spinal cord compression by osteophytes.

OSTEOARTHRITIS OF THE HANDS

OSTEORTHRITIS OF THE KNEE

Of the major joints the knee is the most frequently affected by OA. Knee problems may be unilateral, bilateral or tricompartmental. Pain in the knee with OA may be due to:

Loss of cartilage

Mechanical compression of the medial knee compartment

Microfractures and subchondral fractures

Capsular distention by effusion

Physical findings include slight limitation of the joint motion, usually restriction of the last few degrees of flexion and extension, and mild to moderate joint effusion. A varus or valgus deformity may be associated with some mediolateral instability. Pain and swelling o the knee lead to restricted ROM and contractures of the joint capsule and hamstrings.

The treatment of early osteoarthritis of the knee consists of strengthening exercises for the quadriceps and hamstring muscles, weight reduction in obese patients. Acute pain and swelling, often following a twisting injury or stressful use of the joint, are treated by hot compress, rest, and an elastic knee support. Crutches may be needed until acute symptoms subside.

Osteotomy can correct the deformity and shift the weight bearing load to the less involved side of the jt.

Arthrodesis for a younger, active person with severe degenerative changes limited to one knee.

Arthroplasty, by total joint replacement may result in a painless joint with satisfactory motion, but the durabiity of total knee arthroplasty in an active patient is yet to be established.

Total joint replacement the treatment of choice in severe bilateral osteoarthritis of the knee.

OSTEOARTHRITIS OF THE HIP

Hip osteoarthritis is caused by deterioration of articular cartilage and wear-and-tear of the hip joint. There are several reasons this can develop:

previous hip injury previous fracture, which changes hip alignment genetics congenital and developmental hip disease subchondral bone that is too soft or too hard avascular necrosis

Patients who have hip osteoarthritis have pain localized to the groin area and the front or side of the thigh. Morning stiffness, though for less duration than occurs with rheumatoid arthritis, is also characteristic of hip osteoarthritis. Most significantly, there is

limited range of motion of the hip and pain during motion. The symptoms can worsen to the point that pain is constantly present.

Medications are one way to treat hip osteoarthritis. For mild cases, acetaminophen is usually tried first. NSAIDs (non-steroidal anti-inflammatory) and opioid analgesics are used for moderate to severe hip osteoarthritis.

There are also non-drug treatments that can help:

weight loss (normal weight people have a 20% risk of hip OA, overweight have 25% risk, and obese have 39% risk)

water exercise programs physical therapy (range of motion and strengthening exercises) occupational therapy (assistive devices, joint protection) patient education

Surgery is considered a last resort treatment option. Surgery is appropriate for patients with hip osteoarthritis who have failed other more conservative treatment options. Surgical procedures include:

arthroscopy - an arthroscope checks the condition of the articular cartilage osteotomy - realigns angles of the hip joint total hip replacement - new acetabular and femoral components are implanted

OSTEOARTHRITIS OF THE FEET

Diagnosis of Foot Osteoarthritis

Doctors will perform a physical examination. Foot will be examined for swelling, bone spurs or other deformities, limited range of motion, and pain which occurs with movement. A gait analysis may be performed to evaluate stride while walking and the strength of the feet.

Imaging studies of the bone structure of the affected foot will likely be performed. Evidence from X-rays, CT scans, or MRI may be used to help diagnose foot osteoarthritis.

Symptoms of Foot Osteoarthritis

The usual symptoms associated with foot osteoarthritis include:

pain and stiffness of the affected foot swelling near the affected joint limited range of motion and difficulty walking bony protrusions (spurs)

There are 28 bones and more than 30 joints in the human foot. The foot joints that are most commonly affected by osteoarthritis include:

the ankle (tibioltalar joint) the 3 joints of the hindfoot (talocalcaneal joint, talonavicular joint, calcaneocuboid

joint) the midfoot (metatarsounieform joint) the great toe (first metatarsophalangeal joint)

Treatment of Foot Osteoarthritis

Treatment options for foot osteoarthritis are aimed at relieving symptoms. There are non-surgical and surgical options. Your doctor will likely recommend one or more non-surgical options first. Non-surgical options include:

Non steroidal anti-inflammatory drugs or analgesics (to relieve pain and swelling) Shoe inserts (to add support or provide extra cushioning) Orthotics (custom-made shoes or suppports) Braces (to restrict motion or prevent more deformity) Physical therapy or exercise (to improve range of motion and stability) Steroid injections (to deliver anti-inflammatory medication to the joint directly) Dietary supplements

If non-surgical options are ineffective, your doctor may suggest surgery. Depending on the joint involved, arthroscopy, arthrodesis (fusion), or arthroplasty (joint replacement) may be considered. The goal of foot surgery is to relieve pain and restore function.

CLINICAL MANIFESTATIONS:

Common Areas of Affection of Osteoarthritis

Early Stage of Osteoarthritis

Usual complains of stiffness of one or more joints, associated with an aching pain in or about the affected joint

The involvement is more often monoarticular than polyarticular

Continued use of the joint increases discomfort which may be relieved by rest, support and heat.

The patient tires easily on exertion

The symptoms are worse in cold, wet weather

There is slight enlargement of the affected joints which may be slightly tender about margins (such changes are usually most noticeable in the fingers and knees)

In the hands, bony enlargement of the DIP joints (Heberden’s nodes) is one of the commonest sign.

Less frequent is similar enlargement of the PIP joints (Bouchard’s nodes)

Late Stage of Osteoarthritis

There is limitation of joint motion and disability, especially in the larger weight-bearing joints

Pain may then be present even when the joint is at rest.

Malalignment of the joint is a frequent result of the irregular degeneration and loss of articular cartilage

Crepitation may be noticed frequently, especially in the knee, may produce transient locking

Examination at this stage reveals moderate swelling and puffiness with loss of the normal joint contour

A tendency to early fatigue is more pronounced

DIFFERENTIAL DIAGNOSIS:

Rheumatic Fever

Acute inflammatory stage that may initially appear as migratory polyarthritis simulating early rheumatoid arthritis. The patient with acute rheumatic fever is more likely to have had a streptococcic throat infection and to have electrocardiographic changes and a high fever. Serologic tests may aid in the differentiation. After the acute phase of rheumatic fever the joints recover completely, unlike their usual course in rheumatoid arthritis.

Rheumatoid Arthritis

It is a connective tissue disease characterized by chronic inflammatory changes in the synovial membranes and other structures by migratory swelling and stiffness of the joints in its early stage and by a variable degree of deformity, ankylosis and invalidism in its late stage.

Pyogenic Arthritis

A single large joint is involved. High fever and leukocytosis may distinguish the early case from rheumatoid arthritis and destructive changes in the roentgenograms may distinguish the late case. Aspiration of the joint may yield pus and a positive culture confirms the diagnosis.

Joint Tuberculosis

In its early stages, it may be confused with rheumatoid arthritis, however tuberculosis is more often monoarticular, more insidious its onset and is likely to show more bone destruction roentgenographically. Culture of the joint exudates or biopsy of the synovial membrane may be necessary to establish the diagnosis.

Gout

Its high blood uric acid level is characteristic, especially in the absence of an increase of the non-protein or urea nitrogen. It may be possible to demonstrate urate crystals in the joint aspirate by means of polarized light microscopy. In gout

the joint quickly loses its tenderness between attacks and the great toe is often the first part of the body to be affected.

Systemic Lupus Erythematous

The patient usually shows minimal joint changes, severe systemic symptoms and the characteristic lupus erythematosus cell phenomenon.

Juvenile Rheumatoid Arthritis (Still’s Disease)

This is an uncommon crippling disease of childhood, the systemic form of which is associated with fever and enlargement of lymph nodes and spleen. Children s affected may develop morbilliform rash and severe systemic manifestations.

Felty’s Syndrome

A severe arthritis associated with leucopenia, splenomegaly, subcutaneous nodules and high titers of rheumatoid factor in the serum.

Reiter’s Syndrome

It is an ill-defined disease occurring chiefly in adult males and characterized by the triad of polyarthritis, nongonorrheal urethritis and conjunctivitis. There is also a postdysenteric form of the disease that may follow Shigella infections.

Psoriatic Arthritis

A polyarthritis resembling but probably distinct which is associated with psoriasis. Distinguishing features include frequent involvement of the distal interphalangeal joints, sometimes associated with marked destruction of bone (arthritis mutilans) and the absence of subcutaneous nodules and of rheumatoid factor in the serum.

Palindromic Rheumatism

Characterized by repeated brief episodes of acute arthritis with signs of local inflammation but without residual joint damage. This may be an atypical or prodromal form of rheumatoid arthritis or other connective tissue disease.

Intermittent Hydrarthrosis

A recurring joint effusion characterized by an absence of acute inflammatory signs and by a relatively constant periodicity. The knee is most frequently affected.

Ankylosis Spondylitis

A chronic arthritis usually beginning in the sacroiliac joint and lumbar spine and extending proximally.

Enteropathic Arthritis

A peripheral polyarthritis associated with chronic bowel disease such as ulcerative colitis or Crohn’s disease. The course of the peripheral arthritis generally follows that of the bowel disorder.

Progressive Systemic Sclerosis (Scleroderma)

Generalized disorder of connective tissue characterized by fibrosis and degenerative changes in the skin, synovium, digital arteries or certain internal organs notably the esophagus, intestines, lungs, heart, kidney and thyroid.

Sjorgren’s Syndrome

An immunologic disease characterized by deficient moisture production of the lacrimal, salivary and other glands.

Aseptic necrosis

Bone death caused by poor blood supply to the area. It is most common in the hip, knee, and shoulder.

Aseptic necrosis occurs when part of the bone does not get blood and dies. After a while part of the bone breaks off. If this condition is not treated, bone damage gets worse. Eventually, the healthy part of the bone may collapse.

Aseptic necrosis can be caused by disease, or a severe trauma, such as a break or dislocation, that affects the blood supply to the bone. Many times, no trauma or disease is present. This is called "idiopathic aseptic necrosis" -- aseptic necrosis without any known cause.

PROGNOSIS:

Osteoarthritis generally worsens slowly over time, although it stabilizes in some patients. The course of those with progressive disease is usually one of intermittent worsening (worsening, then stabilization for a period), rather than a slow decrease in function.

Patients with OA may be able to function normally despite pain or may have varying degrees of physical disability. Worsening disability may be correlated with coping styles (e.g., those who avoid activity due to pain may develop muscle weakness, which can increase the risk of joint instability). Exercise may help to prevent loss of strength and decrease disability.

An unstable joint, impaired sensation, obesity, and more severe joint pain can predict subsequent worsening in function in patients with OA of the knee. In contrast, patients with better muscle strength, better mental health, stronger social supports, and those who are better able to perform aerobic exercise experience less disability than those with lesser amounts of these factors.

MEDICAL MANAGEMENT:

Diagnostic Procedure

Physical Examination

A primary care physician or rheumatologist (specialist in rheumatic disorders of the joints and related structures) will ask about:

Joint symptoms Previous or current illnesses Traumatic injuries Operations you may have had Allergies Other medical conditions

The physician will inspect the affected joint(s), checking for swelling, redness and heat, tender points, skin rashes, and other bodily signs. Determining which joints is involved and how their function is impaired helps the physician to distinguish OA from other forms of arthritis.

The muscles that surround painful, underused joints may show signs of weakness. The pattern of arthritis in the hands may be especially helpful in the diagnosis. OA tends to involve the base of the thumb and the middle and end joints of the digits.

Laboratory Tests

While lab tests aren’t needed for every form of arthritis, they are very important to verify and confirm the presence of some diseases, according to Robert Lahita, MD, chief of rheumatology at St. Luke’s/Roosevelt Hospital and associate professor of medicine at Columbia University. If your symptoms and physical examination suggest rheumatoid arthritis, lupus, Sjogren’s syndrome, Lyme disease or one of a few other inflammatory forms of arthritis, the following tests can often confirm your doctor’s suspicions:

Antinuclear antibody (ANA) – Commonly found in the blood of people who have lupus, ANAs (abnormal antibodies directed against the cells’ nuclei) can also suggest the presence of polymyositis, scleroderma, Sjogren’s syndrome, mixed connective tissue disease or rheumatoid arthritis. Tests to detect specific subsets of these antibodies can be used to confirm the diagnosis of a particular disease or form of arthritis.

Rheumatoid factor (RF) – Designed to detect and measure the level of an antibody that acts against the blood component gamma globulin, this test is often positive in people with rheumatoid arthritis.

Uric acid – By measuring the level of uric acid in the blood, this test helps doctors diagnose gout, a condition that occurs when excess uric acid crystallizes and forms deposits in the joints and other tissues, causing inflammation and severe pain.

HLA tissue typing – This test, which detects the presence of certain genetic markers in the blood, can often confirm a diagnosis of ankylosing spondylitis (a disease involving inflammation of the spine and sacroiliac joint) or Reiter’s syndrome (a disease involving inflammation of the urethra, eyes and joints). The genetic marker HLA-B27 is almost always present in people with either of these diseases.

Erythrocyte sedimentation rate – Also called ESR or “sed rate,” this test measures how fast red blood cells cling together, fall and settle (like sediment) in the bottom of a glass tube over the course of an hour. The higher the rate, the greater the amount of inflammation.

Lyme serology – This test detects an immune response to the infectious agent that causes Lyme disease and thus can be used to confirm a diagnosis of the disease.

Skin biopsy – Taking small samples of skin and examining them under a microscope can help doctors diagnose forms of arthritis that involve the skin, such as lupus, vasculitis (inflammation of the blood vessels) and psoriatic arthritis.

Muscle biopsy – By going a little deeper into the tissue than with the skin biopsy, the surgeon can take a sample of muscle to be examined for signs of damage to the muscle fibers. Findings can confirm a diagnosis of polymyositis or vasculitis.

Joint fluid tests – In this procedure, which is similar to drawing blood, the doctor inserts a needle into a joint space and removes fluid. An examination of the fluid may reveal uric acid crystals, confirming a diagnosis of gout or bacteria, suggesting that the joint inflammation is caused by infection.

Monitoring Disease Severity and Medication Response

To determine the progression of the disease or how it is responding to treatment, doctors sometimes use some of the same tests they use to diagnose arthritis. For example, a joint fluid test may show that an infectious agent has been eradicated by

antibiotics. Or a “sed rate” test may be conducted a number of times to determine if inflammation is subsiding.

Salicylate level – This test measures the amount of salicylate (the main ingredient in aspirin and in some other NSAIDs) in the blood to determine if enough is being absorbed to effectively reduce inflammation. The test can also determine if the level of salicylate is high enough to create dangerous side effects.

Muscle Enzyme tests (CPK, aldolase) – Muscles that have been damaged by some rheumatic diseases release certain enzymes into the blood, and these enzymes can be detected through blood tests. Such tests can measure the amount of muscle damaged as well as how effective medication has been in reducing the inflammation that caused the muscle damage.

Creatinine test – This test is used to determine the extent of kidney function by measuring the level of creatinine, a normal waste product of the muscles, in the blood. A test showing a high level of creatinine means that the kidneys are not working well enough to remove waste products from the body. Doctors may use this test to monitor kidney function in people with lupus or in those taking medications that could affect the kidneys.

Checking for Drug Side Effects

Often a drug side effect is obvious – you become nauseated, develop a rash or experience blurred vision or ringing in your ears. In other cases, the effects progress unnoticed – until a liver is damaged or a silent ulcer begins to bleed dangerously. For that reason, doctors often use lab tests to check for side effects – before they become major problems. The following tests are the most common:

Liver enzyme tests (SGOT, SGPT, bilirubin, alkaline phosphatase) – These tests, which measure levels of liver enzymes in the blood, can help doctors determine if certain medications have caused damage to the liver.

Hematocrit (HCT) and hemoglobin (Hgb) – These tests measure the number and quality of your red blood cells. Low counts may suggest that your medications are causing gastrointestinal bleeding.

White blood cell count – A blood test showing a low number of infection-fighting white blood cells may suggest that your medication is decreasing your supply of white blood cells and, thus, your body’s chances of fighting infection.

Platelet count – This test measures the number of platelets, or “sticky” cells, that help the blood to clot. A low number of platelets could suggest that your medication has put you at risk of bleeding heavily.

Lab Tests’ Limitations

Despite their many benefits, lab tests have their limitations. Some may show negative results even when a person has the disease being tested for; others may be positive in people who don’t have – or may never develop – a particular disease. In the early stages of rheumatoid arthritis, for instance, only one in five people tests positive for rheumatoid factor; 15 to 20 percent of people without ankylosing spondylitis have the HLA-B27 genetic marker.

Not all forms of arthritis can be confirmed by lab tests. Other tests, including X-rays and magnetic resonance imaging, may be required to diagnose osteoarthritis, determine the cause of chronic back pain or examine internal organs affected by some forms of arthritis.

Even so, lab tests are essential to the diagnostic and treatment process. The right tests, along with your doctor’s own observations and your participation in the process, can help you get the safest and most effective treatment for your disease.

Surgical Intervention

Surgery represents one of the greatest advances in the management of arthritis in the last 40 years. Surgery is not appropriate, however, for every individual with either RA or OA, and the careful selection of the patients and the timing of the procedure are critical.

The primary indications for surgery are pain, loss of function, and progression of deformity, although the last two are not always correlated.

Three procedures for soft tissue:

a) Synovectomyb) Soft tse. releasec) Tendon transfers

Three procedures for bone and joint:

a) Osteotomyb) Arthroplastyc) Arthrodesis

Drug Therapy

Drug therapy on OA has no effect on disease progression and is ancillary to the more general measures of pain control. The goals of drug therapy in patients with OA are to relieve pain and decrease inflammation when it is present.

PT Management

Hot Packs

Cold Packs

PWB

TENS

orthoses alleviate pain through biomechanical support

Patellofemoral Taping

long shifting knee bones

Adequate quality and quantity of sleep at night and short rest during the day is advisable.

Maintain and regain adequate levels of physical activity.

light intensity isometric contraction, hold for 6 sec. x 10 reps.

isotonic exercise

functional exercise

ROM

proprioceptive training

balance training

endurance training (walking, stationary bicycles)

progressive resistive isotonic exercise

For strengthening, non-weight bearing quadriceps and hamstring isometric and should be performed 2x daily.

With patellofemoral disorder, quadriceps isometrics with the knee extended are best to avoid patellafemoral compression.

Joint conservation technique:

1. Respect the pain.

2. Use larger joint joint than smaller joint.

3. Prevent position of deformity.

4. ROM

5. Pacing

6. Use of adaptive device.

7. Use devices to protect joint.

8. Rest.

INITIAL EVALUATION

GEN INFO:

Patient’s Initial: O.A

Age: 67 y/o

Sex: ♀

Address: 1928 Malvar St. Sta Ana, Manila

Civil Status: Married

Handedness: ®

Occupation: Former teacher

Referring Unit: Philippine Orthopedic Center (OPD)

Rehabilitation Unit: Hospicio de San Jose Rehab Unit

Referring M.D: Dr. M.A

Rehab M.D: Dr. B.N

Date of Referral: Feb. 1, 2010

Date of PT Consultation: Feb. 2, 2010

Date of I.E: Feb. 2, 2010

Dx: Osteoarthritis of the ® knee

HPI:

Present condition started 6 months PTC when pt. experienced intermittent dull nagging pain on ® knee with a P/S of 3/10 upon walking from her house going to the park ~25 meters then pt decided to go home. Pt. use eficascent oil and took a rest and the pain subsided. Pt also experienced ® knee joint stiffness upon awakening especially in the morning and relieve in less than 30 minutes with mild exercise. This condition last for about 48 weeks.

3months PTC, the intermittent dull nagging pain on ® knee increased from 3/10 -5 /10 upon walking from her house going to the sari – sari store ~12 meters. Pt. decided to take medication (Flanax 500 mg PRN) the pain decrease from 5/10 - 2/10. The pt lessened her daily activities (doing household chores, gardening, going to the park). This lasted for about 47 weeks.

1 month PTC, the intermittent dull nagging pain on ® knee increased from 5/10 - 7/10 with marked stiffness. These had made it difficult for the pt to do sit to stand activities (going to bathroom, getting in and out of a car, getting up and down from sitting) and using stairs. This prompted the pt to seek medical assistance and undergone diagnostic procedures (see ancillary procedures), was diagnosed to have OA of the ® knee, and was given medication (see present medications). A week after was referred to PT for further evaluation and tx.

ANCILLARY PROCEDURES:

Diagnostic Procedure

X-rayFindings M.D DateCartilage

degenerationDr. M.A Feb. 1, 2010

Laboratory Exams

Findings M.D DateESR (N) Dr. M.A Feb.1, 2010RF (-) RF Dr. M.A Feb.1, 2010

ANA (-) ANA Dr. M.A Feb.1, 2010Synovial Fluid Clear Dr. M.A Feb.1, 2010

PRESENT MEDICATIONS:

Dosage Indication

Voltaren 50mg P.O. b.i.d.Osteoarthritis;

AnalgesiaMetoprolol 50 mg P.O. b.i.d. HtnMetformin 500 mg P.O. b.i.d. DM

PMHx:

(+) HTN, controlled (Metoprolol 50 mg) since 1986Highest BP: 160/90 mmHg

Baseline: 130/80 mmHg

Lowest BP: 110/80 mmHg

(+) NIDDM, controlled (Metformin 500 mg) since 1986 (-) hospitalization (-) Cardiopulmonary Problems (-) Trauma; (-) fx

FMHx:

Paternal MaternalHTN (+) (+)DM (+) (-)Arthritis (-) (+)Cardiac Condition

(-) (-)

Pulmonary Condition

(-) (-)

PSEHx:

Type A personality; jolly and happy person Sedentary Lifestyle; spends most of the time at home watching TV (-) alcohol beverage drinker (-) smoker Diet includes rice, meat and vegetables Hobbies include cross stitching, cooking and gardening. Pt works as a teacher for 5yrs. (frequent walking) Pt lives in a two-story house c her daughter’s family

Financially stable Home set-up: ~ 10 steps from the garden to front door

~ 10 steps from the front door to living room

~ 10 steps from living room to bathroom

~ 15 steps from bathroom to dining room

~ 30 steps from dining room to master’s bedroom

~ 10 step-staircase

S:

c/o: “Sumasakit ang kanang tuhod ko lalo na kapag naglalakad ako” ~15 meters

PT Translation: Pt complains of intermittent dull nagging pain (p/s 5/10-7/100 on ® knee and is aggravated upon walking approximately ~15 meter

Pt Goal: To relieve the intermittent dull nagging pain on ® knee and eliminate the difficulty in ADL.

O:

VS:

B.P a: 130/80 mmHg

p: 130/70 mmHg

During: 140/90 mmHg

RR: a: 16 cpm

p: 16 cpm

PR: a: 80 bpm

p: 79 bpm

T: 37.1˚ C *(axillary)

Findings: Normal VS

Significance: For baseline purposes

OI:

ambulatory c moderate difficulty s assistive device endomorph alert, coherent, cooperative (+) swelling ® knee (+)® genu varum (+) postural deviation (see postural analysis) (+) gait deviation (see gait analysis) (-) erythema on ® knee (-) skin discoloration

PALPATION:

Normothermic on all exposed body parts on (B) UE/LE except Hyperthermic ® knee

Normotonic on all exposed body parts on (B) UE/LE Senile skin turgor & consistency (+) crepitus on ® knee (+) grade 3 tenderness on ® knee (+) joint effusion on ® knee (+) moderate osteophyte formation

SENSORY A:

Superficial Somatic Sensation

(STD Used)

Superfical pain-pinprick Light touch-wisp of cotton Thermal sensation-hot/cold using test tube

Findings: (N) sensation of (B) UE/LE as to light touch, superficial pain and thermal sensation

Significance: For baseline purposes

DTR:

Findings: Normoreflexia on (B) UE/LE

Findings: For baseline purposes

ROM

All joints of (B) UE and LE are WNL, actively and passively done pain free c normal end feel except for the following:

Legend

0 Areflexia

+ Hyporeflexia

++ Normoreflexia

+++ Hyperreflexia

++++ Clonus

MOTION(L) ® DIFFERENCE

ENDFEELA P A P A P

Knee flexion 0 - 135 0 - 135 0 - 90 0 - 95 45 40boggy

Knee extension 135-0 135-0 0 - 100 0 - 105 35 30 boggy

Findings: LOM on ® knee flexion and extension

Significance: 2˚ to joint effusion

MMT

All ms of (B) UE and LE are grossly graded 5/5 except for:

Note: Break Test was used on ® knee flexors at 90˚ and ® knee extensors at 100˚.

Action Grade

® Knee flexors 3/5

® Knee extensors 3/5

Findings: muscle weakness on ® knee flexors and extensors

Significance: 2˚ to pain

SPECIAL TESTS

Test: Bulge Test

The examiner commences just below the joint line on the medial side of the patella, stroking proximally toward the patient’s hip as far as the suprapatellar pouch two or three times with the palm and fingers. With the opposite hand, the examiner strokes down the lateral side of the patella. A wave of fluid passes to the medial side of the joint and bulges out just below medial distal portion or border of the patella. The wave of fluid may take up to 2 seconds to appear.

Findings: (+) bulging of fluid just below the medial distal portion of the patella

Significance: 2° to joint effusion

Test: Wilson Test

The patient sits with the knee flexed over the examining table. The knee is actively extended with the tibia medially rotated. At approximately 30° of flexion (0° being straight leg), the pain in the knee increases, and the patient is asked to stop the flexion movement. The patient is then asked to rotate the tibia laterally and the pain disappears. This finding indicates a positive test, which is indicative of osteochondritis dissecans of the femoral condyle.

Findings: Pain is evident all throughout the motion indicating of (-) osteochondritis

dissecans

Significance: for ruling out purposes

FUNCTIONAL ANALYSIS:

Legend BalanceTolerance

N (normal) can assume, maintain, weight shift and challenged >45 mins

G (good) can assume, maintain and weight shift 31-45 mins

F (fair) can assume and maintain 16-30 mins

P (poor) can assume 1-15 mins

O (zero) can neither assume nor maintain 0 min

Balance Tolerance

Sitting N N

Standing F F

Findings: Pt has normal balance and tolerance as to sitting, (N) balance and fair tolerance as to standing

Significance: 2˚ to pain on ® knee

POSTURAL ANALYSIS:

All bony landmarks are level except:

Anterior Posterior

ASIS are level PSIS are level

® Knee medial angulation ® Knee medial angulation

Findings: (+) postural deviation manifested by genu varum on ® knee

Significance: 2˚ to position of comfort

GAIT ANALYSIS:

Hip Knee Ankle

Stance phase

® (L) ® (L) ® (L)

Heel strike Decrease Increase Decrease Increase Decrease IncreaseFoot Flat Decrease Increase Decrease Increase Decrease IncreaseMid Stance Decrease Increase Decrease Increase Decrease IncreaseHeel Off Decrease Increase Decrease Increase Decrease IncreaseToe Off Decrease Increase Decrease Increase Decrease Increase

Swing phaseAcceleration Increase Decrease Increase Decrease Increase DecreaseMid Swing Increase Decrease Increase Decrease Increase DecreaseDeceleration Increase Decrease Increase Decrease Increase Decrease

Other Parameters

(N) Result DifferenceStep length 15 in. 12 in. 3 in.Stride length 30 in. 30 in. 0Base width 2-4 in. 2 in. 0Cadence 90-120

steps/min.70 steps/min.

20 steps/min.

Ave. walking speed

80 m 60 m 20 m

Arm swing (N)

Findings: (+)antalgic gait

Significance: 2˚ to OA of the ® knee

ADL:

Fully dependent Partially dependent IndependentSelf-care:

Bathing √Toileting √ c minimal difficultyEating √

Grooming √UE dressing √LE dressing √ c minimal difficulty

Bed mobility:Supine to side- √

lyingSupine to long

sitting√

Rolling √Transfers:

Bed óchair √ c minimal difficultyAmbulation √ c moderate difficulty

Findings: Pt can perform all ADL but with moderate difficulty at most as to ambulation, transfer lower extremity dressing and self-care as to toileting

Significance: 2˚ to pain and deformity

A:

PT Impression: Pt presents with intermittent dull localized aching pain upon walking 20

to OA on ® knee

Rehab Potential: Pt has only a fair potential 2˚ to old age. Maintenance of physical therapy is advised to prevent aggravation of pain and deformity.

Rehab Precaution: monitor BP; Avoid excessive knee motion, Pt have DM &Htn.

PROBLEM LIST:

1. Intermittent dull nagging pain of 7/10 on ® knee2. LOM on ® knee flexion and extension3. ms. weakness on ® knee flexors and extensors4. Grade 3 tenderness on ® knee5. Joint effusion ® knee6. Impaired standing balance and tolerance7. Moderate difficulty as to ambulation, transfer, LE dressing and self-care as to

toileting8. Postural deviation9. Gait deviation

LTG:

1. To prevent the progression of deformity.2. To maintain the normal integrity of unaffected limbs. 3. To maintain the general body condition of the pt.4. To attain the highest functional level of the pt as to ADL (ambulation, transfer, LE

dressing and self-care as to toileting) s pain s/c assistive device.

STG: (6-8 sessions)

1. To decrease the intermittent dull nagging pain from 7/10 to 3/10 on ® knee.2. To increase ROM by 5-10 increments on ® knee flexion and extension3. To increase muscle strength on ® knee flexors and extensors4. To reduce swelling on ® knee5. To improve standing balance and tolerance.6. To improve performance of ADL as to ambulation, transfer, LE dressing and self-

care as to toileting)7. To improve posture.8. To improve gait pattern.

P:

Mgt:

1. HMP with TENS x 20 min on ® knee.2. US x 1.5w/cm2 on ® knee. 3. Isometric exercise4. PRE’s on (L) side using ankle weights towards knee flexion and extension x 10

reps x 2 sets.. 5. Bicycle ergometer x 10 minutes6. Pool Therapy x 1 a week.7. Gait training using cane.8. Patellar mobilization

HI:

1. Perform the instructed exercises at home.a. Quadriceps isometrics x 6 secs hold x 10 reps x 2 sets.b. Step exercises on the staircase as tolerated.

2. Put a hot towel over the ® knee every time the pain is felt.

3. Avoid walking far distances and if un-avoided, use a cane as an assist.4. Avoid the use of pillow under the knee at night because this encourages knee

and hip flexion contracture, plantar flexion at the ankle and venous obstruction in the popliteal area.

5. Always maintain an extended knee position during rest.

HOSPICIO DE SAN JOSE PHYSICAL THERAPY UNIT

AYALA AVENUE, MANILA

WRITTEN REPORT

IN

OSTEOARTHRITIS

DE LEON, ALAN TROY L. SUBMITTED TO:

UDM PT-INTERN BATCH 2012 MS. MARY ROSE ROJO

DE LEON, ALAN TROY L. JUNE 13,2011

UDM PT INTERN BATCH 2012

REACTION PAPER- MUSIC THERAPY

It was my first time to attend & witness what a music therapy is, at first I thought that it would be just like any other treatments combined with background music but then I was mistaken. Music therapy is purely music being played in a room where the patients are gathered. It is composed of songs that is weel suited for pediatric patients.

At first, the children's behavior are the usual that they showed to us during treatments but when the music therapy started, most of the children reacted positively to the music that is being played. Most of them, acts in such a way that is in synchrony & some form of contact to the music. It seems like they are in some form of state wherein everything is serene, peaceful & calm. There are no cryings or any unwanted behavior that manifest during that span of time. Everything is in its right place. Some of the children even dance and sing together with us.

This music therapy is such a great opportunity for I witness the undisputed effect of music to those kids. It is wonderful to think what music can do in their behavior that might help us understand & in order to treat them well as a whole individuals capable of connecting to the society through music.