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CMG

OA knee guidance

Introduction

Osteoarthritis of the knee refers to the condition of

• Damage of the cartilage lining the base joint


• Narrowing of the joint space
• Extra bone formation (osteophytes)
• Increased bone density at the joint margins

The knee joint has three compartments which can be affected – the patello-
femoral joint, between the knee cap and the femur (thigh – bone) and the
medial and lateral tibiofemoral joints, between the tibia and the femur.

It occurs as people get older, and a significant number of people (around


10%) have OA of the knee over the age of 65.

It can occur in younger people, usually following injury.

It is associated with Western populations, the female gender, obesity, high


blood pressure, previous sporting activity, occupational wear and tear (i.e. lots
of bending, and heavy lifting), childhood bone deformities in the legs,
inflammatory arthritis, previous injuries, surgery or infection.

Signs and symptoms

Symptoms
• Pain – related to the activity and can persist for many hours.
• Stiffness – causing a reduced range of movement. However,
morning stiffness usually lasts less than 30 minutes.
• Gelling – the joint is resistant to active movement after a period of
inactivity, but the discomfort goes after a few minutes of movement.
• Instability – Severe osteoarthritis of the knee may exist in
conjunction with ligament injury, which would cause an unstable
joint, and damage to the menisci , which can cause instability, and
prevent the knee from fully locking out (straightening.) This can
cause the joint to give way, leading to problems with stairs, and
walking on uneven ground.

Signs –
• Pain,
• Tenderness,
• Swelling,
• Fluid in the joint (effusion),
• Crepitus (“crunching” sound on movement),

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• Limitation of movement, and muscle wasting of the quadriceps


muscle (thigh muscle above the knee), are the most important
signs.

Investigations

Blood tests are usually normal; X-rays show characteristic changes, such as
joint space narrowing, the presence of bony spurs (osteophytes) and
increased bone density at the margins of the joint.

Treatment

1. Drug treatment – This consists of

a) Simple analgesics , such as Paracetamol, moving on to Co-


codamol, Co -dydramol or Dihydrocodeine if extra medicinal
strength is needed.
b) Non steroidal Anti Inflammatory drugs such as Ibuprofen (Brufen) or
Diclofenac (Voltarol) or COX2 inhibitors such as Celecoxib
(Celebrex).
c) Gels or ointments to rub on, such as Ibuprofen (Ibugel) and
Piroxicam (Feldene Gel).
d) Joint injections (usually steroids) into the joint.
e) Surgery This is carried out when the patient is suffering from
persistent pain, reduction in range of movement, and consequent
functional limitations (see below). There are two types of surgery –

1.) Arthroscopy which is known as “keyhole surgery”, which is


regarded as minor surgery. The joint can be looked at, and
“cleaned out” under this method.

2.) Formal surgery, which is major surgery. Usually, in joint


replacement, one or more of the joint surfaces is replaced by a
prosthesis or artificial joint surface.

Long term results are good, the overall success rate is more
than 85% after 18 years, according to a study.

f) Lifestyle modifications such as keeping fit, losing weight, and


physiotherapy, to
strengthen the muscles around the knee, particularly the Quadriceps
muscle.

Factors Indicating Severe Disease

The following elements would indicate severe disease –

• awaiting joint replacement surgery


• continuous pain, or pain wakes at night
• gross restriction of movement

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• regular use of NSAID’s


• crutches, or wheelchair use prescribed by Physiotherapist /
OP
• stairlift
• Quadriceps muscle weakness and wasting
• effusion, deformity, and instability of joint

Not all these factors need to be present to indicate severe disease. The most
important are the first three.

Functional Limitations
MILD CONDITION

The disabling effects, care and mobility requirements vary within this category
according to the stage of the disease.

Early stages

Disabling effects

The person may experience the following:

Occasional discomfort in the knee on the affected side; There may


be mild stiffness, but this would not normally be prolonged or
severe. There would normally be no limitation of movement of the
knee.

There would not normally be any resultant significant disability on a


day to day basis.

Care

The person would normally be able to carry out self- care tasks
without help.

Specifically they would normally be able to sit, rise, bend and get in
and out of bed in the usual fashion.

Mobility

Mobility would not normally be affected to any great extent. The


person would normally be able to walk normal distances, possibly at
a reduced rate but with no significant impairment of gait.

No guidance or supervision needs are anticipated.

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Later stages

Disabling effects

The person may experience the following:

Pain on movement of the knee on the affected side; Stiffness


may be marked but is rarely prolonged.They would normally
limp on walking. There would normally be some limitation of
movement but not to the extent that it will produce a functional
loss.

There would not normally be any significant resultant disability


on a day today basis.

Care

The person would normally be able to carry out self- care tasks
without help. Specifically they would normally be able to sit, rise,
bend and get in and out of bed, albeit with some discomfort.

They may have some discomfort on climbing stairs but would


normally be able to manage this independently albeit with some
discomfort.

They would normally also have little difficulty in bathing,


dressing and undressing the lower part of the body.

Mobility

Mobility may be reduced but not to a significant degree. The


person would normally be able to walk in excess of several
hundred metres, often at a slightly reduced rate. The person
should be able to use a stick to assist gait and generally
enhance mobility.

No guidance or supervision needs are anticipated.

SEVERE CONDITION

Disabling effects

The person may experience the following:

Continuous pain in the knee on the affected side, and this may wake
them at night:

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Stiffness would normally be severe; they will limp on walking. The knee
may give way due to instability. There may be swelling of the joint with
associated deformity, muscle wasting and gross restriction of
movement.

Care

The person may encounter the following:

• Difficulty in rising from a chair of normal height, (a person with a


severe condition may need a raised chair.) However, particularly if
upper limb is normal, many will be able to perform this activity
without help. A raised chair may help with problems in rising.

• Difficulty bending to an oven.

• Difficulty in bathing, dressing and undressing the lower part of the


body.

• Difficulty getting in and out of bed unaided. However, if upper limb


function is reasonable this will not be impossible. And, in addition,
the use of aids and adaptations will further enable the person to
carry this out independently.

• They may be unable to climb stairs especially if they are unable to


extend (straighten) the knee.

Supervision

With knee instability, which occurs with severe disease, falls indoors may
be a factor, and the use of a stick may not be very helpful, in preventing
falls.

Mobility

Mobility would normally be severely restricted especially if they are unable


to fully extend the knee.

• Distance will be significantly reduced due to poor lower limb


function and pain.

• Speed and time will be restricted because of pain, poor gait or


indeed both. With knee instability, the person would not normally
be able to walk safely.

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Progress

Osteoarthritis of the knee is likely to eventually progress, but operation is


usually successful – (both arthroscopy and total knee replacement), and
follow- up studies show the long term results to be good.
The waiting list time is usually less than 2 years, and recovery time from the
operation would normally be around 3 months.

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