Osteoarthritis Complete Guide: Symptoms, X-Ray Grades & Modern Treatment Options

Below is a **complete, concise but fully comprehensive one-place reference** for **Osteoarthritis (OA)** following your preferred medical-content structure.

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# **OSTEOARTHRITIS (OA) — COMPLETE GUIDE**

## **1. Definition**

Osteoarthritis is a **chronic, progressive degenerative joint disease** characterized by **loss of articular cartilage**, **subchondral bone remodeling**, **osteophyte formation**, and **synovial low-grade inflammation**, leading to **pain, stiffness, reduced function**, and structural deformity.

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## **2. Pathophysiology (Mechanism)**

* **Cartilage degradation:** Imbalance of anabolic vs catabolic enzymes (↑MMPs, ADAMTS → cartilage breakdown).
* **Chondrocyte dysfunction:** Senescent chondrocytes → reduced proteoglycan / collagen synthesis.
* **Subchondral sclerosis:** Microfractures → thickened subchondral bone.
* **Osteophyte formation:** Due to growth factor (TGF-β, BMP) stimulation.
* **Synovitis:** Mild inflammation with macrophages; NOT autoimmune.
* **Joint space narrowing → altered biomechanics → worsening degeneration.**

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## **3. Causes & Risk Factors**

### **Primary OA**

* Age-related degeneration (most common)
* Genetics (COL2A1)
* Obesity (↑ mechanical load + inflammatory adipokines)
* Female sex
* Joint malalignment (genu varum/valgum)

### **Secondary OA**

* Trauma (ACL tears, meniscal injury)
* Inflammatory arthritis (e.g., RA)
* Metabolic: Hemochromatosis, Wilson disease, ochronosis
* Endocrine: Diabetes, acromegaly, hypothyroidism
* Neuropathic joints (Charcot)
* Avascular necrosis

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## **4. Clinical Features**

### **Symptoms**

* **Pain** worse with activity, relieved by rest
* **Morning stiffness < 30 minutes**
* **Crepitus**
* **Reduced range of motion**
* **Functional limitation**

### **Characteristic Joint Involvement**

* **Knee OA:** Joint line tenderness, effusion, varus deformity
* **Hip OA:** Groin pain, difficulty wearing shoes, internal rotation ↓ earliest sign
* **Hand OA:**

* **Heberden’s nodes** (DIP)
* **Bouchard’s nodes** (PIP)
* 1st CMC joint involvement
* **Spine OA:** Facet joint pain, stiffness

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## **5. Diagnosis**

OA is diagnosed clinically + X-ray; MRI only if atypical.

### **Key Investigations**

* **X-ray (most important):**

* **Joint space narrowing (asymmetric)**
* **Osteophytes**
* **Subchondral sclerosis**
* **Subchondral cysts**
* **Blood tests:** Typically normal

* ESR/CRP normal
* RF/Anti-CCP negative (helps rule out RA)

### **Kellgren–Lawrence (KL) X-Ray Grading**

| Grade | Radiographic Features |
| ----- | -------------------------------------------------------------- |
| **0** | Normal |
| **1** | Doubtful joint space narrowing, minute osteophytes |
| **2** | Definite osteophytes, possible joint space narrowing |
| **3** | Moderate narrowing, multiple osteophytes, sclerosis, deformity |
| **4** | Severe narrowing, large osteophytes, severe deformity |

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## **6. Differential Diagnosis**

* Rheumatoid arthritis
* Gout / CPPD (pseudogout)
* Avascular necrosis
* Meniscal tear (knee)
* Trochanteric bursitis (hip pain mimic)

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# **7. Management — Modern, Evidence-Based Approach**

## **A. Non-Pharmacologic (First-Line)**

* **Weight loss:** Most effective intervention
* **Physiotherapy:** Quadriceps strengthening, hip abductors
* **Aerobic exercise & low-impact activity:** Cycling, swimming
* **Activity modification**
* **Assistive devices:** Cane, walker
* **Bracing:** Unloader braces for medial knee OA
* **Thermal therapy:** Hot/cold packs

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## **B. Pharmacologic Therapy**

### **1. NSAIDs (Most effective for symptomatic relief)**

* Oral: Ibuprofen, naproxen, diclofenac
* Topical: Diclofenac gel (preferred in elderly)
* **Risks:** GI bleed, renal dysfunction, CV risk

### **2. Paracetamol**

* Limited efficacy; use if NSAIDs contraindicated.

### **3. Duloxetine**

* Useful in chronic OA pain, especially knee OA.

### **4. Intra-articular Treatments**

* **Corticosteroid injections:** Short-term relief (4–8 weeks)
* **Hyaluronic acid (viscosupplementation):** Mixed evidence; selective use
* **PRP (Platelet-Rich Plasma):** Emerging evidence for early OA, not standard but used clinically

### **5. Topical Capsaicin**

* Good for hand OA.

### **6. Avoid**

* Opioids (except palliative short-term)

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## **C. Surgical Management**

### **Indications**

* Severe pain not controlled with maximal therapy
* Functional limitation
* Radiographic grade 3–4 OA

### **Procedures**

* **Total Knee Replacement (TKR)** — most common
* **Total Hip Replacement (THR)** — excellent long-term outcomes
* **Osteotomy** (for younger pts with malalignment)
* **Arthroscopic lavage/debridement** — **NOT recommended** for routine OA

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# **8. Drug-Wise Quick Reference (Mechanism, Dosing, AE, Monitoring)**

### **NSAIDs**

* **Mechanism:** COX-1/COX-2 inhibition → ↓ prostaglandins → ↓ pain/inflammation
* **Dosing:**

* Ibuprofen 400–600 mg TID
* Naproxen 250–500 mg BID
* **AE:** Gastritis, ulcers, AKI, fluid retention, ↑ CV risk
* **Contra:** CKD, ulcers, heart failure
* **Monitoring:** BP, renal function, occult GI bleed

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### **Duloxetine**

* **MOA:** SNRI → enhances descending inhibitory pain pathways
* **Dose:** 30–60 mg/day
* **AE:** Nausea, dry mouth, insomnia
* **Contra:** MAOI use, severe liver disease
* **Monitoring:** BP, mood changes

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### **Intra-articular Steroids**

* **MOA:** Strong local anti-inflammatory
* **Drugs:** Triamcinolone 20–40 mg
* **AE:** Flare pain, infection risk, cartilage degeneration if repeated frequently
* **Limit:** ≤ 3–4 injections/year

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# **9. Patient Counselling Points**

* OA is chronic but **manageable**
* Maintain daily **exercise & weight control**
* Choose low-impact activities
* NSAIDs should be taken **with food**
* Avoid long-term self-medication
* Joint replacement is **highly successful** in advanced disease

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