Osteoarthritis typically first manifests itself when patients are in their forties or fifties, although some patients develop this disease even earlier than that. The joints involved are primarily weight-bearing, such as the knee, hip, or lower lumbar area. Also the end joints and middle joints of the fingers as well as the joint at the base of the thumb also are often involved. Early on, the pain tends to be worse after increased physical activity such as the day following a long walk when the patient might experience more back or knee pain. As the disease progresses, the pain becomes more noticeable during the course of normal activity. There is some stiffness in the morning associated with pain, but generally lasting less than thirty minutes and certainly not more than one hour. Patients with hip involvement will complain of groin pain made worse by prolonged standing or walking. With more advanced disease, any significant increasing motion of the joint creates pain. Most patients also complain of symptoms with changes in the weather especially if a cold front comes through or rainy weather is expected. This has been found to be associated with changes in the barometric pressure which can be sensed by "pressure" nerves around the joint.

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The physical findings of a joint depends on the severity of involvement. For instance, a knee with osteoarthritis early on may just have some mild "crepitus" which is a creaking or cracking sensation made with motion. The more advanced the arthritis then the more pain that may be felt with putting the joint through a range of motion. Fluid accumulation within the joint may occur causing a swollen appearance with warmth and tenderness to touch. With knee involvement, if there is fluid accumulation, it may be difficult to move the knee or fully flex or extend it. If the diagnosis is in question, an aspiration of the fluid may be helpful to determine the diagnosis, but also may be helpful in relieving the pressure within the joint. The hands may have small nodules overlying the distal joints next to the fingernails. These joints are referred to as DIP or distal interphalangeal joints. These may even become inflamed and red with flares of the osteoarthritis. These are referred to as Heberden's nodes. The middle joint in each finger is called the proximal interphalangeal joint or the PIP joint and may also be involved. When there is bony enlargement at the PIP joint these are called Bouchard's nodes. When the swelling of these joints becomes severe, it is not uncommon to have to change ring sizes to accommodate the changes taking place in the fingers.

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For the most part laboratory data in patients with osteoarthritis is completely unremarkable and are performed for routine screening before starting medications. One should check for the possibility of any excess calcium levels in the blood to exclude a condition which might accelerate osteoarthritis call calcium pyrophosphate deposition disease. Hemachromatosis which is also associated with degenerative arthritis may show high iron levels in the blood. Generally the complete blood count is within normal limits. An erythrocyte sedimentation rate (ESR) is often normal in osteoarthritis patients whereas it is usually elevated in rheumatoid arthritis patients. Synovial fluid may be aspirated from a joint such as the knee and analyzed. It is generally noninflammatory with a total white blood cell count of less than 2,000 cells per mm3. The fluid should be examined for the presence of calcium pyrophosphate crystals and this can be done by a trained pathologist or rheumatologist if equipped with a special polarizing microscope. X-rays are extremely informative. They generally show loss of joint space with osteophyte (bone spur) formation. These occur at the joint margins and they occur in an asymmetric fashion. An increased thickening over the weight bearing part of the joint is sometimes referred to as "eburnation" or sclerosis. As the disease progresses, cysts within the bone may be seen radiographically. An x-ray can be very helpful in distinguishing osteoarthritis from other types of arthritides. Osteoarthritis involves a characteristic distribution of joints generally involving the base of the thumb called the carpometacarpal joint, the DIPs and PIPs as mentioned earlier, weight bearing areas such as the hips, knees and great toes. Neck and back pain also are commonly associated with osteoarthritis and typically occur at the base of the curves of the neck and the lower lumbar region.

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The diagnosis of osteoarthritis is based on clinical findings. Since osteoarthritis primarily affects weight bearing joints as well as the distal interphalangeal joints, proximal interphalangeal joints and the base of the thumb, characteristic findings in these joints can be helpful in the diagnosis of osteoarthritis. There are no specific laboratory data to support the diagnosis of osteoarthritis. X-rays are extremely helpful when there is a significant amount of arthritic change with decreased joint space and marginal osteophytes or bone spurs that are characteristic of osteoarthritis.

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The principal goal in the treatment of osteoarthritis is maintaining function. This is accomplished by reducing pain and improving mobility and increasing strength around the joint. Therapy can be divided into pharmacologic, non-pharmacological, and surgical. The non-pharmacologic therapy includes education of how to help and support a joint, how to increase joint strength with exercise, of the need for weight loss to decrease weight?bearing joint pain, and of the use of assistive devices such as a cane or a walker if necessary. Pharmacologic therapy includes such things as acetaminophen or topical analgesics such as capsaicin cream. The use of nonsteroidal anti-inflammatory medications are also helpful. Occasionally a patient may require joint aspiration with a local injection of steroids to reduce pain and swelling. Patients may also benefit from viscosupplementation with Synvisc or Hyalgan. The use of narcotic therapy may also be employed in severe cases. Other therapy may involve irrigating a joint with saline called a closed tidal joint lavage. Arthroscopic surgery of the knee may be necessary to clean and debride the joint. Surgery including total joint replacement is another option and will require consultation with an orthopedic surgeon. Recently a three year study done in Belgium showed glucosamine to be helpful in degenerative arthritis of the knees. The dose required was 1,500 mg daily.

Rodolfo Molina, M.D.

Joel E. Rutstein, M. D.