Osteoarthritis

Osteoarthritis

1. Definition

Osteoarthritis (OA) is a chronic, degenerative disorder of synovial joints in which the articular cartilage breaks down, the sub‑chondral bone remodels and the surrounding soft tissues become altered. It is the commonest cause of joint pain and functional limitation in the adult population.

2. Synonyms (if any)

• Degenerative joint disease – emphasizes the wear‑and‑tear nature.
• Osteoarthrosis – another term used in older literature.

3. Causes / Etiology

4. Types / Classification

1. Primary (idiopathic) osteoarthritis – occurs without an identifiable preceding event; mainly related to ageing and genetics.
2. Secondary osteoarthritis – follows a known cause such as trauma, infection, metabolic disease or malalignment.

For each type the clinical picture may be acute or chronic:

• Acute exacerbation – sudden increase in pain, swelling and limited motion, often triggered by over‑use or minor injury; lasts days to a few weeks.
• Chronic disease – persistent joint pain, stiffness especially in the morning (≤30 min), gradual loss of function over months to years.

5. Pathophysiology / Pathology

1. Initial cartilage injury – loss of proteoglycans and collagen network weakens the surface.
2. Chondrocyte response – cells attempt repair but produce more matrix‑degrading enzymes (MMPs, ADAMTS).
3. Cartilage fibrillation and erosion – surface becomes rough, fissures develop and cartilage thins.
4. Sub‑chondral bone reaction – bone becomes sclerotic, micro‑fractures form and cysts may appear.
5. Osteophyte formation – new bone grows at joint margins as a stabilising response.
6. Synovial inflammation – debris from cartilage stimulates mild synovitis, leading to effusion.
7. Joint capsule and ligament changes – capsular thickening and ligament laxity further destabilise the joint.

Each step contributes to pain, stiffness and functional loss.

6. Clinical Features

General features – joint pain worsened by use, relieved by rest; stiffness after inactivity; crepitus on movement; reduced range of motion; occasional swelling.

Specific features by joint –

• Knee: pain on climbing stairs, palpable osteophytes, joint line tenderness.
• Hip: groin pain, limp, limited internal rotation.
• Hand (DIP/PIP): bony enlargements (Heberden’s/ Bouchard’s nodes).

Acute flare – sudden swelling, warmth, marked restriction, may mimic inflammatory arthritis.

Chronic disease – persistent dull ache, morning stiffness <30 min, progressive deformity, functional limitation.

Recognition of chronicity helps in planning long‑term management.

7. Complications

• Chronic pain – leads to sleep disturbance, depression and reduced quality of life.
• Functional impairment – difficulty in walking, climbing stairs, self‑care; may cause dependence.
• Joint deformity – malalignment, contractures and loss of joint stability.
• Secondary synovitis – recurrent effusions can predispose to infection.

Early physiotherapy and weight control can lessen these complications.

8. Investigations / Diagnosis

9. Differential Diagnosis

1. Rheumatoid arthritis – symmetric polyarthritis, prolonged morning stiffness (>1 h), positive rheumatoid factor; OA usually asymmetric and stiffness is brief.
2. Gout – acute mono‑articular pain with intense redness, hyperuricemia; OA pain is dull and chronic.
3. Pseudogout (calcium pyrophosphate deposition) – chondrocalcinosis on X‑ray, acute attacks; OA shows osteophytes without calcification.
4. Meniscal tear – mechanical locking, localized tenderness; OA has diffuse joint pain and crepitus.

Key distinguishing features are pattern of joint involvement, laboratory markers and imaging findings.

10. Management / Treatment

General management –

• Educate patient about disease nature and self‑care.
• Encourage weight reduction (5–10 % loss improves knee pain).
• Advise joint protection (use of canes, proper footwear).

Modern medicine treatment –

• Analgesics: Paracetamol as first line for mild pain.
• NSAIDs (oral or topical) for moderate pain; monitor gastrointestinal and renal side effects.
• Intra‑articular steroids for acute flares; limited to a few injections per year.
• Viscosupplementation (hyaluronic acid) – may improve lubrication in selected patients.
• Physiotherapy – muscle strengthening, range‑of‑motion exercises, hydrotherapy.
• Surgical options – osteotomy, unicompartmental or total joint replacement when conservative measures fail.

Diet and lifestyle advice –

• Balanced diet rich in omega‑3 fatty acids (fish, flaxseed) and antioxidants (fruits, vegetables) to reduce low‑grade inflammation.
• Limit saturated fats, refined sugars and processed foods that may aggravate systemic inflammation.
• Regular low‑impact aerobic exercise (walking, cycling, swimming) to maintain joint mobility and muscle strength.
• Avoid prolonged standing or repetitive joint loading; incorporate rest periods during activity.

11. Homeopathic Therapeutics (7 remedies, each with 7–8 bullet points)

1. Arnica montana

• Causation: Direct trauma, bruises, over‑exertion.
• Characteristic symptoms: Deep, throbbing pain that worsens on movement, bruised feeling.
• Modalities: Better from warmth, worse from cold and pressure.
• Mental state: Restless, wants to be active despite pain.
• Thirst & appetite: Increased thirst for cold water; appetite normal.
• Discharges: May have slight joint effusion, clear fluid.
• Physical generals: Tenderness over affected joint, bruised appearance.
• Constitution: Robust, outdoor workers, athletes.
• How it helps: Addresses the traumatic origin and relieves soreness and bruising of the joint.

2. Rhus toxicodendron

• Causation: Repetitive strain, over‑use, damp weather exposure.
• Characteristic symptoms: Stiffness and pain that improve with continued motion, worse on initial use.
• Modalities: Better with warmth and motion, worse in cold, damp conditions.
• Mental state: Irritable, eager to move but limited by pain.
• Thirst & appetite: Craving warm drinks; appetite moderate.
• Discharges: May have sticky synovial fluid.
• Physical generals: Swelling with a feeling of heaviness.
• Constitution: Persons who work in wet or cold environments.
• How it helps: Relieves stiffness that eases with motion, typical of early OA.

3. Bryonia alba

• Causation: Joint over‑extension, prolonged inactivity.
• Characteristic symptoms: Sharp, stitching pain aggravated by movement, relieved by rest.
• Modalities: Better with firm pressure, worse by motion and cold.
• Mental state: Impatient, wants to be left alone.
• Thirst & appetite: Great thirst for large quantities of water; appetite reduced.
• Discharges: Thin, watery effusion.
• Physical generals: Joint appears tense, muscles in spasm.
• Constitution: Individuals who prefer to stay still, often with a dry constitution.
• How it helps: Targets the aggravation of pain by movement, common in chronic OA.

4. Ruta graveolens

• Causation: Over‑use of joints, especially after prolonged strain.
• Characteristic symptoms: Stiffness with a feeling of “drawing” pain, especially in the peri‑osteal region.
• Modalities: Better with warmth, worse from cold wind.
• Mental state: Anxious, anticipates worsening of pain.
• Thirst & appetite: Slight thirst, normal appetite.
• Discharges: May have occasional bloody‑tinged effusion after injury.
• Physical generals: Tenderness over ligaments and peri‑osteal areas.
• Constitution: Persons engaged in heavy manual work.
• How it helps: Relieves peri‑osteal pain and stiffness after over‑use.

5. Calcarea phosphorica

• Causation: Degenerative changes in cartilage, especially in middle‑aged women.
• Characteristic symptoms: Dull aching pain that worsens at night, stiffness in the morning.
• Modalities: Better with warm applications, worse from cold drafts.
• Mental state: Indecisive, anxious about health.
• Thirst & appetite: Craving warm drinks, appetite moderate.
• Discharges: Slightly thickened synovial fluid.
• Physical generals: General weakness, especially of the bones.
• Constitution: Tall, thin individuals with a tendency to develop bone disorders.
• How it helps: Supports cartilage metabolism and reduces nocturnal pain.

6. Ledum palustre

• Causation: Joint injury with puncture‑type pain, often after a fall.
• Characteristic symptoms: Stinging, burning pain that improves with cold applications.
• Modalities: Better from cold, worse from warmth.
• Mental state: Calm, indifferent to surroundings.
• Thirst & appetite: Little thirst, appetite normal.
• Discharges: Clear, watery effusion.
• Physical generals: Swelling that feels “tight” and “pinched”.
• Constitution: Persons who feel better in cool environments.
• How it helps: Relieves puncture‑type pain typical after traumatic onset of OA.

7. Symphytum officinale

• Causation: Repeated micro‑trauma leading to bone and cartilage degeneration.
• Characteristic symptoms: Deep, aching pain over the joint, especially after exertion.
• Modalities: Better with rest, worse by motion and cold.
• Mental state: Quiet, prefers to avoid activity.
• Thirst & appetite: Normal thirst, reduced appetite when pain is severe.
• Discharges: May have serous fluid with occasional blood‑streaks.
• Physical generals: Tenderness over the peri‑osteal region, slight bruising.
• Constitution: Individuals with a history of bone injuries.
• How it helps: Promotes healing of bone and cartilage, eases deep aching pain.

8. Gelsemium sempervirens (optional addition)

• Causation: Joint pain after emotional stress or over‑exertion.
• Characteristic symptoms: Weakness, trembling, pain that feels “heavy”.
• Modalities: Better with rest, worse by mental strain.
• Mental state: Anxious, anticipatory fear of pain.
• Thirst & appetite: Slight thirst, appetite reduced.
• Discharges: Minimal effusion.
• Physical generals: Generalized fatigue, trembling of limbs.
• Constitution: Sensitive, nervous individuals.
• How it helps: Addresses the mental‑emotional component that aggravates OA pain.

12. Prognosis

Osteoarthritis is a slowly progressive, lifelong condition. The rate of progression varies with age, joint involved, body weight, activity level and adherence to treatment. Early intervention (weight loss, physiotherapy, appropriate medication) can delay functional decline, whereas advanced disease may lead to severe disability and the need for joint replacement.

Overall, prognosis is good when lifestyle measures and therapy are consistently applied.

13. Prevention

• Maintain healthy body weight – reduces mechanical load on knees and hips; even modest loss improves symptoms.
• Regular low‑impact exercise – strengthens peri‑articular muscles, preserves joint range and cartilage nutrition.
• Avoid joint over‑use – use proper techniques in work and sports; incorporate rest periods.
• Protect joints from injury – wear protective gear, practice safe lifting.

These measures lower the incidence of primary OA and delay secondary disease after injury.

14. Diet