This document discusses age-related health problems like low back pain and osteoarthritis that are on the rise due to an aging global population living longer lives. It focuses on low back pain, providing details on epidemiology, risk factors, anatomy, clinical evaluation through history, physical exam, imaging tests and diagnostic considerations. Case examples are presented to illustrate lumbar spondylosis, sciatica due to disc herniation, and degenerative spondylolisthesis diagnoses. The summary highlights the rising prevalence of age-related health issues, evaluation of low back pain, and examples of lumbar spine diagnoses.

1. Aches and Pains:
The Health Concerns of the
Aging Population
Allan D. Corpuz
Fellow, section of Rheumatology

2. All over the world,
We have an aging population
h"p://rt.com/business/aging-­‐popula6on-­‐elderly-­‐double-­‐2050-­‐904/

3. Better health care has resulted
in better survival
At what cost?

4. AGE-RELATED health PROBLEMS
ARE ON THE RISE

5. overview
• Low Back Pain
• Osteoarthritis
• Soft Tissue Rheumatisms

6. LOW BACK PAIN

7. Epidemiology
• 65-80%: during entire lifetime
• Most prevalent chronic pain
syndrome
• Leading cause of limitation: <45 y/
o
• 2nd most frequent reason for MD
visit
• 3rd most common surgical
indication

8. Epidemiology
• Pain and function improve
substantially within 1 month
• >90% are better at 8 weeks (but
are susceptible to future brief
relapses)
• 7-10% chronic LBP

9. • Risk Factors
– Heredity
– Psychosocial factors
– Heavy lifting
– Obesity
– Pregnancy
– Weaker trunk strength
– Cigarette smoking
• Persistent disabling LBP
– Maladaptive pain coping behavior
– Non-organic signs
– Functional impairment
– Poor general health status
– Psychiatric comorbidities

10. ANATOMY

11. ANATOMY

12. HISTORY AND PHYSICAL EXAMINATION
CLINICAL
EVALUATION

13. HISTORY
• Identify those with neural compression or
underlying systemic disease (<5%)
• Look for “Red Flags”
• Look for social or psychologic distress
– Job dissatisfaction
– Pursuit of disability compensation
– Depression

14. RED FLAGS

15. HISTORY
MECHANICAL
LBP
INFLAMMATORY
LBP
>95%
Less
common
Usually
seen
in
elderly
people,
postmenopausal
women
Seen
in
men
<40y/o
(sPA)
Typically
increases
with
physical
ac6vity
and
upright
posture
Marked
morning
s6ffness
>30mins
Worse
during
2nd
half
of
the
night
Alterna6ng
bu"ock
pain
Relieved
by
rest
and
recumbency
Improves
with
exercise
but
not
rest
Most
common
cause
is
degenera6ve
change
in
the
LS
Spondyloarthri6des

16. PHYSICAL
EXAMINATION
INSPECTION
Scoliosis;
Spina
bifida
occulta;
muscle
atrophy
PALPATION
Paravertebral
muscle
spasm
(loss
of
normal
lumbar
lordosis);
Fibromyalgia
(widespread
tender
points)
Spondylolisthesis
(palpable
step-­‐off
b/n
adjacent
spinous
processes)
ROM:
-­‐Limited
spinal
mo6on
(flexion,
extension,
lateral
bending,
rota6on):
more
useful
for
Tx
monitoring
-­‐Chest
expansion
<2.5cm
(AS)
-­‐Tenderness
over
greater
trochanter
of
femur
(trochanteric
bursi6s)
–Decreased
ROM
hip
(hip
OA)
PERRCUSSION
Point
tenderness
over
spine
(Sensi6ve
but
not
specific
for
Vertebral
OM
AUSCULTATION
Bruits
(AAA)

17. PHYSICAL
EXAMINATION

18. PHYSICAL
EXAMINATION
• Litigation or with psychologic distress
• Exaggerated symptoms
• Nonorganic signs
• Most reproducible tests*:
– Superficial tenderness
– Overreaction during examination
– Discrepancy in the SLR test done in seated and supine
positions
*Waddell
G,
McCullogh
JA,
Kummel
E,
Venner
RM:
Non-­‐organic
physical
signs
in
low
back
pain,
Spine
5:117–125,
1980.

19. IMAGING
ELECTRODIAGNOSTICS
LAB STUDIES
DIAGNOSTIC
TESTS

20. IMAGING
Imaging is NOT required UNLESS significant symptoms
PERSIST BEYOND 6-8 weeks
Dixit RK: Approach to the patient with low back pain. In Imboden J, Hellmann D, Stone J, editors. Current diagnosis and
treatment in rheumatology, ed 2, New York, 2007, McGraw-Hill
NEITHER MRI NOR PLAIN RADIOGRAPHS taken EARLY
in the course of LBP evaluation improves clinical
outcome, predicts recovery course, or reduces overall
cost of care
Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low back pain: systematic review and meta-analysis, Lancet
373:463–472, 2009.

21. IMAGING
• Weak association between imaging abnormalities
and symptoms
• Up to 85%: cannot make precise pathoanatomic Dx
with identification of the pain generator
• Reinforce suspicion of serious disease, magnify the
importance of non-specific findings, and label
patients with spurious diagnosis
Deyo
RA,
Weinstein
DO:
Low
back
pain,
N
Engl
J
Med
344(5):363–
370,
2001.

22. IMAGING: Plain Xrays

24. IMAGING: MRI
• Best initial test for LBP patients who require advanced
imaging
• Preferred for detection of spinal infection, cancers,
herniated disks, and spinal stenosis
• INDICATIONS:
– Suspicion of systemic disease
– Preop evaluation of surgical candidates on clinical grounds
– Pxs with radiculopathy or spinal stenosis who are candidates
for epidural steroids
Jarvik
JG,
Deyo
RA:
Diagnos6c
evalua6on
of
low
back
pain
with
emphasis
on
imaging,
Ann
Intern
Med
137:586–597,
2002
Chou
R,
Qaseem
A,
Snow
V,
et
al:
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society,
Ann
Intern
Med
147(7):
478–491,
2007

26. IMAGING: CT Scan
• Superior to MRI in evaluation of bone anatomy
• Safe in patients with ferromagnetic implants
• CT myelography is preferred in patients with
surgically placed spinal hardware

27. IMAGING: CT Scan

28. IMAGING: Bone Scan
• Infection, bony
metastases,
Occult fractures
• Differentiation
from
degenerative
changes
• Limited
specificity: Poor
spatial resolution
• Require
confirmatory
imaging by MRI

29. ELECTRODIAGNOSTIC
STUDIES
• LS Radiculopathy
• EMG-NCV
• Confirm nerve root compression and define the distribution
and severity of involvement
• INDICATIONS:
– Pxs with persistent disabling symptoms of radiculopathy with
discordance b/n clinical presentation and findings on imaging
– Evaluation of possible factitious weakness
• LIMITATIONS:
– delayed detection
– Persistent abnormalities

30. ELECTRODIAGNOSTIC
STUDIES

31. LABORATORY
STUDIES
• CBC
• ESR, CRP
• Alkaline phosphatase
• Tumor markers

32. Chou
R,
Qaseem
A,
Snow
V,
et
al.
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society.
Ann
Intern
Med.
2007;147:478-­‐491.

33. DIFFERENTIAL
DIAGNOSIS

35. CASE
• 55M, fisherman, with low back pain
• >5 years duration
• Pain radiates to buttock and anterior thigh
• Alleviated by forward flexion
• Exacerbated by bending to the right side of the body

36. Plain APL Xray

37. Diagnosis
• LUMBAR SPONDYLOSIS (Facet Syndrome)
• Degenerative changes in facet joints
• Imaging evidence is common in the general
population, increases with age and maybe unrelated
to back symptoms
• Patients with severe mechanical LBP may have
minimal radiographic changes, and conversely,
patients with advanced changes may be
asymptomatic

38. CASE
• 35M, businessman
• Low back pain that radiates to the medial aspect foot
• Sudden onset
• Duration: 6 weeks
• Lancinating, sharp pain with numbness and tingling
• Worsened by coughing, sneezing or when he defecates
• +SLR Right
• Weak dorsiflexion of foot and great toe

39. MRI

40. Diagnosis
• SCIATICA secondary to INVERTERBRAL DISK
HERNIATION L4-L5
• Occurs when the NP in a degenerated disk prolapses
and pushes out the weakened annulus, usually
posterolaterally
• Seen in 27% of asymptomatic individuals
Jensen
MC,
Brandt-­‐Zawadski
MN,
Obuchowski
N,
et
al:
Magne6c
resonance
imaging
of
the
lumbar
spine
in
people
without
back
pain,
N
Engl
J
Med
331:69–73,
1994

41. Diagnosis
• LS spine is susceptible to herniation because of its
mobility
• 75% of flexion-extension occurs at the LS joint (L5-
S1)
• 20% occurs at L4-5
• Therefore, 90-95% of clinically significant
compressive radiculopathies occur at these 2 levels

42. Diagnosis
• Disk herniation is rare in young individuals
• Frequency increases with age
• Peak: 44-50y/o (progressive decline in frequency
thereafter)

43. Diagnosis
• L1 radiculopathy: rare; pain, paresthesias and sensory
loss in inguinal areas
• L2-4 radiculopathies: uncommon; seen in elderly with
spinal stenosis
• Cauda equina syndrome: midline L4-5 herniation
– LBP, bilateral radicular pain, bilateral motor deficit with leg
weakness
– Urinary retention with Overflow incontinence
– Asymmetric PE
– Saddle anesthesia
– Surgical emergency!

44. Diagnosis
• Natural history is favorable (progressive
improvement in most patients)
• Regression in sequential MRI
• Partial or complete resolution in 2/3 of cases after 6
mos
• Only 10% have sufficient pain after 6 weeks of
conservative care (consider decompressive surgery))

45. CASE
• 70F, store owner
• Chronic aching low back pain
• Duration: 8 years
• Occasionally relieved by Paracetamol, Mefenamic
Acid, rest
• Normal PE

46. Plain APL Xray

47. Diagnosis
• DEGENERATIVE SPONDYLOLISTHESIS
• Anterior displacement of a vertebra on the one
beneath it
• Two types
ISTHMIC
DEGENERATIVE
Caused
by
bilateral
spondylolyis
Caused
by
severe
degenera6ve
changes
with
subluxa6on
at
the
facet
joints
Acquired
early
in
life;
young
boys
Older
age
group
>60,
women
Most
commonly
a
defect
in
the
pars
ar6cularis
at
L5
MC
L4-­‐5
Nerve
root
impingement
Spinal
stenosis

48. CASE
• 73M, carpenter
• Chronic low back pain
• >5 years
• Pain and paresthesias in buttocks, thighs
and legs
• Exacerbated by erect posture and walking
but has no problems cycling
• Relieved by sitting or flexing forward
• Unsteady gait, weakness lower
extremities
• SLR (-)
• DTRs: + on both LE

49. MRI

50. Diagnosis
• SPINAL STENOSIS
• Neurogenic claudication
• Simian stance; shopping cart sign
• Wide based gait (90% specific)
• 20-30% asymptomatic adults have
abnormal imaging
• Factors that favor neurogenic claudication
(vs vascular)
– Preservation of pedal pulses
– Provocation of Sxs by standing erect as
readily as walking
– Relief of symptoms by spine flexion
– Location of maximal discomfort to the
thighs rather than calves

51. Diagnosis
• Indolent, benign
• Symptoms unchanged
in 70%, improved in
15%, worsened in 15%
• Prophylactic surgical
intervention not
warranted

52. CASE
• 55M, previously diagnosed with prostate cancer, s/p
cTURP
• Persistent, progressive Low back pain for 2 months
• Not alleviated by rest
• Worse at night
• Minimal relief with Paracetamol, NSAIDs
• Weight-loss, anorexia
• Recently, acute weakness of both lower extremities
(MMT 2/5)
• Urinary retention with overflow incontinence

53. MRI

54. Diagnosis
• CAUDA EQUINA Syndrome 2 to Vertebral
Metastases from Prostate Ca
• Neoplasia accounts for <1% of patients with LBP
• Prior history of Ca was the most important
predictor for likelihood of underlying Ca

55. Diagnosis
• Leptomeningeal carcinomatosis: Breast, lung,
lymphoma, leukemia
• Metastatic: kidney, prostate, breast, lung, thyroid
• Multiple myeloma
• Rare: SC tumors, primary vertebral tumors,
retroperitoneal tumors

56. Diagnosis
• Plain radiographs less sensitive
• Metastatic lesions may be lytic (radiolucent), blastic
(radiodense) or mixed.
• Unlike infections, the disk space is usually spared
• MRI: greatest sensitivity and specificity
• Purely lytic lesion (MM) will not be detected by
bone scan

57. CASE
• 30M, kargador, IV drug user
• Fever, low back pain, weight loss
• Pain is persistent, present at rest, exacerbated by
activity
• +point tenderness: L4-L5
• Grade 3/6 systolic murmur over the 4th ICS RPSB
• Leukocytosis
• Elevated ESR, CRP
• Blood CS: Moderate growth of S. aureus

58. MRI

59. Diagnosis
• Vertebral OM
• Hematogenous, direct inoculation, contiguous
spread
• MC: lumbar spine
• MC: #1 S. aureus #2 E.coli
• Leukocytosis in 2/3
• CRP correlates with clinical response to Tx
• Bone Bx if Blood CS (-)

60. Diagnosis
• Plain Xray: initial imaging (late and non-specific)
– Loss of disk height and loss of cortical definition
– Bony lysis of adjacent vertebral bodies
• MRI: most sensitive and specific
– Classic finding: involvement of 2 vertebral bodies with
their intervening disk

61. CASE
• 40F, housewife
• Low back pain after lifting bag of laundry
• Duration: 3 days
• SLR (-)
• No LOM

62. Diagnosis
• Nonspecific LBP
• Lumbago, strain, sprain
• Self-limited, acute, mechanical
• Mild to severe
• Trauma, lifting, twisting injury
• Most patients are better within 1-4 weeks but
remain susceptible to similar future episodes
• <10% develop chronic non-specific LBP

63. TREATMENT

64. ACUTE (Less than 3
mos)
• Excellent prognosis
• Only 1/3 seek medical care
• >90% recover within 8weeks or earlier
• Stay active; continue ordinary daily activities within limits
permitted by pain
• Discourage bedrest >1-2days
• Acetaminophen and NSAIDs: 1st line for symptom relief
• Short term opioids: for severe disabling LBP or if with CI to NSAIDS
• Muscle relaxants are moderately effective (but high prev of adverse
events
Coste
J,
Delecoeuillerie
G,
Cohen
deLara
A,
et
al:
Clinical
course
and
prognos6c
factors
in
acute
low
back
pain:
an
incep6on
cohort
study
in
primary
care
prac6ce,
BMJ
308:577,
1994.
Chou
R:
Pharmacological
management
of
low
back
pain,
Drugs
70(4):384–402,
2010.

65. ACUTE (Less than 3
mos)
• Back exercises not helpful in the acute phase
• PT referral not usually necessary in the first month
• Individually tailored exercise program
• Educational booklets strongly recommended
• Heating pads or blankets
Chou
R,
Qaseem
A,
Snow
V,
et
al:
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society,
Ann
Intern
Med
147(7):478–491,
2007.

66. ACUTE (Less than 3
mos)
• INSUFFICIENT EVIDENCE
– Spinal manipulation
– Cold packs, corsets or braces
– Acupuncture, massage
– Traction
– TENS, PENS, interferential therapy, low-level laser therapy,
shortwave diathermy, ultrasound
– Injection of trigger points, ligaments, SI joints, facet joints,
intradiskal steroid injections
Clarke
JA,
van
Tulder
MW,
Blomberg
SE,
et
al:
Trac6on
for
low
back
pain
with
or
without
scia6ca,
Cochrane
Database
Syst
Rev
(23):CD003010,
2007.
Chou
R,
Qaseem
A,
Snow
V,
et
al:
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society,
Ann
Intern
Med
147(7):478–491,
2007
Chou
R,
Loeser
JD,
Owens
DK,
et
al:
Interven6onal
therapies,
surgery,
and
interdisciplinary
rehabilita6on
for
low
back
pain.
An
evidence
based
clinical
prac6ce
guideline
from
the
American
Pain
Society,
Spine
34(10):1066–1077,
2009.

67. SUBACUTE (More
than 6wks)
– Injection therapy
– Epidural CCS: remarkable but unjustified popularity
– Evidence of moderate benefit compared to placebo for
short term relief of leg pain from HNP
– No significant functional benefit
– No reduction in need for surgery
Care"e
S,
Leclaire
R,
Marcouxs
S,
et
al:
Epidural
cor6costeroid
injec6ons
for
scia6ca
due
to
herniated
nucleus
pulposus,
N
Engl
J
Med
336(23):1634–1640,
1997.

68. ACUTE to SUBACUTE
– Vertebroplasty and Kyphoplasty

69. ACUTE to SUBACUTE
– Vertebroplasty vs Kyphoplasty

70. CHRONIC (More than
3 mos)
– Overall: results of treatment are unsatisfactory
– Complete relief of pain is unrealistic for most
– High costs
– Acetaminophen and NSAIDs as first line
– Opioid analgesics for severe disabling LBP
– No evidence that long-acting RTC dose is superior to
short-acting PRN dosing
– Continuous exposure leads to tolerance and dose
escalation
Chou
R:
Pharmacological
management
of
low
back
pain,
Drugs
70(4):384–402,
2010.

71. CHRONIC (More than
3 mos)
– Muscle relaxants are not recommended for long-term
use
– Antidepressants that inhibit NE uptake: pain modulating
properties
– Low dose TCAs are an option
– No evidence for SSRIs (except for concomitant Tx of
depression)
– Duloxetine (SNRI) has marginal efficacy
– Insufficient evidence for Gabapentin and topiramate

72. CHRONIC (More than
3 mos)
– PT modalities and injection techniques: not recommended
– Lumbar supports and traction: ineffective
– Medium firm mattress or back-conforming mattress (water-
bed or foam): superior to a firm mattress
– Spinal manipulation is superior to sham manipulation but is
no more effective than conventional medical Tx
– Less evidence for massage and acupuncture
– Chemonucleolysis with chymopapain: potentially life-
threatening
– Radiofrequency denervation: lacks evidence

73. CHRONIC (More than
3 mos)
– Lack of evidence:
• Radiofrequency denervation
• Intradiskal electrothermal therapy
• Percutaneous intradiskal RF thermocoagulation
• Prolotherapy
• Spinal cord stimulation
• Instraspinal drug infusion systems (?): morphine

74. CHRONIC (More than
3 mos)
– Supportive measures
• Interdisciplinary rehabilitation
• Functional restoration (work hardening)
– Surgery
• As a general rule, the results of back surgery are disappointing when the
goal is relief of back pain rather than relief of radicular symptoms from
resulting neurologic compression
• Role of surgical treatment for chronic disabling LBP w/o neurologic
improvement in patients with degenerative disease remains controversial
• MC: spinal fusion
• For non-radicular back pain with degenerative changes, fusion is no more
effective than intensive interdisciplinary rehab but is associated with small
to moderate benefits compared with standard non-surgical care

75. CHRONIC (More than
3 mos)

76. NERVE ROOT COMPRESSION SYNDROMES
Disk
HerniaDon
Spinal
Stenosis
Spondylolithesis
Treat
nonsurgically
(as
in
Acute
LBP)
unless
with
serious
or
progressive
neuro
deficit
Conserva6ve
non-­‐opera6ve
Tx
Surgery
if
with
serious
or
progressive
neuro
deficit
Treat
conserva6vely
Only
about
10%
have
sufficient
pain
aoer
6
weeks
of
conserva6ve
Tx
to
warrant
Surgery
Symptoms
stable
for
yrs;
may
improve
in
some
Drama6c
improvement
uncommon
Surgery:
moderate
short
term
benefits
(thru
6-­‐12wks)
vs
non-­‐Sx
but
outcome
differences
diminish
over
6me
and
no
longer
present
in
1-­‐2
yrs
PT:
mainstay
of
mgt
Core
strengthening,
stretching,
aerobic,
loss
of
wt,
Px
educa6on;
Cycling
Lumbar
corsets
Open
diskectomy
or
microdiskectomy
Laminectomy,
par6al
fascetectomy,
excision
of
hypertrophied
LF
Epidural
CCS
injec6ons:
moderate
benefit
for
short
term
relief
but
no
func6onal
benefit
and
don’t
reduce
need
for
Surgery
Lumbar
epidural
CCS
injec6ons:
small
RCT
showed
reduc6on
in
pain
and
improvement
in
fxn
at
6
mos
but
don’t
influence
fxnal
status
and
need
for
surgeyr
at
1yr
Decompression
surgery
with
fusion
be"er
than
non-­‐surgical
care
for
isthmic
spondylolisthesis
and
disabling
isolated
LBP
or
scia6ca
for
at
least
a
year
An6TNF
being
inves6gated
Titanium
interspinous
spacer

77. OUTCOME
• Natural history of acute LBP is favorable
• Improvement in pain and fxn within 1 month in the
majority of patients; >90% are better at 8weeks
• Only 1/3 of acute LBP patients seek medical care
• Rest resolves

78. OUTCOME
• Improvement is also the norm for Pxs with sciatica 2
to HNP
• 1/3 better in 2 weeks, 75% improve after 3 mos,
10% ultimately undergo surgery
• Spinal stenosis: stable in 70%, improved in 15%,
worsened in 15%
• 7-10% with chronic LBP: responsible for high costs

79. Factors that predict
chronicity
• Maladaptive coping behavior
• Presence of non-organic signs
• Functional impairment
• Poor general health status
• Psychiatric comorbidities
• Job dissatisfaction
• Disputed compensation claims
• High level of “fear avoidance”

80. SUMMARY
• History and PE are more important than Imaging
• Prognosis of acute LBP is excellent
• Prognosis of chronic LBP is unsatisfactory
• Surgery is reserved for neurologic deficits

81. Osteoarthritis

82. Prevalence

84. Diagnosis
" Pathologically
" Radiographically
" Osteophyte
" Joint space narrowing (JSN) on Plain Xray (or MRI)
" Clinically
" Nodal changes in the hands
" Limited and painful internal rotation of the hip
" Crepitus with knee movement
SYMPTOMATIC OA = pain, aching or stiffness in a joint
with radiographic OA

85. Diagnosis
ACR Criteria
1986 (Knee), 1991 (Hip), 1990 (Hand)
SENSITIVITY
SPECIFICITY
Hand
92%
98%
Hip
91%
89%
Knee
91%
86%

86. ACR
Radiologic and Clinical Criteria
" HAND
1. Hand pain, aching, or stiffness on most days of prior
months
2. Hard tissue enlargement of >=2 of 10 selected joints*
3. Fewer than 3 swollen MCP joints
4. Hard tissue enlargement of >=2 DIP joints
5. Deformity of >=2 of 10 selected joints*
" DIAGNOSIS REQUIRES ITEMS 1-3 AND EITHER 4 OR 5
" 10 Selected Joints: DIP 2-3, PIP 2-3, and CMC 1
bilaterally

87. Hand OA

88. ACR
Radiologic and Clinical Criteria
" KNEE: Clinical
1. Knee pain for most days of prior month
2. Crepitus with active joint motion
3. Morning stiffness lasting <=30 min
4. Bony enlargement of the knee on examination
5. Age >=38 yr
" Diagnosis REQUIRES 1+2 + 4, or 1+2+3+5, or 1+4+5

89. ACR
Radiologic and Clinical Criteria
" KNEE: Clinical AND Radiographic
1. Knee pain for most days of prior month
2. Osteophytes at joint margins
3. Synovial fluid typical of OA
4. Age ≥ 40 y/o
5. Morning stiffness lasting ≤ 30min
6. Crepitus with active joint motion
" Diagnosis REQUIRES 1+2, or 1+3+5+6, or 1+4+5+6

90. ACR
Radiologic and Clinical Criteria
" HIP: Clinical AND Radiographic
1. Hip pain for most days of the prior month
2. ESR ≤20mm/hr
3. Radiographic femoral and/or acetabular
osteophytes
4. Radiographic hip joint space narrowing
Diagnosis REQUIRES 1+2+3, or 1+2+4, or 1+3+4

91. Primary vs Secondary
• Primary: absence of an injury history or other
joint disease
• Secondary: (+) of predisposing disorder
• Division currently less clear
• Genetics, Hx of injury/jt damage, mechanical
factors, psychosocial milieu à joint à end-
stage or failed joint

92. Etiologies of Secondary OA 1637CHAPTER 99 | CLINICAL FEATURES OF OSTEOARTHRITIS
Table 99-3 Etiologies of Secondary Osteoarthritis
Metabolic
Crystal-associated arthritis
Calcium pyrophosphate or apatite deposition
Acromegaly
Ochronosis
Hemochromatosis
Wilson’s disease
Hyperparathyroidism
Ehlers-Danlos
Gaucher’s disease
Diabetes
Mechanical/Local Factors
Slipped capital femoral epiphysis
Epiphyseal dysplasias
Legg-Calvé-Perthes disease

93. Etiologies of Secondary OA
Ochronosis
Hemochromatosis
Wilson’s disease
Hyperparathyroidism
Ehlers-Danlos
Gaucher’s disease
Diabetes
Mechanical/Local Factors
Slipped capital femoral epiphysis
Epiphyseal dysplasias
Legg-Calvé-Perthes disease
Congenital dislocation
Femoroacetabular impingement
Congenital hip dysplasia
Limb-length inequality
Hypermobility syndromes
Avascular necrosis/osteonecrosis
Traumatic
Joint trauma (e.g., ACL tear)
Fracture through joint

94. Etiologies of Secondary OA
Legg-Calvé-Perthes disease
Congenital dislocation
Femoroacetabular impingement
Congenital hip dysplasia
Limb-length inequality
Hypermobility syndromes
Avascular necrosis/osteonecrosis
Traumatic
Joint trauma (e.g., ACL tear)
Fracture through joint
Prior joint surgery (i.e., meniscectomy, ACL)
Charcot joint (neuropathic arthropathy)
Inflammatory
Rheumatoid arthritis or other inflammatory arthropathies
Crystalline arthropathy (gout)
History of septic arthritis
ACL, anterior cruciate ligament.
Modified from Altman R, Asch E, Bloch D, et al: Development of criteria
for the classification and reporting of osteoarthritis. Classification of osteo-

95. CLINICAL FEATURES

96. General Symptoms & Signs
– Knees, hands, feet, hips and spine
– Symptomatic or radiographic
– Pain in the joints that is:
• Worse with activity
• Limited morning stiffness (≤30mins)
• Pain and stiffness with rest (gelling phenomenon)
– Bony enlargements, crepitus, reduced ROM
– Soft tissue swelling or effusion

97. Joint-Specific Symptoms and
Signs

98. Knee
• Insidious onset of pain
• Gelling
• Limitation of ROM
– Walking, transferring, stair climbing
– Sense of instability or “giving out” at the knee
• Locking sensation
– Stiffness
– Loose bodies in the joint space
– Meniscal lesions
• Crepitus, bony enlargement

99. Knee
• Pain: medial or lateral joint line
• Effusions: cool, generally w/o redness
– Association with Baker’s cyst
• Pain over anserine bursa or greater trochanter: altered biomechanics
• Malalignment (mc: varus) – risk factor for progression
• Severe disease: flexion deformities or joint stability
• Risk factors: Quadriceps weakness (modifiable) à muscle atrophy
(late stage); loss of proprioception and vibratory sense
• Patellofemoral OA: pain, disability; often overlooked

101. Hip
• Groin pain (specific)
• Vague: pain in the thigh, buttock, low back, or ipsilateral knee
• Consider differential Dx
– Femoral neck Fx, Avascular Necrosis
• Limitations in walking, bending, transferring, stair climbing
– Internal rotation: limited and painful (even in early dse)
– Putting on socks, tying shoes, trimming toe nails
• Visible deformity, hip flexion contracture, severe limitations of ROM à
severe dse (superior migration of the femoral head)
• Consider: Femoroacetabular impingement – young, groin pain worsened
by sitting, pain and limitation on F-IR-AD of the hip

102. Hip OA

103. Hand
• Heberden’s nodes: DIP; Bouchard’s nodes: PIP
• Erosive arthritis: episodic inflammation, pain and swelling (elderly women)
• First CMC: significant pain, limitations in fucntionality, reduced grip strength
– CMC squaring: osteophyte formation and JSN
• Bilateral involvement of multiple joints:
– Within (multiple PIPs) and across (both DIPs and PIPs)
• MCP involvement: increasing; consider inflammatory arthropathies or secondary OA
(hemochromatosis)
• DeQuervain’s tenosynovitis: mimic or aggravate symptoms

104. Spine
• Osteophytosis of the spine à older individuals; often asymptomatic
• Lumbar disk degeneration (DSN, end plate sclerosis, herniation): often seen in
association with radiographic osteophytosis (relationship controversial)
• Cervical spine:
– pain in the neck, radiation to the arms, weakness or paresthesia (osteophytic
compression)
– Dysphagia (anterior cervical spine osteophytes)
• Lumbar spine:
– Osteophytes and DSN à sciatic nerve impingement (pain, burning, numbness
and/or weakness down one or both legs)

105. Shoulder
• Symptoms are more often due to
osteophytosis and narrowing of the
acromioclavicular and/or sternoclavicular jts
rather than the glenohumeral jt itself
• DDx: Subacromial bursitis, Rotator Cuff
pathology, Adhesive capsulitis, Cervical
spine pathology
• Milwaukee shoulder syndrome
– Destructive arthropathy: glenohumeral
joint
– Large effusions
• High RBC count
• Basic Calcium crystals

106. Other Joints
• 1st MTP: pain and hallux valgus (bunion)
deformity
• Loss of function due to ankylosis
(hallux rigidus) à altered gait
• Other joints:
– TMJ
– Ankles: talonavicular, subtalar
– Elbow OA: rare
• Trauma, vibration damage,
pseudogout

107. Polyarticular OA
• Generalized OA: no universally understood or accepted
definition
• Kellgren and Moore (1952):
– Primarily: Heberden’s nodes and CMC
– With: spine, knees, hips, feet (descending frequency)
• Later studies:
– >3 or >5 joint sites affected
– Affected joint counts
– Multiple hand involvement
– Nodal hand OA with other jt involvement
– Summed scores of OA across multiple joints

108. DIAGNOSTIC TESTING

109. Diagnostic Approach
• Clinical!
• Labs RARELY required
• If Hx and PE ok à RadioGrx OFTEN NOT required
• Testing is for exclusion of DDx

110. Lab Testing
• RF, ANA, Serologic studies à rarely indicated
• CBC, Chem panel (Glucose, Crea), LFTs
• MCP involvement: test for hypothyroidism,
hemochromatosis

111. Synovial Fluid Analysis
• Normal or mildly inflammatory
• Clear and colorless to slightly yellowish
• WBC ct ≤ 2000 cells/mm3 (<2cells/hpf)
• Concomitant CPPD +/-

112. Imaging: Conventional Radiography, General
Considerations
• Confirm Dx
• Exclude DDx
• Typical findings:
– Osteophytes
– JSN
– Sclerosis
– Cysts of subchondral bone

113. Kellgren-Lawrence Grading
System

115. Knee: sunrise view

116. Hip: Frog Leg View

117. Hand: Gull-wing deformities

118. Spine

120. Imaging: Advanced Modalities
• MRI:
– Exclude DDx
– Define early changes (before Xray changes occur)
– BM lesions (knee) = correlate with pain, bone
attrition, progressive cartilage damage
• Arthroscopy
– Often used as a response to MRI findings
– Overused and generally ineffective
– Cost not indicated in routine practice
• Ultrasound
– Bedside procedure
– Detect small effusions, early cartilage changes,
diff infx vs non-inflx arthropathies
– Therapeutic adjunct

121. Mortality in OA
• Increased compared to gen pop
• CV and GI causes
• Inc mortality with inc jt involvement
• Reduced survival: hand, B knees, cervical
(NOT: hip, foot, lumbar)
• Contributors:
– Reduced physical activity
– Comorbid conditions
– Adverse SE of meds

122. SOFT TISSUE RHEUMATISMS

123. SHOULDER
• Subacromial bursitis
• Bicipital Tendinitis
• Rotator Cuff Tendinitis

124. HAND
• DeQuervain’s Tenosynovitis
• Carpal Tunnel Syndrome
• Trigger Finger

125. Knee
• Anserine bursitis

126. Foot and ANKLE
• Plantar fasciitis

127. SUMMARY
• Aging has caused a lot of health-related disorders
• It is important to get the correct diagnosis so
appropriate treatment can be given
• Most cases of low-back pain are benign, do not need
imaging and respond to conservative therapy
• Osteoarthritis is a degenerative disease that
responds to analgesics and physical therapy
• Soft tissue rheumatisms are overuse diseases and
respond to rest and steroid injections

128. Thank you for your attention
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