Arthritis of a Knee Joint of a Mummy

Arthritis of a Knee Joint of a Mummy

Risk factors and the natural history of accelerated knee osteoarthritis: a narrative review

Osteoarthritis is generally a slowly progressive disorder. However, at least 1 in 7 people with incident knee osteoarthritis develop an abrupt progression to advanced-stage radiographic disease, many within 12 months. We summarize what is known – primarily based on findings from the Osteoarthritis Initiative – about the risk factors and natural history of accelerated knee osteoarthritis (AKOA) – defined as a transition from no radiographic knee osteoarthritis to advanced-stage disease < 4 years – and put these findings in context with typical osteoarthritis (slowly progressing disease), aging, prior case reports/series, and relevant animal models.


Risk factors in the 2 to 4 years before radiographic manifestation of AKOA (onset) include older age, higher body mass index, altered joint alignment, contralateral osteoarthritis, greater pre-radiographic disease burden (structural, symptoms, and function), or low fasting glucose. One to 2 years before AKOA onset people often exhibit rapid articular cartilage loss, larger bone marrow lesions and effusion-synovitis, more meniscal pathology, slower chair-stand or walking pace, and increased global impact of arthritis than adults with typical knee osteoarthritis. Increased joint symptoms predispose a person to new joint trauma, which for someone who develops AKOA is often characterized by a destabilizing meniscal tear (e.g., radial or root tear). One in 7 people with AKOA onset subsequently receive a knee replacement during a 9-year period. The median time from any increase in radiographic severity to knee replacement is only 2.3 years. Despite some similarities, AKOA is different than other rapidly progressive arthropathies and collapsing these phenomena together or extracting results from one type of osteoarthritis to another should be avoided until further research comparing these types of osteoarthritis is conducted. Animal models that induce meniscal damage in the presence of other risk factors or create an incongruent distribution of loading on joints create an accelerated form of osteoarthritis compared to other models and may offer insights into AKOA.


Accelerated knee osteoarthritis is unique from typical knee osteoarthritis. The incidence of AKOA in the Osteoarthritis Initiative and Chingford Study is substantial. AKOA needs to be taken into account and studied in epidemiologic studies and clinical trials.

Can arthritis cause numbness?

Numbness is often a symptom of nerve involvement. For instance, numbness in the arm may be related to nerve irritation in the neck. In such a situation, turning or bending the head to the involved side may increase the symptoms. For example, a pinched nerve in the right side of the neck may cause numbness in the arm and hand when a person attempts to look back over the right shoulder. If nerve irritation becomes more severe, the arm and hand may become weak. A physical examination X-rays and an MRI of the neck and electrodiagnostic tests may be useful in establishing the diagnosis.

The key to diagnosing osteoarthritis is determining the pattern of joints that are affected . For example, if you have symptoms in the set of knuckle joints between the wrists and finger joints (metacarpal-phalangeal joints), the balls of the feet (metatarsal-phalangeal joints), wrists, ankles, or elbows, you probably have a different, inflammatory form of arthritis such as rheumatoid arthritis.


A normal joint is not painful, tender, or swollen, has a full range of motion, and appears structurally normal.


In an abnormal joint, an exam may detect pain or swelling along with a bony hardness. Other abnormal findings that suggest osteoarthritis include:

  • Bony bumps on the finger joint closest to the fingernail ( Heberden's nodes ), bony bumps on the middle joint of the finger ( Bouchard's nodes ), or bony bumps at the base of the thumb.
  • Tenderness and/or swelling in weight-bearing joints such as the hips and knees.
  • Pain, limited movement, and/or a creaking noise or feeling (crepitus) that occurs when the joints are moved.
  • Joints that have been affected by injury or infection. These joints may also show signs of bone or tissue damage.

The History of Rheumatoid Arthritis

Rheumatoid arthritis causes inflammation of the joints and other body areas. It is an autoimmune disease and its symptoms include:

Why Young Women with Rheumatoid Arthritis Are Freezing.

There are periods of arthritis flares and remissions. The joints may get permanently damaged or deformed due to chronic inflammation. Sometimes, the damage may early occur. However, the damage may not correlate with the severity of the symptoms. The antibody called rheumatoid factor (RF) is found in the blood of 80 percent of patients with rheumatoid arthritis. Rheumatoid factor (RF) can be detected by a simple blood test. The risk factors that can increase the chances of developing this disease are:

  • Smoking
  • Genetic background
  • Periodontal disease
  • Silica exposure
  • Microbes in the bowels

Usually, NSAIDs, DMARDs, T cell activation inhibitors, IL-6 inhibitors, TNF-alpha inhibitors, immunosuppressants, steroids, and Janus kinase inhibitors (JAK) inhibitors are used to ease the symptoms of rheumatoid arthritis. There is no cure for the disease, but other treatment options such as joint protection, certain medications, patient education, exercise, rest, and surgery may be occasionally needed.

Better prognosis can be achieved through early detection. The exact cause of the disease is not known and it may affect people of any age. In rheumatoid arthritis, the tissues that normally produce fluid for joint lubrication become inflamed. This loosens the joint ligaments and causes deformities. It erodes away the cartilage and causes deformity. Rheumatoid arthritis is a progressive illness. Approximately 1.3 million people in the United States are affected by the disease.

History of Rheumatoid Arthritis

References to joint pain and diseases were first described around 1500 BC in the Ebers Papyrus, which is an ancient Egyptian medical papyrus. It described a disease that is quite similar to rheumatoid arthritis. Moreover, there has been evidence of rheumatoid arthritis in Egyptian mummies. In G. Elliot's studies, he found out that rheumatoid arthritis was prevalent among Egyptians.

Around 300-200 BC, an Indian literature called Charaka Samhita described a condition, which includes pain, loss of joint mobility and function, as well as joint swelling.

In 400 BC, Hippocrates described arthritis in general. However, he did not specify the types of arthritis. Between 129 and 216 AD, the term "rheumatismus" was introduced by Galen.

In 1493-1511, it was suggested by Paracelsus that some substances collected in the body could not pass through the urine, and instead accumulate in the joints, which causes arthritis. Rheumatic diseases were often linked to humors by practitioners. Ayurveda also considered rheumatoid arthritis as one of the ata.

The disabling form of rheumatoid arthritis was first described by Thomas Sydenham. Later in 1880, such condition was described by Beauvais.

The progressive nature of rheumatoid arthritis was showed by Brodie. He also found how tendon sheaths and synovial sacs in the joints were affected. Moreover, he found other conditions associated with rheumatoid arthritis such as synovitis and cartilage damage.

First Description of RA

In the year 1800, the dissertation of Augustin Jacob Landré-Beauvais gave the first description of rheumatoid arthritis, which was also acknowledged by modern medicine. Landré-Beauvais was a 28-year-old resident physician who worked at the Saltpêtrière asylum in France. He was the first one to notice the signs and symptoms of rheumatoid arthritis. He even treated a few patients who complained of joint pain. At that time, rheumatism or osteoarthritis was still unknown. Rheumatoid arthritis affected poor people and more women than men.

At that time, physicians often treated wealthy patients to earn recognition and compensation. Hence, poor patients were ignored. Landré-Beauvais hypothesized that patients who were complaining of severe joint pain were suffering from goutte asthénique primitive or primary asthenic gout, which was an uncharacterized condition. He related gout to rheumatoid arthritis. Even though his assumption was incorrect, other researchers in the field of bone and joint disorders were encouraged to further study about the disease.

Rheumatoid Arthritis Classified

In the mid to late 19 th century, another person who studied and contributed to the study of rheumatoid arthritis was Alfred Garrod, who was an English physician. He classified rheumatoid arthritis differently from gout and he distinguished them from each other as well as from other forms of arthritis. He found that patients who had gout had an excessive uric acid in their blood. He also found out that patients with other forms of arthritis did not have increased uric acid levels in the blood.

These observations were described in Treatise on Nature of Gout and Rheumatic Gout, which was written by Alfred Garrod. He categorized and differentiated rheumatoid arthritis from gout. He referred rheumatoid arthritis as "rheumatic gout". His work and discoveries laid the groundwork for research on the etiology of rheumatoid arthritis. It was understood that the disease should have its own etiology since it was a different condition from other forms of arthritis.

How "Rheumatoid Arthritis" Was Coined

Further research was conducted by Archibald Garrod, who was the fourth son of Alfred Garrod. In his book called Treatise on Rheumatism and Rheumatoid Arthritis, he created the term "rheumatoid arthritis" to the disease that was discovered by Landré-Beauvais and later called by his father as "rheumatic gout". Archibald Garrod was known for distinguishing rheumatoid arthritis from gout and osteoarthritis.

After the discovery of the disease, it was later called by various names. However, Archibald Garrod called it as "rheumatoid arthritis" since the term would clearly describe the action of the disease on the body. In his book, he also referred to ancient skeletal remains found around the world. He claimed that the skeletal findings showed damage caused by rheumatoid arthritis. Although he was able to record such paleopathological claims, he did not include concrete supporting evidence.

Based on his claims, he said that rheumatoid arthritis is not a disease of the modern age but a disease that already existed from the time of our ancestors. Archibald Garrod's treatise acts as a supporting foundation and backbone when it comes to RA etiology.

The Antiquity of Rheumatoid Arthritis

Charles Short, an American physician, challenged the claims of Archibald Garrod during the 20 th century. Short further examined the paleontological reports and he noted that the diagnoses of ankylosing spondylitis, gout, and osteoarthritis were all confirmed in the skeletal remains. However, he found unconvincing claims of an RA diagnosis since he could not find a definitive RA diagnosis on the samples.

Short further claimed that the ideas of Archibald Garrod were false and that rheumatoid arthritis was a disease of modern origin. Short's work was credited more even though many had valuable claims and findings regarding the basis of RA origin.

History of RA Terms

Bannatyne described the appearance of rheumatoid arthritis that affected the joints. The International Commission on Rheumatism was formed in the year 1932. It later became the American Rheumatism Association and then the American College of Rheumatology.

The term "rheumatologist" was coined by Camroe in 1940 and "rheumatology" by Hollander in 1949.

History of RA Treatment

  • Bloodletting and Leeching - These were the treatments used in the olden days for rheumatoid arthritis. Acupuncture, acupressure, cupping, and moxibustion were developed and practiced in the Far East. Although many treatments were developed, they could not improve the symptoms of rheumatoid arthritis. Heavy metals were also used to treat RA. With varying success rates, different heavy metals such as arsenic, gold, bismuth, and copper salts were used. After many years, the use of gold has shown success. Gold is still used as part of disease-modifying antirheumatic drugs, which are used in the treatment of rheumatism.
  • Willow Extracts - Used by Hippocrates and Galen to treat the pain associated with rheumatoid arthritis. By using the plant extract of willow bark and leaves, pain relief was achieved. They also used the same extract to treat other forms of arthritis.
  • Salicylic Acid - In 1929, salicylic acid was identified as an active substance that could ease the pain. The substance was identified by Henri Leroux, a French chemist.
  • Acetylsalicylic Acid - Gerhardt synthesized acetylsalicylic acid in the year 1853. Then in the year 1949, phenylbutazone and many other nonsteroidal anti-inflammatory agents came into existence.
  • Disease-Modifying Antirheumatic Drugs (DMARDs) - The first one to suggest the use of quinine to treat rheumatic diseases was Payne in 1895.
  • Chloroquine - It was used in the year 1957. A modified version called hydroxychloroquine is used as a part of DMARDs until now.
  • Sulphasalazine - It was used as an anti-inflammatory agent in 1940 until today.
  • Cortisone - The successful use of cortisone in treating rheumatoid arthritis was first showed by Edward Kendall and Philip Hench in the year 1949.
  • Methotrexate - Methotrexate was synthesized in the 1950s. It was used as a folate antagonist for the treatment of leukemia. However, its role in treating rheumatoid arthritis was not discovered until the 1980s. Methotrexate still forms a part of DMARDs.
  • Anti-TNF Antibodies - The role of monocyte-derived tumor necrosis factor in the pathogenesis of rheumatoid arthritis was first identified in 1975. Their effectiveness was shown in the year 1993 and became a part of rheumatoid arthritis treatment.

Literature and Art Evidence on Rheumatoid Arthritis

Some researchers suggest that rheumatoid arthritis has been described in ancient texts even though the first accepted medical report regarding RA was the dissertation of Landré-Beauvais.

Hippocrates, in one text, described a patient with symptoms quite similar to rheumatoid arthritis. In the writings of Arataeus, a Greek physician, a similar description could be found.

Similar descriptions were also found in the writings of:

  • Scribonius - Caesar's physician
  • Michael Psellus - Emperor Constantine IX's adviser
  • Soranus - A Byzantine physician

The ones who believe that rheumatoid arthritis is a disease of the ancient times and are in favor of the Ancient Origin view of etiology of rheumatoid arthritis. They use these texts as an evidence since the symptoms described in the writings were very close to those of rheumatoid arthritis.

However, some argue that the descriptions in these texts are vague and do not meet the scientific standards. Moreover, they provide insufficient evidence for the existence of the disease. Thus, the ancient literature's role in etiology still remains anecdotal.

However, the demonstration of rheumatoid arthritis has been successfully displayed by much artwork. One painting is The Three Graces done by Peter Paul Rubens. Such artwork remains to be one of the most pronounced artistic pieces of RA evidence. It was done even before the thesis of Landré-Beauvais.

Another pronounced case was made by an anonymous painter's depiction of The Temptation of St. Anthony. This painting was reported by Dequeker and Rico in 1992. The painting was made during the mid 15 th to late 16 th centuries. In the painting, the beggar's right hand showed ulnar deviations, wrist dislocation, and finger contractures, which closely resemble the hand condition of a patient with rheumatoid arthritis.

However, any conclusion drawn from paintings should be carefully considered since artwork are not usually regarded as scientific evidence.

The history of osteoarthritis - Episode 5

17th and 18th centuries: at the dawn of modern medicine

While the scholars of the Renaissance, despite their innovations, kept one foot in Antiquity those of these two centuries seem entirely focused on new ideas.
Descartes in France, but also Francis Bacon in England suggested a rationalism free from the religious dogma of the time as a means of advancing science.

Here we are at the beginning of a scientific approach that would lead to significant advances in the fields of physiology, the study of body tissues and the discovery of bacteria. Therapeutics follow in a rather timid way with the exception of the remarkable event of the first vaccination. One still had to wait to dispose of effective treatments against osteoarthritis, but medicine and surgery were getting organised, progress was set in motion and it was never to stop.

  • Cartesian thought and the origins of the scientific revolution
  • A new idea: medical studies attested by a diploma
  • Was osteoarthritis less common than today?
  • First description of Heberden's nodes
  • From the reign of Henry IV to the First Empire, medicine was still powerless against osteoarthritis
  • The Lame Devil was a believer in thermal cures

It was in his Discourse on the Method of Rightly Conducting One's Reason and of Seeking Truth in the Sciences that
René Descartes (1596-1650) laid the foundations of rationalism.

His "method" was based on four fundamental principles

  • "The first of these was to accept nothing as true which I did not clearly recognise to be so: that is to say, carefully to avoid precipitation and prejudice in judgements and to accept in them nothing more than what was presented to my mind so clearly and distinctly that I could have no occasion to doubt it.
  • The second was to divide up each of the difficulties which I examined into as many parts as possible, and as seemed requisite in order that it might be resolved in the best manner possible.
  • The third was to carry on my reflections in due order, commencing with objects that were the most simple and easy to understand, in order to rise little by little, or by degrees, to knowledge of the most complex, assuming an order, even if a fictitious one, among those which do not follow a natural sequence relatively to one another.
  • The last was in all cases to make enumerations so complete and reviews so general that I should be certain of having omitted nothing."

By proposing a logical and almost mathematical sequence of ideas from indisputable evidence, Descartes broke definitively with scholastic thought and inaugurated the reign of scientific thought.
He contributed himself to the advancement of science by inventing analytic geometry and discovering the law of optical refraction. Defender of modern ideas, he was to become a firm believer in the theory of blood circulation proposed by the Englishman Harvey. His biological theories, however, show that his method could still be improved: he has the soul residing in the pineal gland by which it communicates with the body, which now seems strange. However, one can find a distant echo of the thought of Descartes in the concept currently in vogue, particularly in rheumatology, of "evidence-based medicine."

(1) Doctrine according to the dogmas of the Church, incorporating the philosophy of Aristotle in the twelfth century, taught in universities until the 17th century. Scholastic knowledge was based only on knowledge of the texts.

A new idea: medical studies attested by a diploma

In 1794, a decree of the National Convention ordered the establishment of three Schools of Health in Paris, Bordeaux and Montpellier. However, it was under the Consulate that the degree of Doctor of Medicine obtained in one of these schools became necessary for exercising medicine. The cardiologist Jean-Nicolas Corvisart was behind this reform.

The recognition of surgery

The Royal Academy of Surgery was founded in 1731. Physicians and Surgeons would subsequently study in the same Schools of Medicine where they would obtain the title of Doctor.

The creation of major hospitals

Henri IV had the Hospital of St. Louis constructed Louis XIV decided that each major city should have its hospital. Originally intended for the accommodation of the poor, hospitals were quickly to become a place of medical education at the patients' bedside. Some hospital doctors specialised, such as Philippe Pinel (1745-1826), psychiatrist (then called alienist) known to have been the first to order that the mentally ill were no longer put in chains. Pinel exercised his talents at the Salpetriere hospice and prison for women which did not become a hospital until the early 19th century.

Was osteoarthritis less common than today?

The study of skeletons exhumed from the crypt of Christ Church, located in East London and used from 1729 to 1869 showed that men suffered more from osteoarthritis than women (2). The most common sites of osteoarthritis lesions were the shoulder, spine and hands. By contrast, osteoarthritis of large joints was uncommon, affecting 1.1% of men and 2.9% of women in the hips, 0.8% of men and 5.2% of women in the knees. The incidence of osteoarthritis is more common in the population currently living in the same area of London.

In all likelihood, these figures reflect both the difficulty of manual labour at the time (laundry washing could be responsible for affecting the knees in women) and, as in previous eras, a reduced life expectancy lowering apparent frequency of this disease which is, in part, due to ageing.

(2): Waldron HA. Prevalence and distribution of osteoarthritis in a population from Georgian and early Victorian London. Ann Rheum Dis 1991 50 : 301-307.

The first description of Heberden's nodes.

The 17th and 18th centuries abound in descriptions of signs and symptoms of disease and it was in his Commentaries on the History and Cure of Diseases that William Heberden (1710-1801) described the digitorum nodi, signs of osteoarthritis now known as Heberden's nodes:

"What are these little hard nodules, with roughly the size of a pea, frequently observed on the fingers, especially just below the tip, near the joint? They have nothing to do with gout . "

Heberden was thus the first to distinguish "his" famous nodes, affecting the distal interphalangeal joints, other rheumatic lesions of the fingers and gouty tophi.

From the reign of Henry IV to the First Empire, medicine was still powerless against osteoarthritis

Description of the circulation of blood by William Harvey in 1628, then the lymphatic circulation by Jean Pequet, first histological descriptions (study of body tissues) by the inventor of the microscope Anthony Van Leeuvenhoek and then by Marcello Malpighi and Xavier Bichat. The list of new knowledge acquired during these two centuries in the area of human physiology is truly impressive. Remember that Van Leeuvenhoek, once again, identified bacteria in 1683 after having discovered sperm in 1677.

These discoveries were sometimes difficult to impose when they were published. We know that Descartes was one of the protagonists of Harvey's theory of the circulatory system which was very rational and in which he no doubt recognised an application of his own "method". He had to differ on this point with two "anti-circulatory system" doctors, Riolan Jean and Guy Patin, for whom the arteries contained air and not blood. It can be assumed that the discussions were especially lively since it took the intervention of Louis XIV for the theory of the circulatory system to be imposed in France for good!

It was in the guise of Dr. Diafoirus, a professed anti-circulatory system doctor that Drs Riolan and Patin, but perhaps all of their colleagues as well, were ridiculed by Molière. If one believes the retorts of the Imaginary Invalid, the therapists of the time knew only three remedies: purges, bloodletting and enemas. As for the doctors described by Voltaire, they seriously wonder whether bleeding should be done on the healthy side or the diseased side.

These authors produced good caricatures of the medicine of the time. However, it is true that despite the striking evolution in physiological knowledge, advances in treatment were few and far between.

The reality is somewhat more nuanced, but it must be said that the lack of progress in treatment contrasts with the striking evolution in physiological knowledge.

Two notable exceptions are the use of digitalis (from which digitalin would be drawn later on) for certain heart conditions and, above all, the development in 1796 by Edward Jenner of the first vaccination successfully used against smallpox. One also notes the appearance of some new drugs (quinine for fever, ipecac used as an anti-diarrhoeal drug and tea and coffee used as psychostimulants).
All this did not do much for patients with osteoarthritis who, to ease their pain, only had recourse to the old (and ancient) concoction of willow bark, and for the wealthy, thermal cures. Unless they had recourse to homeopathy, the first "alternative" medicine (synonym of non-Cartesian?) proposed in 1796 by Christian Samuel Hahnemann. Visceral surgery had advanced (the first appendectomy was performed in 1763) but we are not yet in the era of the hip or knee prosthesis.

Edward Jenner

The Lame Devil was a believer in thermal cures

Prince Charles-Maurice de Talleyrand-Périgord (1754-1838), an exceptional diplomat and opportunistic enough to serve all regimes from the beginning of the Revolution to the Restoration, was affected by a consecutive club foot. Some dispute this version and now lean more towards a congenital club foot. The fact remains that the Lame Devil, who wore an orthopaedic shoe, took the waters at Bourbon l'Archambault for 30 consecutive years. No doubt he sought to relieve osteoarthritis of mechanical origin?

Osteoarthritis Case Study

Osteoarthritis is a leading cause of disability in older adults in the United States. 1-3 Approximately 33% of American adults report some kind of arthritis or chronic joint symptoms. 3 The incidence increases with age and is higher in women than in men. 3

More than 5 million adults report having osteoarthritis in a knee joint, with pain, swelling, and stiffness, and >75% of these people are women. 4-7 In 1999, osteoarthritis of the knee accounted for nearly 4 million physician office visits, > 150,000 hospital outpatient visits, and >400,000 hospital inpatient stays. 4 Approximately half of the inpatient stays were for primary total knee replacement surgery. 4

Osteoarthritis of the knee has a tremendous impact on a person’s ability to function and to perform everyday activities. Between 25% and 50% of people with osteoarthritis of the knee experience — at best — significant difficulty with walking, carrying items, or stooping, while 20% either cannot perform or have difficulty performing chores around the house. 4 This disease takes a severe emotional toll on its victims, as well. People with osteoarthritis of the knee report higher degrees of emotional distress than those without it, and many consider themselves as having poor or fair health. 4 Patients with osteoarthritis lose more work than their healthy colleagues and spend more time confined to bed. 4

Patients can now be treated with an array of nonpharmacologic, pharmacologic, and surgical interventions. The following report summarizes a case presented at a sports medicine clinic in New York, illustrating the importance of individualizing treatment based on the age of the patient, the level of symptoms, risk factors and comorbidities, and impact on quality of life.

Case Presentation

Mrs Jones (not her real name), 55 years old, came to a musculoskeletal specialist seeking advice for a 3-year history of progressively worsening pain in both knees. Her knees were stiff for about 20 minutes when she arose in the morning and for a few minutes after getting up from a chair during the day. She had difficulty walking > 30 minutes because of pain, and her symptoms were exacerbated by kneeling, squatting, or descending stairs. Although sitting, resting, and reclining relieved her pain, she became stiff if she stayed in one position for too long. Her symptoms were worse on humid or cold days, and she occasionally felt as if one of her knees would “give out.”

Mrs Jones was slightly obese, and physical examination of the lower extremities revealed mild genu varum, which suggested medial compartment involvement. Her gait was mildly antalgic, and passive range of motion of both knees indicated palpable crepitus. She was unable to flex or extend her knees completely. While a physically active osteoarthritis patient commonly has a maximum flexion 8,9 Data have shown that a 12-lb weight loss can decrease the chance of developing osteoarthritis in women by 50%. In addition, Mrs Jones was cautioned to avoid high-impact activities like running and jumping, and encouraged to take up low-impact activities such as swimming and bicycling, which have been proven most beneficial for the arthritic knee.

Because she had significant patello-femoral disease, she was counseled to avoid activities that load the patellofemoral joint, such as squatting and ascending and descending stairs. The importance of maintaining a regular exercise program to maximize aerobic conditioning and increase caloric expenditure was stressed. It has been demonstrated that supervised walking programs increase functional status without increasing symptoms. 10

Physical therapy. A program of physical therapy was recommended, with the goal of increasing ROM and flexibility, especially in the hamstrings. Muscle strength training for both quadriceps and hamstrings was suggested, as was proprioceptive retraining. The importance of stretching all major muscle groups that cross the joint to maintain range of motion was stressed. Tight hamstrings in particular can exacerbate knee pain, and Mrs Jones showed evidence of this. She was advised to strengthen her quadriceps, as weak quadriceps correlate with pain severity in osteoarthritis, 11 and there is evidence that quadricep strengthening improves functioning and knee pain. 12-14

Quadricep sets and isometric strengthening exercise, such as straight-leg raises, were recommended as an initial program. She was advised that, as her strength improved, she should try closed-kinetic-chain strengthening of both quadriceps and hamstrings. This exercise leads to the co-contraction of the hamstrings and quadricep muscles, which results in decreases in patellofemoral joint forces, anterior cruciate ligament strain, and tibial translation. Proprioceptive retraining was prescribed as well, as this can decrease joint stress, and Mrs Jones was encouraged to use a knee sleeve during physical therapy to help her regain a sense of stability. Patellar taping was recommended as well, as this may reduce patellar facet impact on the femoral condyle.

Although Mrs Jones had been active several years prior to her visit to our clinic, her symptoms had increased in both intensity and frequency in recent years, which limited her activity. Therefore, she was advised to implement this exercise program gradually, as increasing the intensity of the program too quickly can exacerbate symptoms in osteoarthritis patients.

Bracing. A knee unloader brace was prescribed to relieve some of Mrs Jones’s symptoms. Knee bracing has been found to provide significant pain relief. 15,16 In a trial of 20 patients with severe medial osteoarthritis of the knee, 19 experienced significant pain relief, and quadriceps muscle strength increased in 17 patients, declined in 2, and remained the same in 1. 15

Another trial, in which 119 patients with varus gonarthrosis were randomized to an unloader brace, a neoprene sleeve, or standard medical treatment (control group), found that patients benefited significantly from the use of a knee brace in addition to standard medical treatment. 16 At the 6-month evaluation, patients assigned to the unloader brace group had significantly less pain than those in the neoprene-sleeve group after both the 6-minute walking test and the 30-second stair-climbing test, although both the neoprene sleeve and the unloader brace were associated with significant improvement in quality of life and function compared with the control group. 16

Occupational therapy. Although Mrs Jones was retired, she enjoyed a number of recreational activities, and her osteoarthritis symptoms were interfering with her ability to participate in them. She attended occupational therapy for training in activities of daily life. Such training can help patients by providing an individual functional assessment and joint protective strategies to be used during activities of daily life. 17 Energy conservation and joint protection principles and stress management techniques are taught so that fatigue can be minimized and pain and stress on joints reduced, with the goal of increasing performance of activities of daily life and preventing loss of function. 17

The use of adaptive equipment and alternative methods may enable patients to carry out daily tasks. For instance, simple placement of grab rails by the bathtub and raising the toilet seat may dramatically improve the home environment for patients with osteoarthritis and promote independent functioning, allowing patients to take care of their personal hygiene. 17 A raised toilet seat decreases the required range of motion and force placed on the hip and knee joints. 17 The use of ice or heat before exercise may alleviate pain and thus encourage activity. 17

Treatment: Pharmacologic Therapy
Mrs Jones was started on 325 mg of acetaminophen three times a day, but it did not alleviate her pain. Six weeks later, she was switched to 500 mg of naproxen twice a day, which improved her symptoms by about 50%. Tramadol, one to two 50-mg tablets every 6 hours as needed, was prescribed for breakthrough pain, and a proton pump inhibitor was added to the regimen to prevent gastric discomfort. Mrs Jones’s symptoms also improved with physiotherapy.

However, over the next several years her symptoms worsened, and she was given a narcotic to take for episodes of severe pain. After experiencing a severe effusion to her right knee with an inflammatory component, Mrs Jones opted to have intra-articular steroid injections. She received 3 injections spaced about 3 months apart and, each time, this provided about 3 months of relief. However, when the pain returned following the third injection, she elected to have hyaluronic acid G-F 20 injections. The first treatment was given in a series of 3 injections. Viscosupplementation with hyaluronic acid provided 18 months of relief, and the patient opted to repeat the hyaluronic acid injections when the symptoms returned.


Mrs Jones responded well to the management program. She lost 15 lb initially and managed to maintain her new weight. The prescribed exercise program proved successful, and she gained strength in her quadriceps as well as functional ROM, while her overall pain decreased. Mrs Jones initially responded to the nonsteroidal anti-inflammatory drugs (NSAIDs). However, because of the side effects including peptic ulcer associated with these agents, we recommend that patients be prescribed the lowest effective dose, take the drug with food, and use it for the shortest time possible. We usually start a patient on an over-the-counter agent, such as ibuprofen. Selective COX-2 inhibitors should be used only in patients with renal or gastrointestinal risk factors.

As Mrs Jones’s condition deteriorated, painkillers were no longer enough to control her symptoms, and we used an intra-articular corticosteroid injection. We find this helpful for patients who no longer respond to NSAIDs and in those for whom NSAIDs are contraindicated. We do not usually aspirate the knee unless there is a tense effusion present. If aspiration is necessary, however, then the fluid is sent for the appropriate studies. If there are no signs of hemarthrosis or infection, the knee joint can be injected with corticosteroid. In patients without an effusion, a cortisone injection may be indicated if there are signs of inflammation such as synovial thickening, nocturnal or diffuse pain, or pain that is felt when the patient is at rest. Localized knee pain that is felt only with weight bearing is less likely to respond to cortisone injection. The solution — 1% lidocaine (3 mL) and triamcinolone (40 mg), or betamethasone sodium phosphate (6 mg) — is injected into the anterolateral soft spot under sterile conditions.

We have found the duration of the effects of this injection to be variable, lasting from a few days to >6 months. In Mrs Jones’s case, the effects lasted 3 months. As the injections are less effective with each successive course, we limit corticosteroid injections to 3 or 4 treatments a year. After the initial injection, we considered viscosupplementation in this patient.

Although surgical interventions including a tibial osteotomy and a total knee replacement were discussed when Mrs Jones’s condition worsened, the patient elected to pursue the more conservative course with viscosupplementation. Viscosupplementation may postpone the need for surgical intervention, and studies have suggested that it may delay structural progression of the disease. Injections provide relief for 6 months to 1 year and can be repeated every 4 to 6 months.

Mrs Jones is still receiving conservative care and is doing well. She is able to participate in recreational activities and continues with a strengthening program. The conservative interventions have allowed her to go back to her hobbies, including gardening, golfing, and shopping, with minimal side effects. She continues to take tramadol intermittently for breakthrough pain, but she takes an NSAID along with a proton pump inhibitor only for flareups. Her use of pain medication, including both opioids and NSAIDs, has decreased significantly since she received viscosupplementation.

Conservative management. This patient’s case illustrates how a conservative management strategy can help maintain patient functioning and quality of life while minimizing side effects and avoiding major surgical trauma to the patient.

Tibial osteotomy is an option for patients such as Mrs Jones, who have varus angulation 4 However, after discussing this intervention with the musculoskeletal specialist, Mrs Jones decided not to pursue it. With surgery there is always some risk of infection or complication from anesthesia, as well as risk of blood clots, nerve damage, or circulatory problems. 4 Furthermore, it is highly probable that a total knee replacement would be needed at some time in the future, as long-term follow-up of patients treated in this manner indicates that clinical results deteriorate over time. 4 Previous tibial osteotomy makes knee replacement more technically challenging. 4

Although surgical procedures remain an option for this patient should the situation deteriorate, by postponing or avoiding surgery in a relatively young patient such as Mrs Jones, the need for multiple knee replacements may be averted. The lifespan of a total knee replacement is not known, but it is believed that as the surgery is performed in younger people, an increasing number of these patients may live long enough to see the failure of their knee prostheses. 4 Performing such surgery in middle-aged patients increases the likelihood that it will have to be repeated, with all the costs and risks inherent to major surgery.

Mrs Jones’s response to viscosupplementation was excellent. She achieved 18 months of relief from her symptoms and was able to reduce the use of both NSAIDs and breakthrough medication by about 75% during this time. She still takes it, but intermittently.

Although the medical community generally considers NSAIDs safe, more than 16,500 Americans die and 103,000 are hospitalized each year as the result of anti-inflammatory drug use. 18 In contrast, use of viscosupplementation is associated with a low incidence of local adverse events, which consist of local inflammation and effusion. 19 Adverse events typically occur within 48 hours of injection and rarely after the first injection of a first course of therapy, and usually resolve spontaneously or respond well to conservative symptomatic treatment. 19,20

To avoid such reactions, patients are told to rest and apply an ice pack for 2 to 3 hours after the injection and avoid strenuous activities until after the course of therapy is completed. 19 Mrs Jones was instructed to apply the ice pack and avoid strenuous activity and did not experience any injection reaction during either of her treatment courses.

Although a first course of viscosupplementation provides relief from pain for up to 6 months in patients with osteoarthritis, a second course also has been shown to reduce pain significantly and improve physical functioning for up to 6 months. 20 Mrs Jones’s experience with viscosupplementation is similar to that found in a recent clinical trial in 71 patients, where the mean interval between first- and second-course treatments was >18 months. 20 Other studies have shown that deterioration in structural parameters is less in the group using viscosupplementation than in control groups. 21


The pain and disability associated with osteoarthritis have a serious impact on the lives of patients, yet conservative treatment in many patients can reduce pain, improve performance, and forestall invasive surgical procedures. A management strategy combining nonpharmacologic treatments such as strength training, appropriate exercise, weight loss, orthotics, and physical therapy with pain medication can be successful in many patients.

When disease progression demands more aggressive treatment, the use of techniques such as viscosupplementation may obviate surgical procedures and achieve good clinical results, allowing patients to return to their everyday activities and more productive lives. It is essential, however, to determine treatment strategies based on individual patient characteristics such as age, comorbidities, symptoms, and risk factors for other diseases. In this way, we can maximize our patients’ quality of life while ensuring that they receive the best possible care.

Diagnosis of Osteoarthritis

The most common presenting symptom in persons with knee osteoarthritis is pain that is worse with use and better with rest. Other presenting signs and symptoms include stiffness that generally improves after 30 minutes of activity (inactivity gelling), crepitus, swelling, and limp. In advanced cases, patients may present with instability symptoms or genu valgum (knock knee) or varum (bow-leg). Varus deformity is more common than valgus deformity because the medial compartment of the knee is more often involved.

The differential diagnosis of chronic knee pain is given in Table 2 . The criteria for diagnosing knee osteoarthritis are based on the presence of knee pain plus at least three of the six clinical characteristics listed in Table 3 .5 , 6 The addition of laboratory and radiographic criteria enchances the diagnostic accuracy however, these tests are not necessary for all patients. In most patients, the history, physical examination, and radiography are all that is needed.

Differential Diagnosis of Knee Pain

Conditions involving soft tissue of knee

Ligamentous instability (medial and lateral collateral ligaments)

Patellofemoral pain syndrome

Differential Diagnosis of Knee Pain

Conditions involving soft tissue of knee

Ligamentous instability (medial and lateral collateral ligaments)

Patellofemoral pain syndrome

Diagnosis of Knee Osteoarthritis

Stiffness for less than 30 minutes

Erythrocyte sedimentation rate less than 40 mm per hour

Rheumatoid factor less than 1:40

Synovial fluid analysis: clear, viscous, white blood cell count less than 2,000 per μL (2.00 × 10 9 per L)

Knee pain plus at least three clinical criteria

Knee pain plus at least five clinical or laboratory criteria

Knee pain plus at least five clinical or laboratory criteria, plus osteophytes present

LR+ = positive likelihood ratio LR– = negative likelihood ratio .

Information from references 5 and 6.

Diagnosis of Knee Osteoarthritis

Stiffness for less than 30 minutes

Erythrocyte sedimentation rate less than 40 mm per hour

Rheumatoid factor less than 1:40

Synovial fluid analysis: clear, viscous, white blood cell count less than 2,000 per μL (2.00 × 10 9 per L)

Knee pain plus at least three clinical criteria

Knee pain plus at least five clinical or laboratory criteria

Knee pain plus at least five clinical or laboratory criteria, plus osteophytes present

LR+ = positive likelihood ratio LR– = negative likelihood ratio .

Information from references 5 and 6.


Pain in and around the joint may be caused by bursitis – inflammation of a small sac that cushions bones and tendons.

Bursitis is inflammation of a bursa, a small fluid-filled sac that acts as a cushion between bone and muscle, skin or tendon. The type of bursitis depends on where the affected bursa is located. This soft tissue condition commonly affects the shoulder, elbow, hip, buttocks, knees and calf. Athletes, the elderly and people who do repetitive movements like manual laborers and musicians are more likely to get bursitis.

Bursitis is sometimes mistaken for arthritis because the pain occurs near a joint.

Bursitis causes swelling, tenderness and pain in areas around a joint. It will be painful to move the affected joint through its full range of motion. The pain of bursitis can occur suddenly, may last for days or longer and usually gets better with rest or treatment. Bursitis can also happen in the same area more than once.

Bursitis often results from sport injuries or repetitive movements. But it can also be caused by:

  • A bruise or cut getting infected.
  • Bad posture or walking habits.
  • Stress on soft tissues from an abnormal or poorly positioned joint or bone (such as leg length differences or joint deformities).
  • Some types of arthritis and related conditions (rheumatoid arthritis, osteoarthritis or gout.)
  • Metabolic conditions such as diabetes.

Diagnosis is based on review of symptoms, medical history and a physical exam. Persistent redness or swelling around a joint, along with fever or chills, should be evaluated immediately. These symptoms can be caused by an infection.

Bursitis may go away over time with self-care. If it doesn't, a primary care doctor will focus on reducing pain and inflammation and preserving mobility. The doctor may refer you to a rheumatologist, an orthopedic surgeon or a physical therapist for specialized treatment. When properly treated, bursitis doesn't result in permanent joint damage or disability.

Common bursitis treatment options include:

Splints and Braces
Many soft tissue conditions are caused by muscle overuse, so the first treatment may include resting the painful area or avoiding a particular activity for a while. Splints, braces or slings provide added support to the affected area until the pain eases.

The doctor may recommend a pain reliever, such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen. You may begin using over-the-counter (OTC) versions. If the pain is severe or the OTC version doesn&rsquot help, the doctor may prescribe a stronger version. If necessary, an anti-inflammatory drug called a corticosteroid may be injected into the bursa. Learn more about the medications used to treat bursitis at the arthritis drug guide.

Physical Therapy
A physical therapist can provide the following:

  • Hot/cold treatments, ultrasound, laser and water therapy
  • Soft tissue manual therapy
  • Orthotics or pressure-relieving devices for the arms and legs
  • A personalized exercise program
  • Analysis of posture and walking
  • Education on ways to avoid overuse injuries

Occupational Therapy
An occupational therapist can different ways to do daily activities and work habits to prevent stress or injury to an affected area. The therapist can also create hand and wrist splints and suggest assistive devices to help make your daily activities easier.

Surgery may be required if symptoms don&rsquot improve between six months and a year.

The best way to prevent or reduce the pain and swelling of bursitis is to:


Arthritis can be distracting. Distressing. And disheartening. It can make you hesitant. It can frustrate &mdash and even prevent &mdash you from doing all the things you love to do. It is, quite literally, a pain. There are more than 100 different types of arthritis. The most common are osteoarthritis and rheumatoid arthritis.

The good news is that you can live &mdash and live well &mdash with arthritis. You can get relief from its pain and its consequences. One of the best and effective ways to combat arthritis pain is simple: exercise. Regular exercise not only helps maintain joint function, but also relieves stiffness and decreases pain and fatigue. Other ways to ease arthritis pain include medications, physical therapy, joint replacement surgery, and some alternative or complementary procedures.

Osteoarthritis is the most common type of arthritis. It starts with the deterioration of cartilage, the flexible tissue lining joints. The space between bones gradually narrows and the bone surfaces change shape. Over time, this leads to joint damage and pain. The symptoms of osteoarthritis usually develop over many years. The first sign is often joint pain after strenuous activity or overusing a joint. Joints may be stiff in the morning, but loosen up after a few minutes of movement. Or the joint may be mildly tender, and movement may cause a crackling or grating sensation.

Osteoarthritis was long considered a natural consequence of aging, the result of gradual wearing down of cartilage. The cause of osteoarthritis is much more complex than simple wear and tear. External factors, such as injuries, can initiate chronic cartilage breakdown. Inactivity and excess weight can also trigger the problem or make it worse. Genetic factors can affect how quickly it gets worse.

There is currently no cure for osteoarthritis. But there are effective treatments that can greatly improve a person's quality of life by relieving pain, protecting joints, and increasing range of motion in the affected joint. Therapy usually involves a combination of nondrug treatments such as heat, ice, and exercise medication for pain and inflammation and the use of assistive devices such as canes or walkers. In some cases, more aggressive treatment with surgery or joint replacement may be needed.