Start with a free account for 3 free CME credits. Already a subscriber? Sign in.

Knee Osteoarthritis (OA)

Andrew Buelt, DO and Jake Anderson, MD
00:00
18:54

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Jake and Andrew break down the data for us on knee OA treatments. Lo and behold, there is not a lot of evidence!

Pearls:

  • Knee osteoarthritis is extremely common and is a clinical diagnosis.

  • Weight loss, exercise therapy (land-based may be better than aquatic), NSAIDs are first-line treatment. Topical NSAIDs may be just as effective with fewer side effects.

  • Bracing/taping/wedge inserts have limited efficacy data.

  • Steroid injections while common actually have little data demonstrating effectiveness and may lead to increased knee cartilage loss.

 

  • Why is knee OA important? Affects one-fifth of the US population and is one of the most common causes of pain and disability.

    • Knee OA is the most prevalent form of OA in women (13%) and men (10%) over 60.

  • Presentation: knee pain that worsens with prolonged activity, crepitus on exam.

  • Diagnosis: clinical

    • Combination of age > 50, presence of bony enlargement, crepitus and no palpable warmth is 92% sensitive and 75% specific for knee OA with a positive likelihood ratio of 3.7.

    • If you’re concerned about inflammatory or infectious process consider X-ray, aspiration and lab testing.

      • X-rays really aren’t necessary if the story fits. But you will see joint space narrowing, bony spurs, subchondral sclerosis/thickening.

      • You can also aspirate the knee if you palpate an effusion and want to send for inflammatory or infectious arthritis work-up.

      • If just OA, the aspirate will reveal a clear synovial fluid with a white blood cell count less than 2000 per uL, an ESR <40 and rheumatoid factor less than 1:40.

  • Treatment:

    • Weight loss for BMI > 25 through calorie restriction and exercise.

    • Exercise therapy: no recommended strategy other than self-management programs that include strengthening, low impact aerobic exercise and neuromuscular education.

      • Cochrane review in 2015 of 54 randomized clinical trials showed some benefit in pain and function with land-based exercises as opposed to aquatic exercise.

      • Cochrane review in 2016 of 13 aquatic therapy vs control in randomized control trials did find improvement in pain, disability and quality of life but did disappear after 4-24 weeks post-intervention.

    • Bracing/wedge inserts/taping: limited evidence of effectiveness.

    • Acetaminophen: number needed to treat between 4 and 16 but this is based on Cochrane review from 2006 that showed those taking properly dosed (1000mg, 4 times a day) improved 4 points on a 100 point scale.

      • American College of Rheumatology still recommends as initial management but American College of Orthopedic Surgeons no longer recommends for or against it.

    • NSAIDs:

      • There doesn’t seem to be a superior NSAID.

      • Be careful in older patients, those with a history of GI bleed and definitely stay away if they have Stage 4 or 5 kidney disease.

      • Topical NSAIDs may be just as effective as oral agents with less GI side effects.

      • Check out the July 2017 PCRAP Paper Chase for more details on topical NSAIDs.

    • Tramadol:

      • Cochrane review of 10 randomized trials showed only small benefit (8 points on 100 point scale).

      • Cepeda MS et. al. Tramadol for osteoarthritis. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005522. Review. PMID: 16856101.

    • Opioids:

      • Minimal benefit (0.7 on a 10-point scale) with high risk potential.

      • da Costa BR et. al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2014 Sep 17;(9):CD003115. PMID: 25229835.

    • Chondroitin sulfate:

      • Data is mixed - Cochrane review in 2015 looked at 800mg per day v. placebo and found pain reduction at less than 6 months, 10 points on a 100 point scale and number needed to treat of 5.

        • Singh JA et. al. Chondroitin for osteoarthritis. Cochrane Database Syst Rev. 2015 Jan 28;1:CD005614. PMID: 25629804.

        • American Academy of Orthopedic Surgeons recommends against using glucosamine for treatment of knee OA.

    • Duloxetine: three studies have shown improvement in pain with number needed to treat of 5 for 50% pain improvement. Data for widespread use is not available.

    • Steroid injections: Have been used since the 1950’s but the data is limited.

      • American Academy of Orthopedic Surgeons is unable to recommend for or against it because of the lack of data, which is a change from 2008 when they recommended it.

      • Cochrane review in 2015 of 27 randomized control trials that had over 7500 patients was unable to draw conclusions due to the small size of the heterogeneous trials.

        • Jüni P et. al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015 Oct 22;(10):CD005328. PMID: 26490760.

      • Study from October 2017 in Journal American Academy of Orthopedic Surgery is the most recent data.

        • 100 patients with mean age of 61, BMI of 31. They all received injections of about 10mg triamcinolone with 4ml of 1% lidocaine without epinephrine. There was no comparison group.

        • They did find improvement in pain scores.

        • Matzkin EG et. al. Efficacy and Treatment Response of Intra-articular Corticosteroid Injections in Patients With Symptomatic Knee Osteoarthritis. J Am Acad Orthop Surg. 2017 Oct;25(10):703-714. PMID: 28953085.

      • Double-blind RCT in May 2017 compared steroid injection with saline injection.

        • 140 adults, 45 years or older with knee OA, were randomly assigned to group (steroid or saline) every 3 months for 2 years.

        • Pain and functional scores were no different.

        • There was cartilage damage on the MRI for those receiving steroids.

Hyaluronic acid injection: largely mixed results and is very expensive.

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.
The Tragically Sore Hip Full episode audio for MD edition 196:52 min - 92 MB - M4AHippo Primary Care RAP - February 2018 Written Summary 339 KB - PDF

To earn CME for this chapter, you need to subscribe.

Sign up today for full access to all episodes and earn CME.

0.25 Free AMA PRA Category 1 Credits™ certified by Hippo Education or 0.25 Free prescribed credits by the American Academy of Family Physicians

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate

3.25 AMA PRA Category 1 Credits™ certified by Hippo Education or 3.25 prescribed credits by the American Academy of Family Physicians

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate