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Musculoskeletal Health Concerns of the Aging Population
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.
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Musculoskeletal Health Concerns of the Aging Population
- 1. Aches and Pains: TheHealth Concerns of the Aging Population Allan D. Corpuz Fellow, section of Rheumatology
- 2. All over theworld, We have an aging population h"p://rt.com/business/aging-‐popula6on-‐elderly-‐double-‐2050-‐904/
- 3. Better health carehas resulted in better survival At what cost?
- 4. AGE-RELATED health PROBLEMS AREON THE RISE
- 5. overview • Low BackPain • Osteoarthritis • Soft Tissue Rheumatisms
- 6.
- 7. Epidemiology • 65-80%: duringentire 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 andfunction 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
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- 12. HISTORY AND PHYSICALEXAMINATION CLINICAL EVALUATION
- 13. HISTORY • Identify thosewith 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.
- 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)
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- 18. PHYSICAL EXAMINATION • Litigation orwith 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.
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- 20. IMAGING Imaging is NOTrequired 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 associationbetween 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.
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- 24. IMAGING: MRI • Bestinitial 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
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- 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
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- 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.
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- 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
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- 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
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- 40. Diagnosis • SCIATICA secondaryto 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 spineis 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 herniationis 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 historyis 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, storeowner • Chronic aching low back pain • Duration: 8 years • Occasionally relieved by Paracetamol, Mefenamic Acid, rest • Normal PE
- 46.
- 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
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- 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, previouslydiagnosed 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
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- 54. Diagnosis • CAUDA EQUINASyndrome 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 radiographsless 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
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- 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
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- 64. ACUTE (Less than3 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 than3 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 than3 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) – Injectiontherapy – 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 – Vertebroplastyand Kyphoplasty
- 69. ACUTE to SUBACUTE – Vertebroplastyvs Kyphoplasty
- 70. CHRONIC (More than 3mos) – 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 3mos) – 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 3mos) – 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 3mos) – 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 3mos) – 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
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- 76. NERVE ROOT COMPRESSIONSYNDROMES 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 historyof 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 isalso 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 andPE are more important than Imaging • Prognosis of acute LBP is excellent • Prognosis of chronic LBP is unsatisfactory • Surgery is reserved for neurologic deficits
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- 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 ClinicalCriteria " 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
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- 88. ACR Radiologic and ClinicalCriteria " 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 ClinicalCriteria " 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 ClinicalCriteria " 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 SecondaryOA 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 SecondaryOA 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 SecondaryOA 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-
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- 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
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- 98. Knee • Insidious onsetof 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: medialor 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
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- 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 ofthe 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 aremore 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 • 1stMTP: 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 • GeneralizedOA: 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
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- 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
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- 116. Hip: Frog LegView
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- 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
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- 123. SHOULDER • Subacromial bursitis • Bicipital Tendinitis • Rotator Cuff Tendinitis
- 124. HAND • DeQuervain’s Tenosynovitis • Carpal Tunnel Syndrome • Trigger Finger
- 125.
- 126. Foot and ANKLE • Plantar fasciitis
- 127. SUMMARY • Aging hascaused 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 foryour attention www.allancorpuzmd.com