Osteoarthritis: Difference between revisions

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'''Osteoarthritis''' is the most common form of [[arthritis]]. It is "a progressive, degenerative joint disease, the most common form of arthritis, especially in older persons. The disease is thought to result not from the aging process but from biochemical changes and biomechanical stresses affecting articular cartilage. In the foreign literature it is often called osteoarthrosis deformans."<ref>{{MeSH}}</ref>
==Cause / etiology==
Obesity may contribute to osteoarthritis of the knee.<ref name="pmid22147711">{{cite journal| author=Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT| title=Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. | journal=Ann Intern Med | year= 2011 | volume= 155 | issue= 11 | pages= 725-32 | pmid=22147711 | doi=10.1059/0003-4819-155-11-201112060-00004 | pmc=PMC3408027 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22147711  }} </ref><ref name="pmid10230743">{{cite journal| author=McAlindon TE, Wilson PW, Aliabadi P, Weissman B, Felson DT| title=Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study. | journal=Am J Med | year= 1999 | volume= 106 | issue= 2 | pages= 151-7 | pmid=10230743 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10230743  }} </ref><ref name="pmid9920009">{{cite journal| author=Hart DJ, Doyle DV, Spector TD| title=Incidence and risk factors for radiographic knee osteoarthritis in middle-aged women: the Chingford Study. | journal=Arthritis Rheum | year= 1999 | volume= 42 | issue= 1 | pages= 17-24 | pmid=9920009 | doi=10.1002/1529-0131(199901)42:1<17::AID-ANR2>3.0.CO;2-E | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9920009  }} </ref>
 
Leg-length inequality > 1 cm is associated with osteoarthritis of the knee.<ref name="pmid20194234">{{cite journal| author=Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, Lewis CE et al.| title=Association of leg-length inequality with knee osteoarthritis: a cohort study. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 5 | pages= 287-95 | pmid=20194234 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20194234 | doi=10.1059/0003-4819-152-5-201003020-00006 }} </ref>
 
==Diagnosis==
==Diagnosis==
===Signs and symptoms===
===Signs and symptoms===
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Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.<ref name="pmidpending">Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007). </ref> This is more likely if the [[quadriceps]] muscle is weak.
Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.<ref name="pmidpending">Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007). </ref> This is more likely if the [[quadriceps]] muscle is weak.


A screening survey is positive if any one of the following is answered yes:<ref name="pmidpending">Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).</ref>
A screening survey is positive if any one of the following is answered yes:<ref name="pmidpending2">Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).</ref>
* During the last 4 weeks, have you had knee pain on most days?
* During the last 4 weeks, have you had knee pain on most days?
* During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
* During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
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====Hip osteoarthritis====
====Hip osteoarthritis====
A screening survey is positive if any one of the following is answered yes:<ref name="pmidpending">Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).</ref>
A screening survey is positive if any one of the following is answered yes:<ref name="pmidpending2">Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).</ref>
* During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
* During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
* During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
* During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
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==Treatment==
==Treatment==
===Medications===
Treatment with combined weight loss and exercise is better than either treatment alone.<ref>Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, Beavers
====Acetaminophen====
DP, Hunter DJ, Lyles MF, Eckstein F, Williamson JD, Carr JJ, Guermazi A, Loeser
RF. Effects of intensive diet and exercise on knee joint loads, inflammation, and
clinical outcomes among overweight and obese adults with knee osteoarthritis: the
IDEA randomized clinical trial. JAMA. 2013 Sep 25;310(12):1263-73. doi:
10.1001/jama.2013.277669. PMID: http://pubmed.gov/24065013.</ref>
 
===Analgesic medications===
The [[World Health Organization]] recognizes a "pain ladder" of increasingly potent analgesics to deal with the pain of osteoarthritis. These may be supplemented with adjuvants.
 
The [[Disease-modifying treatment|Disease-Modifying Anti-Rheumatic Drugs (DMARD)]] used in [[rheumatoid arthritis]] and other autoimmune disorders are not indicated in the essentially mechanical wear involved in osteoarthritis.
 
====Analgesics====
=====Acetaminophen=====
A [[randomized controlled trial]] comparing [[acetaminophen]] to [[ibuprofen]] in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.<ref name="pmid2052056">{{cite journal |author=Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI |title=Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=325 |issue=2 |pages=87-91 |year=1991 |pmid=2052056 |doi=}}</ref> However, [[acetaminophen]] at a dose of 4 grams per day can increase [[liver function test]]s.<ref name="pmid16820551">{{cite journal |author=Watkins PB, Kaplowitz N, Slattery JT, ''et al'' |title=Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial |journal=JAMA |volume=296 |issue=1 |pages=87-93 |year=2006 |pmid=16820551 |doi=10.1001/jama.296.1.87}}</ref>
A [[randomized controlled trial]] comparing [[acetaminophen]] to [[ibuprofen]] in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.<ref name="pmid2052056">{{cite journal |author=Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI |title=Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=325 |issue=2 |pages=87-91 |year=1991 |pmid=2052056 |doi=}}</ref> However, [[acetaminophen]] at a dose of 4 grams per day can increase [[liver function test]]s.<ref name="pmid16820551">{{cite journal |author=Watkins PB, Kaplowitz N, Slattery JT, ''et al'' |title=Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial |journal=JAMA |volume=296 |issue=1 |pages=87-93 |year=2006 |pmid=16820551 |doi=10.1001/jama.296.1.87}}</ref>
=====NSAIDs=====
=====Monoclonal antibodies=====
[[Adalimumab]] did not help in a randomized controlled trial.<ref name="pmid24817417">{{cite journal| author=Chevalier X, Ravaud P, Maheu E, Baron G, Rialland A, Vergnaud P et al.| title=Adalimumab in patients with hand osteoarthritis refractory to analgesics and NSAIDs: a randomised, multicentre, double-blind, placebo-controlled trial. | journal=Ann Rheum Dis | year= 2014 | volume=  | issue=  | pages=  | pmid=24817417 | doi=10.1136/annrheumdis-2014-205348 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24817417  }} </ref>
====Opioids====
======Tramadol======


===Supplements===
====Adjuvants for pain medications====
[[Dietary supplement]]s have been studied.


====Chondroitin====
===Dietary supplements===
A [[meta-analysis]] of [[randomized controlled trial]]s found no benefit from [[chondroitin]].<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |doi=}}</ref> This [[meta-analysis]] included the GAIT  [[randomized controlled trial]] of Clegg et al.<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref> A longer followup of the GAIT show no benefit from sodium chondroitin on reduction in loss of joint space width.<ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref>
Various [[dietary supplement]]s and [[complementary and alternative medicine]] approaches may help.<ref name="pmid21169345">{{cite journal| author=De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ, Arthritis Research UK Working Group on Complementary and Alternative Medicines| title=Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review. | journal=Rheumatology (Oxford) | year= 2011 | volume= 50 | issue= 5 | pages= 911-20 | pmid=21169345 | doi=10.1093/rheumatology/keq379 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21169345  }} </ref> There is no benefit from [[glucosamine]] and [[chondroitin]] according to a network [[meta-analysis]].<ref name="pmid20847017">{{cite journal| author=Wandel S, Jüni P, Tendal  B, Nüesch E, Villiger PM, Welton NJ et al.| title=Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. | journal=BMJ | year= 2010 | volume= 341 | issue= | pages= c4675 | pmid=20847017 | pmc=PMC2941572 | doi=10.1136/bmj.c4675 }} </ref>


A more recent trial is positive. A trial sponsored by the manufacturer reports less loss of joint space with [[chondriotin]].<ref name="pmid19180484">{{cite journal |author=Kahan A, Uebelhart D, De Vathaire F, Delmas PD, Reginster JY |title=Long-term effects of chondroitins 4 and 6 sulfate on knee osteoarthritis: The study on osteoarthritis progression prevention, a two-year, randomized, double-blind, placebo-controlled trial |journal=Arthritis Rheum. |volume=60 |issue=2 |pages=524–33 |year=2009 |month=February |pmid=19180484 |doi=10.1002/art.24255 |url=http://dx.doi.org/10.1002/art.24255 |issn=}}</ref>
A combination of [[glucosamine]] and [[chondroitin]] [[dietary supplement]]s may help moderate to severe osteoarthritis according to the GAIT study while neither supplement seems effective alone.<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392 |issn=}}</ref> However, longer follow-up of the GAIT study showed the combination group tended to have the most loss of joint space.<ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref>


{| class="wikitable" align="right"
====Chondroitin====
|+ Selected randomized controlled trials of chondroitin
{{main|chondroitin}}
! rowspan="2"|Trial!! rowspan="2"|Patients!!rowspan="2"|Intervention!!rowspan="2"|Outcome!!colspan="2"|Results
A [[meta-analysis]] of [[randomized controlled trial]]s found no benefit from [[chondroitin]] as monotherapy.<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |url=http://www.annals.org/cgi/content/full/146/8/580|doi=}}</ref>
|-
! Chondroitin!!Placebo
|-
| GAIT<ref name="pmid17438317"/><br/>2007 || 1583 patients|| 1200 mg of chondroitin sulfate daily|| Response of 20% decrease in WOMAC pain score<ref name="pmid3068365">{{cite journal |author=Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW |title=Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee |journal=J. Rheumatol. |volume=15 |issue=12 |pages=1833–40 |year=1988 |month=December |pmid=3068365 |doi= |url= |issn=}}</ref> at 24 weeks|| 65%|| 60%
|-
| GAIT<ref name="pmid18821708"/><br/>2008 || 1583 patients|| 1200 mg of chondroitin sulfate daily|| Loss of joint space width at two years|| 0.107 mm ||  0.166 mm (not significant)
|-
| Kahan<ref name="pmid19180484"/><br/>2009 || 622 patients|| 800 mg of chondroitin sulfate daily|| loss of minimum joint space width|| 0.07 mm|| 0.31 mm
|}


====Glucosamine====
====Glucosamine====
Neither glucosamine sulfate<ref name="pmid18283204">{{cite journal |author=Rozendaal RM, Koes BW, van Osch GJ, ''et al'' |title=Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial |journal=Ann. Intern. Med. |volume=148 |issue=4 |pages=268–77 |year=2008 |month=February |pmid=18283204 |doi= |url= |issn=}}</ref> nor glucosamine hydrochloride<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref><ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref> is effective for osteoarthritis.
{{main|glucosamine}}


A molecule derived from [[glucosamine]] is used by the body to make some of the components of cartilage and synovial fluid. An initial [[randomized controlled trial]] <ref name="pmid11214126">{{cite journal |author=Reginster JY, Deroisy R, Rovati LC, ''et al'' |title=Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial |journal=Lancet |volume=357 |issue=9252 |pages=251–6 |year=2001 |month=January |pmid=11214126 |doi=10.1016/S0140-6736(00)03610-2 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(00)03610-2 |issn=}}</ref> and [[meta-analysis]].<ref name="pmid15855241">{{cite journal |author=Poolsup N, Suthisisang C, Channark P, Kittikulsuth W |title=Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials |journal=The Annals of pharmacotherapy |volume=39 |issue=6 |pages=1080-7 |year=2005 |pmid=15855241 |doi=10.1345/aph.1E576}}</ref> found that supplemental glucosamine may improve symptoms of OA and delay its progression. However, a large study suggests that glucosamine is not effective in treating OA of the knee.<ref name="pmid15501201">{{cite journal |author=McAlindon T, Formica M, LaValley M, Lehmer M, Kabbara K |title=Effectiveness of glucosamine for symptoms of knee osteoarthritis: results from an internet-based randomized double-blind controlled trial |journal=Am. J. Med. |volume=117 |issue=9 |pages=643–9 |year=2004 |pmid=15501201 |doi=10.1016/j.amjmed.2004.06.023}}</ref> A subsequent [[meta-analysis]] that includes this trial concluded that glucosamine hydrochloride is not effective and that the effect of glucosamine sulfate is uncertain.<ref name="pmid17599746">{{cite journal |author=Vlad SC, Lavalley MP, McAlindon TE, Felson DT |title=Glucosamine for pain in osteoarthritis: Why do trial results differ? |journal=Arthritis Rheum |volume=56 |issue=7 |pages=2267-2277 |year=2007 |pmid=17599746 |doi=10.1002/art.22728}}</ref> This meta-analysis was followed by a [[randomized controlled trial]] that found no benefit from glucosamine sulfate.<ref name="pmid18283204">{{cite journal |author=Rozendaal RM, Koes BW, van Osch GJ, ''et al'' |title=Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial |journal=Ann. Intern. Med. |volume=148 |issue=4 |pages=268–77 |year=2008 |month=February |pmid=18283204 |doi= |url= |issn=}}</ref>
A molecule derived from [[glucosamine]] is used by the body to make some of the components of cartilage and synovial fluid.  


A longer followup of the GAIT that studied combined glucosamine hydrochloride and sodium chondroitin suggests a reduction in loss of joint space width.<ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref>
Neither [[glucosamine]] sulfate<ref name="pmid18283204">{{cite journal |author=Rozendaal RM, Koes BW, van Osch GJ, ''et al'' |title=Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial |journal=Ann. Intern. Med. |volume=148 |issue=4 |pages=268–77 |year=2008 |month=February |pmid=18283204 |doi= |url= |issn=}}</ref> nor glucosamine hydrochloride<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392 |issn=}}</ref><ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref> is effective as monotherapy for osteoarthritis.


====S-adenosylmethionine====
====S-adenosylmethionine====
{{main|S-adenosylmethionine}}
{{main|S-adenosylmethionine}}


====Acupuncture====
===Acupuncture===
{{main|Acupuncture}}
{{main|Acupuncture}}
[[Acupuncture]] is probably not effective according to a meta-analysis that concluded "sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation effects."<ref name="pmid17577006">{{cite journal |author=Manheimer E, Linde K, Lao L, Bouter LM, Berman BM |title=Meta-analysis: acupuncture for osteoarthritis of the knee |journal=Ann. Intern. Med. |volume=146 |issue=12 |pages=868–77 |year=2007 |month=June |pmid=17577006 |doi= |url= |issn=}}</ref>
[[Acupuncture]] is probably not effective according to a meta-analysis that concluded "sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation effects."<ref name="pmid17577006">{{cite journal |author=Manheimer E, Linde K, Lao L, Bouter LM, Berman BM |title=Meta-analysis: acupuncture for osteoarthritis of the knee |journal=Ann. Intern. Med. |volume=146 |issue=12 |pages=868–77 |year=2007 |month=June |pmid=17577006 |doi= |url= |issn=}}</ref>


===Injections===
Injections of the [[hip]] joint for labral tears may not be effective.<ref name="pmid18760208">{{cite journal |author=Martin RL, Irrgang JJ, Sekiya JK |title=The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates |journal=Arthroscopy |volume=24 |issue=9 |pages=1013–8 |year=2008 |month=September |pmid=18760208 |doi=10.1016/j.arthro.2008.04.075 |url=http://linkinghub.elsevier.com/retrieve/pii/S0749-8063(08)00358-7 |issn=}}</ref>


===Surgery===
===Arthroscopic surgery and joint lavage===
[[Arthroscopic surgery]] for osteoarthritis of the knee is not effective according among patients with moderate or severe disease to two [[randomized controlled trial]]s. However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded.<ref name="pmid18784099">{{cite journal |author=Kirkley A, Birmingham TB, Litchfield RB, ''et al'' |title=A randomized trial of arthroscopic surgery for osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=359 |issue=11 |pages=1097–107 |year=2008 |month=September |pmid=18784099 |doi=10.1056/NEJMoa0708333 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18784099&promo=ONFLNS19 |issn=}}</ref><ref name="pmid12110735">{{cite journal |author=Moseley JB, O'Malley K, Petersen NJ, ''et al'' |title=A controlled trial of arthroscopic surgery for osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=347 |issue=2 |pages=81–8 |year=2002 |pmid=12110735 |doi=10.1056/NEJMoa013259}}</ref>
Joint lavage, with or without [[corticosteroid]]s, does not help.<ref name="pmid19955221">{{cite journal|  author=Avouac J, Vicaut E, Bardin T, Richette P| title=Efficacy of  joint lavage in knee osteoarthritis: meta-analysis of randomized  controlled studies. | journal=Rheumatology (Oxford) | year= 2010 |  volume= 49 | issue= 2 | pages= 334-40 | pmid=19955221
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19955221 | doi=10.1093/rheumatology/kep382 }} </ref><ref name="pmid12110735">{{cite journal|  author=Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA,  Kuykendall DH et al.| title=A controlled trial of arthroscopic surgery  for osteoarthritis of the knee. | journal=N Engl J Med | year= 2002 |  volume= 347 | issue= 2 | pages= 81-8 | pmid=12110735 |  doi=10.1056/NEJMoa013259 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12110735  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12614134 Review in: ACP J Club. 2003 Mar-Apr;138(2):49]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12401143 Review in: J Fam Pract. 2002 Oct;51(10):813] </ref><ref name="pmid18784099">{{cite journal|  author=Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR,  Wong CJ et al.| title=A randomized trial of arthroscopic surgery for  osteoarthritis of the knee. | journal=N Engl J Med | year= 2008 |  volume= 359 | issue= 11 | pages= 1097-107 | pmid=18784099 |  doi=10.1056/NEJMoa0708333 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18784099  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172720 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-15] </ref>  However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded from one trial.<ref name="pmid18784099"/>
 
===Intra-articular injections===
Single intraarticular [[corticosteroid]]s of the [[knee]] may reduce pain for one week after the injection according to a systematic review.<ref name="pmid16625636">{{cite journal| author=Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G| title=Intraarticular corticosteroid for treatment of osteoarthritis of the knee. | journal=Cochrane Database Syst Rev | year= 2006 | volume=  | issue= 2 | pages= CD005328 | pmid=16625636 | doi=10.1002/14651858.CD005328.pub2 | pmc= | url= }} </ref>
 
One trial that compared [[corticosteroid]] injections every three months to placebo for two years<ref name="pmid12571845">{{cite journal| author=Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J et al.| title=Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. | journal=Arthritis Rheum | year= 2003 | volume= 48 | issue= 2 | pages= 370-7 | pmid=12571845 | doi=10.1002/art.10777 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12571845  }} </ref> found improvements in outcomes ranging from none to small for the [http://www.rheumatology.org/practice/clinical/clinicianresearchers/outcomes-instrumentation/WOMAC.asp WOMAC pain score]<ref name="pmid3068365">{{cite journal |author=Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW |title=Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee |journal=J. Rheumatol. |volume=15 |issue=12 |pages=1833–40 |year=1988 |month=December |pmid=3068365 |doi= |url= |issn=}}</ref>
 
Intraarticular viscosupplementation of the knee with [[hyaluronic acid]] is "associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."<ref name="pmid16625636">{{cite journal| author=Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G| title=Intraarticular corticosteroid for treatment of osteoarthritis of the knee. | journal=Cochrane Database Syst Rev | year= 2006 | volume=  | issue= 2 | pages= CD005328 | pmid=16625636 | doi=10.1002/14651858.CD005328.pub2 | pmc= | url= }} </ref>
 
[[Intra-articular injection]]s of the [[hip]] joint for labral tears may not be effective.<ref name="pmid18760208">{{cite journal |author=Martin RL, Irrgang JJ, Sekiya JK |title=The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates |journal=Arthroscopy |volume=24 |issue=9 |pages=1013–8 |year=2008 |month=September |pmid=18760208 |doi=10.1016/j.arthro.2008.04.075 |url=http://linkinghub.elsevier.com/retrieve/pii/S0749-8063(08)00358-7 |issn=}}</ref>
 
===Physical therapy===
Some types of [[physical therapy]] may help according to a [[systematic review]] of trials.<ref name="pmid23128863">{{cite journal| author=Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL| title=Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 9 | pages= 632-44 | pmid=23128863 | doi=10.7326/0003-4819-157-9-201211060-00007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23128863  }} </ref>
 
===Knee bracing and shoe prosthesis===
Laterally wedged insoles may (with valgus bracing)<ref  name="pmid20177839">{{cite journal| author=van Raaij TM, Reijman M,  Brouwer RW, Bierma-Zeinstra SM, Verhaar JA| title=Medial knee  osteoarthritis treated by insoles or braces: a randomized trial. |  journal=Clin Orthop Relat Res | year= 2010 | volume= 468 | issue= 7 |  pages= 1926-32 | pmid=20177839 | doi=10.1007/s11999-010-1274-z | pmc=PMC2881986 }} </ref> or may not (without bracing)<ref name="pmid17393448">{{cite journal| author=Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ et al.| title=A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis. | journal=Arthritis Rheum | year= 2007 | volume= 56 | issue= 4 | pages= 1198-203 | pmid=17393448 | doi=10.1002/art.22516 | pmc= | url= }} </ref><ref name="pmid21593096">{{cite journal| author=Bennell KL, Bowles KA, Payne C, Cicuttini F, Williamson E, Forbes A et al.| title=Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. | journal=BMJ | year= 2011 | volume= 342 | issue= | pages= d2912 | pmid=21593096 | doi=10.1136/bmj.d2912 | pmc=PMC3100910 | url= }} </ref> benefit some patients with arthritis of the medial knee according to [[randomized controlled trial]]s.


==Prognosis==
==Prognosis==
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==References==
==References==
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<references/>[[Category:Suggestion Bot Tag]]

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Osteoarthritis is the most common form of arthritis. It is "a progressive, degenerative joint disease, the most common form of arthritis, especially in older persons. The disease is thought to result not from the aging process but from biochemical changes and biomechanical stresses affecting articular cartilage. In the foreign literature it is often called osteoarthrosis deformans."[1]

Cause / etiology

Obesity may contribute to osteoarthritis of the knee.[2][3][4]

Leg-length inequality > 1 cm is associated with osteoarthritis of the knee.[5]

Diagnosis

Signs and symptoms

Knee osteoarthritis

Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.[6] This is more likely if the quadriceps muscle is weak.

A screening survey is positive if any one of the following is answered yes:[7]

  • During the last 4 weeks, have you had knee pain on most days?
  • During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
  • During the last 4 weeks, have you had swelling in one or both knees?
  • Do you have knee OA? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)

Using the prevalence of disease in this study (5% to 8%), the predictive values are:

Hip osteoarthritis

A screening survey is positive if any one of the following is answered yes:[7]

  • During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
  • During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
  • During the last 4 weeks, have you noticed any limitation in the range of motion of one or both hips?
  • Do you have hip osteoarthritis? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)

Using the prevalence of disease in this study (5% to 8%), the predictive values are:

Treatment

Treatment with combined weight loss and exercise is better than either treatment alone.[8]

Analgesic medications

The World Health Organization recognizes a "pain ladder" of increasingly potent analgesics to deal with the pain of osteoarthritis. These may be supplemented with adjuvants.

The Disease-Modifying Anti-Rheumatic Drugs (DMARD) used in rheumatoid arthritis and other autoimmune disorders are not indicated in the essentially mechanical wear involved in osteoarthritis.

Analgesics

Acetaminophen

A randomized controlled trial comparing acetaminophen to ibuprofen in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.[9] However, acetaminophen at a dose of 4 grams per day can increase liver function tests.[10]

NSAIDs
Monoclonal antibodies

Adalimumab did not help in a randomized controlled trial.[11]

Opioids

Tramadol

Adjuvants for pain medications

Dietary supplements

Various dietary supplements and complementary and alternative medicine approaches may help.[12] There is no benefit from glucosamine and chondroitin according to a network meta-analysis.[13]

A combination of glucosamine and chondroitin dietary supplements may help moderate to severe osteoarthritis according to the GAIT study while neither supplement seems effective alone.[14] However, longer follow-up of the GAIT study showed the combination group tended to have the most loss of joint space.[15]

Chondroitin

For more information, see: chondroitin.

A meta-analysis of randomized controlled trials found no benefit from chondroitin as monotherapy.[16]

Glucosamine

For more information, see: glucosamine.


A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid.

Neither glucosamine sulfate[17] nor glucosamine hydrochloride[14][15] is effective as monotherapy for osteoarthritis.

S-adenosylmethionine

For more information, see: S-adenosylmethionine.


Acupuncture

For more information, see: Acupuncture.

Acupuncture is probably not effective according to a meta-analysis that concluded "sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation effects."[18]


Arthroscopic surgery and joint lavage

Joint lavage, with or without corticosteroids, does not help.[19][20][21] However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded from one trial.[21]

Intra-articular injections

Single intraarticular corticosteroids of the knee may reduce pain for one week after the injection according to a systematic review.[22]

One trial that compared corticosteroid injections every three months to placebo for two years[23] found improvements in outcomes ranging from none to small for the WOMAC pain score[24]

Intraarticular viscosupplementation of the knee with hyaluronic acid is "associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."[22]

Intra-articular injections of the hip joint for labral tears may not be effective.[25]

Physical therapy

Some types of physical therapy may help according to a systematic review of trials.[26]

Knee bracing and shoe prosthesis

Laterally wedged insoles may (with valgus bracing)[27] or may not (without bracing)[28][29] benefit some patients with arthritis of the medial knee according to randomized controlled trials.

Prognosis

Knee

The strongest predictors of poor functional outcome are age, body mass index, anxiety and pain severity.[30]

Hip

Among patients presenting with hip pain to their general practitioner, the rates of total hip replacement are:[31]

  • 12% of patients at 3 years
  • 22% after 6 years

Predictors of the need for a total hip replacement are:[31]

  • age >/=60 years, morning stiffness
  • pain in the groin/medial thigh
  • decreased extension/adduction
  • painful internal rotation
  • body mass index </=30 kg/m(2)
  • Kellgren/Lawrence grade of 2 or higher

References

  1. ↑ Anonymous (2024), Osteoarthritis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT (2011). "Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data.". Ann Intern Med 155 (11): 725-32. DOI:10.1059/0003-4819-155-11-201112060-00004. PMID 22147711. PMC PMC3408027. Research Blogging.
  3. ↑ McAlindon TE, Wilson PW, Aliabadi P, Weissman B, Felson DT (1999). "Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study.". Am J Med 106 (2): 151-7. PMID 10230743. [e]
  4. ↑ Hart DJ, Doyle DV, Spector TD (1999). "Incidence and risk factors for radiographic knee osteoarthritis in middle-aged women: the Chingford Study.". Arthritis Rheum 42 (1): 17-24. DOI:<17::AID-ANR2>3.0.CO;2-E 10.1002/1529-0131(199901)42:1<17::AID-ANR2>3.0.CO;2-E. PMID 9920009. <17::AID-ANR2>3.0.CO;2-E Research Blogging.
  5. ↑ Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, Lewis CE et al. (2010). "Association of leg-length inequality with knee osteoarthritis: a cohort study.". Ann Intern Med 152 (5): 287-95. DOI:10.1059/0003-4819-152-5-201003020-00006. PMID 20194234. Research Blogging.
  6. ↑ Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007).
  7. ↑ 7.0 7.1 Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).
  8. ↑ Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, Beavers DP, Hunter DJ, Lyles MF, Eckstein F, Williamson JD, Carr JJ, Guermazi A, Loeser RF. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013 Sep 25;310(12):1263-73. doi: 10.1001/jama.2013.277669. PMID: http://pubmed.gov/24065013.
  9. ↑ Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI (1991). "Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee". N. Engl. J. Med. 325 (2): 87-91. PMID 2052056. [e]
  10. ↑ Watkins PB, Kaplowitz N, Slattery JT, et al (2006). "Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial". JAMA 296 (1): 87-93. DOI:10.1001/jama.296.1.87. PMID 16820551. Research Blogging.
  11. ↑ Chevalier X, Ravaud P, Maheu E, Baron G, Rialland A, Vergnaud P et al. (2014). "Adalimumab in patients with hand osteoarthritis refractory to analgesics and NSAIDs: a randomised, multicentre, double-blind, placebo-controlled trial.". Ann Rheum Dis. DOI:10.1136/annrheumdis-2014-205348. PMID 24817417. Research Blogging.
  12. ↑ De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ, Arthritis Research UK Working Group on Complementary and Alternative Medicines (2011). "Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review.". Rheumatology (Oxford) 50 (5): 911-20. DOI:10.1093/rheumatology/keq379. PMID 21169345. Research Blogging.
  13. ↑ Wandel S, Jüni P, Tendal B, Nüesch E, Villiger PM, Welton NJ et al. (2010). "Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis.". BMJ 341: c4675. DOI:10.1136/bmj.c4675. PMID 20847017. PMC PMC2941572. Research Blogging.
  14. ↑ 14.0 14.1 Clegg DO, Reda DJ, Harris CL, et al (February 2006). "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis". N. Engl. J. Med. 354 (8): 795–808. DOI:10.1056/NEJMoa052771. PMID 16495392. Research Blogging.
  15. ↑ 15.0 15.1 Sawitzke AD, Shi H, Finco MF, et al (October 2008). "The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial". Arthritis Rheum. 58 (10): 3183–91. DOI:10.1002/art.23973. PMID 18821708. Research Blogging.
  16. ↑ Reichenbach S, Sterchi R, Scherer M, et al (2007). "Meta-analysis: chondroitin for osteoarthritis of the knee or hip". Ann. Intern. Med. 146 (8): 580-90. PMID 17438317. [e]
  17. ↑ Rozendaal RM, Koes BW, van Osch GJ, et al (February 2008). "Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial". Ann. Intern. Med. 148 (4): 268–77. PMID 18283204. [e]
  18. ↑ Manheimer E, Linde K, Lao L, Bouter LM, Berman BM (June 2007). "Meta-analysis: acupuncture for osteoarthritis of the knee". Ann. Intern. Med. 146 (12): 868–77. PMID 17577006. [e]
  19. ↑ Avouac J, Vicaut E, Bardin T, Richette P (2010). "Efficacy of joint lavage in knee osteoarthritis: meta-analysis of randomized controlled studies.". Rheumatology (Oxford) 49 (2): 334-40. DOI:10.1093/rheumatology/kep382. PMID 19955221. Research Blogging.
  20. ↑ Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH et al. (2002). "A controlled trial of arthroscopic surgery for osteoarthritis of the knee.". N Engl J Med 347 (2): 81-8. DOI:10.1056/NEJMoa013259. PMID 12110735. Research Blogging. Review in: ACP J Club. 2003 Mar-Apr;138(2):49 Review in: J Fam Pract. 2002 Oct;51(10):813
  21. ↑ 21.0 21.1 Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ et al. (2008). "A randomized trial of arthroscopic surgery for osteoarthritis of the knee.". N Engl J Med 359 (11): 1097-107. DOI:10.1056/NEJMoa0708333. PMID 18784099. Research Blogging. Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-15
  22. ↑ 22.0 22.1 Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G (2006). "Intraarticular corticosteroid for treatment of osteoarthritis of the knee.". Cochrane Database Syst Rev (2): CD005328. DOI:10.1002/14651858.CD005328.pub2. PMID 16625636. Research Blogging.
  23. ↑ Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J et al. (2003). "Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial.". Arthritis Rheum 48 (2): 370-7. DOI:10.1002/art.10777. PMID 12571845. Research Blogging.
  24. ↑ Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (December 1988). "Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee". J. Rheumatol. 15 (12): 1833–40. PMID 3068365. [e]
  25. ↑ Martin RL, Irrgang JJ, Sekiya JK (September 2008). "The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates". Arthroscopy 24 (9): 1013–8. DOI:10.1016/j.arthro.2008.04.075. PMID 18760208. Research Blogging.
  26. ↑ Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL (2012). "Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review.". Ann Intern Med 157 (9): 632-44. DOI:10.7326/0003-4819-157-9-201211060-00007. PMID 23128863. Research Blogging.
  27. ↑ van Raaij TM, Reijman M, Brouwer RW, Bierma-Zeinstra SM, Verhaar JA (2010). "Medial knee osteoarthritis treated by insoles or braces: a randomized trial.". Clin Orthop Relat Res 468 (7): 1926-32. DOI:10.1007/s11999-010-1274-z. PMID 20177839. PMC PMC2881986. Research Blogging.
  28. ↑ Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ et al. (2007). "A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis.". Arthritis Rheum 56 (4): 1198-203. DOI:10.1002/art.22516. PMID 17393448. Research Blogging.
  29. ↑ Bennell KL, Bowles KA, Payne C, Cicuttini F, Williamson E, Forbes A et al. (2011). "Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial.". BMJ 342: d2912. DOI:10.1136/bmj.d2912. PMID 21593096. PMC PMC3100910. Research Blogging.
  30. ↑ Elaine Thomas et al., “Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?,” Ann Rheum Dis (February 4, 2008): ard.2007.080945.
  31. ↑ 31.0 31.1 Lievense AM, Koes BW, Verhaar JA, Bohnen AM, Bierma-Zeinstra SM (2007). "Prognosis of hip pain in general practice: A prospective followup study". Arthritis Rheum 57 (8): 1368–1374. DOI:10.1002/art.23094. PMID 18050175. Research Blogging.
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