pain physician management of oa knee

1. Osteoarthritis knee
Dr Ravi Shankar Sharma
Fellow (Daradia)

2. Anatomy of knee joint

3. Anatomy
• Type – Hinge type synovial joint
• Femoropatellar and femorotibial joint

4. • The articular capsule has
a synovial and
a fibrous membrane separated
by fatty deposits.
• Synovial membrane have
multiple extensions which
includes suprapatellar bursa.

5. Ligaments
Intracapsular and extracapsular
• Intracapsular
o Anterior cruciate ligament (ACL)
o Posterior cruciate ligament (PCL)
o Transverse ligament
o Anterior and posterior
meniscofemoral ligament
o Coronary ligament

6. Extracapsular
• Petallar ligament
• Medial collateral ligament
• Lateral collateral ligament
• Oblique popliteal ligament
• Arcuate popliteal ligament

7. Meniscus
• Medial meniscus
• Lateral meniscus
Structure
• Fibrous cartilate
• Outer 1/3rd blood supply
Function

8. Nerve supply
• Femoral-through its branches in vasti medialis
• Sciatic(through genicular branches)
• Obturator nerve-through its posterior division

9. Blood supply:

10. Osteoarthritis
• Degenerative joint disease affecting joint cartilage and
subchondral bone,leading to the formation of bony spurs and
subchondral cyst.
• Age above 60 years
• Female more after menopause

11. Degenerative changes of Knee

12. Overview: Risk Factors
• Age
• Female
• Obesity ( most important modifiable)
• Previous knee injury
• Lower extremity malalignment
• Repetitive knee bending
• Hereditory and nodal OA
• Low level of vitamin C and D
• Muscle weakness( quardiceps)

13. Pathophysiology
Biomechanical stress
affecting the articular
cartilage and subchondral
bone leading to wear and
tear

14. WHY PAIN ?
• PERIPHERAL SENSITIZATION :
• mediator induced inflammation of articular nociceptors
• Secondary to synovitis
• Stretching of joint capsule and ligaments
• Periosteal irritation due to osteophytes
• Trabeculae microfractures
• Intraosseous hypertension
• Muscle spasm
CENTRAL SENSITIZATION

15. Signs and symptoms
• Pain
• Morning stiffness
• Swelling
• Decreased range of motion
• Swelling
• Sounds- crepitation

16. Clinical examination
• Gait
• Swelling
• Deformity
• Tenderness over joint line
• Active and passive ROM painful
• Hard end feel
• Bony crepitations

17. Diagnosis of Knee OA
Classic Clinical Criteria
• established by ACR, 1981
• sensitivity 95%, specificity 69%
knee pain plus at least 3 of 6 characteristics:
• > 50 yrs
• Morning stiffness < 30 min
• Crepitus
• Bony tenderness
• Bony enlargement
• No palpable warmth 5

18. Kellgren and Lawrence classification
Grade 0 No radiographic features of osteoarthritis
Grade 1 Possible joint space narrowing and osteophyte formation
Grade 2 Definite osteophyte formation with possible joint
space narrowing
Grade 3 Multiple osteophytes, definite joint space narrowing, sclerosis
and possible bony deformity
Grade 4 Large osteophytes, marked joint space narrowing,
severe sclerosis and definite bony deformity

19. Diagnosis of Knee OA

20. Treatment
• Non pharmacological
• Pharmacological-pcm, NSAIDS,disease modifying agents like
collagenase inhibitor, elastase inhibitors,and narcotics
• Intervention
• Surgery

21. Intraarticular injections
• Corticosteroids- max. 3-4 times in a year
• Hyaluronic acid in major co-morbid conditions

22. Prolotherapy
• Proliferation therapy or regenerative injection therapy involves
injecting an otherwise non-pharmacological or non-active irritant
solution into knee joint
• Dextose
• Prolozone
• Platelet rich plasma

23. Platelet Rich Plasma (PRP)
• Platelet derived growth factor
• Transforming growth factor B
• Fibroblast growth factor
• Insulin like growth factor 1&2
• Vascular endothelial growth factor
• Epidermal growth factor
• Keratinocyte growth factor
• Connective tissue growth factor
All these promote cartilage repair

24. Genicular nerve block & RF neurotomy
Indications
• Chronic knee pain secondary to OA
• Patients with failed knee replacement
• Patients unfit for knee replacement
• Patients who want to avoid surgery

25. Surgery
• Arthoscopy debridement
• Osteotomy - malalignment
• Knee replacement