Diagnosing osteoarthritis

1. and

present

Diagnosing osteoarthritisDiagnosing osteoarthritis

2. How to define osteoarthritis
There are several "levels" of osteoarthritis: anatomical
(with presence of joint damage that is not always
detectable), radiological and symptomatic
Many people have radiologically
evident but asymptomatic
osteoarthritis
 Osteoarthritis is not necessarily
synonymous with "pain"
 Thus, of 100 people aged over 65:
2
Société Française de rhumatologie website:
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp
INSERM (National medical research institute) web site:
http://www.inserm.fr/thematiques/circulation-metabolisme-nutrition/dossiers-d-information/arthrose

3. The hips and knees are not the joints
most commonly affected
The spine and fingers are the most commonly affected joints.
In the 65-75 year old age group, the incidence is as follows:
Cervical spine: 75%
Lumbar spine: 70%
Hands: 60%
Knee: 30%
Hip: 10%
It is most severe and debilitating when it affects the knees and hips,
both weight-bearing joints
The ankles, elbows and shoulders can be affected but this is less
common and generally occurs secondary to an earlier joint injury
3
Société Française de rhumatologie website:
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp

4. 4
Cervical spine.
T2 MRI.
Erosive disc disease, different
stages, frontal view of lumbar
spine.
Hand and wrist MRI: coronal SE T1 and FSE T2 images with fat signal suppression.
Patellofemoral knee osteoarthritis.
Internal hip osteoarthritis
with deformation of the
reinforcement cup.

5. Pain: the main symptom of osteoarthritis
1. in the chronic phase
During the chronic phase, osteoarthritis
progresses very slightly or not at all
 Osteoarthritis pain is described as
mechanical:
variable, mild to moderate pain that
changes only slowly over time
arises particularly during movement/usage
and is relieved by rest.
tends to become worse towards the end
of the day and evening
little night time pain
in the morning, stiffness lasts not more
than half an hour.
5
Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686

6. 6
According to Sellam 2012

7. Pain: the main symptom of osteoarthritis
2. during the acute phase: an inflammatory flare
 Recent change in pain intensity:
sudden increase in intensity over a few days
onset of night time pain which wakes the patient up
morning stiffness lasting more than 30 minutes
+/-mechanical pain as soon as any pressure is placed on the joint
Onset of joint effusion with a low cell count, i.e. containing less than
1500 elements per mm
3
Sometimes, presence of signs of moderate local inflammation:
heat and swelling of the knee joint
7
Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686

8. Examining the joint
Examination of the affected joint may show:
a decrease in range of movement
and/or pain when the joint is moved
(distributed through most of the range of movement)
course crepitus through much
of the range of movement
bony swelling
deformity/malalignment
joint-line tenderness +/- peri-articular
tenderness (hip/knee) due to secondary
peri-articular lesions
Between osteoarthritis flares:
the joint is neither swollen, nor warm
8
Site de la Société Française de rhumatologie :
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A1_pourquoi.asp
La Revue du Praticien, Arthrose et obésité. Jérémie Sellam and Francis Berenbaum, 2012; 62: 621-624
The examination must always be
comparative and, as far as the
leg joints are concerned, the patient must
also be examined in a standing position and
during walking.

9. Standard x-rays
First and foremost, the imaging work-up for patients with suspected
osteoarthritis should include a comparative x-ray (for tibiofemoral
compartments weight-bearing films are required) study of the
symptomatic joint
 In more complex cases, it will also help rule out other joint diseases
 The main visible signs are:
reduction in joint space width (inter-osseous distance)
 subchondral bone sclerosis (increased whiteness)
 osteophyte (mainly marginal)
occasionally, the presence of lacunae called
bony cysts or geodes, and osteochondral
“loose” bodies
 eventual development of bone attrition and deformity
sometimes the radiological signs can be very discrete and even absent
9
INSERM (National medical research institute) website:
http://www.inserm.fr/thematiques/circulation-metabolisme-nutrition/dossiers-d-information/arthrose

10. 10
Cystic hip osteoarthritis.
Oblique image hip radiographs.
Fracture of the upper
extremity of the femur
(pertrochanteric).

11. 11
Advanced internal femorotibial knee
osteoarthritis. Standard frontal x-ray.
Sample osteoarthritic knee x-ray
Advanced internal femorotibial knee
osteoarthritis. Standard oblique x-ray

12. Beware of the possible lack of
correspondence between the radiological
findings and the clinical symptoms
There is no direct link between the extent of the lesions seen
on the x-ray and pain intensity
Up to 90% of subjects aged over 50 years old are thought to present
radiological modifications whilst only 30% have clinical symptoms and signs
Severe lesions may only cause occasional pain, whilst minimal damage
may be accompanied by intense pain
More information can be gleaned from monitoring the progress of the
lesions than from assessing radiological severity at any given time
If the patient continues to present with pain despite appropriate
treatment, the radiological work-up should be repeated to screen for
rapidly destructive osteoarthritis
12
Site de la Société Française de rhumatologie :
http ://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp

13. CT and MRI scans: how useful are they?
A conventional x-ray is the gold standard examination
for the diagnosis and follow-up of osteoarthritis in
routine practice although it does not allow direct
visualisation of:
cartilage damage
fibrocartilage lesions (meniscus and fat pad)
 intra-articular inflammation
These abnormalities are only screened
for during clinical trials
13
Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012; 62: 625-629
Site de la Société Française de rhumatologie:
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp

14. 14
Frontal FSE T2 image of internal femorotibial
osteoarthritis with stage 4 cartilage lesion of
plateau and condyle and edema of the tibial
plateau and condyle
Knee osteoarthritis, tibial edema and
synovial inflammation. FSE T2 sagittal
slices.

15. MRI as a second line examination
MRI can be performed as a second line examination
for an atypical presentation:
when a patient experiences mechanical pain in a joint that
appears normal on the x-ray which could potentially be an
indication of pre-radiological stage osteoarthritis or
epiphysial osteonecrosis
a subchondral fissure
Nonetheless, recourse to MRI
for osteoarthritis patients should
be exceptional
15
Chevalier X. Arthrose du genou et de la hanche. Rev Prat Med Gen. 2007; 21: 987-991
Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012 ; 62 : 625-629

16. 16
Rotator cuff rupture. MRI T2 images. External femoral condyle
osteonecrosis, T1 MRI sequence,
frontal image.

17. MRI, cartilage and bone
Used during clinical trials, MRI provides satisfactory exploration
of the knee hyaline cartilage which varies in thickness from 1.5 to 4 mm
(cartilage is thicker in men than women and varies according to height)
 When used for diagnostic purposes, in 35% of cases MRI shows focal
cartilage lesions not evident on the x-ray
 Bone damage may be found with - and sometimes even before - the loss
of cartilage. MRI has made a major contribution to the diagnosis of knee
osteoarthritis by making it possible to distinguish amongst the various types
of bony lesions, especially bone oedema which is not visible on standard
x-rays and which is correlated with pain in patients with knee osteoarthritis
MRI has made major contributions to the understanding of pain
mechanisms in patients with osteoarthritis
17
Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012; 62: 625-629

18. Conclusion
A standard x-ray is the reference examination
for patients with suspected osteoarthritis
 Early diagnosis of osteoarthritis could make it possible
to set up a number of preventive measures
 It is also hoped that, in the future, the use of biomarkers
(for example type 2 collagen derivatives or hyaluronic
acid) may be used to detect the first cartilage changes at
an even earlier stage
18
Chevalier X. Arthrose du genou et de la hanche. Rev Prat Med Gen. 2007; 21: 987-991