Sandhivata (osteoarthritis)

as per Kayachikitsa syllabus

1. 1
ProfSriramChandraMishra
KayachikitsaDepartment
VYDSAyurvedMahavidyalaya,Khurja

2. Sandhivata / Sandhigatavata
•Sandhi-Anatomicalaspect-Theunionof(samyogasthana)oftwo
bones(asthis).
•Vata-Physiologicalaspect
•AsvitiatedVataalonenotinvolvedinSandhivata,soitisnot
describedunder80typesofNanatmajavatavyadhies,but
elaboratedunderVatavyadhichikitsa.
•AsperChakrapani,SandhivataisacceptedasGulpha-
VataorSandhigataVata.
2

3. 3
Theetiologyofthediseasehasnotbeenmentioneddirectlybutthe
NidanaofVatavyadhiandAshtivahaStrotasdushticausesareconsidered.
•SannikrishtaHetu–Ativyayama(excessofphysicalexercise),Abhighata
(injurytojoint),Marmaghata(injurytovitalpointofthejoints),Pradhavana
(running)etc.
•ViprakrishtaHetu–Kashaya,Katu,TiktaRasa,Rooksha,Sheeta,Laghu
Guna,Alpahara,Vishamashana,Adhyashana,Pramitashana,Chinta,Shoka,
Krodha,Bhaya,Atijagarana,Vishamopacara,Ativyavaya,Shrama,
Divasvapna,Vegasandharana
•OtherCausesforVataprakopa-LivinginJangaladesha,Duringtheendof
Greeshmaritu,VarsharituandShishirakala.

4. 4
1.Dhatukshayajanya-Inoldage,VatapredominanceoccurswithdecreaseKapha
andimpairedAgni.SoDhatusnotproducedattheirbestwhichultimatelyleadsto
degeneration.AsKaphaisdecreased,theShleshmak-kaphainjointsalsodepletes
resultinginKshayaofAsthisandhi.FurthercontinuesindulgingofVataaggravating
factorsleadstoSthanasamshrayaofPrakupitaVataintheKhavaigunyayuktasandhi.
ThislocalizedVayuduetoitsRuksha,Laghu,KharadiGunaresultsinSandhivata.
संधिगतवात ( िातुक्षयजन्य ) संप्राप्तत
वातप्रकोपकनिदािकासेवि→वातप्रकोप→स्रोतसोंकेस्थािपर�क्षता,प�षता
एवंखरता→वातकासंधिप्रदेशमेंस्थािसंश्रय(ररक्तस्रोतसोंकेस्थािवायूपूरण)→
संिीकेस्थािपरवातसंग→संधि,स्िायुएवंकण्डराकीववकृनत→नि�पस्तंभित
संधिगतवात(िातुक्षयजन्य)

5. 5
2.Aavaranjanya(InobeseusuallyOsteoarthritisoccursintheweightbearingjoints)-As
Medadhatuisproducedinexcessitwillcauseobstructionanddoesnotnourishesthe
UttrotardhatusleadingtoKshaya.TheexcessivefatwillcauseAavaranaofVata.This
vitiatedVatawhensettledowninjointswillproduceSandhivata.
संधिगतवात (आवरण/ स्रोतारोि प्रिाि) संप्राप्तत
निदािकासेवि(↑शीतगुण)+सन्तपपणजन्यव्याधि→कफप्रकोप→आमदोषोत्पत्ती
(आमकास्थािीयप्रकोप)→स्रोतावरोि→वातकाववमागपगमि→सामवायुकासंधि
स्थलपरस्थािसंश्रय→उपस्ताप्भितसंधिगतवात(स्रोतावरोिप्रिाि)

6. 6
Satkriyakaala

7. NIDANAPANCHAKA
•निदाि:वातप्रकोपकनिदाि
•दोष:वात(व्यािवायु),श्लेष्मककफ
•दुष्य:अप्स्थ,मज्जा,मेद,रस
•स्रोतस:अप्स्थवह,मज्जावह,मेदोवह
•स्रोतोदुप्ष्ि:संग​,ववमागपगमि
•दोषमागप:ममापप्स्थसंधि
•अधिष्ठाि-संधिप्रदेश
•रोगमागप:मध्यम
•व्याधिस्व�प-धिराकारी
•साध्यसाध्याता-िबीि-साध्या,
प्जणप-कृछ्रसाध्य/यातय
7

8. (M.N.Vatavyadhi)
•आिोपम्इषत्सशब्दम्आध्मािम्(सु.सू.१५।१५)
•हप्न्तसप्न्िगतःसन्िीनिनतसप्न्िववश्लेषंस्तभिाददकंवा
करोनत(मिुकोश)
हप्न्तसप्न्िगतःसन्िीि्शूलशोथौकरोनति॥
(िा.प्र.म.२४।२५८)
C.CHI.28/37, A.H. NI. 15/14
SU.NI.1/28, यो.र​. वातव्याधि निदाि २५
8
•Hantisandhi(Lossoffunction)
•Shula/Vedana(Pain)
•Atopa(Crepitussound)
•Vatapurnadritisparsha
(Soundsresemblingthatmade
whenrubagainstaballoonor
transparentcontainerfilledwith
air)
•Shotha(Swelling)
•PrasaranaAkunchanayoho
pravrittisavedana(Painful
movementofthejointsincluding
extensionandflexion)

9. 9

10. Treatmentprinciple
•कुयापत्सप्न्िगतेवातेदाहस्िेहोपिाहिम्।(B.P.M.24/259,Y.R)
•स्िेहोपिाहाप्निकमपबन्ििोन्मदपिानिि।
स्िायुसन्ध्यप्स्थसंप्राततेकुर्ययापद्वायावतप्न्ितः॥(कुर्य्याद्वात ववचक्षणः)
(सु.धि.४।८,Chakradutta22/9)
•स्रावसन्धिशिराप्राप्त स्ि हदाहोपिाहिम्।
तैलंसंकुधचत ऽभ्यङ्गोमाषसैधिवसाधितम्॥(A.H.Chi.21/22)
•बाह्याभ्यधतरतःस्ि हैरन्स्िमज्जगतंजय त्।(च​.धच.२८।९३)
•.
(C.SU.28/27)

11. 1.Nidanaparivarjana
Avoidprolongedstanding,overexertionandinjurytojoints,prolonged
useofsteroidandsedentarylifestyleetc.
2.Samsodhanachikitsa
•Lepa–Jatamamsyadi,Grihadhumadi,LepaGuti,Gandhabirojalepa,
Kottamchukadichurna,KolakulathadiChurna,NagaradiChurna,
JatamayadiChurna,RasnadiChurna
•Snehana(Abhyanga)–
Vataja–Mahanarayantaila,Nirgunditaila,PrabhajanamTaila,KetakimuladiTaila,
ChinchadiTaila,Kayatirumeni,PanchamlaTaila,KarpuradiTaila,
Vatakaphaja-Vishagarbhataila,BrihatSaindhavaditaila,Kottamchukaditaila,
Dasamoolataila,
Degenerationwithatrophy-Aswagandha-bala-lakshaditaila,Dhanwantarataila,
Mahamashataila,Balataila,Sahacharataila,Ksheerabalataila,Panchasneham,11

12. •Svedana–Hotwaterbag,Nadisweda,Balukapottalisweda,Nirgundi
patrapindasweda(Nirgundi,Dashamula,eranda,balamulaetc),Pariseka,Sastikasalipinda
sweda,Snehadravadhara(Pizhichil),Upanaha(LeavesofEranda,Nirgundi,Arka,
Chinchaetc/Grihadhumadichurna),Rukshasweda(KolaKulatthadichurna)
•Basti–PanchatiktaKsheerabasti,Yapanabasti(Madhutailika/Mustadi
Rajayapana),Yogabasti,
•Localbasti–Janubasti,Greevabasti,Katibasti
•Virechana,Anulomana
•Agnikarma,Siraveda
•Jalaukavacharana
12

13. 3.Samsamanatherapy
•SingleDrugs
Sallaki(Glucosamine) Kuchila Rasonakalka
Gandhaprasarini Shunthi ErandaMula
Nirgundi Guggulu
•Kwatha
Maharasnadikvatha Rasnaerandadikvathachurna
Kokilakshakashayam Dashamulakvatha
Rasnadikvatha VaranadiKashayam
GuggulutiktakakashayamRasasaptakamkashayam
Punarnavadikashayam Dhawatarakashayam
Vidaryadikashayam
13
Obese /Lean
Vata / Vatakapha

14. •Guggulu
MahaYogarajaguggulu YogarajaGuggulu
KaisoraGuggulu SimhanadaGuggulu
RasnaGuggulu LakshaGuggulu
NavakaGuggulu
(Vatanubandhipitta–AmritadiGuggulu,Kaishoraguggulu,GokshuradiGuggulu)
•Ghrita
KaraskaraGhritam GuggulutiktakaGhrita
PanchatiktaGhritaGuggulu
14

15. •Rasa
Vatavidhwansanarasa(Vataja)
BrihatVataGajankusharasa(Vatakaphaja)
•Churna
SudhavisatindukachurnaAjamoodadichurna
Aswagadhachurna Narasimhachurna
Pippalimoolachurna Sunthi-Haritakichurna
Chopchinirasayan(Septicarthritis)
•Avaleha
Amritabhallatak DasamulaHaritaki
•Asavarista
Dasamoolarista Aswagandharista
•Taila
Kottamchukaditaila BrihatSaindhavaditaila
Vishagarbhataila Nirgunditaila
Mahanarayanataila Mahamashataila
15

16. 16
Vyavasthapatra
(Sample prescription for sandhivatahaving Vata predominance)
•MahavatavidhwamsanaRasa–125mg
+GodantiBhasma–125mg
+GuduchiSatva–250mg
…………………………………… ..
1dosetwicedailywithhoney
•CapSallaki–1Cap(500mg)
+MahaYogarajaGuggulu-500mg
+KaraskaraGhritam–1tsf(5gm)
…………………………………… ..
1dosetwicedailywithL.W.Water
•Sunthi-HaritakiChurna -5gm
…………………………………… ..
5gmtwicedailywithL.W.Water
•Ahyanga/Janubasti–Dhanwantaratailam+Mahanarayantaila
•Yoga&Physiotherapy(Patellaexercise)

17. 17
Vyavasthapatra
(Sample prescription for sandhivatahaving Vatakaphapredominance)
•BrihatVataGajankushaRasa–125mg
+GodantiBhasma–125mg
+GuduchiSatva–250mg
…………………………………… ..
1dosetwicedailywithhoney
•CapSallaki–1Cap(500mg)
+NavakaGuggulu-500mg
…………………………………… ..
1dosetwicedailywithL.W.Water
•AjamodadiChurna-5gm
…………………………………… ..
5gmtwicedailywithL.W.Water
•Ahyanga/Janubasti–Vishagarbhataila/BrihatSaindhavaditaila/
Kottamchukaditaila
•Yoga&Physiotherapy(Patellaexercise)

18. Pathya
•Ahara:PuranaShali,greengram,milk,grape,Lukewarmwater,Paraval,drumstick,
garlic.
•Vihara:Massage,warmwaterbath,posturecorrection,followtheDinacharyaand
Rutucharya.
Apathya
•Ahara:Driedvegetables,lentils,sprouts,rawvegetablesandsalads,refinedfoodssuchas
whiteflour,excessiveuseofleafygreenvegetables,mushrooms,peas,Excessiveintakeof
pungentfood,colddrinks,beverages,chilledfoodandicecream,Continuouslyfastingor
takinglimitedfoodforaverylongduration.
•Vihara:Inadequatesleeporfrequentchangesinsleeppattern,suppressionofnaturalurge
especiallyofhunger,bowelandurineandemotions,Excessivephysicalstrainlike
swimming,climbing,walking,running,sportswhichinvolvestrainingofjointslikein
badminton,footballetc.,allsuchoccupationwhichinvolvesexcessivemovementofjoints,
resultinginjointinjuries.
18
Pathya-apathya

19. 19

20. Arthritis
(monoarthritisor
polyarthritis)
Inflammation
(Neutrophilia)
Infectious
Septic arthritis
Tuberculosis arthritis
Reactive arthritis(indirectly)
Non-Infectious
Seronegativespondyloarthropathy:
•Reactive arthritis
•Psoriatic arthritis
•Ankylosingspondylitis
Rheumatoid arthritis:
•Juvenile idiopathic arthritis
•Adult-onset Still's disease
•Felty'ssyndrome
Crystal arthropathy:
•Gout
•Chondrocalcinosis
Non-
Inflammation
Osteoarthritis
•Heberden'snode, Bouchard's nodes
Others
•Hemorrhage(Hemarthrosis)
•Pain (Arthralgia)
•Osteophytes
•Villonodularsynovitis
(Pigmented villonodularsynovitis)
•Joint stiffness
20

21. Synonyms
•Osteoarthrosis(Inflammatory/Non-inflammatory)
•DegenerativeArthritis
•Degenerativejointdisease(DJD)
•Wearandteararthritis
21

22. OSTEOARTHRITIS -Greekword
•Osteo–Bone
•Arthr–Joint
•Itis–Inflammation
OAisachronicprogressivedegenerativedisorderaffectingprimarilythe
weight-bearingjointscharacterizedbythebreakdownofthejoint’scartilagewhich
causesthebonestorubagainsteachother,causingstiffness,painandlossof
movementinthejoint.
OAisadiseaseofsynovialjointsduetodegenerationofcartilages.
22

23. 23

24. • Itisauniquetissuewithviscoelasticandcompressivepropertieswhichareimpartedbyits
extracellularmatrix,composedpredominantlyoftypeIIcollagenandproteoglycans.
• Constituentsofcartilage
 Cellularmatrix–Chondrocytes(1-2%)
 Liquidphase–Water(70-80%)
 SolidPhase(20-30%)-Extracellularmatrix
 Collagen–TypeIIandOthers
 Proteoglycans–AggrecanandOthers
 Calciumsalt(Averysmallcomponent)
• Theturnoverrateofcollagenisrelativelyslow,whereasproteoglycanturnoverisrapid.
• Undernormalconditions,thismatrixissubjectedtoadynamicremodelingprocessinwhich
lowlevelsofdegradativeandsyntheticenzymeactivitiesarebalanced,suchthatthevolumeof
cartilageismaintained.
24

25. •Exactaetiologyisunknown
•Multiplefactorsinteracttocause“wearandtear”ofjointsovertime.
Riskfactors:
Olderage(age≥40yrsbutadvanceosteoarthritisoccurinearly20’sifotherriskfactorspersists)
FamilyhistoryofOA(Geneticfactors)
Obesity(putsadditionalpressureonhipsandknees)
Injuryandoveruse,Jointdamage(trauma,sepsis)
Jointdeformity(suchasunequalleglength,bowlegsorknockedknees)
Occupationrelatedmechanicalstress
Bone/Jointrelatedcongenitaldefects
Crystalaccumulationinarticularcartilage
Priorinflammatoryjointdisorder
Metabolic/Endocrinedisorders
25

26. Osteoarthritisresultfromfailureofchondrocytestomaintainhomeostasis
betweensynthesisanddegradationofextracellularmatrixcomponents.
Theexactinitiatingfactorisnotknown.(PrimaryOA)
Interleukin-1(IL-1)isapotentpro-inflammatorycytokinethat,invitro,is
capableofinducingchondrocytesandsynovialcellstosynthesizeMMPs
(MatrixMetalloProteinases).
TheseMMPsaretheprimaryenzymesresponsibleforthedegradationof
articularcartilage.
Inaddition,IL-1suppressesthesynthesisoftypeIIcollagenand
proteoglycans,andinhibitsthetransforminggrowthfactor-ßstimulated
chondrocyteproliferation. 26

27. Thisultimatelyleadstothedegenerationofarticularcartilage.
Presumablyinresponsetothisloss,chondrocytesinitiallyproliferate
andsynthesizeenhancedamountsofproteoglycanandcollagen
molecules.
However,asthediseaseprogresses,reparativeattemptsare
outmatchedbyprogressivecartilagedegradation.
Fibrillation,erosionandcrackinginitiallyappearinthesuperficial
layerofcartilageandprogressovertimetodeeperlayers,resulting
eventuallyinlargeclinicallyobservableerosions.
27

28. (Thoughtheradiologicalfindingssuggestosteoarthriticchanges,somepeoplemaybe
asymptomatic)
●Painintheaffectedjoints ●Muscularspasm(Instability)
●Stiffnessofjoint ●Inflammationandeffusionofaffectedjoint
●ReduceRangeofmotion(ROM) ●Muscleinhibition&Atrophy
●Jointinstability ●Crackingofthejointwithmotion
●Deformityoftheaffectedjoints ●Reducefunction
OnExamination
• TendernessonJointline
• Crepitusonmovement
• RestrictedROM
• FixedDeformities
• WeakMuscles(Quadriceps,HamstringandTensorFasciaeLataemuscle)
28

29. 29
VarusTest (LCL)ValgusTest (MCL)
McMurray Maneuver
(menisci)
LachmanTest (ACL)
Duck Waddle
(stability)

30. 30
Pain
•Slowlyincreasing
•IncreasedonExertion,Stairclimbinganddescending
•Painisdueto
Periarticularsofttissue–capsular/ligamentstrain
Periostealelevationsecondarytoraisedintraosseouspressure
Muscularpain&weakness
Inflamed&overstretchedsynovium
Referpainfromspine.
Musclespasm
•Itisaprotectivemechanism
•Movementcausepainsothebodyattemptstostopmovement
•Butprolongspasmcausepainduetometabolicaccumulation&fatigue.
•Adaptiveshorteningmayalsooccurinmuscles

31. 31
Stiffness
•Initiallyduetopainandspasmbutlatercapsular
•Subchondralmicro-fracturesheal&callusformscauseslossofjointmobility&
stiffness
•StiffnessisdescribedasGellingofjointafterinactivitywithdifferenceininitiating
movement.
Inflammation&effusion
•Itisnotalwayspresentunlessthejointisunderwentoveractivity(Wearandtearlead
toachroniclow-gradeinflammation)
•Sign&symptomsincludesare–Heat,Erythema,Tenderness,Effusion,Discomfort&
Pain.
ReduceRangeofmotion(ROM)
•Combinationofjointpain,stiffness&possibleeffusionwilloftencauselimitationof
endROM
•CertainjointmaydevelopcapsularpatternwithrestrictionincertainROM

32. 32
Locking(DuetoBonyenlargementbyremodellingandosteophytes)
•Thismovementrestrictioniscausedbydysfunctioninthejointcapsule.

33. 33
Muscleinhibition&Atrophy
•Effusionwillinhibitsurroundingmuscleofjoint.
•Thismaybeasafetymechanismastheintraarticularpressurebecomesrelatively
positive.E.g.quadricepscontractionmayleadtoruptureofkneejointcapsule
•Chronicmuscleinhibitionisoftenlinkedtochronicpain&willleadtoatrophy&
ensuringweakness.
Jointinstability
•Surroundingmuscleweaken&imbalance
•Painepisodesareunpredictablecausingjointtogiveaway.
•Theseprocesstogetherwithchronicstretchofsofttissuewillalterjointalignment.
•Thesewillleadtoinstability&possiblysubluxation

34. 34
Crepitus/Grating(soundingharshandunpleasant)
•AcoarseCrepitusheardonfullmovement
•CoarseCrepitusisduetoirregularityofarticularsurface,Theflakedcartilage&
eburnatedboneendgrateagainsteachothercharacterizedsound.
Mildcreaking–indicatesynovitis
Loudcracking–indicateadvancedisease
Reducefunction
•Alltheclinicalfeaturesdescribedabovecanresultinfunctionaldifficulty
Deformities
•Osteophytedevelopmentreducejointinstabilitybyincreasingtheperipheralarticular
surfacearea.
•SuchdeformitiesaremoreprofoundinestablishedOAbutmaynotdevelopedequally
onmedial&lateral.

35. 35
•Heberdennode-Abonyswellingoneither
sideoftheDIPjoint(hard,bonyoutgrowthsor
gelatinouscysts),causedbyformation
ofosteophytesofthearticularcartilagethat
oftenskewsthefingertipsideways.
•Bouchard'snodes-ABouchardnodeisa
similarswellingaffectingthePIPjoint.Much
lesscommonly,Bouchard'snodesmayalsobe
seeninrheumatoidarthritis.
Diff.Diagnosis
•RheumatoidArthritis-Swanneckdeformity(Hyper-extension
ofthePIPjointwithfixedflexonofDIPjoint),Boutonniere
deformity(FlexionofthePIPjointwithextensionoftheDIPjoint)
•Goutyarthritis-Acuteinflammation,Knobbyswellings,
Ulcerateanddischargewhitechalklikeurates.
Deformity in OA

36. 36

37. Accordingtonumberofjointsinvolved
•Monoarticular
•OligoorPolyarticular
AccordingtotypeofOAdescribed
•Inflammatory
•GeneralisedOA(GOA)
•ErosiveOA
Otherclassification
•Primary/IdiopathicOA(Withoutanyobviouscause)
•SecondaryOA(Knowncause)
37

38. Primary/IdiopathicOA(Withoutanyobviouscause)
•Localized
 KneeOA–MedialTibiofemoral,LateralTibiofemoral,Patellofemoral
 HandsOA-Nodalosteoarthritis(Presenceofnodes)
 HipOA–Eccentric,Concentric,Diffuse
 SpineOA–Apophyseal,Intervertebral,Spondylosis
•Generalized
 Occursinoldage,Small(peripheral)joints,Large(central)joints,MixedandSpine
•ErosiveOA(EOA./InflammatoryOA)
 EOAisamuchlesscommonbutmoreaggressiveinflammatoryformofOA
•SecondaryOA(Underlyingprimarydiseaseleadstodegenerationofthejoint)
 Irregularityofjointsurfacefromprevioustrauma/Post-surgery
 Congenitalordevelopmentaldisorders
 Charcotarthropathyandfrostbitedepositiondisease(CPPD)
 Otherboneandjointdisorders(Osteonecrosis,RA,goutyarthritis,septicarthritisand
Pagetdiseaseofbone)
 Othersystemicdiseases(Diabetesmellitus,acromegaly,hypothyroidism,neuropathic
etc
38

39. Knee osteoarthritis
ThekneeisthemostcommonjointlocalizationofsymptomaticOA,and
symptomatickneeOAaffects24%ofgeneralpopulation.
Usuallybilateral,oftenoccursinassociationwithhand
osteoarthritisespeciallyinwomen.
Invariablyfocalwithprincipalsitesinvolvedbeing
Medialtibiofemoralcompartmentwithsevereboneandcartilageattrition
atthissiteresultinginvariousdeformities
Patellofemoralcompartment(lateral>medial)becauseofitsintimate
relationshipwiththequadricepsmechanismleadingtogreaterfunctional
impairment.
39
LOCALISEDOA

40. 40

41. 41

42. 42

43. 43

44. 44

45. Hand osteoarthritis
•Itisachronicconditioninvolvingoneormorejointsofthethumbandfingers.
•Themostcommonlyinvolvedjointswerethedistalinterphalangealandproximal
interphalangealjoints,followedbythebaseofthethumbjoint.
•Thesymptomatichandosteoarthritisisassociatedwithweakgripstrengthand
limitsseveraldailyfunctionalactivities.
•Symptomatichandosteoarthritisisacommondisorderamongelderly,
especiallyamongwomen.
45

46. 46
JSN-Jointspace narrowing

47. Hip osteoarthritis
HipOsteoarthritisisdegenerativediseaseofthehipjointthatcausesprogressivelossof
articularcartilageofthefemoralheadandacetabulum.
Eccentric-Femoralheadmigratedsuperolaterallyorsuperomedially
Superiorpoleosteoarthritisiscommonestwithfocalcartilageandlossinsuperior
partofjoint.
Concentric-Femoralheadmigratedmedially
Osteophyteformationsareprominentatlateralacetabularandmedialfemoral
marginswiththickeningofcortexofmedialfemoralneckbyperiostealosteophytes.
47
Diffuse–Largeareainvolved
Centralmedialosteoarthritisis
lesscommon,withmorecentral
jointspacelosswithlessfemoral
neckbuttressing.Moreassociated
withnodalosteoarthritis.

48. Osteoarthritis at other local joint sites
•SpinalJoints:OAismoreinlowercervical/lumbarspine/facetjoints
(cervicalregion).GeneralisedOAorasanisolatedfeatureareseen.
•Sacroiliacjoint:OAcausesmorefocalspacenarrowingandsclerosiswith
overlyingosteophytes,usuallyanterosuperior/inferiorandisidentifiedby
discontinuityoftrabecularlinesacrossjoint.
•Firstcarpometacarpal(CMC),Firstmetatarsophalangeal(MTP)
joints:OAoccurasapartofpatternofGeneralisedOAorasanisolated
feature.
48

49. GENERALISED OA (GOA)
(Polyarticularosteoarthritis and multi-joint osteoarthritis)
Threeormorejointsorgroupsofjointsareaffected(Polyarticular)
FingerI-Pjointinvolvement
Nodular/Nodalosteoarthritis–Heberden(distalI-Pjoint)andBouchard(proximal
I-Pjoint)nodespresent
Femalepredominancepeakingaroundmenopause
Markedfamilialpredisposition.
49
Typicallypatientisawomanaged40-60years
developingdiscomfortfollowedbyswellingof
singlefingerinter-phalangealjoint,laterinvolving
anotherI-Pjointwithinfewmonthsandthen
anotherproducingstutteringonsetofpolyarthritis
ofdistalandproximalIPjoints.

50. EROSIVE OSTEOARTHRITIS ( EOA)
Characterizedbybothinflammatoryanddegenerativephenomenaofthedistal
interphalangeal(DIP)andproximalinterphalangeal(PIP)jointsofthehand.
*Gull-wingappearance(withabroad,flatandgentlycurvedVshape)
→ Thecombinationofcartilagespaceloss,subchondralCentralerosions,andmarginal
proliferation(osteophyteformation)resultsinagull-wingappearance.
50
Erosion -eating away of a surface
Uncommonvariety
Inflammatorysigns-exhibitsacombinationof
degenerativecartilagechangesaswellasa
rheumatoidarthritis-likeproliferativesynovitis
Erosioninsubchondralregionsinradiography
TendencyforankylosisofI-Pjoints
Subchondralerosivechangemayleadto‘Gull’s
wing’(seagullerosions)*asremodellingoccurs.

51. 51
•ThediagnosisofOAisdependentonpatienthistory,clinicalexaminationofthe
affectedjoint(s),radiologicalfindingsandlaboratorytesting.
•DiagnosticcriteriaofOA
• Threesymptoms
 Persistentpain
 Limitedmorningstiffness
 Reducedfunction
• Threesigns
 Crepitus
 Restrictedmovement
 Bonyenlargement
• Imagingandlaboratoryfindings.
AmericanCollegeofRheumatology(ACR)
classificationCriteriaforOA
Thepresenceofpain
Bonychangesonexamination
AnormalESR
Characteristicosteophytesorjoint
spacenarrowinginRadiographs.

52. DiagnosiscriteriaforOA–Knee
KneepainPlus
PresenceofOsteophytesonradiographsand
Atleastoneofthefollowing
Agemorethan50years
Morningstiffnesslasting30minutesorless
Crepitusonmovement
DiagnosiscriteriaforOA-Hand
Handpain,achingorstiffnessPlus
Hardtissueenlargementoftwoormoreof10selectedjoints*Plus
FewerthanthreeswollenmetacarpophalangealjointsPlus
Hardtissueenlargementoftwoormoredistalinterphalangealjoints
or
Deformityoftwoormoreof10selectedjoints*
(*10selectivejointsare2
nd
and3
rd
DIPjoint,2
nd
and3
rd
PIPjointand1
st
carpo-metacarpaljointofbothhands)
52

53. 53
DiagnosiscriteriaforOA-Hip
HippainPlus
atleasttwoofthefollowing
 ESRoflessthan20mmperhour(Asitisnotainflammatorydisease)
 Femoraloracetabularosteophytesonradiographs
 Jointspacenarrowingonradiographs(superior,axialandormedial)

54. 54
•Radiology
X-Rayofaffectedjoints
MRI-Usefulforpersistentundiagnosedpainofkneejoint.disease.MRIcan
detectmeniscaltearsandloosebodies,largefocalarticularcartilagelesions.
•Synovialfluidanalysis-Highviscosity,mildleukocytosis(<2,000)withpredominantly
mononuclearcells.
•CBC,ESR-MayhelpidentifyanunderlyingcauseofsecondaryOA.
•Serumuricacid
•Serumcalcium/Phosphate
•Arthroscopy-Maydetectearlysubchondralboneabnormalitiesbystereoscopereconstruction.
•Radionuclidestudies-Maydetectabnormalitiesbeforeradiographicsignsareidentified.
•Ultrasound-Foranteriorkneepainwithsuspectedtendinopathyorassociatedbursitis.

55. 55
Normal X-RAY –KNEE
A. Standing anteroposterior(AP)
B. Lateral
C. Sunrise view
RadiologicalfindingsofKneejointsOA

56. 56

57. 57
AP VIEW

58. 58
A.Joint space narrowing
B.New subchondral bone formation
C.Medial osteophytesformation is most prominent initially
AP VIEW

59. 59
PF –PatellofemoralOA LATERAL VIEW

60. 60
SUNRISE VIEW
PF –PatellofemoralOA
Differentpositionsforskylineviewof
patella-femoraljoint,ofwhichKnutsson
viewismostconvenient
NORMAL VIEW

61. 61

62. 62Hand:(Singlepostero-anteriorview).
●Bonesclerosis ●Focalnarrowing ●Lateralsubluxationaccompaniedbyerosions
●Erosiveosteoarthritis,allchangesofosteoarthritisplussubchondralboneerosion-gullwing/sawtooth
appearancepresent
RadiologicalfindingsofHandjointsOA

63. •Thisisdoneusinganarthroscope(atypeofendoscope)thatisinsertedintothe
jointthroughasmallincision.
•Arthroscopyallowsearlierdiagnosisbydemonstratingthemoresubtlecartilage
changesthatarenotvisibleonx-ray
•Theadvantageofarthroscopyovertraditionalopensurgeryisthatthejointdoes
nothavetobeopenedupfully.Instead,onlytwosmallincisionsaremade—
oneforthearthroscopeandoneforthesurgicalinstrumentstobeusedinthe
kneecavity.
•Surgeonsviewthejointareaonavideomonitor,andcandiagnoseandrepair
tornjointtissue.
63
NormalArticularCartilage OAdegeneratedcartilagewithexposedsubchondralbone
OA–ArthroscopicDiagnosis

64. 64
Treatmentgoals:
Relievepainandothersymptoms
Maintainorimprovejointfunction
Minimizedisability
Enhancequalityoflifeandfunctionalindependence
Minimizeanyrisksoftherapy
Educatepatientsandtheirfamilies

65. 65
Treatment principle
ConservativeTreatment(Non-operativeTreatments)
Lifestylemodification
Orthotics
Medication
→Topicaltreatments
→Oralanalgesics
→Chondroprotectiveagents(Neutraceuticals)
→Intra-articularinjections
OperativeTreatments
ArthroscopicLavageandDebridement
CartilageRepairTechniques
OsteotomiesaroundtheKnee
JointArthroplasty

66. •WeightLoss
•Obesityisthemostimportantmodifiablefactorcausing
kneeOA.5%weightreductionresultedinan18%
improvementinfunctioning
•Patienteducationandself-management
•Behaviouralinterventiontoincreaseexercise
andphysicalactivity
•Musclestrengtheningandstretchingexercises
•ImproveROM
Careshouldbetakentominimizestressontheaffectedjoints.
Example–
 LumbarfacetOAmaybeworsenedbyswimmingdueto
hyperextensionofthespine
 Individualswithchondromalaciapatella–nobikeriding
66

67. 67
IMPROVE ROM in KNEE OA
•Increasemuscularstrengthof
•Quadriceps
•Hamstring
•TFL(TensorFasciaeLataemuscle)
•GluteusMedius
•GluteusMaximus
Exampleofexercises
•StretchingofTightmuscles
•Posteriorcapsulestretching
•Patellarmobilityexercises
•TFLstretchingifpatellashiftedlaterally
•Maintenancetherapy
Patellar exercise

68. HamstringStretch CalfStretch StraightLegRaise QuadSet
SeatedHipMarch PillowSqueeze HeelRaise SideLegRaise
SittoStand OneLegBalance StepUps Walking
68
IMPROVE ROM in KNEE OA

69. •Orthoticscantreatpatientswiththeuseofbeltsandbracestocorrectand
supportmal-alignmentsanddefects.
•Usingspecialappliancesmayhelppatientsfeelmorecomfortable,movearound
independentlyandhaveimprovedfunctionbysupportingthemuscleslinkedtothe
affectedjoint.
•ExamplesofOrthoticsforOA
→Cane,Crutches,walkingaids(Walkers)
→Splints,braces
→Kneetaping
→Footwearmodification
69
Cane
Crutches
walkingaids(Walkers)
Braces
Splints

70. Kneetaping
Application&positioningoftapetoalignthekneeina
morestableposition,improvedalignmentreducesstress&
strainonthesofttissuesthatsurroundtheknee
70
Footwearmodification
•Varus(obliquedisplacementtowardsmidline)Lateralwedgeinsole(itreduces
thevarustorque)
•Valgusdeformity(obliquedisplacementawayfromthemidline)-Medialwedge
insole(itreducesthevalgustorque)
•Flatfoot(archoftheinstepisflattened)-Medialarchsupport

71. 71
Topical treatments
Topicaltreatmentsarepreferredoversystemictreatmentsbecauseofsafetyreasons.
•Localcoldorheat:Hotpacks,hydrotherapy
•TopicalNSAIDs(localuse2–4timesdaily)
•Diclofenacgel
•Ketoprofengel
•Topicalcapsaicin(activeingredientinchilipeppers)
•Liniments:Methylsalicylates
(Rubefacientslikemethylsalicylate,camphor,Mentholetccauseirritationand
rednessoftheskinduetoincreasedbloodflow)

72. 72
Oralanalgesics
•Oralanalgesics,particularlyNSAIDs,shouldbeconsideredforalimiteddurationfor
reliefofsymptoms.

73. 73
•Paracetamoland/ortopicalNSAIDsshouldbeconsideredfirst.
•Ifthisisinsufficienttoreliefpain,thentheadditionofanoralNSAID/selective
COX-2inhibitor/opioidsshouldbeconsidered.(example-Tramadolwith
paracetamolorTramadolwithAceclofenac)
→ ParacetamolDose:325to650mgevery4to6hoursor1000mgevery6to8hoursorally
→ TramadolDose:50to100mgorallyevery4to6hours(Maximum400mg/day)
 Extended-Release:100mgorallyonceaday(MaximumDose:300mgorallyperday)
→ Aceclofenac-100mgtwicedaily(200mgSRtab/OD)
→ Diclofenacsodium-50mgorally2-3times/day(max.150mg/day)
 Extended-Release:100mgorallyonceaday
→ Diclofenacpotassium–50mgorally2-3times/day(max.150mg/day)
→ Indomethacin-75mg/day
→ Celecoxib-100mgtwicedaily(200mgSRtab/OD)
→ Etoricoxib–30to120mgoncedaily(90mg/day)
•AllNSAIDSmustbecombinedwithaprotonpumpinhibitor(PPI)

74. 74
Nutraceuticals
Chondroprotective agents
•Glucosamine
 TherearedifferentformsofglucosamineincludingGlucosamineSulfate
(frequentlyused),Glucosaminehydrochloride,andN-acetyl-glucosamine.
 Dose-Glucosaminesulfate
→Oral-1500mgoncedailyor500mgthreetimesdaily.
→Localapplication-30mg/gramofglucosaminesulfate(+50mg/gramof
chondroitinsulfate,32mg/gramofcamphorand9mg/gramofpeppermintoil)
→IM-400mgofGlucosaminesulfatetwiceweeklyfor6weeks.
 Glucosaminesulfate750mg+Turmericrootextract500mgtwicedailyhas
beenusedfor6weeks.
 Dietarysupplements(Nutraceuticals)thatcontainglucosamineoftencontain
additionalingredients.likechondroitinsulfate,methylsulfonylmethane(MSM),
orsharkcartilage.
Nutraceuticals-any product derived from food sources with extra health benefits in addition to the basic nutritional value found in
foods.

75. 75
•Chondroitinsulfate
Dose-800to1,200mg/day(400mgoftwoorthreetimesdaily)
ChondroitinsulfateisoftenmarketedincombinationwithGlucosaminesulfate.
•Methylsulfonylmethane(MSM)
Dose-1.5to6gramsofMSMdailytakeninuptothreedivideddoses
•Diacerein
Dose-50mgonce/twicedailywithfood
Warnaboutredurine/irritablebowel
•Collagenhydrolysate(CollagenpeptideII)
Collagenismadefrombeef,porkorfishbonesandskins.
Dose–1–10gcollagenhydrolysateand0.1–10mgofchickenorbovinetypeII
collagen.
Givenforaperiodof2-3monthsthenbreakfor3to4monthsandrestart
•CalciumsaltsandVitamins

76. 76
Intra-articularinjections
Intra-articularcorticosteroidinjections(Glucocorticoids)
→ Triamcinoloneacetonide(example–kenalog40)
 Combinedwithalocalanesthetic(Lidocaine4mL+kenalog1mL)

77. 77
Intra-articularhyaluronan
→ Lubricatethejoint,decreasefriction,decreaseimpact,delay
jointaging,reducepain,andstiffness.
→ Hyalganisusuallygivenwhenotherarthritismedicationshavenot
beeneffective.
→ Dose-2mLbyintra-articularinjectionintothekneeonceweeklyfor
3to5weeks.
→ Hyalganisnotapprovedforusebyanyoneyoungerthan21years
old.

78. 78
Surgeryshouldbeconsideredforpatientswithstructuralabnormalitieswhenother
treatmentmodalitieshavenotbeensufficientlyeffectiveinrelievingpain.
ArthroscopicIrrigation-WashoutdebrisbypouredaliquidsolutionunderVisuallyguide.
ArthroscopicDebridement-Removalofdamagedcartilagebyinstruments.
CartilageRepairTechniques
•BoneMarrowStimulatingTechniques
•OsteochondralTransplantationTechniques
•AutologousChondrocyteImplantation(ACI)
OsteotomiesaroundtheKnee-Surgicalprocedurethatrealignsthekneejointtorelieve
pressureonthekneejoint(eitherthetibiaorfemuriscuttoreshaped)
JointArthroplasty
 PartialKneeArthroplasty-Surgerytoreplaceonlyonepartofadamagedknee
withartificialmaterial
 TotalKneeArthroplasty–TotalKneereplacementwithartificialmaterial

79. 79
ExampleofsurgicalProceduresinOA
•ThumbbaseOA(thumbmetacarpalandtrapeziuminvolved)-Trapeziectomy
•InterphalangealOA-ArthrodesisorArthroplasty
→Arthrodesisreferstosurgicalfusionofajoint.
→Arthroplastyisreconstructionorreplacementofajoint.
•KneeOA
 ArthroscopicIrrigation-Washoutdebrisbypouredaliquidsolution
 ArthroscopicDebridement-Removedamagedcartilageorboneby
instruments
 HighTibialOsteotomy-surgicalprocedurethatrealignsthekneejoint
 UnicompartmentalKneeArthroplasty(UKA)/PartialKneeArthroplasty-
Surgerytoreplaceonlyonepartofadamagedknee
 TotalKneeArthroplasty(TKA)-Kneereplacementwithartificialmaterial

80. 80
ArthroscopicIrrigation/Debridement

81. High TibialOsteotomyin Unicompartmentalarthritis
 GenuValgusorVarus(distallateralmeansValgusanddistalmedialmeans
varus.)
 Realignmechanicalaxis
81

82. UnicompartmentalKnee Arthroplasty(UKA)
/ Partial Knee Arthroplasty
Total Knee Arthroplasty(TKA)
82

83. Total Knee
Replacement
83

84. THANKS
84