Signs And Symptoms
The typical primary symptoms of osteoarthritis are pain with motion and weight bearing. Onset is typically insidious, and the symptoms worsen over the years. Pain is relieved with rest but is accompanied by short episodes of stiffness after inactivity. This stiffness is thought to occur as a result of an intra-articular gel phenomenon. Another common complaint with osteoarthritis is early morning stiffness lasting less than 30 minutes. Some patients report their pain changes based on falling barometric pressure or significant weather changes.³

Osteoarthritis in the spine can cause back pain, stiffness and, eventually, spinal stenosis. All osteoarthritis symptoms may have neuropathic, radicular or claudicant qualities. Pain, numbness, tingling, perceived weakness or cramping can affect any of the extremities.⁵

As osteoarthritis advances, patients experience less relief of symptoms with rest and may begin to have pain at night. Patients may notice deformity, swelling and limited motion of the affected joints. Progressive disability may affect the performance of everyday activities. Patients may have difficulty standing up from a seated position, standing for prolonged periods, walking long distances or going up and down stairs.⁶  

Physical Examination
Depending on the severity of the disease, the physical examination of a patient with osteoarthritis may reveal joint deformity, soft tissue swelling, warmth and bony enlargement. Pain, crepitus or loss of motion may be present at a joint, and locking of a joint may occur due to fragments of loose cartilage. Joint laxity, subluxation or weakness may be evident.^4,9

The joints most frequently affected by osteoarthritis include the hands, the first metatarsal phalangeal joint of the feet, the spine and weight-bearing joints.¹ Heberden's and Bouchard's nodes are common findings in the hands. In most patients, swelling and localized discomfort are detectable on palpation of the affected joint areas.

Patients with hip osteoarthritis typically complain of groin pain that worsens with motion and palpation. The patient with osteoarthritis of the hips may ambulate with a Trendelenberg-type gait and decreased range of motion. Patients with knee arthritis may have a valgus or varus deformity.⁶ Patients with spinal osteoarthritis may report pain, stiffness and possibly radicular symptoms that worsen with spinal range of motion. The patient may also experience weakness, loss of reflexes or decreased sensation due to spinal stenosis.^1,4  

Management
Manage patients with osteoarthritis with a multipronged approach to improve quality of life. This may include a combination of oral, topical or injectable pharmacologic therapy and nonpharmacologic options including lifestyle changes and complementary therapy.

Surgical management is reserved for select cases. Four goals should guide treatment:

1. Attempt to avoid medication complications.
2. Attempt to diminish symptoms.
3. Attempt to improve patient function.  
4. Attempt to reduce the extent of disability.⁴

Medication Therapy
A variety of pharmaceutical options are available to treat osteoarthritis. Acetaminophen 1,000 mg every 6 hours is widely accepted as a first-line treatment for osteoarthritis.

NSAIDs such as naproxen sodium, ibuprofen and meloxicam are also commonly recommended to reduce pain and associated inflammation. For patients who do not respond to a particular NSAID, a different NSAID class may be beneficial.¹⁰ COX-2 inhibitors such as celecoxib are another potential option for patients at risk for GI complications.¹²

For patients who develop muscle spasm at the spine or affected joint, muscle relaxants can be useful on an as-needed basis. Narcotic and non-narcotic pain medications are helpful adjuncts for acute episodic pain flares. A benefit to the use of non-narcotics such as tramadol is that they may be used in combination with NSAIDs.⁵

Research shows topical use of capsaicin cream can improve pain symptoms in some patients. Repeated applications of capsaicin can reduce pain by depleting substance P at the sensory nerves. The efficacy of this cream is lost if it is not used on a regular basis.^1,3,4 A variety of other over-the-counter creams, liniments and patches can provide temporary symptomatic relief.

Injectable Options
Hyaluronic acid (HA) and intra-articular steroids are injectable treatment options.¹¹ HA is fairly effective for patients with mild to moderate knee osteoarthritis. It is produced from the combs of chickens or by bacterial cell extract. Available brands of HA (Synvisc, Hyalgan, Euflexxa, Orthovisc, Supartz) require 3 or 5 weekly injections and produce results lasting up to 6 months.

HA is a normal component of synovial fluid that acts as a lubricant to protect the joint. Patients with osteoarthritis have decreased HA in the joint. HA injections increase joint fluid viscosity, which may decrease joint pain. The product may also produce an anti-inflammatory effect.^1,3,5,6

Intra-articular steroids are indicated for patients with mild to moderate osteoarthritis. Methylprednisolone acetate or triamcinolone acetonide can be injected with lidocaine or marcaine. The duration of pain relief varies; many studies have demonstrated only short-term relief of symptoms. A joint should not be injected with a steroid more often than every 3 or 4 months due to potential accelerated cartilage deterioration. Other potential side effects of the injection include skin atrophy or discoloration, infection or bleeding.^1-6