Osteoarthritis (OA) is the commonest joint disorder. Among adults age of 45 years or older the prevalence of symptomatic knee OA is 10% in men and 13% in women. The number of people affected with symptomatic OA is likely to increase due to the aging of the population and the obesity epidemic.
Arthritis means “joint inflammation”. Inflammation is one of the body’s natural reactions to disease or injury, and includes; swelling, pain, and stiffness. Inflammation that last for a very long time or recurs, as in arthritis, can also lead to tissue damage. Osteoarthritis is recognized on X-ray by narrowing of joint space (due to loss of cartilage) and the presence of osteophytes, osteosclerosis, and cysts in the bone. The condition is treated with analgesics, by reducing the load to the joint by weight loss or the use of walking stick, by the use of orthosis(braces) for support and also by surgery by osteotomy, arthrodesis, or arthroplasty.
Osteoarthritis (OA) is known to be the most common form of arthritis and it usually occurs in approximately 13% of persons who are aged 60 and above. It is also known as a degenerative joint disease or a group of mechanical abnormalities involving degrading of joints. It may also mean a degenerative non inflammatory disease that result in pain and restricted movement of affected joints. Osteoarthritis occurs in both sexes but is common among women especially after menopause and after effect of pregnancy which exert much load on the weight joint in women. OA usually results from poor posture, sex, occupation of an individual, age, hereditary, occupational stress or strain.
In normal joints, a firm, rubbery material called cartilage is a slippery tissue that covers the ends of each bone. In a joint, healthy cartilage provides a smooth, gliding surface for joint motion and act as a cushion between the bones. It also helps absorb the shock of movement. In osteoarthritis, the top layer of cartilage breaks down and wears away. This allows the bones under the cartilage to rub together. The rubbing causes pain, swelling and problems moving the joint. Overtime, the joint may lose its normal shape.
Patients with OA are usually faced with a set of problems which requires rehabilitation such as orthotic management and medical services. At the chronic stage of OA, rehabilitation may cause permanent disability to a patient and may restrict the patient from general activities, hence early rehabilitation and treatment of osteoarthritis is necessary.
As osteoarthritis worsens over time, bones may break down and develop growths called “bone spurs” which may grow on edges of the joint. Bits of bone or cartilage may chip off and float around inside the joint space, which causes more pain and damage. In the body, an inflammatory process occurs and cytokines (proteins) and enzymes develop that further damage the cartilage. In the final stage of OA, the cartilage wears away and bone rubs leading also to joint damage and more pain.
OA is the most common form of arthritis. It is a joint disease that most often affects middle-age to elderly people, also referred to as “wear and tear” of the joints. It is more commonly diagnosed in females than males. Most often, it occurs in patient age 40 and above. It is defined as a degenerative non inflammatory joint disease characterized by destruction of articular cartilage and formation of new bone at the joint surface and margin.
OA may also mean a degenerative non inflammatory disease that result in pain and restricted movement of the affected joints. This is because the articular cartilage has a poor ability to repair and regenerate when damaged or degraded because it is void of capillaries, as age progresses, a gradual degeneration of all joints occurs which is known as Osteoarthritis.
This articular cartilage is seen as joint between bone articular surfaces. The role of this cartilage is to protect bone articular surfaces and also to prevent bone to bone contact; absorb shock; and cushion shock; thereby reducing friction and wear and tear at the joint. The daily human activities that exert load at joint and age resulting to long use of joint catalysts and degeneration of articular cartilage is one of the major reasons why weight bearing joints are affected.
Other causes of OA include; infection; sex; trauma; being overweight; joint injury; getting older and stresses on the joints from certain jobs and playing sports.
If the articular cartilage is degenerated or damaged, the individual suffers from joint instability and general difficulty in trying to function with the affected joint. The degeneration continues without prompt and adequate intervention and cause permanent disability.
CAUSES OF OSTEOARTHRITIS
Osteoarthritis occurs when the cartilage that cushions the ends of bone in the joints gradually deteriorates. Cartilage is a firm, frictionless joint motion.
Cartilage is a relatively vulnerable tissue, and a number of factors, such as age, predispose it to damage.
Pressure (loading) on the cartilage cells (chondrocytes) to produce a collagen and protein matrix. Replacement process of matrix is normally a slow process, but excessive loading can lead to activation of enzymes (metalloproteases) that digest it, leading to thinning and damage.
It is also more prevalent in women than in men. Genetics heredity factors also predispose one to osteoarthritis. Mechanically, trauma, and strenuous long term exercises also increases the risk of OA. Disease and infective conditions of the joint also causes damage to articular cartilage which results to osteoarthritis.
AGE: The risk of osteoarthritis increases with age. Most people who have osteoarthritis are older than 45 years old. Although advance osteoarthritis may occur in many young people in early 20’s, the frequency of condition escalates markedly in advancing years. Furthermore, older people are found to have rapid radiological progression of osteoarthritis.
SEX: The Framingham Knee Osteoarthritis study suggests that knee osteoarthritis increases in prevalence throughout the elderly years, more so in women than in men. Females are found to have more severe OA, more number of joints are involved, and have more symptoms and increased hand and knee osteoarthritis.
OBESITY: Obesity precedes rather than follow knee osteoarthritis and indeed weight loss prevents development of knee osteoarthritis.
GENETIC: Hip osteoarthritis has a significant genetic component.16 Nodal generalized osteoarthritis is a polyarticular form of osteoarthritis characterized by Heberden’s nodes occurring mainly in women of premenopausal age.
BONE DENSITY: Negative association has been reported between osteoporosis and osteoarthritis at certain sites particularly the hip.
CIGARETTE SMOKING: Protective influence of smoking on knee osteoarthritis has been reported from various studies including Framingham study.
INJURY AND OVERUSE: Repetitive movements or injuries to joint (such as a fracture, surgery or ligaments tears) can lead to OA. Some athletes, for examples repeatedly damage joints, tendons and ligaments, which can speed cartilage breakdown. Certain careers that require standing for long periods of time, repetitive bending, heavy lifting or other movements can also make cartilage wear away more quickly. An imbalance or weakness of the muscles supporting a joint can also lead to altered movement and eventual cartilage breakdown in joints.
JOINT LOCATION: Osteoarthritis is more common in hip and knee joint but occur rarely in ankle. Alteration in chondrocyte responsiveness to different cytokines may be the reason e.g. Knee chondrocytes exhibit more IL-1 receptors than ankle chondrocytes and knee chondrocytes express mRNA for matrix MMP-8.
OTHERS: Several other factors may contribute to osteoarthritis, these factors include bone and joint disorder like “rheumatoid arthritis, certain metabolic disorder such as hemochromatosis, which causes the body to absorb too much iron, or acromegaly, which causes the body to make too much or excess growth hormone, also run a higher risk of osteoarthritis.
Chondrocalcinosis,10 crystals in joint fluid / cartilage, prolonged immobilization, joint hypermobility or instability, peripheral neuropathy, prolonged occupational or sports stress are the important risk factors for the causation of osteoarthritis.
REGIONS AFFECTED BY OSTEOATHRITIS.
Osteoarthritis affects weight bearing joints like the hip, the knee and the joints of the lower lumbar and cervical spine
KNEE: Most commonly affected by osteoarthritis, usually bilateral, often occurs in association with hand osteoarthritis especially in women.
HIP: Superior pole osteoarthritis is commonest with focal cartilage and loss in superior part of joint. Osteophyte formations are prominent at lateral acetabular and medial femoral margins with thickening of cortex of medial femoral neck by periosteal osteophytes. Central medial osteoarthritis is less common, with more central joint space loss with less femoral neck buttressing. More associated with nodal osteoarthritis.
Osteoarthritis at other joint sites: Osteoarthritis of spinal epiphyseal joints (lower cervical and lower lumbar segments), first carpometacarpal and/or first metatarsophalangeal joints is common and may occur as a part of pattern of generalized osteoarthritis or as an isolated feature
CLINICAL FEATURES OF OSTEOARTHRITIS
Osteoarthritis is presents with many symptoms but the most common is pain. Pain is the chief complaint. This is due to stimulation of capsular pain fibers, mechanoreceptors (increased intra-articular pressure due to synovial hypertrophy), periosteal nerve fibers and by perception of subchondralmicrofractures or painful entheses and bursae. Stiffness is other complaint described as gelling of joint after inactivity with difference in initiating movement. Some patients may complain of joint swelling and deformity and coarse crepitus.
SIGN: Coarse crepitus, due to irregularity of articular surface, bony enlargement due to remodeling and osteophytes, deformity, instability, restricted ability and stress pain.
NODAL GENERALIZED OSTEOARTHRITIS: Present commonly as polyarticular, finger I-P joint involvement, Heberden (distal I-P joint) and Bouchard (proximal I-P joint) nodes. There is female predominance peaking around menopause and marked familial predisposition. Typically, patient is a woman aged 40-60 years developing discomfort followed by swelling of single finger inter-phalangeal joint, later involving another I-P joint within few months and then another producing stuttering onset of polyarthritis of distal and proximal IP joints.
EROSIVE OSTEOARTHRITIS: Uncommon variety, with hand I-P joint involvement, inflammatory signs, erosion in subchondral regions in radiography and tendency for ankylosis of I-P joints. Subchondral erosive change may lead to ‘Gull’s wing’ as remodeling occurs.
Hence, pain is the predominant symptom of knee OA with the pain being generally related to joint use and with relief at rest. As OA progresses, pain may become more persistent and can appear also at rest and during the night. For a patient with symptoms, the inability to have restorative sleep may reduce the pain threshold via associated fatigue and reduced well-being.
Another typical feature in knee OA is short-lived morning stiffness, which is distinct from the more prolonged and often generalized joint stiffness characteristic of rheumatoid arthritis. The early morning stiffness, occasionally severe is believed to be related to inflammation. Patients with knee OA describe stiffness as a difficulty to rise from a chair, slowness of movements, or clumsiness later in the day.
Knee osteoarthritis is the greatest contributor to impairment in functional ability of OA patients. The disability can be extensive containing mobility limitation, difficulty to cope with activities of daily living and social isolation. The principal contributors to disability are believed to include pain, reduce range of joint movement as well as muscle weakness.
TYPES OF OSTEOARTHRITIS.
Primary osteoarthritis is a chronic degenerative disorder related to but not caused by aging, as there are people well into their nineties who have no clinical or functional signs of the disease. The pathophysiology of osteoarthritis involves a combination of mechanical, cellular, and biochemical processes.
This type of osteoarthritis is caused by other factors but the resulting pathology is the same as for primary osteoarthritis i.e.
Congenital or developmental disorders of joints. (valgus and varus deformity)
Mechanical: limb length discrepancy, malalignment, hyper-laxity, Ehlers-Danlos syndrome, Marfan’s syndrome.
Inflammatory: rheumatologic diseases, i.e., rheumatoid arthritis, SLE, all chronic forms of arthritis.
Traumatic: injury to joints or ligaments, postsurgical l Infective: septic arthritis, Lyme disease.
Metabolic: haemochromatosis and Wilson’s disease, gout, calcium crystal deposition, alkaptonuria l Endocrine: diabetes, acromegaly, hypothyroidism,
Miscellaneous: haemophilia, osteonecrosis.
INVESTIGATION OF OSTEOARTHRITIS
A combination of the following methods is used to diagnose osteoarthritis:
In this case the patient will be asked when the condition started and how the symptoms have changed since. The patient will also describe any other medical problems she or her family may have, and any medication being taken. This helps the doctor make a diagnosis and understand the disease’s impact on you.
X-rays are still the main diagnostic tool however arthroscopy, ultrasound, MRI, CT scan etc. are used specially for experimental studies and not recommended for routine clinical use. Plain radiographs can show joint space narrowing, osteophytes, sclerosis and subchondral radioluscencies.
Other features like effusions, loose bodies, joint alignment, subluxation, chondrocalcinosis, collapse due to avascular necrosis are also noticed. Arthrocentesis and laboratory testing may help identify an underlying cause of secondary OA.
The affected joint in patients with osteoarthritis will generally be tender to pressure right along the joint line. Joint movement may cause a crackling sound. The bone around the joints may feel larger than normal. The joint’s range of motion is often reduced, and normal movement is often painful.
Blood test results may help identify other types of arthritis beside osteoarthritis. Some examples include: Elevated levels of rheumatoid factor (specific antibodies in the blood) are usually found in patients with rheumatoid arthritis. Abnormal results for test such as the erythrocyte sedimentation rate (ESR, or “sed rate”) and C-reactive protein (CRP) indicates inflammation, which may be caused by conditions such as rheumatoid arthritis or systemic lupus erythematous Elevated uric acid levels in the blood may indicate gout. A number of other blood tests may help identify other rheumatologic illnesses.
Tests of the Synovial Fluid
If the diagnosis is uncertain or infection is suspected, a doctor may attempt to withdraw synovial fluid from the joint using a needle. There will not be enough fluid to withdraw if the joint is normal. If the doctor can withdraw fluid, problems are likely, and the fluid will be tested for factors that might confirm or rule out osteoarthritis.
Cartilage cells in the fluid are signs of osteoarthritis. A high white blood cells count is a sign of infection, gout, pseudogout, or rheumatoid arthritis. Uric acid crystals in the fluid are an indication of gout.
Gout is one of the most painful forms of arthritis. It occurs when too much uric acid builds up in the body. The buildup of uric acid can lead to:
• Sharp uric acid crystal deposits in joints, often in the big toe
• Deposits of uric acid (called tophi) that look like lumps under the skin
• Kidney stones from uric acid crystals in the kidneys.
For many people, the first attack of gout occurs in the big toe. Often, the attack wakes a person from sleep. The toe is very sore, red, warm, and swollen.
Gout can cause:
• Stiffness in joints.
A gout attack can be brought on by stressful events, alcohol or drugs, or another illness. Early attacks usually get better within 3 to 10 days, even without treatment. The next attack may not occur for months or even years.
Gout is caused by the buildup of too much uric acid in the body. Uric acid comes from the breakdown of substances called purines. Purines are found in all of your body’s tissues. They are also in many foods, such as liver, dried beans and peas, and anchovies.
Normally, uric acid dissolves in the blood. It passes through the kidneys and out of the body in urine.
But uric acid can build up in the blood when:
• The body increases the amount of uric acid it makes.
• The kidneys do not get rid of enough uric acid.
A person eats too many foods high in purines. When uric acid levels in the blood are high, it is called hyperuricemia. Most people with hyperuricemia do not develop gout. But if excess uric acid crystals form in the body, gout can develop. You are more likely to have gout if you:
• Have family members with the disease
• Are a man
• Are overweight
• Drink too much alcohol
• Eat too many foods rich in purines
• Have an enzyme defect that makes it hard for the body to break down purines
• Are exposed to lead in the environment
• Have had an organ transplant
• Use some medicines such as diuretics, aspirin, cyclosporine, or levodopa
• Take the vitamin niacin.
Other factors may be present that suggest different arthritic conditions, including Lyme disease and rheumatoid arthritis. In people with known osteoarthritis, researchers may look for certain factors in synovial fluid (sulfated glycosaminoglycan, keratin sulfate, and link protein) that can suggest a more or less severe condition.
Radiological examination of the joint is the most common diagnostic tool. The following features are seen in OA.
• Loss of joint space (due to destruction of articular cartilage)
• Bony collapse (due to compression of weakened bone)
• Deformity and malalignment (due to destruction capsule and surfaces)
• Sclerosis (due to increased cellularity and bone deposition)
• Osteophyte (due to revascularization of remaining cartilage and capsular traction)
• Subchondral cysts (due to synovial fluid intrusion into the bone)
WARNING SIGNS OF OSTEOARTHRITIS
• Swelling or tenderness in one or more joints.
• A crunching feeling or the sound of bone rubbing on bone.
• Stiffness in a joint after getting out of bed or sitting for a long time.
• Loss of flexibility also called the loss of range of motion.
Rehabilitation here means restoring a patient unwanted health condition to its original condition or his improved state acceptable by him.
Aims of rehabilitation include pain reduction, to improve the patient joint congruence, to prevent or to delay total joint arthrodesis or arthroplasty.
There are two methods of rehabilitation and they include surgical and non-surgical methods. Non-surgical is also known as conservative method.
Indications for surgical method include pain, frequent locking episodes’ history, deformities such as genu varum, joint instability, osteochondral fractures. Surgical intervention provides long lasting solution to chronic osteoarthritis. The aim of surgical intervention could be for alignment of the bone, partial or total joint replacement, and to change the line of weight bearing.
Referral for joint replacement surgery should be considered in patients who experience persistent pain and reduced function that are refractory to non-surgical therapies, and which impact markedly on their quality of life.
Total or partial joint arthroplasty surgeries are highly invasive procedures, requiring surgical resection of all or parts of the joint and insertion of prosthesis. Many patients who undergo total knee arthroplasty (TKA) experience improved function and decreased symptoms, many others continue to have some degree of ongoing pain. A recent investigation of post TKA symptoms reported chronic pain in 88% of patients who have had the surgery. Current evidence does not support arthroscopic lavage and/or debridement as part of unselected knee OA treatment.
Several surgical options are available for severe thumb base osteoarthritis when conservative therapies have failed.
COMPLICATIONS ASSOCIATED WITH SURGERY
Some lower limb operations are simply unsuccessful. One of the most common complications of the lower limb surgery is that it does not get rid of all pain. In some cases, it may be possible to actually increase your pain. Be aware of this risk before the surgery and discuss it at length with your surgeon. He or she will be able to give you some idea of the chance that you will not get relief that you expect.
Some pain after surgery is expected, but if you experience chronic pain well after the operation, you should let your doctor know.
One of the interesting things about how the lower limb works is that it behaves like a chain of repeating segments. When the entire limb is healthy, each segment works together to share the load throughout the lower limb column. Each segment works with its neighboring segment to share the stresses imposed by movements and forces acting on the limb. However, when one or two segments are not working properly, the neighboring segments have to take one or more of the load. It is the segment closet to the non-working segment gets most of the extra stress. This means that if one or more levels are fused anywhere in the limb, the lower limb segment next to where the surgery was performed begins to take on more stress. Overtime, this can lead to increased wear and tear to this segment, eventually causing pain from the damaged segment. This is called a transitional syndrome because it occurs where the transition from a normal area of the limb to the abnormal area that has been fused.
Implant migration is a term used to describe the fact that the implant has moved from where the surgeon placed it initially. This usually occurs fairly soon after surgery – before the healing process has progressed to the point where the implant is firmly attached by scar tissue or bone growth. If the implant moves too far, it may not be doing its job of stabilizing the two vertebrae.
If it moves in a direction towards the limb or large vessels – it may damage those structures. If you have problem with implant migration, your surgeon may have to perform a second operation to replace the implant that has moved. You doctor will check the status of the hardware with X-rays taken during your follow-up office visits.
In many different types of lower limb operations, metal screws, plates, and rods are used as part of the procedure to hold the vertebrae in alignment while the surgery heals. These metal devices are called “hardware”. Once the bone heals, the hardware is usually not doing much of anything. Sometimes before the surgery is completely healed the hardware can either break – or move from the correct position. This is called a “hardware fracture”. If this occurs, it may require a second operation or move from the correct position.
NON – SURGICAL OR CONSERVATIVE METHOD
Conservative methods of treatment include the use of traction, reduction of weight, manipulation, massage, manual therapy, which is applied by physical therapist to reduce joint stiffness, heat therapy, and non – steroids anti – inflammatory drugs and intra – articular injection of steroids. During the conservative methods of treatment, the use of orthotic can also be implemented. Types of orthotic used include the knee brace, insole, ankle foot orthosis (AFO), walking frame and walking sticks.
The use of a cane, frame or wheeled walker in patients with hip or knee OA reduces mechanical loading and pain. Patient should be educated on the proper use of canes. The cane should be held in the hand contralateral to, and moved together with, the affected limb. The total length of the cane should be equal to the distance between the upper border of the greater trochanter of the femur and the bottom of the heel of the shoe. This should result in elbow flexion of about 20O.
Knee braces can be used in patients with OA and mild-to-moderate varus or valgus malalignment. Overuse and unnecessary use of braces may worsen joint instability by contributing to muscle atrophy. They should only be used when there is a flare of inflammation, to protect the joint during unusual activity and when all other treatment modalities have failed.
Knee braces are available for treatment of medial compartment osteoarthritis (arthritis inside the knee joint). These braces need to be custom made and therefore can be expensive.
When you have knee osteoarthritis (OA), you might think that exercise will make your knee hurt more. But exercise can be just what the doctor ordered to help ease the symptoms of the knee osteoarthritis.
Non – surgical or conservative methods of treatment also include:
Patient education is an ongoing, integral part of management. The practitioner should address aspects of the disease process, benefits and risks of treatment options. Empowering the patient, by involving them in shared decision making and providing them with positive skills directed at lifestyle changes, goes a long way to ensure treatment adherence.
Reduction of adverse mechanical factors: Obesity is a risk factor for the development and progression of OA in the knee and hip. It remains one of the strongest modifiable risk factors for OA and weight reduction is an effective primary and secondary disease prevention strategy. Weight loss improves pain and function, particularly for knee OA and to a lesser extent, hip OA. It should be achieved by a combination of correct dietary habits (eat correctly, regularly and less) and exercise. Many patients with OA share other chronic cardiac and metabolic disease and the benefits of weight loss are substantial.
All patients with lower limb OA should be advised about appropriate footwear. A shoe with soft thick soles and no raised heel is recommended. Lateral or medial wedged insoles can be used to reduce pain and improve function in patients with medial or lateral tibiofemoral OA, respectively.
Ice and Heat:
The periodic application of superficial heat or cold is a relatively safe and low cost treatment that can be recommended in isolation or in combination with other treatments for patient with knee osteoarthritis.
Ice is essential during the acute phase of pain and is also useful after exercising. Ice therapy causes capillary vasoconstriction with decreased blood flow and decreased metabolic activity. The resulting decreased inflammatory edema which help in preventing further damage and will provide analgesia. It is the safest anti-inflammatory “medication” but its successful use requires discipline. Applying ice for 10-20 minutes after activity is reasonable.
Heat application causes increased capillary blood pressure and increased cellular permeability, with resultant increased swelling and edema. Heat should thus be used after the initial swelling and edema phases have stabilized. The effect of heat is to increase blood flow and local metabolic activity with relaxation of muscle spasm.
Injection of cortisone into the knee joint has been shown to be effective for ‘flares’ of arthritis symptoms, as they are direct acting anti – inflammatory medication. However, research has shown deterioration of articulate cartilage after repeated cortisone injections. Therefore, these injections are used with caution on the knee joint.
Supplement such as glucosamine sulfate and chondroitin sulfate are widely used but not regulated by FDA. Glucosamine, an amino monosaccharide, is a primary component of connective tissue (including cartilage).
In recent years, there have been numerous studies that have demonstrated the effectiveness of exercise and physical activity for individuals with knee osteoarthritis Although, exercise and physical activity programs have been found to be beneficial the overall effects of this intervention have been found to yield small to moderate effects at best for individuals with knee OA, for example a systematic review of the effectiveness of exercise for reducing pain and improving disability.
Therapeutic exercise is a form of physical activity that is provided under the supervision of appropriate health professional for specific treatment goals. Regular physical activity is associated with lower mortality rates for both older and younger adults. Moreover, it is associated with a decreasing risk for a wide range of disease and conditions, such as cardiovascular disease, osteoporosis, falling, cancer, diabetes, blood pressure and osteoarthritis. The main reasons for prescribing exercise in general include;
(1) Achieving therapeutic goals,
(2) Improving general health and reducing secondary disability, and
(3) Modifying possible risk factors in disease progression.Because muscle weakness plays such an important role in development of OA, it is increasingly evident that exercise plays a critical role in the management of the condition. Although, activity avoidance by knee osteoarthritis patients is common, exercise is an effective non-pharmacological treatment for knee osteoarthritis.
Quadriceps weakness is one of the most common and disabling impairments seen in individuals with knee osteoarthritis (OA). Sufficient quadriceps and hamstrings strength, both isometric and dynamic, is essential for undertaking basic activities of daily living such as standing and walking. Muscle strength testing has revealed that those with knee OA have a 25% to 45% loss of knee extension strength and a 19% to 25% loss of knee flexion strength, compared with similarly aged controls.
There are 3 factors thought to contribute to knee extension and flexion weakness in those with knee osteoarthritis: muscle atrophy, failure of voluntary muscle activity, and apparent weakness from increased antagonist muscle co-contraction.
There are 3 main Types of Exercise for Knee Osteoarthritis:
Flexibility exercises are an excellent way to ease yourself into an exercise program for knee OA, especially if you haven’t been active in years. Knee joints can become stiff if you don’t use them regularly. Pilates, yoga, and other types of stretching are all flexibility exercises every day. When you are able to do at least 15 minutes of flexibility exercise, you can gradually begin to add strengthening and aerobic exercise to your routine.
Stretching should be carried out in conjunction with strengthening exercises. If a specific muscle group is restricted, more emphasis may be placed on these areas but there must be stretching of all the major muscle groups of the lower limb, because they all have an effect on the biomechanics of the knee. Patients should be instructed to hold a stretch for 20-30 seconds for it to be effective.
Stretching includes the quadriceps, hamstring muscles, iliotibialband (ITB), and Achilles tendon. Tightness of the ITB can affect normal patella excursion. The distal ITB fibers blend with the superficial and deep fibers of the lateral retinaculum, and tightness in the ITB can contribute to lateral patellar tilt and excessive pressure on the lateral patella. Because the ITB is a very dense and fibrous tissue, the effectiveness of stretching is questionable.
Strengthening exercise is commonly recommended. Patients with knee OA tend to have reduced muscle strength as a consequence of reductions in physical activity and pain inhibition. The quadriceps are the largest group of muscles crossing the knee joint and have the greatest potential to generate and absorb forces at the knee. Many clinical studies have shown consistent improvements in knee extension strength after training, as well as reductions in pain and physical disability in people with knee osteoarthritis.
Strengthening the hamstring muscle has been found to enhance the functional ability of the deficient knee. This is probably due to the fact that, which an overall increase in both the hamstring and quadriceps strength, and increase in the hamstring to quadriceps ratio (H:Q), anterior-lateral subluxation of the tibia may be minimized.
Strengthening exercise helps build up the muscles surrounding the knee joint and acts as a shock absorber for the knee joint, reducing some of the impacts to the joints. It Improves knee strength, mobility, and function.
It also keeps you at a healthy weight or helps you lose weight (extra weight can put extra pressure on your knee joints).
It may decrease the amount of other treatments you need for knee osteoarthritis, such as medications. You need strong muscles (especially in your legs) to do just about anything walk, climb stairs, bend, and lift.
Little by little, work strengthening exercises into your workout routine until you can do about 15 minutes of strengthening exercise a day. Don’t use any weight initially, you can use your own body weight as resistance. However, as you become familiar with the moves, you can add some light weights.
Aerobic exercises such as walking and water aerobics add another dimension to your workouts. For example, working out in the water is so much easier on your joint than running.
Aerobic exercise is also essential when you have knee OA because it gets your heart pumping and helps keep you at a healthy weight.