Understanding Osteoarthritis and Its Management

Understanding Osteoarthritis
and its Management
Understanding Osteoarthritis
and its Management
(For Physiotherapists)
Cmone Mishra
Physiotherapist MPT (Musculoskeletal, Gold Medalist)
Sai Institute of Paramedical and Allied Sciences
Dehradun, Uttarakhand, India
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Understanding Osteoarthritis and its Management
First Edition: 2012
ISBN 978-93-5025-558-2
Printed at
Dedicated to
My Mother
Who taught me that the joy of life lies more in giving than taking
My Father
For the support and encouragement that he gave me
My Best Friend
For being there when I needed him the most and for
being my inspiration to write
My Entire Family
For making my life worthwhile and joyful
and
All My Teachers
Who made me what I am today
Preface
It gives me immense pleasure to present my first edition of the book
entitled Understanding Osteoarthritis and its Management to all the
physiotherapy students. This book is also useful for professionals of
physiotherapy, teachers, doctors, rehabilitation professionals, other
paramedics and general public.
Physiotherapy, if properly understood and skillfully executed by
trained persons, gives excellent results in treating orthopedic disorders and in postoperative rehabilitation. For optimum results,
physiotherapy should be pursued systematically till its final logical
conclusion and should not be abandoned in the middle.
Osteoarthritis is a common condition presenting to most of the
physiotherapists in their clinical practice, but the modes of treatment applied are limited. The book gives you a vast idea about the
condition, its pathology, causes and the various prospects of treatment, which can be approached.
If fifty percent of improvement occurs during the treatment of
an orthopedic condition is through medication or surgery, then the
remaining fifty percent is definitely by physiotherapy.
The book has been written keeping in mind the undergraduate
students of physiotherapy and hence does not focus too much upon
the investigations or the differential diagnosis. The main aim behind
writing the book is to bring the entire concept in a simplified manner and to make the readers understand the protocol-wise treatment
and rehabilitation, which can be followed. The language used is very
viii
simple and the contents very concise that will enable maximum
information be produced by the students in the examination without having to put in too much effort.
The book covers the recent advances in the condition and the
range of exercises which can be followed. All the suggestions and
comments will be accepted with a warm welcome. I hope that the
readers enjoy the effort.
Cmone Mishra
Acknowledgments
First of all, I thank Lord Krishna, the savior, without whose divine
power I would not have been able to get the strength to complete
the book.
I would like to thank my mother, my father and all the members
of my family for giving me the constant morale throughout my life.
I would like to express my thanks and deep gratitude to my
teachers Dr Senthil Selvaseelan, Dr Vasanthan Kumar and lecturers, Oxford College of Physiotherapy, Bengaluru, Karnataka, India,
for their expert guidance, encouragement and support throughout
my course and from whom I have learnt various things in professional
sector. Their unconditional help and words of encouragement
worked as a driving force behind my study. Their constructive
criticism always stimulated me to strive for excellence and perfect
ion in my work.
I thank my friends, well-wishers, and colleagues Mr Brijesh,
Ms Monika, Mr Abhishek, Ms Payal, Ms Jhooma, Mr Rajeev who
had been instrumental in various ways that enabled me to complete
this book.
I thank all the patients who volunteered for this book.
Lastly, I would like to thank all the individuals who directly or
indirectly helped me in this effort of mine.
Contents
1. Osteoarthritis: An Overview..........................................1
Quick Facts2
Osteoarthritis2
Joints in Brief 5
2. Osteoarthritis: Types and Pathogenesis..........................9

Types10
Primary10
Secondary10
Pathology12
Pathogenesis13
3. Osteoarthritis: Clinical Assessment..............................15

Signs and Symptoms16
Capsular Tightness19
Clinical Assessment20
Range of Motion20
Pain Assessment21
Strength22
Assessment of Endurance, Tone and Volume 22
Joint Stability 22
Assessment of Tenderness 22
Assessment of Deformity 23
Functional Assessment (Loss of Function) 23
Mobility and Gait 24
Sensory Integrity 24
xii
Environmental Barriers 24
Investigations25
4. Treatment in Osteoarthritis.........................................27
Treatment28
Lifestyle Modification28
Physiotherapy28
Joint Protection Techniques 51
Medication54
Surgery56
Alternative Treatments57
Other Supplements57
5. Osteoarthritis: Hip Joint..............................................59

Osteoarthritis of the Hip60
General Features of Osteoarthritis60
Primary Symptoms and Signs 61
Classification61
Diagnosis61
Treatment62
Exercises62
Operative Options 67
Rehabilitation after Total Hip Replacement 71
Rehabilitation ProtocolPostoperative THR 75
6. Osteoarthritis: Knee Joint............................................85

The Arthritic Knee86
Review of Pertinent Anatomy and Kinesiology 86
Classification87
Biomechanics89
Diagnosis89
Radiographic Evaluation 92
Nonoperative Treatment Algorithm for Patient
with OA Knee 92
Exercise Regimen 95
Endurance Training 109
Contents
xiii
Functional Training 109

Gait Training 110
Operative Treatment Algorithm 111
Indications for Surgery 111
Operative Options 111
Goals of Rehabilitation after Total Knee
Arthroplasty114
Accelerated ProtocolPostoperative Rehabilitation 115
7. Mobilization Techniques in Arthritic Knee................119

Types of Mobilization Techniques120
8. Osteoarthritis in Various Joints..................................127

The Ankle Joint 128
The Foot128
The Shoulder131
The Elbow131
The Wrist and Hand132
OA of the Small Joints133
Remember133
Summary....................................................................................... 135
Case Study..................................................................................... 136
Appendix 1.................................................................................... 141
Appendix 2.................................................................................... 145
Appendix 3.................................................................................... 146
Appendix 4.................................................................................... 147
Index............................................................................................ 149
Chapter
Quick Facts

Osteoarthritis

Joints in Brief
Introduction
Osteoarthritis:
An Overview
QUICK FACTS
Osteoarthritis (OA)
Whether you have been diagnosed with osteoarthritis or have painful joints that you think may be arthritic, this summary will help you
to understand the causes and how the treatment and physiotherapy
can help you.
What is Osteoarthritis?
Osteoarthritis is a common condition that may cause joint stiffness,
swelling and painusually in the knees, hips, feet, hands and
spine (Fig. 1.1). Some people arthritis can be so severe that joint
replacements are the best solution, while others experience few
symptoms even though X-rays show that they have quite advanced
osteoarthritis.
Fig. 1.1: An arthritic knee
Osteoarthritis: An Overview
What Causes It?
It is not known exactly, what causes osteoarthritis, although it can

be triggered by injury or repeated stress on a joint many years earlier.
For example, carpet layers often develop osteoarthritis in their knees
due to years of wear and tear. It usually affects people aged 50 and
over, and is more common in women. Genetic factors play a role in
some forms of osteoarthritis.
Who is Prone to Get OA?
Middle-aged patients
Women have more risk than men
One in three people over 60 years are affected and more than
three in four person over the age of 70 show some radiographic
evidence of the condition
Very rarely, it can be seen in younger people.
How to Make a Diagnosis?

Physical examination
Symptomatology
Radiology
Blood test
CT scan and MRI.
How can Physiotherapy Help?

Physiotherapists are highly skilled at helping those with osteoarthritis, as they can help improve movement, strengthen muscles, and
increase or restore mobility.
What will Happen When I See a Physiotherapist?
The physiotherapist will assess how your joints are functioning, and
will ask about how they are affecting your life. They will ask questions, watch your movements and feel the joints concerned.
Your consultation is likely to include:

Exercises to do at home
Some manual therapy
Posture and lifestyle, advice on activities to do and those to
avoid
Pain management techniques.
It may also include:
Applying heat or cold to the affected area, and showing you
how to do this at home
Teaching you how to use a walking aid, such as a stick, to help
reduce the pain and make walking easier
Hydrotherapy
Electrotherapy.
Are there Physiotherapists with Extra Training
in this Area?
All physiotherapists have training and skills for treating arthritis.
Physiotherapists with a particular interest in arthritis are likely to be
members of a number of special interest groups.
Meanwhile, How can I Help Myself?
Try to keep mobile. Moving the affected joint helpsreduce
stiffness, and maintains the strength of the supporting muscles
Modify any activities that cause you discomfort, and spread
these activities through the day, taking short rests when necessary
If your joints feel hot or swollen, rest them
Try to be positiveThis will help you to manage the pain and
be motivated to remain active.
Note: If you are getting severe pain in one or more joints, or find
some activities getting very difficult, go to your General Physician.
He or she may prescribe medication to reduce the symptoms or refer

you to a specialist or physiotherapist.
Joints in Brief
Joints are designed to provide flexibility, support, stability, and protection. These functions are essential for normal and painless movements,
and are primarily supplied by specific parts of the joint.
The Synovium and Cartilage
Synovium: Synovium is a membrane that surrounds the entire joint.
It is filled with synovial fluid, a lubricating liquid that supplies nutrient and oxygen to cartilage.
Cartilage: Cartilage is a slippery tissue that coats the ends of the bones.
Cartilage is one of the few tissues in the body that does not have its
own blood supply. It has a number of essential components: ChondrocytesThese are the basic cartilage cells, and are
critical for balance and function
WaterCartilage contains a high percentage of water, although it decreases with age. About 85% of cartilage is water
in young people, an about 70% is water in older individuals
ProteoglycansThese are large molecules, which help to make
up the cartilage. Their important value is their capacity to bind
with water, which ensures a high-fluid content in cartilage
CollagenThis is the critical protein in cartilage. It forms a
mesh to give support and flexibility to the joint. Collagen is the
main protein found in connective tissues of the body, including the muscles, ligaments and tendons.
The combination of the collagen meshwork and the high water content, tightly bound by proteoglycans, creates a resilient and slippery
pad in the joint, which resists the compression between bones during muscle movement. The synovial fluid lubricates and provides
oxygen and nutrients to the bloodless cartilage.
INTRODUCTION
[OA = can be called as OOld age; AArthritis]

Osteoarthritis is derived from the Greek word osteo,
meaning of the bone, arthro, meaning joint, and itis,
meaning inflammation, although many sufferers have little or
no inflammation. Osteoarthritis is not to be confused with rheumatoid arthritis, an inflammatory joint disease. Osteoarthritis
(OA, also known as degenerative arthritis, degenerative joint
disease), is a group of diseases and mechanical abnormalities
entailing degradation of joints, including articular cartilage and
the subchondral bone, next to it. Clinical symptoms of OA may
include joint pain, tenderness, stiffness, inflammation, creaking,
and locking of joints. In OA, a variety of potential forces
hereditary, developmental, metabolic, and mechanicalmay
initiate processes leading to loss of cartilagea strong protein
matrix that lubricates and cushions the joints. As the body
struggles to contain ongoing damage, immune and regrowth
processes can accelerate damage. When bone surfaces become
less well protected by cartilage, subchondral bone may be exposed and damaged, with regrowth leading to a proliferation
of ivory-like, dense, reactive bone in central areas of cartilage
loss, a process called eburnation. The patient increasingly experiences pain upon weight bearing, including walking and
standing. Due to decreased movement because of the pain, regional muscles may atrophy, and ligaments may become more
lax. OA is the most common form of arthritis, and the leading
cause of chronic disability.
The most common type of arthritis is degenerative osteoarthritis,
the incidence of which increases with age. There are however, other
types of arthritis, which are generically termed inflammatory arthritis and include conditions such as rheumatoid arthritis and other
connective tissue related arthropathies.
The knee is the largest synovial joint in the body and is commonly affected by arthritis, as is the hip and the ankle, as well as the foot.
Arthritis is more common in weight bearing joints and so is more
frequently seen in the lower limb than the upper limb (Fig. 1.2).
A common misconception is that OA is solely due to wear and tear,
since OA typically is not present in younger people. However, while
age is correlated with OA incidence, this correlation merely illustrates
that OA is a process that takes time to develop. There is usually an
underlying cause for OA, in which case it is described as secondary OA.
If no underlying cause can be identified it is described as primary OA.
Degenerative arthritis is often used as a synonym for OA, but the
latter involves both degenerative and regenerative changes.
Arthritis of the knee is more common in people who expose
their joints to repetitive microtrauma, of which weight bearing is
a simple example. This will slowly overload the joint, especially
if the person is overweight. It is thought that people involved in
many years of sports, that include running, twisting and jumping
can also be predisposing themselves to an increased risk of arthritis
in future years.
Fig. 1.2: Arthritic joints in the body
There is no doubt that various types of acute trauma to the knee,

such as fractures, dislocations and major ligament injuries, as well
as direct damage to the lining (articular) surface of the knee joint,
can lead to accelerated arthritis development in the years to come.
Chapter
Osteoarthritis:
Types and Pathogenesis
Types

Primary

Secondary
Pathology
Pathogenesis
10
TYPES
Some investigators believe that mechanical stress on joints underlies

all osteoarthritis, with many and varied sources of mechanical stress,
including misalignments of bones due to congenital or pathogenic
causes; mechanical injury; being overweight; loss of strength in muscles supporting joints and impairment of peripheral nerves, leading
to sudden or uncoordinated movements that overstress joints.
Primary
In primary OA, there is no obvious cause. This type of OA 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. As a person ages, the water content
of the cartilage decreases due to a reduced proteoglycan content,
thus causing the cartilage to be less resilient. Without the protective
effects of the proteoglycans, the collagen fibers of the cartilage can
become susceptible to degradation and thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also
occur, though often mild (compared to that which occurs in rheumatoid arthritis). This can happen as breakdown products from
the cartilage are released into the synovial space, and the cells lining
the joint attempt to remove them. New bone outgrowths, called
spurs or osteophytes, can form on the margins of the joints,
possibly in an attempt to improve the congruence of the articular
cartilage surfaces (Fig. 2.1). These bone changes, together with the
inflammation, can be both painful and debilitating.
Secondary
This type of OA is caused by a number of predisposing factors but
the resulting pathology is the same as for primary OA:
Congenital disorders, such as:
Osteoarthritis: Types and Pathogenesis
11
Fig. 2.1: Primary OA in the left knee of an elderly female
Congenital hip luxation

People with abnormally-formed joints e.g. hip dysplasia
(human) are more vulnerable to OA, as added stress is
specifically placed on the joints, whenever they move.
(However, recent studies have shown that double-jointedness
may actually protect the fingers and hand from osteoarthritis)
Diabetes
Inflammatory diseases (such as Perthes disease), (Lyme disease),
and all chronic forms of arthritis (e.g. costochondritis, gout,
and rheumatoid arthritis). In gout, uric acid crystals cause the
cartilage to degenerate at a faster pace
Injury to joints, as a result of an accident
A joint infection, e.g. from an open wound, tuberculosis of
the joint
Hormonal disorders like hyperthyroidism, acromegaly
12
Ligamentous deterioration or instability may be a factor

Marfan syndrome
Obesity: Obesity puts added weight on the joints, especially
the knees
Sports injuries, or similar injuries from exercise or work. Certain sports, such as running or football, put undue pressure on
the knee joints. Injuries resulting in broken ligaments can lead
to instability of the joint and over time to wear on the cartilage
and eventually osteoarthritis
Pregnancy
Alkaptonuria
Hemochromatosis and Wilsons disease.
PATHOLOGY
The first osteoarthritic change in articular cartilage, which has been
confirmed in humans, is an increase in water content. This increase
suggests that the proteoglycans have been allowed to swell with water
far beyond normal, although the mechanism by which this occurs
is unknown. Additionally, there are changes in the composition of
newly synthesized proteoglycan. In later stages of disease progression,
proteoglycans are lost, which diminishes the water content of cartilage. As proteoglycans are lost, articular cartilage loses its compressive
stiffness and elasticity, which in turn, results in the transmission of
compressive forces to underlying bone. Changes in cartilage proteoglycans will also negatively affect the ability of the cartilage to form a
squeeze film over its surface during joint loading. Collagen synthesis is
increased initially, although there is a shift from type 2 collagen fibers
to a larger proportion of type 1 collagen, the kind found in skin and
fibrous tissue. As the articular cartilage is destroyed, the joint space
narrows.
One of the first noticeable changes in cartilage is mild fraying or flaking of superficial collagen fibers. Deeper fraying or
Osteoarthritis: Types and Pathogenesis
13
fibrillation of the upper third of the cartilage follows, and occurs

in areas of greater weight bearing. The cartilage may degenerate to
the point that subchondral bone is exposed. Subchondral bone in
turn can then become sclerotic and stiffer than the normal bone.
These changes in cartilage and bone result in increased friction, decreased shock absorption, and greater impact loading of the joint.
The traditional view of OA is that the disease process starts with an
unrepaired injury to articular cartilage; however, there is also evidence that reduced compliance in bone and periarticular structures
may initiate the degenerative processes.
The process of osteophytes formation in OA is not well understood. Current hypothesis have implicated increased vascularity in
degenerated cartilage, venous congestion from subchondral cysts
and thickened subchondral trabeculae, and the continued sloughing of articular cartilage. Each of these hypotheses, may explain,
how this bony growth contributes to the pain and loss of motion
that accompany OA.
PATHOGENESIS
Unlike the synovium in RA, the major pathological changes of OA
are found in the articular cartilage, particularly the concentration of
proteoglycan, which diminishes according to the severity of the disease. Furthermore, there are metabolic changes in the rate of enzyme
production that facilitate the destruction of cartilage. Even though
proteoglycan concentration decreases with OA, it is also true that
proteoglycan and collagen synthesis increases until the later stages of
the disease. This seeming paradox has given rise to several hypotheses
concerning the pathogenesis of OA, which have yet to be proven.
Given that proteoglycan synthesis increases with OA, it is possible
that the quality of this newly synthesized product may not be equal
to meet the biomechanical load, normally placed on an adult joint.
Chapter
Osteoarthritis:
Clinical Assessment
Signs and Symptoms

Capsular Tightness
Clinical Assessment

Range of Motion

Pain Assessment

Strength

Assessment of Endurance, Tone and Volume

Joint Stability

Assessment of Tenderness

Assessment of Deformity

Functional Assessment (Loss of Function)

Mobility and Gait

Sensory Integrity

Environmental Barriers

Investigations
16
SIGNS AND SYMPTOMS
Not all people with arthritis have symptoms. Arthritis, as stated previously, is an age related phenomenon, and therefore the incidence
increases with age, but the mere presence of arthritic type changes
on X-ray does not equate with symptoms.
Not all joints are equally affected by OA. In the upper extremity,
the DIPs, PIPs, and CMC (Fig. 3.1) of the thumb are commonly
involved. The cervical and lumbar spine, hips, knees and first MTP
are also sites of for OA. Unlike RA, OA does not have a bilateral,
symmetrical presentation. A single joint or any combination of
joints on one individual, may be affected.
OA is not a systemic disease, and is therefore not associated
with systemic complaints such as morning stiffness, fever, and loss
of appetite. Individual with OA, may experience, some stiffness
in articular joints upon awakening that is similar to the stiffness
felt when mobilizing the same joints after inactivity during the
day; but this stiffness does not last as long as in individuals with
Fig. 3.1: Osteoarthritis of CMC joint of thumb
Osteoarthritis: Clinical Assessment
17
RA nor it is generalized to the whole body. The disease process

of OA confines itself to the affected joint. However, the impairment, functional limitation and disability related to OA can reach
far beyond the perimeters of articular cartilage and subchondral
bone.
The symptom that patients will commonly complain of with
arthritis include pain, swelling and limitation of activities. As the
arthritis gets worse, so the symptom severity will increase. Initially,
pain may only occur during walking as in the case of knee arthritis, but eventually rest and night pain is not an uncommon feature. This can lead to one of the other key clinical assessment tools
of arthritis severity, which is that the patient will complain of an
ever decreasing walking distance before the pain will come on. The
swelling is usually related to inflammation, but can also be due to
mechanical factors such as loose pieces of articular cartilage or even
bone floating within the knee, or degenerate associated meniscus
tears.
Although, cartilage degeneration is the primary manifestation of
OA, cartilage is aneural, and therefore not the cause of a persons
pain. Pain in OA may be attributed to incongruent articulation of
joint surfaces, periosteal elevation secondary to bone proliferation
at the joint margin, abnormal pressures on the subchondral bone,
trabecular microfractures and distension of the joint capsule. Many
patients will also experience a secondary synovitis, especially when
the knee is involved.
Heberdens nodes may form in osteoarthritis of hands (Fig. 3.2).
The main symptom is acute pain, causing loss of ability and often
stiffness. Pain is generally described as a sharp ache, or a burning
sensation in the associate muscles and tendons. OA can cause a
crackling noise (called crepitus) when the affected joint is moved
or touched, and patients may experience muscle spasm and contractions in the tendons. Occasionally, the joints may also be filled
18
Fig. 3.2: Nodes in OA hand
with fluid. Humid and cold weather increases the pain in many
patients.
As OA progresses, the affected joints appear larger, are stiff and
painful, and usually feel worse, the more they are used throughout the day, thus distinguishing it from rheumatoid arthritis. In
smaller joints, such as at the fingers, hard bony enlargements,
called Heberdens nodes (on the distal interphalangeal joints) and/
or Bouchards nodes (on the proximal interphalangeal joints), may
form, and though they are not necessarily painful, they do limit
the movement of the fingers significantly. OA at the toes leads to
the formation of bunions, rendering them red or swollen. Some
people notice these physical changes before they experience any
pain.
OA is the most common cause of joint effusion, sometimes
called water on the knee in lay terms, an accumulation of excess
fluid in or around the knee joint. OA of the hip commonly results
in decreased range of motion (ROM) with a tendency for the hip
19
to be held in a somewhat flexed, abducted, and externally rotated

position and the knee in flexion. Decreased hip ROM is clearly
associated with decreased walking speed, decreased stride length
and increased energy expenditure. Moreover, decreased hip ROM
is commonly associated with pain, loss of function and limitations
in physical activity.
Capsular Tightness
One of the most common causes of gross restriction of knee motion is capsular tightness. Fibrosis and subsequent loss of extensibility of the joint capsule, frequently accompanies the progression
of chronic joint diseases such as degenerative joint disease (DJD).
Capsular tightness at the knee results in a characteristic pattern of
restriction in which knee extension is limited by 20 to 30 degree,
and flexion is possible to only 80 to 100 degree. The functional
disability resulting from capsular restriction varies with the patients activity level, but ambulation is inevitably altered because
nearly full knee extension is necessary for normal gait. According to
Laubenthal and coworkers, the mean total flexion-extension necessary for the stance phase of gait is 21 degree for the swing phase
of gait 67 degree; for stair climbing 83 degree; and for sitting and
rising, 83 degree. Because capsular restriction at the knee typically
allows only 50 to 80 degree. Of flexion-extension, some functional
alteration is likely.
Of great significance during walking is the effect of reduced
knee extension on the stresses imposed on the articular surfaces of the joint. Normally, during the stance phase of gait, peak
weight-bearing forces are borne with the joint just short of full
knee extension, a position in which the tibiofemoral contact area
is greatest, and a position in which the joint capsule has not been
drawn completely tight. Since, stress equals force divided by unit
area, the compressive stress of weight-bearing is minimized by a
20
relatively large tibiofemoral contact area. Furthermore, the joint

is not shock loaded by having the slack in the joint capsule suddenly taken up as the knee moves toward extension. If however,
knee extension is lacking due to capsular tightness, the joint cannot move to a position of maximal tibiofemoral contact, and as
the knee extends, the joint capsule suddenly pulls tight. Stress to
the joint surfaces is increased in magnitude and the joint is shock
loaded. The long-term effect is likely to be accelerated wear of
joint surfaces.
CLINICAL ASSESSMENT
The examination should begin by taking patients history that will
orient the therapist to the nature and extent of the current problem
and relate that problem to the past medical history. Following the
history, a review of the cardiopulmonary, integumentary, and neuromuscular systems should be undertaken before performing more
definitive examination of the musculoskeletal system.
A systemic approach is required in order to ensure that all the
relevant aspects are considered. Careful recording of the findings of
the assessment, treatment given and the patients response is necessary.
A great deal of information can be gained from the patients
notes and the PT assessment should concentrate on those aspects
of the patients condition which concern the PT, these include pain,
loss of function and joint stiffness mainly.
Range of Motion (ROM)

Goniometric measurement of passive ROM is indicated at all
affected joints following a gross ROM assessment. When there
is OA in the hip or knee, active motion in functional positions
should be examined in all the joints of both the extremities. It
21
is important to observe motions for symmetry and smoothness

during gait, stair climbing, and arising from a chair. Ascending
stairs requires the greatest amount and velocity of knee flexion
and may be one of the best activities for assessment of knee function. Decreased ROM at the hip and knee, increases the risk for
injury and falls. Nearly 50 degrees of hip flexion and 90 degrees
of knee flexion are required to recover balance from a stumble
during walking.
Accurate evaluation of the passive ROM and its end feel is an
important index of stiffness. The type of joint restriction, whether
capsular or non-capsular, should be noted. The capsular type is indicated by the loss of mobility of the entire joint capsule. A firm
and leathery end feel without effusion, indicates capsular fibrosis,
while abrupt locking end-feel without any apparent stretching of
the antagonists indicates bony ankylosis. The range, at which pain
and discomfort sets in is also recorded along with the overall basic
and accessory movements.
Pain Assessment
It is an indication of joint irritability and not the amount of joint
deterioration.
Site and Distribution of Pain
Quality: Burning, aching, throbbing, searing, referred pain.
Duration: Permanent, persistent, or intermittent.
Triggering factors: Weight bearing, jarring, sustained stress, specific
movement, rest, posture, weather, emotional state.
Relieving factors: Rest, particular movement, temporal/postural adjustments, PT procedures (traction, application of external heat/cold,
massage, manipulative procedures, resisted movements, analgesia).
Also evaluate the intra-articular factors causing pain. This may be
the result of:
22
Destruction of the cartilage exposing the subchondral bone to

the compressive forces.
Osteophytes may encroach upon the synovial lining of the
joint. The osteophytes may directly exert compression on the
soft tissues of the joint as loose bodies. Overall pain could be
reliably assessed by visual analog scale (VAS).
Imbalanced stretch may occur on the weight-bearing joint surfaces due to wear and tear of the cartilage.
Strength
A patient may be strong in the pain free portion of range, but weak
secondary to reflex inhibition in the very portion of the range that is
essential to a functional activity. Joint effusion also inhibits muscle contraction. Individual with deformed joints are inappropriate candidates
for traditional tests of strength. A functional test of strength is therefore
more indicative of rehabilitation needs and will identify the anticipated
goals of strengthening programs prior to initiating treatment.
Assessment of Endurance, Tone and Volume

Assessment of endurance, tone and volume of the muscle groups
related to the involved joints are systematically recorded.
Joint Stability
The ligamentous laxity of any affected joint should be fully investigated. Ligamentous instability of upper and lower extremity joints may
be a significant deterrent to ADL and ambulation. Improper loading
of an unstable joint may also further contribute to its deformation.
Assessment of Tenderness
The degree and the area of tenderness, effusion and crepitus are
carefully examined by palpation, volumetric measures or measuring
tape and relaxed passive ROM respectively.
23
Assessment of Deformity
It is extremely important to measure the degree of deformity accurately. The deformity

may be fixed or dynamic when exposed to
compression. The assessment should therefore
be done in the position of maximum compression, e.g. weight-bearing on the affected leg
alone (Fig. 3.3).
Functional Assessment (Loss of

Function)
The influence of the disease on the functional
performance of the patient are examined and
recorded on a functional evaluation chart. Fig. 3.3: An elderly
lady with arthritis
Damage to a single joint, such as a hip or knee in the right knee.
will have a significant effect on the patients The arthritis has
function. Although, the patient remains am- resulted in a bowlegged (varus) debulant, he may have difficulty in negotiating formity of the right
stairs, bathing or certain aspects of self-care knee
activity.
Difficulty may be encountered negotiating transport, as he
may be unable to get on and off a bus or train and may have
difficulty driving. If the patient is working, restricted mobility
may cause problem. In upper limb, it may be disabling for the
housewife or office worker who requires precise movement and
to be able to handle separate pieces of paper.
Arthritis impact measurement scales are used to measure the
function of an individual. It also includes the performance in psychological and social domains.
24
Mobility and Gait
A complete analysis, particularly noting the gait deviations. Substantial difference in knee ROM and gait velocity between patients
with OA and their peers without arthritis have been demonstrated.
Example
Osteoarthritis of the great toe results in lateral and posterior weight
shift, late heel rise and decreased single limb balance.
Pronation of the foot results in shuffled progression, decreased
step length, initial contact with the medial border of the foot and
decreased single limb support.
Sensory Integrity
Any indication of peripheral neuropathy or nerve involvement
should be investigated using standard examination procedures. Sensory changes that are concomitant with other conditions such as
diabetes or normal processes such as aging should be considered
when appropriate.
Environmental Barriers
The therapist should be aware of physical barriers in the home and
work environments that might require specific examination and
recommendations for change. A discussion about the home and
work environments may reveal conditions that impede regaining
complete independence and make the individual aware of the possibilities for altering these environments. The cost of such changes
may be a limiting factor for implementing these recommendations.
Example
The clinical assessment of a patient with knee arthritis, involves taking a detailed history which will include:
25
Loction of pain
Severity of pain
When the pain comes on activity related, rest pain or night
pain
Swelling of the knee
Walking distance
Activity restriction due to symptoms
The type of analgesia/anti-inflammatories used and their effect
on the symptoms
The effect of any previous treatment that has been givenfor
example, physiotherapy or injections
Any history either in the individual or the individuals family
of inflammatory arthritis or gout.
The next step is to examine the knee joint as well as assessing the hip
joint and the lumbosacral spine both of which can cause radiating
pain to the knee.
During the examination, the patients gait (walking pattern)
is assessed and any deformities of the knee in all the planes are
documented.
Investigations
Laboratory investigations are usually within normal limits. Radiological examination is the most important diagnosis. The following
are the radiological features seen in OA of the knee:
Loss of joint space (due to destruction of the articular cartilage)
Sclerosis (due to increased cellularity and bone deposition)
Subchondral cysts (due to synovial fluid intrusion into the
bone)
Osteophytes (due to revascularization of remaining cartilage
and capsular traction)
Bony collapse (due to compression of weakened bones)
Loose bodies (due to fragmentation of osteochondral surface)
26
Deformity and malalignment (due to destruction of capsules

and ligaments.
Other Investigations
Synovial fluid analysis shows non-inflammatory picture. Bone scan
shows increased uptake of technetium 99, MRI and CT scan to
diagnose Subchondral cysts and Osteophytes, etc.
Chapter
Treatment in
Osteoarthritis
Treatment

Lifestyle Modification

Physiotherapy

Joint Protection Techniques

Medication

Surgery

Alternative Treatments

Other Supplements
28
TREATMENT
Treatment of OA consists of exercise, manual therapy, lifestyle modification, medication and other interventions to alleviate pain.
Lifestyle Modification
No matter the severity or location of OA, conservative measures
such as weight control, appropriate rest, exercise, and the use of
mechanical support devices can be beneficial. In OA of the knees,
knee braces can be helpful. A cane, or a walker can reduce pressure
on involved leg joints which can be helpful for walking and support
(Fig. 4.1). Regular exercise such as walking or swimming, or other
low impact activities are encouraged. Applying local heat before,
and/or cold packs after exercise, can help relieve pain, as can relaxation techniques. Weight loss can relieve joint stress and may delay
progression, although research supporting this is equivocal.
Physiotherapy
Although there is no successful cure for osteoarthritis, the physical
therapy treatment is often directed towards relieving the symptoms
Fig. 4.1: Use of cane on the contralateral side
Treatment in Osteoarthritis
29
and the prevention of further progression of the disease. This may

be hospital, health center or community based. The advantage of
having the patient attend a hospital department is that a wide range
of treatment is available, including hydrotherapy.
Physical therapy is a very popular regimen, which aims to increase range of motion, decrease pain, and improve daily functional
activities and strengthening of weak muscles.
The goals and outcomes of a physical therapy intervention for the
individual with arthritis are to:
Decrease pain
Increase or maintain the ROM of all the joints sufficient for
the patients level of function
Increase or maintain muscle strength sufficient for the patients
functional activities
Increase joint stability and decrease biomechanical stress on all
affected joints
Increase endurance for all functional activities
Promote independence in all ADLs, including bed mobility
and transfers
Improve efficiency and safety of gait pattern
Establish patterns of adequate physical activity or exercise to
maintain or improve musculoskeletal and cardiovascular fitness
Improve coordination and minimize deformity
Train position sense to reduce postural stress and advise rest/
activity relationship
Educate the patient, family and other personnel to promote
the individuals capacity for self-management.
Electrotherapy Modalities Used
These are selected, based on the assessment of the patients needs.
Necessarily, therefore, they are many and various. The primary
30
purpose of using any of these modalities is to suppress and control the

symptoms of inflammation. Appropriate procedures are as follows:
Pain relief
Explaining the idea behind pain relief (pain gate theory)
31
For pain impulse to pass, there should be unopposed passage of information but if impulses are also received from mechanical and
thermoreceptors (application of a hot or a cold pack over the joint
or the use of a modality), then this result in presynaptic inhibition
of C-fibers nociceptive information.
So, for the gate to be open to nociceptive traffic, the i/p has to
be of a smalldiameter nociceptive nature, i.e. through C- fibers.
If largediameter afferent information, i.e. through A- fibers is
superimposed then the gate is closed for pain.
Both the C-fibers and A fibers have a maximum frequency
at which they can conduct, i.e. C-15 pulses/sec. and for A-40
pulses/sec.
If a higher frequency of stimulation is applied, a physiological
block to conduction might occur. This effect can be produced via
TENS or interferential.
Pulsed electromagnetic energy or inductothermy
Pulsed electromagnetic energy or inductothermy is effective in some
patients especially in reducing a dull ache. The localized increase in
arterial blood flow may improve the nutrition to the joint cartilage.
Some patients report an increase in the aching and this is due to
venous congestion in the cysts in the subchondral bone, e.g. in the
head of the femur.
A group of patient with chronic knee arthritis shows improvement when receiving continuous short wave diathermy
with 27.12 MHz. frequency given for 20 minutes for 14 settings along with isometric quadriceps exercise (10 repetitions)
on each setting. Short wave diathermy treatment was given with
participants in sitting position using disk electrode, short wave
diathermy disks were placed at both the sides of the knee and
then the treatment was administered for 20 minutes. Participants
were asked to report any kind of discomfort or burning sensations
within the knee during treatment. Isometric quadriceps exercises
32
were given with the participants in long sitting position with

hands at side, with a roll of towel placed below affected knee. The
participants were now asked to press the towel down and hold it
till count of ten and then relax and repeat again for 10 repetitions
followed by the other side knee.
Wax therapy (Fig. 4.2)
It is useful for hand pain.
Superficial heat
It is used to reproduce localized analgesia and increase local circulation in the area to which it is applied. It penetrates only
a few millimeters, however, and does not enter the depth of
the synovial cavity. Superficial heat can be delivered through a
number of means: infra red radiations, heat pad or a moist hot
pack can bring relief to patients especially where there is associated muscle spasm and the pain is exacerbated by cold. The hot
pack is safer because the heat starts at a given temperature and
gets cooler.
Ice therapy
This is useful if there is acute pain and swelling as can happen at the
knee when loose flakes of cartilage becomes trapped between the
Fig. 4.2: Wax application for OA hand
33
Fig. 4.3: Standard ice pack
joint surfaces (Fig. 4.3). In case of a fat pad on the medial side of the
knee, ice therapy is not indicated.
Ultrasound
This is useful for treating chronic swelling as it softens fluid and loosens scar tissue so that subsequent exercises can be effective in reducing
the swelling and gain pain relief, especially deep aching (Fig. 4.4).
Free Active Exercises and Mobilizations
By restoring mobility and improving circulation can contribute to
pain relief.
Group Therapy
Can provide encouragement to lose weight, carry out home exercises, monitor muscle bulk and by providing moral support to enable
the patient to cope with the pain.
Exercises
Moderate exercise leads to improved functioning and decreased pain
in people with osteoarthritis. Although, exercise appears to be an
important intervention tool, the clinician and the patient should
34
Fig. 4.4: Ultrasound
have a clear understanding of the role of exercise in the treatment

of arthritis. Exercise cannot cure arthritis. It is a powerful tool for
maximizing function and for controlling the emotional, physical,
and societal losses associated with the disease. It is ultimately a tool
that can affect the quality of life. The therapeutic use of exercise
in arthritis is based upon the assumption that bone, ligament, and
muscle change in size and alter material properties as a function of
the amount and magnitude of tissue use. A careful therapeutic exercise program with an emphasis on patient related instruction can
achieve several goals:
Slow or reverse the bodys response to joint pathology by increasing flexibility, strength, endurance and by decreasing pain.
Directly address impairments, functional limitations, and disabilities resulting from arthritis.
Lead to overall improved health status as an effect of cardio-
35
vascular, strengthening, ROM and stretching exercises thereby

improving aerobic fitness and proprioception.
Adequate joint motion and elasticity of periarticular tissues are necessary for cartilage nutrition and health, protection of joint structures from damaging impact loads, function, and comfort in daily
activities. Exercise to regain or maintain motion and flexibility by
low-intensity, controlled movements that do not cause increased
pain. Muscle weakness around an osteoarthritic joint is a common
finding. Progressive resistive/strengthening exercises load muscles in
a graduated manner to allow for strengthening while limiting tissue
injury.
Splinting of the thumb for OA of the base of the thumb leads to
improvements after one year.
In 2002, a randomized, blinded assessor trial was published
showing a positive effect on hand function with patients who
practiced home joint protection exercises (JPE). Grip strength,
the primary outcome parameter, increased by 25 percent in the
exercise group versus no improvement in the control group.
Global hand function improved by 65 percent for those undertaking JPE.
Muscle Strengthening
Decreased muscle function (strength, endurance, power) in persons with arthritis arises from a number of sources: Intra-articular
and extra-articular inflammatory disease processes, side effects of
medication, disuse, reflex inhibition in response to pain and joint
effusion, impaired proprioception and loss of mechanical integrity around the joint. A variety of muscle conditioning programs
can be effective for improving strength, endurance, and function
without exacerbation of pain or disease activity. Initially isometric exercises may be indicated to improve muscle tone, static endurance and strength and to prepare the joint for more vigorous
36
activity. Isometric contractions performed at 70 percent of the

maximal voluntary contraction, held for 6 seconds and repeated
5 to 10 times per day, can increase strength significantly. Successful isometric regimens have included, the contractions at several
combinations of muscle length and joint angles. Isometric exercises at more than 40 percent of maximal voluntary contraction
constricts blood flow through the exercising muscle. Restricted
circulation in the muscle can produce unnecessary post exercise
muscle soreness and the increased peripheral vascular resistance
produce increased blood pressure. In the knee and hip, high intensity isometric contractions tend to increase the intra-articular
pressure.
Instructions to a patient for isometric exercise should include
the cautions to (1) maintain the contraction for no more than 6
seconds, (2) avoid maximal effort because it is neither necessary
nor desirable, (3) exhale during the contraction and inhale during a
similar time period of relaxation, (4) and not to contract more than
two muscle groups at a time.
Dynamic exercise includes both shortening (concentric) and
lengthening (eccentric) contractions. The general principle is to
work the muscle at a high repetition rate and against low resistance. As an example, the main muscles requiring strengthening
B
Fig. 4.5: Strengthening exercises for abductors and quadriceps
37
in the case of knee joint are quadriceps, hip abductors, and so on

(Fig. 4.5).
Slow reversal, repeated contractions are useful for strengthening
muscles, because specific muscles can be worked maximally at different ranges or through range. Although each muscle requires particular strengthening, it is important to perform a daily program of
free active exercises to help maintain muscle balance.
Resisted exercises are equally important for the muscles of
any joint, in which there are osteoarthritic changes. Resistance
can be provided by the weight of the body part. Appropriate
techniques are slow reversal, repeated contractions, and stabilizations. These techniques are particularly useful for working the
muscles in the range appropriate to the patients requirements.
Automanual resistance is useful for some muscles, e.g. sitting,
one leg straightening against resistance of the other leg. Arm
exercises can also be resisted by the other arm. Spring resistance
is useful for certain muscle groups such as elbow extensors, wrist
extensors, latissimus dorsi muscles together with the shoulder
girdle retractors. Rubber balls or bands are useful as resistance
for hand exercises.
In the hydrotherapy pool, buoyancy-resisted exercises strengthen
selected muscle groups. Patterns of movement against resistance
to the water flow (bad ragaz) are particularly useful for hip, knee,
shoulder and spinal joints.
Enhancing Joint Proprioception
Proprioception is the process by which the body can vary muscle contraction in immediate response to incoming information regarding
external forces, by utilizing stretch receptors in the muscle to keep
track of the joint position in the body. So, any pathology that adversely affects joint function may impair force generation and proprioceptive acuity of the muscle. The integrity and control of sensorimotor system (proprioception and muscle contraction) are essential
38
for maintenance of balance, and production of smooth stable gait.

Osteoarthritis of the knee impairs quadriceps function, which in turn,
impairs the patients balance and gait, reducing their mobility and
function.
Therefore, along with the strengthening of quadriceps muscle, exercises which improve balance should also be incorporated in the management of OA of knee patients. The intent of proprioceptive exercise
is to expose people to activities that challenge the stability of the joint
and balance in a controlled manner during rehabilitation, a strategy
that may allow them to develop motor skills adequate to protect the
joint from potentially harmful loads during functional activities.
A group of proprioceptive exercises can be given for 14 sittings continuously which are as follows:
One leg balance: It involved standing on affected foot with relaxed, upright posture and the other
leg flexed at the knee, hip and ankle
(Fig. 4.6). This position was held
for one minute, followed by rest for
10 to 20 seconds and was repeated
twice more. After a brief rest, three
similar repetitions were carried out
with the unaffected leg.
Blind advanced one leg balance: It
was same like one leg balance, except
that the participant was asked top,
keep his/her eyes completely closed,
while performing the routine and
then was repeated twice again.
Toe walking: Here the participants
was made to walk for 20 meters high
Fig. 4.6: Single leg
up on the toes with the toes pointbalance
39
ing straight ahead, then walk with toes pointing outwards and
then with the toes pointing inwards. After a short rest, the
procedure was repeated once again.
Heel walking: Walking for 20 meters on heels with toes pointing straight ahead, walking on heels with toes pointing out and
then with toes pointing in. After a short rest, the procedure was
completed once more (Fig. 4.7).
Cross body leg swings: Leaning slightly forward with hands on
a wall for support and weight on affected leg, other leg was
swung in front of the body, pointing toes upwards as foot
reaches its farthest point of movement. Then the same leg was
swung backwards as far as comfortably possible, again toes
up as the foot reaches its final point of movement. This was
Fig. 4.7: Walking on the heel
40
repeated for 15 times and after a brief rest, 15 similar repetitions with the unaffected leg as weightbearing limb was
performed.
Balance exercises are important
to improve your ability to regulate shifts in your bodys center of gravity while maintaining
control. Usually, balance exercises should be performed for 5
minutes per day initially and progressed to 10 to 15 minutes
or longer provided they do not cause or increase symptoms.
Generally, you should select a range of exercises that challenge
your balancewithout causing an increase in symptoms. Always,set-upyour environment to ensure safety and prevent falls,
incase you lose your balance (e.g. practice at a bench or with a
spotter).
Basic Balance Exercises
Single leg balance
Standing on one leg, maintain your balance (Fig. 4.8). Try to
hold for 1 minute. Once this exercise is too easy, progress to eyes
closed.Afurther progression can involve performing, the exercisestanding on one or more pillows with eyes open and then eyes
closed.
Intermediate Balance Exercises
Ball around back
Standing on one leg, take a ball around your back whilst maintaining your balance (Figs 4.9A and B). Once this exercise is too easy,
progress to eyes closed.
Ball under leg
Standing on one leg, take a ball under your leg whilst maintaining
your balance (Fig. 4.10). Once this exercise is too easy, progress to
eyes closed.
Fig. 4.8: Single leg balance (right side)
Figs 4.9A and B: Ball around back balance exercise
41
42
Fig. 4.10: Ball under leg balance exercise
Ball circles around leg

Standing on one leg, move a ball around your leg whilst maintaining
your balance (Fig. 4.11). Perform clockwise and then anticlockwise.
Once this exercise is too easy, progress to eyes closed.
Ball throws against wall
Standing on one leg, throw a ball against a wall or to a partner whilst
maintaining your balance (Fig. 4.12).
Side throw against wall
Standing on one leg, throw a ball across your body against a wall
or to a partner whilst maintaining your balance (Fig. 4.13). Repeat
the exercise, throwing the ball to the opposite side of your body.
Fig. 4.11: Ball circles around leg balance exercise
Fig. 4.12: Ball throws against wall balance exercise
43
44
Fig. 4.13: Side throw against wall balance exercise
Advanced Balance Exercises

Foam pillow balance exercises
Standing on a foam pillow with both feet, maintain your balance
(Figs 4.14A and B). Once this is too easy you can try these balance
exercises with your eyes closed and, eventually, with only one leg,
eyes open and eyes closed.
Duradisc balance exercises
Begin standing on a Duradisc with both feet and maintain your balance. Progress the exercise by closing your eyes. Once this is too easy
you can progress the exercise by balancing on one leg with eyes open
and eventually with eyes closed.
45
Figs 4.14A and B: Foam pillow balance exercises
Mobility of Joints
Realistically, when the joint surfaces are destroyed, mobility will be
restored only by joint surgery. Success with physiotherapy in restoring mobility depends on the limiting factors which may be:
Pain
Chronic thickened swelling
Muscle spasm
Fibrous contracture
Pain relief may be obtained by the methods already mentioned. This
includes free active exercises, which may release endogenous opiates
and thus relieve pain.
Chronic thickened swellings can be softened and at least partly
cleared by ultrasound. Whole hand and finger kneading together
with effleurage can also help (Fig. 4.15).
46
B
Figs 4.15A and B: Effleurage and finger kneading
Orthotic Supports
Braces are essentially devices or contraptions, which can be worn by

the arthritis sufferer to ease the symptoms and pain of the condition.
Common examples of such braces are knee braces, wrist support
braces, spinal braces, elbow braces and leg braces. In the case of knee
arthritis, the brace will be attached to your leg in order to provide
support.
Braces for arthritis pain are also helpful not only in relieving pain
but in reducing inflammation by realigning the pressure on the sides
of the knee and reducing the painful contact of bones with each
47
other. Hence, braces for arthritis pain can increase a patients mobility, and are a fantastic non-surgical treatment option.
Custom braces for arthritis pain are often used for the care of
rear foot arthritis and ankle arthritis to either hold a painful area in
place or restrict painful movement. In some cases, custom braces for
arthritis pain may also be used in realigning a joint to prevent stress
or overuse of a certain area of the joint.
Braces for arthritis pain can also be worn to support the spine or
the back and ease pain in this area. Spinal braces limits the backs
motion and relieve the stress on the vertebrae, thereby, effectively
controlling back pain.
For patients with knee arthritis, wearing braces for arthritis pain
will help alter their gait to relieve the painful areas from weight or
impact. Bow-legged patients wearing special braces for arthritis pain
will notice that most of their weight will be shifted on the outside of
their knee instead of the inside of their knee, which is what happens
in normal way of walking and which also causes the most pain.

There are also some braces for arthritis pain that insulate the affected joint, keeping it warm to reduce pain. An example of such a
brace is a neoprene sleeve. Where appropriate, the patient may wear an
elasticated support on, for example, the knee so that during walking
the oedematous fluid is compressed and should pass into the lymphatic
channels (Fig. 4.16). Interferential therapy is also effective.
Muscle spasm is best relieved by hold-relax, repeated contractions and possibly by pulsed electromagnetic energy or radiant heat.
If there is spasm in the lower limb muscle, it is worth considering
encouraging the patient to use a walking aid to reduce the weight
taken during the stance phase of walking, which in turn reduces the
pain and diminishes the development of muscle spasm. Ice may be
appropriate when there is acute pain and spasm.
Sling suspensions is helpful for regaining hip, knee and shoulder
movements in the presence of pain or spasm and also were there is
fibrous tightness limiting movements.
48
Fig. 4.16: Clasticated supports
Fibrous contracture tends to occur in the muscles which produce deformity. This may be successfully treated by ultrasound, friction or finger kneading and passive stretching applied as a slow sustained stretch.
Mobilizations as either accessory or physiological movements are
invaluable at the earlier stages of the condition. Stretching the capsule and applying rhythmical movement facilitates synovial sweep
across the cartilage across the cartilage and may help to diminish
degeneration by improving nutrition. Compression and distraction
can be useful for the same reason. Mobilization may be applied in
the hydrotherapy pool, especially for the hip and the lumbar spine.
Grade 1 and 2 relieves pain. Grade 3 reduces resistance-fibrous
thickening and tightening.
Maintenance of Joint Range and Muscle Power
Every patient with OA should practice a program of exercises designed to move the joints and muscles through full range at least once
each day. Attendance at a group therapy session from time-to-time
49
encourages the patient to practice. Joint range, muscle power and

bulk measurements can be taken regularly to identify any evidence
of rapid regress.
Coordination
Frenkels exercises can be used to work the joints and muscles through
smooth coordinated purposeful movements. Stabilization in standing
helps to gain co-contraction around the hip, knee and ankle joints.
Balance-board work is also of value in re-educating proprioceptor
function. The patient may be taught to stand on one leg for 2 to 3
minutes at home with corrected leg posture. PNF slow reversal and
correctly performed free active exercise also contribute to coordination.
Minimizing Deformity
This is done by educating the patient in the mechanism of development of deformity and in the importance of exercises and good
posture. Also the patient should avoid sitting for hours if hip and
knee are affected. It is helpful to stand up turn around, sit down
in every 20 to 30 minutes.
Position Sense
Poor posture leads to stress and muscle imbalance which predisposes to the changes of OA. For example, a forward pelvic tilt
tends to stretch the hip extensors and shortens the flexors. Rounded shoulders result in lengthening of the shoulder girdle retractors, shoulder extensors and lateral rotators with shortening of
the opposing muscle groups, especially the pectorals. A habit of
standing with body weight more on one leg than the other causes
shortening of the hip abductors of the favored side and can be
associated with tightening of the iliotibial tract. Instructions on a
balanced posture in standing, sitting, relaxing position and lying
are essential.
50
Advice to the Patient
In knee OA, walking is good for nutrition and lubricationwalk a

little every day within limits of pain. Monitor pace and distance by
recording effects. Use walking aids to relieve pain and stress, and to
help balance.
Rest 5 to 10 minutes every hour but avoid being in one position
for longer than half an hour. If this is not possible, e.g. in a train or
car, then practice isometric muscle contractions every so often.
Exercise daily. Try to move each joint in every direction every
half hour or so. Also practice isometric contractions.
Weigh regularly at least once a week. Try to keep weight under
control. Perhaps go to weight watchers regularly.
Avoid sitting with knees crossed to prevent deformity. Do not sit
or lie with a pillow under the knee.
Avoid putting sudden strain on the joints, e.g. lifting heavy loads,
long spell of gardening or decorating. Use a bag on wheels for shoppingtry to do a little every day rather than one big exhausting shop
once or twice a month. Carry two small bags, one in each hand.
Do a little housework everyday.
In cold weather, wrap up well; cold predisposes to muscle spasm.
Do not exercise from cold, use a rubber hot water bottle or electric
heat pad to warm the muscles prior to exercise.
Buy a heat lamp (Fig. 4.17) if heat helps but a hot water bottle is
less dangerous and can mould to the part. A heat pad is more versatile.
However, dry heating may not be beneficial for all so go in favor of
moist heating.
Although there is no cure, the effects of OA can be minimized
so that functional capacity can be maintained. Patients sometimes
need to be reassured that OA is not crippling rheumatoid arthritis.
Functional, gait, and balance training has been recommended
to address impairments of proprioception, balance and strength in
individuals with lower extremity arthritis. These deficits can contribute to higher fall risk in older individuals.
51
Fig. 4.17: Infrared lamp
Joint Protection Techniques

Joint protection can reduce stress on arthritic joints and decrease
pain. There are several joint protection principles, which if followed,
will help to conserve energy and preserve joint function. The advice
is quite simple, but you must be mindful of proper movements and
recognize body signals.
Respect Pain
First and foremost, you need to recognize body signals. If you are
experiencing pain after an activity, you must consider that you have
been too active or done too much. Dont disregard the painrespect
the pain you are feeling. For arthritis patients there is a 2-Hour Rule
which states that if you have more arthritis pain two hours after you
exercise than you did before, consider cutting back the next time.
Basically, adjust your activity level to your pain level.
52
Avoid Activities that Hurt Affected Joints
Avoid any activity that causes pain and find a better way of accomplishing the task. Make compromises which will protect your
joints. If standing causes pain, attempt to do the activity while sitting. Avoid excessive pressure on the small joints of the hand. For
example, if opening a water bottle is painful, dont force your hand.
Get a bottle opener that works or have someone else open it for
you. Also, avoid heavy lifting. Ultimately, your common sense will
dictate what is an activity which you should avoid.
Check Out Assistive Devices Which are Available
There are myriad assistive devices which will help you accomplish tasks
that are otherwise difficult and painful. Jar openers, reachers, dressing sticks, long-handled cleaning tools, raised toilet seats, and shower
benches are just a few examples of assistive devices which are easy to
find. By using the assistive devices, you put less stress on your joints.
Use Largest and Strongest Joints and Muscles
You should use both arms when lifting or carrying an object. By using the largest and strongest joints, you will not stress single joints
or weaker areas of your body.
Use Good Posture and Body Mechanics
There are proper ways to stand, sit, bend, reach, and lift that will
allow you to put less stress on your joints. By moving properly, you
can preserve your joints.
Avoid Staying in One Position for Too Long
Staying in the same position for a long time can cause joints to
stiffen and become painful. You should change positions as often as
possible so you can protect your joints.
53
Balance Activity and Rest
Its imperative to balance activity and rest. When your body signals
that it has had enough, schedule a period of rest. By balancing activity and rest, you will be able to do more, though it might take
longer, and you will be protecting your joints as well.
Avoid Prolonged Periods of Immobility
Prolonged inactivity and immobility will cause stiffness and increased pain. Gentle range-of-motion exercises should be performed
daily. Each joint should be put through its full range of motion by
bending, stretching and extending the joint.
Reduce Excess Body Weight
Extra weight adds stress to weight-bearing joints. By losing weight
and then staying at your ideal body weight, you will be protecting
your joints.
Simplify, Plan and Organize
Try to use your muscles and joints more efficiently. By planning and
organizing your work or any activity, the simplicity will translate
into energy conservation and less stress on your joints.
Weight-bearing Joints Carry the Burden
Being overweight, even just moderately, impacts weight-bearing
joints and can increase the pain of arthritis.
Research has shown that during walking the hips, knees and ankles bear three to five times a persons total body weight. For every
pound a person is overweight, three to five pounds of extra weight is
added to each knee during walking. In contrast, a ten pound weight
loss causes 30 to 50 pounds of extra stress to be relieved from the
joints.
54
For a person with arthritis, extra pounds burden the joints and
lead to increased inflammation and pain.
Medication
Drug therapy in OA has no effect on disease progression and is ancillary to the more general measures of pain control, which include patient related instruction, joint protection and exercise. The goal of drug
therapy in patients with OA is to relieve pain and decrease joint inflammation when it is present. Oral analgesics, NSAIDs and corticosteroid
injections are the primary medications used in OA management.
Paracetamol
Paracetamol (Tylenol/acetaminophen), an oral analgesic is commonly used to treat the pain from OA and is the drug of first choice.
It almost has no toxicity in recommended doses and do not causes
GI bleeding. However, there is no anti-inflammatory effect and
acetaminophen cannot be substituted for NSAIDs in this regard.
Acetaminophen may be taken episodically as needed for pain or
regularly when symptoms are more severe and long lasting. Liver
and kidney toxicity can occur with its use. Hepatoxicity most often
occurs after a drug overdose, but also may appear with therapeutic
use, especially in individuals who drink excessive amounts of alcohol. Kidney toxicity is less common. NSAIDs appear to be more
potent, but pose greater risk of side-effects.
Non-steroidal anti-inflammatory drugs
In more severe cases, non-steroidal anti-inflammatory drugs
(NSAID) may reduce both the pain and inflammation; they all act
by inhibiting the formation of prostaglandins, which play a central
role in inflammation and pain. However, it should be noted that
this class of drugs is not without risk for adverse events including increased gastrointestinal bleeding. Most prominent drugs in the class
include diclofenac, ibuprofen, naproxen and ketoprofen. High oral
55
drug doses are often required. However, diclofenac has been found
to cause damage to the articular cartilage. Even more importantly all
systemic NSAIDs are rather taxing on the gastrointestinal tract, and
may cause stomach upset, cramping, diarrhea and peptic ulcer. Such
systemic adverse side effects are normally not observed when using
NSAIDs topically, that is, on the skin around the target area. The
typically weak and/or short-lived therapeutic effect of such topical
treatments may be improved by using the drug in more modern
formulations, including or ketoprofen associated with the Transfersome carriers or diclofenac in DMSO solution.
Corticosteroids
Oral steroids are not recommended in the treatment of OA due to
their modest benefit and high rate of adverse effects. However intraarticular corticosteroid temporarily improve symptoms. Intra-articular corticosteroid injections are often used for acute episodes with an
expected modest response of 1 to 4 weeks duration. The knee is the
most common site; however, soft tissue injections for subacromial,
anserine and trochanteric bursitis also may be effective.
Narcotics
For moderate to severe pain a narcotic such as morphine may be
necessary.
Topical
There are several NSAIDs available for topical use (e.g. diclofenac,
ibuprofen, and ketoprofen) with little, if any, systemic side-effects
and at least some therapeutic effect. The more modern NSAID formulations for direct use, containing the drugs in an organic solution
or the Transfersome carrier based gel, reportedly, are as effective as
oral NSAIDs.
Creams and lotions, containing capsaicin, are effective in treating pain associated with OA if they are applied with sufficient fre-
56
quency. Creams and gels that are available over-the-counter may

provide temporary pain relief, but only in the areas where they are
applied. These creams arent as effective as anti-inflammatories.
Brands available include: Bengay arthritis, deep heating rub cream,
minards joint relief, menthacin, and arthritis patch. The majority of
creams and gels use heat or cold to distract you from pain.
Injectable
Injection of glucocorticoids (such as hydrocortisone) leads to short
term pain relief that may last between a few weeks and a few months.
Surgery
Surgery represents one of the greatest advances in the management
of arthritis in the last 35 years. Surgery is not appropriate, however,
for every individual with OA, and the careful selection of the patient
and the timing of the procedure is critical. The primary indication
of surgerypain, loss of function and progression of deformity, although the last two are not always correlated.
In general, there are three procedures that may be performed on
soft tissues: Synovectomy, soft tissue release, and tendon transfer.
Similarly, there are three general bone and joint procedures: Osteotomy, prosthetic arthroplasty, and arthrodesis. The choice of
specific postoperative physical therapy procedures will depend on
the articular surgical intervention, the extent of joint involvement
prior to surgery, individual characteristics of the patient and manifestations of the disease.
If the above management is ineffective, joint replacement surgery may be required. Individuals, with very painful OA joints may
require surgery such as fragment removal, repositioning bones, or
fusing bone to increase stability and reduce pain. Arthroscopic surgical intervention for osteoarthritis of the knee has been found to be
no better than placebo at relieving symptoms. Once the individual
has achieved an adequate level of function and release from surgical
57
precautions, instruction in establishing a routine of regular exercise

and physical activity to support musculoskeletal and cardiovascular
fitness is crucial to long term outcomes and quality of life.
Alternative Treatments
The majority of patients with arthritis have tried alternative treatments for their pain. Various studies have reported some benefit for
many of these approaches, including acupuncture and some herbal
supplements. However, the response rates tend to be low and there
is concern about bias in many studies.
Acupuncture
A meta-analysis of randomized controlled trials of acupuncture for
knee osteoarthritis concluded that it provided no clinical benefit.
Glucosamine/Chondroitin
There is controversy about glucosamines effectiveness for OA of
the knee. A 2005 review concluded that glucosamine may improve
symptoms of OA and delay its progression.
Chondroitin sulfate has also become a widely used dietary supplement for treatment of osteoarthritis, both in combination with
glucosamine and by itself.
Other Supplements
S-adenosylmethionine (SAMe) has been tested; a review of 10
studies found that it has an effect on pain relief similar to nonsteroidal anti-inflammatory drugs
Frankincense resin from Boswellia serrata treesIndian frankincense is a traditional treatment for arthritis in Ayurvedic medicine
Bromelain, protease enzymes extracted from the plant family
Bromeliaceae (pineapple), blocks some proinflammatory metabolites
58
Antioxidants, including vitamins C and E in both foods and

supplements, provide pain relief from OA
Ginger (rhizome) extracthas improved knee symptoms
moderately
Selenium deficiency has been correlated with a higher risk and
severity of OA
Vitamin B9 (folate) and B12 (cobalamin) taken in large doses
has been thought to reduce OA hand pain in one very small,
non-quantitative study of 25 people, the results of which are
extremely vague at best
Vitamin D deficiency has been reported in patients with OA,
and supplementation with Vitamin D3 is recommended for
pain relief.
Chapter
Osteoarthritis:
Hip Joint
Osteoarthritis of the Hip

General Features of Osteoarthritis

Primary Symptoms and Signs

Classification

Diagnosis

Treatment

Exercises

Operative Options

Rehabilitation after Total Hip Replacement

Rehabilitation ProtocolPostoperative THR
60
OSTEOARTHRITIS OF THE HIP (FAMILIARLY

CALLED AS MALUM COXAE SENILIS)
Arthritis of the hip can result from many causes such as slipped
capital epiphysis, childhood sepsis, and rheumatoid arthritis. About
30 percent of the patients with hip arthritis have a mild form of
acetabular dysplasia (a shallow socket), and 30 percent have a retroverted socket. Both of these conditions reduce the contact area of
the femoral head in the acetabulum, which increase the pressure and
makes wear more likely.
Arthritis of the hip is marked by progressive loss of articular
cartilage with joint space narrowing and pain. Stiffness encourages
development of osteophytes formation (bone spurs), which in turn
lead to further stiffness, making it difficult for the patient to put
on socks and shoes. This eventually leads to the general picture of
shortening, adduction deformity, and external rotation of the hip,
often with a fixed flexion contracture. Bone loss usually occurs slowly, but in AVN occasionally it occurs precipitously.
General Features of Osteoarthritis

A heterogeneous group of conditions that share common pathologic
and radiological features.
Focal loss of articular cartilage in part of a synovial joint is accompanied by hypertrophic reaction in the subchondral bone and
joint margin.
Radiographic changes of joint space narrowing, subchondral
sclerosis, cyst formation, and marginal osteophytes.
Common and age-related, with identified patterns of involvement targeting the hands, hips, knees, and apophyseal joints of the
spine.
Clinical findings often include joint pain with use, stiffness of
joints after a period of inactivity, and losts range of motion (ROM).
Osteoarthritis: Hip Joint
61
Primary Symptoms and Signs

Symptoms

Pain during activity

Stiffness after inactivity (stiffness usually last less than 30 minutes)
Loss of movement (difficulty with certain tasks)
Feeling of insecurity and instability
Functional limitations and handicap.
Signs

Tender spots around the joint margin

Firm swelling of the joint margin
Coarse crepitus (creaking or locking)
Mild inflammation (cold effusion)
Restricted, painful movements
Joint tightness
Instability (obvious bone or joint destruction).
Classification
According to radiographic appearance, OA can be classified as:
Concentric, in which there is uniform loss of the articular cartilage
Downward and medial migration of the femoral head
Upward and superolateral migration of the femoral head.
Diagnosis
The classic clinical test of hip arthritis is internal rotation of the hip
in flexion. With hip arthritis, this internal rotation is limited and
painful. Differential diagnosis include Hip dislocation, Hip fracture, Pelvic fracture or disruption, Entrapment of the lateral femoral
cutaneous nerve of the thigh, Tendonitis of piriformis or gluteus
62
maximus, or minimus tendons, Trochanteric bursitis, L3-L4 sciatica, Spine referred pain, Internal iliac artery stenosis, and Strain or
contusion of the quadriceps or hamstring muscle.
Radiographic examination includes an AP view of the pelvis and
AP and lateral views of the hip.
Treatment
Anti-inflammatory and analgesics are of some value.
Neutraceuticals, such as chondroitin sulphate and glucosamine
are popular but unproven.
A cane in the opposite hand helps to unload the hip significantly.
A proper fitted cane should reach the top of the patients greater
trochanter of the hip, while wearing shoes. Stretching and strengthening exercises or joining a yoga class can be of surprising value in
terms of regaining ROM because it may be stiffness rather than pain
that makes surgery necessary.
Exercises
Rules of Exercises in the Management of OA Hip

Build-up the exercise gradually

Avoid rough ground while exercising
To take warm baths before starting the exercise
To perform the exercises 20 times each, twice a day and later
four times a day.
We use exercises that strengthen and stretch the muscles and capsule
of the arthritic hip, incorporating motion and strength needed by
the patient for daily functioning. These exercises are for the arthritic
hip, not after hip replacement.
Exercises Lying on the Back
Pelvic tiltTighten the thigh and buttock muscles pushing the
knee flat. Hold for a count of 5 and relax (Fig. 5.1).
63
Fig. 5.1: Pelvic tilting
Pelvic liftBend both the knees up, push on the feet and lift.
Hold for a count of 5 and relax.
Leg stretchPush one leg along the floor as though you are trying to make it longer than the other. Hold for a count of 5 and
then repeat with the other leg.
Alternate leg raiseKeeping the knee straight, lift the alternate
leg, six inches from the ground.
Exercises Lying on your Side with the Painful Hip Up
Side leg raiseKeep the top leg straight and lift it up as high
(Fig. 5.2)
Knee and hip flexionBend the hip and knee of the top leg forwards, and hold for a count of 5. Then straighten the leg and
stretch backwards as far as it will go, hold for a count of 5, then
relax.
Exercises in Sitting Position
Knee together, feet apart
Feet together, knee apart.
Fig. 5.2: Side leg lifting
64
Exercises in Standing
Standing leg swingHold onto a table or chair with one hand,

swing one leg forward and backwards. Try to get the backward
swing as wide as possible.
Standing side leg swingHold onto a chair with both the
hands. Swing bad leg out as far as it will go and then in.
Below are some other exercises, which can be followed in a routine by
the patient (Figs 5.3A to H):
Fig. 5.3A: Leg rotation
Fig. 5.3B: Front and back leg raises
Fig. 5.3C: Knee crossovers
Fig. 5.3D: Leg scissors against resistance
Fig. 5.3E: Side kicks
65
66
Fig. 5.3F: Straight leg lifts
Fig. 5.3G: Knee to chest lifts
Fig. 5.3H: Mini squat
Figs 5.3A to H: Exercises to be followed for nonoperative protocol in OA hip
67
Suggested Exercise Plan for Patients

with Osteoarthritis of the Hips
Mild symptoms
Active ROM exercises
Stretches for hip flexors, adductors, iliotibial band, and gastrocnemius muscles and for hamstring tendon.
Strengthening (belt exercises,
leg lifts, closed kinetic chain,
standing on one foot, walking).
Aerobic conditioning (preferably walk 1 hour five times a

week).
Aquatic therapy in warm water
to unload.
Moderate to severe symptoms

(pain on range of motion)
Active-assisted ROM exercises
Stretches.
Isometric strengthening when
ROM is less painful.
Physical therapy modalities as
needed.
Unloaded ambulation, once

to several times a day, gradually increasing to 45 min. then
gradually reload (shallower
water, less pressure on cane)
until fully loaded for 1 hr three
to five times a week.
Exercise Device Suitable for Patients with Arthritis

Stationary bicycle (Fig. 5.4)
Arm-crank ergometer
Rowing machine
Cross-country skiing machine
Climbing machine
Water running with limited-buoyancy vest.
Operative Options
Osteotomies, such as pelvic and intertrochnateric osteotomies, were
popular in the past, with limited role now.
68
Fig. 5.4: Stationary cycle
Choice of Osteotomy
Pauwells varus osteotomyIt is done if OA is due to coxa valga.
Valgus osteotomyThis is more common and is done in adduction
deformity of the hip.
Displacement osteotomy (Mcmurrays)This is indicated in severe
OA of hip with large osteophytes. Osteotomy helps by changing the
line of weight bearing and bringing the normal surface into the line
of weight transmission.
The mainstay of surgical treatment is total hip replacement/
arthroplasty. It is a Latin word arth meaning joint and plasty
69
meaning molding. The first successful THA was done in 1960 by

Sir John Charnley. In general, for elderly patients with low activity demands, both the acetabular and the stem components can be
cemented (Figs 5.5A and B). For young, high demand patients, the
current trend is to use noncemented implants.
Indications
Pain
Disability
Health status
Age
Weight-bearing instructions are very different after arthroplasty with cemented and noncemented hip devices. Cement is as
strong as it will ever be 15 minutes after insertion. It is however,
believed that the initial stability achieved with cement fixation
B
Figs 5.5A and B: The acetabular and stem components
70
is adequate to allow immediate full weight bearing with a cane

or a walker.
With a noncemented hip prosthesis, the initial fixation is pressfit, and maximal implant fixation is unlikely to be achieved until
some tissue growth into the implant has been established. Stability is usually adequate by 6 weeks. However, maximal stability is
probably not achieved until approximately 6 months with noncemented prosthesis. It is believed that the initial stability achieved
is adequate to allow weight-bearing as tolerated immediately after
surgery.
Straight leg raising (SLR) and side leg lifting can produce very
large loads on the hip and should be avoided. It is preferable to
protect the hip from large rotational forces for 6 weeks or more.
The most common rotational load comes when arising from a most
sitting position, so pushing with hands from a chair is strongly recommended.
After full weight-bearing, it is essential to use a cane in the contra
lateral hand until the limp stops. This helps to prevent the development of Tredelenburg gait, which may be difficult to eradicate, at a
later date. In general, when a patient gets up and walks away, forgetting about the cane, this is an indicator that the cane may be safely
discarded.
Hip Resurfacing (Figs 5.6A and B)

Younger more active patients

Higher expectations
Proven benefit/cost ratio
Continuing to push the envelope.
There is minimal bone resection and normal femoral loading. Maximum proprioceptive feedback.
Restores natural anatomy
71
Figs 5.6A and B: Hip resurfacing
Offset, leg length

Anteversion
Minimal risk of dislocation.
Selection of candidate
Hip resurfacing is most appropriate for physically active patients with good bone quality and adequate femoral and acetabular bone stock
Such patients will generally be under the age of 65
OA
Strong Heavy Male
Women < 50 years
Men < 60 years
High Expectation
High activity level.
Rehabilitation after Total Hip Replacement

Weight-bearing should be limited to toe touch, if an osteotomy of
the femur has been done for any reason. Osteotomies can be required
for alignment correction, either angular or rotational; Shortening or
72
exposure. Treatment needs to be adjusted at various stages according

to the approach of surgery.
Patient Instruction for Total Hip Replacement
You have been instructed to AVOID (Figs 5.7A to D):
1. Crossing your legs or bringing them together-adduction.
2. Bringing the knee too close to your chest-extreme hip flexion.
3. Turning the foot in towards the other leg.
4. Do not lie on the involved side until cleared by the doctor.
5. Avoid sitting in low chairs and, especially, overstuffed sofas or
chair.
6. Do not cross legs while walking, especially when turning.
7. Avoid raising knee higher than the hip when sitting in a chair.
8. Do not try to get into a bathtub for a bath, unless using a tub
chair.
A: Do not lean to get up
B: Do not sit on low toilets
C: Do not pull up blankets
73
74
D: Do not lie without a pillow between legs
Figs 5.7A to D: Precautions to be taken after total hip replacement
Positions to be Adopted during Everyday Activities

When sitting, sit with knees comfortably apart.
When lying on the uninvolved side, always have a large pillow
or two small pillows between your knees. Have the knees in
slightly bent position.
Continue to use elevated commode seat after you have been
discharged from the hospital (Usually around 610 weeks).
Sit in a slightly reclined positionavoid leaning forward when
sitting on the commode. Do not let your shoulders get ahead
of your hips when sitting and getting up.
Going up and down the stairs UPStep up with uninvolved leg, keeping crutches on the
step below until both feet are on the step below until both feet
are on the step above and then bring both. The crutches on the
step.
DownPlace crutches on the step below, step down with the
involved leg, and then with the uninvolved leg.
Continue to use your crutches or walker until you return to see
a doctor.
75
Avoid prolonged sitting for longer than 1 hr before standing

and stretching.
You can return to driving 6 wk after surgery only if you have
good control over the involved leg and can move your extremity
from accelerated to brake with little effort.
Place nightstand on the same side of the bed as the uninvolved
leg. Avoid twisting the trunk toward the involved side, which
would be the same as turning the leg inwards.
Try to lie flat in bed atleast 15 to 30 min. per day to prevent
tightness in the front part of the hip.
Rehabilitation ProtocolPostoperative THR

Goals
Goalsguard against dislocation of the implant, gain functional
strength, strengthen hip and knee musculature, prevent bed rest hazards
(e.g. thrombophlebitis, pulmonary embolism, decubiti, pneumonia),
teach independent transfers and ambulation with assistive devices, obtain pain free ROM within precaution limits.
Rehabilitation Considerations in Cemented
and Cementless Techniques
Cemented total hip
Weight bearing to tolerance (WBTT) with walker immediately after surgery.
Preoperative Instructions
Instruct on precautions of hip dislocation
Transfer instructionsIn and out of bed
Chair
Avoid deep depth in chairs
76
Avoid crossing the legs while sitting

Scoot to the edge of the chair before rising from it
Use of elevated commode seatelevated seat is placed on
commode at a slant, with higher part at the back, to aid rising.
Have elevated seat sent to house prior to surgery
AmbulationInstruct on use of anticipated assistive device
(walker)
ExercisesDemonstrate day one exercises (see below).
Postoperative Regimen
Out of bed in a chair, which is not low in depth
Begin ambulation with a walker support 1 or 2 days postoperatively, with assistance from a therapist.
Weight-bearing Status
Cemented prosthesisWeight-bearing as tolerated with walker for
atleast 6 wk, then use a cane in the contra lateral hand for 4 to 6 mo.
Cement less techniqueTouch down weight-bearing with walker
for 6 to 8 wk, then use a cane in the contra lateral hand for 4
to 6 mo. A wheelchair can be used for long distance with careful
avoidance of excessive hip flexion of more than 80 degrees, while
in wheelchair.
Isometric Exercises
SLRTighten knee and lift the leg off the bed, keeping the
knee straight
Quadriceps setsTighten quadriceps by pushing knee down
and holding for a count of 4
Gluteal setsSqueeze buttocks together and hold for a count
of 4
Ankle pumpsPump ankle up and down, repeatedly
Isometric hip abduction with self-resistance while lying. Later
77
wrap a theraband around the knee and perform abduction

against the theraband.
Four point exercise:
Bend knee up while standing
Straighten knee
Bend knee back
Return foot to starting position.
Hip abduction-adduction:
In supine position
In standing position
Sidelying position (probably 5-6 weeks postoperatively)
(Fig. 5.8).
ROM and Stretching Exercises
1 or 2 days postoperative, begin daily Thomas stretch to
avoid flexion contracture of the hip. Perform this stretch five
to six times per session, six times a day (Fig. 5.9)
May begin static exercise cycle with a high seat 4 to 7 days
postoperative. The seat can be progressively lowered to increase
hip flexion within safe parameters
May also perform extension stretching of the anterior capsule
(Fig. 5.10)
Observe and correct the gait faults. See on later pages.
Fig. 5.8: Shows hip abduction exercises
78
Fig. 5.9: A Thomas stretch
Fig. 5.10: Anterior capsular stretch
79
Abduction Pillow
Keep an abduction pillow between the legs while in bed.

Bathroom Rehabilitation
Permit bathroom privilege with assistance and with an elevated
commode seat.
Use elevated commode seat at all times.
Assistive Devices
Reachers and Grabbers to help retrieve objects on the floor or
assist with socks and stockings. Do not bend to put on the slippers.
Transfer Instructions
Bed to chair
Avoid leaning forward to get out of the chair or off the
bed
Slide hips forward to the edge of the chair first, and then
come to standing
Do not cross legs when pivoting from supine to bed side
sitting
Bathroom
Use elevated toilet seat with assistance
Continue assistance until able to perform safe, secure transfer.
Exercise Progression
Hip abduction: Progress from isometric abduction against self
resistance to theraband wrapped around the knees. Can also be
done with the use of weights, sports cord, and pulleys. Continue hip abduction exercises until the patient exhibits a normal
gait with good abductor strength (Fig. 5.11).
80
Fig. 5.11: Hip abduction in standing
Perform hip extensors exercise in prone lying position to

strengthen gluteus maximus (Fig. 5.12)
Initiate general strengthening exercises: Develop endurance,
perform cardiovascular exercise, and general strengthening of
all extremities.
Fig. 5.12: Gluteus maximus strengthening
81
Home Instructions

Continue previous exercises and ambulation activities

Continue to observe hip precautions
Install elevated toilet seat at home
Ensure home physical therapy and/or home nursing care
Reiterate avoidance of driving for 6 weeks.
Managing Problems after Total Hip Replacement

1. Trendelenburg gait (weak hip abductors)
Concentrate on hip abduction exercise to strengthen abductors
Evaluate leg length discrepancy
Have patient stand on involved leg while flexing opposite
(uninvolved) knee 30 degrees. If opposite hip drops, have
patient try to lift and hold in an effort to re-educate and
work gluteus medius muscle (hip abductors).
2. Flexion contracture of the hip
Avoid placing pillows under the knee joint after surgery
Walking backwards helps stretch flexion contracture. Perform a Thomas stretch of 30 stretches a day (five stretches
six times per day) (Fig. 5.13).
Fig. 5.13: Passive stretching of hip flexor contracture
82
3. Gait faults
Occurs, if the patient takes a large step with the involved
leg and a short step with the uninvolved leg. The patient
does so to avoid extension of the involved leg, which causes
a stretching discomfort in the groin.
Occurs, when the patient breaks the knee in late stance
phase. Again, this is done to avoid extension of the hip.
It is associated with flexion of the knee early and excessive heel rise at stance phase. The patient should be
instructed to keep the heel on the ground in late stance
phase.
Occurs when the patient flexes forward at the waist in mid
and late stance. Once again, the patient is attempting to
avoid hip extension. To correct this, the patient is taught to
thrust the pelvis forward and the shoulders backward during
mid and late stance of gait.
Occurs simply as a habit which is difficult to break.
Additional Rehabilitation Points
Going up stairs: Step up first with the uninvolved leg, keeping crutches on the step below until both feet are on the step
above, then bring both crutches up on the step.
Going down the stairs: Place crutches on the step below, then
step down with the involved leg, and then with the uninvolved leg.
Cane use: Advocate the long term use of cane in the contra lateral
hand to minimize daily forces across the hip arthroplasty.
Deep Vein Thrombosis in Total Joint Replacement
Thromboembolic disease is the most common cause of serious complications, after total hip replacement. The risk appears to be higher
in the first 3 weeks of surgery. The most commonly used agents are
83
low-dose warfarin, low dose heparin, dextran, and aspirin. Most authors recommend early ambulation, leg elevation, and use of graded
pressure stockings.
Other Complications

Leg length discrepancy

Component malalignment
Infection
Improper implant fixation to surrounding bone
Nerve palsy
Prosthetic hip dislocation.
Chapter
Osteoarthritis:
Knee Joint
The Arthritic Knee

Review of Pertinent Anatomy and Kinesiology

Classification

Biomechanics

Diagnosis

Radiographic Evaluation

Nonoperative
Treatment Algorithm for

Patient with OA Knee

Exercise
Regimen
Training

Functional Training

Gait Training

Endurance
Operative Treatment Algorithm

Indications for Surgery

Operative Options

Goals of Rehabilitation after Total Knee
Arthroplasty

Accelerated ProtocolPostoperative
Rehabilitation
86
THE ARTHRITIC KNEE
Osteoarthritis being more common in the knee joint is one of the

five leading causes of disability among elderly men and women (Figs
6.1A and B). Some degree of osteoarthritis develops in everyone by
the age of 65 years and approximately. Eighty percent have radiographic evidence by age of 75 years.
As the disease progresses in the knee and becomes chronic, it
develops pain, morning stiffness and limitation of movement which
further alters lower limb function and ambulation and thus makes
the person disabled as it limits his ability to walk, to rise from chair,
and to use stairs. The quadriceps muscle strength in patients with
osteoarthritis of knee has also been seen to be consistently lower.
It is believed to be due to disuse atrophy secondary to joint pain,
quadriceps inhibition, delayed activation of quadriceps onset, and
muscle impaired proprioceptive acuity.
Review of Pertinent Anatomy and Kinesiology

Synovial joints are the primary sites of arthritis. Their dysfunction
can affect the ability of the entire organism to function. In a normal
Figs 6.1A and B: Arthritic changes in the knee joint
Osteoarthritis: Knee Joint
87
synovial jointligaments, muscles, tendons, capsule, cartilage,

subchondral and trabecular bone provide stabilizing, shockabsorbing, shock transmitting, and shock absorbing structures to cope
with the considerable stress on the joint that occurs with movement
and weight-bearing. For example, in running, the tibiofemoral joint
experiences forces 2.5 to 3 times body weight. In deep knee bends,
the patellofemoral joint experiences force 10 times the body weight.
Classification
Although, joint inflammation is implied by the itis in osteoarthritis, inflammation is typically found only after there has been substantial articular degeneration. The synovium of an osteoarthritic
joint, however, can demonstrate marked changes similar to those
seen in RA, in some joints. In epidemiological studies, OA is often graded on radiographs according to the criteria of Kellgren and
Lawrence, an ordinal scale of 5 levels:
1. Grade 0: Normal radiograph
2. Grade 1: Doubtful narrowing of the joint space and possible
osteophytes
3. Grade 2: Definite osteophytes and absent or questionable narrowing of the joint space
4. Grade 3: Moderate osteophytes and joint space narrowing,
some sclerosis, and possible deformity
5. Grade 4: Large osteophytes, marked narrowing of the joint
space, severe sclerosis and definite deformity.
Most studies have used grade 2 (the presence of definite osteophytes) as the criterion for defining disease, although a few others
have required evidence of joint space narrowing (grade 3), corresponding to clinically identified disease, to designate OA. Although,
radiographic evidence of joint space narrowing and osteophytes may
help confirm the diagnosis and classify the stage of OA, the clinical
criteria for hip and knee OA are described in terms of pain and limi-
88
tation of motion. In OA of knee, muscle strength and pain are more

explanatory of functional loss than radiographic findings.
Clinical classification criteria for knee and hip osteoarthritis
(95% sensitivity, 69% specificity)
Knee osteoarthritis
knee pain
Joint stiffness<= 30 minutes
Crepitus
Bony enlargement
Bony tenderness
No palpable warmth
Hip osteoarthritis
Hip internal rotation >= 15 with pain, morning
stiffness <= 60 minutes, and age > 50 years, or
Hip internal rotation <15, and hip flexion <=155
Arthritic deformity of the knee is classified as varus or valgus

(with or without symptomatic patellar involvement). Patellofemoral
arthritis is common in an arthritic knee, but is surprisingly seldom
a source of symptoms.
Articular surface damage has been variously classified, but the
most useful categories are minimal, in which there is no radiologic
narrowing; mild, in which there is loss of one third of the joint
space; moderate, in which two third of the joint space has been lost;
and severe, in which there is bone-on-bone contact.
Os in OA
Obesity
Occupation
Over 40 years of age
Other predisposing joint diseases
89
Osteophytes as the main predisposing features

Outward deviation of knee
Osteotomy required to correct knee deformities.
Biomechanics
Normal alignment of the lower limb results in weight-bearing forces
of the body going through the medial (inner) compartment of the
knee (Fig. 6.2). Therefore medial compartment arthritis is the usual
starting point for knee arthritis as this is the compartment that is
being continually loaded.
Any condition that changes the loading pattern and alters the
mechanical axis of the leg can result in arthritis distribution in other
compartments of the knee. This can
occur in fractures which heal with
malalignment or even with removal
of meniscus tissue which will result
in increased force being put through
the articular cartilage in the affected
compartment.
The increase force applied to the
articular cartilage over time causes
breakdown of the articular cartilage
and the development of arthritis.
Diagnosis
To examine the arthritic joint of the
knee, move the joint under load (e.g.,
to examine the medial compartment,
a varus strain is applied to the knee
and the knee is moved). Crepitus felt
under the hand applying varus strain
and pain will be produced. Similarly,
Fig. 6.2: Biomechanical

loading
90
a valgus strain and load are applied to the lateral joint. The knee is
examined for any laxity of the ligaments and the presence of any
fixed flexion deformity is noted. The patellar position (central or
subluxed) is important, as is the presence of a rotatory deformity of
the tibia. When the patient stands note the amount of genu varum
(bow-legged) and valgum (knock-knee).
Findings indicating the presence of knee osteoarthritis
Symptoms
Signs
Radiography
Pain with
activity
Joint line
or condylar
tenderness
Stiffness
Effusion
Subchondral
sclerosis
Intra-articular
osseous
debris (loose body).
Crepitation
Decreased ROM
Angular deformity
Joint narrowing
(unicompartmental)
Joint irregularity
Subchondral cysts
Osteophytosis
Similar to RA, no single factor that predisposes an individual

to OA has been identified. Although, aging is indeed strongly associated with OA, it must be emphasized that aging in itself does
not cause OA, nor should OA be considered a normal aging
process. Several factors related to aging may, however, contribute to its development. Trauma prior to adulthood may initiate
a remodeling of bone that alters joint mechanics and nutrition
in a way that becomes problematic only later in life. Although, it
commonly arises from trauma, osteoarthritis often affects multiple members of the same family, suggesting that there is hereditary susceptibility to this condition. Bow legs, one leg shorter than
the other, and flat arches are other commonly seen biomechanical
91
disorders that can cause premature and uneven wearing down

of the knee cartilage. These biomechanical disorders prevent the
lower leg from being straight, so that the lower leg applies uneven
pressure across the knee joint (cartilage). This uneven pressure
causes premature and uneven wearing down of the knee cartilage.
A number of studies have shown that there is a greater prevalence
of the disease between siblings and especially identical twins, indicating a hereditary basis. Up to 60 percent of OA cases are thought
to result from genetic factors. Researchers are also investigating the
possibility of allergies, infections, or fungi as a cause.
A poor posture, aging process in the joint cartilage are also
related, climate has not been shown to be related to the pathological changes, but pain is greater in cold, damp climates. One
of the predisposing factors for knee osteoarthritis is pronation
of the foot. Pronation is a turning out of the foot at the ankle,
so that one has a tendency to walk on the inner border of the
foot. When the foot turns out, the lower leg and knee are forced
to turn inward (internal rotation). This causes extra pressure to
be exerted on the inner knee cartilage, which in turn produces a
premature and uneven wearing down of this portion of the knees
cartilage. The result is inflammation, stiffness, pain, and eventually, osteoarthritis. Custom-made foot orthotics are needed to
control pronation in order to straighten out the lower leg, and to
insure an even pressure across the knees cartilage. This will help
to preventuneven wear and tear on the knees cartilage, and
osteoarthritis.
Defective lubrication mechanism and uneven nutrition of the
articular cartilage is also a cause. A congenital deformity, such as an
axial or a rotatory deformity can also be a cause. Eighty percent of
patients develop medial compartment OA, and as the bone wears
away, they develop a varus or bow-legged deformity. Five to ten
percent develop a lateral compartment OA of the knee resulting in
a valgus or knock-kneed deformity. A small percentage have rota-
92
tory deformities of the tibia that causes significant patellar maltracking or subluxation.
Risk factors for osteoarthritis of the knee
Established
Controversial
Obesity
Age
Osteoarthritis at other site
Previous knee trauma
Previous knee surgery
Sex (female)
Physical activity
Genetics
Smoking
Estrogen deficiency
Radiographic Evaluation
Evaluation should always include a standing (weight-bearing) AP
view of the knee. A lateral radiograph is required as is a skyline view
of the patella. If the problem is on the lateral side of the joint, a
standing postero-anterior view must be obtained with the knee in
30 degree of flexion. The reason for this is that the articular cartilage
loss in the medial compartment is in the distal femur and the central
tibia, but articular cartilage loss in the lateral compartment is in the
posterior femur and posterior tibia.
NONOPERATIVE TREATMENT ALGORITHM FOR

PATIENT WITH OA KNEE
Nonoperative options:
Weight lossSuccessful weight loss dramatically reduces pain in
the lower extremity arthritis. Physician should direct the patient
to the weight loss center.
Activity modificationDiscontinue high impact sports (e.g.
running, tennis, basketball) change to low impact water based
sports or cycling.
93
Avoid stair climbing, kneeling, squatting, low chairs if patellofemoral arthritis exists.
NSAIDs- employ COX 2 inhibitors
There are though long term complications associated with
their use like peptic ulcer, renal effects, gastrointestinal
bleeding.
Cane in the opposite hand
Greatly decreases stress on the arthritic joint.
The most successful treatment is to protect the knee joint, especially
when we are weight-bearing. This is the Gold-Standard of medical
treatmentthe treatment most recognized by all of medicine to be
effective. Protecting the joint will ensure:
A reduction in joint pain
Significant slow down in the progress of the disease
A reduction in the chances of our injuring other joints when
we walk. If we have a painful knee, we sub-consciously force
ourselves to walk in an abnormal way, so as to try and minimize the pressure we exert on the knee joint. When we do this,
we apply abnormal and excessive pressure on other parts of
our body (such as the hip, back, etc.). This is called compensation. This compensation leads to overutilization of these areas,
and new sites of osteoarthritis.
The two most effective treatments used by doctors and therapists
to protect the arthritic knee joint are:
1. Knee braces (Figs 6.3 to 6.5) that provide pain relief by:
Stabilizing the knee
Exerting mild and soothing compression to reduce swelling of
the knee
Providing support for the knee ligaments and tendons that
have been affected by arthritis. When the knee joint wears
down unevenly, some of the ligaments and tendons around
94
Fig. 6.3: Thermoskin comfort arthritic knee wrap
Fig. 6.4: Comfort elastic knee stabilizer
95
Fig. 6.5: Neoroprene elastic knee braces
the knee are stretched. Unless supported by a knee brace, these

stretched ligaments and tendons will cause pain.
Knee sleeve for proprioception
A light neoprene sleeve may improve proprioceptive feedback
Physical therapyPain relief and treatment as given in the
general protocol in previous chapters.
Pain reliefInterferential therapy and ultrasound given loosen
the fluid and break the adhesions (Figs 6.6 and 6.7).
Exercise Regimen
Isometric Exercise
For quadriceps and hamstring done for 5 min, every hour is found
to be effective.
Types Speedy: Helps to reduce effusion in the joint

Slow and sustained: To reduce pain and improve strength.
96
Fig. 6.6: Interferential therapy and its application
Fig. 6.7: Ultrasound therapy
97
Active ROM Exercises
The patient sits at the edge of the high table and actively flexes and
extends the knee joint in a free swinging manner till there is no pain.
This helps in improving the ROM of the knee joint, facilitates joint
lubrication, and provides joint relaxation.
Isokinetic Exercises
In this group of exercises, resistance to the movement is either given
normally by the therapist or by the patient himself with the other
leg.
It is a self-controlled movement, is easy to do, and can be done
frequently, and helps in improving the muscle strength (Fig. 6.8).
Fig. 6.8: Quadriceps strengthening
98
SLR (Straight Leg Raising)
First done unilaterally with isometrics to the quadriceps and DF of the

ankle, then can be done bilaterally. By adding weight or by offering
resistance of the opposite leg this exercise can be made resistive. This
exercise provides stability to the knee during weight-bearing (Fig. 6.9).
Stretching Exercises
The following knee stretches are designed to restore movement to
the knee and improve flexibility of muscles crossing the knee. Generally, they should be performed 3 times daily provided they do not
cause or increase pain.
Knee Bend to StraightenBend and straighten your knee as far as
possible pain-free. Repeat 10 to 20 times (Figs 6.10A and B).
Hamstring Stretching
Patient in long sitting position. Keep a towel roll under the ankle
and press down keeping the knee straight (Fig. 6.11).
Place your foot on a step or chair. Keep your knee and back
straight, lean forward at your hips until you feel a stretch in the back
of your thigh/knee (Fig. 6.12). Hold for 15 seconds and repeat 4
times at a mild to moderate stretch pain-free.
Fig. 6.9: Shows straight leg raise
Figs 6.10A and B: Straightening and bending the knee
Fig. 6.11: Hamstring stretching
Fig. 6.12: Hamstring stretch
99
100
Calf stretch
With your hands against the wall, place your leg to be stretched
behind you as demonstrated (Fig. 6.13). Keep your heel down, knee
straight and feet pointing forwards. Gently lunge forwards until you
feel a stretch in the back of your calf/knee. Hold for 15 seconds and
repeat4 times at a mild to moderate stretch pain-free.
ITB stretch
Cross your leg to be stretched behind your other leg, taking it as far as
you comfortably can. Then push your hips to the side of your leg to
be stretched until you feel a stretch in your outer thigh/hip (Fig. 6.14).
Keep your back straight. Hold for 15 seconds and repeat4 times at a
mild to moderate stretch pain-free.
Adductor stretch
Standing tall, back straight, place your feet approximately twice
shoulder width apart. Gently lunge toone side, keeping yourother
Fig. 6.13: Calf stretch
101
Fig. 6.14: ITB stretch (left leg)
knee straight, until you feel a stretch in the groin of your straight
leg (Fig. 6.15). Hold for 15 seconds and repeat4 times at a mild to
moderate stretch pain-free.
Note: - Slogan for a OA knee patient, care for the joint to have a care
free joint in old age.
Strengthening Exercises
The following knee strengthening exercises are designed to improve
strength of the muscles of the knee. You should discuss the suitability of these exercises with your physiotherapist prior to begin
them. Generally, they should only be performed provided they do
not cause or increase pain.
Begin with the basicknee strengthening exercises. Once these are
too easy, they can be replaced with the intermediateknee strengthening exercises and eventually, the advanced knee strengthening
exercises.
102
Fig. 6.15: Adductor stretch (left leg)
Knee strengtheningbasic exercises

To begin with, the following basic knee strengthening exercises
should be performed approximately 10 times3 times daily. As
your knee strength improves, the exercises can be progressed by
gradually increasing the repetitions and strength of contraction provided they do not cause or increase pain.
Static Inner Quadriceps Contraction
Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel (Fig. 6.16). Put your fingers on
your inner quadriceps (VMO - vastus medialis obliquus) to feel the
muscle tighten during contraction. Hold for 5 seconds and repeat
10 times as hard as possible pain free.
Quads over Fulcrum
Begin this knee strengthening exercise lying on your back with a
rolled towel or foam roll under your knee and your knee relaxed
(Fig. 6.17). Slowly straighten your knee as far as possible tightening
103
Fig. 6.16: Static inner quadriceps contraction
Fig. 6.17: Quads over fulcrum
the front of your thigh (quadriceps). Hold for 5 seconds and repeat
10 times as hard as possible pain free.
Knee strengtheningintermediate exercises
The following intermediate knee strengthening exercises should
generally be performed 1 to 3 times per week, provided they do
not cause or increase pain. Ideally, they should not be performed on
consecutive days, to allow muscle recovery. As your knee strength
improves, the exercises can be progressed by gradually increasing the
repetitions, number of setsor resistance of the exercisesprovided
they do not cause or increase pain.
104
Knee Extension in Sitting Vs Resistance Band

Begin this knee strengthening exercise in sitting with your knee bent
and a resistance band tied around your ankle as shown (Fig. 6.18).
Keeping your back straight, slowly straighten your knee tightening
the front of your thigh (quadriceps). Perform 3 sets of 10 repetitions
provided it is pain free.
Begin this knee strengthening exercise in standing with your feet
shoulder width apart and your feet facing forwards. A Swiss ball can
be placed between a wall and your lower back to improve your technique (Figs 6.19A and B). Slowly perform a squat, keeping your back
straight. Your knees should be in line with your middle toes and should
not move forward past your toes. Perform 3 sets of 10 repetitions provided the exercise is pain free.
Lunges
Begin this knee strengthening exercise standing with your back
straight in the position demonstrated (Figs 6.20A and B). Slowly,
lower your body until your front knee is at a right angle. Keep your
knee in line with your middle toe and your feet facing forward.
Perform 3 sets of 10 repetitions.
Fig. 6.18: Resistance exercise with a band
105
Figs 6.19A and B: Squat with swiss ball
Figs 6.20A and B: Lunges
Heel Raises
Begin this knee strengthening exercise standing at a bench or chair
for balance (Fig. 6.21). Keep your feet shoulder width apart and
facing forwards. Slowly, move up onto your toes, raising your heels
as far as possible and comfortable without pain. Perform 3 sets of
10 repetitions.
106
Fig. 6.21: Heel raises
Knee strengtheningadvanced exercises

The following advanced knee strengthening exercises should generally be performed 1 to 3 times per week provided they do not cause
or increase pain. Ideally, they should not be performed on consecutive days, to allow muscle recovery. As your knee strength improves,
the exercises can be progressed by gradually increasing the repetitions, number of setsor resistanceof the exercises provided theydo
not cause or increase pain.
Single Leg Squat with Swiss Ball
Begin this knee strengthening exercise in standing on one leg with
your foot facing forwards. A Swiss ball can be placed between a
wall and your lower back to improve your technique (Figs 6.22A
and B). Slowly, perform a squat, keeping your back straight. Your
knee should not bend beyond right angles and should be in line
107
B
Figs 6.22A and B: Single leg squat with swiss ball
with your middle toe. Your knee also should not move forward past
your toes. Perform 3 sets of 10 repetitions provided the exercise is
pain free.
Lunges with Weight
Begin this knee strengthening exercise standing holding light
weights, with your back straight in the position demonstrated (Figs
6.23A and B). Slowly, lower your body until your front knee is at a
right angle. Keep your knee in line with your middle toe and your
feet facing forward. Perform 3 sets of 10 repetitions.
Single Leg Heel Raises
Begin this knee strengthening exercise standing on one leg at a
bench or chair for balance (Fig. 6.24). Keeping your foot facing
forwards, slowly move up onto your toes, raising your heel as far
as possible and comfortable without pain. Perform 3 sets of 10
repetitions.
108
Figs 6.23A and B: Lunges with weight
Fig. 6.24: Single leg heel raises
109
Endurance Training
The cardiovascular fitness of individuals with OA may be compromised. A number of well-controlled trials have reported the ability to
improve this impairment through regular cardiovascular conditioning
without aggravating joints. Programs similar to those designed for deconditioned individuals can be instituted for individual with arthritis.
If weight-bearing is a barrier to exercise, a non-weight-bearing apparatus such as a cycle ergometry or aquatic program may be used.
For most people walking and stationary bicycles are safe and effective
means of aerobic exercise (Figs 6.25A and B). Furthermore, patients
who have engaged in such a program often report an increase in selfesteem and improved emotional status. Medical screening as appropriate for age and medical condition should occur prior to beginning an
exercise program that entails marked increase in physical activity levels.
Functional Training
Functional training for the individual with arthritis proceeds in the
same fashion as for other individuals with similar deficits. Therapists
may choose to reduce the functional demands of an activity either
temporarily, such as under conditions of acute inflammation, or permanently by incorporating a variety of aids into ADLs that substitute
for lost ROM and strength. Raising beds and chairs can reduce the
effort needed to stand up. Railings placed around the bed, bath and
along stairways also can help increase an individuals independence.
Figs 6.25A and B: Aerobics/heart and lung health
110
Gait Training
Specific deviations will be evident throughout the gait cycle. These

may include gait asymmetries, decreased velocity, cadence, stride
length, prolonged period of double support, inadequate heel strike
and toe-off, and diminished joint excursion through both swing and
stance. Therapist should address the underlying joint and muscle
impairments that contribute to these deviations in the gait training
program with persons with arthritis.
The degree to which the gait of an individual with arthritis should,
or can, approximate normal is one of the most difficult questions in
designing a therapeutic program. Some abnormalities such as antalgic limping may in fact reduce joint loading. Joint destruction may
necessitate the introduction of ambulatory aids. The gait of the individual with OA should be safe, functional, and cosmetically acceptable
to the patient rather than an attainable idealized version of the norm.
Decreased walking speed in arthritis is common, and there is general
agreement that increased speed is a meaningful measure of functional improvement. For example, a persons walking ability to walk fast
enough to cross the street with the timing of the traffic light is important for functional community locomotion. However, increase walking speed without attention to joint biomechanics may be undesirable.
Core strengtheningreduction in the quantum of load on
the joint is an important aspect of the treatment of OA. An
obese patient is usually advised to reduce weight and minimize compressive forces on the affected joint by teaching
proper body mechanics and the use of ambulatory aids. Apart
from this core muscle strengthening provides a good corset
like support surrounding your lower abdominal area thereby,
reducing the amount of load falling on your knee joints. Core
muscles include transversus abdominis and multifidus mainly.
A complete protocol should be followed (refer appendix).
Mobilization techniques applied at the joint to increase the
flexibility, ROM and to stretch the surrounding structures.
111
OPERATIVE TREATMENT ALGORITHM

Indications for Surgery

Pain refractory to conservative measures

History of frequent locking episodes
Hemarthrosis due to loose bodies or osteochondral disease
Deformity called genu varum
Joint instability
Progressive limitation of knee motion.
Operative Options
Arthroscopy
With OA, degenerating articular cartilage and synovial tissue
release proinflammatory cytokines that include chondrocytes to
release lytic enzymes leading to the degradation of type 2 collagens and PG.
The lavaging effect of arthroscopy may dilute or wash out
these inflammatory mediators, although the effect is temporary.
Patients who benefit most from arthroscopy have mechanical symptoms (locking meniscus) of short duration (<6 mon.)
with mild arthritis on radiographs.
Patients with 3 to 6 month of unsuccessful supervised nonsurgical management with normal mechanical alignment and
mild to moderate arthritis on weight-bearing films are considered candidates for arthroscopic debridement.
Patients with tibial spine pain, osteophytes formation, and lack
of extension (flexion deformity) may benefit from arthroscopic
notch plasty and osteophytes removal.
Osteotomy
This is a mechanical load shifting procedure. The mechanical axis of
the knee is shifted from the worn compartment to the good compart-
112
ment. Closing wedge osteotomy have an inherent disadvantage that

the tibiofibular joint must be disrupted with some degrees of shortening and joint line alteration. Because the joint line must remain horizontal, in OA with a valgus deformity, the osteotomy is done through
the supracondylar region of the femur; and for the varus deformity, it
is done through the proximal tibia (Figs 6.26 and 6.27).
Varus malalignment of the knee (bow-legged) in a younger
active patient with medial compartment arthritis is addressed
with the valgus producing high tibial osteotomy
Mild valgus malalignment (<10 degrees of valgus) may be treated
with the medial, high tibial closing wedge osteotomy. Patients
with greater than 10 degrees of valgus undergo femoral osteotomy.
The high tibial osteotomy is performed 2 cm. distal to the tibial articular surface but proximal to the tibial tubercle, i.e. proximal to the insertion of ligamentum patellae. The osteotomy may be fixed internally
by staples or immobilized in an above knee or cylindrical plaster cast.
The plaster cast is maintained for a period of 3 weeks where the
staples have been used for internal fixation or for 6 weeks, where no
Figs 6.26A and B: Tibial osteotomy for genu varum
113
Figs 6.27A and B: Supracondylar osteotomy for genu valgum
staples are used. Weight-bearing in the plaster may be allowed at the

end of 4 to 6 weeks in the latter case. After removal of the plaster,
knee mobilization is initiated. Full weight-bearing is permitted after
8 to 10 weeks.
Unicompartmental Knee Replacements
Candidates ideally, should be older than 60 year, low demand sedentary, thin, isolated unicompartmental arthritic involvement.
Arthrodesis: It is less commonly indicated than arthroplasty. If the
patient is young and involved in heavy occupations, arthrodesis is
indicated to give him a stable and strong knee. However, it results in
a stiff knee which is a severe disability.
Total Knee Arthroplasty (Fig. 6.28)
Works best in thin sedentary patients older than 65 year
A proportion of replacements wear out with time, requiring
revision. This is increased with obesity, high impact activity,
overuse, and so on.
114
Fixation Method for Total

Knee Implants
Cemented
Used for older, more sedentary
patients.
Porous ingrowths
Theoretically, porous ingrowths fixation should not
deteriorate with time (unlike
cemented fixation) and is thus
the ideal choice for younger or
more active candidates.
Hybrid technique
Noncemented
ingrowths
femoral and patellar compoFig. 6.28: Total knee
nent with a cemented tibial
arthroplasty
component
Frequently used because of
failure to achieve fixation with some of the original porous
coated tibial components reported in the literature.
Goals of Rehabilitation after

Total Knee Arthroplasty
Prevent hazards of bed rest (e.g. DVT, pulmonary embolism,
pressure ulcers)
Assist with adequate and functional ROM
Strengthen knee musculature
Assist patient in achieving functional independent activities of
daily living
Independent ambulation with an assistive device.
115
Rehabilitation of Patients with Hybrid Ingrowths

Implants Versus those with Cemented Total Knee
Replacement
Cemented total knee arthroplasty
Ability for weight-bearing as tolerated with walker from day
one, postoperatively.
Hybrid or ingrowths total knee arthroplasty
Touchdown weight-bearing (TDWB) only with walker for
first 6 week.
Next 6 week, begin crutch walking with weight-bearing as tolerated.
Accelerated ProtocolPostoperative Rehabilitation

Day 1
Initiate isometric exercises SLR, Qceps sets
Ankle pumps with leg elevation
Ambulate twice a day with knee immobilizer, assistance, and
walker.
Use knee immobilizer during ambulation until patient is able to
perform three SLR in succession out of the immobilizer.
Cemented prosthesisweight-bearing as tolerated (WBAT)
with the walker
Noncemented prosthesisTDWB with the walker
Transfer out of bed and into chair twice a day with leg in full
extension on stool or another chair
CPM machinedo not allow more than 40 degree of flexion
until 3 days.
Usually 1 cycle per minute.
Progress 5 to 10 degree a day as tolerated.
Never record passive range from the patient degrees it may differ by
5 to 10 degree.
116
Initiate active ROM and active-assisted ROM exercises

During sleep, replace the knee immobilizer and place a pillow
under the ankle to help passive knee extension
Cryotherapy commercial unit used
Deep vein thrombosis prophylaxis per physician.
2 days to 2 weeks
Continue isometrics
CPM 0 to 90 as tolerated
Use VMO biofeedback, if patient has difficulty in quadriceps
strengthening
Begin gentle passive ROM exercises for the knee
knee extension/flexion (Fig. 6.29)
Heel/wall slides.
Begin patellar mobilization after 3 to 5 days
Perform active hip abduction and adduction exercises
Continue active and active assisted knee ROM exercises
Plan discharge with a home exercise program when involved
knee is from 0 to 90 degrees and patient can independently
perform transfer and ambulation.
10 days to 3 weeks
Continue previous exercises
Continue use of walker
Ensure that home physical therapy has been arranged.
Fig. 6.29: Passive knee extension
117
3 to 6 weeks
Improve ROM
Enhance muscular strength and endurance
Dynamic joint stability.
6 weeks
Begin weight-bearing as tolerated with ambulatory aid
Perform wall slides, progress to lunges
Perform quadriceps dips or step ups (Fig. 6.30)
Begin closed-chain knee exercises on total gym and progress
over 4 to 5 weeks
bilateral lower extremities
single leg exercises
incline
Progress to stationary bicycle
Perform lap stool exercises (hamstring strengthening) (Fig.
6.31)
Cone-walkingprogress from 4 to 6 to 8 inches cone.
Use McConnell taping of patella to unload patellofemoral
stress, if symptoms occur with exercise
Continue home physical therapy.
In later weeks, it is important to enhance the endurance, eccentricconcentric control of the limb, cardiovascular fitness, and to improve the functional activity performance.
Fig. 6.30: Step ups
118
Fig. 6.31: Lap stool of hamstring strengthening
Major Complications

Joint deformities
Subluxation
Ankylosis
Intra-articular loose bodies.
Chapter
Types
Mobilization Techniques in
Arthritic Knee
of Mobilization Techniques
120
TYPES OF MOBILIZATION TECHNIQUES
Mobilization of the joint can be given as a High Glide Mobilization

Technique (HGMT) or as a Low Glide Mobilization Technique
(LGMT). HGMT is given at the end range of the movement and
helps in increasing the range of motion. Whereas, LGMT is given
at pain range and helps in reducing pain and making the movement tolerable. Below are shown the techniques, which are used in
case of the knee joint (Figs 7.1 to 7.6). However, the details of these
mobilization techniques are beyond the scope of this handbook.
B
Figs 7.1A and B: Proximal tibiofibular joint. (A) Anterior glide;
(B) Posterior glide
Mobilization Techniques in Arthritic Knee
121
B
Figs 7.2A and B: Superoinferior glide of the patellofemoral joint. (A) With
the knee in extension; (B) With knee in flexion
122
B
Figs 7.3A and B: Patellofemoral joint. (A) Medial glide in sidelying;
(B) Medial tilt
123
B
Figs 7.4A and B: Medial lateral glide of femorotibial joint. (A) Lateral glide
in side lying; (B) Medial glide in side lying
124
B
Figs 7.5A and B: Medial lateral glide of tibia. (A) Lateral glide;
(B) Medial glide
125
B
Figs 7.6A and B: Tilt of femorotibial joint. (A) Medial (varus) tilt of
femorotibial joint; (B) Lateral (valgus) tilt of femorotibial joint
Chapter
Osteoarthritis in
Various Joints
The Ankle Joint

The Foot

The Shoulder

The Elbow

The Wrist and Hand
OA of the Small

Remember
Joints
128
THE ANKLE JOINT
Arthritis of the ankle joint is rare and is usually secondary to some

old trauma or disease. The surgical treatment includes either arthrodesis or total joint replacement.
The conservative management includes the use of short wave
diathermy, if there is no swelling around the joint. One electrode
is placed on the sole of the foot and the other above the flexed
knee, in such a case the field density and hence, the heating will
be greatest in the ankle. Exercises to maintain the ROM and flexibility of the joint. Strengthen the muscles to increase the stability
of the joint.
The Foot
Any degenerative changes resulting in wear and tear of the joint
or injury can cause osteoarthritis to develop even years after the
injury has occurred. Severe sprains or fractures can lead to osteoarthritis.
Abnormal foot structure and, consequently, abnormal foot mechanics can also cause osteoarthritis to develop. People with flat feet
or high arches are at greater risk for developing foot osteoarthritis.
Diagnosis of Foot Osteoarthritis
When diagnosing foot osteoarthritis, the therapist must differentiate osteoarthritis from other types of arthritis. The therapist will
consider your medical history and your description of symptoms.
The therapist will ask questions that will help to formulate your
diagnosis, such as:
When did the pain start?
Is the pain continuous or does it come and go?
Have you injured the foot? If yes, when and how was it
treated?
Osteoarthritis in Various Joints
129
Are the symptoms worse at night or following weight-bearing

activity (i.e. walking, running)?
Are the symptoms associated with one or both feet?
The therapist will also perform a physical examination. Your foot
will be examined for swelling, bone spurs or other deformities, limited range of motion, and pain which occurs with movement. A gait
analysis may be performed to evaluate your stride while walking and
the strength of your feet.
Lastly, imaging studies of the bone structure of the affected foot
will likely be performed. Evidence from X-rays, CT scans, or MRI
may be used to help diagnose foot osteoarthritis.
Symptoms of Foot Osteoarthritis
The usual symptoms associated with foot osteoarthritis include:
Pain and stiffness of the affected foot
Swelling near the affected joint
Limited range of motion and difficulty walking
Bony protrusions (spurs).
There are 28 bones and more than 30 joints in the human foot. The
foot joints that are most commonly affected by osteoarthritis include:
The ankle (tibioltalar joint)
The 3 joints of the hindfoot (talocalcaneal joint, talonavicular
joint, calcaneocuboid joint)
The midfoot (metatarsocunieform joint)
The great toe (first metatarsophalangeal joint) (Fig. 8.1).
Treatment of Foot Osteoarthritis
Treatment options for foot osteoarthritis are aimed at relieving
symptoms. There are nonsurgical and surgical options. Therapist
will likely recommend one or more nonsurgical options first. Nonsurgical options include:
130
Nonsteroidal anti-inflammatory drugs or analgesics (to relieve

pain and swelling)
Shoe inserts (to add support or provide extra cushioning)
Orthotic (custom-made shoes or supports)
Braces (to restrict motion or prevent more deformity)
Physical therapy or exercise (to improve range of motion and
stability)
Steroid injections (to deliver anti-inflammatory medication to
the joint directly)
Dietary supplements.
If nonsurgical options are ineffective, doctor may suggest surgery.
Depending on the joint involved, arthroscopy, arthrodesis (fusion),
or arthroplasty (joint replacement) may be considered. The goal of
foot surgery is to relieve pain and restore function.
Osteoarthritis of the joint of big toe is seen occasionally, and
is discussed under hallux valgus and hallux rigidus. Osteoarthritis
of subtalar joint is secondary to an old fracture of the calcaneum.
A severely disorganized, painful joint may need arthrodesis of the
subtalar joint for pain relief.
Fig. 8.1: Osteoarthritis of the joint of big toe
131
The Shoulder
Osteoarthritis of the shoulder is rare and do not needs anything

more than conservative treatment in the form of anti-inflammatory
drugs and physiotherapy. The following are the ways to maintain
functional independence of the upper extremity with minimal
discomfort:
Pain during movement and occasionally during rest is the main
cause of disability. The correct choice of therapeutic modality is necessary. Deep heat, cryotherapy, ultrasound, interferential currents,
and TENS are some of the modalities used. The choice of the particular modality depends upon patients response.
Hydrotherapy, which promotes relaxation and at the same time
facilitates movement is the treatment of choice.
Exercises are aimed at improving ROM of the shoulder, which
many a times is prevented by protective muscle spasm. Therefore, relaxed passive movements are given to reduce pain, prevent spasm, as well as promote further ROM at the glenohumeral
joint.
Active resisted movements or PNF techniques are useful in improving strength and endurance of the shoulder muscles besides assistance in gaining ROM.
Maintenance of the functional ROM and strength is greatly facilitated by providing guidance in the use of whole arm.
Use of axial traction relieves pressure on the sensitive intra-articular structures and is used in relieving pain and muscular spasm.
The Elbow
Osteoarthritis of the elbow is secondary and leads to a stiff joint. Arthroplasty (excisional or total joint replacement) may be indicated
in selected cases. Therapeutic modalities are employed to induce
relaxation and to reduce pain to the maximum. Functional use is
encouraged and guided within the limits of pain and discomfort.
132
Self resistive controlled active movements are encouraged without

causing excessive compression of the elbow joint.
The Wrist and Hand

It is usually secondary to trauma (fracture scaphoid or fracture
dislocation of other carpal bones), or avascualar necrosis of lunate. Pain and stiffness of the wrist are the presenting symptoms.
Arthrodesis of the wrist in the position of slight extension is the
treatment of choice. In the hand, osteoarthritis of the carpometacarpal joint of the thumb is common. It is usually treated conservatively by analgesics and physical therapy. Distal interphalangeal
joints are usually affected by osteoarthritis and require no specific
treatment. In addition to the methods to reduce pain, to induce
relaxation and to improve strength, the patient may be provided
with a splint. A cock-up splint maintaining the wrist in extension
not only provides rest to the arthritic joints, but also facilitates
hand functions without causing much discomfort. Maintaining
optimal pain free function of the hand and functional re-education are the basis of the therapy.
Osteoarthritis of the hand affects mainly the interphalangeal
joints of the hand. The distal interphalangeal joints are commonly involved initially, but proximal interphalangeal joints may
get involved later on. Rarely, metacarpophalangeal joints may
also be involved. Osteophytes formation at the margins of these
joints give rise to hard prominences known as Heberdens nodes at
the DIP joints and Bouchards node at the PIP joint (Fig. 8.2).
The occurrence of these nodes in the dominant hand, particularly
in women, indicates excessive use as one of the etiological factors.
Initially, pain in these nodes is minimal. However, further constant use precipitates inflammatory reaction with increase in pain
and decreased function of hand. Inflammation may lead to a cystic
swelling containing gelatinous material, which is extremely painful
and may even burst.
133
OSTEOARTHRITIS OF THE SMALL JOINTS

OA may affect the peripheral joints of the hand and foot. It may
cause ankylosis at an increased rate in these joints.
REMEMBER
Heberdens nodeOsteophytes around the distal interphalangeal joints of the hand (Fig. 8.2)
Bouchards nodeOsteophytes along the proximal interphalangeal joints of hand (Fig. 8.2)
Mucinous cystCysts containing degenerative myxomatous
fibrous tissue at the distal and proximal IP joints
BunionIt is a combination of OA and valgus angulation of
the first MTP joint of foot
Erosive OAIt is a hereditary severe OA involving distal and
proximal IP joints. Joint deformities and ankylosis result more
often
Fig. 8.2: Upper arrow shows Heberdens node at DIP joint; lower arrow
shows Bouchards node at proximal IP joint
134
OA of first CMC joint of thumbIt is seen in more than 50

years. They complain of pain and loss of grip
OA wristKienbocks disease, trauma, gout, non-union
scaphoid, etc.
OA of the AC jointThis is quite common.
Summary
OA is a condition commonly seen by physical therapists in their
clinical practice. The functional limitations seen in such cases
results from musculoskeletal impairments. Irregularities on the
bone surface, loss of joint mobility, muscle weakness, and atrophy
contribute directly to limitations in ADL and the ability to work.
Pain secondary to changes in normal joint structure and function often limits function as well. Musculoskeletal impairments
related to arthritis may also lead to impairments of other systems,
such as decreased cardiovascular endurance for functional activities. The physical therapist is well suited to evaluate and treat these
impairments, remediate the functional limitations, and educate the
patient in self-management skills to avoid unnecessary disability.
Rehabilitation of the individual with arthritis is most often directed
towards restoring or maintaining joint mobility and strength; and
emphasizes functional retraining and health promotion.
Appendix 1
The arthritis impact measurement scales (AIMS) is an American
questionnaire designed to measure the health status of patients with
arthritis.
Arthritis Impact Measurement Scales 2 (AIMS2-SF)

During the past four weeks
1. How often were you physically
able to drive a car or use public
transportation?
2. How often were you in a bed
or chair for most of the day?
3. Did you have trouble doing
vigorous activities such as
running, lifting heavy objects,
or participating in strenuous
sports?
4. Did you have trouble either
walking several blocks or
climbing a few flights of stairs?
All Most Some Few No

Days Days Days Days Days
142
5. Were you unable to walk unless

assisted by another person or
by a cane, crutches or walker?
6. Could you easily write with a
pen or pencil?
7. Could you easily button a shirt
or blouse?
8. Could you easily turn a key in
a lock?
9. Could you easily comb or brush

your hair?
10. Could you easily reach shelves
that were above your head?
11. Did you need help to get
dressed?
12. Did you need help to get out
of bed?
13. How often did you have severe
pain from your arthritis?
14. How often did your morning
stiffness last more than one
hour from the time you woke
up?
Appendix 1
15. How often did your pain make

it difficult for you to sleep?
16. How often have you felt
tense or high strung?
17. How often have you been
bothered by nervousness
or your nerves?
18. How often have you been in
low or very low spirits?
19. How often have you enjoyed
the things you do?
20. How often did you feel like
a burden to others?
21. How often did you get
together with friends or
relatives?
22. How often did you go to a
meeting of a church, club,
team, or other groups?
23. Did you feel that your family

or friends were sensitive to your
personal needs?
143
144
If you are unemployed, disabled, or retired, stop here.

24. How often were you unable
to do any paid work,
house work or school work?
25. On the days you did work,
how often did you have to
work a shorter day?
Appendix 2
Biomechanical Consideration
Related to Rehabilitation
Hip exercises (such as SLRs) are more stressful to hip than
walking
Functional activities including descending stairs, getting out
of a chair, and bending/lifting with bent knees, put the most
stress on hips and knees
During daily activities, loads of 3 to 4X body weight occur
5 to 10X in sports activities to 25X with weight lifting
Increased speed of walking or running, increased loads
But slower than normal walking speed also increases joint
forces
Exercise will decrease fall risk, increase bone density and thus
prosthesis fixation (amongst other benefits!).
Exercise and Activity Recommendation

Patients should be advised to comply with their exercise programs for at least one year after surgery
Avoid sporting activities that create high compressive or rotary
forces or increase risk of injury to the new joint.
Appendix 3
Getting Additional Rest
Rest is important because it reduces the pain and fatigue that accompany arthritis. It reduces the stress on the joints and protects
them from any further damage. Not only whole body rest, but the
local joint rest is very important.
The following points are essential:
1. Plenty nightly rest
2. Daily rest periodsyou can stretch out for several times in a
day, particularly supporting your joints
3. Five minute breathers are important
4. Local joint rest- when a joint hurts, stop and rest
5. Take out time for relaxing activities like listening to music,
reading, watching television.
Energy Conservation to Reduce Fatigue

One of the major symptoms of arthritis is fatigue, i.e. getting tired
very easily. We hope to reduce this fatigue by conserving energy and
using it carefully. This way you will be able to do much more activity with less pain and fatigue. Never overwork your joints. It will not
help in keeping the joints mobile, but will result in causing damage. You can conserve energy by modifying and simplifying your
activities, pacing yourself, getting additional rest and using adapted
equipments.
Appendix 4
Core Strengthening Exercises
Core stabilization involves a co-contraction of lumbar multifidus
and transversus abdominis and seems to be an effective approach to
resolving osteoarthritic pain.
In 1992, a model proposed by Punjabi introduced a refinement in the definition of stabilization.
Instead of just looking at the joint in terms of bone and
ligament, Punjabi argued that muscle involvement and neurological control would play key roles in joint stability. The
ligaments main influence comes at the end range of the movement within the joint.
In the mid-range of the joint, what Punjabi calls the neutral
zone, the action of muscles would be necessary to maintain the
joints stability. [neutral zone] Panjabis model suggests that
the three aspectsosseoligamentous, muscular and neurologicalhave to work together.
The length of fibers of the stabilizers does not change very
much over the course of a movement. Instead, they remain
consistently short to hold the joint in its neutral zone (before
the end range where the ligaments get involved), to help it keep
its integrity while it is handling load or doing larger motion.
The muscle must be strong enough to do its job of stabilizing,
and also it must act at the proper time. In Panjabis model (see
above), knee problems or back pain were associated with too large
148
a neutral zone, in other words, the stabilizer muscles took too long
to begin to fire.
There are various exercises available for strengthening the muscle. Exercises done for the pelvic floor muscles accompany the
contraction of transversus abdominis. A sphygmomanometer or
a real time ultrasound biofeedback can be used to get a visual
feedback of the contraction.
Exercise is done with the patient in a supine lying position with
knees flexed bilaterally. Patient is asked to bring the stomach out
with every inhalation and take it in with exhalation. Repeat it two
times and then with the end exhalation try to touch the back to the
couch. The clinical measure used to ensure correct activation of the
transversus abdominis muscle was to observe a slight drawing-in
maneuver of the lower part of the anterior abdominal wall below
the umbilical level, consistent with the action of this muscle. In
addition, a bulging action of the multifidus muscle should have
been felt under the clinical physical therapists fingers when they
were placed on either side of the spinous processes of the L4 and L5
vertebral levels, directly over the belly of this muscle.
10 contraction repetitions for 10 second duration each 3 and
release done 3 to 4 times a day, helps in strengthening the core
muscles.
These exercises will be supplemented with exercises for the pelvic floor muscles, breathing control and control of spinal posture.
Patients are taught how to contract these muscles independently,
from the superficial trunk muscles. When this level of competence
has been achieved, patients will be considered ready to progress to
Stage 2.
Stage 2 of the approach involves increasing the complexity of
the exercise by progressing through a range of functional tasks and
exercises targeting coordination of trunk and limb movement and
maintenance of trunk stability.
Index
Page numbers followed by f refer to figure
A
Abduction pillow 79
Accelerated protocol 115
Active ROM exercises 97
Acupuncture57
Additional rehabilitation
points82
Adductor stretch 100, 102f
Advanced balance exercises 44
Alkaptonuria12
Alternate leg raise 63
Ankle
joint128
pumps76
Ankylosis118
Anterior capsular stretch 78f
Arthritic
changes in knee joint 86f
joints in body 7f
knee2f, 86
Arthritis 6, 11, 16
Arthrodesis 56, 113
Arthroplasty56
Arthroscopy111
Articular cartilage 17
Assessment of
deformity22
endurance, tone and
volume22
tenderness22
Assistive devices 79
B
Balance activity and rest 53
Ball
around back 40
balance exercise41f
circles around leg 42
leg balance exercise 43f
throws against wall 42
under leg 40
balance exercise42f
Basic balance exercises 40
Bathroom rehabilitation 79
Bend knee
back77
up while standing 77
Blind advanced one leg
balance38
150
Blood test 3
Bony
collapse26
enlargement88
tenderness88
Boswellia serrata 57
Bouchards node 18, 132, 133f
C
Calcaneocuboid joint 129
Calf stretch 100, 100f
Capsular tightness 19
Cartilage5
Cement less technique 76
Cemented
prosthesis76
total knee arthroplasty 115
Choice of osteotomy 68
Chondrocytes5
Chondroitin57
Chronic thickened swelling 45
Clasticated supports 48f
Cold effusion 61
Collagen5
Comfort elastic knee
stabilizer94f
Component malalignment 83
Congenital
disorders10
hip luxation 11
Corticosteroids55
Costochondritis11
Crepitus88
Cross body leg swings 39
Deep vein thrombosis 82

Degenerative
arthritis6
joint disease 6, 19
osteoarthritis6
Diagnosis of foot
osteoarthritis128
Displacement osteotomy 68
Distal interphalangeal joints 18
Duradisc balance exercises 44
E
Endurance training 109
Enhancing joint
proprioception37
Environmental barriers 24
Estrogen deficiency 92
Exercises 33, 62
in sitting position 63
in standing 64
lying on back 62
Extra-articular inflammatory
disease35
F
Fibrous contracture 45
First metatarsophalangeal
joint129
Fixation method for total knee
implants114
Flexion contracture of hip 81
Foam pillow balance
exercises44, 45f
Free active exercises and

mobilizations33
Front and back leg raises 64f
Functional training 109
G
Gait faults 82
General features of
osteoarthritis60
Glucosamine57
Gluteal sets 76
Gluteus maximus
strengthening80f
Gout11
Group therapy 33
H
Hamstring stretching 98, 99f
Heberdens nodes 18, 133f
Heel
raises105
walking39
Hemochromatosis12
High glide mobilization
technique120
Hip
abduction
adduction77
exercises77f
in standing80f
dysplasia11
internal rotation 88
joint59
osteoarthritis88
resurfacing 70, 71f
Index
151
Hormonal disorders 11
Hybrid technique 114
Hyperthyroidism11
I
Ice therapy 32
Indications for surgery 111
Inflammatory
arthritis6
diseases11
Infrared lamp 51f
Intermediate balance exercises 40
Intra-articular loose bodies 118
Isometric
exercises 76, 95, 97
hip abduction 76
J
Joint
deformities118
in brief 5
irregularity90
narrowing90
of thumb 134
protection
exercises35
techniques51
stability22
stiffness88
tightness61
K
Kienbocks disease 134
Knee
and hip flexion63
braces93
152
crossovers65f
extension in sitting vs resistance
band104
joint85
osteoarthritis 88, 90
pain88
strengthening 102, 103, 106
to chest lifts 66f
L
Lap stool of hamstring
strengthening118f
Leg
rotation64f
scissors against resistance 65f
stretch63
Location of pain 25
Loss of
joint space 25
movement61
Low glide mobilization
technique120
Lyme disease 11
M
Maintenance of joint range and
muscle power48
Malum coxae senilis 60
Marfan syndrome 12
Medial lateral glide of
femorotibial joint 123f
tibia124f
Metatarsocunieform joint 129
Mild inflammation 61
Minimizing deformity 49
Minimus tendons 62
Mobility of joints 45
Mobilization techniques in
arthritic knee119
Muscle
spasm45
strengthening35
N
Narcotics55
Neoroprene elastic knee
braces95f
Nerve palsy 83
Nodes in OA hand 18f
Non-steroidal anti-inflammatory
drugs54
O
Obesity 12, 88, 92
One leg balance 38
Orthotic supports 46
Osteoarthritic joint 35
Osteoarthritis 2, 6, 15, 24, 59,
85, 127, 131
of CMC joint of thumb 16f
of hip 60
of joint of big toe 130f
of knee 92
of small joints 133
Osteophytes 26, 89
Osteotomy 56, 89, 111
P
Pain
assessment21
gate theory 30
relief 30, 95
Paracetamol54
Passive
Index
knee extension 116f

stretching of hip flexor
contracture81f
Patellofemoral joint 122f
Pauwells varus osteotomy 68
Pelvic
lift63
tilt62
Perthes disease 11
Postoperative rehabilitation 115
Primary OA in left knee of elderly
female11f
Prosthetic
arthroplasty56
hip dislocation 83
Proteoglycans5
Proximal
interphalangeal joints 18
tibiofibular joint 120f
Pulsed electromagnetic energy 31
Q
Quadriceps
sets76
strengthening97f
Quads over fulcrum 102, 103f
R
Range of motion 18, 20
Reduce excess body weight 53
Rehabilitation
after total hip replacement 71
protocol75
Resistance exercise with
band104f
Rheumatoid arthritis 6, 11, 18
153
ROM and stretching exercises 77
Rules of exercises in management
of OA hip 62
S
S-adenosylmethionine57
Sclerosis25
Selenium deficiency 58
Sensory integrity 24
Severity of pain 25
Side
kicks65f
leg lifting 63f
throw against wall 42
Single leg
balance 38f, 40, 41f
heel raises 107, 108f
squat with Swiss ball
106, 107f
Site and distribution of pain 21
Sports injuries 12
Squat with Swiss ball 105f
Standard ice pack 33f
Standing
leg swing 64
side leg swing 64
Static inner quadriceps
contraction102, 103f
Stationary cycle 68f
Stiffness90
Straight leg
lifts66f
raising 70, 98
Straighten knee 77
Straightening and bending
knee99f
154
Strengthening exercises 101

for abductors and
quadriceps36f
Stretching exercises 98
Subchondral
bone17
cysts 25, 26, 90
Superficial heat 32
Superoinferior glide of
patellofemoral joint121f
Supracondylar osteotomy for genu
valgum113f
Swelling of knee 25
Symptoms of foot
osteoarthritis129
Synovectomy56
Synovium5
T
Talonavicular joint 129
Tendon transfer 56
Thermoskin comfort arthritic knee
wrap94f
Thomas stretch 78f
Tibial osteotomy for genu
varum112f
Tibioltalar joint 129
Tilt of femorotibial joint 125f
Toe walking 39
Total
hip replacement 72, 74f
joint replacement 82
knee arthroplasty 113-115
Treatment
in osteoarthritis 27
of foot osteoarthritis 129
Trendelenburg gait 81
Trochanteric bursitis 62
Types of
arthritis6
mobilization techniques 120
U
Ultrasound 33, 34f
therapy96f
Unicompartmental knee
replacements113
V
Valgus osteotomy 68
Visual analog scale 21
Vitamin
B9 and B12 58
D deficiency 58
W
Walking on heel 39f
Wall balance exercise 43f, 44f
Water on knee 18
Wax
application for OA hand 32f
therapy32
Weak hip abductors 81
Weight-bearing
joints carry burden 53
status76
to tolerance 75
Wilsons disease 12
Wrist and hand 132

Understanding Osteoarthritis and Its Management

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Jaypee-Highlights Medical Publishers Inc.

Understanding Osteoarthritis and its Management

2. Osteoarthritis: Types and Pathogenesis..........................9

3. Osteoarthritis: Clinical Assessment..............................15

Understanding Osteoarthritis and its Management

5. Osteoarthritis: Hip Joint..............................................59

6. Osteoarthritis: Knee Joint............................................85

Functional Training 109

7. Mobilization Techniques in Arthritic Knee................119

8. Osteoarthritis in Various Joints..................................127

Understanding Osteoarthritis and its Management

Fig. 1.1: An arthritic knee

What Causes It?

It is not known exactly, what causes osteoarthritis, although it can

How can Physiotherapy Help?

Understanding Osteoarthritis and its Management

Your consultation is likely to include:

He or she may prescribe medication to reduce the symptoms or refer

Understanding Osteoarthritis and its Management

[OA = can be called as OOld age; AArthritis]

Fig. 1.2: Arthritic joints in the body

Understanding Osteoarthritis and its Management

There is no doubt that various types of acute trauma to the knee,

Understanding Osteoarthritis and its Management

Some investigators believe that mechanical stress on joints underlies

Osteoarthritis: Types and Pathogenesis

Fig. 2.1: Primary OA in the left knee of an elderly female

Congenital hip luxation

Understanding Osteoarthritis and its Management

Ligamentous deterioration or instability may be a factor

Osteoarthritis: Types and Pathogenesis

fibrillation of the upper third of the cartilage follows, and occurs

Signs and Symptoms

Understanding Osteoarthritis and its Management

SIGNS AND SYMPTOMS

Fig. 3.1: Osteoarthritis of CMC joint of thumb

Osteoarthritis: Clinical Assessment

RA nor it is generalized to the whole body. The disease process

Understanding Osteoarthritis and its Management

Fig. 3.2: Nodes in OA hand

Osteoarthritis: Clinical Assessment

to be held in a somewhat flexed, abducted, and externally rotated

Understanding Osteoarthritis and its Management

relatively large tibiofemoral contact area. Furthermore, the joint

Range of Motion (ROM)

Osteoarthritis: Clinical Assessment

is important to observe motions for symmetry and smoothness

Understanding Osteoarthritis and its Management

Destruction of the cartilage exposing the subchondral bone to

Assessment of Endurance, Tone and Volume

Osteoarthritis: Clinical Assessment

It is extremely important to measure the degree of deformity accurately. The deformity

Functional Assessment (Loss of

Understanding Osteoarthritis and its Management

Mobility and Gait

Osteoarthritis: Clinical Assessment

Understanding Osteoarthritis and its Management

Deformity and malalignment (due to destruction of capsules

Understanding Osteoarthritis and its Management

Fig. 4.1: Use of cane on the contralateral side

and the prevention of further progression of the disease. This may