Osteophytosis of the knee: association with changes in weight-bearing exercise

Review Article: Osteophytes

An osteophyte is a fibrocartilage-capped bony outgrowth that is one of the features of osteoarthritis. This study reviewed the types, risk factors, pathophysiology, clinical presentations, and medical and surgical treatment of osteophytes. Extraspinal osteophytes are classified as marginal, central, periosteal, or capsular, whereas vertebral osteophytes are classified as traction or claw. Risk factors for development of osteophytes include age, body mass index, physical activity, and other genetic and environmental factors. Transforming growth factor β plays a role in the pathophysiology of osteophyte formation. Osteophytes can cause pain, limit range of motion, affect quality of life, and cause multiple symptoms at the spine. Medical treatment involves the use of bisphosphonates and other non-steroidal anti-inflammatory agents. Surgical treatment in the form of cheilectomy for impingement syndromes during joint replacement is recommended.

Articular and abarticular manifestations in type 2 diabetes mellitus

OBJECTIVE

Diabetes mellitus (DM), a worldwide high-prevalence disease, is associated with a large variety of rheumatic manifestations. It affects the connective tissues in many ways and causes alterations in the periarticular and the musculoskeletal systems. In most cases, these manifestations are associated with functional disability and pain, affecting the quality of life of the diabetic patient. The aim of our study is to review the different articular and abarticular manifestations in diabetic patients and the associated factors of these rheumatic manifestations.

MATERIAL AND METHODS

A cross-sectional study that includes all patients suffering from type 2 DM who present with articular or abarticular manifestations.

RESULTS

We included 116 diabetic patients presenting with articular or abarticular manifestations. Our study showed four important findings. First, a large variety of articular and abarticular manifestations were present in patients with type 2 DM. Second, osteoarthritis (OA) of the knee was the most frequent articular manifestations. It was seen in 49% of our patients. Third, the most common manifestations in diabetic Moroccan patients were carpal tunnel syndrome (CTS), adhesive capsulitis of the shoulder, and diabetic cheiroarthropathy (29%, 23%, and 16%, respectively). Fourth, there was a significant association between vascular complications and the development of articular and abarticular manifestations.

CONCLUSION

This study shows that the articular and abarticular manifestations in diabetic Moroccan patients are dominated by CTS, adhesive capsulitis of the shoulder, and diabetic cheiroarthropathy, with a significant association between vascular complications and the development of some of these manifestations.

Effects of exercise and physical activity on knee osteoarthritis

Exercise is one of the most discussed and controversial nonpharmacologic management strategies for osteoarthritis (OA) of the knee. Health care providers and patients share varied and often pseudoscientific beliefs regarding the effects of exercise on knee OA formulated on outdated notions of the etiology, pathophysiology, and progression of the condition. Based on the contemporary literature, regular light to moderate physical activity has both preventive and therapeutic benefits for individuals with knee OA. Exercise regimens with strong evidence of benefit include those that focus on aerobic/cardiovascular conditioning and lower extremity strength training. Health care providers should confidently incorporate exercise recommendations into clinical management and offer patients evidence-based and individually tailored exercise prescriptions to help manage the painful and often disabling symptoms of this condition.

What is the effect of physical activity on the knee joint? A systematic review

PURPOSE

Although several studies have examined the relationship between physical activity and knee osteoarthritis, the effect of physical activity on knee joint health is unclear. The aim of this systematic review was to examine the relationships between physical activity and individual joint structures at the knee.

METHODS

Computer-aided searches were conducted up until November 2008, and the reference lists of key articles were examined. The methodological quality of selected studies was assessed based on established criteria, and a best-evidence synthesis was used to summarize the results.

RESULTS

We found that the relationships between physical activity and individual joint structures at the knee differ. There was strong evidence for a positive association between physical activity and tibiofemoral osteophytes. However, we also found strong evidence for the absence of a relationship between physical activity and joint space narrowing, a surrogate method of assessing cartilage. Moreover, there was limited evidence from magnetic resonance imaging studies for a positive relationship between physical activity and cartilage volume and strong evidence for an inverse relationship between physical activity and cartilage defects.

CONCLUSIONS

This systematic review found that knee structures are affected differently by physical activity. Although physical activity is associated with an increase in radiographic osteophytes, there was no related increase in joint space narrowing, rather emerging evidence of an associated increase in cartilage volume and decrease in cartilage defects on magnetic resonance imaging. Given that optimizing cartilage health is important in preventing osteoarthritis, these findings indicate that physical activity is beneficial, rather than detrimental, to joint health.

Rheumatic complications of long term treatment with hemodialysis

Patients undergoing hemodialysis therapy develop serious osteoarticular diseases. The treatment is based on prevention. The aim of our study is to determine the frequency and the associated factors to the rheumatic manifestations in hemodialysis patients. A cross-sectional study was conducted, including all hemodialysed patients in our dialysis unit. Information was obtained from patients' symptoms, examination findings, and biological and radiological signs. The frequency of symptoms was 70% in our patients. It was proportional to the duration of hemodialysis and number of hemodialysis sessions per week. Early transplantation is of course a plausible solution, but other therapies such as improved dialysis must be considered.

Osteoarthritis in hemodialysis patients: relationships with bone mineral density and other clinical and laboratory parameters

OBJECTIVE

The aim of this study was to determine the role that hemodialysis (HD) plays in radiologically assessed osteoarthritis (OA) of the hand, knee, and hip.

MATERIALS AND METHODS

Eighty patients who had been on regular HD for at least 2 years were included. Anterior-posterior radiographs of the pelvis, weight-bearing knees, and hands and wrists of each patient were examined. Bone mineral density (BMD) of spine, femur, and forearm was measured.

RESULTS

Radiologic assessment of the 80 patients' hands showed that 41 individuals had osteopenia, 12 had midphalangeal subperiosteal resorption, 11 had cystic bone lesions, eight had bone erosion, four had osteophytic lesions, and three had subchondral sclerosis. Bone erosion in the hands was significantly associated with HD duration, forearm T score, and serum parathyroid hormone level. Radiologically, OA was demonstrated in eight knee and ten hip joints. Minimum joint space in the tibiofemoral compartment correlated with body mass index, and minimum joint space in the hip correlated with age. The mean BMD measurements at all three sites studied in the HD patients were low. Only the duration of HD significantly correlated with forearm BMD.

CONCLUSION

Osteoarticular complications are common in HD patients.

The validity of different definitions of radiographic worsening for longitudinal studies of knee osteoarthritis

Several definitions have been used to characterize radiographic worsening of knee osteoarthritis in longitudinal studies, yet a valid definition with maximal power to detect differences between groups is not known. We used serial radiographs from the Framingham Osteoarthritis Study to compare five dichotomous definitions according to construct validity (strength of association) and discriminant power (power to reject null hypotheses of no difference) for 1) known risk factors for knee osteoarthritis, and 2) development of new knee pain. For risk factors: definitions that included scores for osteophytes (bone spurs) showed good construct validity and discriminant power; a definition using the Kellgren and Lawrence grade of overall knee osteoarthritis was conservative with good construct validity but low discriminant power; a definition based solely on ordinal assessment of joint space narrowing had weak construct validity and low discriminant power. All definitions had comparably strong associations with the development of new knee pain. Similar associations with new knee pain were found when the analysis was confined to either knees with no osteoarthritis at baseline or knees with prevalent osteoarthritis, with increased standard errors for prevalent osteoarthritis. Use of any of these definitions, other than joint space narrowing alone, would permit detection of associations with most known risk factors. Definitions incorporating both osteophytes and joint space narrowing offer the most precise estimation of the association of risk factors with disease worsening.

Relationship between quadriceps strength and rate of loading during gait in women

One function of skeletal muscle is to serve as the body's shock absorbers and thus dampen rates of loading during activity. The aim of this cross-sectional study was to determine the significance of muscle strength on rates of loading during gait. Thirty-seven women (mean age: 34.5 +/- 8.2 years) were solicited by advertisement and placed into one of two groups-strength-trained or sedentary-on the basis of training history. They walked (10 trials) over a 10-m walkway at a controlled speed of 1.22-1.35 m/s while the rate of loading was sampled with a 1,000-Hz force platform. Quadriceps and hamstring strength was measured at 90 degrees/s with an isokinetic dynamometer. Statistical analyses (p < 0.05) included descriptive statistics and unpaired t tests for comparison between groups. The women in the sedentary group weighed more and had significantly less concentric and eccentric strength of the quadriceps and hamstrings relative to body weight than did those in the strength-trained group. In addition, they demonstrated significantly higher rates of loading (2.21 +/- 0.15 compared with 1.75 +/- 0.08%wt/ms) than those in the strength-trained group.

Exercise in the treatment of osteoarthritis

Exercise, both therapeutic and recreational, is an effective therapy in successful management of osteoarthritis. Exercise is integral in reducing impairment, improving function, and preventing disability. Benefits of flexibility, muscular conditioning, and cardiovascular exercise and the role of regular physical activity in maintaining general health are discussed. Exercise recommendations and safety considerations are provided.

Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study

PURPOSE

Because osteoarthritis may be caused by "wear and tear," we examined the association between level of physical activity and risk of knee osteoarthritis in the elderly.

SUBJECTS AND METHODS

Eligible subjects were participants in the Framingham Heart Study cohort who had radiographically normal knees at biennial exam 18 (1983-1985) and who also completed a physical activity questionnaire at exam 20 (1988-1989). Follow-up knee radiographs were obtained at biennial exam 22 (1992-1993). The study outcomes were the development of incident radiographic or symptomatic knee osteoarthritis between the baseline and follow-up exams.

RESULTS

The number of hours per day of heavy physical activity was associated with the risk of incident radiographic knee osteoarthritis (odds ratio = 1.3 per hour, 95% confidence limits 1.1-1.6, P for trend = 0.006). Adjustment for age, sex, body mass index, weight loss, knee injury, health status, total calorie intake, and smoking strengthened this association (eg, odds ratio for > or = 4 hours heavy physical activity/day compared with no heavy physical activity = 7.0, 95% confidence limits 2.4-20, P for trend = 0.0002). Risk was greatest among individuals in the upper tertile of body mass index (odds ratio for > or = 3 hours/day of heavy physical activity = 13.0, 95% confidence limits 3.3-51). For incident symptomatic knee osteoarthritis, the results were similar, although the number of cases was small. No effects on these outcomes were observed from moderate and light physical activity, number of blocks walked, or number of flights of stairs climbed daily.

CONCLUSIONS

Heavy physical activity is an important risk factor for the development of knee osteoarthritis in the elderly, especially among obese individuals. Light and moderate activities do not appear to increase risk.

The role of physical therapy and physical modalities in pain management

This article provides an overview to arthritis care of the common physical modalities (heat, cold, transcutaneous electrical nerve stimulation, low-energy laser, topical applications, and external devices). The rationale for use and effectiveness of the various physical modalities are discussed. Exercise is presented in terms of mode and effect of range of motion, muscle conditioning, and aerobic exercise.

Prevention of osteoporotic fractures: possibilities, the role of exercise, and limitations

The Compression of Morbidity paradigm seeks to reduce lifetime illness and morbidity by compressing the dominant morbidity, that of the senior years, between an increasing age of onset of morbidity and a more slowly increasing average age at death. Fractures, often associated with osteoporosis, cause a substantial part of this morbidity. For morbidity resulting from fractures to be reduced, the age-specific incidence of fractures needs to decline, since treatment of fractures after they occur is not likely to prove a major benefit. Thus, the risk factors need to be identified and appropriate preventive interventions undertaken. The medical model seeks to diagnose, then to treat those with disease. In considering prevention, many apply the medical model. The disease is "osteoporosis", we must identify people with this disease and then treat them. The public health model, in contrast, seeks to prevent "disease" in all susceptibles. The disease is "morbidity resulting from fractures". The fatal flaws in the medical screening approach will be discussed, together with a lament that this conference was not entitled: "Recent Progress in the Prevention of Morbidity Associated with Fractures". Osteoporosis is only one of many factors associated with increased morbidity resulting from fractures. A fracture management model for reduction in this morbidity will be presented. Osteoporosis finds its genesis in many well-identified risk factors, including age, sex, estrogen levels, and exercise levels, together with positive (e.g. calcium, estrogen) and negative (corticosteroids) effects of medications. Falls, the other main branch of the model, find their genesis is such risk factor as slippery floors, medication side effects, and co-morbid conditions, often with their own antecedent risk factors. Together, over twenty preventable risk factors contribute to the major morbidity associated with fractures.

Relationship of running to musculoskeletal pain with age. A six-year longitudinal study

OBJECTIVE

To determine, by longitudinal study, whether long-distance running, maintained for many years, is associated with increased musculoskeletal pain with age.

METHODS

A 6-year prospective longitudinal study of 410 runners' club members and 289 community controls, age 53-75 years at study initiation, was conducted. Subjects were also categorized as ever-runners (n = 488) and never-runners (n = 211). The primary dependent variable was pain score as indicated on a horizontal double-anchored analog scale; data for this variable were available beginning in 1987. Statistical adjustment for age, education level, smoking, alcohol consumption, history of arthritis, and presence of other major medical conditions was done by analysis of covariance. Further analyses of previously reported associations of regular vigorous physical activity with decreased disability and mortality after 9 years were performed.

RESULTS

The degree of musculoskeletal pain was slightly lower in the exercise group compared with controls, and the difference was statistically significant for women but not for men. Average adjusted pain scores for men were 18.3 (SEM 0.8) in runners' club members, 20.2 (1.2) in controls, 18.6 (0.8) in ever-runners, and 20.3 (1.6) in never-runners. For women, these scores were 17.5 (1.8) in runners' club members versus 22.8 (1.4) in controls (P < 0.05), and 17.2 in ever runners versus 23.7 (1.5) in never-runners (P < 0.002). Disability had continued to develop in runners' club members at a rate only one-third that in the controls after 9 years of observation. Mortality over 9 years consisted of 51 deaths, of which 41 were in the control group and only 10 were among runners' club members.

CONCLUSION

Vigorous running activity over many years is not associated with an increase in musculoskeletal pain with age, and there may be a moderate decrease in pain, particularly in women. Vigorous physical activity is associated with greatly decreased levels of disability and with decreased mortality rates.

Exercise in the management of osteoarthritis of the knee and hip

Osteoarthritis OA is a disorder that confines itself to affected joints; however, impairment, functional limitation, and disability related to OA can reach far beyond the perimeters of articular cartilage and subchondral bone. OA often is compared to other arthritides and defined by what it is not: OA is not a systemic disease; OA is not a disease of primary inflammation; OA is not life threatening. Too often OA also has been considered not interesting, not important, and not responsive to conservative treatment. However, reports documenting the personal and socioeconomic impact of OA are increasing recognition of its importance [1] and recent advances in understanding its pathogenesis are stimulating research [2]. OA is characterized by specific changes in articular cartilage and subchondral bone. Cartilage shows fibrillations, increased water content, and loss of integrity. Underlying bone is less compliant and may exhibit microfractures, sclerosis, and osteophytes at joint margins [3]. These changes 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. There is also evidence, however, that reduced compliance in bone and periarticular structures may initiate degenerative processes [4,5]. Although radiographic evidence of joint space narrowing and osteophytes may help confirm a diagnosis of OA, the clinical criteria for classification and reporting of hip and knee OA are described in terms of pain and limitation of motion [6,7] Table 1. Radiographic and laboratory data add little to the accuracy of these criteria [6]. Moreover, there is no clear association between radiographic findings and function or pain [8].(ABSTRACT TRUNCATED AT 250 WORDS)