Osteoarthritis (OA) is the most common form of arthritis, and it is due to cartilage destruction and changes in the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Physical exam may reveal crepitus with joint motion and osteophyte formation (Heberden and Bouchard nodes). The diagnosis is clinical and supported by radiographic joint findings. Management includes conservative measures, analgesic medications, glucocorticoid intra-articular injections, and surgery for advanced disease.
IncidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency: approximately 492 cases per 100,000 people worldwide
PrevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency increases with age.
80%–90% of individuals > 65 years have radiographic osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis (OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis).
Symptoms are generally not noticed until after the age of 50.
Nodal OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis
ScoliosisScoliosisScoliosis is a structural alteration of the vertebral column characterized by a lateral spinal curvature of greater than 10 degrees in the coronal plane. Scoliosis can be classified as idiopathic (in most cases) or secondary to underlying conditions. Scoliosis
Slipped femoral capital epiphysisEpiphysisThe head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united.Bones: Structure and Types
Congenital hip dislocation
Metabolic disorders
HemochromatosisHemochromatosisA disorder of iron metabolism characterized by a triad of hemosiderosis; liver cirrhosis; and diabetes mellitus. It is caused by massive iron deposits in parenchymal cells that may develop after a prolonged increase of iron absorption.Hereditary Hemochromatosis
Wilson’s disease
Crystal deposition disease (goutGoutGout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout)
HemoglobinopathiesHemoglobinopathiesA group of inherited disorders characterized by structural alterations within the hemoglobin molecule.Anemia: Overview and Types (thalassemiaThalassemiaThalassemia is a hereditary cause of microcytic hypochromic anemia and results from a deficiency in either the α or β globin chains, resulting in hemoglobinopathy. The presentation of thalassemia depends on the number of defective chains present and can range from being asymptomatic to rendering the more severely affected patients to be transfusion dependent. Thalassemia)
Infection
BoneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types disorders
Paget disease
Osteonecrosis
Neuropathic (Charcot joint)
DiabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus mellitus
SyphilisSyphilisSyphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis
Risk factors[1,2,6,12,17]
Age
ObesityObesityObesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
SexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria
Hypertrophic repair of articular cartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology: mechanical stress → cartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology damage → ↑ proteoglycan and collagenCollagenA polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth).Connective Tissue: HistologysynthesisSynthesisPolymerase Chain Reaction (PCR) → swellingSwellingInflammation of joint cartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology[2,5‒7,12]
CartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology destruction:[2,5‒7]
Continued damage → ↑ chondrocyte proliferation and activity → matrix metalloproteinaseMatrix metalloproteinaseA family of zinc-dependent metalloendopeptidases that is involved in the degradation of extracellular matrix components.Pulmonary Fibrosis production → matrix degradation
Inflammatory mediators and matrix proteinMatrix proteinProteins associated with the inner surface of the lipid bilayer of the viral envelope. These proteins have been implicated in control of viral transcription and may possibly serve as the ‘glue’ that binds the nucleocapsid to the appropriate membrane site during viral budding from the host cell.Parainfluenza Virus fragments continue chondrocyte stimulation.
Ultimately leads to chondrocyte death
↓ CollagenCollagenA polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth).Connective Tissue: Histology and proteoglycansProteoglycansGlycoproteins which have a very high polysaccharide content.Basics of Carbohydrates → ↓ cartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: HistologyelasticityElasticityResistance and recovery from distortion of shape.Skeletal Muscle Contraction → ↓ joint integrity
Loss of cartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology → ↓ joint space → boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types becomes denuded
Articulation of exposed boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types with an opposing surface → ↑ stress on the boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types
Vascular invasion and ↑ cellularity → boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types becomes thickened and dense (subchondral sclerosisSubchondral SclerosisOsteochondritis Dissecans)
Osseous metaplasiaOsseous MetaplasiaOsteoarthritis and ossificationOssificationThe process of bone formation. Histogenesis of bone including ossification.Bones: Development and Ossification of connective tissueConnective tissueConnective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix.Connective Tissue: Histology → outgrowth of new boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types (osteophytes)
Pathology of osteoarthritis Destruction of cartilage leads to decreased joint space. With severe destruction, bone becomes denuded.
Stages of osteoarthritis of the knee joint:
A. There is minimal disruption and approximately 10% cartilage loss.
B. Narrowing of the joint space is seen, cartilage begins to break down, and osteophytes develop.
C. There is moderate reduction of the joint space. Gaps in the cartilage can expand until the bone is reached.
D. The joint space is greatly reduced and approximately 60% of the cartilage is lost. Large osteophytes are seen.
SpineSpineThe human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum.Vertebral Column: Anatomy:
Intervertebral disks
Zygapophyseal (facet) joints
Feet: 1st metatarsophalangeal (MTP) joints
Symptoms[4‒7]
Joint painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Gradual onset
Asymmetric
More severe with:
Activity
Weight bearing
Relieved with rest
Later in the disease:
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways is more constant.
Affects sleepSleepA readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility.Physiology of Sleep and level of activity
Morning stiffness
Duration < 30 minutes
Improves with movement
Inguinal painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways due to hip involvement
SpondylolisthesisSpondylolisthesisDisplacement of a vertebra forward in relation to the vertebra belowBack Pain
Nerve impingement
Physical exam[4‒7]
Joint line tenderness
Limited range of motionRange of motionThe distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises.Examination of the Upper Limbs (ROM)
Heberden’s nodes in osteoarthritis: bony growth spurs at the DIP joints due to osteophytes
Image: “Bony growth spurts” by School of Dentistry, Franciscan University Center, Andradas Street, 1614, 97010-032 Santa Maria, RS, Brazil. License: CC BY 3.0
Heberden’s nodes in osteoarthritis: Osteophytes of the distal interphalangeal (DIP) joints
Image: “Grading of osteoarthritis” by Landspitalinn University Hospital, University of Iceland, IS-108 Fossvogur, Reykjavik, ICELAND. License: CC BY 2.0, edited by Lecturio.
Diagnosis
Clinical criteria[8,9,12]
Age > 50 years (≥ 45 years in the UK)
Activity-related joint painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
No morning joint stiffness or morning joint stiffness lasting < 30 minutes
Imaging
OsteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis is a clinical diagnosis that is confirmed with imaging. Imaging is not routinely required but may be needed to diagnose atypical presentations of osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis, such as morning joint-related stiffness > 30 minutes, rapid progression of symptoms, recent trauma, hot swollen joint, or history suggestive of infection or malignancyMalignancyHemothorax.[8,9]
Kellgren-Lawrence classification of osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis (widely accepted scaleScaleDermatologic Examination of osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis severity):[11,12]
Grade 0: no radiologic findings of osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis
Grade 1: possible osteophytic lipping, doubtful joint space narrowing
Grade 2: definite osteophytes, possible joint space narrowing
Grade 3: moderate multiple osteophytes, definite narrowing of joint space and some sclerosisSclerosisA pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve.Wilms Tumor, and possible deformityDeformityExamination of the Upper Limbs of boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types ends
Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosisSclerosisA pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve.Wilms Tumor, and definite deformityDeformityExamination of the Upper Limbs of boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types ends.
Magnetic resonance imaging (MRI)[10–12]
Order if radiographs are normal or reveal a joint effusionJoint EffusionSeptic Arthritis with persistent painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways.
More sensitive for early disease
Additional findings:
CartilageCartilageCartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology defects
Bone marrowBone marrowThe soft tissue filling the cavities of bones. Bone marrow exists in two types, yellow and red. Yellow marrow is found in the large cavities of large bones and consists mostly of fat cells and a few primitive blood cells. Red marrow is a hematopoietic tissue and is the site of production of erythrocytes and granular leukocytes. Bone marrow is made up of a framework of connective tissue containing branching fibers with the frame being filled with marrow cells.Bone Marrow: Composition and Hematopoiesis lesions
Joint effusions
Radiographic features of osteoarthritis: This image shows joint space narrowing, osteophytes, and subchondral sclerosis (arrows).
Image: “Examples of JSN” by Center for Hip and Knee Replacement (CHKR), Department of Orthopaedic Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, 622 W. 168th Street, PH 1155, New York, NY 10032, USA. License: CC BY 4.0
Radiographic features of osteoarthritis: Close-up imaging shows a subchondral cyst on distal clavicle. This signals osteoarthritis of the acromioclavicular joint.
Image: “Case presentation” by Department of Orthopaedic Surgery, Japanese Red Cross Sendai Hospital, Yagiyama Honcyo, Taihaku-Ku, Sendai, Miyagi, Japan. License: CC BY 2.5
Radiographic features of erosive osteoarthritis: Central subchondral erosions give the DIP joint a “seagull wing” appearance.
Image: “X-ray of erosive osteoarthritis of the fingers” by Rennett Stowe and Mikael Häggström . License: CC BY 4.0
Supporting workup
The following tests are not used for the diagnosis of OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis, but are used to exclude other causes of arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis.
ArthrocentesisArthrocentesisPuncture and aspiration of fluid (e.g., synovial fluid) from a joint cavity. It is used sometimes to irrigate or administer drugs into a joint cavity.Septic Arthritis with synovial fluid analysisSynovial Fluid AnalysisRheumatoid Arthritis (can use US or fluoroscopyFluoroscopyProduction of an image when x-rays strike a fluorescent screen.X-rays)[10,12]
Non-inflammatory with a WBC count < 2,000 cells/μL
Crystal analysis to rule out goutGoutGout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout and pseudogout
Laboratory testing[12]
Negative rheumatoid factorRheumatoid factorAntibodies found in adult rheumatoid arthritis patients that are directed against gamma-chain immunoglobulins.Autoimmune Hepatitis (RFRFRheumatoid Arthritis) and anti-cyclic citrullinated peptide (anti-CCP)
The goals of management include alleviating painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and minimizing the loss of physical function. Therapy is individualized and different methods are used. The following recommendations are based on US, UK, and international guidelines.
Osteoarthritis management flowchart Patients start with conservative measures (weight loss and physical therapy). If symptoms do not improve, or if they worsen, management progresses through this flowchart. Surgery is reserved for patients with severe, unrelenting disease.
Image by Lecturio.
Medical management
Initial assessment:[14,15]
Locate the sites of OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis
Identify comorbiditiesComorbiditiesThe presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.St. Louis Encephalitis Virus
SleepSleepA readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility.Physiology of SleepqualityQualityActivities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.Quality Measurement and Improvement
Health beliefs and expectations
Core approaches (all patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship):[13‒15]
SleepSleepA readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility.Physiology of Sleep on a firm bed.
Improves overall qualityQualityActivities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.Quality Measurement and Improvement of life and physical function
PhysiotherapyPhysiotherapySpinal Stenosis (structured land-based exercises, with aquatic exercises as alternative) to increase:
Strength
Flexibility
Range of motionRange of motionThe distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises.Examination of the Upper Limbs
Endurance
Assistive devices (remove or redistribute the load on the joint):
Topical capsaicin/nonsteroidal antiinflammatory drugsNonsteroidal Antiinflammatory DrugsNonsteroidal antiinflammatory drugs (NSAIDs) are a class of medications consisting of aspirin, reversible NSAIDs, and selective NSAIDs. NSAIDs are used as antiplatelet, analgesic, antipyretic, and antiinflammatory agents. Nonsteroidal Antiinflammatory Drugs (NSAIDs) (NSAIDsNSAIDSPrimary vs Secondary Headaches) (knee, handHandThe hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy)[8,13,14]
AcetaminophenAcetaminophenAcetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood.Acetaminophen (knee, hip, handHandThe hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy)[13‒16]
Oral (nonselective) (NSAIDsNSAIDSPrimary vs Secondary Headaches (knee, hip, handHandThe hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy)[13‒16]
DiclofenacDiclofenacA non-steroidal anti-inflammatory agent (nsaid) with antipyretic and analgesic actions. It is primarily available as the sodium salt.Nonsteroidal Antiinflammatory Drugs (NSAIDs) (1st choice)[12,17]
NaproxenNaproxenAn anti-inflammatory agent with analgesic and antipyretic properties. Both the acid and its sodium salt are used in the treatment of rheumatoid arthritis and other rheumatic or musculoskeletal disorders, dysmenorrhea, and acute gout.Nonsteroidal Antiinflammatory Drugs (NSAIDs) (2nd choice)
COX-2 inhibitors (GI protective)
2nd-line medical therapy:[13‒16]
Combine 2 of the initial treatments.
DuloxetineDuloxetineA thiophene derivative and selective neurotransmitter uptake inhibitor for serotonin and noradrenaline (SNRI). It is an antidepressant agent and anxiolytic, and is also used for the treatment of pain in patients with diabetes mellitus and fibromyalgia.Serotonin Reuptake Inhibitors and Similar Antidepressants:[12]
AntidepressantAntidepressantAntidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressants with analgesic effect
Can be used in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with contraindicationsContraindicationsA condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks).Noninvasive Ventilation to NSAIDsNSAIDSPrimary vs Secondary Headaches
Alternative for those who do not respond to the above interventions
Can be used orally or as an intra-articular injection
Consider intra-articular corticosteroid injections in the following:
Knee OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis
Hip OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis should be performed under ultrasound guidance.
Should not be performed in the 3 months leading up to joint replacement surgery
Hyaluronic acidHyaluronic acidA natural high-viscosity mucopolysaccharide with alternating beta (1-3) glucuronide and beta (1-4) glucosaminidase bonds. It is found in the umbilical cord, in vitreous body and in synovial fluid. A high urinary level is found in progeria.Connective Tissue: Histology:[8,9,13‒16]
Intra-articular injection
Controversial, and evidence is limited
Supplements:[8,12‒16]
Glucosamine, chondroitin, turmeric, ginger extract, and vitamin DVitamin DA vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone.Fat-soluble Vitamins and their Deficiencies may reduce painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways in knee OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis.
Evidence is limited.
OpioidsOpioidsOpiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics:[12‒17]
Generally best to avoid in most patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis but can be considered for short-term use.
TramadolTramadolA narcotic analgesic proposed for severe pain. It may be habituating.Opioid Analgesics may be beneficial for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship for whom other treatments have failed or who are not candidates for other treatments (e.g., other agents are contraindicated).
Non-tramadol opioidsOpioidsOpiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics may be used when other agents have been exhausted, but these carry the risk of toxicityToxicityDosage Calculation and dependence.
Consider referral to a chronic painChronic painAching sensation that persists for more than a few months. It may or may not be associated with trauma or disease, and may persist after the initial injury has healed. Its localization, character, and timing are more vague than with acute pain.Pain Management management clinic.
Important pharmacotherapy considerations
Prescribe the lowest effective dose of acetaminophenAcetaminophenAcetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood.Acetaminophen, NSAIDsNSAIDSPrimary vs Secondary Headaches, COX-2 inhibitors, or opioidsOpioidsOpiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics for the shortest possible time.
AcetaminophenAcetaminophenAcetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood.Acetaminophen: Use the lowest effective dose, preferably ≤ 3 g/day (because of hepatotoxicityHepatotoxicityAcetaminophen).[12–15]
Use with caution in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with cardiovascular disease, chronic kidney diseaseChronic Kidney DiseaseChronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities.Chronic Kidney Disease, or gastrointestinal (GI) comorbiditiesComorbiditiesThe presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.St. Louis Encephalitis Virus.
Consider adding a proton pumpPumpACES and RUSH: Resuscitation Ultrasound Protocols inhibitor in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship who have GI comorbiditiesComorbiditiesThe presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.St. Louis Encephalitis Virus.
Avoid in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with estimated GFRGFRThe volume of water filtered out of plasma through glomerular capillary walls into Bowman’s capsules per unit of time. It is considered to be equivalent to inulin clearance.Kidney Function Tests < 30 mL/min/1.73 m2
Surgical management[12,17]
Reserved for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with advanced disease who have failed other treatments
Rheumatoid arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis: an autoimmune disease of the joints, causing an inflammatory and destructive arthritisDestructive ArthritisJuvenile Idiopathic Arthritis. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship typically have swellingSwellingInflammation and painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways of the peripheral joints (e.g., hands, wrists, knees, ankles). The DIP joints are generally spared, and morning stiffness typically lasts > 60 minutes. Diagnosis is based on the clinical picture, inflammatory markers, RFRFRheumatoid Arthritis, and anti-CCP. Management starts with glucocorticoidsGlucocorticoidsGlucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs.Glucocorticoids, disease-modifying antirheumatic drugsDisease-modifying antirheumatic drugsDisease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects.Disease-Modifying Antirheumatic Drugs (DMARDs) (DMARDsDMARDsDisease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects.Disease-Modifying Antirheumatic Drugs (DMARDs)), and NSAIDsNSAIDSPrimary vs Secondary Headaches.
Reactive arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis: a spondyloarthropathySpondyloarthropathyAnkylosing Spondylitis that is often precipitated by a gastrointestinal or genitourinary infection. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may present with an asymmetric arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis, typically of the lower extremities. Reactive arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis can be associated with feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, tendinitisTendinitisAnkylosing Spondylitis, enthesitisEnthesitisAnkylosing Spondylitis, mucocutaneous ulcers, and conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis. Diagnosis is clinical. Management includes NSAIDsNSAIDSPrimary vs Secondary Headaches, DMARDsDMARDsDisease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects.Disease-Modifying Antirheumatic Drugs (DMARDs), and treatment of the infection.
Psoriatic arthritisPsoriatic ArthritisA type of inflammatory arthritis associated with psoriasis, often involving the axial joints and the peripheral terminal interphalangeal joints. It is characterized by the presence of hla-b27-associated spondyloarthropathy, and the absence of rheumatoid factor.Psoriasis: a spondyloarthropathySpondyloarthropathyAnkylosing Spondylitis that occurs in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with psoriasisPsoriasisPsoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis. This inflammatory arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis is frequently asymmetric. Small and large joints are involved, including the DIP joints and the sacroiliac spineSpineThe human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum.Vertebral Column: Anatomy. EnthesopathyEnthesopathyReactive Arthritis and dactylitisDactylitisAnkylosing Spondylitis are also seen. The diagnosis is clinical, and should be suspected in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with psoriasisPsoriasisPsoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis. Management includes DMARDsDMARDsDisease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects.Disease-Modifying Antirheumatic Drugs (DMARDs) and biologic agentsBiologic AgentsImmunosuppressants.
GoutGoutGout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout: a disease caused by hyperuricemiaHyperuricemiaExcessive uric acid or urate in blood as defined by its solubility in plasma at 37 degrees c; greater than 0. 42 mmol per liter (7. 0 mg/dl) in men or 0. 36 mmol per liter (6. 0 mg/dl) in women.Gout that leads to arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis from precipitation of monosodium urate crystalsMonosodium Urate CrystalsGout in the joints. GoutGoutGout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout is often monoarticular, and usually involves painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways, tenderness, swellingSwellingInflammation, erythemaErythemaRedness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes.Chalazion, and warmth of the first MTP joint. The diagnosis is made with identificationIdentificationDefense Mechanisms of negatively birefringent, needle-shaped crystals in the synovial fluid. Management includes NSAIDsNSAIDSPrimary vs Secondary Headaches, colchicineColchicineA major alkaloid from colchicum autumnale l. And found also in other colchicum species. Its primary therapeutic use is in the treatment of gout.Gout Drugs, corticosteroidsCorticosteroidsChorioretinitis, and uric acidUric acidAn oxidation product, via xanthine oxidase, of oxypurines such as xanthine and hypoxanthine. It is the final oxidation product of purine catabolism in humans and primates, whereas in most other mammals urate oxidase further oxidizes it to allantoin.Nephrolithiasis reduction with allopurinolAllopurinolA xanthine oxidase inhibitor that decreases uric acid production. It also acts as an antimetabolite on some simpler organisms.Gout Drugs.
Pseudogout: intra-articular calciumCalciumA basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes.Electrolytes pyrophosphate deposition. The etiology is not clear. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship present with acute flares of joint swellingSwellingInflammation, warmth, and painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways. Pseudogout usually affects larger joints, such as the knee. Diagnosis is with identificationIdentificationDefense Mechanisms of positively birefringent, rhomboid crystals in the synovial fluid. Management includes NSAIDsNSAIDSPrimary vs Secondary Headaches, corticosteroidsCorticosteroidsChorioretinitis, and colchicineColchicineA major alkaloid from colchicum autumnale l. And found also in other colchicum species. Its primary therapeutic use is in the treatment of gout.Gout Drugs.
Septic arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis: a joint infection due to bacteriaBacteriaBacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology (rarely, virusesVirusesMinute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells.Virology) in the synovial or periarticular tissues. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship present with an acute onset of monoarticular swellingSwellingInflammation, painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways, erythemaErythemaRedness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes.Chalazion, and warmth. FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever may also be present. Diagnosis is made with synovial fluid analysisSynovial Fluid AnalysisRheumatoid Arthritis, including Gram stainGram stainKlebsiella, culture, and WBC count > 20,000 cells/μL. Management includes intravenous antibiotics and drainage of pus from the joint.
Billing and Coding
Diagnosis Codes:
OsteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis (OAOAOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion.Osteoarthritis) is coded based on the location and laterality (left, right, bilateral). The codes can also specify whether it is primary (age-related) or secondary to another condition.
Coding System
Code
Description
ICD-10-CM
M19.90
Unspecified osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis, unspecified site
This CPT code is for a plain X-rayX-rayPenetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source.Pulmonary Function Tests, the primary imaging modality used to evaluate osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis, which can show characteristic findings like joint space narrowing, osteophytes (boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types spurs), and subchondral sclerosisSubchondral SclerosisOsteochondritis Dissecans.
Coding System
Code
Description
CPT
73562
Radiologic examination, knee; 3 views
Procedures/Interventions:
These codes represent common procedures for osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis. A corticosteroid joint injection is used for temporary painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways relief, while a total knee arthroplastyArthroplastySurgical reconstruction of a joint to relieve pain or restore motion.Osteoarthritis (TKA) is a surgical procedure to replace the damaged joint.
Coding System
Code
Description
CPT
20610
ArthrocentesisArthrocentesisPuncture and aspiration of fluid (e.g., synovial fluid) from a joint cavity. It is used sometimes to irrigate or administer drugs into a joint cavity.Septic Arthritis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
CPT
27447
ArthroplastyArthroplastySurgical reconstruction of a joint to relieve pain or restore motion.Osteoarthritis, knee, condyle and plateauPlateauCardiac Physiology; medial AND lateral compartments with or without patellaPatellaThe flat, triangular bone situated at the anterior part of the knee.Knee Joint: Anatomy resurfacing (total knee arthroplastyArthroplastySurgical reconstruction of a joint to relieve pain or restore motion.Osteoarthritis)
Medications:
These codes are for common medications used to manage the painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways of osteoarthritisOsteoarthritisOsteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis, including simple analgesicsSimple AnalgesicsPrimary vs Secondary Headaches like acetaminophenAcetaminophenAcetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood.Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDsNSAIDSPrimary vs Secondary Headaches) like ibuprofenIbuprofenA nonsteroidal anti-inflammatory agent with analgesic properties used in the treatment of rheumatism and arthritis.Nonsteroidal Antiinflammatory Drugs (NSAIDs), and topical agents.
Coding System
Code
Description
RxNorm
161
AcetaminophenAcetaminophenAcetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood.Acetaminophen (ingredient)
National Institute for Health and Care Excellence. (2022). Osteoarthritis in over 16s: diagnosis and management. Retrieved January 7, 2023, from https://www.nice.org.uk/guidance/ng226
Sakellariou, G., Conaghan, P. G., Zhang, W., et al. (2017). EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Annals of the Rheumatic Diseases, 76(9), 1484–1494. https://doi.org/10.1136/annrheumdis-2016-210815
Fox, M. G., Chang, E. Y., Amini, B., et al. (2018). ACR appropriateness criteria® chronic knee pain. Journal of the American College of Radiology, 15(11), S302–S312. https://doi.org/10.1016/j.jacr.2018.09.016
Hayashi, D., Roemer, F. W., Guermazi, A. (2016). Imaging for osteoarthritis. Annals of Physical and Rehabilitation Medicine, 59(3), 161–169. https://doi.org/10.1016/j.rehab.2015.12.003
Kolasinski, S. L., Neogi, T., Hochberg, M. C., et al. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology, 72(2), 220–233. https://doi.org/10.1002/art.41142
Bannuru, R. R., Osani, M. C., Vaysbrot, E. E., Arden, N. K., Bennell, K., Bierma-Zeinstra, S. M. A., Kraus, V. B., Lohmander, L. S., Abbott, J. H., Bhandari, M., Blanco, F. J., Espinosa, R., Haugen, I. K., Lin, J., Mandl, L. A., Moilanen, E., Nakamura, N., Snyder-Mackler, L., Trojian, T., … McAlindon, T. E. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage, 27(11), 1578–1589. https://doi.org/10.1016/j.joca.2019.06.011
American Academy of Orthopaedic Surgeons. (2021). Management of osteoarthritis of the knee (non-arthroplasty) evidence-based clinical practice guideline. Retrieved January 9, 2023, from https://www.aaos.org/oak3cpg