The main symptoms of osteoarthritis

In most cases, the patient cannot accurately indicate the time and reason when the first symptoms of osteoarthrosis appear. A sufficiently long time, even in the presence of histopathological changes and radiographic signs, is asymptomatic.

The most frequent early sign of the disease is diffuse, non-permanent joint pain, usually occurring during or immediately after the load on the joint. For osteoarthritis is also characterized by morning stiffness of not more than 30 minutes. Sometimes there is a slight pain in the periarticular tissues (mainly muscles). Gradually and, as a rule, the volume of movements in the joint decreases unnoticed. For example, a patient may complain that in recent times (year / several years) it has become increasingly difficult for him to bend over to put on his socks because of a feeling of stiffness in the hip joint.

In rare cases, the first symptoms of osteoarthritis develop quickly (within a few days or weeks) after an injury. Probably, the injury in this case plays the role of a "trigger" for the clinical manifestation of changes in the joint, which were asymptomatic for a long time.

The main signs and symptoms of osteoarthritis (by Dieppe PA, 1995, modified)

Symptoms

• "Mechanical" nature of pain (arises / increases with the load on the joint in the evening; subsides at rest, at night)
• Morning stiffness (<30 min)
• Limiting the range of motion
• Decreased functional ability (difficulty in putting on socks, etc.)

Signs of

• Painful points along the edge of the joint space (tenderness to palpation of periarticular tissues)
• The appearance of dense thickening along the edge of the joint space
• Rough crepitations (clicking or jamming)
• Mild signs of inflammation ("cold effusion")
• Restricted, painful movements
• Feeling of "tension" in the joint
• Instability (signs of severe bone / joint destruction)

Factors that may influence the outcome of osteoarthritis

• Age at the beginning of the disease, race and gender
• Obesity and other factors associated with osteoarthritis
• Excessive use of appropriate joints
• The degree of development of the periarticular muscles and innervation
• Joint stability
• Reaction of bone and synovial tissue
• Crystal deposition
• Psychological and social factors
• Drug and Other Therapy

Osteoarthritis is a disease that does not have systemic manifestations, so complications are always associated with the affected joint / joints. Local complications include the development of secondary periarticular syndromes (bursitis, tendovaginitis, etc.), tunnel syndromes caused by the formation of large osteophytes or deformities of the joints. Severe deformities of the affected joints can cause secondary fractures and aseptic bone necrosis.

[1], [2], [3], [4], [5]

Pain

The most important symptom of osteoarthritis is, undoubtedly, pain. Comparative studies have demonstrated a difference in the quantitative and qualitative characteristics of pain in osteoarthritis and rheumatoid arthritis. Osteoarthrosis is characterized by “mechanical” pain, i.e. Arising / increasing during load on the joint and subsiding at rest. The pain usually occurs after some time (minutes / hours) after the onset of the load on the joint (less often - right after the load) and may last for several hours after it stops. The nature of the pain syndrome is one of the main differential diagnostic signs of osteoarthritis: inflammatory processes in the joints (arthritis, including rheumatoid), unlike degenerative, are characterized by an "inflammatory" nature of pain (arises / increases at rest and at night, diminishes during movements in joint). Rarely, patients with osteoarthritis complain of pain at rest and at night, but at the same time they are usually worried about joint pain during exercise, i.e. "Mechanical pain".

Pain with manifest osteoarthritis is not as pronounced as with arthritis, more local, although with the progression of the disease becomes persistent. To a certain extent, the severity of the disease as a whole can be determined by the nature of the pain, its persistence in osteoarthrosis. For example, at first the pain in a particular joint is associated with movement and disappears when it stops. Later, the pain in the joint (s) worries and at rest, aggravated by exertion. Finally, the pain bothers the patient at night. And although clinically pain in the joint is definitely perceived, in reality, the mechanisms of pain in osteoarthritis are associated not only with synovitis, as with arthritis. When synovitis pain occurs when rising from bed with a feeling of stiffness ("gel") in the affected joint, the pain subsequently increases with the load. The pain during certain movements in the joint may be due to the involvement of the periarticular tissues, and the pain caused by periosteum detachment due to the development of osteophytes is local, aggravated by palpation of the joint. In addition, in osteoarthritis, the pain may be due to muscle pathology, increases with anxiety and depression, as well as due to a violation of motor activity, etc.

In epidemiological and clinical studies found significant differences in the intensity of pain in different groups of patients with osteoarthritis.

The severity of changes detected on radiographs of the affected joints is associated with an increased likelihood of osteoarthrosis clinical manifestation. At the same time, the authors of this study note that even significantly pronounced changes on radiographs may be asymptomatic. J. Cashnaghan (1991) indicates that painful syndrome is more intense in women with osteoarthritis than in men. The results of MN Summers et al. (1988) show a direct correlation between pain and anxiety / depression in patients with osteoarthritis.

The study of pain in patients with osteoarthritis has been the subject of several studies. FA Hart (1974) described six types of pain in osteoarthritis. The results of a detailed study of pain in 500 patients with osteoarthritis of the peripheral joints confirmed this data. So, the most frequent option was pain when moving in a joint or resting on a limb (userelated pain). Such pain, according to the authors, usually occurred within a few seconds / minutes after the onset of a static or dynamic load and could persist for several hours after its termination. Some patients complained of unstable sharp pain, which exactly coincided with certain movements in the joints or the wearing of the same; others - on the constant nature of the pain, while they found it difficult to pinpoint its localization. While almost all patients with manifest osteoarthrosis complained of pain associated with movements in the joint or resting on a limb, only half of them indicated pain at rest and about 30% showed pain at night. Only in a small number of those examined, the intensity of pain in the affected joints hampered daily activity or caused insomnia. As a rule, in these cases, radiographs of the joints showed significant and rapidly progressive changes, often involving the subchondral bone.

Joint pain in osteoarthritis is often accompanied by a sensation of pain during palpation of the joint area. The patient may indicate the presence of several pain points located along the joint space and in the area of the adjacent skeletal muscles.

The mechanism underlying pain in osteoarthritis is still a matter of debate. Factors affecting the occurrence of pain in osteoarthritis can be divided into local, systemic and central nervous system factors.

Changes in the outlines of articular surfaces, osteophytosis and other local mechanical factors can cause abnormal loads on the ligaments, the articular capsule and other innervated structures. Such a mechanism may play an important role in the appearance of pain in the periarticular structures and in the acute pain that arises in the joint during movement.

Factors affecting the severity of pain in osteoarthritis, and the possible causes of its occurrence (by Dieppe PA, 1995)

Factors affecting the severity of pain in OA	Possible causes of pain in OA
X-ray stage Pop (in women, pain is more pronounced than in men) Age (pain less pronounced in young and old age) Localization (pain is less pronounced in osteoarthritis of the joints of the hands, more pronounced in coxarthrosis) Psychological factors (anxiety, depression)	Increased intraosseous pressure Sionovite Changes in the periarticular tissues (stretching of the capsule, ligaments, tendons, etc.) Periosteum thickening Changes in the periarticular muscles Fibromyalgia Changes by the central nervous system

It is known that in osteoarthritis, intraosseous pressure in the subchondral bone increases due to difficulty in venous outflow. Reducing intraosseous pressure reduces pain in osteoarthritis. It is believed that this mechanism is responsible for the pronounced pain syndrome - a long-lasting one, appearing alone at night. Perhaps one of the sources of pain in osteoarthritis is periosteum, which thickens as a result of osteophytes and chondrophytes.

Mild synovitis often accompanies osteoarthritis, especially in the later stages, and may contribute to increased pain. The reduction of pain in osteoarthrosis in response to the treatment of NSAIDs suggests this mechanism.

The pain caused by inflammation has long been a subject of serious attention, and now the mechanisms of pain associated with inflammation are being actively studied. It was shown that any peripheral pain is associated with an increase in the sensitivity of specialized neurons, nociceptors, which create a signal that is recognized as pain. An increase in the sensitivity of the primary nociceptor in the affected peripheral tissue leads to an increase in the activity of neurons that send a signal to the spinal cord and central nervous system, but it must be emphasized that spontaneous electrical activity can be generated in the inflammatory focus, resulting in persistent pain. Such a powerful inducer of pain sensitivity are proinflammatory components: bradykinins, histamine, neurokinins, complement, nitric oxide, which are usually found in the focus of inflammation. In recent years, more and more attention is paid to prostaglan-dinam, the accumulation of which correlates with the intensity of inflammation and hyperalgesia. However, prostaglandins themselves are not mediators of pain, they only increase the sensitivity of nociceptors to various stimuli. They seem to "include" normal ("silent") nociceptors in a state where they are easily excited by various effects.

Violation of biomechanics in the affected joint contributes to the development of secondary periarticular syndromes - bursitis, tenosynovitis, etc. When taking a history and examining a patient with osteoarthritis, it is necessary to determine whether the pain is caused directly by joint damage or inflammation located in the articular bags and synovial vagina.

Patients with osteoarthritis often complain of pain in the periarticular muscles on palpation. It is believed that the weakness of the muscles that perform movement in the joint may be one of the causes of pain. This is evidenced by the reduction of pain in patients with gonarthrosis who perform exercises to strengthen the quadriceps muscle of the thigh.

JH Kellgren (1939) pointed to the "thrust" of pain and pain during palpation from the affected joints to the muscles that perform movement in the joints. This phenomenon may explain the frequent occurrence of pain "close" to the affected joint.

Patients with osteoarthritis may have signs of fibromyalgia. In addition, MN Summers et al. (1988) point out the importance of central neurogenic mechanisms in the genesis of pain in osteoarthritis.

[6], [7], [8]

Constraint

The feeling of stiffness in the joints is a frequent complaint of patients. Stiffness is usually characterized by difficulty of the first movements, the phenomenon of a “frozen” joint after a period of rest, by limiting the range of motion in the affected joint. Stiffness in osteoarthritis, as a rule, lasts a few minutes (rarely up to 30 minutes) and occurs only in the affected joint.

The cause of stiffness in osteoarthritis remains unknown. Complaints about the "frozen" joint after a period of rest can be explained by simple mechanical reasons (thickening of the joint capsule, etc.). Prolonged (up to 30 min) morning stiffness, observed in some patients with osteoarthritis, may be due to the development of synovitis (by analogy with morning stiffness in rheumatoid arthritis).

[9], [10], [11]

Limiting the range of motion

Limiting the range of motion is a frequent complaint of patients with osteoarthritis. It is usually accompanied by complaints of pain during movement in the joint, with maximum pain occurring at the height of the restricted movement. Chondrophytosis and osteophytosis, joint remodeling, thickening of the articular capsule help to limit the range of motion in the joint affected by osteoarthritis. The latter may also explain the difficulty in maintaining the available range of motion in the affected joint.

[12], [13], [14], [15], [16]

Dense thickening of the articular margins

Dense thickening of the articular margins are often well palpated and may be painful. Along with coarse crepitations, which are felt during movements in the affected joints, dense thickening of the articular margins are an important differential diagnostic sign of osteoarthritis. Crepitations are detected by palpation of the affected joint, in the late stages of osteoarthritis, they can be heard from a distance. The likely cause of crepitus in osteoarthritis, along with the formation of gas bubbles in the synovial fluid, which "burst" during movements in the joint, is the roughness of the articular surfaces of the affected joint. It is necessary to differentiate crepitations and the feeling of a rough crunch when moving in normal joints. The latter, as a rule, is always heard at a distance and represents one or several non-constant separate sound phenomena during movement in a joint. Crepitations are felt (less often they can be heard) in the joints always and throughout the movement in the joint.

The formation of dense (“bone”) thickenings along the edge of the joint space is more characteristic of osteoarthritis of the hands: the nodularity of the proximal interphalangeal joints is called Bouchard nodes, and the distal interphalangeal joints are Heberden's nodes. Less commonly, dense thickenings are found along the edge of the articular crevices of other joints, in particular the knees.

[17], [18], [19], [20], [21], [22]

Crepitations

Crepitations are one of the main differential diagnostic signs of osteoarthritis. Crepitus in osteoarthritis must be differentiated from a crunch in the joint in a healthy person, the cause of which may be gas bubbles in the synovial fluid that burst during movement.

[23], [24], [25], [26], [27]

Sionovite

Most often synovitis in osteoarthritis occurs in the knee joints. In patients with synovitis, the nature of the pain changes: it occurs in a number of cases immediately after resting on the leg and during normal (not long) walking. Such “starting” pain does not disappear completely at rest, and in some patients acquires an indefinite rhythm (the patient cannot clearly determine the time of their greatest intensity). Synovitis with gonarthrosis can be subclinical, weak, moderate, significant; the prevalence is limited and diffuse; depending on the course - primary, recurrent and often recurrent. The presence and intensity of synovitis correlates with the X-ray stage of gonarthrosis.

Less commonly, synovitis occurs in the proximal and distal interphalangeal joints of the hands with the presence of Heberdain and / or Bouchard nodes (manifested by tenderness, swelling, joint hyperemia), which requires a differential diagnosis with rheumatoid arthritis.

Signs of destruction of the joints

At the late stages of osteoarthrosis, signs of destruction of cartilage, bone and surrounding soft tissues are found: varus deformity of the knee joints (due to damage to the medial tibiofemoral part of the joint), weakness of the ligamentous apparatus, instability of the joints (often develops in the distal interphalangeal joints). The destruction of bone tissue in osteoarthritis of the hip joint can lead to shortening of the limb.

Clinical manifestations of synovitis

Symptoms of synovitis	Sionovite
	Subclinical	Weak	Moderate	Significant
Pain: intensity time of occurrence	Very weak Only when going down the stairs	Mostly Only during long walking, at rest disappears	Moderate When walking, alone does not disappear immediately	Strong Leg support
Increased skin temperature above the joint: intensity localization	Very weak In a limited area of the inner surface	Weak Across the inside	Noticeable On the inner and outer surface	Moderate Whole joint
Soreness: intensity of localization	-	Weak By internal Surface	Noticeable Across the joint space	Moderate Whole joint surface
Swelling: localization intensity	-	Weak In the area of the inner surface of the joint	Noticeable On the inner surface and in the prepatelary region	Moderate Total Joint
Effusion	-		Suspicion of effusion	Slight effusion

The course of osteoarthritis of different locations differs from each other. In general, the disease progresses slowly. In most patients, osteoarthritis occurs as periods of exacerbation (days / months can last), when the pain is particularly intense, the function of the affected joints is significantly impaired and articular effusion can appear, and periods of relative remission, when the pain is absent or mild, the affected joints function in full volume or their function is slightly reduced and effusion is absent. Some patients with diagnosed osteoarthritis for months or even years may not present any complaints.

The most rapid progression of osteoarthritis is observed in the joints of the hands, the slowest - in the knee joints, the defeat of the hip joints occupies an intermediate position. “Rapid” progression, meaning a change in clinical symptoms and radiological signs in a short time, measured in months, is found only in a small number of patients. Destruction of bone tissue is more common in older women. For osteoarthritis of the joints of the hands and hip joints, the phenomenon of reverse development of not only clinical symptoms, but also radiographic signs is described. Radiographic signs of changes in the anatomy of the joints do not always correlate with changes in the clinical symptoms of osteoarthritis and the disability of patients.

[28], [29], [30], [31]

Peculiarities of osteoarthrosis of different localizations

The most common primary osteoarthritis affects the articular groups that carry the most static (knee, hip, apophysial spinal joints) and dynamic (proximal and distal interphalangeal joints of the hands) load. Symptoms of osteoarthritis vary significantly depending on the location of the lesion.

[32], [33], [34], [35], [36], [37]