Joints Spared

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Hands (often asymmetric) DIP (Heberden nodes) PIP (Bouchard nodes) Carpal metacarpophalangeal (CMP) of thumb Knee Hip

Feet (usually first toe metatarsophalangeal joint)

Hands (all except DIP/PIP/CMP)

Wrist

Elbow

Shoulder

Spine characteristics seen on x-rays include joint space narrowing, subchondral sclerosis, and subchondral cysts.

It is critical to differentiate OA from other conditions that may present similarly. Periarticular pain that is not reproduced with passive motion suggests bursitis or tendonitis. Prolonged pain lasting more than 1 hour points toward an inflammatory arthritis. Intense inflammation suggests one of the micro-crystalline diseases (gout/pseudogout) or infectious arthritis. Systemic constitutional symptoms, such as weight loss, fatigue, fever, anorexia, and malaise, indicate an underlying inflammatory condition, such as polymyalgia rheumatic, rheumatoid arthritis, systemic lupus erythematosus, or a malignancy, and generally demands aggressive evaluation. Table 56-2 lists the American College of Rheumatology diagnostic criteria for OA.

Management

Education is critical. Encourage the patient to stay active, because not using the joint can cause further immobility. Multiple short periods of rest throughout the day are better than one large period.

Equipment such as canes and/or walkers are helpful for patients with advanced disease because these patients are less stable and. as a result, have frequent falls. Physical therapy in the form of heat applied to the affected joints in early disease often is helpful. Perhaps the most important intervention is having the patient maintain full/near-full range of motion with regular exercise.

Table 56-2

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