Identification and Evaluation of Osteoarthritis

Risk Factors for Osteoarthritis

• Obesity – Being overweight or obese can increase the risk of osteoarthritis. This is especially true for the weight-bearing knees and hips, due to added stress on the joints.
• Age – Osteoarthritis may occur in younger individuals, but it more commonly begins in adults who are 50 or older.¹⁴
• Family history – Osteoarthritis tends to “run in families” but does not follow Mendel’s laws of inheritance.
• Gender – Osteoarthritis affects females more frequently than males.
• Joint injury history – Previous fracture or other injury can result in the development of osteoarthritis.
• Structural deformity – Certain structural deformities can place additional stress on the joints, increasing the likelihood of developing osteoarthritis. Common structural deformities include:
  • Knee
    • Leg length discrepancy
    • Varus/valgus leg deformities
  • Hip
    • Hip dysplasia
    • Femoroacetabular impingement (FAI)
      • Cam impingement
      • Pincer impingement
      • Childhood developmental conditions
        • Perthes disease
        • Slipped capital femoral epiphysis (SCFE)

Patient History

• Symptoms of Osteoarthritis
  Knee – Patients may report a gradual onset of diffuse knee pain and stiffness, with medial knee pain being common, although pain may be present in other regions of the knee. The patient may have crepitus, limited range of motion or swelling of the joint. Stiffness and pain are typically worse in the morning or after sitting or resting and may worsen with vigorous activity.
• Hip – Patients typically report a gradual onset of deep, aching pain and stiffness of the joint that is worse with weight-bearing or activity and relieved by rest.¹⁵ The location of osteoarthritic hip pain is typically seen in the anterior hip/groin > lateral hip > posterior hip. Some patients with hip arthritis have referred pain to the knee.

Differential Diagnosis
Obtaining a thorough patient history can be an insightful way to help rule in or out other causes of hip or knee pain, such as bursitis, referred back pain or radicular symptoms, acute bony contusions, stress reactions or fractures, trauma, periarticular sprains or strains, inflammatory arthritis, infectious arthritis, fibromyalgia, and complex regional pain syndromes.

Review of Systems
Performing a review of systems helps identify signs and symptoms that could point to other issues and identify red flag symptoms suggestive of cancer, infection, autoimmune disease or trauma.

• Patient History
  Occupation – Certain jobs require more repetitive motions or load-bearing activities.
• Tobacco use – The impact smoking has on joints is controversial, but smoking cessation should always be encouraged for overall health and prevention.
• Family history – There is not a Mendelian pattern of inheritance for osteoarthritis, but some genes are implicated as possibly involved in the development of this disease.

Treatment History
In patients with a known history of osteoarthritis, it is important to obtain a treatment history over the past year and their response to treatment. This may help direct future care.

Physical Examination

Evaluate the patient’s BMI, height, weight, body proportions, gait and limb positioning, noting congenital deformities, and inspect the lower extremities to evaluate for joint hypertrophy or swelling.

Palpate the joint, noting any tenderness to palpation of the joint line or surrounding soft tissue (bursa, tendons, muscles), which may help distinguish osteoarthritis from other joint disease. Focal pain over a bony area may also represent an acute bony contusion in the appropriate historical context. Synovitis (soft, boggy feel along the joint line) could indicate underlying autoimmune joint disease. Joints that are erythematous, warm and/or tender to touch indicate possible inflammatory etiology.

• Test range of motion, noting limited motion. Pain with passive range of motion could indicate transient synovitis, inflammatory or septic arthritis. Pain with internal rotation is common with hip osteoarthritis. Take note of any crepitus on exam.
• Knee-specific tests:
  • Range of motion reduced in extension (> 5 degrees) and in flexion (< 110 degrees)
  • Other tests that may be performed to rule out other structural issues, such as integrity of the anterior and posterior cruciate ligaments, medial and lateral collateral ligaments, meniscus, and patella
• Hip-specific tests (reproduction of hip pain with each testing maneuver):
  • Log roll (rolling the thigh internally and externally while lying supine)
  • FABER (flexion, abduction and external rotation of the hip)
  • Stinchfield sign (straight leg raise test with resistance applied by the clinician during active hip flexion)
  • Other tests that may be performed to rule out other structural issues, such as labral tears, impingement syndrome or bursitis
• Other testing that may be performed to evaluate for radicular pain (straight leg raise). Sometimes if the source of pain is unclear, a diagnostic injection with local anesthetic or steroids into the joint may be helpful.
• Red flags (see Table 4 for knee and Table 5 for hip). A red flag should elevate suspicion of an alternative cause of pain. Consider additional testing or an earlier referral, in particular, in suspected cases of septic arthritis, which is an emergency.
  • Septic arthritis consideration
  • Traumatic injury history
  • Unexplained fever, chills, night sweats
  • History of cancer
  • Unexplained weight loss
  • Signs of trauma
  • IV drug use
  • Known malignancy
  • Knee effusion (under physical exam)

Laboratory testing is typically not required for osteoarthritis but may be considered if there is concern for infection, microcrystalline arthropathy (i.e., gout) or autoimmune disease. Labs to consider in these instances would be:

• Complete blood count (CBC), serum uric acid, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF) and cyclic citrullinated peptide antibody (anti-CCP) testing, antinuclear antibody (ANA)
• Possible joint aspiration with examination of aspirate fluid, which is typically performed by a specialist, if concern for microcrystalline arthropathy or infection
• Plain X-ray imaging/radiographs should always be the first step in diagnostics

Imaging

Osteoarthritis of the knee and hip may be diagnosed by clinical presentation only, though plain X-ray imaging is helpful in most cases to confirm the diagnosis and can help rule out fracture and other less common causes of joint pain. Serial radiographs are also useful to help monitor disease progression over time.

• Imaging may be used to grade severity of disease (see Table 1 and Table 2). Weight-bearing, plain radiographs of the knee are recommended: anteroposterior (AP), lateral, Rosenberg (PA view while weight-bearing, knee 45-degree flexion) and Merchant.
• MRI in radiographically advanced cases of knee osteoarthritis (KL 3–4) and hip osteoarthritis (Tonnis grades 2–3) is not typically indicated, unless the clinician has concern for injury to surrounding soft tissues. MRI may be useful in cases of radiographically mild (KL 1–2 and Tonnis 0–1) after the patient has tried and failed more than six weeks of conservative measures.

Sidebar 2 Autoimmune Arthritis

Additional evaluation may be necessary in patients with symptoms consistent with autoimmune arthropathy. Rheumatoid arthritis: Patients may present with similar pain to those with osteoarthritis; but they often have joint inflammation and swelling, and joints commonly affected are those in the hands, wrists and knees.16 Diagnosis may include laboratory studies [rheumatoid factor (RF) and cyclic citrullinated peptide antibody (anti-CCP) testing], imaging and referral to rheumatology.

Psoriatic arthritis: Patients have psoriasis of the skin and may present with joint swelling, tenderness and inflammation (often asymmetric), nail changes (pitting, color changes), swelling of the entire digits, and back pain that is worse with rest and improves with activity.17 Diagnosis may involve confirmation of psoriasis by dermatology and possible skin biopsy, imaging, labs and rheumatology consult. Ankylosing spondyloarthritis: Patients may present with pain and stiffness, most commonly in the lower back, buttock and hip. Patients may also present with eye symptoms (iritis or uveitis). Imaging may show fusion of the sacroiliac joints or the vertebrae (“bamboo-spine” appearance on radiographs). Disease-specific labs include genetic testing of the human leukocyte antigen-B27 (HLA-B27) protein.

 

 

 

 

Diagnosis and Classification of Osteoarthritis

The initial diagnosis of osteoarthritis should be based on patient history and physical exam. Plain X-ray imaging is useful to confirm the diagnosis and should always precede advanced imaging techniques such as MRI. Osteoarthritis is classified as either primary or secondary disease:

• Primary disease occurs from normal wear and tear on the joints.
• Secondary disease occurs as a result of trauma to the joint, congenital deformity or another inflammatory arthropathy.

Management of Osteoarthritis

The overall treatment goal for osteoarthritis is to reduce pain to a manageable level and improve function and quality of life for the patient as it relates to joint pain. PROMs to assess pain and function—such as KOOS Jr, HOOS Jr and WOMAC—may be used to establish a baseline as well as response to treatment, which ultimately can be used to guide future therapies.

Lifestyle Modification

Weight reduction should be recommended, if applicable to achieve a normal BMI of 18.5–24.9. Patients with a high BMI are at greater risk of developing osteoarthritis and may achieve lower outcome scores compared to those with normal BMI after total joint arthroplasty.^20,21 Encouraging weight loss through dietary change and increased physical activity is recommended. Nutritionist referral may be beneficial for some patients, and advocating for food journaling as a source to improve self-management strategies for weight loss may lead to more successful outcomes in weight management.²²

Increasing physical activity should be encouraged in those with osteoarthritis with a focus on strength training to improve muscle conditioning. Low-impact aerobic exercises and exercises and stretches to improve range of motion and flexibility may also be beneficial.

The American Academy of Orthopedic Surgeons strongly recommends self-management programs for those with symptomatic osteoarthritis of the knee with a focus on:

• Strengthening (e.g., high-resistance strength training)
• Low-impact aerobic exercises (e.g., walking on a spongy surface, yoga, aquatic therapy)
• Neuromuscular education (e.g., proprioception, kinesthesia, balance training)²³

Tobacco cessation should be recommended for all patients but particularly those preparing to undergo total joint arthroplasty due to increased risk for complications.²⁴

Mental health disorders should be appropriately identified and treated, as these patients are at higher risk of poor outcomes, including reduced pain control, decreased function and poor quality of life compared to those without comorbid psychosocial factors.²⁵ Patients with anxiety, depression or other mental health disorders may have a disproportionately higher degree of joint pain symptoms for a given amount of arthritic joint damage compared to patients without, affecting response to treatment and diminished outcomes.

Physical Therapy

PT is strongly recommended for patients with osteoarthritis of the knee²⁶ or hip²⁷ to improve strength, range of motion and overall function. Techniques used may include but are not limited to:

• Therapeutic exercise program for strength training: Quadriceps strengthening for knee osteoarthritis and hip and core strengthening for hip osteoarthritis
• Range-of-motion exercises and stretches to improve lower extremity flexibility
• Proprioception training
• Cardiovascular conditioning
• Other treatment modalities:
• Dry needling
• Cryotherapy
• Assistive devices and orthotics (i.e., heel lifts to correct leg-length discrepancies)

Pharmacotherapy

Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for symptomatic knee²⁸ and hip²⁹ osteoarthritis.

Clinicians should select individualized therapies for those with comorbidities and/or contraindications to certain medications and presence of other types of pain (muscle spasm or neuropathic pain). Pharmacotherapy details are outlined in Table 3.

Additional medication information is listed below:

• Non-steroidal anti-inflammatory drugs (NSAIDs). After two to four weeks of taking NSAIDs, the patient should be evaluated to reassess the need for NSAID and, if still needed, switched to a more selective NSAID, such as meloxicam or celecoxib, which carry a lower risk of GI bleed. The PRECISION trial of 2016 shows a similar risk of CV events for both COX-2 selective and non-selective NSAIDs. It is recommended that renal and hepatic function be reviewed or, if not available, tested at least once per year.
• Acetaminophen (APAP) may provide short-term relief of symptoms, but data supporting use in knee osteoarthritis is inconclusive.³⁰ Patients should be counseled to check all OTC medications for other APAP-containing products and limit their total daily intake of APAP to 4 grams/day (3 grams in the elderly).
• Glucosamine and chondroitin sulfate are the most widely used dietary supplements for osteoarthritis. The GAIT study was designed to rigorously evaluate the efficacy of glucosamine, chondroitin sulfate and the two in combination in treating knee pain related to osteoarthritis. The primary outcome measure did not show that either supplement, alone or in combination, was efficacious in the overall group of patients with osteoarthritis of the knee. Exploratory analysis of the subgroup of patients with moderate to severe pain suggest that combination therapy may be effective in decreasing knee pain.³¹
• Skeletal muscle relaxants (SMRs) may be an appropriate secondary option for certain patients, particularly those with associated muscle spasm, but should be used with caution and only for a short time. All SMRs have a potential for sedating side effects, but some tend to be more sedating than others. Choose SMRs in consultation with the patient and based on each drug’s risk of side effects. Carisoprodol (Soma) is not recommended because of the potential for abuse and addiction and because it offers no significant benefit over other SMRs.
• Avocado/soybean unsaponifiables (ASUs) treatment has been shown to have significant symptomatic efficacy over placebo in the treatment of osteoarthritis, including pain, functional impairment and patient opinion. The onset of action is delayed two to four months and persists for up to two months following discontinuation of treatment. Additional study is required to understand and confirm the efficacy of ASUs for pain relief and function improvement.
• Turmeric extracts/curcumin – A systematic review and meta-analysis of randomized clinical trials does not currently permit a definitive recommendation for the use of turmeric/curcumin as a treatment for arthritis but provides some justification for its use as a dietary adjunct to conventional therapy.³²
• Cannabidiol (CBD) extract is classified as an herbal supplement, and as such, the FDA has no oversight of the approval process of CBD extract for treating health conditions. Some animal studies have shown favorable results in reducing peripheral pain and inflammation in established osteoarthritis.³³ Dosing is not well defined: Patients who select to pursue this treatment should be counseled to avoid inhaled use (i.e., vaping) due to acute or chronic pulmonary disease risk. CBD oil can be used orally, via capsule or sublingual formulation, or topically. Patients should be counseled to start with a small dose twice daily and titrate up weekly as needed for pain relief.³⁴
• Opioids are not recommended for osteoarthritis pain but, if selected, should be prescribed with caution and only in very short courses (two to three days) in patients with moderate to severe osteoarthritis who have failed other pharmacologic and non-pharmacologic therapies. Tramadol can lower the seizure threshold and, therefore, should be avoided in patients with epilepsy. There is a risk of serotonin syndrome when tramadol is combined with SSRIs, SNRIs, trazodone or cyclobenzaprine. Patients should be counseled that opioids may mask their pain but provide no therapeutic effect to aid in recovery.

Opioid Avoidance and Precautions

Opioid treatment requires serious assessment of the potential risks and benefits, and should only be used as a last resort after other treatments have proven ineffective. Brief, judicious use of tramadol could be considered in patients who have failed other pharmacologic and non-pharmacologic therapies. Opioid overdose has been declared an epidemic by the Centers for Disease Control and Prevention, with four times more opioid-related deaths in 2017 compared with 1999.³⁵ In 2017, opioid overdose was responsible for an average of 130 deaths per day in the United States.³⁶

• Before prescribing opioids, review psychological history for any type of substance abuse, assess Prescription Drug Monitoring Program and/or Controlled Substance Monitoring Database, and perform baseline urine drug screen.
• Review patient responsibilities, risk of therapy and treatment goals, and shared decision making. Implement a pain contract when prescribing opioids long term.
• Common side effects include constipation (consider using stool softener while taking opioids), nausea (take with food), sedation and cognitive ability.
• Use with caution in elderly patients and those with renal, hepatic or respiratory disease.

Sidebar 3 Signs of Drug-Seeking Behavior

History of substance abuse Prescription monitoring database shows controlled substances prescriptions from multiple providers Previous provider discharged the patient from the practice for breaking contract or for unclear reasons Patient may request an opioid saying they are allergic to all other conservative medications Failed drug testing (other substances or negative) Noncompliance with other aspects of care, such as completion of diagnostic studies or specialist referrals Patient reporting lost or stolen opioid prescription without a viable police report to corroborate

Intra-articular Injections

• Corticosteroids are typically the first-line choice for intra-articular injections, and strong evidence supports their use to reduce pain and improve function temporarily in patients with hip osteoarthritis.³⁷ Even though evidence supporting their efficacy in treating knee osteoarthritis is lower, intra-articular corticosteroids remain widely utilized for the symptomatic management of knee osteoarthritis in the United States. While it is a generally accepted practice, we are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee due to the absence of well-controlled comparative data, and thus the strength of recommendation is inconclusive. If employed, it should be limited to no more than four injections per year.
  • Relatively insoluble injectable corticosteroid examples:
    • Triamcinolone acetonide (Kenalog)
    • Triamcinolone acetonide extended release (Zilretta)
    • Slightly soluble injectable corticosteroid examples:
    • Methylprednisolone acetate (Depo-Medrol)
    • Methylprednisolone sodium succinate (Solu-Medrol)
• Viscosupplementation, injectable hyaluronic acid (sometimes referred to as HLA or “rooster comb”), is an alternative injectable treatment for knee osteoarthritis. Its efficacy continues to be debated among musculoskeletal care specialists, in spite of several studies suggesting limited effectiveness compared with placebo and very high cost compared with corticosteroids.^38,39 Its use persists, however, and careful consideration should be made at the discretion of the provider and patient on a case-by-case basis, weighing the potential benefits against cost.
• Growth factor injections: Platelet rich plasma (PRP) and “stem cell” injections are potential therapies that are not currently approved by the FDA. While there is limited but growing evidence showing some symptomatic improvement with intra-articular PRP treatments, large variance in preparation and cost, as well as the confounding effect caused by the economic incentives for providers recommending and performing these treatments, means that the recommendation for their use is currently inconclusive.⁴⁰

Joint Aspiration

While most patients with osteoarthritis do not require arthrocentesis, patients with symptoms concerning for microcrystalline arthropathy may benefit from joint aspiration with aspirate analysis, as identifying the type of microcrystalline arthropathy could help direct treatment. This procedure is typically performed by an orthopedic surgery specialist or rheumatologist.

Bracing

Neoprene bracing provides compression, which may help patients with joint effusions, but it provides minimal support.

Hinged bracing provides more support in varus and valgus movements of the knee.

Valgus directing force braces may be beneficial for medial compartment knee osteoarthritis, and while evidence may be inconclusive,⁴¹ unloader braces may be beneficial for some patients with medial knee osteoarthritis.

Genicular Nerve Block/Radiofrequency Ablation

Genicular nerve block/radiofrequency ablation (RFA) is a procedure for the treatment of chronic knee pain during which the genicular nerves are treated with radiofrequency ablation, leading to a reduction in nociceptive signal and neuropathic pain. While successful reduction in pain from this treatment is not permanent, it can be a useful, though costly, adjuvant for the management of knee osteoarthritis.

Referrals

• Emergency
  • Septic arthritis is a surgical emergency. The suspicion or diagnosis of septic arthritis should result in referral to the emergency department or emergency orthopedic consult for arthroscopic or open irrigation or debridement.⁴²
• Integrative Medicine
  • Mindfulness/meditation
  • Acupuncture may be beneficial in patients with muscle spasm, but it is not recommended for knee osteoarthritis.⁴³
• Orthopedic Surgery
  • Arthroscopic surgery
    • Knee and hip arthroscopy are generally not recommended in the setting of advanced radiographic degenerative changes (KL Grades 3 and 4 for knee, Tonnis stage 2 and 3 for hip).
    • Arthroscopic surgery may be considered in selective cases for the treatment of mechanical symptoms associated with knee and hip osteoarthritis, but the merits and decision-making for such intervention should be considered on a case-by-case basis: It should be made using shared decision-making by the surgeon and the patient.
• Joint arthroplasty
  • Hip and knee replacement surgery is indicated for high-grade osteoarthritis of the hip and knee in patients whose function and/or quality of life is limited by their joint pain after nonsurgical treatments fail to provide symptomatic relief.
  • Surgical intervention is considered after appropriate risk stratification and patient comorbidity optimization, a process managed by the orthopedic joint replacement surgical specialist.
  • In cases of severe medical comorbidity, surgical intervention may be recommended against.
• Rheumatology referral is recommended if evidence of autoimmune disease is present.
• Infectious disease referral is recommended if evidence of septic arthritis is present.
• Mental health specialist (behavioral health, psychologist or psychiatrist) referral is recommended for those with poorly controlled mood disorder, as psychosocial factors can impede treatment.

Patient Education

Patient education is an important aspect in managing osteoarthritis. Enhanced patient understanding of the condition and treatment options may support improved function and overall outcomes. This section includes links to information about osteoarthritis that may be useful educational resources for patients.

National Resources

OARSI Patient Guide to Managing Osteoarthritis Pain
This Osteoarthritis Research Society International (OARSI) webpage lists nine self-care approaches for patients managing osteoarthritis pain, including activity pacing, footwear and environment modifications.

OARSI Non-Surgical Management of Knee Osteoarthritis
This PDF from OARSI contains a summary of nonsurgical treatment options for different categories of patients with osteoarthritis of the knee, including those with osteoarthritis in other joints and those with other comorbidities, such as diabetes, hypertension, heart or vascular disease, renal impairment, gastrointestinal bleeding, depression, or mobility-limiting conditions.

American Association of Hip and Knee Surgeons
This site provides information about hip and knee replacement surgery as well as videos about specific surgeries (total and partial knee replacement; anterior and posterior approach hip replacement) and home exercises that patients often perform before and after surgery.

Arthritis Foundation Living With Arthritis
This site from the Arthritis Foundation includes links to sites regarding treatment options, pain management tools, arthritis dietary strategies, exercise, comorbidities that can affect care, healthcare (financial, insurance and pharmacy information), coping with change as it relates to how osteoarthritis can affect relationships, caregiving, pregnancy and workspace modifications.

AFP Patient Information: HLA Injections for Knee OA
This printable/shareable two-page guide from the American Family of Physicians defines OA, discusses treatment progression and explains hyaluronic acid injections.

AAOS Patient Information: Platelet-Rich Plasma
This printable/shareable three-page guide from the American Academy of Orthopedic Surgeons (AAOS) examines platelet-rich plasma treatment and discusses the lack of research to back up treatment efficacy.

Vanderbilt Health Affiliated Network Resources

Osteoarthritis: Injections and Surgery
Information about injections (corticosteroid and viscosupplementation) and surgeries (total joint arthroplasty, arthroscopy and other surgeries) for osteoarthritis.

Arthritis: Exercise
Recommendations for exercising (aerobic, strengthening and range of motion exercises) for patients with osteoarthritis.

Understanding Osteoarthritis of the Knee
Information about pathophysiology, etiology, symptoms, treatment and red flags with osteoarthritis of the knee.

Understanding Osteoarthritis of the Hip
Information about pathophysiology, etiology, symptoms, treatment and red flags with osteoarthritis of the hip.

Osteoarthritis: Tips for Daily Living
Occupational health information about body mechanics, managing activities of daily living and assistive devices to improve function with osteoarthritis.

What Is Osteoarthritis?
General information about pathophysiology, etiology, risk factors, symptoms, treatment, red flags and questions to ask during office visits regarding osteoarthritis.

What Is Osteoarthritis? (Part 2)
General information about pathophysiology and symptoms of osteoarthritis.

Osteoarthritis: Natural and Alternative Treatments
Information about complementary therapies, including thermal therapy, meditation and relaxation, acupuncture, massage, nutritional supplements, physical therapy, weight management, and psychological treatments (CBT, biofeedback, stress management, pain coping skills training and hypnosis) used in the treatment of osteoarthritis.

Living With Osteoarthritis
Information about exercise, weight management, assistive devices and other aids, pharmacotherapy, complementary therapy, injections, and surgeries for osteoarthritis.

Osteoarthritis: Home Care
Home care treatment options for osteoarthritis and information about when to seek medical care.

Osteoarthritis: Coping With Pain
Information regarding coping skills to help improve pain tolerance, including relaxation techniques, sleep hygiene, thermal therapy, acupuncture, massage, nutritional supplements, physical therapy, occupational therapy, weight management and psychological treatments.

Osteoarthritis Medications
Pharmacotherapy information regarding over-the-counter, prescription, topical and intra-articular medications.

Other Resources

Tennessee Disability Pathfinder
A statewide database of social services, low-income medical clinics, recreational programs and other resources for disabled persons.

The following resource may be useful for patients with cost barriers to care:

Applying for TennCare
Healthcare.gov
1-800-318-2596
Any Department of Health and Human Services office in Tennessee can help people apply and pick a plan.

References

^{1,2,3,5,6,7,9}Arthritis Foundation. Arthritis By the Numbers/Book of Trusted Facts & Figures. 2018;v2;4100.17.10445. Accessed October 2019. https://www.arthritis.org/getmedia/e1256607-fa87-4593-aa8a-8db4f291072a/2019-abtn-final-march-2019.pdf.

⁴National Institutes of Health. Fact Sheet – Osteoarthritis. October 2010. https://archives.nih.gov/asites/report/09-09-2019/report.nih.gov/nihfactsheets/Pdfs/Osteoarthritis(NIAMS).pdf. Accessed December 2019.

⁸Murphy L, Helmick C. The impact of osteoarthritis in the United States: a population health perspective. Am J Nurs. 2012 Mar;112(3 Suppl 1):S13-9. doi: 10.1097/01.NAJ.0000412646.80054.21.

¹⁰Work Loss Data Institute. Low back—lumbar and thoracic (acute and chronic) [withdrawn]. Encinitas; 2013. Cited by: Nordin M, Randhawa K, Torres P, et al. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):816-827. doi: 10.1007/s00586-017-5446-3.

¹¹Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi:10.1046/j.1525-1497.2001.016009606.x.

¹²Roos EM, Lohmander LS. The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes. 2003;1:64. Published 2003 Nov 3. doi:10.1186/1477-7525-1-64.

¹³Nilsdotter AK, Lohmander LS, Klässbo M, Roos EM. Hip disability and osteoarthritis outcome score (HOOS)—validity and responsiveness in total hip replacement. BMC Musculoskelet Disord. 2003;4:10. doi:10.1186/1471-2474-4-10.

¹⁴Arthritis Foundation. Osteoarthritis. https://www.arthritis.org/diseases/osteoarthritis. Accessed November 2020.

¹⁵Am Fam Physician. Evaluation of the Patient with Hip Pain. 2014 Jan 1;89(1):27-34. https://www.aafp.org/afp/2014/0101/p27.html. Accessed October 2019.

¹⁶Centers for Disease Control and Prevention. Rheumatoid Arthritis (RA). https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html. Accessed October 2019.

¹⁷National Psoriasis Foundation. Psoriatic Arthritis Screening Test. https://www.psoriasis.org/psoriatic-arthritis/diagnosis/tests-to-confirm. Accessed October 2019.

¹⁸Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop Relat Res. 2016;474(8):1886–1893. doi:10.1007/s11999-016-4732-4.

¹⁹Kovalenko B, Bremjit P, Fernando N. Classifications in Brief: Tönnis Classification of Hip Osteoarthritis. Clin Orthop Relat Res. 2018;476(8):1680–1684. doi:10.1097/01.blo.0000534679.75870.5f.

^{20,24,25,27,29,37,39}American Academy of Orthopedic Surgeons. Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. doi: 10.5435/JAAOS-D-19-00416.

^{21,23,26,28,30,38,40,41,43}American Academy of Orthopedic Surgeons. Treatment of Osteoarthritis of the Knee, 2^nd Edition. doi:10.5435/JAAOS-21-09-571.

²²Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011 Jan;111(1): 92–102. doi:10.1016/j.jada.2010.10.008.

³³Philpott HT, O’Brien M, McDougall JJ. Attenuation of early phase inflammation by cannabidiol prevents pain and nerve damage in rat osteoarthritis. Pain. 2017;158(12):2442–2451. doi:10.1097/j.pain.0000000000001052.

³⁴Arthritis Foundation CBD Guidance for Adults with Arthritis. https://www.arthritis.org/living-with-arthritis/pain-management/chronic-pain/arthritis-foundation-cbd-guidance-for-adults.php. Accessed November 2019.

^35,36Centers for Disease Control and Prevention. Understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed March 2019.

Contributors

Greg Polkowski, MD, Orthopedic Surgery

Leon Scott, MD, Pediatric Sports Medicine

Mary Duvanich, ANO, Ortho and Surgery

Kristine Phillips, MD, PhD, Rheumatology and Immunology

Brian Richardson, PT, Sports Therapy

Marissa McDonald, PharmD, Clinical Pharmacist

Phebe Bloomingburg, Ortho Nurse Manager

Shellian Elliott, Ortho Manager

Mike Modic, MD, Sr. Vice President

Vanderbilt Health Affiliated Network

Esther Smith, Admin Director

Vanderbilt Health Affiliated Network Strategic Ops

Megan Pacella, Content Manager

Vanderbilt Health Affiliated Network B2B Marketing

Karen Stone, Director

Vanderbilt Health Affiliated Network B2B Marketing

Justin Bachmann, MD, MPH, Assistant Professor

Vanderbilt University Medical Center Cardiovascular

Andrew O. Smith, Sr. Project Manager, Population Health

Vanderbilt Health Affiliated Network

Russell Brothers, Principal Analytics Cslt, Enterprise Analytics

Vanderbilt Health Affiliated Network

Lane Stiles, Director of Patient Education

Vanderbilt Health Affiliated Network

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