Osteoarthritis History Taking: Knee Pain

Disclaimer: Consent obtained from patient. 

Osteoarthrosis is a degenerative disease. So the actual term is indeed osteoarthrOSIS. Osteoarthritis is always seen as a misnomer.

( latest studies show that osteoarthrosis is both degenerative and inflammatory though. Osteoarthritis is now used but remember that some senior examiners stick to osteoarthrosis. )

Details of patient. Before starting your History Of Presenting Illness ( HOPI ), mention these important points:

1. Is patient is ADL  independent or ADL dependent. This is EXTREMELY IMPORTANT. 

2. Relevant comorbidities like current or past history of obesity or high BMI ( gives a picture of primary OA ).

ADL= activities of daily living

Then, go to chief complaint.

Your chief complaint will be a symptom right? Eg. Pain over knee etc + duration

So, you have to approach knee pain. Use the etiological tree. Think about all causes of knee pain. You have to rule out all etiologies. Then, give points to favour for the provisional diagnosis.

Firstly, understand OA and the relevant questions specific to OA. There are two types of OA.

Primary OA.

This happens at the weight bearing joints ( hip and knee ). It is a result of degeneration of joint as one ages. This is associatied with subjection of weight on the joints.

Primary OA starts after 50 typically. It occurs bilaterally. More common in females. It is associated with excessive weight. This can come in the form of obesity or even occupation. Some of them may be physically fit but their occupation demands them to carry weights ( labourer ) which is subjected to the weight bearing joints.

Relate symptoms with ADL. With the knee pain, what activities can they do / not do. Can they bend down to PRAY? Can solat? Can they walk up and down the stairs ? squat and toileting ? Gardening ? cooking ? 

Is their daily activity impaired in any way? Are they burdenful to the family? Was modification done to their homes to accomodate their issue? Eg. having to convert squatting toilet to sitting fashion? Shifting their room to the ground floor to avoid them from climbing up the stairs? etc

Why is this important to ask? If the patient is already bedridden or barely active, the option for knee replacement is considerable. However, if patient is active, ambulating well, it is very wise to do a total knee replacement. This will enable and enhance patient's mobility. This will reduce the risk of osteoporosis and will eventually lessen the risk of pathological fractures which is directly linked to mortality.

Ask if they can hear or feel crepitations over the joint when they move or locomote.

Ask for morning stiffness. Duration is very important. The duration of morning stiffness in OA is less than 30 minutes. Ask patient if he feels as though the joints are glued together upon waking up.

Ask for LOCKING OF KNEE. What does this mean? When the patient attempts to fully extend the leg, it gets stuck halfway and he will not be able to extend it fully. There are two causes for this:

1. Meniscus injury, which can be a complication of OA.

2. Loose bodies, which is a pathological finding of OA.

Image: Xray findings of OA, cardinal ones include reduced joint space, osteophytes, subchondral cyst, subchondral sclerosis and loose bodies.

Secondary OA

Secondary OA happens in any joint, secondary to a pathology. For example, shoulder OA after a fracture humerus. It can happen in any age. For example, avascular necrosis of the hip of femur can result in hip OA. It does not need to be gender specific, bilateral or even at the weight bearing joints. Otherwise, the other questions can be asked. They are relevant. Basically ask for pain, restricted range of movement, crepitation.

RULE OUT OTHER ETIOLOGIES

You have to include differentials in the history. If your chief complaint is PAIN, rule out all possible etiologies for PAIN over that particular site.

Let us take knee pain as an example:

Etiologies:

1. TRAUMA: Any recent trauma? Fracture and soft tissue injury can cause the same chief complaint. Is patient active in sports as this can cause overuse syndrome secondary to trauma. A previous history of trauma can liken the diagnosis of secondary OA also. So, by asking patient about trauma, you are ruling out fracture, soft tissue injury, overuse syndrome, secondary OA.

2. INFECTION: Ask for any episode of fever. Mention in HOPI. By asking this, you are ruling out Osteomyelitis, septic arthritis, infected hematoma, cellulitis and abscess.

3. INFLAMMATORY: Ask if any other joints are affected. For example, in gouty arthritis, it is more common to get symptoms at the first MTP joint of the great toe. Pseudogout is more common in the knee joint. Rheumatoid arthritis of knee is mostly unilateral and you will probably note symptoms in the small joints like in the hands. Rule out symptoms of SLE and Sjogren also. Ask for morning stiffness ( ask patient if he feels the joint glued together when he wakes up in the morning ). Morning stiffness duration is longer in inflammatory cause, typically more than 1 hour. It is less than 30 minutes in OA.

4. GASTROINTESTINAL: Very important - ask about symptoms of inflammatory bowel disease ( Ulcerative colitis and Crohns ), typically bloody diarrhea. Arthritis is a an extra-intestinal features of IBD. Other Extra-intestinal features you can rule out is 

- aphthous ulcers ( mouth ulcers )

- pyoderma gangrenosum ( skin ulcerations )

Image: Typical Pyoderma Gangrenosum with the classical 'Margheritta Pizza' appearance, with red base and yellow topping.

- Irits or Uveitis ( Red, painful eyes )

- Erythema nodosum ( skin changes )

- Sclerosing cholangitis ( jaundice )

- Arthritis ( joint pain )

5. TUMOUR: Ask if they noticed any bony swelling. Ask for constitutional symptoms

6. REFERRED PAIN: The knee pain might be a referred one from hip or spine pathology!  Ask symptoms related to spine / hip which includes any hip pain or radicular pain with or without numbness.

Management of OA ( To be also included in history )

Also, ask the spectrum of management that the patient has undergone. OA is a chronic illness. The patient would have definitely been advised to exercise conservative care. These can include:

Analgesia? What do they take to relieve their pain? Are they overdosing NSAIDS ( risk for peptic ulcer disease and renal failure + nonunion in fractures )? What is the mode of administration? Topical NSAIDS have lesser adverse effects than oral NSAIDS. Are they taking paracetamols? How is their liver function test? 

Image: Topical NSAIDs.

Physiotherapy and exercise? This will involve exercise to build the quadriceps muscles so that the muscles can bear the partial weight exerted by the body. When you have weak muscles which cannot bear the body weight, the body weight will be all subjected to the joints.

What type of exercise is good for OA? Non weight bearing muscle training namely swimming and cycling.

NSAID and steroid injection for analgesia?

Weight reduction? ( very important to ask )

Any orthotic devices used? Like a cane or crutches?

Did the patient get any intraarticular injection ( Hyaluronidase which is supposed to increase synovial fluid to lubricate )

The last resort is surgery ( Total joint replacement ) or high tibial osteotomy.

Causes of failure of Total knee replacement:

-Periprosthetic fracture

-Infection / Periprosthetic infection

-Aseptic loosening

-Wear

Risk factors for periprosthetic infection:

-Smoking / tobacco ( this is why smoking history is important )

-Obesity ( Obesity is also a risk for failure post-op )

-Malnutrition

-Poor glycemic control

-Anemia 

For knee examination, click here

Purusha Suktam: Word to Word Meaning and Commentary

सहस्रशीर्षा पुरुषः। सहस्राक्षः सहस्रपात्।

स भूमिं विश्वतो वृत्वा। अत्यतिष्ठद्दशाङ्गुलम्॥ १ ॥

sahasraśīrṣā puruṣaḥ | sahasrākṣaḥ sahasrapāt |

sa bhūmiṁ viśvato vṛtvā | atyatiṣṭhad daśāṅgulam || 1 ||

सहस्रशीर्षा (sahasraśīrṣā) = thousand-headed

पुरुषः (puruṣaḥ) = Person

सहस्राक्षः (sahasrākṣaḥ) = thousand-eyed

सहस्रपात् (sahasrapāt) = thousand-footed

स भूमिं (sa bhūmiṁ) = He, pervades the earth

विश्वतः (viśvataḥ) = on all sides

वृत्वा (vṛtvā) = having encompassed

अत्यतिष्ठत् (atyatiṣṭhat) = stood beyond

दशाङ्गुलम् (daśāṅgulam) = ten fingers  

Meaning: The cosmic person is thousand headed. He has thousand eyes and a thousand feet. He pervades the entire earth completely, from all sides. He extends beyond the ten-fingers ( ten-directions )

Diabetic Foot Ulcer / Peripheral Arterial Disease History Taking and Examination

Diabetic Foot Ulcer is a triad of:

1.Peripheral neuropathy 

2.Vasculopathy ( microangiopathy )

3.Immunopathy ( infection )

This is called the 'devil's triad'

Sandhya Vandanam as Per Shaiva Tantra

Let us understand Sandhya vandanam itself in detail.

Firstly, what is Sandhya?

Sandhya is defined as the junction between two time period. When one period of time overlaps the other, that junction is sandhya.

History Taking for Fracture Case

This article is catered for medical students during the orthopaedics posting. The rationale is to understand the mechanism of fracture and to note relevant points in history to arrive at a proximate diagnosis prior to imaging modalities.

Details of Patient

• Name ( Always address the patient with due respect. Use 'sir', 'mdm', 'gentleman' etc. They are not your servants to be addressed with name directly. )

• Age: It is important to ask for age as it tallies with the mechanism of fracture. An old patient at their 7th decade of life would be having primary osteoporosis. A female patient beyond her 5th decade of life is probably post-menopausal. These are risk factors for pathological fractures. So you would anticipate a low-energy trauma from their history.

*Osteoporosis is the reduction of volume and density of the bones which otherwise have a normal histology. It has primary and secondary causes*

• Occupation - 

Applying Vibhuti as Per Shaiva Tantra

The detailed explanation on bhasma application can be found in the snāna vidhiḥ of Kāmika Āgama, Pūrva pāda. For ritual purposes, bhasma must be adorned at at least 16 places.

5 Kala in Shaiva Tantra

Image source: himalayanacademy

This article is an expansion from the writeup on Tattvas in Shaivism. You will not understand this article without reading the mentioned article.

All the tattva-s in Shaivism come from the five kalā-s, which represent different states of consciousness and planes of existence.

Scriptural References for Deepavali

Dīpāvali (दीपावली) comes from the roots:

1. Dīpa (दीप) – From the root dīp (दीप्), which means "to shine" or "to illuminate."

2. Āvali (आवली) – meaning "a row" or "a series".

Vegan Sushi-s For the Delight in Butterworth

Image from Google. Courtesy: Lim Hueh Hueh

The 36 Tattvas of Shaivism

तत्त्वं यद्वस्तुरूपं स्यात्स्वधर्म प्रकटात्मकम्। तत्त्वं वस्तुपदं व्यक्तं स्फुटमाम्नायदर्शनात्॥ 3
tattvaṃ yadvasturūpaṃ syātsvadharma prakaṭātmakam। tattvaṃ vastupadaṃ vyaktaṃ sphuṭamāmnāyadarśanāt॥ 3

Meaning: The principle (tattva) that assumes the form of reality, manifesting its inherent nature, is called tattva. This principle is the manifest, clear expression of the underlying reality, as revealed by the scriptures

यदच्युतं स्वकाद्वृत्तात्ततः शाक्तवशं जगत्। ततमन्येन वा यत्स्यात्तत्तत्त्वं तत्त्वसन्ततौ॥ 4

yadacyutaṃ svakādvṛttāttataḥ śāktavaśaṃ jagat। tatamanyena vā yatsyāt tattattvaṃ tattvasantatau॥ 4

Meaning: When the immutable (acyuta) deviates from its original state and the world falls under the influence of Śakti, whatever form it may take thereafter, that is considered a tattva in the continuum of principles.

Mṛgendra Āgama, (Mataṅga Pārameśvaram Vidyā Pādaḥ 5th Paṭalaḥ) verses 3 & 4