13MUSCULOSKELETAL DISORDERS
detectable and include subchondral bony sclerosis, synovitis, loss of articular cartilage, and osteophytes formed by proliferation of bone and cartilage in the joint. [Braun 2012, Altman 1986, Spector 1993] In about 60% of sufferers these changes are accompanied by symptoms that include erythema, swelling and joint pain that often result in reports of morning stiffness, limitations in range of motion and restrictions in the activities of daily living.[Fries 1980, Felson 2009]
Pharmacological treatments for OA include analgesics, non-steroidal anti- inflammatory drugs (NSAIDs), intra-articular (IA) injections of steroids and IA injections of hyaluronic acid (IA-HA), commonly referred to as viscosupplementation. [Kirchner 2006] Topical preparations, including capsaicin and NSAIDs, can also be used. [Jordan 2003] The supplements chondroitin sulfate and glucosamine are also commonly used by patients despite a lack of evidence for effectiveness.[Wandel 2010]
Although the usual population associated with OA is the elderly, athletes and younger individuals are also susceptible.[Amoako 2014] The etiology may differ, depending on the population; injuries, occupational activities, and obesity appear to be the most common causes of OA in young and athletic populations.[Amoako 2014] Increased pain tolerance in athletes and young individuals can sometimes make diagnosis challenging. However, in these populations, the treatment of OA does not differ from its management in the general population.
Post-traumatic osteoarthritis (PTOA) develops after joint injury. Patients with anterior cruciate ligament (ACL) injury have a high risk of developing PTOA.[Friel 2013, Luc 2014] As a progressive and chronic condition, PTOA should be treated at an early stage to minimize its long-term effects and prevent the development of end-stage OA.[Riordan 2014, Titchenal 2017]
OARSI guidelines published in 2019[Bannaru 2019] stress the importance of managing patients holistically and tailoring treatment individually, particularly with regard to comorbidities. Thus, topical NSAIDs are recommended for those with no comorbidities and those with GI comorbidities, but not for those with cardiovascular comorbidities. Similarly, oral NSAIDs are not recommended for patients with cardiovascular comorbidities, while regimens providing GI protection (COX-2 inhibitors or combined with proton pump inhibitor) should be used in those with no comorbidities, and potentially, with caution, in those with GI comorbidities. For those with cardiovascular comorbidities pharmacologic options are limited to IA injections of corticosteroids and/or hyaluronic acid.
IA corticosteroid is a common treatment for OA of the knee, however, clinical evidence suggests that the benefit is short-lived, usually one to four weeks.[Aroll 2004] Additionally, concern has been expressed that IA corticosteroid may speed the pace of OA and contribute to joint destruction.[Komplel 2019]
Systematic reviews of IA-HA have provided confusing results. One concluded that IA HA has not been proven clinically effective and may be associated with a greater risk
