1

Degenerative Joint Disease: DJD/OA and Our Future

Suraj Achar, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

2

DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Suraj Achar, MD, FAAFP Professor, Department of Family Medicine and Public Health, Department of Orthopaedics, University of California, San Diego (UCSD); Professor, Department of Orthopedics, Rady Children’s Hospital, San Diego, California; Team Physician, UCSD Varsity Teams, San Diego Padres, San Diego Sockers, United States Olympic Training Center

Dr. Achar earned his medical degree from State University of New York (SUNY) Buffalo School of Medicine and Biomedical Sciences. He completed his residency and fellowship at the University of California, San Diego (UCSD). He is board-certified in family medicine and sports medicine, practicing at UCSD and Rady Children’s Hospital. His specialty topics include pediatric sports medicine and the legal aspects of medicine. At UCSD, Dr. Achar cares for a wide variety of patients, including professional and Olympic athletes. He is the editor of The 5-Minute Sports Medicine Consult and is consistently named a top doctor by the San Diego County Medical Society.

3

Learning Objectives1. Conduct a thorough physical exam of patients who present with the

signs and symptoms of osteoarthritis and refer for appropriate diagnostic imaging tests to confirm the condition.

2. Develop evidence-based treatment plans that focus on a stepwise approach.

3. Counsel patients on lifestyle modifications they can make to prevent osteoarthritis and safe treatments they can utilize to minimize pain.

4. Counsel older adult patients to engage in preventive occupational therapy with a goal to maintain function and mobility.

Audience Engagement SystemStep 1 Step 2 Step 3

4

Part 1: Evaluation: Probing the puzzle of OA

5

6

MSK CostBack pain, Injuries, OA• 950 billion (7.4% of US GDP)

• Annual direct & indirect costs for bone and joint health

Spending growing the fastest: 2000‐

2013

7

↑All cause & disease specific mortality in patients with walking disability.

• Eveline Nüesch et al. BMJ 2011;342

• ⇡ All cause, GI, Cardiovascular, Respiratory (p < 0.001)

• > Cardiovascular disease

• >smoking

• Only Cancer and Diabetes are associated with > mortality

• Why?

• Systemic inflammation?

• NSAIDS?

• Lack of physical activity?

Pathophysiology: OA

Biomechanical Forces &

Cytokines (IL‐1, TNF‐b)

Growth Factors(TGF‐1, IGF)>

Destructive forces > rebuilding forces

8

Johny Unitas permanent disabilities of NFL playersUnitaslost almost total use of his right hand middle finger & thumb noticeably disfigured from being repeatedly broken during games He died during a PT session

Key: Uni vs BL + childhood long jump 

injury

54 y/o Primary vs 2nd?

9

Primary vs Secondary OA?:

Clinical Pearls?Severity and location helps

AES Question #1

Does ACL reconstruction reduce long term development of OA?

1. Yes

2. No

10

Female soccer players with ACL tears, radiographic findings and symptoms 12 years after injury. ‐ Roos & Ostenberg

• Swedish study: 

• Subjects 

• 106 ♁ soccer players + ACL injury 

• Mean age =19y

• 62% reconstructive surgery

Results: Swedish study

• Joint space narrowing & Osteophytes• 34%

• Pain and functional limitations (unable to play‐‐> < QOL)

• 11%

• No diff +/‐ surgery

34%

11%

Symptoms and Signs

symptoms

OA x‐ray

11

Implications: Swedish study

• Sports injuries in female youth 

• Young with old knees• ACL reconstruction no benefit 

for OA

• Figure• BL ACL injuries

• R reconstructed

• L not

Does exercise lead to OA?

Long distance running and OA

Lars Konradsen et al, The American J of Sports Med. 

1990

Retrospective, case controlled

•30 long distance runners and 27 nonrunners

•Median period of running = 40 years!

Results

•No difference in pain, ROM

•No X‐ray difference

12

Sports and OA: Uncontrolled cross‐sectional studies

• Wrestling (cervical spine, knees, and elbows)

• Boxing (carpometacarpal joints)

• Pitching in baseball (shoulders and elbows)

• Cycling (patellofemoral joints?)

• Gymnastics (shoulders, wrists, and elbows)

• Ballet dancing (talar joints, 1st MTP)

• Soccer (hips, knees, ankles, cervical spine, and talarjoints)

• Football (knees, feet, and ankles)

Risk and Exercise

• Neuroanatomically normal joints

• ↑risk in the absence of adequate exercise.

• Neuroanatomically normal joints are 

• not at increased risk with repetitive, exercise.

• Neuroanatomically abnormal joints

• Low impact may improve symptoms.

• Neuroanatomically abnormal joints

• ↑risk upon exposure to repetitive, high‐impact exercise

• Talar Joints in Ballet

13

The role of Knee alignment in OA

• Sharma et al. JAMA 2001 • Prospective longitudinal cohort study

• 237 pts, 18 month study

• Varus alignment at baseline

• OR 4.09 (95% CI 2.2‐7.62)

• Valgus alignment

• OR 4.89 (95% CI 2.13‐11.2)

Clinical Features of OA

• Symptoms

• Joint pain

• Morning stiffness lasting <30minutes

• Joint instability or buckling

• Loss of function

14

AES Question #2

Which joint is often spared in OA?

1. Elbow

2. 1st CMC

3. Hip

4. Ankle

Symptomatic joints?

• The Knees, Hips, ankles,  are the most symptomatic.

• 1st CMC, 1st MTP

• Rare• AC joint, DIP and PIP are rarely significantly symptomatic!

• GH, elbow, wrist, mcp

15

Clinical features of OA thumb 1st CMC

• Difficulty pinching and grasping

• ~50% also have CTS

• PE

• Painful grind test

• Swelling and crepitus

• X‐ray: images that are useful?

Location of pain in hip OA

C Sign

Greater Trochanter

Groin

Buttocks 

16

Key ImagesWeight BearingRosenbergMerchant

Value of Tunnel/Rosenberg View in OA!

AP view• Sclerosis

• Cysts

• Osteophytes

Rosenberg/Tunnel view• Joint space loss in lat

tibial‐femoral OA

17

Value of Merchant view for OA

FAI? Alpha Angle

18

Advanced Imaging‐Ultrasound?

Is MRI helpful?

• Other pathology

• Meniscus

• Ligaments

• OCD

• synovium

• Earlier dx

• Bone marrow edema for full thickness cartilage defects

19

Grade 3 OA: MRI

AES Question #3

What is this?1. Chronic meniscal tears

2. Gout

3. RA

4. CPPD

20

Erosive OA?

• Uncommon

• Abrupt

• Pain, TTP, warmth, soft tissue swelling more pronounced

• Affects Ligaments

• Lateral instability of Interphalangeal joints

• Neg CRP/ESR and RF

Gout 

21

Diff Dx: Hemochromatosis

• Abdominal pain

• Weakness

• Lethargy

• Weight loss

• Joint pain• 2nd/3rd MCP’s!

• Iron overload• Ferritin >200/300, transferrin saturation

RA vs OADIP flexion with PIP hyperextension + MCP/wrist synovial hypertrophy

22

RA vs OA

• Pattern

• Radiographs

• Stiffness

• AM vs PM

• Transient vs long

• Swelling Joints

• OA: hard and bony

• RA: soft, warm, boggy, and tender

OA vs RAOA RA

Pathophysiology Degenerative hyaline cartilage

Autoimmune, synovium

Joints Knees, spine, hips, 1st cmc,  Elbows, Atlanto/axial

Other body parts none Pericardium, pleura, lung fibrosis, anemia, CVA

Treatment Exercise, topical Rx DMARDS

X‐ray Joint space narrowing.   Bone erosions

Etiology Trauma, obesity, sedentary genetics

23

Low back pain and Spine OA: Are they related?

• What is OA• disc space narrowing together + vertebral osteophyte formation

• facet joint DJD• only synovial joint in the spine that has a similar pathological degenerative process to appendicular joints

• LBP: 80%

• OA spine: • prevalence ranging from 40–85 %

• Rubin DI: Epidemiology and risk factors for spine pain. Neurol Clin. 2007 May; 25(2):353‐71.

Lumbar DJD and Claudication?

24

Summary OA: Key points

OA is not only common but 

associated with 

decreased exercise and ↑ mortality

Key joints

Spine, 1st cmc, knee and hips

Remember C sign and Rosenberg View

LBP vs X‐ray

Trauma, Urinary system, 

Associated symptoms 

weakness, weight loss 

hemachromatosis

Redness and warmth  gout

Osteoarthritis RxEvidenced‐based approach to OA

25

Part 2: What is the best first line RX for knee OA(pill for all ills?)

Exercise

1

Weight loss

2

NSAIDS?

3

Topical NSAIDS

4

Insoles

5

Should all patients with knee OA be counseled on exercise?

• All patients with knee OA should be counseled on exercise irrespective

• Age

• radiographic disease severity

• pain intensity

• functional levels

• comorbidities USA vs Columbia Masters World Medical Football Championships 

Prague 2018

26

Cochrane review of 54 trials (Grade A)• 19 low risk of bias

• High quality evidence suggesting that land‐based exercise improves knee pain and function with moderate effect size immediately

• No strong evidence on modality and dosage

• Magnitude effect = nsaids

• Often use PT to optimize program• Walking, cycling, rowing, and deep‐water running• Lower extremity strengthening

Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med 2015; 49:1554.

What about running or jumping exercises?• Evidence for joint damage is scarce.

• Meta‐analysis suggested a protective effect of running against surgery due to OA: pooled odds ratio 0.46 (95% CI, 0.30‐0.71)

Timmins KA, Leech RD, Batt ME, Edwards KL. Running and Knee Osteoarthritis: A Systematic Review and Meta‐analysis. Am J Sports Med 2017; 45:1447.

27

AES Question #4

What% of pts with OA receive opioids?

1. 9%

2. 17%

3. 40%• DeMik, David E. et al Are We Still Prescribing Opioids for 

Osteoarthritis?  The Journal of Arthroplasty , Volume 32 , Issue 12 , 3578 ‐ 3582.e1

What works better?

• ARS Questions

• What works better for pain relief of chronic back pain, hip or knee OA?

1. Opioids (IR, morphine, oxycodone or hydrocodone/acetaminophen)

2. Non‐Opioids (Acetaminophin or NSAIDS)

• Effect of Opioid vs Nonopioid Medications on Pain‐Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872‐882

• Pragmatic, 12‐month RCT

28

Should we use opioids to Rx pain before 

knee replacement?

• Impact of Preoperative Opioid Use on Total Knee Arthroplasty Outcomes. J Bone Joint Surg Am. 2017 May 17;99(10):803‐80

• Prospective cohort of 156 pts

• Brigham and Women’s scheduled for knee replacement

• Questionnaires• WOMAC, opioid use. Pain Catastrophizing Scale

Results

• Womac pain reduction scores

• opioids before TKA had a mean 6‐month WOMAC

• 27.0 points (95% CI = 22.7 to 31.3) vs

• Non Opioid group

• 33.6 points (95% CI = 31.4 to 35.9) for the non–opioid‐use group.

29

Conclusions

Consistent with other risks of opioidsConsistent with other risks of opioidsZywiel and colleagues reported that patients using opioids prior to TKA had significantly higher rates of revision for 

residual pain or stiffness (8 of 49 knees) than those who had not used opioids (0 revisions)

Zywiel et al. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011. November 

02;93(21):1988‐93

Clinicians should consider limiting pre‐TKA opioid prescribing to optimize benefits of TKA

Clinicians should consider limiting pre‐TKA opioid prescribing to optimize benefits of TKA

Why is the Brigham and Women’s study importantWhy is the Brigham and Women’s study important

(Need for pain relief) Pts spend ~13 years undergoing non‐operative therapies

•NSAIDS/PT/IA injections

Grading OAMild vs Mod/Severe

• low levels of or intermittent knee pain

• relatively well‐preserved joint function and quality of life.

Mild Mild 

• persistent pain

• significantly impairs functionality, activity participation, and quality of life

Moderate knee osteoarthritisModerate knee osteoarthritis

30

Rx Mild

• Mild• Non‐pharmacologic

• Exercise

• Weight loss 

• Topical therapies prn

Rx Mod/Severe OA

• Mod/Severe• 1st line: non pharmacologic

• Land based vs Aquatic exercises?

• 2nd line• Short Rx NSAIDS• Pts with risk for PUD

• Celecoxib• Non selective NSAID + PPI

• IA CSI/hyaluronic acid/PRP• Capsaicin• Braces• Surgery knee replacement

31

Tai Chi

• Limited # of large trials

• Effective after 12 weeks• Knee pain• Physical function• Reduction in analgesic use• Improved depression scores• Improved less falls

• Yan et al. Efficacy of Tai Chi on pain, stiffness and function in patients with osteoarthritis: a meta‐analysis. PLoS One 2013; 8:e61672.

• Wang, et al. Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial. Ann Intern Med 2016; 165:77.

• Mat et al. Physical therapies for improving balance and reducing falls risk in osteoarthritis of the knee: a systematic review. Age Ageing 2015; 44:16.

AES Question #5

Can we realistically say to patients with knee OA that we can get your pain to zero?

•Yes •No

32

Weight loss!

• IDEA trial: The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale

• BMC Musculoskeletal Disorders 2009

• 454 overweight/obese pts with knee OA

• D + E, D, E

• D +E (11.4% weight loss)

• 18 months

• < pain 50%

• 38% no pain!

Topical NSAIDS

•60% of pts > 50%  pain relief

•Comparable to oral nsaids

•Low risk of GI/CVD

Cochrane review

Reduced systemic absorption (5‐17 fold for diclofenac)

Mild skin rash (tolerable)

QID

Diclofenac & ketoprofen

Why not OTC? (60$?)

33

Topical Capsaicin (old data?)

Altman et al. Capsaicin cream 0.025% as Monotherapy for Osteoarthritis: A double‐blind study. Semin Arthritis Rheum 1994; 23 

(Suppl 3):25.

Deal et al. Treatment of arthritis with topical capsaicin: a double‐blind trial. Clin Ther 1991; 13:383.

12 week RCT

QID33% reduction in 

symptoms

Local burning sensation >50% mild to moderate 

and improves

Not good when comes into eyes or abraided 

skin areas!

Hot chili peppers (0.025%)

Down regulate TRPV‐1 receptor on nociceptive sensory neurons?

Few randomized trials

AES Question #6  

Should we consider Duloxetine for OA?

1.Yes

2.No

34

Duloxetine

(extra-articular factors)Mood issuesPain catastrophizingSleep problems

Wang et al. Efficacy and Safety of Duloxetine on Osteoarthritis Knee Pain: A Meta‐Analysis of 

Randomized Controlled Trials. Pain Med 2015; 16:1373.

meta‐analysis of three trials (~1000pts)

RR of pain 30%‐50% improvement ~ 1.5‐1.7 (95% CI 1.31–1.70)

No serious harms, (mild AE and discontinuation RR 2.15)

Studied in pts already taking nsaids

Insoles (mixed data)

• Medial wedged for patients with lateral tibiofemoral OA (one study+)

• Lateral (no better than neutral soles)

• Don’t recommend  OK if helps?• Duivenvoorden et al. Braces and orthoses for treating 

osteoarthritis of the knee. Cochrane Database Syst Rev 2015; :CD004020.

• Parkes et al. Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta‐analysis. JAMA 2013; 310:722.

35

Hyaluronans

• Controversy

• AMSSM Yes

• AAOS No! (strongly against!)

• Costly

• Flares

• No ultrasound study

• New agents coming on the market may be better!

• Hunter DJ. Viscosupplementation for osteoarthritis of the knee. N Engl J Med 2015; 372:1040.

PRP

• New  Rapidly increasing evidence

• Data at 12 months

• Better than HS or placebo

• Who should we do this on?

• Severe or less severe?

• Real cost?

• Meheux et al. Efficacy of Intra‐articular Platelet‐Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy 2016; 32:495.

36

Acetaminophen (paracetamol)

• Meta‐analysis (10 trials, 3541 pts)

• Small, non clinical benefits

• Not superior to placebo!

• Risks of intentional overdose

• Risks in therapeutic level (Grade C data?)

• Similar to NSAIDS?

• GI bleeding

• Liver toxicity

• Renal failure?

• CVD?

• Machado et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta‐analysis of randomized placebo controlled trials. BMJ 2015;

• Roberts et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis 2016; 

Glucosamine

Don’t encourage or discourage

Most major guidelines don’t recommend

Mixed data!

Strong placebo effect

37

Mixed data?

• Nutritional supplements

• Avocado soybean (ASU)

• +Industry sponsored trials

• Vitamin D‐no benefit

• Fish Oil

• Dose dose > high dose?

• GI upset

• Clinical benefits unclear

• TENS

• Poor data, placebo more effective

Comparison of intra‐articular glucocorticoids for OA, based on joint size

DailyMed Web site. US National Library of Medicine, National Institutes of Health, Health & Human Services. Available at: www.dailymed.nlm.nih.gov/dailymed.  Accessed January 25, 2014.

38

Duration of Effect or IA glucocorticoids?

• RA: longer duration of effect (up to 22 months in wrist)

• OA: shorter benefit

• All studies prior to ultrasound guidance

• 6 weeks or less

• Aspiration prolongs effect >6months

• Frequent dosing > 4‐6 weeks may have deleterious effects on bone and skin

• Cartilage loss?

• McAlindon et al. Effect of Intra‐articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA 2017; 317:1967.

• Jüni et al. Intra‐articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev 2015;

Adjustable Valgus bracing: Non op Rx of Med Compartment OA 

• Meta‐analysis• Brace> no brace• Valgus slightly > neutral sleeve• 25% slipping or poor fit• Low compliance 45%• Small benefits noted with PF brace or tape if > 7.4 hrs/day

• Moyer RF, Birmingham TB, Bryant DM, et al. Valgus bracing for knee osteoarthritis: a meta‐analysis of randomized trials. Arthritis Care Res (Hoboken) 2015; 67:493.

39

Walking aids

•Opposite side•RCT small improvements

• Jones A, Silva PG, Silva AC, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis 2012; 71:172.

Psychological interventions

• Do they help?

• Yes

• CBT and even internet based education helps!

• Keefe et al. Psychosocial interventions for managing pain in older adults: outcomes and clinical implications. Br J Anaesth 2013; 111:89.

• Bennell et al. Effectiveness of an Internet‐Delivered Exercise and Pain‐Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med 2017; 166:453.

40

Adjunctive pharmacologic options for OA management

Agent Benefit Risk Evidence

Glucosamine/Chrondroitin

Potential Improvement in pain

Generally safe Concept Study:800mg pharmaceutical grade Condroitin = 

Celebrex

SAMe (S‐adendosymethionine)

Symptomatic improvement in pain 

and function

Tolerability similar to placebo better than 

NSAIDS

Meta‐analysis of 11 RCT’s 

Improved function and pain = NSAIDS

Colchicine Decreased frequency and attacks of OA

GI bleeding  RCT’s BID > benefit at 12 & 20 weeks than 

placebo

Dextrose Prolotherapy Improvement in pain, function and stiffness

Risk of bleeding, infection similar to CSI

Need Training!

Statistical improvement compared to saline at 26, and 52 weeks

PRP Augmentation of tissue healing, improvement in 

pain and function

Pain at injection siteBleeding and infection 

similar to CSI

RCT’s show benefit > 6 months up to a year 

> CSI and HA

Value of Ultrasound Guidance

• Improved

• Accuracy

• Outcomes

• Discomfort of the procedures

41

IA Thumb

Co‐morbidities

• Htn

• COPD

• CVD

• HIV

2/3 pts

• OA of knee on imaging >17% excess mortality

Excess mortality in patients with OA

42

DM

• Especially in those with CVD or renal disease

Avoid NSAIDS

• Not sure where to purchase pharma grade (Concept study)

Condroitin may be safer

• Isolated 1‐2 day increase in glucose

IA CSI

Pts with OA and walking 

disability

• Increased death from CVD

• Rx 

• PT

• Canes/braces

• Walkers

• Exercise programs

• Cardiovascular rehab programs + effect• OA & CVD!

• Use topical nsaids, Intra‐articular CSI

• Acetaminophen no longer preferred >risk

• Avoid long term opioid therapy increase MI >40%

43

PUD

• Avoid NSAIDS• >4

• Risks >• SSSRI

• Corticosteroids

• Antigualants

• If using combine with PPI

• COX 2 may be safer but still have risk!

Older patients

•Reduce daily max to 2‐3 grms

Acetaminophen metabolism variableAcetaminophen metabolism variable

NSAIDS?NSAIDS?

•Cognitive impairment

•Delirium

•Injuries

•CVD events

•Pneumonia

•Hospitalizations 

•Mortality!

Opioid risks (avoid!)Opioid risks (avoid!)

44

Surgery

• Arthroscopy no benefit, may make it worse• Isolated OA‐‐Moseley, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81.

• Osteoarthritis with Meniscal Tear Khan et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta‐analysis. CMAJ 2014; 186:1057.

• Osteotomy  young patients

• Joint replacement 3rd most common surgery in US

Specialized surgery

• Not helpful

• ARTHROSCOPIC ABRASION ARTHROPLASTY

• ARTHROSCOPIC SYNOVECTOMY, partial meniscectomy, debridement

• Helpful Sometimes

• AUTOLOGOUS CHONDROCYTE IMPLANTATION

• focal cartilage defect involving only one side of the joint

• Unicompartmental Arthroplasty

45

ACI

• 3 stage procedure • ~50% complications

• arthrofibrosis and joint adhesions

• graft overgrowth• chondromalacia or chondrosis

• cartilage injury• meniscal lesion• graft delamination• osteoarthritis

1st CMC Surgery

• Joint fusion (arthrodesis).

• Osteotomy.

• The bones in the affected joint are repositioned to help correct deformities.

• Trapeziectomy.

• trapezium is removed.

• Joint replacement (arthroplasty).

• All or part of the affected joint is removed and replaced with a graft from one of your tendons.

46

Practice recommendations

1. Weight loss and exercise are by far the best Rx for OA and can cure the symptoms!

2. Topical therapies are 1st line pharmacological Rx

3. Think about joint replacement before it is too late!

Questions

47

Contact Information

Suraj Achar MD

sachar@ucsd.edu

Editor in chief 5 minute sports medicine consult