O

Condition/Disorder Synonyms

• Osteoarthrosis

ICD-9-CM Codes

• 715 Osteoarthrosis and allied disorders
• 715.0 Osteoarthrosis generalized
• 715.00 Osteoarthrosis generalized involving unspecified site
• 715.04 Osteoarthrosis generalized involving hand
• 715.09 Osteoarthrosis generalized involving multiple sites
• 715.1 Osteoarthrosis localized primary
• 715.10 Osteoarthrosis localized primary involving unspecified site
• 715.11 Osteoarthrosis localized primary involving shoulder region
• 715.12 Osteoarthrosis localized primary involving upper arm
• 715.13 Osteoarthrosis localized primary involving forearm
• 715.14 Osteoarthrosis localized primary involving hand
• 715.15 Osteoarthrosis localized primary involving pelvic region and thigh
• 715.16 Osteoarthrosis localized primary involving lower leg
• 715.17 Osteoarthrosis localized primary involving ankle and foot
• 715.18 Osteoarthrosis localized primary involving other specified sites
• 715.2 Osteoarthrosis localized secondary
• 715.20 Osteoarthrosis localized secondary involving unspecified site
• 715.21 Osteoarthrosis localized secondary involving shoulder region
• 715.22 Osteoarthrosis localized secondary involving upper arm
• 715.23 Osteoarthrosis localized secondary involving forearm
• 715.24 Osteoarthrosis localized secondary involving hand
• 715.25 Osteoarthrosis localized secondary involving pelvic region and thigh
• 715.26 Osteoarthrosis localized secondary involving lower leg
• 715.27 Osteoarthrosis localized secondary involving ankle and foot
• 715.28 Osteoarthrosis localized secondary involving other specified sites
• 715.3 Osteoarthrosis localized not specified whether primary or secondary
• 715.30 Osteoarthrosis localized not specified whether primary or secondary involving unspecified site
• 715.31 Osteoarthrosis localized not specified whether primary or secondary involving shoulder region
• 715.32 Osteoarthrosis localized not specified whether primary or secondary involving upper arm
• 715.33 Osteoarthrosis localized not specified whether primary or secondary involving forearm
• 715.34 Osteoarthrosis localized not specified whether primary or secondary involving hand
• 715.35 Osteoarthrosis localized not specified whether primary or secondary involving pelvic region and thigh
• 715.36 Osteoarthrosis localized not specified whether primary or secondary involving lower leg
• 715.37 Osteoarthrosis localized not specified whether primary or secondary involving ankle and foot
• 715.38 Osteoarthrosis localized not specified whether primary or secondary involving other specified sites
• 715.8 Osteoarthrosis involving or with mention of more than one site but not specified as generalized
• 715.80 Osteoarthrosis involving or with more than one site but not specified as generalized and involving unspecified site
• 715.89 Osteoarthrosis involving or with multiple sites but not specified as generalized
• 715.9 Osteoarthrosis unspecified whether generalized or localized
• 715.90 Osteoarthrosis unspecified whether generalized or localized involving unspecified site
• 715.91 Osteoarthrosis unspecified whether generalized or localized involving shoulder region
• 715.92 Osteoarthrosis unspecified whether generalized or localized involving upper arm
• 715.93 Osteoarthrosis unspecified whether generalized or localized involving forearm
• 715.94 Osteoarthrosis unspecified whether generalized or localized involving hand
• 715.95 Osteoarthrosis unspecified whether generalized or localized involving pelvic region and thigh
• 715.96 Osteoarthrosis unspecified whether generalized or localized involving lower leg
• 715.97 Osteoarthrosis unspecified whether generalized or localized involving ankle and foot
• 715.98 Osteoarthrosis unspecified whether generalized or localized involving other specified sites

ICD-10-CM Codes

• M15 Polyarthrosis
• M19 Other arthrosis
• M47 Spondylosis

Preferred Practice Patterns1

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders
• 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty
• 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery

Key Features

Description

• Most common form of arthritis
• Degenerative joint disease
• Commonly affects
  • Weight-bearing joints (e.g., hand, hip, knee)
  • Interphalangeal joints, first metatarsophalangeal joint, and spinal facet joints
• Associated with increasing age, obesity, females and race/ethnicity
• Associated with abnormal loading of the joints
• Joint pain

Essentials of Diagnosis

• X-ray
• Kellgren and Lawrence (KL) grade ≥ 2 (definite radiographic OA)2
• Osteophytes, joint-space narrowing, sclerosis
• Cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
• Erosion of articular cartilage
• Synovial hyperplasia
• Fibrosis
• Inflammatory cell infiltration with or without OA symptoms
• OA is a clinical diagnosis which can be based on
  • Persistent usage-related pain in joint or joints
  • Age usually ≥ 45 years3
  • Morning stiffness equal or less than 30 minutes3

General Considerations

• Low bone mineral density (BMD)
• Repetitive joint use or loading
• Poor joint alignment
• Leg-length discrepancy (LLD)/inequality
• Bone or joint morphology
• Calcification (e.g., of the knee meniscus)
• Bone formation, cyst formation
• Thickening of subchondral bone plate (osteosclerosis)
• Overall joint dysfunction
• Joint swelling and inflammation (in certain severe cases)
• Joint pain
• Morning stiffness
• Long-term disease
• Secondary problems
  • Muscle atrophy and weakness
  • Bony protrusion / prominence
  • Joint deformity
  • Walking difficulty
  • Difficulty with ADLs

Demographics

• Prevalent in middle to older age groups
• Women are more affected than men
• Predominantly affects African-Americans and Caucasians
• May affect about 12% of the population (U.S. and other developed countries)3

Clinical Findings

Signs and Symptoms

• Joint pain
• Aching joint
• Joint stiffness
• Muscle weakness
• Muscle atrophy
• Crepitus
• Bony enlargement
• Limited joint ROM
• Joint line tenderness
• Joint deformity in severe cases
• Activity limitation
• Heberden’s nodes

Functional Implications

• Limited mobility
• Household and work-related activity limitations/restrictions
• Decreased overall activity and participation

Possible Contributing Causes

• Chronic factors affecting the joint such as obesity, BMD, LLD
• Aging
• Chronic and vigorous joint loading
• Previous chronic joint injury (e.g., accident, trauma); hence, secondary OA

Differential Diagnoses

• Rheumatoid arthritis
• Gout
• Fibromyalgia
• Spondyloarthropathy
• Ankylosing spondylitis

Means of Confirmation or Diagnosis

Laboratory Tests

• Synovial fluid examination
• Other laboratory tests can be done to rule out other conditions

Imaging

• X-ray of the joint
• MRI of the joint

Diagnostic Procedures

• Ultrasound of the joint and synovium

Findings and Interpretation

• Imaging studies (e.g., x-ray):
• Osteophytes, joint-space narrowing, sclerosis
• Cartilage and/or bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
• Erosion of articular cartilage

Treatment

Medication

• NSAIDs (including topical NSAIDs, e.g., capsaicin)
• Acetaminophen
• Opioids
• Glucosamine and chondroitin sulfate
• Glucocorticoids or corticosteroids
• Intra-articular injections (corticosteroids, hyaluronic acid)
• Emerging drugs e.g., anti-tumor necrosis factors (anti-TNFs), calcitonin, growth factors, nerve growth factor antibodies

Medical Procedures

• Total joint replacements
• Joint lavage
• Debridement

Referrals/Admittance

• To rheumatologist to assess underlying complications
• To internal medicine specialist
• To orthopedist for surgical consult
• To physical and rehabilitation medicine specialist
• To dietician/nutritionist

Impairments

• Mobility
• Self-care
• Role at home and in the community
• School and work
• Recreation, leisure, and sports

Tests and Measures

• Range of motion
• Manual muscle testing
• Joint mobility

Intervention

• Exercises
  • Aquatic exercises
  • Resistance
  • Endurance
  • Flexibility
• ADL training
• Use of assistive or adaptive devices
• Heat therapy
• Weight management; diet
• Rest
• Orthoses; splints; footwear
• Walking aids
• Ice
• Acupuncture
• Pain management
• Energy conservation techniques
• Joint protection
• Psychosocial support
• Ultrasound
• Electric stimulation
• Patient education

Functional Goals

• Improve joint mobility and stability for balance
• Improve muscle strength to climb stairs
• Improve muscle and general (aerobic) endurance
• Improve activity and participation at home, at work, and in the community
• Walk 0.5 mile pain free without assistive device
• Walk 1 mile pain free with assistive device
• Pain-free ADLs: e.g., sweeping, mopping
• Turn a key or door knob pain free
• Lift baby from crib without pain and maintain a neutral wrist posture

Prognosis

• No definite cure for OA; it is a chronic, long-term disease
• Joint damage is irreversible
• Treatment is for symptoms, but emerging drugs may modify OA disease management
• Recovery or relief depends on disease duration and timely intervention
• Prognosis can be affected by
  • Demographics
  • Severity and natural history of the disease
  • Medical and behavioral comorbidities, e.g., fear avoidance, catastrophization, central sensitization
• Positive prognosticating factors: competent general endurance, good muscle strength, and joint mobility
• PT treatment outcomes improved by motivation and compliance with physical therapy intervention (e.g., home exercise program), and family and environmental support

References

Additional Resources

ICD-9-CM Codes

• 715 Osteoarthrosis and allied disorders
• 715.14 Osteoarthrosis localized primary involving hand
• 715.24 Osteoarthrosis localized secondary involving hand
• 715.9 Osteoarthrosis unspecified whether generalized or localized
• 715.94 Osteoarthrosis unspecified whether generalized or localized involving hand

ICD-10-CM Codes

• M19.049 Primary osteoarthritis, unspecified hand
• M19.249 Secondary osteoarthritis, unspecified hand
• M18.9 Osteoarthritis of first carpometacarpal joint, unspecified

Preferred Practice Patterns1

• 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders
• 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty
• 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery

Key Features

Description

• Most common form of Osteoarthritis (OA)
• Degenerative
• Commonly affects hand and weight-bearing joints
• Can also affect interphalangeal joints and first metatarsophalangeal joint
• Associated with increasing age, obesity, sex and race/ethnicity
• Associated with abnormal loading of the joints
• Characterized by joint pain
• Arthrosis
• Osteoarthrosis
• Polyarthrosis
• Degenerative joint disease

Essentials of Diagnosis

• Radiography is a standard method for diagnosis
• Kellgren and Lawrence (KL) grade ≥ 2 (definite radiographic OA)2
• Osteophytes, joint-space narrowing, sclerosis
• Also cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
• Erosion of articular cartilage
• Synovial hyperplasia
• Fibrosis
• Inflammatory cell infiltration
• Conventional radiograph is the most commonly used tool in OA.
• Diagnosis is made based on a careful history taking, physical examination, imaging studies, laboratory examination, and exclusion of other possible diseases.

General Considerations

• Low bone mineral density (BMD)
• Repetitive joint use or loading
• Joint alignment
• Bone or joint morphology
• Calcification (e.g., of the knee meniscus)
• Bone formation, cyst formation
• Thickening of subchondral bone plate, osteosclerosis
• Overall joint dysfunction
• Joint swelling and inflammation (in certain cases, severe cases)
• Joint pain
• Morning stiffness
• Long-term disease
  • Secondary problems
    • Muscle atrophy and weakness
    • Bony protrusion/prominence
    • Joint deformity
    • Grasping difficulty
    • Difficulty with ADLs

Demographics

• Increase in age (middle to older age)
• Women are more affected than men
• African American and Caucasian
• May affect about 12% of the population (US and other developed countries)3

Clinical Findings

Signs and Symptoms

• Joint pain
• Aching joint
• Joint stiffness
• Muscle weakness
• Muscle atrophy
• Crepitus
• Bony enlargement
• Limited joint ROM
• Joint line tenderness
• Joint deformity in severe cases
• Activity limitation
• Heberden’s nodes

Functional Implications

• Limited mobility
• Household- and work-related activity limitation/restriction
• Decreased overall activity and participation

Possible Contributing Causes

• Chronic factors affecting the joint such as obesity, BMD, and leg length discrepancy (LLD)
• Aging
• Chronic and vigorous joint loading
• Previous chronic joint injury (e.g. accident, trauma), hence secondary Osteoarthritis (OA)

Differential Diagnosis

• Rheumatoid arthritis
• Gout
• Fibromyalgia syndrome
• Spondyloarthropathy
• Cervical radiculopathy
• Carpal tunnel syndrome

Means of Confirmation or Diagnosis

Laboratory Tests

• Not required: synovial fluid examination
• Other laboratory tests can be performed to rule out other conditions

Imaging

• Conventional radiograph of the joint
• MRI of the joint
• Diagnostic ultrasound of the joint and synovium

Findings and Interpretation

• OA is a clinical diagnosis that can be based on:
  • Persistent usage-related pain in joint(s)
  • Age ≥ 45 years3
  • Morning stiffness equal or less than 30 min3
  • Imaging studies (e.g., radiograph):
  • Osteophytes, joint-space narrowing, sclerosis
  • Also cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
  • Erosion of articular cartilage

Treatment

Medication

• NSAIDs (including topical NSAIDs, capsaicin)
• Acetaminophen
• Opioids
• Glucosamine and chondroitin sulfate
• Glucocorticoids or corticosteroids
• Intra-articular injections (corticosteroids, hyaluronic acid)
• Emerging drugs such as anti-TNF, calcitonin, growth factors, nerve growth factor antibodies

Medical Procedures

• Surgery: total joint replacement, joint lavage and debridement

Referrals/Admittance

• Rheumatologist to assess underlying complications
• Internal medicine specialist
• Orthopedic specialist
• Surgical consult
• Dietician/nutritionist

Impairments

• Mobility
• Self-care
• Role at home and in the community
• School and work
• Recreation, leisure, and sports

Intervention

• Exercises (resistance, endurance, and flexibility)
• Training on ADLs
• Use of assistive or adaptive devices
• Heat therapy
• Rest
• Orthoses, splints
• Ice
• Acupuncture
• Pain management
• Energy conservation techniques
• Joint protection
• Ultrasound
• Electric stimulation
• Patient education

Functional Goals

• Improve joint mobility and stability to improve grasping
• Improve muscle and general (aerobic) endurance
• Improve activity and participation related to role at home, work, and in the community
• Return to pain-free ADL, sweeping, mopping
• Turn a key or door knob, pain free
• Lift baby crib without pain and maintain a neutral wrist posture

Prognosis

• No definite cure for OA
• Treatment is for symptoms, but emerging drugs may modify OA disease mechanism.
• Joint damage is irreversible.
• Recovery or relief from symptoms may depend on disease duration and timely intervention.
• OA is a chronic disease and may mean long-term burden.
• May affect prognosis: demographics, severity and natural history of the disease, medical comorbidities, and behavioral comorbidities such as fear avoidance, catastrophization, and central sensitization
• Competent general endurance, good muscle strength, and mobile joints are good prognosticating factors.
• Motivation and compliance with PT intervention (e.g., home exercise program) and family and environmental support could also improve PT treatment outcomes.

References

Additional Resources

Condition/Disorder Synonyms

• Glenohumeral joint osteoarthritis (OA)

ICD-9-CM Codes

• 715 Osteoarthrosis and allied disorders
• 715.11 Osteoarthrosis localized primary involving shoulder region
• 715.21 Osteoarthrosis localized secondary involving shoulder region
• 715.9 Osteoarthrosis unspecified whether generalized or localized

ICD-10-CM Codes

• M19.019 Primary osteoarthritis, unspecified shoulder
• M19.219 Secondary osteoarthritis, unspecified shoulder

Preferred Practice Patterns

• 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction1
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders2
• 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty3
• 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery4

Key Features

Description

• Most common form of arthritis
• Degenerative joint disease
• Commonly affects weight-bearing joints
• Associated with increased age, obesity, previous trauma, previous surgery
• Associated with abnormal loading of joints
• Characterized by joint pain
• Arthrosis
• Osteoarthrosis
• Polyarthrosis

Essentials of Diagnosis

• Radiography is standard method for diagnosis
• Kellgren and Lawrence (KL) grade ≥ 2 (definite radiographic OA)5
• Osteophytes, joint-space narrowing, sclerosis
• Cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
• Erosion of articular cartilage
• Synovial hyperplasia
• Fibrosis
• Inflammatory cell infiltration
• Conventional radiograph is most commonly used tool in OA6
• Diagnosis based on careful history, physical examination, imaging studies, laboratory examination, exclusion of other possible diseases

General Considerations

• Low bone-mineral density (BMD)
• Repetitive joint use or loading
• Joint alignment
• Bone or joint morphology
• Calcification of the biceps tendon
• Bone formation, cyst formation
• Thickening of subchondral bone plate, osteosclerosis
• Overall joint dysfunction
• Joint swelling and inflammation (in certain, severe cases)
• Joint pain
• Morning stiffness
• Long-term disease
• Secondary problems
  • Muscle atrophy and weakness
  • Bony protrusion or prominence
  • Joint deformity
  • Difficulty with ADLs

Demographics

• More common in middle- to older-aged populations
• Women more commonly affected than men
• More common African American and Caucasian than other ethnicities
• May affect approximately 12% of the population in U.S. and other developed countries7

Clinical Findings

Signs and Symptoms

• Joint pain, aching
• Joint stiffness
• Muscle weakness
• Muscle atrophy
• Crepitus
• Bony enlargement
• Limited range of motion (ROM) in joint
• Joint-line tenderness
• Joint deformity in severe cases
• Activity limitation

Functional Implications

• Limited mobility
• Household and work-related activity limitations/restrictions
• Decreased overall activity and participation

Possible Contributing Causes

• Chronic factors affecting the joint (obesity, BMD, LLD)
• Ageing
• Chronic and vigorous joint-loading
• Previous chronic joint injury (e.g., accident, trauma); secondary OA

Differential Diagnosis

• Rheumatoid arthritis
• Gout
• Rotator cuff tear
• Bursitis
• Biceps tendinitis
• Adhesive capsulitis
• Fibromyalgia syndrome
• Spondyloarthropathy

Means of Confirmation

Laboratory Tests

• Synovial fluid examination (optional, not required)
• Other laboratory tests can be done to rule out other conditions

Imaging

• Conventional radiograph of the joint
• MRI of the joint
• Diagnostic ultrasound of the joint and synovium

Findings and Interpretation

• OA is a clinical diagnosis, which can be based on
  • Persistent usage-related pain in joint or joints
  • Age ≥ 45 years7
  • Morning stiffness ≤ 30 minutes7
• Imaging studies (e.g., radiograph):
  • Osteophytes, joint-space narrowing, sclerosis
  • Cartilage lesions, bone marrow lesions, synovitis, effusion, subchondral bone attrition/sclerosis
  • Erosion of articular cartilage

Treatment

Medication

• NSAIDs (including topical NSAIDS, capsaicin)
• Acetaminophen
• Opioids
• Glucosamine and chondroitin sulfate
• Glucocorticoids or corticosteroids
• Intra-articular injections (corticosteroids, hyaluronic acid)
• Emerging drugs: anti-tumor necrosis factor (TNF), calcitonin, growth factors, nerve growth factor antibodies

Medical Procedures

• Surgery: total joint replacement, joint lavage and debridement

Referrals/Admittance

• To rheumatologist for assessment of underlying complications
• To internal medicine specialist
• To orthopedic specialist
• To surgeon for surgical consult
• To dietician/nutritionist for dietary counseling

Impairments

• Mobility
• Self-care
• Overhead reaching
• Sleeping on affected side
• Role at home and in community
• School and work
• Recreation, leisure, sports

Intervention

• Exercises (resistance, endurance, flexibility)
  • Aquatic exercises
• Training on ADLs
• Use of assistive or adaptive devices
• Heat therapy
• Weight management
• Rest
• Orthoses, shoulder sling
• Ice
• Diet
• Acupuncture
• Pain management
• Energy conservation techniques
• Joint protection
• Ultrasound
• Electric stimulation
• Patient education

Functional Goals

• Patient will have
  • Improved joint mobility and stability to reach overhead
  • Improved muscle strength to lift dishes into cabinet
  • Improved muscle and aerobic endurance
  • Improved activity and participation at home, at work, and in the community
• Patient will be able to
  • Walk 0.5 miles pain-free without assistive device
  • Walk 1 mile pain-free with assistive device
  • Resume ADLs pain-free
  • Turn a key or doorknob pain-free
  • Lift a baby from crib without pain, maintaining neutral wrist posture

Prognosis

• No definite cure for OA
• Treatment is for symptom-management, though emerging drugs may modify OA disease mechanism
• Joint damage is irreversible
• Recovery or relief from symptoms may depend on disease duration and timely intervention
• OA is a chronic disease, may mean long-term burden
• Factors affecting prognosis: demographics, severity and natural history of disease, medical comorbidities, behavioral comorbidities (fear avoidance, catastrophizing, central sensitization)
• General endurance, good muscle strength, mobile joints are good prognosticating factors
• Motivation and compliance with physical therapy intervention (e.g., home exercise program), and support from family and environment could also improve treatment outcomes

References

Additional Resources

Condition/Disorder Synonyms

• Hip arthritis
• Hip degenerative joint disease

ICD-9-CM Codes

• 715 Osteoarthrosis and allied disorders
• 715.15 Osteoarthrosis localized primary involving pelvic region and thigh
• 715.25 Osteoarthrosis localized secondary involving pelvic region and thigh
• 715.35 Osteoarthrosis localized not specified whether primary or secondary involving pelvic region and thigh
• 715.9 Osteoarthrosis unspecified whether generalized or localized
• 715.95 Osteoarthrosis unspecified whether generalized or localized involving pelvic region and thigh

ICD-10-CM Codes

• M16.10 Unilateral primary osteoarthritis, unspecified hip
• M16.7 Other unilateral secondary osteoarthritis of hip
• M16.9 Osteoarthritis of hip, unspecified

Preferred Practice Patterns

• 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction1
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders2
• 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty3
• 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery4

Key Features

Description

• Most common form of arthritis
• Degenerative
• Commonly affects hip and knee joints (weight-bearing joints)
• May also affect spinal facet joints
• Associated with increased age, obesity, female sex, race/ethnicity
• Associated with abnormal loading of joints
• Characterized by joint pain
• Arthrosis
• Osteoarthrosis
• Polyarthrosis
• Degenerative joint disease

Essentials of Diagnosis

• Radiography is standard method for diagnosis
• Kellgren and Lawrence (KL) grade ⩾ 2 (definite radiographic OA)2
• Osteophytes, joint-space narrowing, sclerosis
• Cartilage lesions, bone marrow lesions, synovitis, effusion, subchondral bone attrition or sclerosis
• Erosion of articular cartilage
• Synovial hyperplasia
• Fibrosis
• Inflammatory cell infiltration
• With or without OA symptoms
• Conventional radiograph is most commonly used tool for diagnosing OA
• Diagnosis based on a careful history, physical examination, imaging studies, laboratory examination, exclusion of other possible diseases

General Considerations

• Low bone-mineral density (BMD)
• Repetitive joint use or loading
• Joint alignment
• Leg-length discrepancy (LLD)
• Bone or joint morphology
• Calcification (e.g., of the knee meniscus)
• Bone formation, cyst formation
• Thickening of subchondral bone plate, osteosclerosis
• Overall joint dysfunction
• Joint swelling and inflammation (in severe cases)
• Joint pain
• Morning stiffness
• Long-term disease
• Secondary problems
  • Muscle atrophy and weakness
  • Bony protrusion or prominence
  • Joint deformity
  • Difficulty walking
  • Difficulty with ADLs

Demographics

• Increased age (middle- to older-age)
• Women more commonly affected than men
• African American and Caucasian more commonly affected than other ethnicities
• May affect approximately 12% of population in U.S. and other developed countries3

Clinical Findings

Signs and Symptoms

• Joint pain or aching
• Joint stiffness
• Muscle weakness
• Muscle atrophy
• Crepitus
• Bony enlargement
• Limited joint range of motion (ROM)
• Joint-line tenderness
• Joint deformity in severe cases
• Activity limitation

Functional Implications

• Limited mobility
• Limited household and work-related activity
• Decreased overall activity and participation

Possible Contributing Causes

• Chronic factors affecting the joint, such as obesity, BMD, LLD
• Ageing
• Chronic, vigorous joint loading
• Previous chronic joint injury (e.g., accident, trauma): secondary OA

Differential Diagnosis

• Rheumatoid arthritis
• Gout
• Bursitis
• Fibromyalgia syndrome
• Spondyloarthropathy
• Ankylosing spondylitis

Means of Confirmation or Diagnosis

Laboratory Tests

• Synovial fluid examination (not required)
• Other laboratory tests can be done to rule out other conditions

Imaging

• Conventional radiograph of joint
• MRI of joint
• Diagnostic ultrasound of the joint and synovium

Findings and Interpretation

• OA is a clinical diagnosis, can be based on
  • Persistent usage-related pain in joint(s)
  • Age ⩾ 45 years3
  • Morning stiffness ⩽ 30 minutes3
• Imaging studies (e.g., radiograph)
  • Osteophytes, joint-space narrowing, sclerosis
  • Cartilage lesions, bone marrow lesions, synovitis, effusion, subchondral bone attrition or sclerosis
  • Erosion of articular cartilage

Treatment

Medication

• NSAIDs (including topical NSAIDs, capsaicin)
• Acetaminophen
• Opioids
• Glucosamine and chondroitin sulfate
• Glucocorticoids or corticosteroids
• Intra-articular injections (corticosteroids, hyaluronic acid)
• Emerging drugs: anti-tumor necrosis factors (TNF), calcitonin, growth factors, nerve growth factor antibodies

Medical Procedures

• Surgery: total joint replacement, joint lavage and debridement

Referrals/Admittance

• To rheumatologist for assessment of underlying complications
• To internal medicine specialist
• To orthopedic specialist
• To physical and rehabilitation medicine specialist
• To surgeon for surgical consult
• To dietician or nutritionist for dietary consult/counseling

Impairments

• Mobility
• Self-care
• Role at home and in community
• School, work, recreation, leisure, sports

Intervention

• Exercises (resistance, endurance, flexibility)
  • Aquatic exercises
• Training on ADLs
• Use of assistive or adaptive devices
• Heat therapy
• Weight management
• Rest
• Orthoses, splints
• Walking aids
• Ice
• Diet
• Acupuncture
• Pain management
• Energy conservation techniques
• Joint protection
• Footwear
• Psychosocial support
• Ultrasound
• Electric stimulation
• Patient education

Functional Goals

• Patient will have improved
  • Joint mobility and stability to improve balance
  • Muscle strength so as to climb stairs
  • Muscle and general (aerobic) endurance
  • Level of activity and participation in home, work, community
• Patient will be able to
  • Walk 0.5 miles pain-free without assistive device
  • Walk 1 mile pain-free with assistive device
  • Resume ADLs (e.g., sweeping, mopping) pain-free

Prognosis

• No definite cure for OA: chronic disease, may mean long-term burden
• Treatment primarily for symptom management, though emerging drugs may modify disease mechanism
• Joint damage is irreversible
• Recovery or relief from symptoms may depend on disease duration and timely intervention
• Factors affecting prognosis include: demographics, severity and natural history of the disease, medical and behavioral comorbidities (fear avoidance, catastrophization, central sensitization)
• General endurance, muscle strength, and mobile joints are good prognosticating factors
• Motivation, compliance with PT intervention (e.g., home exercise program), support from family and environmental can improve outcomes

References

Additional Resources

Condition/Disorder Synonyms

• Knee arthritis
• Knee degenerative joint disease

ICD-9-CM Code

• 715 Osteoarthrosis and allied disorders
• 715.16 Osteoarthrosis localized primary involving lower leg
• 715.26 Osteoarthrosis localized secondary involving lower leg
• 715.36 Osteoarthrosis localized not specified whether primary or secondary involving lower leg
• 715.9 Osteoarthrosis, unspecified whether generalized or localized
• 715.95 Osteoarthrosis, unspecified whether generalized or localized involving pelvic region and thigh

ICD-10-CM Code

• M17.10 Unilateral primary osteoarthritis, unspecified knee
• M17.5 Other unilateral secondary osteoarthritis of knee
• M17.9 Osteoarthritis of knee, unspecified

Preferred Practice Patterns

• 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction1
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders2
• 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty3
• 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery4

Key Features

Description

• Most common form of arthritis
• Degenerative
• Commonly affects hip and knee joints, weight-bearing joints
• Can also affect spinal facet joints
• Associated with increasing age, obesity, female sex and race/ethnicity
• Associated with abnormal loading of the joints
• Characterized by joint pain
• Arthrosis
• Osteoarthrosis
• Polyarthrosis
• Degenerative joint disease

Essentials of Diagnosis

• Radiography is standard method for diagnosis
• Kellgren-Lawrence (KL) Grade ≥ 2 (definite radiographic OA)5
• Osteophytes, joint-space narrowing, sclerosis
• Cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
• Erosion of articular cartilage
• Synovial hyperplasia
• Fibrosis
• Inflammatory cell infiltration
  • With or without OA symptoms
• Conventional radiograph is most commonly used tool in OA
• Diagnosis based on careful history and physical examination, imaging studies, laboratory examination, exclusion of other possible diseases

General Considerations

• Low bone mineral density (BMD)
• Repetitive joint use or loading
• Joint alignment
• Leg-length discrepancy or inequality (LLD)
• Bone or joint morphology
• Calcification (of the knee meniscus)
• Bone formation, cyst formation
• Thickening of subchondral bone plate, osteosclerosis
• Overall joint dysfunction
• Joint swelling and inflammation (in certain cases, severe cases)
• Joint pain
• Morning stiffness
• Long-term disease
• Secondary problems
  • Muscle atrophy and weakness
  • Bony protrusion/prominence
  • Joint deformity
  • Difficulty walking
  • Difficulty with ADLs

Demographics

• Aging (onset middle- to old-age)
• Women more commonly affected than men
• African American and Caucasian more commonly affected
• May affect approximately 12% of the population (U.S. and other developed countries)6

Clinical Findings

Signs and Symptoms

• Joint pain
• Aching joint
• Joint stiffness
• Muscle weakness
• Muscle atrophy
• Crepitus
• Bony enlargement
• Limited joint range of motion (ROM)
• Joint line tenderness
• Joint deformity in severe cases
• Activity limitation

Functional Implications

• Limited mobility
• Limited or restricted household and work-related activity
• Decreased activity and participation overall

Possible Contributing Causes

• Chronic factors affecting the joint such as obesity, BMD, LLD
• Ageing
• Chronic and vigorous joint loading
• Previous chronic joint injury (e.g., accident, trauma); hence secondary OA

Differential Diagnosis

• Rheumatoid arthritis
• Gout
• Tendinitis
• Stress fracture
• Lumbar radiculopathy
• Fibromyalgia syndrome
• Spondyloarthropathy
• Ankylosing spondylitis

Means of Confirmation or Diagnosis

Laboratory Tests

• Synovial fluid examination (not required)
• Other laboratory tests may be done to rule out other conditions

Imaging

• Conventional radiograph of the joint
• MRI of the joint
• Diagnostic Ultrasound of the joint and synovium

Findings and Interpretation

• OA is a clinical diagnosis, which can be based on
  • Persistent usage-related pain in joint(s)
  • Age ≥ 45 years2
  • Morning stiffness equal or less than 30 minutes2
• Imaging studies (radiograph)
  • Osteophytes, joint-space narrowing, sclerosis
  • Cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis
  • Articular cartilage erosion

Treatment

Medication

• NSAIDs (including topical, capsaicin)
• Acetaminophen
• Opioids
• Glucosamine and chondroitin sulfate
• Glucocorticoids or corticosteroids
• Intra-articular injections (corticosteroids, hyaluronic acid)
• Emerging drug options (e.g., anti-TNF, calcitonin, growth factors, nerve growth factor antibodies

Medical Procedures

• Surgery: total joint replacement, joint lavage, debridement

Referrals/Admittance

• To rheumatologist, assess underlying complications
• To internal medicine specialist
• To orthopedic specialist
• To physical and rehabilitation medicine specialist
• For surgical consult
• To dietician, nutritional counseling

Impairments

• Mobility
• Self-care
• Roles at home and in the community
• School and work
• Recreation, leisure, sports

Intervention

• Exercises (resistance, endurance, flexibility)
  • Aquatic exercises
• Training on ADLs
• Assistive or adaptive devices
• Heat therapy
• Weight management
• Rest
• Orthoses, splints
• Walking aids
• Ice
• Diet
• Acupuncture
• Pain management
• Energy conservation techniques
• Joint protection
• Footwear
• Psychosocial support
• Ultrasound
• Electric stimulation
• Patient education

Functional Goals

• Patient will demonstrate
  • Improved joint mobility and stability; improved balance
  • Improved muscle strength so as to climb stairs
  • Improved muscle and aerobic endurance
  • Improved activity, participation in home, work, and community activities
  • Ability to walk 0.5 miles pain-free without assistive device
  • Ability to walk 1 mile pain-free with assistive device
  • Return to pain-free ADLs (sweeping, mopping, etc.)

Prognosis

• No definite cure
• Treatment for symptom management, but emerging drugs may modify OA disease mechanism
• Joint damage irreversible
• Recovery or relief from symptoms may depend on disease duration and timely intervention
• OA is a chronic disease with possible long-term burden
• Factors that may affect prognosis include
  • Demographics
  • Severity and natural history of the disease
  • Medical comorbidities
  • Behavioral comorbidities, such as fear avoidance, catastrophization, central sensitization
• General endurance, good muscle strength, and mobile joints are good prognosticating factors
• Motivation and compliance with physical therapy intervention (e.g., home exercise program) and family/environmental support could improve outcomes

References

Additional Resources

Condition/Disorder Synonym

• Brittle bone disease

ICD-9-CM Code

• 756.51 Osteogenesis imperfecta

ICD-10-CM Code

• Q78.0 Osteogenesis imperfecta

Preferred Practice Pattern1

• 5B: Impaired Neuromotor Development

Key Features

Description

• Autosomal dominant genetic disorder that affects type I collagen resulting in osteopenia and frequent fractures that may be apparent in a newborn infant

Essentials of Diagnosis

• Four types
  • Type I: Mild (most common)
  • Type II: Perinatal lethal
  • Type III: Progressive deforming
  • Type IV: Deforming with normal scleras
• Types I and IV do not have fractures while in utero
• Type II characterized by fractures in utero
• Type III characterized by fractures at birth or as infant

General Considerations

• Disorder results from type I collagen impairment that affects skin, bone, connective tissue of organs (including GI tract), and vascular system
• Type I: fewer fractures after puberty; short stature and hearing loss as adult; blue sclera
• Type II: usually results in death during infancy due to respiratory problems
• Type III: usually non-ambulatory as an adult due to progressive deformities from multiple fractures over time; sclera affected; short stature, scoliosis
• Type IV: short stature as adult, fractures continue as adult, but remains ambulatory; scoliosis; hearing loss; sclera unaffected

Demographics

• 1 in 20,000 births2
• Infants
• Males and females affected equally2

Clinical Findings

Signs and Symptoms

• Fracture(s) at various times throughout lifespan (dependent on type of OI)
• Blue sclera
• Deafness at early age
• Genu varum (bow legged)
• Scoliosis
• Kyphosis
• Muscle weakness
• Joint laxity
• Brittle teeth

Functional Implications

• May cause short stature or joint deformities that can interfere with function
• May cause developmental delay due to immobility or casting associated with fractures
• Weakness may limit function

Possible Contributing Causes

• Inherited disorder

Differential Diagnoses

• Child abuse
• Juvenile osteoporosis
• Temporary brittle-bone syndrome
• Hypophosphatasia
• Menkes syndrome
• Steroid-induced osteoporosis

Means of Confirmation or Diagnosis

Laboratory Tests

• DNA analysis
• Collagen testing

Imaging

• Prenatal ultrasound
• X-rays

Diagnostic Procedures

• Chorionic villus sampling (CVS)
• Amniocentesis
• Skin punch biopsy

Findings and Interpretation

• Chorionic villus sampling (CVS) is a prenatal test identifying chromosome abnormalities and other inherited disorders

Treatment

Medication

• Pamidronate

Medical Procedures

• Surgical correction of fractures, such as intramedullary rod
• Surgical correction of scoliosis

Referrals/Admittance

• To hospital for surgical repair of fractures as needed
• To geneticist for testing (especially if interested in offspring)
• To occupational therapist
• To orthosist
• To orthopedic surgeon
• To audiologist

Impairments

• Gross motor delay
  • Unable to sit independently
  • Unable to creep on hands and knees
  • Unable to stand at furniture
• Decreased strength
• Decreased ROM
• Dependent for transfers
• Dependent for ADLs
• Non-ambulatory

Tests and Measures

• Active ROM (but not passive)
• Manual muscle testing (assessed functionally in children)
• Leg length discrepancy (LLD)

Intervention

• Neurodevelopmental treatment
  • Facilitation techniques to assist with attaining age-appropriate gross motor milestones
• Therapeutic exercise
  • Strengthening
  • Stretching
  • Aerobic
• Functional activities
  • Transfers
  • Gait training
  • Stair climbing
• Aquatic exercise
• Adaptive equipment (may include wheelchair or gait aides)
• Orthotics
• Patient education regarding energy conservation and joint protection
• Family/caregiver education regarding safe handling, positioning, dressing, and bathing

Functional Goals

• Tailor sit on the floor with contact guard assistance with good spinal alignment for 2 minutes within 1 month
• Pull-to-stand independently with stand-by assistance within 3 months
• Creep on hands and knees for 5’ with moderate assistance in 2 months
• Increase quad strength to 5/5 to allow for independence climbing stairs; holding railing with one hand in 6 weeks.
• Increase elbow flexion to 110˚ in 2 weeks to allow patient to brush hair
• Transfer from bed to bedside chair with minimal assistance to improve mobility in 2 days
• Stand with contact guard assistance to allow for improved independence with hygiene in 1 day
• Ambulate 75’ with rolling walker and stand-by assistance in 3 days to improve mobility

Prognosis

• Type I: fewer fractures after puberty; short stature and hearing loss as adult; blue sclera; normal life span
• Type II: usually results in death during infancy due to respiratory problems
• Type III: usually non-ambulatory as an adult due to progressive deformities from multiple fractures over time; sclera affected; short stature, scoliosis
• Type IV: short stature as adult, fractures continue as adult, but remains ambulatory; scoliosis; hearing loss; sclera unaffected; normal life span

References

Additional Resources

Condition/Disorder Synonym

• Rickets (specific to occurrence children)

ICD-9-CM Code

• 268.2 Osteomalacia unspecified

ICD-10-CM Code

• M83.9 Adult osteomalacia, unspecified

Preferred Practice Patterns1

• 4A: Primary Prevention/Risk Reduction for Skeletal Demineralization
• 4B: Impaired Posture
• 4C: Impaired Muscle Performance
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, ROM, and Reflex Integrity Association With Spinal Disorders
• 4G: Impaired Joint Mobility, Muscle Performance, and ROM Associated With Fracture

Key Features

Description

• Softening of bone mass and density with a marked decrease in cortical thickness and cancellous bone trabeculae, leading to increased fragility, deformity and/or fracture
• Due to a lack or an inability to process of vitamin D
• Metabolic bone disease
• Normal amount of collagen
• Fracture with minimal injury
• Rickets in children affects mineralization of the growth plates
• Inadequate or delayed mineralization in mature cortical and spongy bone

Essentials of Diagnosis

• Bone mineral density (BMD) measurements are related to both peak bone mass and bone loss
• Decreased serum calcium levels
• Low levels of serum 25-hydroxyvitamin D
• Bone densitometry: Normal BMD within 1 standard deviation (SD) of the mean; T-score at -1.0 and greater
• Bone densitometry: Low BMD (referred to as osteopenia) occurs between 1 and 2.5 SDs below the mean; T-score between -1.0 and -2.5
• Increased fracture propensity is due to demineralization secondary to osteoporosis; often occurs at the spine, hips, pelvis, or wrist
• Accurate patient and family medical histories and early recognition through physical examination may lead to improved therapeutic outcomes
• 10-year risk for fracture can be measured through Fracture Risk Assessments (FRAX® score)
• Pharmacotherapy can be measured through changes in laboratory values

General Considerations

• Widespread bone pain
• Persons with low BMD are at an increased risk for the development of osteoporosis; prevention is critical to reduce incidence
• According to the National Osteoporosis Foundation (NOF), over 10 million Americans have osteoporosis and another 34 million have low BMD and therefore at increased risks for the development of osteoporosis

Demographics

• Children (rickets)
• Elderly
• Individuals with absorption issues in the intestines

Clinical Findings

Signs and Symptoms

• Known clinically as a ‘silent’ disease; can be asymptomatic until fracture occurs
• Vertebral fractures may present as severe back pain or with no pain or sensation noted
• Muscle weakness
• Hypocalcemia
• Bone pain (common in the hips)
• Deformations of the vertebral spine and loss of height may present clinically as kyphosis or lordosis
• Spasms in the hands and feet
• Heart arrhythmia

Functional Implications

• Causes disability for aging and elderly women and men
• Approximately 20% of women and 30–50% of men with hip fractures secondary to osteoporosis die within 1 year of sustained fracture2,3

Possible Contributing Causes

• Vitamin D deficiency
• Age (>/= 50 years)
• Gender (female>male)
• Kidney failure
• Liver disease
• Limited sun exposure
• Overuse of suntan lotion with no sun exposure
• Cancer
• Menopause in women; low testosterone levels in men
• History of broken bones
• Consumption of alcohol or tobacco
• Poor dietary habits or eating disorders
• Lifestyle (sedentary vs. active)
• Use of medications known to increase risk for fracture or bone mineral loss
• Certain comorbid diseases

Differential Diagnoses

• Trauma
• Pathologic fracture from neoplasm
• Osteogenesis imperfecta
• Inadequate mineralization of existing bone matrix (osteoid) or poor bone quality
• Paget's disease
• Infections (such as tuberculosis)
• Fibrous dysplasia
• Peripheral neuropathy
• Repetitive stress fractures
• Multiple myeloma, lymphoma, or metastatic cancer
• Leukemia
• Renal osteodystrophy
• Hormone deficiency (estrogen in women; androgen in men)
• Cushing's syndrome or glucocorticoid administration
• Hyperthyroidism
• Hyperparathyroidism
• History of drug abuse or misuse (alcohol, tobacco)
• Excessive vitamin D or A
• Juvenile osteoporosis occurs in children or young adults of both genders with normal gonadal function; onset typically occurs around age 8 to 14 years and hallmarks include rapid onset of bone pain and/or fracture secondary to trauma
• Type I (postmenopausal osteoporosis) typically occurs in women 50 to 65 years of age and is characterized by accelerated bone loss (trabecular bone)
• Type II (age-associated or senile osteoporosis) presents in women and men older than 70 years of age as a result of bone loss associated with the aging process; fractures occur in both cortical and trabecular bone

Means of Confirmation or Diagnosis

Laboratory Tests

• Blood calcium levels
• 24-hour urine calcium measurement
• Thyroid function test
• Parathyroid hormone levels
• Testosterone level (men)
• 25-hydroxyvitamin D test
• Biochemical markers

Imaging

• X-ray
• Computer assisted tomography (CT)
• Vertebral fracture assessment (VFA)
• Bone scan
• Diagnostic ultrasound (mobile community-based screening)
• Spinal and pelvic radiographs may demonstrate demineralization, vertebral compression
• Posterior, anterior, and lateral x-rays of affected areas of spine are utilized to identify location and severity of fracture(s)
• Single-energy x-ray absorptiometry (SXA)
• Quantitative computed tomography (QCT)
• Radiographic absorptiometry (RA)

Diagnostic Procedures

• Dual-energy x-ray absorptiometry (DEXA) is used to diagnose and confirm osteoporosis at both the axial and appendicular skeleton; delivers negligible radiation with a high degree of precision
• Qualitative CT delivers more radiation, but is also accurate in conformation

Findings and Interpretation

• Disability for aging and elderly women and men
• Improved rates of screenings may help identify persons at increased risk for fracture or low BMD, which enables health care providers to educate the patient on healthy lifestyle changes and preventative strategies

Treatment

Medication

• Pain management
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Narcotics
  • Topical pain relieving agents
  • Nerve-blocking injections
• Stimulation of bone formation
  • Bisphosphonates
  • Vitamin D, phosphorus, and calcium supplement
• Reduction of bone resorption
  • Bisphosphonates
  • Estrogens
  • Selective estrogen receptor modulators (SERMS)
  • Calcitonin
  • Calcium
  • Human monoclonal antibody (denosumab)
  • Thiazide diuretics
  • Anabolic agents (Teriparatide®) if failed bisphosphonate therapy
  • Parathyroid hormone

Medical Procedures

• Kyphoplasty
• Vertebroplasty
• Surgical (repair of fracture): utilized for pain control

Referrals/Admittance

• To endocrinologist
• To general practitioner
• To geriatrician
• To orthopedist for joint assessment
• To rheumatologist
• To registered dietitian for nutrition education
• To pharmacist for bone supplements
• To occupational therapist for ADL training

Impairments

• Physical impairment
  • Chronic or recurrent pain or discomfort
  • Difficulty gripping or holding objects
  • Incomplete use of arms or fingers
  • Incomplete use of feet or legs
  • Disfigurement or deformity
• Activity limitations
  • Self care
  • Mobility
  • Physical transport
  • ADLs
  • Socialization and social activities
  • Work loss or employment restrictions
• Quality of Life (QoL) and Health-Related Quality of Life (HQoL)
• Environment and adjustments
  • Assistive devices
  • Home and occupational modifications
  • Family assistance

Intervention

• Fall Risk Assessment Tool: FRAT
• Therapeutic exercise
• Progressive weight bearing exercises, e.g., aquatic therapy
• Patient education and lifestyle changes
• Moist heat/cryotherapy
• Ultrasound/phonophoresis/iontophoresis
• Transcutaneous electric nerve stimulation (TENS)
• Manual therapy/joint mobilization with precaution of bone density
• Soft tissue massage
• Orthotics to decrease flexion forces and reduce pain or dysfunction

Functional Goals

• Reduction in calcium loss
• Prevention of future fractures
• Adequate control of pain
• Prevention of disability
• Improvements in strength, flexibility, posture, balance
• Decrease in risks for falls

Prognosis

• Reductions in bone pain may occur within 2 to 4 weeks of therapy, depending on appropriateness of pharmacologic therapy
• High-risk patients are recommended to receive a DEXA scan every 2 to 3 years (if the baseline is found to be normal); every 1 to 2 years if currently on pharmacotherapy
• If from vitamin deficiency can be reversible in 4 to 8 months for increased bone calcium

References

Additional Resources

Condition/Disorder Synonyms

• Bone infection
• Pyogenic osteomyelitis

ICD-9-CM Codes

• 730 Osteomyelitis periostitis and other infections involving bone
• 730.0 Acute osteomyelitis
• 730.00 Acute osteomyelitis, site unspecified
• 730.01 Acute osteomyelitis, shoulder region
• 730.02 Acute osteomyelitis, upper arm
• 730.03 Acute osteomyelitis, forearm
• 730.04 Acute osteomyelitis, hand
• 730.05 Acute osteomyelitis, pelvic region and thigh
• 730.06 Acute osteomyelitis, lower leg
• 730.07 Acute osteomyelitis, ankle and foot
• 730.08 Acute osteomyelitis, other specified sites
• 730.09 Acute osteomyelitis, multiple sites
• 730.1 Chronic osteomyelitis
• 730.10 Chronic osteomyelitis, site unspecified
• 730.11 Chronic osteomyelitis, shoulder region
• 730.12 Chronic osteomyelitis, upper arm
• 730.13 Chronic osteomyelitis, forearm
• 730.14 Chronic osteomyelitis, hand
• 730.15 Chronic osteomyelitis, pelvic region and thigh
• 730.16 Chronic osteomyelitis, lower leg
• 730.17 Chronic osteomyelitis, ankle and foot
• 730.18 Chronic osteomyelitis, other specified sites
• 730.19 Chronic osteomyelitis, multiple sites
• 730.2 Unspecified osteomyelitis
• 730.20 Unspecified osteomyelitis, site unspecified
• 730.21 Unspecified osteomyelitis, shoulder region
• 730.22 Unspecified osteomyelitis, upper arm
• 730.23 Unspecified osteomyelitis, forearm
• 730.24 Unspecified osteomyelitis, hand
• 730.25 Unspecified osteomyelitis, pelvic region and thigh
• 730.26 Unspecified osteomyelitis, lower leg
• 730.27 Unspecified osteomyelitis, ankle and foot
• 730.28 Unspecified osteomyelitis, other specified sites
• 730.29 Unspecified osteomyelitis, multiple sites
• 730.3 Periostitis without mention of osteomyelitis
• 730.30 Periostitis, without mention of osteomyelitis, site unspecified
• 730.31 Periostitis, without mention of osteomyelitis, shoulder region
• 730.32 Periostitis, without mention of osteomyelitis, upper arm
• 730.33 Periostitis, without mention of osteomyelitis, forearm
• 730.34 Periostitis, without mention of osteomyelitis, hand
• 730.35 Periostitis, without mention of osteomyelitis, pelvic region and thigh
• 730.36 Periostitis, without mention of osteomyelitis, lower leg
• 730.37 Periostitis, without mention of osteomyelitis, ankle and foot
• 730.38 Periostitis, without mention of osteomyelitis, other specified sites
• 730.39 Periostitis, without mention of osteomyelitis, multiple sites

ICD-10-CM Codes

• M46.20 Osteomyelitis of vertebra, site unspecified
• M86.10 Other acute osteomyelitis, unspecified site
• M86.119 Other acute osteomyelitis, unspecified shoulder
• M86.129 Other acute osteomyelitis, unspecified humerus
• M86.139 Other acute osteomyelitis, unspecified radius and ulna
• M86.149 Other acute osteomyelitis, unspecified hand
• M86.159 Other acute osteomyelitis, unspecified femur
• M86.169 Other acute osteomyelitis, unspecified tibia and fibula
• M86.179 Other acute osteomyelitis, unspecified ankle and foot
• M86.18 Other acute osteomyelitis, other site
• M86.19 Other acute osteomyelitis, multiple sites
• M86.20 Subacute osteomyelitis, unspecified site
• M86.219 Subacute osteomyelitis, unspecified shoulder
• M86.229 Subacute osteomyelitis, unspecified humerus
• M86.239 Subacute osteomyelitis, unspecified radius and ulna
• M86.249 Subacute osteomyelitis, unspecified hand
• M86.259 Subacute osteomyelitis, unspecified femur
• M86.269 Subacute osteomyelitis, unspecified tibia and fibula
• M86.279 Subacute osteomyelitis, unspecified ankle and foot
• M86.28 Subacute osteomyelitis, other site
• M86.29 Subacute osteomyelitis, multiple sites
• M86.60 Other chronic osteomyelitis, unspecified site
• M86.619 Other chronic osteomyelitis, unspecified shoulder
• M86.629 Other chronic osteomyelitis, unspecified humerus
• M86.639 Other chronic osteomyelitis, unspecified radius and ulna
• M86.642 Other chronic osteomyelitis, left hand
• M86.659 Other chronic osteomyelitis, unspecified thigh
• M86.669 Other chronic osteomyelitis, unspecified tibia and fibula
• M86.679 Other chronic osteomyelitis, unspecified ankle and foot
• M86.68 Other chronic osteomyelitis, other site
• M86.69 Other chronic osteomyelitis, multiple sites
• M86.9 Osteomyelitis, unspecified

Preferred Practice Patterns1

• 4C: Impaired Muscle Performance
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, ROM and Reflex Integrity Association with Spinal Disorders

Key Features

Description

• Bone infection by bacteria or fungi
• Can spread to the bone through a skin ulcer or skin infection
• Can be spread throughout the body by the bloodstream
• Can begin after surgery

Essentials of Diagnosis

• Cultured bone biopsy
• High fever
• Tenderness
• Bone pain
• Local swelling and redness
• Pyogenic osteomyelitis caused by bacterial infection

General Considerations

• Widespread bone infection
• Can occur after dental work
• Higher incidence once spleen is removed
• Can cause the need for amputation
• Can be caused by M kansasii and M fortuitum

Demographics

• Can occur across the lifespan
• In children: in the long bones
• In adults: in the spine, feet

Clinical Findings

Signs and Symptoms

• Pain with movement
• Bone pain at night
• Abscess
• Soft tissue swelling
• Muscle weakness
• Fever
• Malaise
• Chills
• Low back pain
• Swelling in the lower legs
• Bone pain (common in the hips)

Functional Implications

• Causes disability for aging and elderly women and men
• Necrosis of the bone
• Removal of prosthesis or metal implant

Possible Contributing Causes

• Poor dietary habits or eating disorders
• Surgery
• Trauma
• Diabetes
• Sickle cell disease
• Spleen removal
• Poor blood supply
• Compromised immune system

Differential Diagnoses

• Trauma
• Pathologic fracture from neoplasm
• Osteogenesis imperfecta
• Paget's disease
• Tuberculosis
• Multiple myeloma, lymphoma, or metastatic cancer
• Leukemia
• Cushing's syndrome or glucocorticoid administration
• Hyperthyroidism
• Hyperparathyroidism
• History of drug abuse or misuse (alcohol, tobacco)
• Excessive vitamin D/A

Means of Confirmation or Diagnosis

Laboratory Tests

• Blood cultures
• C-reactive protein (CRP)
• Complete blood count (CBC)
• Erythrocyte sedimentation rate (ESR)

Imaging

• X-ray
• Computer assisted tomography (CT)
• Diagnostic ultrasound
• Spinal and pelvic x-rays may demonstrate demineralization, vertebral compression
• Posterior, anterior, and lateral x-rays of affected areas of spine are utilized to identify location and severity of fracture(s)
• MRI of the area of possible infection
• Single-energy x-ray absorptiometry (SXA); quantitative computed tomography (QCT); radiographic absorptiometry (RA)

Diagnostic Procedures

• Needle aspiration

Findings and Interpretation

• Elevated erythrocyte sedimentation rate (ESR)
• Necrosis on x-ray

Treatment

Medication

• Oral and IV antibiotics

Medical Procedures

• Surgical removal of metal appliance
• Removal of infection
• Removal of bone and followed bone graft

Referrals/Admittance

• To endocrinologist
• To general practitioner
• To geriatrician
• To orthopedist for joint assessment
• To rheumatologist
• To pharmacist for bone supplements
• To occupational therapist for ADL training
• To registered dietitian for nutrition education

Impairments

• Physical impairment
  • Chronic or recurrent pain or discomfort
  • Incomplete use of arms or fingers
  • Incomplete use of feet or legs
  • Disfigurement or deformity
  • Disability with reduced use of the limb
• Activity limitations
  • Self care
  • Mobility
  • Physical transport
  • ADLs
  • Socialization and social activities
  • Work loss or employment restrictions
• Quality of Life (QoL) and Health-Related Quality of Life (HQoL)
• Environment and adjustments
  • Assistive devices
  • Home and occupational modifications
  • Family assistance

Tests and Measures

• Fall Risk Assessments: FRAS® score (10-year risk assessment)

Intervention

• Therapeutic exercise
• Progressive weight-bearing exercises, e.g., aquatic therapy
• Patient education and lifestyle changes
• Transcutaneous electric nerve stimulation (TENS)
• Manual therapy/joint mobilization with precaution of bone density
• Soft tissue massage
• Orthotics to decrease flexion forces and reduce pain or dysfunction

Functional Goals

• Adequate control of pain/infection
• Prevention of disability
• Improve strength, flexibility, posture, and balance
• Decrease in risks for falls

Prognosis

• If poor blood supply, outcome less positive with possible need for amputation
• Depends on type of infection
• Depends on general health
• Depends on location and duration of infection

References

Additional Resources

ICD-9-CM Codes

• 733.0 Osteoporosis
• 733.00 Osteoporosis unspecified
• 733.01 Senile osteoporosis
• 733.02 Idiopathic osteoporosis
• 733.03 Disuse osteoporosis
• 733.09 Other osteoporosis

ICD-10-CM Codes

• M81.0 Age-related osteoporosis without current pathological fracture
• M81.8 Other osteoporosis without current pathological fracture

Preferred Practice Patterns1

• 4A: Primary Prevention/Risk Reduction for Skeletal Demineralization
• 4B: Impaired Posture
• 4C: Impaired Muscle Performance
• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, ROM and Reflex Integrity Association with Spinal Disorders
• 4G: Impaired Joint Mobility, Muscle Performance, and ROM Associated With Fracture

Key Features

Description

• Deterioration of bone mass and density with a marked decrease in cortical thickness and cancellous bone trabeculae, leading to increased fragility, deformity and/or fracture
• Osteoporosis is initially categorized by etiology and skeletal localization then further divided into primary and secondary classifications
• Considered both a progressive and chronic disease with primary prevention tied to childhood bone health and reduced risk factors (skeletal and nonskeletal)
• Primary osteoporosis
  • Type 1: postmenopausal osteoporosis
  • Type 2: age-associated (senile) osteoporosis
  • Idiopathic osteoporosis (juvenile, premenopausal women, middle-aged men)
• Secondary osteoporosis (identifiable cause of bone loss)
  • Underlying disease, deficiency, or drug induced

Essentials of Diagnosis2-5

• The operational definition of osteoporosis by the World Health Organization (WHO) is bone density that falls 2.5 standard deviations (SDs) or more below the mean for a young healthy same sex adult; referred to as a T-score of -2.5
• Bone mineral density (BMD) measurements are related to both peak bone mass and bone loss
• Bone densitometry: normal BMD within 1 SD of the mean; T-score at -1.0 and greater
• Bone densitometry: low BMD (referred to as osteopenia) occurs between 1 and 2.5 SDs below the mean; T-score between -1.0 and -2.5
• Increased fracture propensity is due to demineralization secondary to osteoporosis; often occurs at the spine, hips, pelvis, or wrist
• As a comorbid condition, low levels of serum 25-hydroxyvitamin D are noted
• Accurate patient and family medical histories and early recognition through physical examination may lead to improved therapeutic outcomes
• 10-year risk for fracture can be measured through Fracture Risk Assessments (FRAX® score)
• Pharmacotherapy can be measured through changes in laboratory values

General Considerations2-5

• Osteoporosis is considered a major public health problem of the elderly, especially postmenopausal women
• Lifetime osteoporosis-related fracture will be experienced by 50% of all women and 25% of all men over age 50
• Persons with low BMD are at an increased risk for the development of osteoporosis; prevention is critical to reduce incidence
• According to the National Osteoporosis Foundation (NOF), over 10 million Americans have osteoporosis and another 34 million have low BMD, and therefore at increased risks for the development of osteoporosis

Demographics2-5

• Osteoporosis is the cause of approximately 1.5 million fractures per year, with 80% occurring in women and 20% occurring in men
• Recovery to pre-fracture levels of activity and function are estimated to be only 33% of all sustained fractures
• More than 50% of fractures among postmenopausal women, including hip fractures, are secondary to low BMD
• Juvenile osteoporosis occurs in children or young adults of both genders with normal gonadal function; onset typically occurs around age 8 to 14 years and hallmarks include rapid onset of bone pain and/or fracture secondary to trauma
• Type I (Postmenopausal osteoporosis) typically occurs in women 50 to 65 years of age and is characterized by accelerated bone loss (trabecular bone)
• Type II (Age-associated or senile osteoporosis) presents in women and men older than 70 years of age as a result of bone loss associated with the aging process; fractures occur in both cortical and trabecular bone
• Although osteoporosis occurs in all races and ethnicities, increased risk and incidence is documented for whites and Asians; approximately 20% are estimated to have osteoporosis and another 52% to have low BMD
• Approximately 1:3 women and 1:5 men over the age of 50 will experience osteoporotic fractures, with worldwide estimates projected to increase over 200-fold by 2050

Clinical Findings

Signs and Symptoms

• Known clinically as a silent disease, osteoporosis is asymptomatic until fracture occurs
• Vertebral fractures may present as severe back pain or with no pain sensation noted
• Deformations of the vertebral spine and loss of height may present clinically as kyphosis or lordosis

Functional Implications

• One of the leading causes of disability for aging and elderly women and men
• Approximately 20% of women and 30 to 50% of men with hip fractures secondary to osteoporosis die within 1 year of sustained fracture2-4

Possible Contributing Causes

• Age (50 years and greater)
• Gender (female>male)
• Menopause in women; low testosterone levels in men
• History of broken bones or osteoporosis (personal and family)
• Consumption of alcohol or tobacco
• Poor dietary habits or eating disorders
• Lifestyle (sedentary vs. active)
• Use of medications known to increase risk for fracture or bone mineral loss
• Certain comorbid diseases

Differential Diagnoses

• Trauma
• Pathologic fracture from neoplasm
• Osteomalacia or rickets
• Osteogenesis imperfecta
• Inadequate mineralization of existing bone matrix (osteoid) or poor bone quality
• Paget's disease
• Infections, such as tuberculosis
• Fibrous dysplasia
• Peripheral neuropathy
• Repetitive stress fractures
• Multiple myeloma, lymphoma, or metastatic cancer
• Leukemia
• Renal osteodystrophy
• Hormone deficiency (estrogen in women; androgen in men)
• Cushing's syndrome or glucocorticoid administration
• Hyperthyroidism
• Hyperparathyroidism
• History of drug abuse or misuse (alcohol, tobacco)
• Excessive vitamin D/A

Means of Confirmation or Diagnosis

Laboratory Tests

• Blood calcium levels
• 24-hour urine calcium measurement
• Thyroid function test
• Parathyroid hormone levels
• Testosterone level (men)
• 25-hydroxyvitamin D test
• Biochemical markers

Imaging

• X-ray
• Computer assisted tomography (CT)
• Vertebral fracture assessment (VFA)
• Bone scan
• Diagnostic ultrasound (mobile community-based screening)
• Spinal and pelvic x-rays may demonstrate demineralization, vertebral compression
• Posterior, anterior, and lateral x-rays of affected areas of spine are utilized to identify location and severity of fracture(s)
• MRI of the area of possible infection
• Single-energy x-ray absorptiometry (SXA); quantitative computed tomography (QCT); radiographic absorptiometry (RA)

Diagnostic Procedures

• Dual-energy x-ray absorptiometry (DEXA) is used to diagnose and confirm osteoporosis at both the axial and appendicular skeleton; delivers negligible radiation with a high degree of precision
• Qualitative CT delivers more radiation, but is also accurate in conformation

Findings and Interpretation

• One of the leading causes of disability for aging and elderly women and men
• Improved rates of osteoporosis screenings may help identify persons at increased risk for fracture or low BMD, which enables health care providers to educate the patient on healthy lifestyle changes and preventative strategies to decrease the onset of osteopenia and eventual development osteoporosis
• Normal values are usually found for serum parathyroid hormone (PTH), calcium, phosphorus, and alkaline phosphatase

Treatment

Medication

• Pain management
  • NSAIDs
  • Narcotics
  • Topical pain relieving agents
  • Nerve blocking injections
• Stimulation of bone formation
  • Bisphosphonates
  • Vitamin D
• Reduction of bone resorption
  • Bisphosphonates
  • Estrogens
  • Selective estrogen receptor modulators (SERMS)
  • Calcitonin
  • Calcium
  • Human monoclonal antibody (denosumab)
  • Thiazide diuretics
  • Anabolic agents (Teriparatide®) if failed bisphosphonate therapy
  • PTH

Medical Procedures

• Kyphoplasty
• Vertebroplasty
• Surgical (repair of fracture): utilized for pain control

Referrals/Admittance

• To endocrinologist
• To general practitioner
• To geriatrician
• To orthopedist for joint assessment
• To rheumatologist
• To pharmacist for bone supplements
• To occupational therapist for ADL training
• To registered dietitian for nutrition education

Impairments

• Physical impairments
  • Chronic or recurrent pain or discomfort
  • Difficulty gripping or holding objects
  • Incomplete use of arms or fingers
  • Incomplete use of feet or legs
  • Disfigurement or deformity
• Activity limitations
  • Self care
  • Mobility
  • Physical transport
  • ADLs
  • Socialization and social activities
  • Work loss or employment restrictions
• Quality of Life (QoL) and Health-Related Quality of Life (HQoL)
• Environment and adjustments
  • Assistive devices
  • Home and occupational modifications
  • Family assistance

Tests and Measures

• Fall Risk Assessment Tool: FRAT

Intervention

• Therapeutic exercise
• Progressive weight-bearing exercises, e.g., aquatic therapy
• Patient education and lifestyle changes
• Moist heat/cryotherapy
• Ultrasound/phonophoresis/iontophoresis
• Transcutaneous electric nerve stimulation (TENS)
• Cervical and lumbar traction
• Manual therapy/joint mobilization with precaution of bone density
• Soft tissue massage
• Orthotics to decrease flexion forces and reduce pain or dysfunction

Functional Goals

• Reduction in bone loss
• Prevention of future fractures
• Adequate control of pain
• Prevention of disability
• Improves strength, flexibility, posture, and balance
• Decrease in risks for falls

Prognosis

• Osteoporosis is not curable, but has a good prognosis when fracture is decreased through pharmacotherapy and reduction in risk factors
• Progressive osteopenia can be reversed if caught early through screenings and assessment of risk factors, which may lead to a decrease in the incidence of osteoporosis
• Reductions in bone pain may occur within 2 to 4 weeks of therapy, depending on appropriateness of pharmacologic therapy (combinations of pain and antiresorptive agents)
• Approximately 20% of women and 30 to 50% of men with hip fractures secondary to osteoporosis die within 1 year of sustained fracture
• High-risk patients are recommended to receive a DEXA scan every 2 to 3 years (if the baseline is found to be normal); every 1 to 2 years if currently on pharmacotherapy

References

Additional Resources