Osteoarthritis in Young People

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Original Editor ­ Anna Jansma

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Definition / Description
Osteoarthritis intion young people has two components. Osteoarthritis, which means inflammation (itis) of the joint (arthro) and bones (osteo). The second component, namely young people is harder to define, because young is a relative conception. It is considered that  young people in combination with osteoarthritis means that patients are not older than 55 years of age. 1,2,3

Epidemiology / Etiology
There are two main classifications of OA, primary and secondary.
Primary osteoarthritis is the form where you don't know what could have triggered the disease, inferring history or clinical/radiographic examination.
Secondary osteoarthritis can be caused by trauma, metabolic disease, congenital malformations, premature menopause, etc. Sometimes, it can happen that a patient is suffering from secondary osteoarthritis before the age of 40.
The etiology of osteoarthritis is multifactorial. The most common joint site for OA is the knee. The ankle was the fourth most common site for OA after the knee, hand and hip. Ankle OA is most often a result of trauma and is associated with chronic ankle instability.4,5

Developmental dysplasia of the hip (DDH) is one of the most common causes of secondary osteoarthritis in young adults2

Genetic factors also contribute to the pathogenesis of osteoarthritis. More than 50% of all cases of OA result from a hereditary disposition. The interleukin-1 gene cluster, a key regulator in several chronic disease processes, conferred a twofold risk of OA in those with a specific genotype. These findings support that OA is not just a disease of the older people.5
The development of OA is determined by risk factors including:

- Biomechanical factors
- Malalignment
- Joint laxity
- Muscle weakness
   - Reduced proprioception
- Overweight

Obesity in children and adolescents has been linked to musculoskeletal disorders.
Excess force or joint loading may lead to osteoarthritis in overweight teens.10

- Metabolic, and inflammatory processes
- Elevated levels of C-reactive protein
- Elevated levels of hyaluronic acid
- Atrophy of the bone

- Other risk factors
  - Age
- Genetic predisposition
- Psychological and socio-economical factors
- Sedentary lifestyle
- Comorbidity (heart/lung, diabetes, articular disorders, poor vision, …)
- Female gender
- African American race 
- Sports participation / occupation

High-impact, high-intensity, and repetitive athletics have a strong association with OA.
Power and team sports such as soccer, basketball, track and field, boxing, wrestling and
weight lifting have been linked with the development of early-onset OA.4

These risk factors may lead to the development of premature osteoarthritis in a genetically susceptible person.4,5

Characteristics / Clinical Presentation
Hip pain in young adults often is characterized by nonspecific symptoms, mainly local:
- Pain
- Loss in ROM
- Crepitation
- Stiffness / total blocking
- Morphological deformities

Pain is more likely caused by congenital hip dysplasia, athletic injuries, trauma, spondyloarthropathy, and by conditions that first appear during this stage of life, such as rheumatoid arthritis, osteoarthritis, intravenous drug use, alcoholism, or corticosteroid use.6
Furthermore the more common characteristics of generalized osteoarthritis can be found in the young adult, mainly in the Hip and Knee.
Diagnostic procedures
The diagnostic procedures for young people suffering from osteoarthritis is not different from people who are older. There are guidelines for diagnosis for different types of osteoarthritis, like hip andknee osteoarthritis.11 Main focus in both (and thus also in young patients) is the evolution of pain. The diagnosis itself is confirmed by radiography.
 
Outcome Measures
Oftenly used tests to quantify “body function, activity and participation” are:
- Patient-specific complaints (PSC) questionnaire11
- Timed Up and Go (TUG) test11

In young subjects however, some of these tests should be adjusted for the age:
- Difficult terminology should be avoided in questionnaires.
- Score outcomes should be compared with subjects of the same age.
- Exercise difficulty should be appropriate for the subject.

Examination
The examination should evaluate the patient’s functional performance.11 The examiner should:
- Inspect posture and movement in daily activities, with special attention for the back, pelvis, ankles and feet. If walking aids are used, the upper extremity must also be inspected.
- Palpate for presence of swelling or raised temperature and muscle tone.
- Do active/passive functional testing to assess muscle strength, mobility, balance, coordination and stability.

Medical Management
For patients with osteoarthritis there  is variety of options for surgery. For young patient especially there is a special techniques which  focusses on the level of activity after surgery. Autologous Chondrocyte Implantation is used for joint preservation. The chondrocytes are said to produce hyaline-like repair tissue. Early reports suggests that this procedure reduces symptoms and increases functions.7  Furthermore, more and more young patients are undergoing a total arthroplasty of hip or knee1,3

Physical Therapy Management
Physical therapy for young people suffering from osteoarthritis is still a novelty.  There are indications that physical therapy for hip osteoarthritis consisting of muscle strengthening, muscle stretching and neuromuscular control exercises have positive results8
This is in agreement with another finding that says that the following physiotherapy techniques are valuable therapeutic adjuvants for the treatment of osteoarthritic symptoms. 9

- Muscle relaxing action
- Hot or cold application on osteoarthritic joint

- Traction
- (Massage)
- Hydrotherapy and Spa Treatment

- Range of motion exercises
- Strengthening exercises
- Stretching exercises

- Proprioceptive reeducation
- TENS (may be beneficial to patient with knee OA)12
Following KNGF-guidelines massage has lost its place to exercises, which should be the cornerstones in all therapy for OA.

Differential Diagnosis
The goal of the differential diagnosis of hip pain is to identify the location and underlying mechanism of the pain. An accurate history and physical examination may indicate whether the pain is intra-articular, extra-articular, or referred from more distal locations. Additional laboratory or imaging tests may be necessary to determine the exact cause. Fractures, infection, and ischemic necrosis should be ruled out early because they require immediate treatment to prevent damage to the joint.6

Prevention
The prevention of development of osteoarthritis in the adolescent can be achieved by reducing risk factors. Physiotherapists can promote the maintenance of a healthy weight, low-impact activities, giving exercices to improve joint stability to prevent joint injuries.4 They can have influence by preventing further progression or complications of a disorder and improving the patient’s self-efficacy.11
In case of malalignments (like: leg-length discrepancy, varus/valgus, …)  young patients should be referred to a podiatrist for insoles to prevent the development of OA (in the hip or knee) at an older age.

Clinical Bottom Line

Resources
Royal Dutch Society for Physical Therapy (2010). KNGF Guideline for Physical Therapy in patients with osteoarthritis of the hip and knee. De Fysiotherapeut, V120, 1

References
1W-Dahl A., Robertsson O., Lidgren L. Surgery for knee osteoarthritis in younger patients: A Swedish Register Study. (2010) Acta Orthopaedica, 81, 161-164 (B)
2Okano K. et al. Joint congruency in abduction before surgery as an indication for rotational acetabular osteotomy in early hip osteoarthritis. (2010) International Orthopaedics, 34, 27-32 (B)
3Nieuwenhuijse MJ. et al. 5-year clinical and radiostereometric analysis (RSA) followup of 39 CUT femoral neck total hip prostheses in young osteoarthritis patients. (2012) Acta Orthopaedica, 83, 334-341. (B)
4Nicholson S. et al. Reducing Premature Osteoarthritis in the Adolescent Through Appropriate Screening. (2009) Journal of Pediatric Nursing, 24, 69-74 (B)
5Yvonne M. et al. FUTURE SHOCK: Youth sports and osteoarthritis risk (2011) Lower extremity revieuw (ler). October  (B)
6 Troum OM., Crues JV. The Young Adult With Hip Pain: Diagnosis and Medical Treatment (2004) Division of Rheumatology, University of Southern California, 9-17 (C)
7Minas T et al. Autologous Chondrocyte Implantation for Joint Preservation in Patients with Early Osteoarthritis.(2010) Clinical Orthopaedics and Related Research, 468, 147-157 (B)
8 Wright AA. et al. Predictors of Response to Physical Therapy Intervention in Patients With Primary Hip Osteoarthritis. (2011) Physical Therapy, 91, 510-524. (A2)
9 Reginster et al. 'Osteoarthritis. Clinical and Experimental Aspects'. (1999) Springer, Verlag Berlin, Heiderlberg, 454 – 469 (A1)
10Sanjeev Sabharwarl MD., Michael   Z. Impact of Obesity on Orthopaedics (2012) The Journal Of Bone And Joint Surgery, 94, 1045-1052 (A1)
11 Royal Dutch Society for Physical Therapy (2010). KNGF Guideline for Physical Therapy in patients with osteoarthritis of the hip and knee. De Fysiotherapeut, V120, 1 (D)
12 Mascarin NC. et al. Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis. (2012) BMC Musculoskeletal Disorders, 13, 182 (A2)