What are the signs and symptoms of osteoarthritis in an older patient with underlying osteopenia?

Signs and Symptoms of Osteoarthritis

Osteoarthritis presents with usage-related joint pain, short-duration morning stiffness (typically less than 30 minutes), and functional limitation, most commonly affecting patients over age 40 in the knees, hips, hands, and spine. 1, 2

Cardinal Clinical Features

Primary Symptoms

• Pain: Mechanical in nature, worsening with activity and improving with rest; initially presents as self-limiting episodes but progresses to near-constant pain in advanced disease 3, 4
• Morning stiffness: Brief duration (less than 30 minutes), distinguishing it from inflammatory arthritis 1, 2
• Functional limitation: Progressive difficulty with valued activities such as walking, climbing stairs, and performing daily tasks 4, 5

Physical Examination Findings

• Bony enlargement: Palpable osteophytes at affected joints, particularly prominent in knee OA 5
• Coarse crepitus: Audible or palpable grinding sensation with joint movement 4
• Joint line tenderness: Localized pain on palpation 4
• Limited range of motion: Progressive restriction of joint movement 4
• Joint deformity: Occurs in advanced cases 3, 4

Joint-Specific Presentations

Knee Osteoarthritis

• More frequent in women and commonly associated with hand OA and obesity 3
• Bony enlargement is a key diagnostic finding 5
• Weight-bearing views on radiography optimize detection 1

Hip Osteoarthritis

• Inguinal pain radiating to the anterior and medial thigh, often extending to the knee 3
• Pain with internal hip rotation is a highly useful diagnostic finding 5
• Progressive mobility limitation with disease advancement 3

Hand Osteoarthritis

• Distal interphalangeal joints most commonly affected, followed by proximal interphalangeal joints 3
• Heberden nodes (DIP joints) and Bouchard nodes (PIP joints) are characteristic bony enlargements 3
• Trapeziometacarpal joint involvement (rhizarthrosis) causes the greatest functional limitation 3

Spine Osteoarthritis

• Affects facet joints and vertebral bodies 3
• May present with localized back pain and stiffness 3

Advanced Disease Features

In severe cases, patients develop:

• Rest pain: Pain occurring even without joint use 4
• Night pain: Disrupting sleep quality 4
• Significant deformity: Visible joint changes 4
• Marked functional impairment: Substantial impact on quality of life and independence 4, 5

Important Clinical Considerations

Diagnostic Approach

• Clinical diagnosis is sufficient in patients over 40 with usage-related pain, characteristic joint distribution, bony enlargement, and minimal morning stiffness 2
• Imaging is not required for typical presentations 1, 2
• Plain radiography should be ordered only when diagnosis is uncertain, before surgical referral, or when mechanical symptoms suggest alternative pathology 2

Correlation Pitfalls

• Poor correlation exists between radiographic findings and symptom severity 3, 6
• Symptoms should guide management decisions rather than imaging findings alone 1
• Meniscal tears are frequently incidental findings in older patients and should not automatically be attributed to symptoms 7

Context for Patients with Osteopenia

In older patients with underlying osteopenia:

• The same clinical features apply for OA diagnosis 1, 2
• Bone health evaluation is important given fracture risk, with consideration of calcium, vitamin D supplementation, and possible bisphosphonate therapy 8
• Fall prevention strategies should be implemented, as these patients face dual risks from both OA-related functional limitation and reduced bone density 8
• Weight-bearing activity should be encouraged to maintain mobility and bone health despite pain 8