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Standardized Examinations of the Knee and Hip Help Catch Osteoarthritis Early

Detecting OA before it shows up on X-rays

In the late 1990s when Dr. Jolanda Cibere was recruiting patients for a study of osteoarthritis (OA), she suspected that many people who applied had the disease. Unfortunately, they did not qualify for the study. Why? Because signs of their disease did not yet show up on X-rays. They had pain, stiffness and other symptoms, but at the time the gold standard for the diagnosis of OA was what could be seen on X-rays.

Osteoarthritis is a degenerative disease of the cartilage in the joints and is the most common form of arthritis. It can be a long-term consequence of mechanical injury to the joint. Other risk factors for OA include old age, heredity and obesity, and it can affect any joint in the body. Joints in the hips, knees, spine, feet and hands are all vulnerable. An estimated 10% of Canadians live with symptomatic OA,¹ and the disease is the leading cause of knee replacements.²

The Evidence: Earlier Diagnosis

The gold standard for the diagnosis of OA was what could be seen on X-rays. A new and proven methodology standardizing examination of the knee detects the disease much earlier – before it even shows up on X-rays. Dr. Cibere's research found 49% of patients had early OA that did not show up on X-rays.

While osteoarthritis is a condition that takes years to develop, diagnosis tends to be made after symptoms occur. Traditionally, diagnosis is confirmed well after physical changes in the joints can be seen on X-rays.

"If it were diagnosed earlier, strategies and treatments could be put in place that would potentially slow the progression of the disease, reduce disability, and lower long-term costs associated with the disease," said Dr. Cibere, a rheumatologist and assistant professor of medicine at the University of British Columbia. A 2005 survey in Ontario of over 1,200 people with hip and knee OA reports an average annual cost of $12,200, mainly in time lost from work and for unpaid, informal caregivers.³

Back in the 1990s when Dr. Cibere was working on that first study, she realized a lot of patients could get help earlier if relying on X-ray evidence was not the only means of defining the disease. And, that there would be value in studying patients early on to learn more about how the disease progresses, including why it progresses more quickly in some and takes its time in others.

"I became interested in early-stage disease at that point," she said.

There was one problem: there was no standardized way of detecting the disease early. In fact, there were over 40 existing physical signs and techniques available to rheumatologists and researchers to help assess the knee, but there were questions about just how accurate and reliable these tests were and it was unclear which tests were most useful to diagnose the disease earlier.

The tools and techniques for examining knees for OA varied between centres and practitioners, and little work had been done to assess how well they worked. Dr. Cibere decided it was time to learn more about early-stage disease, find ways to better detect it, and see if it was possible to develop standardized testing with good scientific evidence behind it.

"The first thing I had to do is standardize how we examine the knee," she said. This was not an easy task, but she launched a study to assess those forty-odd physical signs and techniques, and published her findings in 2004.⁴ The study highlighted which of the existing tests were the most helpful, and she came up with a process for using them in a standardized fashion. It also showed that a standardized examination for detecting the disease early on works.

"What we can say for sure is that certain findings from knee examination are highly predictive of early-stage disease," Dr. Cibere said. Since then, the standardized knee exam has become a valuable tool and is used around the world.

Standardized Examination Used Internationally

One researcher who is using the standardized protocol is Gayle Lester, PhD, project officer for the US National Institutes of Health Osteoarthritis Initiative (NIH-OAI). The NIH-OAI is a long-term, prospective, observational study of knee osteoarthritis which began in 2002. Over 5,000 people from eight countries who are at risk of developing OA are enrolled, and it is the largest project of its kind in the world. The researchers use the standardized knee examination as the key tool for assessing knee health.

If the standardized knee exam weren't around, "we would've used something less complete. What this has helped us do is use one exam protocol that covers all aspects," Dr. Lester said. The examination is relatively quick to perform, and can be carried out by nurses and clinical staff who have undergone training.

Michael Nevitt, PhD, principal investigator for the NIH-OAI, adds that, in general, existing exams "are difficult to standardize because they are based on the perceptions of individual clinicians on whether a physical finding is present. Dr. Cibere's advice was instrumental in helping us decide which of the usual joint exams could be adequately standardized," he said. Dr. Nevitt is an adjunct professor of epidemiology and biostatistics at the University of California, San Francisco.

Researchers in the United Kingdom are also using the standardized examination. In 2008, Dr. Cibere was contacted by Lyndsey Goulston, a rheumatology research physiotherapist at the Southampton General Hospital. Goulston was interested in the possibility of adapting the standardized knee exam for a large, long-term population study.

Called the Chingford Study, the project is a prospective population-based longitudinal study that is following a cohort of women over a 20-year period and tracking trends in health. As part of the study, participants are seen annually to determine risk factors for osteoarthritis and osteoporosis. The Chingford Study began in 1989 and examination protocols for the knee were needed for a 20-year follow-up.

"The 20-year follow-up would involve myself performing physical knee and hip examinations on each of the remaining women in the cohort. I asked Dr. Cibere if she would share her standard operating protocols for the knee and hip examinations ... She very kindly obliged and emailed me descriptions of the knee and hip examinations used in her papers," Goulston said. The Chingford group is using the examination strictly as a research tool, and Dr. Cibere helped adapt it so non-physicians could perform the exams.

Standardized Hip Examination

Dr. Cibere's research into OA doesn't stop there. She went beyond the knees and developed a standardized hip examination for determining early OA in the hip joints. This work was published in 2008 and is also being used as a research tool.⁵ In fact, the Chingford Study research group is also using the standardized hip examination.

In addition, Dr. Cibere has been involved in studies of pain related to OA, population patterns and trends of OA, knee mechanics, and more. Plus, beyond the realm of research labs, Dr. Cibere's group has developed short educational videos available to health care workers. They demonstrate how to perform standardized knee examinations.

But there are always more steps in research. "We don't just want to diagnose people earlier, we want to be able to figure out who is at risk of getting worse, who is at risk of progressing," she said. Standardized testing is helping researchers find answers to these questions.

1. Arthritis in Canada – An Ongoing Challenge.
2. Number of Hip and Knee Replacements, by Jurisdiction, Canada, 2007–2008.
3. The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition. Rheumatology. 2005; l44: 1531–7.
4. Reliability of the knee examination in osteoarthritis: effect of standardization. Arthritis Rheum. 2004; Feb; 50(2): 458–68.
5. Reliability of the hip examination in osteoarthritis: effect of standardization. Arthritis Rheum. 2008 Mar 15; 59(3):373–81.