Osteoarthritis

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Understanding this condition

What osteoarthritis is

OA is a whole-joint disease characterised by cartilage degradation, subchondral bone remodelling, osteophyte formation, and synovial inflammation, producing pain, stiffness, swelling, and loss of function. It is the most common form of arthritis and a leading cause of disability in older adults, most commonly affecting the knees, hips, and hands.^[1]

Common symptoms

Activity-related joint pain, short-lived (usually under 30 minutes) morning or inactivity stiffness, reduced range of motion, crepitus, bony enlargement (for example Heberden and Bouchard nodes in hand OA), and functional limitation. Hip and knee OA commonly impair weight-bearing activities and gait.^[1]

Who gets it

OA affects an estimated 302 million people worldwide and is a leading cause of disability in older adults. Risk factors include increasing age, obesity (notably for knee and hip OA), prior joint injury, occupational or mechanical joint loading, malalignment, and genetic predisposition.^[1]

How it is diagnosed

OA is largely a clinical diagnosis from history and examination. Radiographs can support the diagnosis and grade structural severity but correlate imperfectly with symptoms and are not always required. No laboratory test is diagnostic; bloods are used chiefly to exclude inflammatory or crystal arthritis. For hand OA, the 2023 EULAR classification criteria (overall hand, interphalangeal, and thumb base sets) are transcribed in the classification callout for research use; hip and knee OA classification and radiographic grading remain described in kind.^{[1, 4]}

What to expect over time

OA is typically slowly progressive over years, with a variable course. It is managed rather than cured; most patients achieve meaningful symptom and function control with conservative measures. For end-stage disease refractory to non-surgical management, joint arthroplasty is effective. Structural progression and symptom burden are not tightly coupled.^[1]

Living with and treating it

The goals of treatment

Goals are pain reduction, preservation of function and mobility, and maintenance of independence, individualised by affected joint and patient priorities. Management is typically multimodal, combining core non-pharmacologic measures with pharmacologic and, where indicated, procedural options. There is no numeric treat-to-target composite in OA.^[1]

Treatment options

Core (all patients), concordant across ACR 2019 (strong), OARSI 2019 (Core Treatments), and EULAR 2023 (1a/A): exercise, education and self-management, and weight management. Devices: cane, tibiofemoral knee brace, first-CMC orthosis (ACR strong); walking aids, footwear, and assistive devices (EULAR 1b/A). Pharmacologic: topical NSAIDs (ACR strong knee; OARSI favoured in comorbid patients), oral NSAIDs (ACR strong; OARSI comorbidity-stratified, avoid in cardiovascular comorbidity and frailty, COX-2 or NSAID-plus-PPI for GI risk, lowest dose shortest duration), intra-articular glucocorticoids (ACR strong knee/hip; OARSI conditional short-term); acetaminophen, duloxetine, topical capsaicin (knee) conditional. Flagged divergence: intra-articular hyaluronic acid (ACR against; OARSI conditionally for knee). Recommended against (ACR): glucosamine, chondroitin for knee/hip, PRP and stem cell injections, hyaluronic acid in the hip, TNFi and IL-1 antagonists, methotrexate, hydroxychloroquine, bisphosphonates. Joint arthroplasty for end-stage disease is outside all three non-surgical guidelines.^{[1, 2, 3]}

Monitoring and check-ups

Routine laboratory or imaging surveillance is not required; follow-up is clinical, tracking pain, function, and treatment response. Monitor for NSAID-related gastrointestinal, renal, and cardiovascular risk, particularly with long-term or higher-dose use and in older or comorbid patients. Agent-specific monitoring is on the medication guides.^[1]

Flares and painful spells

Symptom flares are common and often activity-related. Management includes activity modification (not immobilisation), short courses of topical or oral NSAIDs, thermal modalities, and, for knee or hip, intra-articular glucocorticoid injection. Acute monoarticular hot, swollen joints warrant evaluation for septic or crystal arthritis rather than assuming an OA flare.^[1]

Living well with OA

Self-management centres on sustained physical activity, weight management, appropriate assistive devices and orthoses, activity pacing, and structured self-efficacy and self-management programs, all strongly recommended. Tai chi is strongly recommended for knee and hip OA. Physiotherapy and occupational therapy individualise exercise, joint protection, and device selection; the practice's exercise-medicine and injection pathways support this.^[1]

Related problems to consider

OA frequently coexists with obesity, cardiovascular disease, diabetes, and depression, which influence pharmacologic choices (for example NSAID cautions in cardiorenal and gastrointestinal risk). Muscle weakness, deconditioning, and falls risk are common and are addressed by exercise. Comorbidity-aware, individualised selection is emphasised.^[1]

What to expect at your appointment

Initial assessment: pattern and burden of joint involvement, functional impact, examination, and selective imaging. Shared plan anchored on core non-pharmacologic measures, escalating to pharmacologic and procedural options as needed. Care is delivered through a team that may include rheumatology or primary care, physiotherapy and occupational therapy, the intra-articular injection service, and orthopaedic surgery for arthroplasty candidates, presented non-exclusively.^[1]

Overall hand OA · classify if score 9 or more of 15

Interphalangeal OA · classify if score 8 or more of 15

Thumb base OA · classify if score 8 or more of 15

Transcribed and verified from the 2023 EULAR classification criteria for hand OA (Haugen et al, Ann Rheum Dis 2024;83:1428-1435, Tables 1 to 3). These are classification criteria for research and clinical trials, explicitly not a diagnostic tool for individual patient care. Hip and knee OA classification is described in kind only, pending primary sources.

Treatment ladder

1. 1

   Foundation for everyone

   Core, recommended for all and concordant across ACR 2019 (strong), OARSI 2019 (Core Treatments), and EULAR 2023 (1a/A): exercise (strength, aerobic, flexibility, or neuromotor including tai chi and yoga), education and self-management (EULAR's highest implementation priority), and weight management (with support to achieve and maintain loss; OARSI cautions against weight loss in frailty). Devices per joint: cane, tibiofemoral knee brace, first-CMC orthosis (ACR strong); walking aids, footwear, assistive devices, and home or work adaptations (EULAR 1b/A). Consider behaviour change techniques to support lifestyle change (EULAR 1b/A).

   Concordant across ACR 2019, OARSI 2019, and EULAR 2023. No drug guide applies at this step.

2. 2

   Topical first for pain

   Topical NSAIDs are strongly recommended for knee OA and conditionally for hand OA, and are an appropriate first pharmacologic option, particularly with limited joint involvement. Topical capsaicin is conditional for knee OA (recommended against for hand OA).

   Verified from ACR/AF 2019.

3. 3

   Oral medicines and joint injections

   Oral NSAIDs are strongly recommended (lowest effective dose, shortest duration, comorbidity-aware). Intra-articular glucocorticoid injections are strongly recommended for knee and hip (hip injection image-guided). Conditional add-ons: acetaminophen (limited, short-term), duloxetine, tramadol (over non-tramadol opioids; opioids generally discouraged).

   Verified from ACR/AF 2019. Dosing on the NSAID and glucocorticoid guides.

4. 4

   Severe, end-stage joints: surgery

   For end-stage disease refractory to optimised non-surgical management, refer for orthopaedic surgical evaluation (joint arthroplasty), guided by symptom burden, function, and shared decision-making. Surgical management is outside the scope of the 2019 ACR/AF non-surgical guideline.

   Consensus and outside the ACR guideline scope.

Guideline recommendations

Key points

Medication guides

Plain-language guides to the medicines used for this condition. Each has a patient and a clinician view.

• NSAIDs
• Glucocorticoids

References

1. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2):220-233. doi:10.1002/art.41142 https://doi.org/10.1002/art.41142
2. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27:1578-1589. doi:10.1016/j.joca.2019.06.011 https://doi.org/10.1016/j.joca.2019.06.011
3. Moseng T, Vliet Vlieland TPM, Battista S, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update. Ann Rheum Dis. 2024;83(6):730-740. doi:10.1136/ard-2023-225041 https://doi.org/10.1136/ard-2023-225041
4. Haugen IK, Felson DT, Abhishek A, et al. 2023 EULAR classification criteria for hand osteoarthritis. Ann Rheum Dis. 2024;83:1428-1435. doi:10.1136/ard-2023-225073 https://doi.org/10.1136/ard-2023-225073