Musculoskeletal

Osteoarthritis

A clinical syndrome of joint pain, stiffness and functional limitation in which tissue remodelling, load, prior injury and low-grade inflammation interact; treatment is guided by symptoms and function, with exercise and weight management as the core interventions.

In a nutshell

Diagnose osteoarthritis clinically in people aged 45 or over with activity-related pain and no or brief morning stiffness. Core treatment for everyone is tailored therapeutic exercise and, when appropriate, weight management. Add a topical NSAID for knee osteoarthritis, consider an oral NSAID with gastroprotection after risk assessment, and refer for joint replacement when symptoms substantially impair quality of life despite non-surgical care.

Classic presentation

A person aged 45 or over has gradual or fluctuating knee, hip or hand pain related to activity, morning stiffness lasting no more than 30 minutes, bony enlargement or crepitus, and functional difficulty without systemic illness.

Key points

NICE clinical diagnosis: age 45 or over, activity-related joint pain and no morning stiffness or stiffness lasting no longer than 30 minutes.
Do not routinely image typical osteoarthritis or use imaging for follow-up; investigate atypical features or a possible alternative diagnosis.
The core treatment for everyone is tailored therapeutic exercise, with education and behaviour-change support when useful.
For overweight or obesity, support a chosen weight-loss goal; any loss may help and 10% is likely more beneficial than 5%.
Offer topical NSAID for knee osteoarthritis; consider an oral NSAID only after gastrointestinal, renal, liver, cardiovascular, pregnancy and interaction risk assessment, with gastroprotection.
Do not routinely offer paracetamol or weak opioids, and do not offer glucosamine or strong opioids.
Intra-articular corticosteroid injections provide short-term relief of around 2 to 10 weeks; hyaluronan injections are not offered.
Refer for hip, knee or shoulder replacement when symptoms substantially affect quality of life and non-surgical management is ineffective or unsuitable; do not use a numerical severity score or BMI as an exclusion rule.

First-line investigation

Clinical diagnosis using the NICE age, activity-related pain and morning-stiffness criteria; investigate rather than image routinely only when atypical features suggest another diagnosis.

Management

Confirm the pattern and screen for red flags

Use the clinical criteria in a person aged 45 or over with activity-related pain and no or brief morning stiffness; check for atypical features suggesting another diagnosis.^1,4
Do not routinely image a typical presentation; use targeted tests or urgent pathways for hot swelling, trauma, rapid worsening, systemic illness or concern about infection or malignancy.^1,3

Start the core treatment package

Offer tailored therapeutic exercise combining local strengthening and general aerobic fitness, explaining that consistency matters even if pain briefly increases at first.^1,5
For overweight or obesity, support a chosen weight-loss goal and explain that any loss can help, with 10% likely more beneficial than 5%.^1,3

Add function-focused support and safe analgesia

Consider walking aids for lower-limb disease and selected manual therapy only alongside exercise; use braces or supports selectively, not routinely.¹
If medication is needed, offer a topical NSAID for knee osteoarthritis and consider one for other joints; use the lowest effective dose for the shortest time.^1,6

Escalate medication or surgery by need

If topical treatment is unsuitable or ineffective, consider an oral NSAID after individual toxicity and interaction assessment, with gastroprotection; consider intra-articular corticosteroid for short-term relief when appropriate.^1,9,7
Refer for joint replacement when symptoms substantially impair quality of life despite non-surgical management; do not exclude on age, comorbidity, smoking or BMI alone.^1,4

Review function and safety-net

Use patient-initiated follow-up for most people, with planned review when treatment monitoring, severe functional limitation, occupation, access needs or multimorbidity make it necessary.¹
Explain that non-surgical management is symptom and function led; seek review if the agreed plan is not working or if new red flags such as hot swelling, systemic symptoms or rapid deterioration appear.^1,3

Exam traps

A hot, red, acutely swollen joint is not routine osteoarthritis: consider septic arthritis or crystal arthritis urgently.
Morning stiffness over 30 minutes, systemic symptoms or rapid progression should prompt consideration of inflammatory, infective, malignant or other diagnoses.
Radiographic severity does not determine symptom severity and routine imaging is not needed for a typical diagnosis or follow-up.
Exercise is core treatment even if pain briefly increases at the start; medication should support exercise rather than replace it.
Do not routinely use paracetamol, weak opioids, glucosamine, strong opioids or hyaluronan injections under current NICE NG226.

Illustrations

Radiographic hallmarks of osteoarthritisRadiograph of a joint showing joint-space narrowing, subchondral sclerosis and marginal osteophytes, the structural features commonly associated with osteoarthritis.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Heberden's nodes in osteoarthritisBony swellings at the distal interphalangeal joints (Heberden's nodes) in hand osteoarthritis; equivalent proximal interphalangeal swellings are termed Bouchard's nodes.Drahreg01, Wikimedia Commons · CC-BY-SA-3.0

Cartilage degeneration and bone remodellingDiagram illustrating cartilage thinning, subchondral bone remodelling and osteophyte formation in osteoarthritis.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.