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.
Definition
Osteoarthritis is a common whole-joint condition causing pain, stiffness and functional limitation through interacting structural change, mechanical loading, tissue remodelling and low-grade inflammation.
Epidemiology
Osteoarthritis is common from midlife onwards and often affects the knee, hip, hands, feet or spine. Risk is influenced by age, sex, body weight, previous injury or surgery, occupation, joint loading and genetic factors; symptoms and progression vary between people.
Pathophysiology
Cartilage, subchondral bone, synovium, capsule, ligaments and muscle undergo interacting changes. Mechanical loading, previous injury and metabolic factors can lead to cartilage loss, bone remodelling, osteophytes, synovial irritation and reduced muscle support. These changes produce variable pain, stiffness and loss of function rather than a simple radiograph-to-symptom relationship.
First principles
Osteoarthritis is an active whole-joint disorder, not just worn cartilage
Osteoarthritis involves cartilage, subchondral bone, synovium, capsule, ligaments and muscle. Age, joint loading, previous injury, alignment and body weight can shift tissue repair and remodelling towards pain and loss of function. The process is not simply inevitable wear, and radiographic change does not reliably determine symptom severity.1,2,3
The diagnosis is usually clinical
In a person aged 45 or over with activity-related joint pain and no morning joint-related stiffness or stiffness lasting no longer than 30 minutes, NICE recommends clinical diagnosis without imaging. Imaging is reserved for atypical features or concern about an alternative or additional diagnosis.1,4
Symptoms and imaging do not have to match
Joint-space narrowing, osteophytes, subchondral sclerosis and cysts reflect structural remodelling, but management should be guided by pain, function and the person's goals rather than an X-ray score. Flares and variable symptoms are common, and routine imaging is not useful for follow-up or non-surgical management.1,4
Exercise and weight management change function, not just pain scores
Therapeutic exercise is a core treatment for everyone with osteoarthritis and should be tailored to local strength, general fitness, function and preference. Pain can increase when exercise begins, but consistent adherence improves pain, function and quality of life. For people living with overweight or obesity, any weight loss is likely to help, with 10% generally more beneficial than 5%.1,5
Medicines support activity and have to be risk-balanced
Use medicines alongside non-pharmacological treatment, at the lowest effective dose for the shortest possible time. NICE recommends a topical NSAID first for knee osteoarthritis, consideration for other joints, and an oral NSAID with gastroprotection when topical treatment is unsuitable or ineffective; renal, gastrointestinal, liver, cardiovascular, pregnancy and medication risks determine whether an NSAID is appropriate.1,6,7
Presentation
Gradual or fluctuating joint pain, stiffness and functional limitation, usually worse with activity, in a pattern consistent with osteoarthritis; diagnose clinically when the typical age and symptom criteria are met and look for atypical features.1,4,3
Cardinal features
- Activity-related joint pain with variable flares
- Morning joint-related stiffness absent or lasting no longer than 30 minutes
- Bony enlargement, crepitus or restricted movement
- Knee, hip, hand, foot or other joint symptoms with a mechanical pattern
- Functional difficulty with walking, stairs, grip, work or activities
Red flags
- Hot, red, acutely swollen joint or systemic illness suggesting infection or crystal arthritis
- Prolonged morning stiffness, widespread soft-tissue swelling or other inflammatory features
- Recent significant trauma or suspected fracture
- Rapid worsening, marked deformity, unexplained night or rest pain, fever or weight loss
- Neurological deficit, referred pain or features suggesting another structural or malignant cause
Investigations
Clinical diagnosis
Diagnose clinically without imaging when the person is aged 45 or over, has activity-related joint pain and has no morning stiffness or stiffness lasting no longer than 30 minutes.
Expected finding: A typical symptom pattern with expected examination findings and no red flags or features suggesting an alternative diagnosis.
1Plain radiography when the presentation is atypical or surgery is being considered
Do not routinely image a typical presentation. Consider targeted radiography for recent trauma, prolonged morning stiffness, rapid worsening or deformity, a hot swollen joint, concern about infection or malignancy, or when imaging is part of the surgical assessment.
Expected finding: Joint-space narrowing, osteophytes, subchondral sclerosis or cysts may support osteoarthritis, but structural severity does not determine symptoms or treatment by itself.
1,4Targeted tests for an alternative diagnosis
Do not order routine blood tests for typical osteoarthritis. If the history or examination suggests inflammatory arthritis, infection, crystal disease, fracture or another diagnosis, investigate that clinical question with appropriate blood tests, aspiration or imaging.
Expected finding: Results should either support the alternative diagnosis or reduce its likelihood; normal tests do not override a concerning clinical presentation.
1,3Functional and symptom assessment
Assess pain, stiffness, sleep, mobility, work, activities, mood, falls risk and the person's goals. Symptoms and physical function guide treatment, follow-up and referral more usefully than a radiographic severity score.
Expected finding: A baseline functional impact and shared treatment goal that can be revisited after exercise, weight management or analgesic changes.
1,8Medicine-safety assessment before an NSAID
Review renal, gastrointestinal, liver and cardiovascular risk, age, pregnancy, anticoagulants, antiplatelets, antihypertensives and other medicines before prescribing topical or oral NSAIDs. Use the BNF and local formulary for medicine-specific choices.
Expected finding: The assessment may favour topical treatment, an oral NSAID with gastroprotection, another analgesic strategy or non-pharmacological management alone.
1,6,9,7Management
| Step | Detail | Source |
|---|---|---|
| Explain the diagnosis and set a functional goal | Explain that osteoarthritis is usually diagnosed clinically, symptoms can fluctuate and management is guided by pain, function and the person's goals rather than routine imaging. Give accessible information about exercise, weight management, symptom control and when to seek review.1,8 | NICE NG226: diagnosis, information and support |
| Offer tailored therapeutic exercise to everyone | Offer a plan combining local muscle strengthening and general aerobic fitness, adapted to ability, joint involvement and preference. Explain that pain may increase initially and that regular, consistent adherence is what improves pain, function and quality of life. Consider supervised sessions or an education/behaviour-change package.1,5 | NICE NG226: therapeutic exercise |
| Offer weight-management support when appropriate | For people living with overweight or obesity, support a personally chosen weight-loss goal and explain that any amount is likely to help quality of life, function and pain; 10% loss is likely to be more beneficial than 5%. Avoid presenting weight loss as a prerequisite for exercise, referral or respect.1,3 | NICE NG226: weight management |
| Add selected physical or assistive interventions | Consider a walking aid for lower-limb osteoarthritis. Only consider manual therapy for hip or knee osteoarthritis alongside exercise. Do not routinely offer insoles, braces, tape, splints or supports unless there is instability or abnormal loading, exercise alone is ineffective or unsuitable, and the device is likely to improve movement and function. NICE advises against acupuncture, dry needling and listed electrotherapies.1 | NICE NG226: manual therapy, devices, acupuncture and electrotherapy |
| Use a topical NSAID when medication is needed | Use pharmacological treatment alongside exercise and weight management, at the lowest effective dose for the shortest possible time. Offer a topical NSAID for knee osteoarthritis and consider it for other joints; check product instructions, skin precautions and the BNF before prescribing.1,6 | NICE NG226; BNF diclofenac sodium |
| Use an oral NSAID only after individual risk assessment | If topical treatment is ineffective or unsuitable, consider an oral NSAID after assessing gastrointestinal, renal, liver and cardiovascular toxicity, age, pregnancy, current medicines and comorbidity. Offer gastroprotection such as a proton pump inhibitor while an oral NSAID is taken, and review whether it remains needed.1,9,7 | NICE NG226; BNF ibuprofen and naproxen |
| Avoid low-value or high-risk routine analgesia | Do not routinely offer paracetamol or weak opioids; reserve them for infrequent, short-term relief only when other pharmacological options are contraindicated, not tolerated or ineffective, and explain the limited evidence for paracetamol. Do not offer glucosamine or strong opioids because benefit is not established or risks outweigh benefits.1,4 | NICE NG226: pharmacological management |
| Consider a short-term intra-articular corticosteroid injection | Consider an intra-articular corticosteroid injection when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise. Explain that relief is short term, around 2 to 10 weeks. Do not offer intra-articular hyaluronan injections.1 | NICE NG226: intra-articular injections |
| Use patient-initiated or needs-based follow-up | Consider patient-initiated follow-up for most people. Plan review when medicines or interventions need monitoring, the person may struggle to seek help, occupation or activity requires support, or symptoms and functional limitations are severe. Do not routinely repeat imaging for follow-up or non-surgical management.1,4 | NICE NG226: follow-up and review |
| Refer for joint replacement when quality of life is substantially affected | Consider referral for hip, knee or shoulder replacement when pain, stiffness, reduced function or progressive deformity substantially affects quality of life and non-surgical management is ineffective or unsuitable. Use clinical assessment rather than a numerical severity score, and do not exclude referral because of age, sex or gender, smoking, comorbidities or overweight/obesity based on BMI.1,4 | NICE NG226: referral for joint replacement |
| Escalate atypical or acutely inflamed presentations | A hot, red, acutely swollen joint, systemic illness, prolonged morning stiffness, rapid progression, trauma, unexplained rest pain or suspected malignancy is not a routine osteoarthritis presentation. Investigate the alternative diagnosis urgently and use the relevant local pathway.1,4 | NICE NG226: atypical features and diagnosis |
Illustrations
Differentials
Rheumatoid or other inflammatory arthritis
Prolonged morning stiffness, symmetrical soft-tissue synovitis, systemic features or extra-articular disease.
Gout or acute CPP crystal arthritis
Rapidly painful, red and swollen joint; aspiration may identify monosodium urate or calcium pyrophosphate crystals.
Septic arthritis
Acute hot swollen joint with fever, systemic illness or infection risk, requiring urgent assessment and aspiration.
Fracture or internal derangement
Trauma, acute loss of function, focal bony tenderness, locking or instability.
Malignancy or referred pain
Unexplained night or rest pain, systemic symptoms, rapid progression, neurological signs or a mismatch between the symptomatic joint and examination.
Complications
- Chronic pain, stiffness and restricted mobility
- Functional disability, falls risk and loss of independence
- Sleep disturbance, low mood and reduced quality of life
- Joint deformity or instability
- Adverse effects from NSAIDs, opioids or other symptom treatments
- Complications of joint replacement surgery
Prognosis
Symptoms fluctuate and do not inevitably worsen. Many people improve function and pain with exercise, weight management and appropriate support. Joint replacement can help advanced hip, knee or shoulder disease when symptoms substantially affect quality of life despite non-surgical treatment.
Guidelines
- Osteoarthritis in over 16s: diagnosis and management (NG226) (NICE, 2022)
References
- NICE: Osteoarthritis in over 16s: diagnosis and management, recommendations (NG226)
- NICE: Osteoarthritis in over 16s, context (NG226 context)
- NHS: Osteoarthritis (NHS osteoarthritis)
- NICE: Osteoarthritis in over 16s, rationale and impact (NG226 rationale and impact)
- NHS: Osteoarthritis treatment and support (NHS osteoarthritis treatment and support)
- BNF: Diclofenac sodium (BNF diclofenac sodium)
- BNF: Naproxen (BNF naproxen)
- NICE: Osteoarthritis in over 16s, information for the public (NG226 public information)
- BNF: Ibuprofen (BNF ibuprofen)
- NICE: Osteoarthritis in over 16s, update information (NG226 update information)
Evidence checked: 2026-08-03
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.