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Osteoarthritis

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"osteoarthritis"[MeSH Terms]

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osteoarthritis overview diagnosis management NICE guideline

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https://www.nice.org.uk/guidance/ng226

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Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis. It is a disorder of the whole joint in which cartilage breaks down and the underlying bone changes, causing pain, stiffness, reduced movement, and sometimes bony enlargement. It most often affects the knees, hips, hands, spine, and base of the thumb.

Typical features

  • Pain that worsens with activity or joint use and improves with rest
  • Brief morning stiffness, usually less than 30 minutes
  • Stiffness after inactivity
  • Crepitus, a grating or crackling sensation on movement
  • Reduced range of motion and, later, deformity
  • Bony swellings in the fingers: Heberden nodes at DIP joints and Bouchard nodes at PIP joints
OA is primarily degenerative, although low-grade inflammation may contribute to symptoms and cartilage damage. Structural changes include cartilage loss, subchondral bone sclerosis/cysts, and osteophytes. Robbins Pathology describes the progression from cartilage injury and attempted repair to matrix and chondrocyte loss. Robbins & Kumar Basic Pathology, p. 790.

Risk factors

  • Increasing age
  • Higher body weight, especially for knee and hip OA
  • Previous joint injury or surgery
  • Repetitive occupational joint loading
  • Joint malalignment or congenital joint abnormalities
  • Muscle weakness, particularly quadriceps weakness in knee OA
  • Genetic predisposition
  • Metabolic or joint diseases causing secondary OA, such as gout, CPPD disease, hemochromatosis, or inflammatory arthritis

Diagnosis

OA is often diagnosed clinically in adults with typical activity-related joint pain and little or no prolonged morning stiffness. X-rays are not routinely needed when the presentation is typical. If obtained, they may show joint-space narrowing, osteophytes, subchondral sclerosis, and cysts. Symptoms and X-ray severity do not always match. NICE guidance supports clinical diagnosis and management in people over 16.
Consider another diagnosis or urgent evaluation if there is:
  • A hot, markedly swollen joint or fever
  • Sudden severe pain after trauma or inability to bear weight
  • Prolonged morning stiffness, multiple swollen small joints, rash, or systemic symptoms
  • Unexplained weight loss or night pain

Treatment

There is no proven treatment that reverses established OA, but symptoms and function can often improve substantially.
  1. Exercise and rehabilitation
    • Strengthening exercises, aerobic exercise, and range-of-motion work
    • Physiotherapy, especially for knee or hip OA
    • Activity modification, without avoiding all activity
    • Walking aids or braces when appropriate
  2. Weight management
    • Weight loss can reduce knee and hip joint load and pain when weight is contributing.
  3. Pain relief
    • Topical NSAIDs are commonly considered first for knee OA.
    • Oral NSAIDs may help but require assessment of stomach, kidney, cardiovascular, bleeding-risk, and drug-interaction issues.
    • Paracetamol may help some people but is often less effective.
    • Opioids are generally avoided for long-term OA because harms commonly outweigh benefit.
  4. Injections
    • Intra-articular corticosteroid injections may provide short-term symptom relief for selected painful joints.
    • They do not repair cartilage and are not a long-term solution.
  5. Surgery
    • Joint replacement may be appropriate when severe pain and functional limitation persist despite suitable non-surgical treatment. Goldman-Cecil Medicine, p. 2364.
A 2024 systematic review of knee OA management also supports exercise as a central component of care (PMID: 38963824).
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