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History Taking for an Osteoarthritis Patient

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1. Presenting Complaint

• Location of joint pain (which joint/s - knee, hip, hand, spine, etc.)
• Onset: gradual vs. sudden
• Duration of symptoms

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2. Pain History (SOCRATES)

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3. Stiffness

• Morning stiffness: duration (OA typically < 30 minutes, often < 45 minutes - distinguishes from RA where stiffness lasts hours)
• Gel phenomenon: stiffness after prolonged rest or inactivity (e.g., rising from a chair) - resolves within minutes of activity
• Does stiffness improve or worsen with activity? (OA improves; RA worsens with activity)

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4. Functional History

• Difficulty with activities of daily living (ADLs): dressing, bathing, rising from a chair, climbing stairs
• Occupational impact: ability to work
• Gait disturbance, limping
• Difficulty descending stairs (knee OA - buckling/instability)
• Use of walking aids (cane, walker)
• Sleep disturbance from pain

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5. Joint-Specific Symptoms

• Knee OA: buckling, instability, difficulty with stairs, "locking" (suggests loose cartilage fragment)
• Hip OA: groin pain, pain radiating down anterior thigh, difficulty with hip flexion/rotation
• Hand OA: finger node swellings (Heberden's at DIP, Bouchard's at PIP), difficulty gripping, handwriting, pinching (1st carpometacarpal joint)
• Spine OA: neck/back stiffness, radicular pain (arm or leg), numbness, weakness
• Crepitus (grinding/clicking sounds in joint)

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6. Inflammatory Features (to distinguish from inflammatory arthritis)

• Significant joint warmth, redness, or marked swelling? (suggests infection, gout, RA instead of OA)
• Systemic symptoms: fever, rash, weight loss, fatigue? (absent in OA)
• Eye symptoms (uveitis), skin changes, oral ulcers?
• Morning stiffness > 1 hour? (suggests RA or PMR)

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7. Past Medical History

• Previous joint injury or trauma (key risk factor for secondary OA - post-traumatic OA)
• Previous joint surgery (meniscectomy, ACL repair)
• Congenital hip abnormalities (dysplasia, slipped capital femoral epiphysis, Legg-Calvé-Perthes)
• Neuropathies (neuropathic arthropathy)
• Metabolic/endocrine disorders: obesity, hemochromatosis, Wilson's disease, calcium pyrophosphate deposition (CPPD) disease, Paget's disease, acromegaly
• Inflammatory arthritis history: rheumatoid arthritis, gout, psoriatic arthritis (secondary OA can follow cartilage damage from these)
• Joint infections (septic arthritis leading to secondary OA)
• Diabetes mellitus, thyroid disease

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8. Occupational & Activity History

• Occupation: repetitive joint loading (miners, shipyard workers, carpet layers, floor layers - significantly higher knee OA risk)
• History of high-impact or high-intensity sports (associated with OA when combined with joint injury)
• Current activity level (> 44% of OA patients are inactive)
• History of repetitive kneeling, squatting, or heavy lifting

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9. Family History

• OA in first-degree relatives (especially hand OA with Heberden/Bouchard nodes - strong familial component)
• Collagen gene defects (hereditary OA variant)
• Inflammatory arthritis in family (RA, ankylosing spondylitis)

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10. Drug History

• Current analgesics and their efficacy (NSAIDs, paracetamol, opioids)
• Topical treatments (diclofenac gel, capsaicin)
• Glucosamine or chondroitin supplements
• Intra-articular injection history (corticosteroids, hyaluronic acid)
• Drugs that may worsen or complicate management: anticoagulants (relevant to injections/surgery), antihypertensives (NSAIDs interact), nephrotoxic drugs (NSAIDs contraindicated in CKD)
• Allergies (especially NSAID allergy)

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11. Social History

• BMI / obesity (major modifiable risk factor - Mendelian randomization confirms causal role of BMI)
• Smoking status (affects healing and operative risk)
• Alcohol use
• Living arrangements (ability to manage at home independently)
• Stairs at home, bathroom layout
• Support network/carer availability

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12. Review of Systems (to exclude other diagnoses)

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13. Impact Assessment

• WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) or KOOS domains in the clinical history:
  • Pain scale
  • Stiffness scale
  • Physical function scale
• Patient's own goals and concerns
• Previous physiotherapy or rehabilitation
• Prior surgical discussion or referral

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Complete Question List for OA Diagnosis & Medical Record

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SECTION 1 - DEMOGRAPHICS & BASIC INFORMATION

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SECTION 2 - PRESENTING COMPLAINT

"What brings you in today? Which joint is bothering you the most?"

• "When did this problem first start?"
• "Did it come on gradually or suddenly?"
• "Has it been getting worse over time?"

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SECTION 3 - PAIN HISTORY

Site & Radiation

• "Exactly where is the pain? Can you point to it with one finger?"
• "Does the pain spread anywhere? Down your leg? Into your groin?" (hip OA: groin + anterior thigh)
• "Do you feel pain, numbness, or weakness in your arms or legs?" (cervical/lumbar spine OA)

Onset & Timing

• "When during the day is your pain worst - in the morning, afternoon, or by evening?"
  • (OA: worsens as the day progresses and with use)
• "Does the pain get better when you rest?"
  • (OA hallmark: pain relieved by rest)
• "Is the pain present at night, or does it wake you from sleep?"
  • (Night pain = advanced/severe OA)
• "Is the pain constant, or does it come and go?"

Character

• "How would you describe the pain - aching, sharp, burning, throbbing?"
• "On a scale of 0-10, how bad is the pain right now? At its worst?"

Exacerbating & Relieving Factors

• "What makes the pain worse?" (walking, stairs, kneeling, cold/damp weather)
• "Does cold or rainy weather make it worse?" (barometric pressure changes exacerbate OA)
• "What makes it better?" (rest, warmth, analgesics)

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SECTION 4 - STIFFNESS (Critical for diagnosis)

• "Do you feel stiff in your joints when you wake up in the morning?"
• "How long does that morning stiffness last before it goes away?"
  • (OA: < 30 minutes. RA: > 60 minutes - key differentiator)
• "Do you feel stiff after sitting or resting for a while - for example, after getting up from a chair or after a long car ride?"
  • (This is the "gel phenomenon" - stiffness after inactivity, resolves quickly with movement in OA)
• "How quickly does that stiffness go away once you start moving?"
  • (OA: resolves within minutes of activity)

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SECTION 5 - JOINT-SPECIFIC SYMPTOMS

For Knee OA:

• "Does your knee ever give way or buckle under you?"
• "Do you have difficulty going up or down stairs?"
• "Does your knee ever lock or get stuck in one position?"
• "Do you hear a grinding or clicking sound in your knee?"
• "Is there any swelling around your knee?"

For Hip OA:

• "Where exactly is your hip pain - in the groin, outer hip, or buttock?"
• "Is it painful to put your socks and shoes on?"
• "Do you have difficulty getting in and out of a car?"
• "Do you limp when walking?"

For Hand OA:

• "Do you have lumps or swellings on your finger joints?"
• "Do you have difficulty gripping objects, opening jars, or turning a key?"
• "Which knuckles are affected - the ones closest to your fingertips, or the middle ones?"
  • (DIP = Heberden's nodes; PIP = Bouchard's nodes)

For Spine OA:

• "Do you have neck or back pain and stiffness?"
• "Do you have any tingling, numbness, or weakness in your arms or legs?"

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SECTION 6 - FUNCTIONAL IMPACT (For the medical record)

• "Can you walk? How far before the pain stops you?"
• "Can you climb stairs?"
• "Can you get up from a chair without using your arms to push yourself up?"
• "Can you dress and bathe yourself independently?"
• "Has this affected your ability to work or do your job?"
• "Has this affected your sleep?"
• "What activities have you had to give up because of this condition?"

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SECTION 7 - INFLAMMATORY RED FLAGS

• "Is the joint red, hot, or very swollen?"
  • (Marked redness/heat = septic arthritis, gout, or crystal disease, NOT typical OA)
• "Do you have fever or chills?"
• "Have you lost weight recently without trying?"
• "Do you feel very fatigued or generally unwell?"
• "Do you have stiffness that lasts for hours in the morning?"
  • (> 1 hour = RA/inflammatory arthritis flag)
• "Do you have pain or swelling in many joints at the same time, symmetrically?"
  • (Symmetric polyarthritis = RA; OA is typically asymmetric)
• "Do you have any rashes, mouth sores, or eye problems?"
  • (Psoriatic arthritis, reactive arthritis, lupus)
• "Have you had a recent infection - urinary, gut, or skin?"
  • (Reactive arthritis, septic arthritis)

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SECTION 8 - PAST MEDICAL HISTORY

• "Have you ever injured this joint before? A fracture, dislocation, ligament injury, or surgery?"
  • (Post-traumatic secondary OA)
• "Were you told as a child that you had a hip problem or hip dysplasia?"
  • (Congenital hip dysplasia, Legg-Calvé-Perthes, slipped capital femoral epiphysis all predispose to hip OA)
• "Have you ever been diagnosed with rheumatoid arthritis, gout, or psoriatic arthritis?"
  • (Inflammatory arthritis damages cartilage, leading to secondary OA)
• "Do you have diabetes, thyroid problems, or a hormonal condition?"
• "Have you been diagnosed with hemochromatosis (iron overload), Paget's disease, or acromegaly?"
  • (Metabolic causes of secondary OA)
• "Do you have any nerve or muscle problems?"

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SECTION 9 - DRUG HISTORY

• "What medications are you currently taking?"
• "What have you tried for the pain - paracetamol, ibuprofen, other anti-inflammatories?"
• "Do they help? How much and for how long?"
• "Have you had any joint injections - steroid or gel injections?"
• "Have you tried any creams or gels on the joint?"
• "Do you take any supplements - glucosamine, fish oil, vitamin D?"
• "Do you have any allergies to medications - especially anti-inflammatories?"
• "Are you on blood thinners, blood pressure tablets, or kidney medications?"
  • (NSAIDs interact with antihypertensives; contraindicated in CKD)

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SECTION 10 - FAMILY HISTORY

• "Does anyone in your family have arthritis - parents, siblings?"
• "Any family history of joint replacements or severe joint disease?"
  • (Hand OA with Heberden's nodes has a strong hereditary component)

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SECTION 11 - SOCIAL & LIFESTYLE HISTORY

• "What is your occupation? Does your job involve repetitive kneeling, squatting, heavy lifting, or vibration?"
  • (Miners, carpet layers, shipyard workers have higher knee OA risk)
• "Do you do any sports or regular exercise?"
• "Have you had any sports injuries to your joints?"
• "Do you smoke? How much?"
• "How much alcohol do you drink per week?"
• "How has this condition affected your daily life, relationships, and activities you enjoy?"

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SECTION 12 - PSYCHOLOGICAL & HOLISTIC SCREENING

• "Has the pain made you feel low in mood or depressed?"
• "Are you anxious about your condition or what the future holds?"
• "What do you understand about osteoarthritis? What are your main concerns?"
• "What are you hoping we can achieve together with treatment?"
• "Do you live alone, or do you have family support at home?"
• "Do you have difficulty with access to exercise facilities or physiotherapy?"

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SECTION 13 - SYSTEMS REVIEW (Brief screening)

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ACR Diagnostic Criteria Summary (Confirm at end of history)

Test characteristics: sensitivity 89-94%, specificity 86-91%, LR+ 6.5-9.9 - OA is primarily a clinical diagnosis.

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