1. Early medial-compartment knee osteoarthritis: subchondral sclerosis is an early degenerative change. Joint space is still preserved, so this is not advanced arthritis.
2. Possible generalized low bone density: “osteopenic bones” on X-ray is not a diagnosis of osteoporosis. It should be confirmed or excluded with a DEXA bone-density scan if clinically appropriate.

Management plan

1. Clinical assessment

• Pain location, severity, swelling, stiffness, locking/giving way, walking tolerance and function
• Previous injury or surgery
• Body weight, activity, footwear, occupation
• Osteoporosis risks: age, menopause status, prior low-trauma fracture, parental hip fracture, smoking, alcohol, low BMI, long-term steroid use, rheumatoid/inflammatory disease, thyroid/parathyroid disease, malabsorption, renal disease, and medicines affecting bone.

2. First-line treatment for the knee

• Physiotherapy or a structured home exercise programme: quadriceps, hip-abductor and hamstring strengthening; knee range-of-motion work; low-impact aerobic exercise such as cycling, swimming, or walking.
• Continue normal activity within tolerable limits. Avoid repeated deep squats, kneeling, twisting/pivoting, and high-impact activity during a painful flare.
• If overweight, gradual weight reduction can meaningfully reduce knee loading and symptoms.
• Supportive footwear may help. A walking stick in the opposite hand can reduce load if walking is painful. Consider an unloading brace only after an MSK assessment, particularly if there is clear medial-sided pain or varus alignment.

3. Pain control, if needed

• Topical NSAID gel is usually the first medication option for knee OA, if safe for you.
• If pain remains limiting, a clinician may consider a short course of an oral NSAID, after checking kidney function, blood pressure, heart disease, ulcer/bleeding history, anticoagulants and other drugs. Gastroprotection may be needed.
• Paracetamol can be reserved for occasional short-term relief, but regular use is often not very effective for OA.
• Avoid routine opioid use.
• Steroid injection may be considered for a significant painful flare that has not responded to conservative treatment, but it is not a long-term solution.

4. Evaluate the “osteopenic” appearance

• DEXA scan and fracture-risk assessment, particularly if age 50+, postmenopausal, male over 70, history of fragility fracture, or any major risk factor.
• Review calcium intake from food, vitamin D status/risk of deficiency, protein intake, smoking, alcohol, falls risk, and weight-bearing/resistance exercise.
• Clinician-directed tests may include calcium, phosphate, alkaline phosphatase, kidney function, vitamin D, thyroid function and blood count, depending on history.
• Bone-specific medicines are not started solely because an X-ray looks osteopenic. That decision depends on DEXA results and overall fracture risk.

5. Follow-up and escalation

Seek urgent assessment if

• Hot, red, markedly swollen knee, fever, or feeling unwell
• Inability to bear weight after injury
• Sudden severe pain or deformity
• Calf swelling, chest pain, or breathlessness
• Night pain, unexplained weight loss, or progressive severe pain