Changes

December 2023 — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations and basis for recommendation sections have been updated in line with current evidence in the literature.

Update

Goals

To support primary healthcare professionals to:

• Make an accurate assessment of suspected osteoarthritis.
• Advise on self-management strategies for symptom relief and joint protection.
• Advise on drug treatment for symptom relief in primary care.
• Offer referral to the musculoskeletal multidisciplinary team for management of symptoms if needed.
• Offer referral to orthopaedic surgery if needed.
• Provide advice on sources of information and support.

Outcome measures

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

• Adults aged 45 or over are diagnosed with osteoarthritis clinically without imaging if they have activity‑related joint pain and any morning joint stiffness that lasts no longer than 30 minutes.
• Adults with osteoarthritis are given information about their condition and its management at diagnosis and follow-up appointments.
• Adults with osteoarthritis are advised to do tailored therapeutic exercise.
• Adults with osteoarthritis who are overweight or obese are offered support to lose weight.
• Adults with osteoarthritis discuss and agree their follow-up with their primary healthcare team.
• Adults with osteoarthritis are supported with non‑surgical core treatments for at least 3 months before any referral for consideration of joint surgery.
• Healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.

[NICE, 2022b]

What is it?

• Osteoarthritis is defined as a long-term disorder of synovial joints which occurs when damage triggers repair processes leading to structural changes within a joint, with features of localized loss of cartilage, remodelling of adjacent bone and the formation of osteophytes, and mild synovitis (inflammation of the synovial membrane that lines the joint capsule).
  • In some people, these repair processes may alleviate symptoms, but in others, they cannot fully compensate for the joint damage, and symptoms of pain, stiffness, and loss of function may occur.
  • Any synovial joint can be involved, and the most commonly affected peripheral joints are the knees, hips, and the small joints of the hand.
• A 'flare' of OA describes a sudden, sustained increase in symptoms for at least 24 hours, which is worse than usual patterns and which typically lasts 3–8 days. A flare may also affect sleep, daily activities, and lead to mood changes.

 [Arthritis Research UK, 2013; Aresti, 2016; Sharma, 2021; NICE, 2022a; Parry, 2023] 

How common is it?

The prevalence of osteoarthritis (OA) varies depending on the joint(s) affected, the person's age, sex, socio-economic group, and comorbidities.

• A Versus Arthritis UK data report states that [Versus Arthritis, 2023]:
  • An estimated 10 million people (6 million women, 4 million men) in the UK have OA, with an estimated 5.4 million people affected by knee OA and 3.2 million by hip OA.
  • An estimated 350,000 people are diagnosed with OA each year.
  • The median age of symptom onset is 55 years.
• An Arthritis Research UK report about OA in general practice states that [Arthritis Research UK, 2013]:
  • Over 8.75 million people aged over 45 years in the UK have sought treatment for OA.
  • About 18% of people aged over 45 years have sought treatment for knee OA, about 8% for hip OA, and 6% for OA of the hand and wrist.
  • One-third of women and almost one-quarter of men aged 45–64 years have sought treatment for OA. This rises to almost half of people aged 75 years and over.
• A population-based study of primary care data in England between 2000 and 2010 (total practice population of 94,955) found [Yu, 2015]:
  • Newly diagnosed cases of OA of any joint occur in 9 per 1000 at-risk adults each year.
  • The joint-specific incidence of OA was 3.5, 1.4, and 1.3 cases per 1000 at-risk adults each year for the knee, hip, and hand, respectively.
  • The annual consultation incidence of OA increased sharply between 45–64 years of age, peaking at 75–84 years of age.
• A study of global temporal trends of OA incidence rates from 1990 to 2019 found [Chen, 2023]:
  • In 2019, there was an age-standardized incidence rate of 492.21 per 100,000 people and an estimated 527.8 million prevalent cases of OA.
  • The global burden of OA rose steadily over the study period in terms of prevalence, incidence, and disability-adjusted life years (DALYs).

What are the risk factors?

The exact causes of osteoarthritis (OA) are not fully known. It is a complex, multifactorial condition involving genetic, biological, and biomechanical components [Versus Arthritis, 2021] [NICE, 2022a].

Genetic

• Epidemiological studies of family history and family clustering, twin studies, and exploration of rare genetic disorders provide evidence of a genetic basis for the pathogenesis of OA [Versus Arthritis, 2021].
  • A review article cites evidence from a classic twin study which assessed the relative contribution of genetic and environmental factors to OA of the hands and knees. It found the correlations of X-ray changes and clinical features of OA were higher in monozygotic than dizygotic pairs. It concluded that the influence of genetic factors in X-ray confirmed OA of the hand and knee in women is between 39% and 65%, independent of known environmental or demographic confounding factors. Another study in a larger sample of twins found that joint space narrowing of the hip was also heritable, with an estimated heritability of 60% [Spector, 2004].

Biological

• Increasing age — OA typically presents in people aged over 45 years. Age is the strongest risk factor for developing OA [Glyn-Jones, 2015; Versus Arthritis, 2021; NICE, 2022a].
• Women — for most joints, OA is more common and more severe in women [Versus Arthritis, 2021; Versus Arthritis, 2023].
• Overweight or obesity — increases the load on weight-bearing joints and accelerates disease progression [Glyn-Jones, 2015; Versus Arthritis, 2021; NICE, 2022a]. See the CKS topic on Obesity for more information.
• Low bone density — increases the risk for rapid progression of knee and hip OA [Arthritis Research UK, 2013]. See the CKS topic on Osteoporosis - prevention of fragility fractures for more information.

Physical/biomechanical

• Joint injury and damage — due to repeated excessive or abnormal loading onto joints, for example, due to obesity, previous trauma such as fracture or ligamentous injury, or inflammatory arthropathy [Glyn-Jones, 2015; Versus Arthritis, 2021; Versus Arthritis, 2023].
  • Joint laxity and reduced muscle strength may cause abnormal wear and joint loading [Glyn-Jones, 2015; Aresti, 2016].
  • Joint malalignment — developmental dysplasia of the hip (DDH); femoroacetabular impingement; leg length discrepancy; varus and valgus knee deformities may all cause abnormal or excess loading of joints [Glyn-Jones, 2015; Aresti, 2016; Sharma, 2021].
  • Exercise stresses — may increase joint load, microtrauma, and structural damage, for example, in professional sports people [Aresti, 2016]. Conversely, physical inactivity increases the risk of developing OA [Versus Arthritis, 2021].
  • Occupational stresses — knee involvement is more common if there is repetitive squatting, bending, and kneeling; hip involvement is more common with heavy work, prolonged lifting and standing [Arthritis Research UK, 2013; Sharma, 2021].

What are the complications?

Osteoarthritis (OA) can impact various aspects of a person's physical, social, and psychological functioning:

• Joint deformity — due to bony nodules on the dorsum of the finger next to the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints (Heberden's and Bouchard's nodes, respectively). As the disease progresses, there may be ulnar or radial deviation at affected joints [Dickson, 2015].
• Functional limitation [Dickson, 2015; Versus Arthritis, 2021; Kloppenburg, 2019; Moseng, 2023].
  • Hand OA may affect grip and pinch strength, causing difficulty with activities such as opening jars, turning keys or door handles, lifting saucepans, fastening buttons, and writing.
  • Knee and hip OA may cause difficulty walking, climbing stairs, dressing, driving, having sex, and risk of falls. See the CKS topic on Falls - risk assessment for more information.
• Psychosocial — may affect self-confidence, self-esteem, sleep quality, relationships, ability to work, and ability to self-care and care for others; and may cause anxiety and depression [Bannuru, 2019; Versus Arthritis, 2021; Moseng, 2023]. See the CKS topics on Generalized anxiety disorder and Depression for more information.
• Chronic pain — may worsen existing chronic pain or trigger chronic pain due to persistent activation of neural pain pathways [Geenen, 2018; Bannuru, 2019; Versus Arthritis, 2021]. See the CKS topic on Chronic pain for more information.

What is the prognosis?

Osteoarthritis (OA) is not always a progressive condition that inevitably leads to increasing pain and functional impairment. Symptoms may fluctuate with intermittent acute-on-chronic flares. Prognosis varies depending on the joint(s) involved and may also vary between people [Sharma, 2021] [NICE, 2022a] [Parry, 2023].

• Hand involvement generally has a good prognosis.
  • Interphalangeal joint involvement usually becomes asymptomatic after a few years.
  • Involvement of the first carpometacarpal (CMC) joint generally has a poorer prognosis.
• Hip involvement has a poorer prognosis than hand or knee OA.
  • A significant proportion of people require hip replacement within 5 years of diagnosis.
  • In 2011, 93% of initial hip replacements in the UK were performed for hip OA [Arthritis Research UK, 2013].
• Knee involvement has a variable prognosis.
  • A review article on OA flares cites various studies of adults in England with, or at risk of, OA knee in the community, which found significant pain variability or flares were observed in 23–66% of study participants [Parry, 2023].
  • Some people improve spontaneously, some people's symptoms remain stable, and some have progressively worsening symptoms and structural changes on X-ray, which eventually require joint surgery.
  • In 2011, 98% of initial knee replacements in the UK were performed for knee OA [Arthritis Research UK, 2013].

When should I suspect a diagnosis of osteoarthritis?

Suspect a diagnosis of osteoarthritis (OA) if alternative conditions have been excluded and a person is aged 45 years or over, with suggestive clinical features.

• The clinical features of OA are variable, both between people and at different joint sites. Typically, there is a history of:
  • Activity-related joint pain — typically only one or a few joints are affected at any one time, and pain develops over months or years and
  • No morning joint-related stiffness or morning stiffness lasting no longer than 30 minutes.
  • Some form of functional limitation.
• On examination, there may be:
  • Bony swelling and joint deformity.
  • Small-to-moderate joint effusion (uncommon except for the knee).
  • Soft tissue swelling, warmth, and/or tenderness (may suggest synovitis).
  • Muscle wasting and weakness.
  • Restricted and painful range of joint movement, crepitus (a grating sound or sensation produced by friction between bone and cartilage).
  • Joint instability and misalignment.

Clinical features of specific joint OA may include:

• Hand OA
  • Typically affects the first carpometacarpal (CMC) joint at the base of the thumb, the distal interphalangeal (DIP) joint, and the proximal interphalangeal (PIP) joint.
    • Pain can radiate distally towards the thumb or proximally to the wrist and distal forearm and is often exacerbated by pinching actions or strong grip.
    • There may be wasting of the thenar muscles at the base of the thumb.
    • The CMC joint may develop a fixed flexion deformity, with hyperextension of the distal joints.
    • In advanced disease, there may be 'squaring' at the joint caused by subluxation (partial dislocation), formation of osteophytes, and remodelling of the bone.
    • As disease progresses, there may be ulnar or radial deviation at affected joints.
  • May have associated features, including:
    • Mucoid cysts (painful mucus-filled cysts) adjacent to the joint on the dorsum of the finger, which may cause longitudinal ridging of the nail.
    • Heberden's and Bouchard's nodes (bony nodules on the dorsum of the finger next to the DIP and PIP joints, respectively).
• Hip OA
  • May present with:
    • Deep pain in the anterior groin on walking or climbing stairs, with possible referred pain to the lateral thigh and buttock, anterior thigh, knee, and ankle.
    • Painful restriction of internal rotation with the hip flexed.
  • In advanced disease, there may be:
    • A Trendelenburg gait — a lurch towards the affected hip with less time spent weight-bearing on that side and the pelvis tilting down on the unaffected side, caused by wasting and weakness of the gluteal and anterior thigh muscles
    • A fixed flexion external rotation deformity, with compensatory increased lumbar lordosis and pelvic tilt. The lower limb can be significantly shortened.
• Knee OA
  • Typically is bilateral and symmetrical, affecting the medial tibiofemoral, lateral tibiofemoral, or patellofemoral compartments, with pain localized to the affected compartment.
    • Medial tibiofemoral involvement causes anteromedial pain, mainly on walking.
    • Lateral tibiofemoral involvement causes anterolateral pain, mainly on walking.
    • Patellofemoral involvement causes anterior knee pain worsened on inclines or stairs, particularly when going down, and progressive aching on prolonged sitting that is relieved by standing.
  • May have associated features, including:
    • Giving way — due to altered patella tracking, weak quadriceps muscles, severe patellofemoral involvement, and altered load-bearing mechanics. Note: weakness of the quadriceps is suggested if passive extension of the knee joint is greater than active extension.
    • Locking (inability to straighten the knee) — suggests loose meniscal cartilage in the joint.
    • Crepitus and tenderness along the joint line or with pressure on the patella.
    • Restricted flexion and extension.
  • In advanced disease, there may be:
    • Bony swelling of the femoral condyles and lateral tibial plateau.
    • Varus (bow-legged), or less commonly valgus (knock-knee), deformity.
    • An antalgic gait.

How should I assess suspected osteoarthritis?

If a person has suspected osteoarthritis (OA) and alternative conditions have been excluded, assess to guide appropriate management.

• Ask about:
  • The location, onset, duration, progression, pattern, and severity of symptoms, including joint pain, swelling, and stiffness, and any flares of OA.
  • Any symptoms of joint instability such as locking or giving way under pressure (may suggest more severe disease).
  • Any risk factors for OA and any comorbidities, such as chronic pain syndrome, falls risk, and obesity. See the CKS topics on Chronic pain, Falls - risk assessment, and Obesity for more information.
  • Any atypical features such as history of recent trauma, prolonged morning joint-related stiffness, systemic symptoms, or a rapid worsening of symptoms which may suggest an alternative or additional diagnosis.
  • Hand dominance (if relevant) and any functional limitations, including impact on walking, exercise, sleep, work, and leisure activities.
  • Any psychosocial impact, including the person's quality of life, effect on mood and relationships, housing situation, any dependents affected, and health beliefs and expectations. See the CKS topics on Generalized anxiety disorder and Depression for more information.
  • Any self-help strategies and treatments tried, including over-the-counter medication.
  • Any family history of OA or other joint problems.
  • Social support available, such as family and/or carer(s), any adjustments to home or workplace needed.
• Examine the person:
  • For typical clinical features of OA of the affected joint(s), posture and alignment, and gait (if relevant).
    • Note: if there is suspected knee involvement, exclude referred pain from the hip, which may be suggested by groin tenderness and pain on internal rotation of the hip.
  • For atypical features such as joint deformity or a hot, swollen joint.
  • For associated sources of pain, such as peri-articular pain, trigger finger, ganglion, bursitis, neurovascular disease including neuropathy, or pseudogout (pyrophosphate arthropathy), which may coexist with OA.
  • Check body weight and body mass index (BMI). See the CKS topic on Obesity for more information.
• Do not routinely arrange an X-ray of the affected joint(s) to diagnose OA. Consider arranging an X-ray, depending on clinical judgement, if:
  • Diagnostic uncertainty or atypical features suggest an alternative or additional diagnosis.
  • There is a sudden or unexpected worsening of symptoms.
    • Typical radiological features of OA include subchondral bone thickening and/or cysts; osteophyte formation (new bone formation at joint margins); loss or narrowing of the joint space (provides an estimate of the severity of cartilage damage).
  • Note: structural changes on X-ray may not correlate with the presence or severity of symptoms or degree of functional impairment.

What else might it be?

Other conditions that may present similarly to osteoarthritis (OA) include:

• General
  • Inflammatory arthropathy — suggested by prolonged morning stiffness lasting more than 30 minutes; night pain; stiffness and pain relieved by activity; multiple joints affected; associated with systemic symptoms. See the CKS topics on Rheumatoid arthritis, Psoriasis, Ankylosing spondylitis, and Gout for more information.
  • Widespread pain disorders, such as fibromyalgia. See the CKS topic on Chronic pain for more information.
  • Septic joint — suggested by a red, hot, swollen joint associated with systemic symptoms. See the CKS topic on Sepsis for more information.
  • Fracture of the bone adjacent to the joint — suggested by a history of trauma.
  • Malignancy, including bony metastases — suggested by persistent and progressive bone pain unrelated to activity; rapid worsening of symptoms; night pain; unexplained mass or swelling. See the CKS topic on Bone and soft tissue sarcoma - recognition and referral for more information.
• Hand OA (first carpometacarpal [CMC] joint)
  • OA of the wrist.
  • Scapholunate ligament injury — causes pain at the base of the thumb, often following a history of trauma.
  • Ganglion — cystic lesions which are smooth and round, fluctuate in size, and occur at characteristic locations in the hand and wrist, such as the base of the thumb, the base of the finger on the palmar side, and on the dorsum of the end joint of a finger.
  • De Quervain's tenosynovitis — pain is typically over the radial styloid where there is localized swelling and tenderness (rather than the base of the thumb), caused by irritation of thumb tendons where they run through a fibrous sheath.
  • Trigger thumb — there may be pain and a palpable nodule over the palmar aspect of the metacarpophalangeal (MCP) joint, with clicking on flexing the thumb.
• Hip OA
  • Greater trochanteric pain syndrome. See the CKS topic on Greater trochanteric pain syndrome for more information.
  • Meralgia paraesthetica (entrapment of the lateral femoral cutaneous nerve) — suggested by localized pain and paraesthesia over the lateral aspect of the thigh.
  • Sciatica. See the CKS topic on Sciatica (lumbar radiculopathy) for more information.
  • Spinal stenosis — suggested by lateral or posterior hip pain that may radiate to the lower leg or groin; symptoms are exacerbated when walking or standing and relieved by sitting and leaning forward or by lying down; may be numbness and weakness in the lower leg, which is exacerbated by walking.
  • Osteonecrosis of the hip — suggested by anterior groin pain, which is exacerbated by activity and rest; may cause thigh and buttock pain; may be a history of corticosteroid use or alcohol dependency.
  • Iliotibial band syndrome — suggested by lateral hip pain that radiates down the side of the leg and is exacerbated by walking or running; tenderness over the iliotibial band, including where it runs over the hip joint.
• Knee OA
  • Patellofemoral pain — causes anterior knee pain, which is aggravated by going up or down stairs, squatting, or sitting for prolonged periods. It most commonly presents in teenagers or young adults. See the CKS topic on Knee pain - assessment for more information.
  • Pre-patellar or anserine bursitis. See the CKS topic on Pre-patellar bursitis for more information.
  • Greater trochanteric pain syndrome. See the CKS topic on Greater trochanteric pain syndrome for more information.
  • Iliotibial band syndrome — suggested by tenderness over the iliotibial band, including where it runs lateral to the knee and inserts into the head of the fibula. See the CKS topic on Knee pain - assessment for more information.
  • Meniscal tear — suggested by joint locking; tenderness over the joint line. See the CKS topic on Knee pain - assessment for more information.
  • Anterior cruciate ligament tear — suggested by prominent mechanical symptoms; excessive anterior movement of the tibia when it is pulled just distal to the knee. See the CKS topic on Knee pain - assessment for more information.

Scenario: Management

From age 45 years onwards.

Topical NSAIDs

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of osteoarthritis.

Search dates

May 2018 - Otober 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

• (MH "Osteoarthritis+") 
• AB osteoarthritis OR TI osteoarthritis

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

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Our policy

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• Animal studies
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• Sample size too small or study underpowered
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• Review article
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Organizational, behavioural and financial barriers

Our policy

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• Feasibility
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• Organizational and Financial Impact Analysis
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  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

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Competing interests declared for this topic:

None.