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Osteoarthritis

Last updated: June 9, 2021

Summarytoggle arrow icon

Osteoarthritis is a disabling joint disease characterized by noninflammatory degeneration of the joint complex (articular cartilage, subchondral bone, and synovium) that can have various causes, most notably advanced age and overuse. It mainly affects weight-bearing joints and joints that are heavily used, such as the hip, knee, hands, and vertebrae. Despite the widespread view that osteoarthritis is a condition caused exclusively by degenerative “wear and tear” of the joints, newer research indicates that there are various causes, including preexisting joint abnormalities, genetics, local inflammation, mechanical forces, and biochemical processes that are promoted by proinflammatory mediators and proteases. Major risk factors for osteoarthritis include advanced age, obesity, previous injuries, and asymmetrically stressed joints. In early-stage osteoarthritis, patients typically report a reduced range of motion, joint stiffness, and pain that is aggravated with heavy use. As the disease advances, persistent pain may also be present during the night and/or at rest. The diagnosis is predominantly based on clinical features and supported by radiological findings, as classic radiographic features of osteoarthritis do not always correlate with the patient's clinical symptoms or appearance. If lifestyle changes (e.g., moderate exercise, weight loss) fail to improve symptoms, pharmacotherapy is typically used for the management of active osteoarthritis. If these measures do not improve the patient's quality of life, surgical procedures such as arthroplasty may be necessary.

See also “Osteoarthritis of the hip and knee” for more specific information.

Epidemiological data refers to the US, unless otherwise specified.

Osteoarthritis can be classified according to the underlying cause: [2]

Chronic mechanical stress on the joints and age-related decrease in proteoglycans cartilage loses elasticity and becomes friable → degeneration and inflammation of cartilage ; joint space narrowing and thickening and sclerosis of the subchondral bone [3][4]

Common clinical findings [5][6][7][8]

Joint-specific findings [5]

In contrast to rheumatoid arthritis, osteoarthritis can affect the distal interphalangeal joints.

Approach

  • Osteoarthritis is a clinical diagnosis
    • Consider the diagnosis in patients ≥ 45 years of age with typical clinical features. [7]
    • There are no specific diagnostic criteria. [9]
  • If there is clinical doubt, consider imaging and additional testing to:
    • Support the clinical diagnosis with radiological evidence of joint degeneration [1]
    • Rule out differential diagnoses [7][10]
  • Invasive procedures are not routinely recommended, but may be helpful in select circumstances, for example:
    • Uncertain diagnosis
    • Assessing cartilage damage
    • Ruling out septic arthritis
    • Procedures with dual diagnostic and therapeutic purposes.

Osteoarthritis is often diagnosed based on the patient's history and the presence of typical clinical features. Radiographic signs often do not correlate with the patient's reported symptoms or clinical findings; therefore, imaging is usually used to support the diagnosis.

Imaging [7][10]

The presence of at least one of the radiological signs of osteoarthritis, in addition to typical clinical features, supports the diagnosis of osteoarthritis.

First-line modality: radiography of affected joints

  • Indications
  • Consideration: Multiple views are typically more accurate than a single view.

Other imaging modalities

Other modalities may be indicated if the diagnosis remains uncertain after radiography.

Radiological signs of osteoarthritis [1]

  • Irregular joint space narrowing
  • Subchondral sclerosis: a dense area of bone (visible on x-ray) just below the cartilage zone of a joint that forms as a result of a compressive load on the joint
  • Osteophytes (bone spurs): spurs or densifications that develop on the edges of the joint, increasing its surface area
  • Subchondral cyst: a fluid-filled cyst that develops on the surface of a joint due to local bone necrosis induced by the joint stress caused by osteoarthritis

Further investigations

See “Differential diagnoses of inflammatory arthritis.”

The differential diagnoses listed here are not exhaustive.

Treatment recommendations are consistent with the 2019 American College of Rheumatology (ACR) management guidelines for osteoarthritis of the hand, hip, and knee. [12]

Approach [12][13]

  • Follow a stepwise approach to treatment: Start with nonpharmacological management, followed by pharmacological and/or surgical treatment if needed.
  • Individualize treatment based on patient preferences, comorbidities, treatment goals, and available resources.
  • Consider referral to physical therapy or occupational therapy.

Nonpharmacological management

  • Educate patients about the disease and self-management techniques.
  • Exercise: indicated in all patients, especially those with osteoarthritis of the hip and knee
    • Formulate a specific exercise plan, taking into account patient preference and availability.
    • There is no clear evidence that one form of exercise is superior to another.
    • Tai chi offers benefits that are comparable to physical therapy in patients with osteoarthritis of the knee. [14]
  • Weight loss: indicated in overweight and obese patients [15]
  • Supportive devices (e.g., a cane or knee brace): Consider for patients with osteoarthritis of the hip and knee who are experiencing joint instability and pain when weight is placed on the joint.
  • Other symptomatic therapy: e.g., acupuncture, kinesiology taping, or heat/cold therapy

Pharmacotherapy [12][13]

Pharmacotherapy for osteoarthritis should be consistent with the WHO pain ladder. See “Treatment of pain” for dosages and important considerations.

Pharmacotherapy should only be used as a short-term treatment in symptomatic patients; long-term therapy is associated with many adverse effects.

Surgical management [17][18]

Surgery is typically indicated if conservative measures fail.

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