AKT · Musculoskeletal/Crystal & degenerative

Osteoarthritis

Degenerative 'wear-and-repair' joint disease — cartilage loss + subchondral bone change

Overview

The commonest joint disease: progressive loss of articular cartilage with subchondral bone change, osteophytes and low-grade inflammation. It is a clinical diagnosis in those over 45 with activity-related joint pain and no prolonged morning stiffness. Management is core (exercise, weight loss, education) plus analgesia, with joint replacement for end-stage disease.

Recognise

Activity-related joint pain, relieved by rest; stiffness <30 min after rest ('gelling'); commonly knees, hips, hands, spine, first CMC
Hand OA: Heberden (DIP) and Bouchard (PIP) nodes, squaring of the thumb base
X-ray (LOSS): Loss of joint space, Osteophytes, Subchondral Sclerosis, Subchondral cysts

Red flags

Rest/night pain, systemic symptoms, or a hot swollen joint → reconsider inflammatory/septic/malignant cause
Rapidly progressive hip OA → exclude other pathology

Differentials & how to tell them apart

Rheumatoid arthritissymmetrical MCP/PIP synovitis, >1 h morning stiffness, raised inflammatory markers, erosions

Gout/pseudogoutacute hot joint with crystals

Avascular necrosiship/shoulder pain with risk factors (steroids, alcohol); MRI changes

Osteoarthritis of the knee — joint-space loss, osteophytes and subchondral sclerosis (X-ray)
James Heilman, MD / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Clinical diagnosis (NICE) if ≥45 with activity-related pain and no prolonged morning stiffness — no investigations needed. X-ray (LOSS changes) only if doubt or pre-operative; inflammatory markers normal (helps exclude inflammatory arthritis).

Management

Core exercise + weight loss + topical/oral NSAID; arthroplasty for end-stage disease

1Diagnose clinically in over-45s with activity-related pain and no prolonged morning stiffness. Core treatment for everyone = therapeutic exercise, weight loss and education. Add a topical NSAID (knee/hand), then an oral NSAID with a PPI.Gate: Rest/night pain, prolonged morning stiffness or a hot joint → reconsider an inflammatory, septic or malignant cause rather than OA.
2Intra-articular corticosteroid for flares; refer for joint replacement when symptoms and function are not controlled by conservative therapy.

Core: therapeutic exercise, weight loss, education — first-line for ALL — exercise is the single most effective intervention

Topical NSAID (knee/hand) first; then oral NSAID + PPI at lowest effective dose — NICE now de-emphasises paracetamol/weak opioids; topical NSAIDs preferred for knee/hand

Intra-articular corticosteroid injection — for short-term relief of a flare

Joint replacement (arthroplasty) — for severe symptoms/disability not controlled by conservative measures

Key points

Over-45, activity-related pain, stiffness <30 min, Heberden/Bouchard nodes, X-ray LOSS = osteoarthritis → exercise + weight loss (core) + topical/oral NSAID; replace end-stage joints. NICE de-emphasises paracetamol. Inflammatory markers are normal.

Monitor & prognosis

Function/pain, weight, NSAID tolerability; arthroplasty outcomes.

Slowly progressive; exercise and joint replacement give good functional outcomes.

Source: NICE NG226 (osteoarthritis)