Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Diagnose osteoarthritis clinically, distinguish expected mechanical symptoms from inflammatory or destructive disease, prioritise exercise and weight support, use analgesia proportionately, and refer for joint replacement according to disability rather than an arbitrary radiographic threshold.
Osteoarthritis is use-related pain and functional limitation caused by failure of the whole synovial joint. Common sites are knees, hips, first metatarsophalangeal joints, thumb bases and distal or proximal finger joints. Ask which activities provoke symptoms, how long stiffness lasts after waking or rest, whether swelling is abrupt or persistent, and how pain affects walking, stairs, sleep, work, self-care and valued activities. Establish prior injury, inflammatory disease, dysplasia, occupational loading, medicines, gastrointestinal or kidney disease, cardiovascular risk, falls and the person's priorities.
Typical findings include bony enlargement, crepitus, restricted movement, malalignment, joint-line tenderness and reduced supporting muscle strength. Effusions can occur, but intense warmth, fever or rapid fluid accumulation needs a different pathway. Assess gait and adjacent joints, distinguish joint restriction from periarticular tenderness or spinal referral, and record function rather than reducing severity to a pain score. Heberden and Bouchard nodes support hand osteoarthritis; hip disease commonly produces groin or anterior-thigh pain and reduced internal rotation.
Prevalence rises with age as cartilage, subchondral bone, menisci, ligaments and periarticular muscle become less able to absorb repeated mechanical stress and repair small injuries.
Obesity, occupational kneeling or lifting, malalignment, instability, muscle weakness and previous joint injury increase focal load; hand disease also has a substantial genetic component.
Congenital dysplasia, slipped epiphysis, inflammatory arthritis, haemochromatosis, avascular necrosis, infection and intra-articular fracture can produce earlier or atypically distributed osteoarthritis.
Osteoarthritis is not simple cartilage wear. Chondrocyte stress, matrix loss, subchondral remodelling, osteophytes, low-grade synovitis and altered muscle control interact across the joint.
Malalignment or instability concentrates force on a smaller articular area; cartilage loss then narrows joint space and transfers additional stress to innervated subchondral bone.
Cartilage lacks nerves. Pain arises from synovium, capsule, periosteum, bone-marrow lesions, periarticular tissues and sensitised nociceptive pathways, explaining imperfect radiograph-symptom correlation.
Pain-related avoidance weakens supporting muscle and reduces confidence, balance and cardiovascular fitness, amplifying disability and load per movement even when structural change is stable.
Age at least 45 years, activity-related joint pain and morning stiffness absent or no longer than 30 minutes form the NICE clinical pattern.
Pain with walking, stairs or rising, brief gelling after sitting, crepitus, bony enlargement, effusion and quadriceps weakness are characteristic.
Groin, buttock or anterior-thigh pain with reduced internal rotation and difficulty putting on footwear suggests hip-joint disease; knee pain may be referred.
Thumb-base pain, first carpometacarpal squaring and nodal distal or proximal interphalangeal enlargement occur, while metacarpophalangeal synovitis suggests an alternative.
Prolonged morning stiffness, rapid deterioration, marked warmth, systemic illness or persistent soft swelling should trigger assessment for infection, crystals or inflammatory arthritis.
Observe gait, sit-to-stand ability, grip, balance and muscle strength, and ask about sleep, mood, falls, caring responsibilities and occupational consequences.
Persistent soft swelling, prolonged morning stiffness, systemic features or symmetrical small-joint disease suggests rheumatoid, psoriatic or another inflammatory arthritis rather than isolated mechanical disease.
Abrupt severe pain with warmth and effusion may be gout, calcium-pyrophosphate arthritis or infection; finding crystals does not exclude coexisting sepsis.
Radiculopathy, trochanteric pain, tendinopathy and bursitis can mimic joint pain; preserved passive movement and pain reproduced outside the joint redirect examination.
Occult fracture, osteonecrosis, malignancy and Paget disease deserve consideration when onset, age, location, systemic context or pain behaviour is atypical.
Pain, stiffness, deformity and reduced range can restrict walking, hand function, work, self-care and participation, with secondary loss of independence.
Weakness, poor balance, fear of movement and inactivity increase falls, frailty, weight gain and cardiometabolic risk, creating a self-reinforcing disability cycle.
Oral NSAIDs can cause gastrointestinal bleeding, kidney injury, fluid retention and cardiovascular events; opioids add constipation, sedation, dependence and falls.
Persistent pain can disturb sleep, mood, employment and relationships; these treatable contributors to disability do not imply that symptoms are unreal.
Radiographic severity and pain correlate only moderately; base escalation on quality-of-life impact, functional restriction and informed preference.
A short initial increase in discomfort is common when strengthening starts; appropriate progression improves pain and function without accelerating cartilage loss.
Corticosteroid is most useful when temporary analgesia permits movement, sleep or therapy; it should not replace rehabilitation or delay referral.
BMI affects peri-operative discussion and optimisation, but NICE advises against using it, age or comorbidity alone to withhold joint-replacement referral.
Do not label every painful joint in an older adult as osteoarthritis; acute warmth, prolonged stiffness, constitutional symptoms and rapid progression demand a fresh differential.
Do not order imaging reflexively or imply that a severe-looking radiograph proves inevitable decline; incidental structural change is common.
Do not advise complete rest, which weakens muscle, reduces confidence and worsens the functional consequences treatment should reverse.
Do not move from topical treatment to chronic opioid prescribing without reassessing diagnosis, rehabilitation, comorbidity and referral threshold.
Do not inject through cellulitis or into a possibly infected joint, and never let a planned injection delay synovial sampling.
Do not require failure of every analgesic before referral when symptoms substantially impair life and further exposure would be unsafe.
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A 68-year-old has gradually progressive knee pain on walking, crepitus and morning stiffness lasting ten minutes. There is no warmth, trauma or systemic illness. What is the most appropriate diagnostic approach?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
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Avoid broken skin, NSAID hypersensitivity and concurrent excess NSAID exposure; systemic harms remain possible. In pregnancy use only when clearly necessary and avoid completely during the third trimester.
Assess ulcer history, anticoagulants, eGFR, heart failure, blood pressure and cardiovascular disease. Avoid severe kidney disease and pregnancy from 20 weeks unless necessary; contraindicated from 28 weeks.
Count combination products to prevent overdose and avoid automatic repeats. Therapeutic excess can cause liver failure, especially with low weight, alcohol dependence, fasting or hepatic disease.
Exclude joint or overlying infection, use aseptic technique, warn about post-injection flare and transient hyperglycaemia, and consider timing before arthroplasty; repeated exposure may damage cartilage.