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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Osteoarthritis

Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Acutely hot or damaged joint

A suddenly hot swollen joint, systemic illness, inability to bear weight after trauma, neurovascular compromise or rapidly destructive pain is not routine osteoarthritis and may represent sepsis, fracture or dislocation.

Action: Assess vital signs and the joint immediately, give appropriate analgesia, obtain urgent trauma imaging, and arrange same-day hospital assessment and synovial-fluid sampling when septic arthritis cannot be excluded.

Synopsis

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.

  • In an adult aged 45 years or older, activity-related joint pain with absent morning stiffness or stiffness lasting no longer than 30 minutes can usually be diagnosed clinically as osteoarthritis.
  • Do not request routine imaging to confirm a typical presentation; image when features are atypical, trauma or another diagnosis is suspected, or a result will change procedural planning.
  • Therapeutic exercise and sustained weight-loss support when appropriate are core treatments; temporary discomfort after starting exercise does not mean joint damage is accelerating.
  • For knee osteoarthritis, offer a topical NSAID before an oral NSAID; if oral treatment is needed, use the lowest effective dose briefly with gastroprotection.
  • Do not routinely offer strong opioids, glucosamine, acupuncture, dry needling or electrotherapy; paracetamol and weak opioids are limited rescue options when alternatives cannot be used.
  • An intra-articular corticosteroid can provide relief for roughly two to ten weeks to enable rehabilitation, but is neither disease modifying nor an indefinite repeated treatment.
  • Refer for joint replacement when symptoms and reduced function substantially affect quality of life despite appropriate non-surgical care, without requiring a particular radiographic grade.
  • Do not deny referral solely because of age, sex, smoking, comorbidity, disability or body mass index; discuss individual operative risk and optimisation instead.

Key red flags

Fever, rigors, marked warmth, rapid effusion or immunosuppression with acute monoarthritis requires urgent exclusion of septic arthritis rather than attribution to an osteoarthritis flare.

Progressive night pain unrelated to movement, unexplained weight loss, a mass or previous cancer warrants investigation for malignancy or destructive bone disease.

Major trauma, sudden inability to bear weight, deformity or focal bony tenderness requires a fracture or dislocation pathway, especially in an older or osteoporotic adult.

New motor weakness, saddle sensory loss, bladder dysfunction, a cold limb or absent pulses indicates neurological or vascular compromise and needs emergency assessment.

Investigation priorities

01
First-line clinical assessmentFirst stepFirst line

Make a positive diagnosis in a typical adult and identify findings requiring a competing diagnostic pathway.

Management branches

First-lineBuild an individual non-drug plan

A clinical diagnosis is secure and no red flag or urgent alternative explains the painful joint.

  1. Explain whole-joint disease, the imperfect image-pain relationship, expected fluctuations and why gradual movement is protective rather than evidence of further wear.
  2. Offer tailored local muscle strengthening plus aerobic activity, beginning within tolerance and progressing dose, frequency or resistance with physiotherapy support when needed.
  3. If excess weight contributes, offer respectful sustained weight-management support; any loss may help, while around ten percent generally improves symptoms more than five percent.
  4. Address footwear, pacing, work tasks, walking aids and falls, using devices because they solve a defined biomechanical or functional problem.
Urgent alternativeLeave the routine pathway safely

The joint is acutely hot, symptoms follow major trauma, systemic illness is present or neurological, vascular or malignant features emerge.

  1. Repeat observations and examine skin, effusion, perfusion and neurology; never inject a joint when infection has not been excluded.
  2. Arrange urgent radiography for suspected fracture or dislocation and same-day acute care for possible septic arthritis, collecting cultures where feasible.

Key medicines

Topical diclofenac gelApply the product-specified amount to the painful joint, commonly 2–4 g of 1.16% gel three or four times daily; remain below the product maximum and review after two to four weeks.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.
Naproxen with gastroprotectionTake 250 mg orally twice daily and increase if necessary to 500 mg twice daily, with food, for the shortest course; add omeprazole 20 mg once daily unless another protective plan is chosen.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.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

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.

  • NICE NG226 Osteoarthritis in over 16s recommendationsClinical diagnosis, core treatment, medicines, injections and referral principles.
  • NICE QS87 Osteoarthritis quality standardQuality priorities for diagnosis, exercise, weight management and surgery access.
  • MHRA NSAIDs after 20 weeks of pregnancy safety updatePregnancy timing and fetal renal or ductal safety restrictions for systemic NSAIDs.
  • Diclofenac gel Summary of Product CharacteristicsProduct-specific topical administration, contraindications and adverse effects.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Use an expedited cancer, spinal or vascular route when progressive night pain, a mass, neurological loss or limb ischaemia indicates time-dependent disease.