History and physical examination is sufficient for diagnosis
What approach do you use for diagnosis if you suspect osteoarthritis in a patient older than 45 years with hip or knee pain?
Our Osteoarthritis: Practical tools for diagnosis and management visiting program emphasises that history and physical examination, using validated clinical criteria, is sufficient to diagnose osteoarthritis. This is supported by Australian and international guidelines. 1-3
Typical symptoms of osteoarthritis include a history of activity-related joint pain and either no morning joint-related stiffness, or morning stiffness that lasts no longer than 30 minutes, in people aged 45 years and over. 1,3
The program also identifies validated clinical criteria that can be used for diagnosis of osteoarthritis, and provides a refresher musculoskeletal examination of the knee or hip.
In patients with typical symptoms of osteoarthritis, the likelihood of missing serious pathology without imaging is low, as long as validated clinical criteria and physical examination are used.3
X-ray and MRI have a limited role for diagnosis and management
The evidence shows that some patients with osteoarthritis on X-ray have no symptoms of osteoarthritis, and some patients with painful osteoarthritis based on clinical diagnosis don’t have radiological features.4-6
Imaging for monitoring progress is also limited as the majority of patients with osteoarthritis have stable radiological findings over at least 10 years, regardless of clinical disease progression. Therefore, management decisions after diagnosis are better based on things like managing the patient’s pain and function.1
Remember to treat the patient based on their symptoms, and not the X-ray or MRI features.
Develop an individualised management plan for all patients with osteoarthritis
This plan includes the core management strategies of education and information, weight management and physical activity. The plan should be tailored to the patient’s identified goals, needs and social determinants including their general health literacy and stage of acceptance of their condition.3,7
For patients who are eligible, this plan can be part of a GP Management Plan or Team Care Arrangement.
Patient education needs to be targeted according to their needs, goals, level of health literacy and acceptance. Offer accurate verbal and written information to all people with osteoarthritis. This will enhance understanding of the condition and its management, and counter misconceptions, such as that it inevitably progresses and cannot be treated. Treating the patient as an individual and not a disease state will be crucial to improved communication and better outcomes.1,3,7
For patients who are overweight or obese, every 1 kg of weight loss reduces pressure on the knee by up to 4 kg.8,9
Encourage overweight and obese patients with osteoarthritis to set a realistic goal of 5% or greater weight loss over a 20-week period (0.25% a week), as this is associated with improved function.2,10
Patients with normal weight, or patients who have achieved their weight loss goals, require support with weight maintenance to prevent weight gain. Prevention of weight gain is addressed by strategies that focus on weight maintenance, diet and physical activity.11
Physical activity, including aerobic and strengthening exercises, has been shown to be safe and effective, and is recommended as a core treatment for all patients with osteoarthritis, irrespective of age, comorbidity, pain or disability.1,3,12
The Osteoarthritis: Practical tools for diagnosis and management program covers strategies for exercise and weight management for your patients with osteoarthritis.
Optimise core management strategies before considering pharmacological management
Analgesics are not an inevitable component of osteoarthritis management as individual needs vary and a medicine is not always necessary.2
If an analgesic is required consider a trial-based approach to help enable the patient to do core management strategies with clearly defined management goals, and regular assessment of the patient to determine if the medicine is beneficial. The need for analgesics may change as osteoarthritis symptoms can fluctuate. If symptoms improve, patients should be advised to try stopping the medicine.1
Analgesic options may include topical or oral NSAIDs, topical capsaicin or paracetamol.1
Opioids have a limited role in the management of osteoarthritis, with very small effect sizes equivalent to around 0.9 cm on a 10 cm visual analogue scale.12,13 They also have a significant risk of harm.1
- Rheumatology Expert Group. Osteoarthritis Therapeutic Guidelines. West Melbourne: Therapeutic Guidelines Ltd, 2017 (accessed 6 April 2017).
- Australian Commission on Safety and Quality in Health Care. Osteoarthritis of the Knee Clinical Care Standard. Sydney: ACSQHC, 2017 (accessed 25 May 2017).
- National Institute for Health and Care Excellence. Osteoarthritis: Care and management in adults. Clinical guideline CG177 - methods, evidence and recommendations (February 2014). London: NICE, 2014 (accessed 1 May 2017).
- Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord 2008;9:116.
- Litwic A, Edwards MH, Dennison EM, et al. Epidemiology and burden of osteoarthritis. Br Med Bull 2013;105:185-99.
- Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ 2015;351:h5983.
- Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis 2013;72:1125-35.
- Messier SP, Gutekunst DJ, Davis C, et al. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 2005;52:2026-32.
- Aaboe J, Bliddal H, Messier SP, et al. Effects of an intensive weight loss program on knee joint loading in obese adults with knee osteoarthritis. Osteoarthritis Cartilage 2011;19:822-8.
- Christensen R, Bartels EM, Astrup A, et al. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis 2007;66:433-9.
- National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013 (accessed 15 June 2017).
- McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22:363-88.
- da Costa BR, Nuesch E, Kasteler R, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database Syst Rev 2014:CD003115.