What are the treatment options for osteoarthritis (OA)?

Treatment Options for Osteoarthritis (OA)

The comprehensive management of osteoarthritis requires a stepwise approach beginning with core non-pharmacological treatments (exercise, weight loss, and self-management education), followed by appropriate pharmacological options and eventually surgical interventions for those with refractory symptoms. 1

Core Treatments (First-Line)

Exercise

• Strongly recommended for all OA patients regardless of age, comorbidity, pain severity, or disability 1
• Types of beneficial exercise:
  • Strengthening exercises (particularly quadriceps for knee OA) 1
  • Low-impact aerobic activities (walking, cycling, swimming) 1
  • Range-of-motion/flexibility exercises 1
  • Tai chi (strongly recommended) 1
  • Balance exercises (conditionally recommended) 1
  • Yoga (conditionally recommended) 1
  • Water-based exercises 2

Weight Management

• Weight loss strongly recommended for overweight/obese patients (BMI >25) 1
• Target: Minimum 5% body weight reduction 1
• Combine dietary modification with exercise program 1

Self-Management Education

• Strongly recommended for all OA patients 1
• Should include:
  • Disease information to counter misconceptions 1
  • Self-efficacy strategies 1
  • Behavioral modifications (activity pacing) 1

Adjunct Non-Pharmacological Treatments

Assistive Devices

• Walking aids (canes) strongly recommended 1
• Braces and orthoses:
  • First CMC joint orthoses for hand OA (strongly recommended) 1
  • Tibiofemoral knee braces for knee OA (strongly recommended) 1
  • Patellofemoral braces (conditionally recommended) 1
  • Orthoses for other hand joints (conditionally recommended) 1

Physical Modalities

• Local heat/cold applications 1
• Transcutaneous electrical nerve stimulation (TENS) 1
• Kinesiotaping (conditionally recommended) 1
• Radiofrequency ablation (conditionally recommended) 1
• Thermal modalities (conditionally recommended) 1

Manual Therapy

• Manipulation and stretching (particularly for hip OA) 1

Pharmacological Management

Topical Treatments

• Topical NSAIDs strongly recommended for knee OA 1
• Topical NSAIDs conditionally recommended for hand OA 1
• Topical capsaicin conditionally recommended for knee OA 1

Oral Analgesics

• Oral NSAIDs strongly recommended for hand, knee, and hip OA 1, 3
  • Use at lowest effective dose for shortest duration 1
  • Consider patient-specific risk factors (age, comorbidities) 1, 3
  • Co-prescribe with proton pump inhibitor 1
• Acetaminophen (paracetamol) conditionally recommended 1
  • Less effective than previously thought 4
• Duloxetine conditionally recommended 1
• Tramadol conditionally recommended 1

Intra-articular Treatments

• Intra-articular corticosteroid injections strongly recommended for knee and hip OA 1
• Intra-articular corticosteroids conditionally recommended for hand OA 1
• Hyaluronic acid injections not recommended 1

Not Recommended Treatments

• Glucosamine and chondroitin products 1
• Electroacupuncture 1
• Acupuncture (recommendations vary between guidelines) 1

Surgical Interventions

• Consider referral for joint replacement when:
  • Symptoms substantially affect quality of life 1
  • Symptoms are refractory to non-surgical treatments 1
  • Patient has been offered core treatments 1
• Arthroscopic lavage and debridement not routinely recommended 1

Treatment Algorithm

1. Start with core treatments for all patients (exercise, weight management if applicable, self-management education)
2. Add appropriate non-pharmacological adjuncts based on joint involvement
3. For pharmacological management:
   • For localized knee or hand OA: Begin with topical NSAIDs
   • For widespread or hip OA: Begin with oral NSAIDs (with PPI)
   • If inadequate relief: Consider intra-articular corticosteroid injections
   • For patients with contraindications to NSAIDs: Consider acetaminophen, duloxetine, or tramadol
4. Consider surgical referral only after failure of comprehensive non-surgical management

Common Pitfalls to Avoid

• Relying solely on pharmacological treatments without implementing core non-pharmacological approaches
• Using opioids before trying other safer analgesic options
• Recommending glucosamine/chondroitin despite lack of evidence
• Delaying referral for joint replacement until severe functional limitation occurs
• Failing to address weight management in overweight/obese patients
• Performing arthroscopic lavage/debridement for OA without mechanical locking