What are the recommendations for osteoarthritis (OA) screening and management?

Osteoarthritis Screening and Management Recommendations

Imaging is not required to make the diagnosis of osteoarthritis in patients with typical presentation, and routine screening for osteoarthritis is not recommended. 1

Diagnosis of Osteoarthritis

• Diagnosis is primarily based on clinical presentation without the need for routine imaging 1, 2

• Typical presentation includes:

  • Joint pain that worsens with activity and improves with rest
  • Morning stiffness lasting less than 30 minutes
  • Reduced range of motion
  • Crepitus (especially in knee OA)
  • Joint line tenderness 3

• Imaging should only be used in atypical presentations to confirm diagnosis or rule out alternative conditions 1

• When imaging is needed, conventional radiography should be used before other modalities 1

• For knee OA, weight-bearing and patellofemoral views are recommended for optimal detection 1

Core Management Recommendations

Non-Pharmacological Approaches (First-Line)

1. Exercise therapy (strongly recommended) 1, 4

   • Land-based exercises including strengthening, flexibility, and aerobic activities
   • Aquatic exercises (particularly beneficial for bilateral hip OA)
   • Tai Chi (strongly recommended for knee and hip OA)
   • Exercise programs should be supervised when possible for better outcomes

2. Education and self-management programs (strongly recommended) 1, 4

   • Information about disease process
   • Joint protection techniques
   • Activity modification
   • Pain management strategies

3. Weight loss (strongly recommended for overweight/obese patients) 1, 4

   • Target minimum weight loss of 5-10% of body weight
   • Reduces mechanical stress on weight-bearing joints

4. Assistive devices 1, 4

   • Cane use (strongly recommended)
   • Hand orthoses for first carpometacarpal joint OA (strongly recommended)
   • Tibiofemoral bracing for tibiofemoral knee OA (strongly recommended)
   • Patellofemoral bracing for patellofemoral knee OA (conditionally recommended)

Pharmacological Interventions

1. Topical NSAIDs (strongly recommended for knee OA) 1, 4

   • First-line pharmacological therapy, especially for patients with comorbidities
   • Lower systemic absorption reduces risk of adverse effects

2. Oral NSAIDs (strongly recommended) 1, 4, 5

   • Use lowest effective dose for shortest duration (maximum 3200mg daily for ibuprofen)
   • Consider patient's age, comorbidities, and risk factors
   • Monitor for GI side effects; consider gastroprotective agents if needed

3. Intra-articular glucocorticoid injections (strongly recommended for knee OA) 1, 4

   • Provides short-term pain relief
   • Imaging may improve accuracy of injection, particularly for difficult-to-access joints

4. Other medications (conditionally recommended) 1, 4

   • Acetaminophen (up to 3g/day)
   • Duloxetine
   • Tramadol (when NSAIDs are contraindicated)
   • Chondroitin sulfate (for hand OA)
   • Topical capsaicin (for knee OA)

Surgical Interventions

• Total joint replacement for end-stage disease not responding to conservative measures 4
• Joint-preserving procedures (e.g., osteotomy) for younger adults with symptomatic hip OA 4
• Consider surgical referral when:
  • Conservative treatment fails after adequate trial
  • Pain significantly impacts quality of life
  • Imaging confirms significant structural abnormalities 4

Treatment Algorithm

1. Initial approach for all patients:

   • Exercise therapy (supervised if possible)
   • Education and self-management strategies
   • Weight loss (if overweight/obese)
   • Assistive devices as appropriate

2. If inadequate response, add:

   • Topical NSAIDs (first pharmacological choice, especially for knee OA)
   • Oral NSAIDs if topical treatment insufficient (lowest effective dose)

3. For persistent symptoms:

   • Intra-articular glucocorticoid injections
   • Consider adjunctive medications (acetaminophen, duloxetine)

4. For end-stage disease:

   • Referral for surgical evaluation

Monitoring and Follow-up

• Regular assessment of pain control and functional status
• Monitoring for medication side effects, particularly with NSAIDs
• Assessment of treatment efficacy and adjustment as needed 4

Important Considerations

• OA affects nearly 1 in 2 people by age 85 and is a significant cause of disability 4, 6
• Patients with OA often have comorbidities (59-87%), especially cardiometabolic conditions 6
• Avoid long-term opioid use due to risk of side effects and dependency 4
• Imaging features do not predict non-surgical treatment response 1

By implementing these evidence-based recommendations, clinicians can provide comprehensive care for patients with osteoarthritis, focusing on improving function, reducing pain, and enhancing quality of life.