What are the management options for osteoarthritis?

Management of Osteoarthritis

All patients with osteoarthritis should begin with a foundation of exercise, weight loss (if overweight/obese), and self-management education before escalating to pharmacological therapies, as these core non-pharmacological interventions improve both pain and function with minimal risk. 1, 2, 3

Core Non-Pharmacological Treatments (Universal for All Patients)

Exercise (Strongly Recommended)

• Exercise is the cornerstone of osteoarthritis management and should be prescribed to every patient regardless of joint involvement. 1, 2, 3
• Acceptable forms include walking, strengthening exercises, aquatic exercise, and neuromuscular training—no single type is superior, so patient preference and access should guide selection. 1, 2
• Supervised exercise programs (often delivered by physical therapists) are more effective than home-based programs alone, particularly when combined with self-management education. 1
• Patients experiencing pain should not avoid exercise; clinical trials demonstrate benefit even in symptomatic patients, and shared decision-making should determine when to initiate rather than arbitrary pain thresholds. 1

Weight Loss (Strongly Recommended)

• Weight loss of ≥5% body weight produces clinically meaningful improvements in knee and hip osteoarthritis, with greater benefits at 10-20% loss. 1, 2, 3
• Weight loss combined with exercise produces superior outcomes compared to either intervention alone. 1

Self-Management and Patient Education (Strongly Recommended)

• Provide structured self-management programs that combine skill-building (goal-setting, problem-solving), disease education, joint protection strategies, and fitness instruction. 1, 2, 3
• Counter the misconception that osteoarthritis is inevitably progressive and untreatable. 1
• These programs can be delivered by health educators, nurses, physical therapists, or peer leaders, either in-person or online. 1

Mind-Body Approaches

• Tai chi is strongly recommended for knee and hip osteoarthritis, combining physical movement with meditation, breathing, and relaxation to improve strength, balance, pain, and self-efficacy. 1
• Yoga is conditionally recommended for knee osteoarthritis but lacks sufficient data for hip osteoarthritis. 1

Joint-Specific Physical Modalities

Hand Osteoarthritis

• First carpometacarpal (CMC) joint orthoses (rigid or neoprene) are strongly recommended for thumb base osteoarthritis. 1, 2, 3
• Orthoses for other hand joints are conditionally recommended. 1, 2

Knee Osteoarthritis

• Tibiofemoral bracing is strongly recommended for tibiofemoral osteoarthritis. 1, 2, 3
• Patellofemoral bracing is conditionally recommended for patellofemoral osteoarthritis. 1, 2
• Lateral heel wedges should NOT be prescribed for medial compartmental knee osteoarthritis. 3

Hip Osteoarthritis

• Cane use is strongly recommended to reduce joint load and improve mobility. 2, 3
• Manipulation and stretching are particularly beneficial for hip osteoarthritis. 1

Additional Physical Modalities

• Local heat or cold applications provide symptomatic relief. 1, 2
• Transcutaneous electrical nerve stimulation (TENS) can be used for pain management. 1
• Balance exercises are conditionally recommended for knee and hip osteoarthritis. 1, 2
• Assistive devices (walking sticks, tap turners) should be provided for patients with specific functional limitations. 1

Pharmacological Treatment Algorithm

Step 1: Topical Therapies (First-Line for Accessible Joints)

• Topical NSAIDs are strongly recommended as first-line pharmacological treatment for knee osteoarthritis, providing effective pain relief with minimal systemic exposure and lower risk than oral NSAIDs. 2, 4, 3
• Topical NSAIDs should also be considered for hand osteoarthritis before oral agents. 1
• Topical capsaicin is an alternative option for knee and hand osteoarthritis. 1

Step 2: Oral Analgesics

• Acetaminophen (paracetamol) up to 4,000 mg/day can be tried for mild-to-moderate pain, though recent evidence shows limited efficacy compared to NSAIDs. 1, 2, 4
• Regular dosing may be more effective than as-needed administration. 1
• Monitor for hepatotoxicity, particularly in elderly patients or those with liver disease. 4

Step 3: Oral NSAIDs (When Topical Therapy Insufficient)

• Oral NSAIDs are strongly recommended for hand, knee, and hip osteoarthritis when topical treatments fail, but use the lowest effective dose for the shortest duration. 1, 2, 3, 5
• Choose between a standard NSAID or COX-2 inhibitor (other than etoricoxib 60 mg) based on individual risk factors. 1
• Always co-prescribe a proton pump inhibitor with oral NSAIDs or COX-2 inhibitors to reduce gastrointestinal risk, selecting the lowest-cost option. 1, 3
• Before prescribing, assess cardiovascular, gastrointestinal, renal, and hepatic risk factors, particularly in elderly patients. 1, 4
• NSAIDs demonstrate comparable analgesic efficacy to aspirin and indomethacin but with fewer gastrointestinal and nervous system adverse effects. 5
• For patients requiring low-dose aspirin, consider other analgesics before adding NSAIDs due to increased bleeding risk. 1

Step 4: Duloxetine (For Refractory Cases or Comorbid Depression)

• Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments or those with comorbid depression. 2, 3

Step 5: Tramadol (Reserve for Refractory Cases)

• Tramadol is conditionally recommended only when other options have failed, recognizing risks of dependence, falls, and cognitive impairment, particularly in elderly patients. 2, 3

Intra-Articular Injections

Corticosteroid Injections

• Corticosteroid injections are strongly recommended for knee and hip osteoarthritis to provide short-term pain relief (4-8 weeks) during acute flares. 2, 3, 6
• Effective for painful flares in hand osteoarthritis, especially the trapeziometacarpal joint. 3
• These provide inexpensive, rapid relief but do not alter disease progression. 7, 6

Hyaluronic Acid Injections

• Hyaluronic acid injections are more expensive than corticosteroids but may maintain symptom improvement for longer periods in knee osteoarthritis. 7, 6

Treatments NOT Recommended

The following interventions should be avoided as they lack evidence of benefit:

• Glucosamine and chondroitin products are NOT recommended despite popular use, as they show no significant benefit over placebo. 1, 2, 4, 3, 8
• Electroacupuncture should NOT be used. 1, 2, 3
• Acupuncture has insufficient evidence for firm recommendation. 1
• Arthroscopic lavage or débridement should NOT be routinely performed, as these procedures show no benefit over sham surgery or optimized medical therapy. 3, 8

Surgical Considerations

• Joint replacement surgery (hip, knee, shoulder) should be reserved for patients with severe osteoarthritis and chronic pain/disability despite maximal medical management, as it generally provides excellent results. 4, 3, 7, 8, 6
• Partial meniscectomy or loose body removal may be considered when specific mechanical symptoms are present. 3
• Realignment osteotomy may be appropriate for select candidates. 3
• For severe thumb base osteoarthritis refractory to conservative treatment, consider interposition arthroplasty, osteotomy, or arthrodesis. 3

Critical Implementation Points

Holistic Assessment

• Assess the impact of osteoarthritis on function, quality of life, occupation, mood, relationships, and leisure activities at each visit. 1
• Formulate management plans in partnership with patients, considering comorbidities that compound osteoarthritis effects. 1
• Provide periodic review tailored to individual needs, as disease course and requirements change over time. 1, 4, 9

Common Pitfalls to Avoid

• Do not combine NSAIDs with aspirin, as aspirin increases NSAID excretion and the combination increases adverse event frequency without proven additional benefit. 5
• Do not prescribe NSAIDs without gastroprotection in at-risk patients. 1, 3
• Do not delay exercise prescription due to patient pain—supervised programs with gradual progression are safe and effective even in symptomatic patients. 1
• Do not rely solely on pharmacological therapy; the evidence strongly supports non-pharmacological interventions as foundational treatment. 1, 2, 3