What are the management options for osteoarthritis?

Osteoarthritis Management

Start all patients with osteoarthritis on exercise therapy and weight loss (if overweight/obese) as the foundation of treatment, then add topical NSAIDs for knee OA or oral NSAIDs for hand/hip/knee OA, reserving intra-articular corticosteroid injections for flares and joint replacement for severe refractory disease. 1, 2, 3

Core Non-Pharmacological Treatments (Start Here for All Patients)

Exercise (Strongly Recommended)

• Prescribe exercise programs for all patients with hand, hip, and knee OA regardless of pain level. 1
• Acceptable exercise modalities include walking, strengthening exercises, aquatic exercise, and neuromuscular training—no single type is superior, so choose based on patient preference and access. 1
• Supervised exercise programs (often delivered by physical therapists) produce better outcomes than home-based programs alone. 1
• Combine exercise with self-efficacy training or weight loss programs for enhanced effectiveness. 1

Weight Loss (Strongly Recommended)

• Mandate weight loss for all overweight or obese patients with knee or hip OA. 1, 2, 3
• Target at least 5% body weight reduction; greater losses (10-20% or more) produce progressively better clinical outcomes. 1
• Combine weight loss with exercise for optimal symptom improvement. 1

Self-Management and Education (Strongly Recommended)

• Enroll all patients in self-efficacy and self-management programs that include goal-setting, problem-solving, disease education, and joint protection strategies. 1, 2
• These programs can be delivered in-person or online by health educators, nurses, physical therapists, or peer leaders. 1

Mind-Body Interventions

• Prescribe tai chi for knee and hip OA (strongly recommended) as it addresses strength, balance, depression, and self-efficacy through combined meditation, gentle movement, and breathing exercises. 1, 2
• Consider yoga for knee OA (conditionally recommended), though evidence is less robust than for tai chi. 1, 2

Joint-Specific Physical Interventions

Hand OA

• Prescribe first carpometacarpal (CMC) joint orthoses (neoprene or rigid) for thumb base OA (strongly recommended). 1, 2, 3
• Consider orthoses for other hand joints (conditionally recommended). 1, 2

Knee OA

• Prescribe tibiofemoral bracing for tibiofemoral OA (strongly recommended). 1, 2, 3
• Consider patellofemoral bracing for isolated patellofemoral OA (conditionally recommended). 1, 2
• Recommend cane use to reduce joint load and improve mobility (strongly recommended). 2, 3, 4

Hip OA

• Recommend cane use (strongly recommended). 3, 4
• Consider manipulation and stretching exercises specifically for hip OA. 1, 4

Additional Physical Modalities

• Offer local heat or cold applications for symptomatic relief. 1, 4
• Consider transcutaneous electrical nerve stimulation (TENS) for pain management. 1, 4
• Consider balance exercises for knee and hip OA to improve stability (conditionally recommended). 1, 4

Pharmacological Management Algorithm

First-Line: Topical Therapy

• Prescribe topical NSAIDs for knee OA (strongly recommended) as they provide effective pain relief with minimal systemic exposure and lower risk than oral agents. 2, 3, 4
• Consider topical capsaicin for knee and hand OA. 1

Second-Line: Oral NSAIDs

• Prescribe oral NSAIDs for hand, knee, and hip OA when topical therapy is insufficient or impractical (strongly recommended). 1, 2, 3, 4
• Use the lowest effective dose for the shortest duration to minimize gastrointestinal, cardiovascular, and renal toxicity. 1, 3, 5
• Co-prescribe a proton pump inhibitor with all oral NSAIDs or COX-2 inhibitors to reduce gastrointestinal risk, selecting the lowest-cost option. 1, 3
• Choose either a COX-2 inhibitor (other than etoricoxib 60 mg) or standard NSAID based on individual cardiovascular and gastrointestinal risk factors. 1

Third-Line: Alternative Oral Agents

• Consider acetaminophen for mild-to-moderate pain (conditionally recommended), though recent evidence shows limited efficacy. 2, 4
• Consider duloxetine for patients with inadequate response to NSAIDs or comorbid depression (conditionally recommended). 2, 4
• Reserve tramadol for refractory cases only due to dependence risk and side effects (conditionally recommended). 2, 4, 6
• Avoid routine opioid use; if prescribed for moderate-to-severe pain, carefully select and monitor patients due to inherent adverse effects. 6

Intra-Articular Injections

• Administer corticosteroid injections for knee and hip OA during painful flares for short-term relief (strongly recommended). 3, 4
• Consider corticosteroid injection for hand OA, especially the trapeziometacarpal joint. 3
• Evidence for hyaluronic acid injections is mixed and inconsistent. 6

Treatments NOT Recommended

• Do not prescribe glucosamine or chondroitin products due to lack of efficacy evidence. 1, 3, 4
• Do not use electroacupuncture. 1, 3, 4
• Do not prescribe lateral heel wedges for medial compartmental knee OA. 3
• Do not perform arthroscopic lavage or débridement routinely, as studies show no benefit. 3, 6

Surgical Interventions

• Reserve total joint replacement for severe OA unresponsive to comprehensive medical management. 3, 6
• Consider partial meniscectomy only for mechanical symptoms (loose bodies). 3
• Consider realignment osteotomy, interposition arthroplasty, or arthrodesis for appropriate candidates with severe disease. 3

Common Pitfalls to Avoid

• Do not delay exercise therapy because patients report pain—clinical trials demonstrate that patients with pain can safely participate in and benefit from exercise programs. 1
• Do not combine NSAIDs with aspirin routinely, as aspirin increases naproxen excretion and the combination increases adverse event frequency without proven additional benefit. 5
• Do not use NSAIDs and aspirin together without gastroprotection, as this significantly increases gastrointestinal bleeding risk. 1
• Avoid prescribing exercise without addressing patient barriers (preference, access, transportation), as these determine adherence more than exercise type. 1
• Do not prescribe tramadol or opioids as first-line agents—these have poor risk-benefit profiles compared to NSAIDs and non-pharmacological interventions. 6