What is the initial management for a patient with chondrosis?

Initial Management of Chondrosis

For patients with chondrosis (osteoarthritis/cartilage degeneration), begin immediately with the core triad of patient education, exercise therapy, and weight loss if overweight, followed by acetaminophen or topical NSAIDs as first-line pharmacological treatment. 1

Core Non-Pharmacological Treatments (Start These First)

All patients with symptomatic chondrosis must receive these foundational interventions before or alongside any medication 1:

• Patient education: Provide written and oral information countering the misconception that osteoarthritis is inevitably progressive and untreatable 1
• Exercise prescription: Implement local muscle strengthening exercises combined with general aerobic fitness training 1
• Weight management: For patients with BMI ≥25 kg/m², weight loss interventions are essential 2
• Activity modification: Advise on pacing activities to avoid peaks and troughs, and recommend shock-absorbing footwear 1

First-Line Pharmacological Management

Step 1: Acetaminophen (Paracetamol)

• Start with regular-dose acetaminophen for pain relief, as it carries lower cardiovascular and gastrointestinal risk than NSAIDs 1
• Use at the lowest effective dose for the shortest duration necessary 1
• While efficacy in osteoarthritis is modest and uncertain, acetaminophen remains appropriate when oral NSAIDs are contraindicated 1

Step 2: Topical NSAIDs

• For knee and hand chondrosis specifically, topical NSAIDs should be considered before oral NSAIDs 1
• Topical formulations provide localized pain relief with reduced systemic side effects 1, 2

Step 3: Oral NSAIDs (If Above Insufficient)

• Use oral NSAIDs or COX-2 inhibitors only at the lowest effective dose for the shortest possible period 1
• Prescribe alongside a proton pump inhibitor to reduce gastrointestinal risk 1
• Evaluate cardiovascular, renal, and gastrointestinal risk factors before prescribing 1
• For patients with cardiovascular disease or risk factors, use a stepped-care approach prioritizing agents with lowest cardiovascular risk 1

Adjunctive Non-Pharmacological Interventions

Consider these evidence-based additions 1:

• Local heat or cold applications for symptomatic relief 1
• Manual therapy (manipulation and stretching), particularly beneficial for hip osteoarthritis 1
• TENS (transcutaneous electrical nerve stimulation) for pain management 1
• Assistive devices (walking sticks, braces, insoles) for patients with biomechanical joint pain or instability 1
• Occupational therapy to address functional limitations 1

What NOT to Use

Avoid chondroitin sulfate and glucosamine for knee and hip osteoarthritis, as high-quality evidence shows no clinically important benefit over placebo 2. The American College of Rheumatology and American Academy of Orthopaedic Surgeons strongly recommend against these agents 2. The single exception is hand osteoarthritis, where chondroitin may be considered based on limited evidence from one trial 1, 2.

Intra-Articular Corticosteroid Injections

• For interphalangeal joint involvement: Consider intra-articular corticosteroid injections for moderate to severe pain with clear inflammation 1
• For thumb base osteoarthritis: Generally avoid, as evidence does not support efficacy over placebo 1
• Use judiciously for relief of local inflammatory symptoms 1

Monitoring and Follow-Up

• Provide periodic review tailored to individual needs 1
• Assess impact on function, quality of life, occupation, mood, and leisure activities 1
• Monitor for adverse effects of medications, particularly with NSAID use 1

Common Pitfalls to Avoid

• Do not delay core treatments while waiting for pharmacological interventions to work 1
• Do not prescribe NSAIDs without gastrointestinal protection in at-risk patients 1
• Do not use systemic glucocorticoids as initial management; reserve for specific inflammatory presentations and limit duration to <6 months 1
• Do not recommend rubefacients or intra-articular hyaluronan injections, as these are not supported by evidence 1