What is the recommended treatment for osteoarthritis with bone spurs?

Treatment of Osteoarthritis with Bone Spurs

Begin with exercise therapy and weight loss if overweight, then add acetaminophen or topical NSAIDs as first-line pharmacologic treatment, reserving oral NSAIDs with gastroprotection for inadequate response. 1

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

Exercise is the foundation of osteoarthritis management and must be initiated regardless of bone spur presence. 1 The presence of bone spurs (osteophytes) does not contraindicate exercise—these are radiographic findings that correlate poorly with symptoms. 1

• Participate in strengthening exercises, low-impact aerobic exercise, and neuromuscular training. 1 Options include walking, stationary cycling, resistance training with elastic bands or weight machines, and aquatic exercise. 1
• Choose exercise based on patient preference and access—walking, cycling, water-based exercise, and tai chi all demonstrate similar efficacy for pain and function improvement. 1
• Weight loss is strongly recommended if BMI ≥25 kg/m², as this reduces mechanical joint stress independent of bone spur presence. 1
• Self-management programs and patient education counter the misconception that osteoarthritis with bone spurs is inevitably progressive and untreatable. 1

First-Line Pharmacologic Treatment

Start with acetaminophen at regular doses up to 4,000 mg daily (consider maximum 3,000 mg daily in elderly patients for enhanced safety). 1 Use scheduled dosing rather than "as needed" for chronic pain control. 1

Topical NSAIDs (such as diclofenac gel) should be considered before oral NSAIDs, particularly for knee and hand osteoarthritis, as they provide similar pain relief with minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications. 1

Second-Line Pharmacologic Treatment

If acetaminophen and topical NSAIDs fail, prescribe oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest duration, always co-prescribed with a proton pump inhibitor for gastroprotection. 1 Choose the proton pump inhibitor with the lowest acquisition cost. 1

• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing any oral NSAID, particularly in patients over age 50 or with comorbidities. 1
• Tramadol is an alternative if NSAIDs are contraindicated or poorly tolerated. 1

Intra-Articular Corticosteroid Injections

Consider intra-articular corticosteroid injections for moderate to severe pain, particularly when accompanied by joint effusion. 1 These provide short-term relief (weeks to months) but do not modify disease progression or affect bone spurs. 1

What NOT to Use

Do not prescribe glucosamine or chondroitin—multiple high-quality guidelines strongly recommend against their use, as data with the lowest risk of bias show no clinically important benefits over placebo. 1

Do not use hyaluronic acid injections—these are not recommended by the American Academy of Orthopaedic Surgeons. 1

Acupuncture is not recommended based on lack of statistically and clinically significant outcomes. 1

Critical Safety Pitfalls to Avoid

• Never exceed 4,000 mg daily of acetaminophen and counsel patients to avoid all other acetaminophen-containing products including over-the-counter cold remedies and combination opioid products. 1
• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription). 1
• Avoid prolonged NSAID use at high doses, particularly in elderly patients who face substantially higher risks of GI bleeding, renal insufficiency, and cardiovascular complications. 1

Surgical Referral Considerations

Refer for joint replacement surgery when symptoms substantially affect quality of life and are refractory to non-surgical treatment, before there is prolonged and established functional limitation. 1 Patient age, sex, smoking status, obesity, and comorbidities should not be barriers to referral. 1

Do not routinely refer for arthroscopic lavage and debridement unless there is a clear history of mechanical locking—not for "giving way," gelling, or radiographic evidence of loose bodies or bone spurs alone. 1