What are the signs and symptoms of osteoarthritis in an adult over 50 with a history of previous joint injury or family history of osteoarthritis?

Signs and Symptoms of Osteoarthritis

In adults over 50 with prior joint injury or family history, osteoarthritis presents with usage-related joint pain, brief morning stiffness (<30 minutes), and intermittent symptoms affecting characteristic joints—most commonly the knees, hips, hands (DIP and PIP joints), and spine. 1, 2

Cardinal Symptoms

Pain Characteristics

• Mechanical pain worsened by joint use and movement, improving with rest 1, 3
• Pain severity is variable and often fluctuates over time 1
• In advanced disease, rest pain and night pain may develop 3
• Pain is multifactorial in origin and poorly correlates with radiographic severity 4

Stiffness Pattern

• Brief morning stiffness or inactivity stiffness, typically lasting less than 30 minutes 1, 2
• This short duration distinguishes OA from inflammatory arthritis (which causes prolonged stiffness >30 minutes) 1, 2
• Stiffness after periods of immobility is characteristic 5

Symptom Distribution

• Symptoms are intermittent and affect one or a few joints at any given time, not all joints simultaneously 1
• Gradual onset with slow, progressive worsening over time 4

Physical Examination Findings

Joint-Specific Signs

• Coarse crepitus (grinding sensation) with joint movement 3, 6
• Bony enlargement at affected joints 1, 3
• Tenderness along the joint line 3
• Limited range of motion and functional impairment 3, 7

Hand Osteoarthritis Hallmarks

• Heberden's nodes (bony enlargement at distal interphalangeal joints) 1, 2
• Bouchard's nodes (bony enlargement at proximal interphalangeal joints) 1, 2
• Lateral deviation or deformity of interphalangeal joints 1
• Thumb base involvement (rhizarthrosis) causing significant functional limitation 4

Advanced Disease Features

• Joint deformity in severe cases 3, 4
• Subluxation and adduction deformity at thumb base 1

Most Commonly Affected Joints

Primary Target Sites

• Knees (most common, especially in women with obesity) 3, 4, 6
• Hips (produces inguinal and anterior thigh pain radiating to knee) 4, 6
• Hands: DIP joints > thumb base > PIP joints > MCP joints (index and middle fingers) 1, 4
• Spine (facet joints and vertebral bodies) 3, 4
• Feet (big toe), shoulders, and ankles less commonly 3, 7

Risk Factor Context for Your Patient

Given the history of prior joint injury and family history, this patient has established risk factors that increase OA likelihood 1:

• Age over 40-50 years is a primary risk factor 1, 7
• Prior joint injury is a recognized risk factor 1
• Family history increases risk 1
• Female sex confers higher risk (relative risk 1.23-1.54) 1

Clinical Diagnosis Algorithm

For patients over 40 years presenting with typical features (usage-related pain, brief morning stiffness, characteristic joint involvement), a confident clinical diagnosis can be made without imaging 1, 2:

When Imaging Is NOT Required

• Age >40 years with typical symptom pattern 2
• Usage-related pain affecting one or few joints 2
• Short duration morning stiffness 2
• Presence of Heberden's or Bouchard's nodes 2

Red Flags Requiring Imaging

• Age <40 years with joint symptoms 2
• Prolonged morning stiffness >30 minutes (suggests inflammatory arthritis) 2
• Marked inflammatory signs (significant warmth, effusion, systemic symptoms) 2
• Rapid symptom progression or sudden clinical change 2
• Atypical joint distribution (e.g., predominantly MCP joints suggesting rheumatoid arthritis) 2

Important Differential Diagnoses to Consider

The differential diagnosis is wide, and certain conditions can mimic or coexist with OA 1:

• Rheumatoid arthritis (targets MCPs, PIPs, wrists rather than DIPs) 1, 2
• Psoriatic arthritis (may target DIPs or single ray) 1, 2
• Gout (can superimpose on pre-existing OA) 1, 2
• Hemochromatosis (mainly MCPs and wrists) 1

Functional Impact

• Functional impairment in OA can be as severe as in rheumatoid arthritis 1
• Decreased physical activity and quality of life due to pain and stiffness 3
• Disability in activities of daily living is common 7, 6
• Function should be carefully assessed using validated outcome measures 1

Common Pitfall to Avoid

Do not rely on radiographic findings to make the diagnosis or guide treatment—there is poor correlation between X-ray severity and symptom severity 7, 4. The diagnosis is primarily clinical, driven by history and physical examination 2. Imaging is reserved for atypical presentations or when considering surgical referral 2, 7.