What is the recommended treatment for osteoarthritis?

Treatment for Osteoarthritis

Begin with the core triad of patient education, regular exercise (including strengthening and aerobic activities), and weight loss if overweight—these non-pharmacological interventions form the foundation for all osteoarthritis management and should be implemented before or alongside any pharmacological therapy. 1

Core Non-Pharmacological Treatments (Required for All Patients)

Education and Self-Management

• Provide education to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1
• Establish self-management strategies emphasizing exercise adherence and behavioral modifications 1
• Direct patients to evidence-based resources for ongoing education 1

Exercise Programs

• Prescribe aerobic exercise, aquatic exercise, and/or resistance training for knee and hip osteoarthritis (this is a strong recommendation based on high-quality evidence) 1
• Implement local muscle strengthening exercises, particularly quadriceps strengthening for knee osteoarthritis 1
• Include range of motion activities and functional training, especially for hand osteoarthritis 2

Weight Management

• Mandate weight loss interventions for overweight or obese patients—this directly reduces mechanical joint loading and systemic inflammation 1, 2

Assistive Devices and Biomechanical Interventions

• Prescribe shock-absorbing footwear for all weight-bearing joint osteoarthritis 1
• Consider medial wedge insoles specifically for valgus knee osteoarthritis 1
• Consider subtalar strapped lateral insoles for varus knee osteoarthritis 1
• Provide walking aids (canes, walkers) for patients with gait instability 1
• Refer to occupational therapy for joint protection techniques, splinting (especially trapeziometacarpal joint splints for hand osteoarthritis), and adaptive equipment 1, 2

Pharmacological Treatment Algorithm

Step 1: First-Line Analgesics

Start with acetaminophen (paracetamol) up to 4,000 mg/day in divided doses—this is the safest initial oral analgesic and preferred long-term option if effective. 1, 2

• For knee and hand osteoarthritis specifically, consider topical NSAIDs (applied 3-4 times daily) before advancing to oral NSAIDs 1, 2
• Topical NSAIDs provide localized pain relief with minimal systemic absorption and superior safety profile 2, 3

Step 2: Oral NSAIDs (If Acetaminophen/Topical NSAIDs Insufficient)

Use oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible duration, always with proton pump inhibitor co-prescription for gastroprotection. 1, 2

• Select either a COX-2 inhibitor (excluding etoricoxib 60 mg) or standard NSAID based on individual cardiovascular, gastrointestinal, renal, and hepatic risk factors 1
• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but differ in toxicity profiles 1
• Conduct risk assessment considering age (particularly >65 years), cardiovascular disease, renal function, and gastrointestinal history before prescribing 1, 2

Step 3: Additional Pharmacological Options

For topical therapy: Apply topical capsaicin to hand or knee joints for localized pain relief 1

For systemic therapy: Consider tramadol for patients with inadequate response to NSAIDs or those with NSAID contraindications 1

For severe refractory pain: Duloxetine may be added for patients with inadequate response to initial therapies 1

For opioid therapy: Reserve opioid analgesics for patients who are either unwilling to undergo or have contraindications for total joint arthroplasty after failing all other medical therapies (this is a strong recommendation) 1

Step 4: Intra-Articular Injections

Administer intra-articular corticosteroid injections for acute exacerbations with moderate to severe pain, especially when accompanied by joint effusion. 1

• These provide temporary relief and are appropriate for flare management 2
• Repeat injections may be considered for recurrent acute exacerbations 4

Adjunctive Non-Pharmacological Modalities (Joint-Specific)

For All Joints

• Apply local heat or cold therapy for symptomatic relief 1
• Consider transcutaneous electrical nerve stimulation (TENS) 1
• Implement tai chi programs for knee osteoarthritis 1
• Provide psychosocial interventions and self-management programs 1

For Hip Osteoarthritis

• Prescribe manual therapy including manipulation and stretching 1

For Knee Osteoarthritis

• Apply medially directed patellar taping for anterior knee pain 1
• Utilize manual therapy techniques 1

Treatments NOT Recommended

Do not prescribe the following interventions as they lack efficacy or have unfavorable risk-benefit profiles:

• Glucosamine and chondroitin products 1, 2
• Intra-articular hyaluronic acid injections (conditionally recommended against by ACR; small effect size with unclear patient selection criteria) 1, 4
• Hydroxychloroquine for erosive hand osteoarthritis 2
• Methotrexate for erosive hand osteoarthritis 2
• Electroacupuncture 1
• Routine arthroscopic lavage and debridement (unless clear mechanical locking is present) 1

Surgical Referral Criteria

Refer for joint replacement surgery when:

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life 1
• Symptoms remain refractory to comprehensive non-surgical treatment including core therapies 1
• Make referral before prolonged and established functional limitation develops—do not wait until severe disability occurs 1

Do not use patient-specific factors (age, sex, smoking, obesity, comorbidities) as barriers to surgical referral—these should inform perioperative planning but not prevent appropriate referral 1

Critical Implementation Points

Common Pitfalls to Avoid

• Do not skip core non-pharmacological treatments and jump directly to pharmacological therapy—this undermines long-term outcomes 1
• Do not continue oral NSAIDs indefinitely without periodic risk reassessment 1
• Do not prescribe combination therapy with topical and oral NSAIDs without clear benefit justification and monitoring 3
• Do not delay surgical referral until severe, irreversible functional limitation has occurred 1

Special Precautions for Topical NSAIDs

• Avoid showering/bathing for at least 30 minutes after application 3
• Do not apply to open wounds or mucous membranes 3
• Avoid external heat or occlusive dressings over treated areas 3
• Protect treated areas from natural and artificial sunlight 3
• Ensure complete drying before applying other topical products or covering with clothing 3