Osteoarthritis:​Rapid Evidence Review

Mark H. Ebell, MD, MS, University of Georgia College of Public Health, Athens, Georgia

Osteoarthritis (OA) should be suspected in patients with pain in the fingers, shoulders, hips, knees,
or ankles, especially if they are older than 40 years. Patients older than 50 years who have joint pain,
minimal morning stiffness, and functional impairment likely have OA. Radiography can confirm the
diagnosis and may be helpful before surgical referral, but findings generally do not correlate well with
symptoms. Exercise, physical therapy, knee taping, and tai chi are beneficial for knee OA. Medical ther-
apy provides modest benefits in pain reduction and functional improvement;​however, nonsteroidal
anti-inflammatory drugs, tramadol, and other opioids have significant potential harms. Joint replace-
ment may be considered for patients with moderate to severe pain and radiographically confirmed OA.
Corticosteroid injections may be helpful in the short term. Vitamin D supplements, shoes specifically
designed for persons with OA, antioxidant supplements, physical therapy for hip OA, ionized wrist
bracelets, lateral wedge insoles for medial knee OA, and hyaluronic acid injections are not effective.
(Am Fam Physician. 2018;​97(8):​523-526. Copyright © 2018 American Academy of Family Physicians.)

Osteoarthritis (OA) is a condition commonly SIGNS AND SYMPTOMS

encountered in primary care. This article pro- Signs and symptoms that are common in OA
vides a brief summary and review of the best include:
available patient-oriented evidence for OA. • Pain that is typically worse later in the day and
relieved by rest.
Epidemiology • Joint swelling and tenderness, with or without
The prevalence of OA by age is shown in Table 1.1 crepitus.
Risk factors include: • Bony enlargement in prolonged or severe OA.
• Older age (especially older than 50 years) • Joint pain, minimal morning stiffness, and
• Female sex functional impairment in patients older than
• Overweight or obesity 50 years.2,3 The presence of these findings is
• Previous joint injury moderately helpful in ruling in OA, but their
• Job that requires bending or squatting absence does not rule it out3 (Table 2 4).
• Family history • Older age, obesity, difficulty walking down
• Participation in sports associated with repet- stairs, and clinical findings of decreased range
itive impact (e.g., soccer, American football).2 of motion, effusion, and crepitus in patients
with knee pain.5
Diagnosis
• OA should be suspected in patients with pain
in the fingers, shoulders, hips, knees, or ankles, CME This clinical content conforms to AAFP

especially if they are older than 40 years.2,3 criteria for continuing medical education (CME).
• A lternative diagnoses should be considered in See CME Quiz on page 503.
patients with inflammation, erythema, or pain Author disclosure:​ Dr. Ebell is cofounder and
editor-in-chief of Essential Evidence Plus, pub-
that increases or changes significantly.
lished by Wiley-Blackwell, Inc.
• The differential diagnosis includes collagen
Patient information:​ A handout on this topic is
vascular disease, gout and pseudogout, trauma, available at https://​family​doctor.org/condition/
septic arthritis, ankylosing spondylitis, and osteoarthritis.
psoriatic arthritis.

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 OSTEOARTHRITIS

• Lateral wedge insoles are ineffective for medial knee OA.19

TABLE 1 • K nee bracing has insufficient evidence to draw conclu-
sions about its effectiveness.20
Prevalence of OA and Activity Limitation • Physical therapy was not beneficial for hip OA in a well-
Due to OA designed trial.21
Prevalence Prevalence of • Weight loss has been recommended for patients with
of physician- activity limitation knee and hip OA 22;​however, a systematic review found
Age (years) diagnosed OA (%) due to OA (%)
only low-quality evidence that bariatric surgery reduces
18 to 44 7.3 2.7 pain and improves function in morbidly obese persons
with knee pain.23
45 to 64 30 13
• Ginger consumption significantly reduced pain and dis-
65 and older 50 22 ability in five studies (N = 593) included in a systematic
review.24 However, patients were more likely to stop tak-
OA = osteoarthritis.
ing it, and the overall quality of studies was moderate.
Information from reference 1.
Similarly, avocado unsaponifiables may be effective at
dosages of 300 to 600 mg per day. Both of these inter-
ventions, although likely safe, are limited by the small
DIAGNOSTIC TESTING number and methodologic flaws of studies.25
• Radiography is not required to diagnose OA in patients
with risk factors and typical symptoms.3  MEDICAL THERAPY
• Radiographic findings in patients with OA do not always • Acetaminophen is less effective than nonsteroidal anti-
correlate well with symptoms. Two studies found that inflammatory drugs (NSAIDs) for OA, but given its
only 16% of patients with frequent hip pain had radio- safety, a trial at an adequate dosage is appropriate.26,27
graphic evidence of OA;​conversely, only 21% of patients • Of the NSAIDs currently available in the United States,
who met the radiographic criteria for hip OA had fre- diclofenac, 150 mg per day, is most likely to be effective
quent pain.6 for OA, followed by naproxen, according to a system-
• Typical radiographic findings in patients with OA atic review.26 A Cochrane review concluded that topical
include joint space narrowing, osteophytes, and sub- diclofenac and ketoprofen are moderately effective.28
chondral sclerosis. • Topical capsaicin appeared to be somewhat effective in


• Radiography can be helpful before referral for joint several small trials, although it is associated with a tran-
replacement, as radiographic severity is an important sient burning sensation.29-32
factor in determining whether surgery is appropriate.
• Magnetic resonance imaging detects joint abnormalities
in about 90% of both obese and nonobese adults older BEST PRACTICES IN ORTHOPEDICS
than 50 years who do not have joint pain.7
Recommendations from the Choosing
Treatment Wisely Campaign
Figure 1 presents a suggested approach to the treatment Recommendation Sponsoring organization
of OA. Several therapies are supported by good-quality
evidence. However, some widely used treatments (e.g., Do not use glucosamine and American Academy of
chondroitin to treat patients Orthopaedic Surgeons
hyaluronic acid injections, arthroscopic surgery) are not
with symptomatic osteoarthritis
effective and should be abandoned. of the knee.

EXERCISE, DIET, AND PHYSICAL THERAPY Do not use lateral wedge American Academy of
insoles to treat patients with Orthopaedic Surgeons
• Aquatic exercise has small short-term benefits for OA. 8
symptomatic medial compart-
• Vitamin D supplements, antioxidant supplements, shoes ment osteoarthritis of the knee.
specifically designed for persons with OA, and ionized
wrist bracelets are ineffective for OA.9-13 Source:​For more information on the Choosing Wisely Campaign,
see http://​w ww.choosingwisely.org. For supporting citations and
• E xercise, tai chi, knee taping, and physical therapy are to search Choosing Wisely recommendations relevant to primary
beneficial for knee OA and can be recommended based care, see https://​w ww.aafp.org/afp/recommendations/search.htm.
on patient preference and acceptability.14-18

524  American Family Physician www.aafp.org/afp Volume 97, Number 8 ◆ April 15, 2018
 OSTEOARTHRITIS
TABLE 2

Accuracy of Key Signs and Symptoms for the Diagnosis of Knee OA

Percentage of patients with OA Percentage of patients with
when clinical findings are pres- OA when clinical findings are
ent or absent (45 to 64 years of present or absent (65 years and
Positive Negative age;​pretest probability = 30%) older;​pretest probability = 50%)
likelihood likelihood
Clinical finding ratio ratio Present Absent Present Absent

Bony enlargement 3.3 0.6 59 20 77 38

Functional limitation 3.2 0.7 58 23 76 41

Pain during flexion 2.8 0.8 55 26 74 44

Heberden nodes (hard or 2.0 0.9 46 28 67 47

bony swellings in the distal
interphalangeal joint)

OA = osteoarthritis.
Information from reference 4.

• Tramadol is moderately effective for OA, according to a improved pain and function after joint replacement com-
systematic review of 11 randomized trials (N = 1,019), and pared with those receiving usual care, although serious
has a number needed to treat (NNT) of 6 for one person to adverse effects can occur, including deep venous throm-
report at least moderate improvement.33 Conversely, the bosis, infection, and the need for further surgery or mobi-
number needed to harm (NNH) for one person to stop lization under anesthesia.41 Obese and nonobese patients
taking tramadol because of adverse effects is 8. have similar outcomes after knee replacement.42-44
• Duloxetine (Cymbalta) is a serotonin–norepinephrine • Arthroscopic meniscectomy with or without debridement
reuptake inhibitor approved for treatment of painful con- is no more effective than sham procedures or exercise for
ditions. Its NNT is 7 for clinically significant pain reduc- knee OA, according to a systematic review of nine studies
tion in OA.34,35 The most common adverse effect is mild (N = 1,279).45 It is also ineffective for patients with degen-
to moderate nausea (23% vs. 7% for placebo;​NNH = 6).36 erative meniscal tears.46
• Because tramadol and duloxetine have harms and adverse • Corticosteroid injections improve function and provide
effects similar in magnitude to their potential benefits, short-term pain relief, but do not improve overall quality
they should be used only in select patients. of life, according to systematic reviews.47,48 A recent large
• Propoxyphene (not available in the United States) plus
acetaminophen is no better than acetaminophen alone,
has more adverse effects, and should be avoided.37 FIGURE 1
• Oral and transdermal opioids (not including tramadol)
have only modest benefits that are of questionable clini- First-line treatments: full-dose acetaminophen, topical
cal significance, according to a Cochrane review.38 These therapies, exercise, tai chi, knee taping, physical therapy
medications also have significant adverse effects, and
long-term use is discouraged. Patients taking opioids
should be closely monitored, and the dose should be kept Second-line treatments: nonsteroidal anti-inflammatory drugs
as low as possible. Daily dosages of more than 50 mg of
hydrocodone or 30 mg of oxycodone are discouraged.39
• In general, it is reasonable to begin treatment with full- Third-line treatments: tramadol or duloxetine (Cymbalta)

dose acetaminophen and/or topical therapy and progress

to an NSAID such as naproxen or diclofenac, then, if nec-
essary, to tramadol or duloxetine. Fourth-line treatments: carefully supervised opiates (50 mg
of hydrocodone or 30 mg of oxycodone per day or less), joint
replacement in patients with moderate to severe pain and
SURGICAL THERAPY moderate to severe radiographic evidence of osteoarthritis
• Joint replacement is an option for patients with moder-
ate to severe pain and radiographically confirmed OA.40 Suggested treatment approach to the patient with
A randomized trial found that patients with moderate osteoarthritis.
radiographically confirmed knee OA had significantly

April 15, 2018 ◆ Volume 97, Number 8 www.aafp.org/afp American Family Physician 525
 OSTEOARTHRITIS
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Radiography can confirm the diagnosis of OA and may be helpful before surgical referral, but C 6, 7
findings tend not to correlate well with symptoms.

Exercise, physical therapy, knee taping, and tai chi are beneficial for knee OA. B 14-18

Ineffective treatments for OA include vitamin D and antioxidant supplements, shoes specifically B 9-13, 19, 21,
designed for persons with OA, lateral wedge insoles for medial knee OA, physical therapy for hip 50-52
OA, ionized wrist bracelets, and hyaluronic acid injections.

Medical therapy for OA should begin with full-strength acetaminophen and topical therapy, then A 26-36
proceed to nonsteroidal anti-inflammatory drugs and selectively to tramadol and other opioids.
Nonsteroidal anti-inflammatory drugs and opioids may reduce pain and improve function, but
have significant potential harms.

Joint replacement should be considered for patients with moderate to severe pain and radio- A 40, 41
graphically confirmed OA.

Corticosteroid injections may be helpful in the short term, but evidence is mixed. B 47-49

OA = osteoarthritis.
A = consistent, good-quality patient-oriented evidence;​ B = inconsistent or limited-quality patient-oriented evidence;​ C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://​w ww.aafp.
org/afpsort.

randomized trial found no benefit and greater cartilage

loss in patients receiving corticosteroid injections.49 Editor’s Note: Rapid Evidence Review is a new article for-
mat that was created with the goal of providing key clinical
• Hyaluronic acid injections are not effective for OA, information that can be read quickly and that answers ques-
according to a review of the highest-quality studies and tions at the point of care. These articles are unique in that
unpublished research.50-52 the references are only available online and the SORT table
• Dextrose prolotherapy injections showed a modest benefit recommendations are linked to the corresponding areas of
the text in the online version of the article. Please let us know
for knee OA in two small randomized trials, but the evi-
what you think of the new format by commenting online or
dence base is limited, and the technique may be operator- e-mailing us at afpedit@aafp.org.
dependent and not easily reproduced.53,54
•P  latelet-rich plasma or bone marrow aspirate concentrate Data Sources:​ This article was based on literature cited in Essen-
injections are not effective for OA.55,56 tial Evidence Plus, the Cochrane database, recently published
InfoPOEMs, and a PubMed search using the Clinical Queries
COMPLEMENTARY THERAPY database for the term osteoarthritis. Search date:​July 2017.
The following complementary therapies have been studied
for the treatment of OA: The Author
• Acupuncture is at best minimally effective for OA of the MARK H. EBELL, MD, MS, is a professor in the Department of
knee or hip.57-59 Epidemiology at the University of Georgia College of Public
• Oral glucosamine with or without chondroitin does not Health, Athens.
appear to be effective in well-designed trials.60-62 Address correspondence to Mark H. Ebell, MD, MS, University
• S-adenylmethionine and methylsulfonylmethane have

of Georgia College of Public Health, 150 Yonah Dr., Athens,
uncertain effectiveness based on systematic reviews.63,64 GA 30601. Reprints are not available from the author.
Observed benefits were small in magnitude and probably
not clinically significant. References
References for this article are available online at https://www.
Prognosis aafp.org/afp/2018/0415/p523.html.
Symptoms of OA tend to progress over time, although they
may temporarily improve in the short term.

526  American Family Physician www.aafp.org/afp Volume 97, Number 8 ◆ April 15, 2018
 OSTEOARTHRITIS

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526B  American Family Physician www.aafp.org/afp Volume 97, Number 8 ◆ April 15, 2018