Treatment Guideline Chart

Osteoarthritis is a chronic progressive disease where there is degeneration and loss of articular cartilage that occurs together with new bone formation at the joint surfaces and margins that causes pain and deformity.

The patient experiences pain, stiffness, decreased movement, inflammation and crepitus.

The pain is usually aggravated by activities and relieved by rest.

Osteoarthritis Diagnosis


  • Clinical diagnosis based on history and physical exam, with laboratory and radiologic investigations requested to exclude other diagnosis

Physical Examination

  • Normal exam does not rule out osteoarthritis
  • Features that suggest diagnosis of osteoarthritis include:
    • Tenderness usually over the joint
    • Crepitus on joint movement
    • Limited range of motion
    • Bony enlargement of the finger joints (eg Heberden’s or Bouchard’s nodes)
    • Pain on passive range of motion
    • Deformity (eg angulation in the hand joints, varus, valgus)
    • Joint instability
    • Periarticular muscle weakness (ie quadriceps muscle)


Diagnostic Criteria of Osteoarthritis by the American College of Rheumatology (ACR)

Osteoarthritis of the Hand

  • Hand pain, aching or stiffness plus at least 3 of the following features:
    • Hard tissue enlargement on ≥2 of selected joints [1st carpometacarpal (CMC), bilateral 2nd or 3rd distal interphalangeal (DIP), or 2nd and 3rd proximal interphalangeal (PIP) joints]
    • Hard tissue enlargement of ≥2 DIP joints
    • <3 swollen metacarpophalangeal joints
    • Deformity of at least 1 of selected joints (1st CMC, bilateral 2nd or 3rd DIP, or 2nd and 3rd PIP joints)
  • With sensitivity of 94% and specificity of 87%

Osteoarthritis of the Knee (Clinical and Radiographic Features)

  • Knee pain plus 1 of the following features:
    • Patient >50 years old
    • Stiffness <30 minutes
    • Crepitus
    • Presence of osteophytes on X-ray
  • With sensitivity of 91% and specificity of 86%

Osteoarthritis of the Hip

  • Hip pain plus at least 2 of the following features:
    • Erythrocyte sedimentation rate (ESR) <20 mm/hr
    • Presence of femoral and acetabular osteophytes on X-ray
    • Presence of superior, axial, and/or medial joint space narrowing on X-ray
  • With sensitivity of 89% and specificity of 91%


Laboratory Tests

  • May help exclude other diagnosis and monitor side effects of medications
  • Not reliable and required in establishing the diagnosis of osteoarthritis
  • Usually normal, except for possible elevated ESR and anemia, which are common in the elderly
  • Should consider obtaining complete blood count (CBC), liver function test (LFT), creatinine (Cr) level before starting therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), especially in elderly and in patients with other chronic illness
  • Aspiration of synovial fluid may be done to exclude other diagnosis such as septic arthritis, gout, pseudogout
    • Usually clear, viscous and with leukocyte count <2000/mm3


Imaging Procedures

  • Assist in diagnosing osteoarthritis
  • Suggested for patients ≥45 years, with joint pain especially at movement, and with morning stiffness lasting for >30 minutes

Plain X-rays

  • Primary imaging method used to confirm the diagnosis of osteoarthritis, stage its severity and follow its progression
    • Severity of radiographic findings does not correlate well with the severity of the symptoms or the presence of functional disability
    • Absence of radiologic features does not exclude osteoarthritis
    • May be used to exclude other diagnosis (eg trauma)
  • Almost always sufficient in diagnosing osteoarthritis
  • Radiologic features indicative of osteoarthritis but may not be observed in early disease include the following:
    • Joint space narrowing which is often irregular or asymmetric
    • Subchondral sclerosis which appears as an increased density in subchondral bone
    • Bony proliferation with the presence of osteophytes/spurs
    • Cysts in subchondral marrow adjacent to or sometimes remote from the joint which is usually seen in late cases
    • Soft tissue changes (eg small effusions, calcification and soft tissue swelling)
  • Taken in standing antero-posterior (AP) and lateral position; should be interpreted together with the clinical presentation of the patient

Magnetic Resonance Imaging (MRI)

  • Used to study joints, cartilage, subchondral bone and synovial tissue simultaneously
  • May be useful in studying the secondary causes of osteoarthritis (ie meniscal tear, previous ligament injury) or identifying any intraarticular loose body


  • May be useful in investigating alterations in joint structure and in guiding intra-articular steroid injections but should not be used routinely
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