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Osteoarthritis
Osteoarthritis is diagnosed clinically — over 45, activity-related pain and morning stiffness shorter than 30 minutes — with no need for an X-ray in a typical picture; the base of treatment is exercise and weight loss, followed by topical NSAIDs.
Why it matters in the exam
The question presents an older adult with pain in the knee, hip or hand joints that worsens with activity and improves with rest, with short morning stiffness and crepitus. In the hands the DIP (Heberden nodes), PIP (Bouchard nodes) and thumb base are involved — unlike RA, which spares the DIP. The candidate must know that in a typical picture no blood tests or X-ray are needed, and that X-ray findings (joint-space narrowing, osteophytes, subchondral sclerosis and cysts) do not always match the severity of pain.
The order of treatment is tested: explanation, exercise (strengthening and aerobic) and weight loss (5%–10% reduces knee pain); topical NSAIDs for the knee and hands before oral ones; oral NSAIDs at the lowest dose for the shortest time, with caution for the kidney, heart and stomach; intra-articular steroid injection for short relief; duloxetine as an alternative. Distractors: glucosamine and chondroitin are not recommended, hyaluronic acid injections are not recommended routinely, and strong opioids are unsuitable for long-term treatment. When pain and disability are severe despite conservative treatment — joint replacement. A single swollen, warm, red joint in a patient with osteoarthritis is not "just another flare" until infection or crystals have been excluded by aspiration.
Key points
- Clinical diagnosis: over 45, activity pain, stiffness under 30 minutes.
- Hands: DIP, PIP and thumb base.
- Exercise and 5%–10% weight loss are the base.
- Topical NSAIDs before oral; steroid injection for a flare.
- No glucosamine; joint replacement when conservative treatment fails.
Summary table
| Topic | Finding | Action | Exam note |
|---|---|---|---|
| Clinical diagnosis | Over 45, activity pain, morning stiffness under 30 minutes | No X-ray in a typical picture | Long stiffness → think of inflammation |
| Hands | DIP (Heberden), PIP (Bouchard), thumb base | — | RA spares the DIP |
| X-ray | Narrowing, osteophytes, sclerosis, cysts | Does not always match the pain | Do not treat the X-ray |
| Base of treatment | Every patient | Exercise, 5%–10% weight loss | Most effective long term |
| Drugs | Persistent pain | Topical NSAIDs, then low-dose oral; steroid injection; duloxetine | No glucosamine, no routine hyaluronic acid |
| Surgery | Severe pain and disability despite treatment | Knee or hip replacement | Major gain in quality of life |
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Sources
- ACR/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee, 2019 — Exercise, weight loss, topical and oral NSAIDs, injections
- NICE Guideline NG226: Osteoarthritis in over 16s: diagnosis and management, 2022 — Clinical diagnosis without imaging
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Osteoarthritis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.