Osteoarthritis is a condition affecting joints. Changes affect all parts of the joint including cartilage (the slippery tissue that covers the ends of bones), joint linings and ligaments and muscles.
Osteoarthritiscan occur in any joint, but the most common joints to be affected are hands, fingers, knees, hips, spine (neck and lower back).
Osteoarthritis is more common in people who are older but can also affect younger people, it has been found in some people under the age of 21.
You are more at risk for osteoarthritis if you are overweight or have had a joint injury.
Exercise and weight loss (if required) in conjunction with other treatments can help to improve mobility and daily functioning, reduce pain and flares, and prevent your osteoarthritis from worsening.
Not everyone who has early osteoarthritis will develop severe osteoarthritis.
How does osteoarthritis affect joints?
Changes with osteoarthritis affect all parts of a joint. Cartilage is a firm rubbery material that covers the end of each bone and provides a smooth, slippery surface for movement. With osteoarthritis the cartilage can become softer, then pitted, and eventually be lost from the bone ends. Bone can become thicker and spurs can form at joint margins, often where tendons or ligaments attach. Joint linings can become inflamed and thickened. Muscles around the joint can become weaker and nerves can become more sensitive. These changes can reduce movement and result in pain.
Osteoarthritis most commonly affects the knee joint, followed by the hip, and then other joints such as the small joints of the hands and the spine.
What causes osteoarthritis?
Previously osteoarthritis was thought to be a result of normal wear and tear during a person’s lifetime. But researchers now recognise that several factors lead to its development, including:
Being overweight over a long period of time.
Damage by joint injury, such as a fracture or torn cartilage.
Infection in the joint or bone.
Some forms of osteoarthritis do run in families, especially the form that affects the finger joints. However, in general, heredity is not a major reason for having osteoarthritis. The precise causes and mechanisms leading to osteoarthritis are still unknown.
What are the symptoms of osteoarthritis?
Osteoarthritis progresses slowly and develops over many years. It is often very mild and does not always have many symptoms even though x-rays may show joint changes. Sometimes, however, the symptoms are more pronounced and may include any or all of the following:
Pain and stiffness
Joint pain can increase with use of the joint. It does not indicate increased damage to the joint.
Stiffness usually occurs when the joint has been rested.
Swelling occurs when irritation of the synovial membrane (joint lining) causes an outpouring of extra joint fluid – just as your eye produces tears when irritated. But in the joint, the extra fluid cannot escape as easily, and so it causes swelling.
This most often occurs in the knees.
Creaking or cracking
Creaking or cracking sensations with joint movement may reflect a loss of the cartilage and the smooth gliding movement of the joint that cartilage should provide or soft tissues moving past each other.
As a result of the changes in the affected joint, the ends of the bones can change shape, forming bony spurs called osteophytes.
These may be felt as hard and bony swellings. They are especially apparent when osteoarthritis affects the finger joints.
The joint may feel unstable as if it is about to give way.
These symptoms can make it difficult for people with osteoarthritis to carry out many of their regular activities and can cause sleep problems, anxiety, depression, tiredness or fatigue.
If you are concerned about symptoms of osteoarthritis, see your doctor without delay. The sooner osteoarthritis is diagnosed the sooner treatment can be begun to help reduce pain, maintain mobility and prevent damage from getting worse.
See your doctor immediately if you develop any of the following:
Sudden pain, redness, swelling, and tenderness in a joint.
Pain in the joint following an injury.
Pain in the joint that continues (is persistent) despite resting the joint.
Pain in the joint that is so severe that you cannot weight bear on the joint such as when standing or walking.
These symptoms could be signs of more serious conditions such as fracture, infection in the joint or bone, or other forms of arthritis such as rheumatoid arthritis.
How is osteoarthritis diagnosed?
Your doctor will ask what you are able to do and what makes your pain worse. A physical examination will be carried out with close attention to your affected joints. There are no specific blood tests for osteoarthritis, but tests may be made to exclude other forms of arthritis.
X-rays are not needed to diagnose osteoarthritis but can be helpful in some instances. X-ray findings are not a good guide to how severe symptoms may become and X-ray findings do not correlate with the amount of pain or impairment someone experiences.
How is osteoarthritis treated?
Treatments for osteoarthritis cannot cure the condition, but can help with:
reducing the pain
maintaining your ability to work or do activities you enjoy
reducing how often your joints become more inflamed and painful (flares)
preventing joint changes from getting worse.
Your doctor or physiotherapist is likely to advise a treatment that takes into account the severity of the disease, what joints are affected, your symptoms, other medical problems, your age, occupation and everyday activities.
Changes to your lifestyle
How you manage day-to-day activities can make a big difference in the impact osteoarthritis has on your lifestyle. Most of the loss of mobility in the early stages of osteoarthritis can be reversed with a programme of exercises and losing weight if necessary.
Regular exercise is one of the best treatments to reduce pain and stiffness, reduce your usage of medicines, improve muscle strength, balance, mood and quality of life.
If you are overweight, weight loss of approximately 10% can result in symptom improvement comparable to the effect of joint replacement surgery.
Medication for osteoarthritis focuses mainly on pain relief. Usually, the approach is to try the milder pain relief medications first, such as paracetamol and gels or sprays, and if that does not provide relief, move to the stronger pain relief medications such as NSAIDs, or steroid injections in some cases. This approach reduces the risk of side effects.
Paracetamol: is recommended as the pain reliever to try first. It is best taken regularly and not just when pain is present.
Gels or sprays (also called topical agents): are useful for people with mild-to-moderate pain, especially when the pain is limited to a few joints or to a specific area such as the knee or finger joints. Examples include ibuprofen gel, diclofenac gel or spray and capsaicin cream.
Non-steroidal anti-inflammatories (NSAIDs): are useful for people with ongoing pain and discomfort despite treatment with paracetamol, in people with severe symptoms or during a flare. They are not suitable for everyone and are usually not recommended as a long-term treatment but some people may need to take them on an ongoing basis. They can cause serious side effects such as stomach bleeding, increased risk of heart attacks and stroke and kidney problems. Common examples of oral NSAIDs include ibuprofen (Ibugesic®, I-Profen®, Nurofen®), diclofenac (Voltaren®), naproxen (Noflam®, Naprosyn®) and celecoxib (Celebrex®).
Steroid injections: are given into the painful joint to reduce inflammation. These are reserved for extremely painful osteoarthritis and used for treating flares.
Complementary or alternative treatments are not usually recommended in the treatment of osteoarthritis, due to a lack of quality evidence or evidence that they are ineffective. Some people may find them beneficial, possibly due to a placebo effect. Examples of therapies include:
heat or cooling, such as a hot bath or cooling pack on the affected joint. There is little evidence regarding whether these methods are effective but they are often used because they have a low risk of adverse effects.
TENS (transcutaneous electrical nerve stimulation) may be helpful if given in a healthcare setting but the use if TENS machines at home has not proven to be helpful.
Glucosamine, chondroitin and fish oil have been suggested for use in osteoarthritis. The evidence shows that glucosamine and fish oil probably does not reduce symptoms, and that chondroitin might reduce pain a little.
If you are considering the use of complementary or alternative treatments, it is important to consider the risks, benefits and costs. Read more about the considerations if you are using complementary or alternative therapy.
If joint changes, pain and disability are all severe and a comprehensive management programme including the above measures is not helping, a joint replacement may be necessary. See: Knee replacement; Hip replacement
The following links have more information about osteoarthritis. Be aware that websites from other countries may have information that differs from New Zealand recommendations.
Dr Ben Darlow is a musculoskeletal physiotherapy specialist in private practice in Wellington and a senior lecturer and researcher in the Department of Primary Health Care and General Practice at the University of Otago, Wellington.
Credits: Health Navigator Editorial Team. Reviewed By: Dr Ben Darlow, Musculoskeletal Physiotherapy Specialist Wellington, Senior Lecturer and researcher, Department of Primary Health Care and General Practice, University of Otago, Wellington (June 2018)
Last reviewed: 18 Jun 2018
Exercise and weight loss
Regular exercise is one of the best treatments to reduce pain and stiffness, reduce your usage of medicines, improve muscle strength, balance, mood and quality of life. Exercise also has other benefits like weight loss and reducing your risk of heart disease.
Include exercises that improve muscle strength around the affected joints, maintain the range of motion of affected joints and improve general fitness.
Options include strengthening exercises, walking, using a gym, riding a bike, swimming, aqua jogging (aquacise), Tai Chi and gentle exercise classes.
Try exercising in a group – it can keep you motivated and be fun.
It can be challenging to exercise if you are in pain. If you do have pain, it is safe for you to exercise, as long as any pain or discomfort feels manageable and stable and does not get significantly worse. Ask your doctor if you should take a dose of your pain relief medication before exercising. You can also see a physiotherapist to design a specific programme for you.
If you are overweight and have osteoarthritis of weight-bearing joints, weight loss can greatly improve your physical function and reduce pain. Research shows that a reduction of 5–10% of initial body weight can produce significant improvements in symptoms, with a weight loss of approximately 10% resulting in symptom improvement comparable to the effect of joint replacement surgery.
Also, weight loss is beneficial if you may require joint replacement surgery in the future. People who are overweight have greater risks of complications after surgery, poorer recovery in function following joint replacement and are more likely to need further surgeries on the replaced joint.
Reorganising your daily schedule
One of the main ways you can manage your pain is to pace your activities in your day – plan your activities or exercises so they are divided into manageable portions which do not make your symptoms much worse. For example, try completing a task over a few short blocks of time throughout the day, rather than all at once in the morning. If done properly, this strategy of reorganising your daily schedule can help you gain confidence and feel in control, by being able to continue with the activities you enjoy.
Physiotherapist or occupational therapist
A physiotherapist can work with you to develop an exercise programme to improve your balance, strength and joint mobility. They can also advise you about suitable footwear and orthotic devices, such as shoe wedges, and the use of walking aids, joint supports or bracing to correct any malalignment of joints. An occupational therapist can provide you with guidance on assistance devices for difficulty with tasks of daily living, such as shower or toilet rails, tap-turning, jar-opening and grabbing devices. Using assistive devices such as these can reduce pain and help you to maintain function and independent living, and may help prevent hospitalisations due to falls.
Attending a self-management programme or learning about coping and self-efficacy skills can reduce pain and disability according to a recent study.
Medication for osteoarthritis focuses mainly on pain relief. Usually, the approach is to try milder pain relief medications first, such as paracetamol and gels or sprays, and if that does not provide relief, move to the stronger pain relief medications such as NSAIDs, or steroid injections in some cases. This approach reduces the risk of side effects.
Paracetamol is recommended for mild pain. It has a low risk of side effects when used at the recommended dose of 4 grams per day (which equates to 8 x 500 mg tablets, or 6 X 665 mg tablets per day).
You may need lower doses (3 grams per day), if you are dehydrated, weigh less than 50 kilograms, have liver problems or have a high alcohol intake.
Taking paracetamol at regular times (every 6 hours) is likely to be most helpful, although some people may prefer to use it as needed, only when the pain arises.
If paracetamol does not provide adequate pain relief when used alone, it can be combined with other pain relief options like NSAIDs or opioids.
When taking paracetamol it is important to:
avoid any over-the-counter products which contain paracetamol, such as cold and flu medicines
use dosing aids such as pillboxes to assist with taking the correct doses at the correct times. Taking your paracetamol dose it too soon after the previous dose or taking more than your daily limit, can cause serious liver problems.
Creams or gels (called topical pain relief)
These are useful for people with mild-to-moderate pain, especially when the pain is limited to a few joints or to a specific area such as the knee or finger joints.
Non-steroidal anti-inflammatory (NSAID) creams or gels
NSAID creams or gels such as diclofenac and ibuprofen can be bought over-the-counter from your pharmacy. They are not subsidised – you have to pay the full price.
These are used by applying a small amount of the cream or gel to the affected joint 3 to 4 times daily.
You are likely to feel improvements in your symptoms within the first week of treatment, and there may be further improvements in the following weeks.
Using creams or gels can cause side effects such as stomach bleeding but the risk is lower than when taking NSAID tablets or capsules. The main side effects of NSAID gels or sprays is redness or itching on the affected area.
Capsaicin cream is another example of topical pain relief. It is available on prescription with special approval.
Apply a small amount of cream to the affected joint 4 times daily. You may get a burning sensation which eases quickly.
It’s important to wash your hands after applying capsaicin cream to avoid transfer to other areas such as the eyes and mouth.
You may require treatment for 1 to 2 weeks before you experience a reduction in pain. You can then reduce applications to two times a day.
Talk to your doctor or pharmacist about whether capsaicin cream is suitable for you. Read more about capsaicin.
NSAID tablets or capsules
Common examples of NSAIDs include ibuprofen (Ibugesic®, I-Profen®, Nurofen®), diclofenac (Voltaren®), naproxen (Noflam®, Naprosyn®) and celecoxib (Celebrex®).
These are useful for people with ongoing pain and discomfort despite treatment with paracetamol, in people with severe symptoms or during a flare.
NSAIDs are effective in reducing the signs of inflammation including redness, warmth, swelling and pain.
These can cause serious side effects such as stomach bleeding, increased risk of heart attacks and stroke and kidney problems. They are not suitable for everyone and are usually not recommended as a long-term treatment but some people may need to take them on an ongoing basis.
Check with your doctor or pharmacist if NSAIDs are suitable for you. These should be used at the lowest possible dose for the shortest possible time. Read more about the safe use of NSAIDs.
Steroid injection into the joints
These are also called intra-articular corticosteroid injections. Examples include triamcinolone, dexamethasone and methylprednisolone.
These steroids are given as injections into the painful joint.
They may provide short-term pain relief, usually for a month, but do not improve joint function or stiffness.
They are most useful for treating flares.
Repeating steroid injections every three months does not reduce pain and may cause increased cartilage loss. Regular steroid injections are not recommended.
Injections in the joints have a very small risk of causing infection.
Weak opioids such as codeine or tramadol
Opioid medication does not improve your ability to do your daily activities more than other pain-relieving medications. Opioid medications may provide small improvements in pain and function but these need to be balanced against the side effects. Side effects include falls, drowsiness, constipation and addiction. Opioids are not recommended for the management of chronic pain. Read more about opioid painkillers.
Rupesh Puna discusses foot pain throughout the lifespan. He uses a case-based approach highlighting four common conditions: Sever’s disease, Morton’s neuroma, plantar fasciitis and osteoarthritis of the foot.
(Goodfellow Podcast, 2020)
Osteoarthritis – Dan Exeter Goodfellow Unit, 2016 "Dr Dan Exeter talks about non-surgical management of osteoarthritis. Dan is a sport and exercise physician based at Axis Sports Medicine clinic in Auckland. He is medical director for Athletics New Zealand and a senior lecturer at the University of Auckland."
Felson DT, Zhang Y, Hannan MT, et al. The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum. 1995;38:1500-1505.[Abstract]
McKnight PE, Kasle S, Going S, et al. A comparison of strength training, self-management, and the combination for early osteoarthritis of the knee. Arthritis Care Res (Hoboken). 2010;62:45-53.[Abstract]
The economic cost of arthritis in NZ in 2018. Report for Arthritis NZ. [Full text]
Habib GS. Systemic effects of intra-articular corticosteroids. Clin Rheumatol. 2009;28:749-756.[Abstract]
Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64:455-474. [Full Text]