Osteoarthritis

People sometimes call osteoarthritis simple wear and tear, yet it is closer to an active process: every part of the joint changes over time, the cartilage, the bone underneath and the lining alike, faster than the joint's natural repair can keep up with. Seldom is there one cause to point to. Several things make it likelier:

• Getting older, and an earlier injury to the joint or an operation on it
• Being overweight, which puts extra load through the knees and hips especially
• A family history of it, with osteoarthritis of the hands commoner after the menopause
• Work or activities that put a joint under repeated stress

Changes in the joints become very common with age, yet growing older does not have to mean painful osteoarthritis: many people whose scans show changes have few symptoms or none, and the amount of change an X-ray shows may not match how much pain someone has.

Osteoarthritis usually comes on slowly, and its symptoms can vary. Typical features are:

• Pain in the joint that tends to grow with activity and settle with rest
• Brief stiffness first thing or after sitting still, which usually passes within half an hour
• Less movement in the joint than before
• A sense of grating or crackling in the joint, and at times a little swelling
• Now and then, a knee that gives way beneath you

Inflammatory arthritis is treated in quite another way, so ruling it in or out is much of what a specialist assessment is for. Osteoarthritis in the hands, the thumb's base included, has its own section in our hand and wrist pain guide, and the spine is the subject of the back pain and neck pain guides, each with the warning signs for its own part of the body.

In most cases the history and the examination settle the diagnosis, with imaging where it helps. A key part of the assessment is checking that no inflammatory or other condition needing different treatment is causing the pain.

Ultrasound can help here, showing whether a joint is actively inflamed and helping to make clear what is causing the pain. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so a scan is often possible at the same visit; you can read about the scan on our ultrasound clinic page.

Easing the pain, keeping the joint moving and keeping you active are what treatment is for. Each plan is personal, often bringing together exercise and strengthening, guidance on pacing the load the joint carries, and pain relief as needed: an anti-inflammatory gel applied to the joint first, and for some people anti-inflammatory tablets, taken with a stomach-protecting medicine. Where that gel is ibuprofen, do not smoke or let any open flame near you while using it, because fabric it touches burns more easily. Exercise kept up regularly can make a considerable difference.

Where a particular joint is troublesome, an ultrasound-guided injection may help settle it and support rehabilitation. Depending on what is most suitable for you, this may be a steroid injection to calm inflammation, or a hyaluronic acid injection, which aims to lubricate and cushion the joint. It is worth knowing that NICE, which advises the NHS, recommends against hyaluronic acid injections for osteoarthritis: the average benefit in its evidence review was too small and too uncertain to count as clinically meaningful. At the knee, that same review did find a real average reduction in pain, just short of the threshold NICE applies, which is part of why some specialist bodies read the evidence more permissively; the full picture is set out honestly in our dedicated guide. In private care you pay yourself, so the question becomes whether a modest chance of worthwhile relief is worth the cost to you, and it is offered here as a self-pay option on that basis. Which option would suit you best, including what the evidence does and does not show, is discussed with you, and any treatment plan is agreed together.

Day to day, much of osteoarthritis is in your own hands, and regular activity is among the most helpful things you can do for it. The goal is a joint that keeps moving, with strong muscles around it, rather than one that is rested.

• Make regular movement and strengthening a habit, building up as our arthritis and exercise guide explains
• A healthier weight takes load off the knees and hips, and sensible diet and arthritis choices help you reach and keep it
• Lean on heat, supportive footwear and pacing when a flare or a busy day comes
• Keep up your work and hobbies where you can, adapting them rather than giving them up

Over the years the symptoms often come and go rather than worsen steadily, and good spells are common. Most people never need a joint replaced.

Routine review suits most osteoarthritis. Some patterns point to something other than wear, such as an infected joint or a crystal attack of gout or pseudogout; the warning signs come below in order of seriousness, and what is left goes to the closing paragraph.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory tablets, which some people take for the pain, can make the stomach bleed
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• Joint pain that has suddenly become severe, without a fall or injury, since a sudden change like this can point to another problem in the joint, which should be checked that day; a joint you cannot put weight on or move is in the first list instead
• A joint that locks or gives way so that it stops normal use, since a joint that does this can have a problem inside it that should be looked at the same day; if you cannot put weight on it or move it, it belongs to the first list as a 999 or A&E emergency
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day

Short of the signs in the lists above, new stiffness each morning lasting more than half an hour is for a GP to see within days, since it can point to inflammatory arthritis rather than wear, which our early inflammatory arthritis guide describes. If the spine or neck is affected, the back pain and neck pain guides give the warning signs where they say when to seek help. Pain that disturbs your sleep, limits walking or everyday tasks, or no longer responds to your usual measures calls for a routine appointment with your GP or team. If you cannot tell how urgent something is, asking is never a mistake.

However common osteoarthritis is, joint pain that lingers deserves an assessment before it is put down to age. A specialist can confirm what is causing it, rule out inflammatory arthritis and set out a clear plan for comfort and movement.

Must I arrange an X-ray or scan first?

No, imaging does not need arranging beforehand. Most often the diagnosis is made from your symptoms and an examination, and imaging is kept for the times it would tell us something more. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so a scan can often be done on the day. Any X-rays or scan reports you already have are worth bringing.

How can I tell whether my pain is osteoarthritis or inflammatory arthritis?

A specialist assessment is at its most valuable in telling the two apart, because they are managed quite differently. Strong clues come from the pattern of your symptoms and from the examination, and ultrasound can reveal active inflammation inside a joint. Pain that worsens the more you use the joint, and stiffness that wears off soon after you start moving, are typical of osteoarthritis; new stiffness that lasts more than half an hour each morning points the other way and is for a GP to see within days.

Can an injection be given at the same appointment?

Often, yes. Because point-of-care ultrasound is used during the consultation, an ultrasound-guided injection can usually be carried out in the same visit where it is clinically appropriate, once it has been discussed and agreed with you. Depending on the joint and your circumstances, this may be a steroid injection, or in some cases a hyaluronic acid injection as a self-pay option; NICE recommends against hyaluronic acid injections for osteoarthritis on the evidence it reviewed, so one is only ever suggested after an honest discussion of that evidence, which our hyaluronic acid injections guide sets out in full.

Does exercise wear the joints out faster?

No. Done regularly, strengthening and other exercise can ease pain and improve how the joint works, and they are central to treatment. The same plan covers how much load to put through the joint, so you can build activity up at a pace that suits you.

Is osteoarthritis simply part of growing older?

Getting older and years of use contribute, but pain that persists in a joint should never be written off as ageing before it has been properly assessed. Other conditions can imitate osteoarthritis, so the cause is worth confirming, and at any age the pain can be eased and the joint kept moving.