26th January 2024

Presentation

Background

There is large variability in clinical presentation of OA between individuals and different joints affected in the same person. The diagnosis of OA is largely clinical and can be made in patients with suggestive features without the need for further investigations. The most common symptoms are joint pain and stiffness, although patients often present with functional impairment. The knees, hips and small joints of the hands, namely the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, and the spine (particularly lumbar and cervical regions) are most commonly affected. OA is an unlikely diagnosis in patients with ankle or wrist symptoms, and other differentials should be considered.

Symptoms

Joint pain:
- Exacerbated by activity/weight-bearing
- Relieved by rest (except in advanced disease where rest and night pain can occur)
- Typically, only one or a few joints are affected at any given point
- Develops over months or years
Joint stiffness:
- Occurs usually in the morning for less than 30 minutes or after rest
- Typically resolves in a few minutes with motion of the joint
Functional impairment

Signs

Bony swelling and joint deformity (due to osteophytes)
Joint effusion (can occur in the knee)
Reduced range of movement in the joint
Pain at extremes of joint movement
Tenderness/warmth around the joint
Joint instability
Muscle weakness or wasting around affected joint
Crepitus – grating/crunching sound, commonly felt on passive or active movement of joint, caused by friction between bone and cartilage
Absence of systemic features, e.g. rash, fever

The specific presentation of OA depends on the affected joint, and a detailed history and examination can reveal the following features:

Hand OA
History	Examination
Pain can radiate towards the thumb or wrist and distal forearm. Often exacerbated by strong grip	Typically affects the first carpometacarpal (CMC) joint at the base of the thumb, the DIP joints and the PIP joints
Reduced grip or pinch strength, which can cause difficulties with tasks such as opening jars, turning keys, fastening buttons, writing, etc	Fixed flexion deformity of CMC joint, with hyperextension of the distal joints
	Wasting of thenar muscles
	Heberden’s nodes: bony nodules on the DIP joints Bouchard’s nodes: bony nodules on the PIP joints
	Pain/warmth/redness/swelling of affected joints
	Ulnar or radial deviation at affected joints
	Painful mucous-filled cysts on the dorsum of the finger
	“Squaring” at the base of the thumb caused by partial dislocation of CMC joint

Table 1: Possible clinical features of hand osteoarthritis

Adapted from: National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries: Osteoarthritis [Internet]. Cks.nice.org.uk. 2021 [cited 12 August 2022]. Available from: https://cks.nice.org.uk/topics/osteoarthritis/diagnosis/diagnosis/

MRCP Part 1 – Heberden’s and Bouchard’s nodes

Image Source: Wikimedia Commons (2006). Heberden-Arthrose, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Heberden-Arthrose.JPG#globalusage (Accessed: 24 June 2021).

Hip OA
History	Examination
Pain felt in the groin and anterior/lateral thigh. Can also be referred to the knee or the testicle on the affected side in males	Painful restriction of internal rotation with hip flexed
Difficulty walking, climbing stairs, driving, painful sexual intercourse	Antalgic gait Trendelenburg gait in advanced disease – towards affected hip with reduced time weight-bearing on that side; pelvis tilting down on unaffected side due to wasting and weakness of gluteal and anterior thigh muscles
	Shortening of the lower limb

Table 2: Possible clinical features of hip osteoarthritis

Knee OA
History	Examination
Usually, bilateral pain, felt in and around the knee. Unilateral symptoms usually secondary to pre-existing trauma or disease	Varus (bow-legged) or valgus (knock-knee) deformities
Difficulty walking, particularly when going down the stairs if patellofemoral involvement	Locking (inability to straighten knee due to loose meniscal cartilage in the joint
Progressive pain on sitting, relieved by standing	Crepitus or joint line tenderness
Sensation of knee ‘giving way’ due to weak quadriceps and altered load-bearing	Small to moderate effusions
	Bony swelling around knee in advanced disease
	Antalgic gait – towards affected hip with reduced time weight-bearing on that side; pelvis is in neutral position

Table 3: Possible clinical features of knee osteoarthritis

MRCP Part 1 – Valgus deformity

Image Source: Wikimedia Commons (2007). Valgus, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Valgus.jpg (Accessed: 24 June 2021).

References

Conaghan PG, Dickson J, Grant RL. Care and management of osteoarthritis in adults: summary of NICE guidance. Bmj. 2008 Feb 28;336(7642):502-3.
National Institute for Health and Care Excellence (Great Britain).Osteoarthritis: care and management. National Institute for Health and Care Excellence (NICE); 2014
Arden N, Blanco F, Cooper C, Guermazi A, Hayashi D, Hunter D, Javaid MK, Rannou F, Roemer F, Reginster JY. Atlas of osteoarthritis. Springer Healthcare Limited; 2014.
Osteoarthritis | Health topics A to Z | CKS | NICE [Internet]. Cks.nice.org.uk. 2021 [cited 12 August 2022]. Available from: https://cks.nice.org.uk/topics/osteoarthritis/diagnosis/diagnosis/

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