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{{Infobox medical condition
| Name = Osteoarthritis
| Image = Heberden-Arthrose.JPG
| Caption = The formation of hard nobs at the [[proximal interphalangeal joint|middle finger joints]] (known as [[Bouchard's nodes]]) and at the farther away finger joint (known as [[Heberden's node]]) are a common feature of osteoarthritis in the hands.
| Field = [[Rheumatology]], [[orthopedics]]
| synonyms = degenerative arthritis, degenerative joint disease, osteoarthrosis
| DiseasesDB = 9313
| ICD10 = {{ICD10|M|15||m|15}}-{{ICD10|M|19||m|15}}, {{ICD10|M|47||m|45}}
| ICD9 = {{ICD9|715}}
| ICDO =
| OMIM = 165720
| MedlinePlus = 000423
| eMedicineSubj = med
| eMedicineTopic = 1682
| eMedicine_mult = {{eMedicine2|orthoped|427}} {{eMedicine2|pmr|93}} {{eMedicine2|radio|492}}
| MeshID = D010003
}}
<!-- Definition and symptoms -->
'''Osteoarthritis''' ('''OA''') is a type of [[joint disease]] that results from breakdown of [[articular cartilage|joint cartilage]] and underlying [[bone]].<ref>{{cite book|title=Atlas of Osteoarthritis|date=2015|publisher=Springer|isbn=9781910315163|page=21|url=https://books.google.ca/books?id=qT1FBgAAQBAJ&pg=PA21}}</ref> The most common symptoms are [[joint pain]] and stiffness.<!-- <ref name=NIH2015/> --> Initially, symptoms may occur only following exercise, but over time may become constant.<!-- <ref name=NIH2015/> --> Other symptoms may include [[joint effusion|joint swelling]], decreased [[range of motion]], and when the back is affected weakness or numbness of the arms and legs.<!-- <ref name=NIH2015/> --> The most commonly involved joints are those near the ends of the fingers, at the base of the thumb, neck, lower back, knee, and hips.<!-- <ref name=NIH2015/> --> Joints on one side of the body are often more affected than those on the other.<!-- <ref name=NIH2015/> --> Usually the symptoms come on over years.<!-- <ref name=NIH2015/> --> It can affect work and normal daily activities.<!-- <ref name=NIH2015/> --> Unlike other types of [[arthritis]], only the joints are typically affected.<ref name=NIH2015/>

<!-- Cause and diagnosis -->
Causes include previous joint injury, abnormal joint or limb development, and [[Heredity|inherited]] factors.<!-- <ref name=NIH2015/><ref name=Lancet2015/> --> Risk is greater in those who are [[overweight]], have one leg of a different length, and have jobs that result in high levels of joint stress.<ref name=NIH2015/><ref name=Lancet2015/> Osteoarthritis is believed to be caused by mechanical stress on the joint and low grade inflammatory processes.<ref name=Berenbaum2013>{{cite journal |author=Berenbaum F |title=Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!) |journal=Osteoarthritis and Cartilage |volume=21 |issue=1 |year=2013 |pages=16–21 |doi=10.1016/j.joca.2012.11.012|pmid=23194896}}</ref> It develops as cartilage is lost and the underlying bone becomes affected.<ref name=NIH2015/> As pain may make it difficult to exercise, [[atrophy|muscle loss]] may occur.<ref name=Lancet2015>{{cite journal|last1=Glyn-Jones|first1=S|last2=Palmer|first2=AJ|last3=Agricola|first3=R|last4=Price|first4=AJ|last5=Vincent|first5=TL|last6=Weinans|first6=H|last7=Carr|first7=AJ|title=Osteoarthritis.|journal=Lancet|date=3 March 2015|pmid=25748615|doi=10.1016/S0140-6736(14)60802-3|volume=386|pages=376–87}}</ref><ref name=NICE>{{cite web |author=Conaghan P |title=Osteoarthritis — Care and management in adults |url=http://www.nice.org.uk/guidance/cg177/evidence/full-guideline-191761309 |format=PDF| date=2014}}</ref> Diagnosis is typically based on signs and symptoms, with [[medical imaging]] and other tests occasionally used to either support or rule out other problems.<!-- <ref name=NIH2015/> --> In contrast to [[rheumatoid arthritis]], which is primarily an [[inflammatory arthritis|inflammatory condition]], in osteoarthritis, the joints do not typically become hot or red.<ref name=NIH2015/>

<!-- Treatment and prognosis -->
Treatment includes exercise, efforts to decrease joint stress, [[support group]]s, and [[analgesics|pain medications]].<ref name=NIH2015/><ref name="OARSI2014">{{cite journal |vauthors=McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M |title=OARSI guidelines for the non-surgical management of knee osteoarthritis |journal=Osteoarthr. Cartil. |volume=22 |issue=3 |pages=363–88 |year=2014 |pmid=24462672 |doi=10.1016/j.joca.2014.01.003 |url=}}</ref> Efforts to decrease joint stress include resting and the use of a [[cane]].<!-- <ref name=NIH2015/> --> Weight loss may help in those who are overweight.<!-- <ref name=NIH2015/> --> Pain medications may include [[paracetamol]] (acetaminophen) as well as [[NSAID]]s such as [[naproxen]] or [[ibuprofen]].<ref name=NIH2015>{{cite web|title=Osteoarthritis|url=http://www.niams.nih.gov/health_info/Osteoarthritis/default.asp|website=National Institute of Arthritis and Musculoskeletal and Skin Diseases|accessdate=13 May 2015|date=April 2015}}</ref> Long-term [[opioid]] use is generally discouraged due to lack of information on benefits as well as risks of [[addiction]] and other side effects.<ref name=NIH2015/><ref name="OARSI2014"/> If pain interferes with normal life despite other treatments, [[joint replacement]] surgery may help.<ref name=Lancet2015/> An artificial joint typically lasts 10 to 15 years.<ref>{{cite journal|last1=Di Puccio|first1=F|last2=Mattei|first2=L|title=Biotribology of artificial hip joints.|journal=World journal of orthopedics|date=18 January 2015|volume=6|issue=1|pages=77–94|pmid=25621213|doi=10.5312/wjo.v6.i1.77|pmc=4303792}}</ref>

<!-- Epidemiology -->
Osteoarthritis is the most common form of arthritis with disease of the knee and hip affecting about 3.8% of people as of 2010.<ref name=cross2014>{{cite journal|pmid=24553908|year=2014|author1=Cross|first1=M|title=The global burden of hip and knee osteoarthritis: Estimates from the global burden of disease 2010 study|journal=Annals of the Rheumatic Diseases|volume=73|issue=7|pages=1323–30|last2=Smith|first2=E|last3=Hoy|first3=D|last4=Nolte|first4=S|last5=Ackerman|first5=I|last6=Fransen|first6=M|last7=Bridgett|first7=L|last8=Williams|first8=S|last9=Guillemin|first9=F|last10=Hill|first10=C. L.|last11=Laslett|first11=L. L.|last12=Jones|first12=G|last13=Cicuttini|first13=F|last14=Osborne|first14=R|last15=Vos|first15=T|last16=Buchbinder|first16=R|last17=Woolf|first17=A|last18=March|first18=L|doi=10.1136/annrheumdis-2013-204763}}</ref><ref name=Mar2014>{{cite journal |authors=March L|title=Burden of disability due to musculoskeletal (MSK) disorders |journal=Best Pract Res Clin Rheumatol |volume=28 |issue=3 |pages=353–66 |year=2014 |pmid=25481420 |doi=10.1016/j.berh.2014.08.002}}</ref> Among those over 60 years old, about 10% of males and 18% of females are affected.<ref name=Lancet2015/> It is the cause of about 2% of [[years lived with disability]].<ref name=Mar2014/> In Australia, about 1.9 million people are affected,<ref>{{cite journal|last=Elsternwick|title=A problem worth solving.|journal=Arthritis and Osteoporosis Victoria|year=2013|url=http://www.arthritisvic.org.au/Research/AOV-Funded-Research/Completed/A-Problem-Worth-Solving/APWS.aspx}}</ref> and in the United States, 30 to 52.5 million people are affected.<ref name=cdc2016>{{cite web|url=https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm|title=Arthritis-Related Statistics: Prevalence of Arthritis in the United States|publisher=Centers for Disease Control and Prevention, US Department of Health and Human Services|date=9 November 2016}}</ref><ref name=Cisternas2015>{{cite journal |title=Alternative Methods for Defining Osteoarthritis and the Impact on Estimating Prevalence in a US Population-Based Survey |authors=Cisternas MG, Murphy L, Sacks JJ, Solomon DH, Pasta DJ, Helmick CG |journal=Arthritis Care Res (Hoboken) |date=May 2016 |volume=68 |issue=5 |pages=574–80 |doi=10.1002/acr.22721}}</ref> It becomes more common in both sexes as people become older.<ref name=NIH2015/>
[[File:Osteoarthritis.webm|thumb|upright=1.4|Video explanation]]
{{TOC limit|3}}

==Signs and symptoms==
[[File:Areas affected by osteoarthritis.gif|thumb|Osteoarthritis most often occurs in the hands (at the ends of the fingers and thumbs), neck, lower back, knees, and hips]]
The main symptom is [[pain]], causing [[disability|loss of ability]] and often stiffness. "Pain" is generally described as a sharp ache or a burning sensation in the associated [[muscle]]s and [[tendon]]s, and is typically made worse by prolonged activity and relieved by rest. Stiffness is most common in the morning, and typically lasts less than thirty minutes after beginning daily activities, but may return after periods of inactivity. Osteoarthritis can cause a crackling noise (called "[[crepitus]]") when the affected joint is moved or touched and people may experience muscle [[spasm]]s and contractions in the tendons. Occasionally, the joints may also be filled with fluid.<ref>{{MedlinePlusEncyclopedia|000423|Osteoarthritis}}</ref> Some people report increased pain associated with cold temperature, high humidity, and/or a drop in barometric pressure, but studies have had mixed results.<ref name="pmid22124595">{{cite journal |vauthors=de Figueiredo EC, Figueiredo GC, Dantas RT |title=Influência de elementos meteorológicos na dor de pacientes com osteoartrite: Revisão da literatura |language=Portuguese |journal=Rev Bras Reumatol |volume=51 |issue=6 |pages=622–8 |date=December 2011 |pmid=22124595 |doi=10.1590/S0482-50042011000600008 |trans_title=Influence of meteorological elements on osteoarthritis pain: a review of the literature}}</ref>

Osteoarthritis commonly affects the hands, feet, [[vertebral column|spine]], and the large [[weight-bearing]] joints, such as the [[hip joint|hips]] and knees, although in theory, any joint in the body can be affected. As osteoarthritis progresses, the affected joints appear larger, are stiff, painful and may swell, but usually feel better with gentle use but worse with excessive or prolonged use, thus distinguishing it from [[rheumatoid arthritis]].{{Citation needed|date=December 2016}}

In smaller joints, such as at the fingers, hard bony enlargements, called [[Heberden's node]]s (on the [[distal interphalangeal joints]]) and/or [[Bouchard's nodes]] (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. Osteoarthritis at the toes leads to the formation of [[bunion]]s, rendering them red or swollen. Some people notice these physical changes before they experience any pain, in part because the cartilage damage in osteoarthritis is generally painless because cartilage is aneural.{{citation needed|date=December 2016}}

Osteoarthritis is the most common cause of a [[joint effusion]] of the knee.<ref>{{cite web |url=http://www.mayoclinic.com/health/water-on-the-knee/DS00662 |title=Water on the knee |publisher=MayoClinic.com}}</ref>

==Risk factors==
Damage from mechanical stress with insufficient self repair by joints is believed to be the primary cause of osteoarthritis.<ref name=Brandt2009/> Sources of this stress may include misalignments of bones caused by congenital or pathogenic causes; mechanical injury; excess body weight; loss of strength in the muscles supporting a joint; and impairment of peripheral nerves, leading to sudden or uncoordinated movements.<ref name=Brandt2009>{{cite journal |vauthors=Brandt KD, Dieppe P, Radin E |title=Etiopathogenesis of osteoarthritis |journal=Med. Clin. North Am. |volume=93 |issue=1 |pages=1–24, xv |date=January 2009 |pmid=19059018 |doi=10.1016/j.mcna.2008.08.009 |url =}}</ref> However [[exercise]], including running in the absence of injury, has not been found to increase the risk.<ref name=Bosomworth09>{{cite journal |author=Bosomworth NJ |title=Exercise and knee osteoarthritis: benefit or hazard? |journal=Can Fam Physician |volume=55 |issue=9 |pages=871–8 |date=September 2009 |pmid=19752252 |pmc=2743580}}</ref> Nor has cracking one's knuckles been found to play a role.<ref name="pmid21383216">{{cite journal |vauthors=Deweber K, Olszewski M, Ortolano R |title=Knuckle cracking and hand osteoarthritis |journal=J Am Board Fam Med |volume=24 |issue=2 |pages=169–74 |year=2011 |pmid=21383216 |doi=10.3122/jabfm.2011.02.100156}}</ref>

===Primary===
A number of studies have shown that there is a greater prevalence of the disease among [[sibling]]s and especially [[Semiidentical twins|identical twins]], indicating a hereditary basis.<ref name="pmid18687274">{{cite journal |vauthors=Valdes AM, Spector TD |title=The contribution of genes to osteoarthritis |journal=Rheum. Dis. Clin. North Am. |volume=34 |issue=3 |pages=581–603 |date=August 2008 |pmid=18687274 |doi=10.1016/j.rdc.2008.04.008}}</ref> Although a single factor is not generally sufficient to cause the disease, about half of the variation in susceptibility has been assigned to genetic factors.<ref name="pmid14698640">{{cite journal |vauthors=Spector TD, MacGregor AJ |title=Risk factors for osteoarthritis: genetics |journal=Osteoarthr. Cartil. |volume=12 Suppl A |issue=|pages=S39–44 |year=2004 |pmid=14698640 |doi=10.1016/j.joca.2003.09.005}}</ref>

As early human ancestors evolved into bipeds, changes occurred in the pelvis, hip joint and spine which increased the risk of osteoarthritis.<ref>{{cite journal |vauthors=Hogervorst T, Bouma HW, de Vos J |title=Evolution of the hip and pelvis. |journal=Acta Orthopaedica Supplementum |volume=80 |issue=336 |pages=1–39 |date=August 2009 |pmid=19919389 |doi=10.1080/17453690610046620}}</ref> Additionally genetic variations that increase the risk were likely not selected against because usually problems only occur after reproductive success.<ref>{{cite journal |vauthors=van der Kraan PM, van den Berg WB |title=Osteoarthritis in the context of ageing and evolution. Loss of chondrocyte differentiation block during ageing. |journal=Ageing Research Reviews |volume=7 |issue=2 |pages=106–13 |date=April 2008 |pmid=18054526 |doi=10.1016/j.arr.2007.10.001}}</ref>

The development of osteoarthritis is correlated with a history of previous joint injury and with obesity, especially with respect to knees.<ref name="pmid11360143">{{cite journal |vauthors=Coggon D, Reading I, Croft P, McLaren M, Barrett D, Cooper C |title=Knee osteoarthritis and obesity |journal=Int. J. Obes. Relat. Metab. Disord. |volume=25 |issue=5 |pages=622–7 |date=May 2001 |pmid=11360143 |doi=10.1038/sj.ijo.0801585}}</ref> Since the correlation with obesity has been observed not only for knees but also for non-weight bearing joints and the loss of body fat is more closely related to symptom relief than the loss of body weight, it has been suggested that there may be a metabolic link to body fat as opposed to just mechanical loading.<ref name="pmid17038451">{{cite journal |vauthors=Pottie P, Presle N, Terlain B, Netter P, Mainard D, Berenbaum F |title=Obesity and osteoarthritis: more complex than predicted! |journal=Ann. Rheum. Dis. |volume=65 |issue=11 |pages=1403–5 |date=November 2006 |pmid=17038451 |pmc=1798356 |doi=10.1136/ard.2006.061994}}</ref>

Changes in sex hormone levels may play a role in the development of osteoarthritis as it is more prevalent among post-menopausal women than among men of the same age.<ref name="pmid22632696">{{cite journal |vauthors=Linn S, Murtaugh B, Casey E |title=Role of sex hormones in the development of osteoarthritis |journal=PM&R |volume=4 |issue=5 Suppl |pages=S169–73 |date=May 2012 |pmid=22632696 |doi=10.1016/j.pmrj.2012.01.013}}</ref><ref name="pmid21481553">{{cite journal |vauthors=Tanamas SK, Wijethilake P, Wluka AE, Davies-Tuck ML, Urquhart DM, Wang Y, Cicuttini FM |title=Sex hormones and structural changes in osteoarthritis: a systematic review |journal=Maturitas |volume=69 |issue=2 |pages=141–56 |date=June 2011 |pmid=21481553 |doi=10.1016/j.maturitas.2011.03.019}}</ref> A study of mice found natural female hormones to be protective while injections of the male hormone [[dihydrotestosterone]] reduced protection.<ref name="pmid17207643">{{cite journal |vauthors=Ma HL, Blanchet TJ, Peluso D, Hopkins B, Morris EA, Glasson SS |title=Osteoarthritis severity is sex dependent in a surgical mouse model |journal=Osteoarthr. Cartil. |volume=15 |issue=6 |pages=695–700 |date=June 2007 |pmid=17207643 |doi=10.1016/j.joca.2006.11.005}}</ref>

===Secondary===
{{multiple image|caption_align=center|header_align=center
| footer = Secondary osteoarthritis (due to an old injury with fracture) of the ankle in a woman of 82 years old
| image1 = Secondary osteoarthritis Ankle P.png
| width1 = 168
| alt1 =
| caption1 = lateral
| image2 = Secondary osteoarthritis Ankle F.png
| width2 = 104
| alt2 =
| caption2 = front
}}
This type of osteoarthritis is caused by other factors but the resulting pathology is the same as for primary osteoarthritis:
* [[Alkaptonuria]]
* [[Congenital]] [[disease|disorder]]s of joints
* [[Diabetes]] doubles the risk of having a joint replacement due to osteoarthritis and people with diabetes have joint replacements at a younger age than those without diabetes.<ref>{{cite journal | vauthors = King KB, Rosenthal AK | title = The adverse effects of diabetes on osteoarthritis: update on clinical evidence and molecular mechanisms | journal = Osteoarthritis Cartilage | volume = 23 | issue = 6 | pages = 841–50 | year = 2015 | pmid = 25837996 | doi = 10.1016/j.joca.2015.03.031 }}</ref>
* [[Ehlers-Danlos Syndrome]]
* [[Hemochromatosis]] and [[Wilson's disease]]
* Inflammatory diseases (such as [[Perthes' disease]]), ([[Lyme disease]]), and all chronic forms of arthritis (e.g., [[costochondritis]], [[gout]], and [[rheumatoid arthritis]]). In gout, [[uric acid]] crystals cause the cartilage to degenerate at a faster pace.
* [[Injury]] to joints or ligaments (such as the [[Anterior cruciate ligament|ACL]]), as a result of an accident or orthopedic operations.
* [[Ligament]]ous deterioration or instability may be a factor.
* [[Marfan syndrome]]
* [[Obesity]]
* [[Septic arthritis|Joint infection]]

==Pathophysiology==
{{multiple image
|width=200
|direction=vertical
|image1=0910 Oateoarthritis Hip B.png
|caption1=''Normal hip joint''
|image2=0910 Oateoarthritis Hip A.png
|caption2=''Hip joint with osteoarthritis''<ref>{{Cite web|title = OpenStax CNX|url = http://cnx.org/contents/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@7.30:59/Synovial-Joints|website = cnx.org|accessdate = 2015-10-14}}</ref>}}
While osteoarthritis is a degenerative joint disease that may cause gross cartilage loss and morphological damage to other joint tissues, more subtle biochemical changes occur in the earliest stages of osteoarthritis progression. The water content of healthy cartilage is finely balanced by compressive force driving water out and hydrostatic and osmotic pressure drawing water in.<ref name="pmid25182679">{{cite journal |vauthors=Sanchez-Adams J, Leddy HA, McNulty AL, O'Conor CJ, Guilak F |title=The mechanobiology of articular cartilage: bearing the burden of osteoarthritis |journal=Curr Rheumatol Rep |volume=16 |issue=10 |pages=451 |year=2014 |pmid=25182679 |pmc=4682660 |doi=10.1007/s11926-014-0451-6 |url=}}</ref><ref name="Maroudas A 1976">{{cite journal |author=Maroudas AI |title=Balance between swelling pressure and collagen tension in normal and degenerate cartilage |journal=Nature |volume=260 |issue=5554 |pages=808–9 |date=April 1976 |pmid=1264261 |doi=10.1038/260808a0}}</ref> Collagen fibres exert the compressive force, whereas the [[Gibbs–Donnan effect]] and cartilage proteoglycans create osmotic pressure which tends to draw water in.<ref name="Maroudas A 1976"/>

However, during onset of osteoarthritis, the collagen matrix becomes more disorganized and there is a decrease in proteoglycan content within cartilage. The breakdown of collagen fibers results in a net increase in water content.<ref name="Bollet AJ 1966">{{cite journal |vauthors=Bollet AJ, Nance JL |title=Biochemical Findings in Normal and Osteoarthritic Articular Cartilage. II. Chondroitin Sulfate Concentration and Chain Length, Water, and Ash Content |journal=J. Clin. Invest. |volume=45 |issue=7 |pages=1170–7 |date=July 1966 |pmid=16695915 |pmc=292789 |doi=10.1172/JCI105423}}</ref><ref name="Brocklehurst R 1984">{{cite journal |vauthors=Brocklehurst R, Bayliss MT, Maroudas A, Coysh HL, Freeman MA, Revell PA, Ali SY |title=The composition of normal and osteoarthritic articular cartilage from human knee joints. With special reference to unicompartmental replacement and osteotomy of the knee |journal=J Bone Joint Surg Am |volume=66 |issue=1 |pages=95–106 |date=January 1984 |pmid=6690447 |doi =}}</ref><ref name="Chou MC 2009">{{cite journal |vauthors=Chou MC, Tsai PH, Huang GS, Lee HS, Lee CH, Lin MH, Lin CY, Chung HW |title=Correlation between the MR T2 value at 4.7 T and relative water content in articular cartilage in experimental osteoarthritis induced by ACL transection |journal=Osteoarthr. Cartil. |volume=17 |issue=4 |pages=441–7 |date=April 2009 |pmid=18990590 |doi=10.1016/j.joca.2008.09.009}}</ref><ref name="Grushko G 1989">{{cite journal |vauthors=Grushko G, Schneiderman R, Maroudas A |title=Some biochemical and biophysical parameters for the study of the pathogenesis of osteoarthritis: a comparison between the processes of ageing and degeneration in human hip cartilage |journal=Connect. Tissue Res. |volume=19 |issue=2–4 |pages=149–76 |year=1989 |pmid=2805680 |doi=10.3109/03008208909043895 |url =}}</ref><ref name="Mankin HJ 1975">{{cite journal |vauthors=Mankin HJ, Thrasher AZ |title=Water content and binding in normal and osteoarthritic human cartilage |journal=J Bone Joint Surg Am |volume=57 |issue=1 |pages=76–80 |date=January 1975 |pmid=1123375 |doi =}}</ref> This increase occurs because whilst there is an overall loss of proteoglycans (and thus a decreased osmotic pull),<ref name="Brocklehurst R 1984"/><ref name="Venn M 1977">{{cite journal |vauthors=Venn M, Maroudas A |title=Chemical composition and swelling of normal and osteoarthrotic femoral head cartilage. I. Chemical composition |journal=Ann. Rheum. Dis. |volume=36 |issue=2 |pages=121–9 |date=April 1977 |pmid=856064 |pmc=1006646 |doi=10.1136/ard.36.2.121}}</ref> it is outweighed by a loss of collagen.<ref name="Maroudas A 1976"/><ref name="Venn M 1977"/> Without the protective effects of the proteoglycans, the [[collagen]] fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration. [[Inflammation]] of the [[synovium]] (joint cavity lining) and the surrounding [[joint capsule]] can also occur, though often mild (compared to the synovial inflammation that occurs in [[rheumatoid arthritis]]). This can happen as breakdown products from the cartilage are released into the synovial space, and the cells lining the joint attempt to remove them.{{citation needed|date=December 2016}}

Other structures within the joint can also be affected.<ref>{{cite journal | vauthors = Madry H, Luyten FP, Facchini A | title = Biological aspects of early osteoarthritis | journal = Knee Surg. Sports Traumatol. Arthrosc. | volume = 20 | issue = 3 | pages = 407–22 | year = 2012 | pmid = 22009557 | doi = 10.1007/s00167-011-1705-8 }}</ref> The [[ligament]]s within the joint become thickened and [[fibrosis|fibrotic]] and the [[Meniscus (anatomy)|menisci]] can become damaged and wear away.<ref>{{cite journal | vauthors = Englund M, Roemer FW, Hayashi D, Crema MD, Guermazi A | title = Meniscus pathology, osteoarthritis and the treatment controversy | journal = Nat. Rev. Rheumatol. | volume = 8 | issue = 7 | pages = 412–9 | year = 2012 | pmid = 22614907 | doi = 10.1038/nrrheum.2012.69 }}</ref> Menisci can be completely absent by the time a person undergoes a [[joint replacement]]. New bone outgrowths, called "spurs" or [[osteophyte]]s, can form on the margins of the joints, possibly in an attempt to improve the congruence of the [[articular cartilage]] surfaces in the absence of the menisci. The [[subchondral bone]] volume increases and becomes less mineralized (hypomineralization).<ref>{{cite journal | vauthors = Li G, Yin J, Gao J, Cheng TS, Pavlos NJ, Zhang C, Zheng MH | title = Subchondral bone in osteoarthritis: insight into risk factors and microstructural changes | journal = [[Arthritis Research & Therapy]] | volume = 15 | issue = 6 | pages = 223 | year = 2013 | pmid = 24321104 | doi = 10.1186/ar4405 }}</ref> All these changes can cause problems functioning. The [[pain]] in an osteoarthritic joint has been related to thickened [[synovium]]<ref>{{cite journal | vauthors = Hill CL, Gale DG, Chaisson CE, Skinner K, Kazis L, Gale ME, Felson DT | title = Knee effusions, popliteal cysts, and synovial thickening: association with knee pain in osteoarthritis | journal = J. Rheumatol. | volume = 28 | issue = 6 | pages = 1330–7 | year = 2001 | pmid = 11409127 }}</ref> and [[subchondral bone]] lesions.<ref>{{cite journal | vauthors = Felson DT, Chaisson CE, Hill CL, Totterman SM, Gale ME, Skinner KM, Kazis L, Gale DR | title = The association of bone marrow lesions with pain in knee osteoarthritis | journal = Ann Intern Med |date=3 Apr 2001 | volume = 134 | issue = 7 | pages = 541–9 | pmid = 11281736 | doi = 10.7326/0003-4819-134-7-200104030-00007 }}</ref>

==Diagnosis==
[[medical diagnosis|Diagnosis]] is made with reasonable certainty based on history and clinical examination.<ref name="pmid19762361">{{cite journal |vauthors=Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, Herrero-Beaumont G, Kirschner S, Leeb BF, Lohmander LS, Mazières B, Pavelka K, Punzi L, So AK, Tuncer T, Watt I, Bijlsma JW |title=EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis |journal=Ann. Rheum. Dis. |volume=69 |issue=3 |pages=483–9 |date=March 2010 |pmid=19762361 |doi=10.1136/ard.2009.113100}}</ref><ref name="pmid12180735">{{cite journal |vauthors=Bierma-Zeinstra SM, Oster JD, Bernsen RM, Verhaar JA, Ginai AZ, Bohnen AM |title=Joint space narrowing and relationship with symptoms and signs in adults consulting for hip pain in primary care |journal=J. Rheumatol. |volume=29 |issue=8 |pages=1713–8 |date=August 2002 |pmid=12180735 |doi =}}</ref> [[X-ray]]s may confirm the diagnosis. The typical changes seen on X-ray include: [[joint]] space narrowing, subchondral [[Sclerosis (medicine)|sclerosis]] (increased bone formation around the joint), subchondral [[Bone cyst|cyst]] formation, and [[osteophytes]].<ref>{{MerckManual|04|034|e||Osteoarthritis (OA): Joint Disorders}}</ref> Plain films may not correlate with the findings on physical examination or with the degree of pain.<ref name="Phillips">{{cite journal |vauthors=Phillips CR, Brasington RD |title=Osteoarthritis treatment update: Are NSAIDs still in the picture? |journal=Journal of Musculoskeletal Medicine |volume=27 |issue=2 |year=2010 |url=http://www.musculoskeletalnetwork.com/display/article/1145622/1517357}}</ref> Usually other imaging techniques are not necessary to clinically diagnose osteoarthritis.

In 1990, the [[American College of Rheumatology]], using data from a multi-center study, developed a set of criteria for the diagnosis of hand osteoarthritis based on hard tissue enlargement and swelling of certain joints.<ref>{{cite web |url=http://www.uptodate.com/patients/content/topic.do?topicKey=~77ll0j9jfS9fuD |title=Patient information: Osteoarthritis symptoms and diagnosis (Beyond the Basics) |author=Kalunian KC |year=2013 |work=|publisher=UpToDate |accessdate=15 February 2013}}</ref> These criteria were found to be 92% [[sensitivity (tests)|sensitive]] and 98% [[specificity (tests)|specific]] for hand osteoarthritis versus other entities such as rheumatoid arthritis and [[spondyloarthropathy|spondyloarthropathies]].<ref name="pmid2242058">{{cite journal |vauthors=Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, Brown C, Cooke TD, Daniel W, Gray R |title=The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand |journal=Arthritis Rheum. |volume=33 |issue=11 |pages=1601–10 |date=November 1990 |pmid=2242058 |doi=10.1002/art.1780331101}}</ref>

Related pathologies whose names may be confused with osteoarthritis include pseudo-arthrosis. This is derived from the Greek roots ''pseudo-'', meaning "false", and ''arthr-'', meaning "joint", together with the ending ''-osis'' used for disorders. Radiographic diagnosis results in diagnosis of a fracture within a joint, which is not to be confused with osteoarthritis which is a degenerative pathology affecting a high incidence of distal phalangeal joints of female patients. A polished ivory-like appearance may also develop on the bones of the affected joints, reflecting a change called [[eburnation]].<ref>{{cite book |vauthors=Vasan N, Tao L, Vikas B |title=First Aid for the USMLE Step 1, 2010 (First Aid USMLE) |publisher=McGraw-Hill Medical |year=2010 |page=378 |isbn=0-07-163340-5 |url=https://books.google.se/books?id=eVAtPktgw0UC&pg=PA169}}</ref>

<gallery>
Image:Osteo of the hand.jpg|Severe osteoarthritis and [[osteopenia]] of the carpal joint and 1st carpometacarpel joint.
Image:Gonarthrose-Knorpelaufbrauch.jpg|MRI of osteoarthritis in the knee, with characteristic narrowing of the joint space.
Image:Osteoarthritis left knee.jpg|Primary osteoarthritis of the left knee. Note the [[osteophytes]], narrowing of the joint space (arrow), and increased subchondral bone density (arrow).
Image:Damaged cartilage Danish sow.png|Damaged cartilage from sows. (a) cartilage erosion (b)cartilage ulceration (c)cartilage repair (d)osteophyte (bone spur) formation.
Image:Primary osteoarthrosis (2) at knee joint.jpg|Histopathology of osteoarthrosis of a knee joint in an elderly female.
Image:Primary osteoarthrosis (5) at knee joint.jpg|Histopathology of osteoarthrosis of a knee joint in an elderly female.
image:Health joint.png|In a healthy joint, the ends of bones are encased in smooth cartilage. Together, they are protected by a joint capsule lined with a synovial membrane that produces synovial fluid. The capsule and fluid protect the cartilage, muscles, and connective tissues.
image:Joint with severe osteoathritis.png|With osteoarthritis, the cartilage becomes worn away. Spurs grow out from the edge of the bone, and synovial fluid increases. Altogether, the joint feels stiff and sore.
File:Osteoarthritis.png|thumb|Osteoarthritis
</gallery>

===Classification===
{{See|Radiographic classification of osteoarthritis}}
A number of classification systems are used for gradation of osteoarthritis:

*[[WOMAC]] scale, taking into account [[pain]], stiffness and functional limitation.<ref>{{cite journal|last1=Quintana|first1=José M.|last2=Escobar|first2=Antonio|last3=Arostegui|first3=Inmaculada|last4=Bilbao|first4=Amaia|last5=Azkarate|first5=Jesús|last6=Goenaga|first6=J. Ignacio|last7=Arenaza|first7=Juan C.|title=Health-Related Quality of Life and Appropriateness of Knee or Hip Joint Replacement|journal=Archives of Internal Medicine|date=23 January 2006|volume=166|issue=2|pages=220–226|doi=10.1001/archinte.166.2.220}}</ref>
*[[Kellgren-Lawrence grading scale]] for osteoarthritis of the knee. It uses only [[projectional radiography]] features.
*[[Tönnis classification]] for osteoarthritis of the [[hip joint]], also using only [[projectional radiography]] features.<ref>{{cite web|url=http://www.preventivehip.org/hip-scores/tonnis-classification|title=Tönnis Classification of Osteoarthritis by Radiographic Changes|website=Society of Preventive Hip Surgery|accessdate=2016-12-13}}</ref>

Osteoarthritis can be classified into either primary or secondary depending on whether or not there is an identifiable underlying cause.

Both primary generalized nodal osteoarthritis and erosive osteoarthritis (EOA, also called inflammatory osteoarthritis) are sub-sets of primary osteoarthritis. EOA is a much less common, and more aggressive inflammatory form of osteoarthritis which often affects the distal interphalangeal joints of the hand and has characteristic articular erosive changes on x-ray.<ref name="pmid15454130">{{cite journal |vauthors=Punzi L, Ramonda R, Sfriso P |title=Erosive osteoarthritis |journal=Best Pract Res Clin Rheumatol |volume=18 |issue=5 |pages=739–58 |date=October 2004 |pmid=15454130 |doi=10.1016/j.berh.2004.05.010}}</ref>

==Management==
[[File:Exercise.png|thumb|left|People with osteoarthritis should do different kinds of exercise for different benefits to the body.]]
Lifestyle modification (such as weight loss and exercise) and [[analgesics]] are the mainstays of treatment. [[Acetaminophen]] (also known as paracetamol) is recommended first line with [[NSAIDs]] being used as add on therapy only if pain relief is not sufficient.<ref name=Cochrane10>{{cite journal |author=Flood J |title=The role of acetaminophen in the treatment of osteoarthritis |journal=Am J Manag Care |volume=16 |issue=Suppl Management |pages=S48–54 |date=March 2010 |pmid=20297877 |url=http://www.ajmc.com/publications/supplement/2010/A278_10mar_Pain/A278_2010mar_Flood/}} {{open access}}</ref> This is due to the relative greater safety of acetaminophen.<ref name=Cochrane10/>

===Lifestyle changes===
For overweight people, [[weight loss]] may be an important factor.<ref name="Hip Osteoarthritis 2009"/> Patient education has been shown to be helpful in the self-management of arthritis.<ref name="Hip Osteoarthritis 2009"/> It decreases pain, improves function, reduces stiffness and fatigue, and reduces medical usage.<ref name="Hip Osteoarthritis 2009">{{cite journal |vauthors=Cibulka MT, White DM, Woehrle J, Harris-Hayes M, Enseki K, Fagerson TL, Slover J, Godges JJ |title=Hip pain and mobility deficits—hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association |journal=J Orthop Sports Phys Ther |volume=39 |issue=4 |pages=A1–25 |date=April 2009 |pmid=19352008 |doi=10.2519/jospt.2009.0301}}</ref> Patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip osteoarthritis.<ref name="Hip Osteoarthritis 2009"/>

===Physical measures===
Moderate exercise is beneficial with respect to pain and function in those with osteoarthritis of the knee and hip.<ref name="pmid23253613">{{cite journal |vauthors=Hagen KB, Dagfinrud H, Moe RH, Østerås N, Kjeken I, Grotle M, Smedslund G |title=Exercise therapy for bone and muscle health: an overview of systematic reviews |journal=BMC Med |volume=10 |page=167 |year=2012 |pmid=23253613 |pmc=3568719 |doi=10.1186/1741-7015-10-167}}</ref><ref>{{cite journal |vauthors=Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S |title=Exercise for osteoarthritis of the hip. |journal=Cochrane Database Syst Rev |issue=4 |pages=CD007912 |year=2014 |pmid=24756895 |doi=10.1002/14651858.CD007912.pub2 |volume=4}}</ref> These exercises should occur at least three times per week.<ref>{{cite journal |vauthors=Juhl C, Christensen R, Roos EM, Zhang W, Lund H |title=Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. |journal=Arthritis & Rheumatology |volume=66 |issue=3 |pages=622–36 |date=Mar 2014 |pmid=24574223 |doi=10.1002/art.38290}}</ref> While some evidence supports certain [[physical therapy|physical therapies]], evidence for a combined program is limited.<ref name="pmid23128863">{{cite journal |vauthors=Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL |title=Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review |journal=Annals of Internal Medicine |volume=157 |issue=9 |pages=632–44 |date=November 2012 |pmid=23128863 |doi=10.7326/0003-4819-157-9-201211060-00007}}</ref> There is not enough evidence to determine the effectiveness of [[massage therapy]].<ref name="pmid22632691">{{cite journal |author=De Luigi AJ |title=Complementary and alternative medicine in osteoarthritis |journal=PM&R |volume=4 |issue=5 Suppl |pages=S122–33 |date=May 2012 |pmid=22632691 |doi=10.1016/j.pmrj.2012.01.012}}</ref> The evidence for [[manual therapy]] is inconclusive.<ref>{{cite journal |vauthors=French HP, Brennan A, White B, Cusack T |title=Manual therapy for osteoarthritis of the hip or knee — a systematic review |journal=Man Ther |volume=16 |issue=2 |pages=109–117 |year=2011 |pmid=21146444 |doi=10.1016/j.math.2010.10.011}}</ref> Functional, gait, and balance training have been recommended to address impairments of position sense, balance, and strength in individuals with lower extremity arthritis as these can contribute to a higher rate of falls in older individuals.<ref name="pmid15517643">{{cite journal |vauthors=Sturnieks DL, Tiedemann A, Chapman K, Munro B, Murray SM, Lord SR |title=Physiological risk factors for falls in older people with lower limb arthritis |journal=J. Rheumatol. |volume=31 |issue=11 |pages=2272–9 |date=November 2004 |pmid=15517643 |doi =}}</ref>

Lateral wedge insoles and neutral insoles do not appear to be useful in osteoarthritis of the knee.<ref name="pmid23612781">{{cite journal |vauthors=Penny P, Geere J, Smith TO |title=A systematic review investigating the efficacy of laterally wedged insoles for medial knee osteoarthritis |journal=Rheumatol. Int. |volume=33 |issue=10 |pages=2529–38 |date=October 2013 |pmid=23612781 |doi=10.1007/s00296-013-2760-x}}</ref><ref name="pmid23989797">{{cite journal |vauthors=Parkes MJ, Maricar N, Lunt M, LaValley MP, Jones RK, Segal NA, Takahashi-Narita K, Felson DT |title=Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta-analysis |journal=JAMA |volume=310 |issue=7 |pages=722–30 |date=August 2013 |pmid=23989797 |doi=10.1001/jama.2013.243229}}</ref><ref name=Cochrane2015>{{cite journal|last1=Duivenvoorden|first1=T|last2=Brouwer|first2=RW|last3=van Raaij|first3=TM|last4=Verhagen|first4=AP|last5=Verhaar|first5=JA|last6=Bierma-Zeinstra|first6=SM|title=Braces and orthoses for treating osteoarthritis of the knee.|journal=The Cochrane database of systematic reviews|date=16 March 2015|volume=3|pages=CD004020|pmid=25773267|doi=10.1002/14651858.CD004020.pub3}}</ref> [[Orthotics|Knee braces]] may help<ref>{{cite journal |vauthors=Page CJ, Hinman RS, Bennell KL |title=Physiotherapy management of knee osteoarthritis |journal=Int J Rheum Dis |volume=14 |issue=2 |pages=145–152 |year=2011 |pmid=21518313 |doi=10.1111/j.1756-185X.2011.01612.x |url =}}</ref> but their usefulness has also been disputed.<ref name=Cochrane2015 /> For pain management heat can be used to relieve stiffness, and cold can relieve muscle spasms and pain.<ref name="url_Mayo Clinic">{{cite web |url=http://www.mayoclinic.org/diseases-conditions/osteoarthritis/basics/lifestyle-home-remedies/con-20014749 |title=Osteoarthritis Lifestyle and home remedies |work= Diseases and Conditions |publisher=Mayo Clinic}}</ref> Among people with hip and knee osteoarthritis, exercise in water may reduce pain and disability, and increase quality of life in the short term.<ref>{{cite journal|last1=Bartels|first1=EM|last2=Juhl|first2=CB|last3=Christensen|first3=R|last4=Hagen|first4=KB|last5=Danneskiold-Samsøe|first5=B|last6=Dagfinrud|first6=H|last7=Lund|first7=H|title=Aquatic exercise for the treatment of knee and hip osteoarthritis.|journal=The Cochrane database of systematic reviews|date=23 March 2016|volume=3|pages=CD005523|doi=10.1002/14651858.CD005523.pub3|pmid=27007113|url=http://onlinelibrary.wiley.com/wol1/doi/10.1002/14651858.CD005523.pub3/abstract|accessdate=5 April 2016}}</ref>

===Medication===
{| class="wikitable" style="float:right; width:30em; border:solid 1px #999; margin:0 0 1em 1em"
|-
! colspan=3 style="background:#cee"| Treatment recommendations by risk factors
|-
! GI risk
! [[Cardiovascular disease|CVD]] risk
! Option
|-
| Low
| Low
| NSAID, or paracetamol<ref name="BBDNSAIDs">{{Citation |author1=Consumer Reports Health Best Buy Drugs |author1-link=Consumer Reports |date=July 2013 |title=NSAIDs |publisher=Consumer Reports |publication-place=[[Yonkers, New York]] |page= |url=http://consumerhealthchoices.org/catalog/nsaids/ |contribution=The Nonsteroidal Anti-Inflammatory Drugs: Treating Osteoarthritis and Pain. Comparing effectiveness, safety, and price. |contribution-url=http://consumerhealthchoices.org/wp-content/uploads/2012/02/BBD-NSAIDs-Full.pdf |accessdate=12 February 2014}}</ref>
|-
| Moderate
| Low
| Paracetamol, or low dose NSAID with [[antacid]]<ref name="BBDNSAIDs"/>
|-
| Low
| Moderate
| Paracetamol, or low dose aspirin with an antacid<ref name="BBDNSAIDs"/>
|-
| Moderate
| Moderate
|Low dose paracetamol, aspirin, and antacid. Monitoring for [[abdominal pain]] or black stool.<ref name="BBDNSAIDs"/>
|}
<!-- oral -->
The [[analgesic|pain medication]] [[acetaminophen]] is the first line treatment for osteoarthritis.<ref name=Cochrane10/><ref name=OARSI2007>{{cite journal |vauthors=Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P |title=OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence |journal=Osteoarthr. Cartil. |volume=15 |issue=9 |pages=981–1000 |date=September 2007 |pmid=17719803 |doi=10.1016/j.joca.2007.06.014}}</ref> However, a 2015 review found acetaminophen to only have a small short term benefit.<ref>{{cite journal|last1=Machado|first1=GC|last2=Maher|first2=CG|last3=Ferreira|first3=PH|last4=Pinheiro|first4=MB|last5=Lin|first5=CW|last6=Day|first6=RO|last7=McLachlan|first7=AJ|last8=Ferreira|first8=ML|title=Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials.|journal=BMJ (Clinical research ed.)|date=31 March 2015|volume=350|pages=h1225|pmid=25828856|doi=10.1136/bmj.h1225}}</ref> For mild to moderate symptoms effectiveness is similar to [[non-steroidal anti-inflammatory drug]]s (NSAIDs), though for more severe symptoms NSAIDs may be more effective.<ref name=Cochrane10/> NSAIDs such as [[naproxen]], while more effective in severe cases, are associated with greater side effects, such as [[gastrointestinal bleeding]].<ref name=Cochrane10/> [[Diclofenac]] may be the most effective NSAID.<ref>{{cite journal|last1=da Costa|first1=BR|last2=Reichenbach|first2=S|last3=Keller|first3=N|last4=Nartey|first4=L|last5=Wandel|first5=S|last6=Jüni|first6=P|last7=Trelle|first7=S|title=Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis.|journal=Lancet (London, England)|date=21 May 2016|volume=387|issue=10033|pages=2093–105|pmid=26997557|doi=10.1016/s0140-6736(16)30002-2}}</ref>

Another class of NSAIDs, [[COX-2 selective inhibitor]]s (such as [[celecoxib]]) are equally effective when compared to nonselective NSAIDs, and have lower rates of adverse gastrointestinal effects, but higher rates of cardiovascular disease such as [[myocardial infarction]].<ref name="pmid18405470">{{cite journal |vauthors=Chen YF, Jobanputra P, Barton P, Bryan S, Fry-Smith A, Harris G, Taylor RS |title=Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and rheumatoid arthritis: a systematic review and economic evaluation |journal=Health Technol Assess |volume=12 |issue=11 |pages=1–278, iii |date=April 2008 |pmid=18405470 |doi =10.3310/hta12110}}</ref> They are also more expensive than non-specific NSAIDs.<ref>{{cite journal|last1=Wielage|first1=RC|last2=Myers|first2=JA|last3=Klein|first3=RW|last4=Happich|first4=M|title=Cost-effectiveness analyses of osteoarthritis oral therapies: a systematic review.|journal=Applied Health Economics and Health Policy|date=December 2013|volume=11|issue=6|pages=593–618|pmid=24214160|doi=10.1007/s40258-013-0061-x}}</ref> Benefits and risks vary in individuals and need consideration when making treatment decisions.<ref>{{Cite journal|last=van Walsem|first=Anneloes|last2=Pandhi|first2=Shaloo|last3=Nixon|first3=Richard M.|last4=Guyot|first4=Patricia|last5=Karabis|first5=Andreas|last6=Moore|first6=R. Andrew|date=2015-01-01|title=Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or rheumatoid arthritis: a network meta-analysis|url=http://dx.doi.org/10.1186/s13075-015-0554-0|journal=Arthritis Research & Therapy|volume=17|pages=66|doi=10.1186/s13075-015-0554-0|issn=1478-6354|pmc=4411793|pmid=25879879}}</ref> NSAIDS applied topically are effective for a small number of people.<ref>{{cite journal|last1=Derry|first1=S|last2=Conaghan|first2=P|last3=Da Silva|first3=JA|last4=Wiffen|first4=PJ|last5=Moore|first5=RA|title=Topical NSAIDs for chronic musculoskeletal pain in adults.|journal=The Cochrane database of systematic reviews|date=22 April 2016|volume=4|pages=CD007400|pmid=27103611|doi=10.1002/14651858.CD007400.pub3}}</ref>

Failure to achieve desired pain relief in osteoarthritis after 2 weeks should trigger reassessment of dosage and pain medication.<ref>{{Cite journal|last=Karabis|first=Andreas|last2=Nikolakopoulos|first2=Stavros|last3=Pandhi|first3=Shaloo|last4=Papadimitropoulou|first4=Katerina|last5=Nixon|first5=Richard|last6=Chaves|first6=Ricardo L.|last7=Moore|first7=R. Andrew|date=2016-01-01|title=High correlation of VAS pain scores after 2 and 6 weeks of treatment with VAS pain scores at 12 weeks in randomised controlled trials in rheumatoid arthritis and osteoarthritis: meta-analysis and implications|url=http://dx.doi.org/10.1186/s13075-016-0972-7|journal=Arthritis Research & Therapy|volume=18|pages=73|doi=10.1186/s13075-016-0972-7|issn=1478-6362|pmc=4818534|pmid=27036633}}</ref> [[Opioids]] by mouth, including both weak opioids such as [[tramadol]] and stronger opioids, are also often prescribed. Their appropriateness is uncertain, and opioids are often recommended only when first line therapies have failed or are contraindicated.<ref name="ReferenceA">{{cite journal|last1=McAlindon|first1=TE|last2=Bannuru|first2=RR|last3=Sullivan|first3=MC|last4=Arden|first4=NK|last5=Berenbaum|first5=F|last6=Bierma-Zeinstra|first6=SM|last7=Hawker|first7=GA|last8=Henrotin|first8=Y|last9=Hunter|first9=DJ|last10=Kawaguchi|first10=H|last11=Kwoh|first11=K|last12=Lohmander|first12=S|last13=Rannou|first13=F|last14=Roos|first14=EM|last15=Underwood|first15=M|title=OARSI guidelines for the non-surgical management of knee osteoarthritis.|journal=Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society|date=March 2014|volume=22|issue=3|pages=363–88|pmid=24462672|doi=10.1016/j.joca.2014.01.003}}</ref><ref>{{cite journal|last1=Hochberg|first1=MC|last2=Altman|first2=RD|last3=April|first3=KT|last4=Benkhalti|first4=M|last5=Guyatt|first5=G|last6=McGowan|first6=J|last7=Towheed|first7=T|last8=Welch|first8=V|last9=Wells|first9=G|last10=Tugwell|first10=P|last11=American College of|first11=Rheumatology|title=American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.|journal=Arthritis Care & Research|date=April 2012|volume=64|issue=4|pages=465–74|pmid=22563589|doi=10.1002/acr.21596}}</ref> This is due to their small benefit and relatively large risk of side effects.<ref>{{cite journal|last1=da Costa|first1=BR|last2=Nüesch|first2=E|last3=Kasteler|first3=R|last4=Husni|first4=E|last5=Welch|first5=V|last6=Rutjes|first6=AW|last7=Jüni|first7=P|title=Oral or transdermal opioids for osteoarthritis of the knee or hip.|journal=The Cochrane database of systematic reviews|date=17 September 2014|volume=9|pages=CD003115|pmid=25229835|doi=10.1002/14651858.CD003115.pub4}}</ref> Oral [[steroid]]s are not recommended in the treatment of osteoarthritis.<ref name=OARSI2007/>

<!-- topical -->
There are several NSAIDs available for [[topical]] use, including [[diclofenac]]. A Cochrane review from 2016 concluded that reasonably reliable evidence is available only for use of topical diclofenac and ketoprofen in people aged over 40 years with painful knee arthritis.<ref>{{cite journal|last1=Derry|first1=Sheena|last2=Conaghan|first2=Philip|last3=Da Silva|first3=José António P|last4=Wiffen|first4=Philip J|last5=Moore|first5=R Andrew|title=Topical NSAIDs for chronic musculoskeletal pain in adults|journal=Cochrane Database of Systematic Reviews|date=22 April 2016|doi=10.1002/14651858.cd007400.pub3|url=http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007400.pub3/full|accessdate=26 April 2016|pmid=27103611|volume=4|pages=CD007400}}</ref> Transdermal [[Opioid analgesic|opioid pain medications]] are not typically recommended in the treatment of osteoarthritis.<ref>{{cite journal |vauthors=da Costa BR, Nüesch E, Kasteler R, Husni E, Welch V, Rutjes AW, Jüni P |title=Oral or transdermal opioids for osteoarthritis of the knee or hip. |journal=The Cochrane database of systematic reviews |volume=9 |pages=CD003115 |year=2014 |pmid=25229835 |doi=10.1002/14651858.CD003115.pub4}}</ref> The use of [[topical]] [[capsaicin]] to treat osteoarthritis is controversial, as some reviews found benefit<ref name=Silva2011/><ref name="pmid19856319">{{cite journal |vauthors=Cameron M, Gagnier JJ, Little CV, Parsons TJ, Blümle A, Chrubasik S |title=Evidence of effectiveness of herbal medicinal products in the treatment of arthritis. Part I: Osteoarthritis |journal=Phytother Res |volume=23 |issue=11 |pages=1497–515 |date=November 2009 |pmid=19856319 |doi=10.1002/ptr.3007}}</ref> while others did not.<ref name=PM09>{{cite journal |vauthors=Altman R, Barkin RL |title=Topical therapy for osteoarthritis: clinical and pharmacologic perspectives |journal=Postgrad Med |volume=121 |issue=2 |pages=139–47 |date=March 2009 |pmid=19332972 |doi=10.3810/pgm.2009.03.1986 |url =}}</ref>

<!-- injectable -->
[[Joint injection]]s of glucocorticoids (such as [[hydrocortisone]]) leads to short term pain relief that may last between a few weeks and a few months.<ref>{{cite journal |vauthors=Arroll B, Goodyear-Smith F |title=Corticosteroid injections for osteoarthritis of the knee: meta-analysis |journal=BMJ |volume=328 |issue=7444 |page=869 |date=April 2004 |pmid=15039276 |pmc=387479 |doi=10.1136/bmj.38039.573970.7C |url =}}</ref> Injections of [[hyaluronic acid]] have not been found to lead to much improvement compared to placebo when the knee joint is affected<ref name=Rutjes12>{{cite journal |vauthors=Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E, Reichenbach S |title=Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis |journal=Annals of Internal Medicine |volume=157 |issue=3 |pages=180–91 |date=August 2012 |pmid=22868835 |doi=10.7326/0003-4819-157-3-201208070-00473 |url=http://www.annals.org/article.aspx?volume=157&page=180}}</ref><ref>{{cite journal|last1=Jevsevar|first1=D|last2=Donnelly|first2=P|last3=Brown|first3=GA|last4=Cummins|first4=DS|title=Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence.|journal=The Journal of bone and joint surgery. American volume|date=16 December 2015|volume=97|issue=24|pages=2047–60|pmid=26677239|doi=10.2106/jbjs.n.00743}}</ref> but have been associated with harm.<ref name=Rutjes12/> This may stand true for hip osteoarthritis. In ankle osteoarthritis, evidence is unclear.<ref>{{cite journal|last1=Witteveen|first1=AG|last2=Hofstad|first2=CJ|last3=Kerkhoffs|first3=GM|title=Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle|journal=The Cochrane database of systematic reviews|date=17 October 2015|volume=10|issue=10|pages=CD010643|pmid=26475434|quote=It is unclear if there is a benefit or harm for HA as treatment for ankle OA|doi=10.1002/14651858.CD010643.pub2}}</ref> The effectiveness of injections of [[platelet-rich plasma]] is unclear; there are suggestions that such injections improve function but not pain, and are associated with increased risk.{{vague|date=May 2015}}<ref>{{cite journal |vauthors=Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, Gandhi R, Takhar K, Lum G, Chahal J |title=The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis |journal=Arthroscopy |volume=29 |issue=12 |pages=2037–48 |date=December 2013 |pmid=24286802 |doi=10.1016/j.arthro.2013.09.006}}</ref><ref>{{cite journal|last1=Rodriguez-Merchan|first1=EC|title=Intraarticular Injections of Platelet-rich Plasma (PRP) in the Management of Knee Osteoarthritis|journal=Archives of bone and joint surgery|date=September 2013|volume=1|issue=1|pages=5–8|pmid=25207275|pmc=4151401}}</ref>

===Surgery===
If the impact of symptoms of osteoarthritis on quality of life is significant and more conservative management is ineffective, [[joint arthroplasty|joint replacement surgery]] or resurfacing may be recommended. Evidence supports joint replacement for both knees and hips as it is both clinically effective,<ref name="pmid19057730">{{cite journal |vauthors=Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Kreder HJ, Coyte PC, Wright JG |title=Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review |journal=Can J Surg |volume=51 |issue=6 |pages=428–36 |date=December 2008 |pmid=19057730 |pmc=2592576}}</ref><ref name="pmid22398175">{{cite journal |vauthors=Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, Beard DJ |title=Knee replacement |journal=Lancet |volume=379 |issue=9823 |pages=1331–40 |date=April 2012 |pmid=22398175 |doi=10.1016/S0140-6736(11)60752-6}}</ref> and cost-effective.<ref>{{cite journal |vauthors=Jenkins PJ, Clement ND, Hamilton DF, Gaston P, Patton JT, Howie CR |title=Predicting the cost-effectiveness of total hip and knee replacement: A health economic analysis |journal=The bone & joint journal |volume=95-B |issue=1 |pages=115–21 |year=2013 |pmid=23307684 |doi=10.1302/0301-620X.95B1.29835}}</ref><ref>{{cite journal |vauthors=Daigle ME, Weinstein AM, Katz JN, Losina E |title=The cost-effectiveness of total joint arthroplasty: A systematic review of published literature |journal=Best practice & research. Clinical rheumatology |volume=26 |issue=5 |pages=649–58 |year=2012 |pmid=23218429 |pmc=3879923 |doi=10.1016/j.berh.2012.07.013}}</ref> Surgery to transfer articular cartilage from a non-weight-bearing area to the damaged area is one possible procedure that has some success, but there are problems getting the transferred cartilage to integrate well with the existing cartilage at the transfer site.<ref>{{cite journal | vauthors = Hunziker EB, Lippuner K, Keel MJ, Shintani N | title = An educational review of cartilage repair: precepts & practice – myths & misconceptions – progress & prospects | journal = Osteoarthritis Cartilage | volume = 23 | issue = 3 | pages = 334–50 | year = 2015 | pmid = 25534362 | doi = 10.1016/j.joca.2014.12.011 }}</ref>

[[Osteotomy]] may be useful in people with knee osteoarthritis, but has not been well studied.<ref>{{cite journal|last1=Brouwer|first1=RW|last2=Huizinga|first2=MR|last3=Duivenvoorden|first3=T|last4=van Raaij|first4=TM|last5=Verhagen|first5=AP|last6=Bierma-Zeinstra|first6=SM|last7=Verhaar|first7=JA|title=Osteotomy for treating knee osteoarthritis|journal=The Cochrane database of systematic reviews|date=13 December 2014|volume=12|issue=12|pages=CD004019|pmid=25503775|doi=10.1002/14651858.CD004019.pub4}}</ref> [[Arthroscopic surgery]] is largely not recommended, as it does not improve outcomes in knee osteoarthritis,<ref>{{cite journal |vauthors=Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM |title=A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative |journal=Seminars in arthritis and rheumatism |volume=43 |issue=6 |pages=701–12 |year=2014 |pmid=24387819 |doi=10.1016/j.semarthrit.2013.11.012}}</ref><ref>{{cite journal|last1=Katz|first1=JN|last2=Brownlee|first2=SA|last3=Jones|first3=MH|title=The role of arthroscopy in the management of knee osteoarthritis.|journal=Best practice & research. Clinical rheumatology|date=February 2014|volume=28|issue=1|pages=143–56|pmid=24792949|doi=10.1016/j.berh.2014.01.008}}</ref> and may result in harm.<ref>{{Cite journal | last1 = Thorlund | first1 = JB. | last2 = Juhl | first2 = CB. | last3 = Roos | first3 = EM. | last4 = Lohmander | first4 = LS. | title = Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms | journal = BMJ | volume = 350 | issue = | pages = h2747 | year = 2015 | doi = 10.1136/bmj.h2747| pmid = 26080045 | pmc = 4469973 }}</ref>

===Alternative medicine===

====Glucosamine and chondroitin====
The effectiveness of [[glucosamine]] is controversial.<ref>{{cite journal |vauthors=Burdett N, McNeil JD |title=Difficulties with assessing the benefit of glucosamine sulphate as a treatment for osteoarthritis. |journal=International Journal of Evidence-based Healthcare |volume=10 |issue=3 |pages=222–6 |date=Sep 2012 |pmid=22925619 |doi=10.1111/j.1744-1609.2012.00279.x}}</ref> Reviews have found it to be equal to<ref>{{cite journal |vauthors=Wandel S, Jüni P, Tendal B, Nüesch E, Villiger PM, Welton NJ, Reichenbach S, Trelle S |title=Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. |journal=BMJ (Clinical research ed.) |volume=341 |pages=c4675 |date=Sep 16, 2010 |pmid=20847017 |pmc=2941572 |doi=10.1136/bmj.c4675}}</ref><ref>{{cite journal |vauthors=Wu D, Huang Y, Gu Y, Fan W |title=Efficacies of different preparations of glucosamine for the treatment of osteoarthritis: a meta-analysis of randomised, double-blind, placebo-controlled trials. |journal=International Journal of Clinical Practice |volume=67 |issue=6 |pages=585–94 |date=Jun 2013 |pmid=23679910 |doi=10.1111/ijcp.12115}}</ref> or slightly better than [[placebo]].<ref>{{cite journal |title=Analgesics for Osteoarthritis: An Update of the 2006 Comparative Effectiveness Review |date=Oct 2011 |pmid=22091473 |vauthors=Chou R, McDonagh MS, Nakamoto E, Griffin J|journal=PubMed Health, US National Library of Medicine|url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0016485/}}</ref><ref>{{cite journal |vauthors=Miller KL, Clegg DO |title=Glucosamine and chondroitin sulfate |journal=Rheumatic Diseases Clinics of North America |volume=37 |issue=1 |pages=103–18 |date=February 2011 |pmid=21220090 |doi=10.1016/j.rdc.2010.11.007 |quote=The best current evidence suggests that the effect of these supplements, alone or in combination, on OA pain, function, and radiographic change is marginal at best.}}</ref> A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not.<ref>{{cite journal |vauthors=Rovati LC, Girolami F, Persiani S |title=Crystalline glucosamine sulfate in the management of knee osteoarthritis: efficacy, safety, and pharmacokinetic properties. |journal=Therapeutic Advances in Musculoskeletal Disease |volume=4 |issue=3 |pages=167–80 |date=Jun 2012 |pmid=22850875 |pmc=3400104 |doi=10.1177/1759720X12437753}}</ref> The evidence for glucosamine sulfate having an effect on osteoarthritis progression is somewhat unclear and if present likely modest.<ref>{{cite journal|last1=Gregory|first1=PJ|last2=Fellner|first2=C|title=Dietary supplements as disease-modifying treatments in osteoarthritis: a critical appraisal.|journal=Pharmacy and Therapeutics|date=June 2014|volume=39|issue=6|pages=436–52|pmid=25050057|pmc=4103717}}</ref> The [[Osteoarthritis Research Society International]] recommends that glucosamine be discontinued if no effect is observed after six months<ref>{{cite journal|vauthors=Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P |title=OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines |journal=Osteoarthr. Cartil. |volume=16 |issue=2 |pages=137–62 |date=February 2008 |pmid=18279766 |doi=10.1016/j.joca.2007.12.013 |url=http://www.oarsi.org/pdfs/part_II_OARSI_recommendations_for_management_of_hipknee_OA_2007.pdf |deadurl=yes |archiveurl=https://web.archive.org/web/20110721225626/http://www.oarsi.org/pdfs/part_II_OARSI_recommendations_for_management_of_hipknee_OA_2007.pdf |archivedate=July 21, 2011 }}</ref> and the [[National Institute for Health and Care Excellence]] no longer recommends its use.<ref name=NICE/> Despite the difficulty in determining the efficacy of glucosamine, it remains a viable treatment option.<ref name=Hen2012>{{cite journal |vauthors=Henrotin Y, Mobasheri A, Marty M |title=Is there any scientific evidence for the use of glucosamine in the management of human osteoarthritis? |journal=Arthritis Research & Therapy |volume=14 |issue=1 |page=201 |date=Jan 30, 2012 |pmid=22293240 |pmc=3392795 |doi=10.1186/ar3657}}</ref> Its use as a therapy for osteoarthritis is usually safe.<ref name=Hen2012/><ref>{{cite journal|last1=Vangsness CT|first1=Jr|last2=Spiker|first2=W|last3=Erickson|first3=J|title=A review of evidence-based medicine for glucosamine and chondroitin sulfate use in knee osteoarthritis.|journal=Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association|date=January 2009|volume=25|issue=1|pages=86–94|pmid=19111223|doi=10.1016/j.arthro.2008.07.020}}</ref>

A 2015 [[Cochrane (organisation)|Cochrane]] review of clinical trials of [[chondroitin]] found that most were of low quality, but that there was some evidence of short-term improvement in pain and few side effects; it does not appear to [[Disease-modifying antirheumatic drug|improve or maintain the health of affected joints]].<ref name=Cochrane2015>{{cite journal|last1=Singh|first1=JA|last2=Noorbaloochi|first2=S|last3=MacDonald|first3=R|last4=Maxwell|first4=LJ|title=Chondroitin for osteoarthritis.|journal=The Cochrane database of systematic reviews|date=28 January 2015|volume=1|pages=CD005614|pmid=25629804|pmc=4881293|doi=10.1002/14651858.CD005614.pub2}}</ref>

====Other remedies====
Avocado/soybean unsaponifiables (ASU) is an extract made from avocado oil and soybean oil<ref name=Cochrane2014>{{cite journal|last1=Cameron|first1=M|last2=Chrubasik|first2=S|title=Oral herbal therapies for treating osteoarthritis.|journal=The Cochrane database of systematic reviews|date=22 May 2014|volume=5|pages=CD002947|pmid=24848732|pmc=4494689|doi=10.1002/14651858.CD002947.pub2}}</ref> that is sold under many brand names worldwide as a dietary supplement<ref>{{cite journal|last1=Christiansen|first1=BA|last2=Bhatti|first2=S|last3=Goudarzi|first3=R|last4=Emami|first4=S|title=Management of Osteoarthritis with Avocado/Soybean Unsaponifiables.|journal=Cartilage|date=January 2015|volume=6|issue=1|pages=30–44|pmid=25621100|pmc=4303902|doi=10.1177/1947603514554992}}</ref> and as a drug in France.<ref>{{cite web|title=Piascledine|url=http://www.has-sante.fr/portail/upload/docs/application/pdf/2013-07/piascledine_ct_9142.pdf|publisher=Haute Autorité de santé|date=July 25, 2013}} See [Piascledine HAS index page for Piascledine]</ref> A 2014 [[Cochrane (organisation)|Cochrane]] review found that while ASU might help relieve pain in the short term for some people with osteoarthritis, it does not appear to improve or maintain the health of affected joints; the review noted a high quality two year clinical trial comparing to ASU to [[chondroitin]], which has uncertain efficacy in arthritis—the study found no difference between the two.<ref name=Cochrane2014/> The review also found that while ASU appears to be safe, it has not been adequately studied to be sure.<ref name=Cochrane2014/>

[[Harpagophytum|Devil's claw]],<ref>{{cite journal|last1=Sanders|first1=M|last2=Grundmann|first2=O|title=The use of glucosamine, devil's claw (Harpagophytum procumbens), and acupuncture as complementary and alternative treatments for osteoarthritis.|journal=Alternative medicine review : a journal of clinical therapeutic|date=September 2011|volume=16|issue=3|pages=228–38|pmid=21951024}}</ref> [[Curcumin]],<ref>{{cite journal|last1=Grover|first1=AK|last2=Samson|first2=SE|title=Benefits of antioxidant supplements for knee osteoarthritis: rationale and reality.|journal=Nutrition journal|date=5 January 2016|volume=15|pages=1|pmid=26728196|doi=10.1186/s12937-015-0115-z|pmc=4700773}}</ref> phytodolor,<ref name=Silva2011/> SKI306X<ref name="pmid16859534">{{cite journal|last1=Ameye|first1=LG|last2=Chee|first2=WS|title=Osteoarthritis and nutrition. From nutraceuticals to functional foods: a systematic review of the scientific evidence.|journal=Arthritis research & therapy|date=2006|volume=8|issue=4|pages=R127|pmid=16859534}}</ref><ref name="pmid19856319">{{cite journal |vauthors=Cameron M, Gagnier JJ, Little CV, Parsons TJ, Blümle A, Chrubasik S |title=Evidence of effectiveness of herbal medicinal products in the treatment of arthritis. Part I: Osteoarthritis |journal=Phytother Res |volume=23 |issue=11 |pages=1497–515 |date=November 2009 |pmid=19856319 |doi=10.1002/ptr.3007}}</ref> and [[S-Adenosyl methionine|SAMe]]<ref name=Silva2011/><ref name=Lopez2012>{{cite journal |author=Lopez HL |title=Nutritional interventions to prevent and treat osteoarthritis. Part II: focus on micronutrients and supportive nutraceuticals |journal=Physical Medicine and Rehabilitation |volume=4 |issue=5 Suppl |pages=S155–68 |date=May 2012 |pmid=22632695 |doi=10.1016/j.pmrj.2012.02.023}}</ref> may be effective in improving pain. There is tentative evidence to support [[Uncaria guianensis|cat's claw]],<ref name=Altmed2010/> [[hyaluronan]],<ref>{{cite journal|last1=Oe|first1=M|last2=Tashiro|first2=T|last3=Yoshida|first3=H|last4=Nishiyama|first4=H|last5=Masuda|first5=Y|last6=Maruyama|first6=K|last7=Koikeda|first7=T|last8=Maruya|first8=R|last9=Fukui|first9=N|title=Oral hyaluronan relieves knee pain: a review.|journal=Nutrition journal|date=27 January 2016|volume=15|pages=11|pmid=26818459|doi=10.1186/s12937-016-0128-2|pmc=4729158}}</ref> [[methylsulfonylmethane|MSM]],<ref name=Silva2011/><ref name="pmid16859534"/> and [[rose hip]].<ref name=Silva2011>{{cite journal |vauthors=De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ |title=Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review |journal=Rheumatology (Oxford) |volume=50 |issue=5 |pages=911–20 |date=May 2011 |pmid=21169345 |doi=10.1093/rheumatology/keq379}}</ref> A few high-quality studies of ''[[Boswellia serrata]]'' show consistent, but small, improvements in pain and function.<ref name=Cochrane2014/>

There is little evidence supporting benefits for some supplements, including: the Ayurvedic herbal preparations with brand names Articulin F and Eazmov, collagen, Duhuo Jisheng Wan (a Chinese herbal preparation), fish liver oil, [[ginger]], the herbal preparation gitadyl, [[omega-3 fatty acid]]s, the brand-name product Reumalax, stinging nettle, vitamins A, C, and E in combination, vitamin E alone, vitamin K and willow bark. There is insufficient evidence to make a recommendation about the safety and efficacy of these treatments.<ref name=Silva2011/><ref name=Altmed2010>{{cite journal |vauthors=Rosenbaum CC, O'Mathúna DP, Chavez M, Shields K |title=Antioxidants and antiinflammatory dietary supplements for osteoarthritis and rheumatoid arthritis |journal=Altern Ther Health Med |volume=16 |issue=2 |pages=32–40 |year=2010 |pmid=20232616}}</ref>

====Acupuncture and other interventions====
While [[acupuncture]] leads to improvements in pain relief, this improvement is small and may be of questionable importance.<ref>{{cite journal|last1=Lin|first1=X|last2=Huang|first2=K|last3=Zhu|first3=G|last4=Huang|first4=Z|last5=Qin|first5=A|last6=Fan|first6=S|title=The Effects of Acupuncture on Chronic Knee Pain Due to Osteoarthritis: A Meta-Analysis.|journal=The Journal of bone and joint surgery. American volume|date=21 September 2016|volume=98|issue=18|pages=1578-85|pmid=27655986}}</ref> Waiting list-controlled trials for peripheral joint osteoarthritis do show clinically relevant benefits, but these may be due to placebo effects.<ref name="pmid20091527">{{cite journal |author=Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DA, Berman BM, Bouter LM |title=Acupuncture for peripheral joint osteoarthritis |journal=Cochrane Database of Systematic Reviews |volume=|issue=1 |pages=CD001977 |year=2010 |pmid=20091527 |pmc=3169099 |doi=10.1002/14651858.CD001977.pub2 |editor1-last=Manheimer |editor1-first=Eric}}</ref> Acupuncture does not seem to produce long-term benefits.<ref name="pmid18227323">{{cite journal |vauthors=Wang SM, Kain ZN, White PF |title=Acupuncture analgesia: II. Clinical considerations |journal=Anesthesia and Analgesia |volume=106 |issue=2 |pages=611–21, table of contents |date=February 2008 |pmid=18227323 |doi=10.1213/ane.0b013e318160644d |url=http://www.mvclinic.es/wp-content/uploads/2008_Wang_Acupuncture-Analgesia_II_Clinical-Considerations.pdf}}</ref> While [[electrostimulation techniques]] such as [[TENS]] have been used for twenty years to treat osteoarthritis in the knee, there is no conclusive evidence to show that it reduces pain or disability.<ref name="pmid19821296">{{cite journal |author=Rutjes AW, Nüesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M, Brosseau L, Reichenbach S, Jüni P |title=Transcutaneous electrostimulation for osteoarthritis of the knee |journal=Cochrane Database of Systematic Reviews |volume=|issue=4 |pages=CD002823 |year=2009 |pmid=19821296 |doi=10.1002/14651858.CD002823.pub2 |editor1-last=Rutjes |editor1-first=Anne WS|url=http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002823.pub2/abstract}}</ref>

A [[Cochrane review]] of [[low level laser therapy]] found unclear evidence of benefit.<ref>{{cite journal|last1=Brosseau|first1=L|last2=Welch|first2=V|last3=Wells|first3=G|last4=DeBie|first4=R|last5=Gam|first5=A|last6=Harman|first6=K|last7=Morin|first7=M|last8=Shea|first8=B|last9=Tugwell|first9=P|title=Low level laser therapy (Classes I, II and III) for treating osteoarthritis.|journal=Cochrane Database of Systematic Reviews|date=2004|issue=3|pages=CD002046|pmid=15266461|doi=10.1002/14651858.CD002046.pub2}}</ref> Another review found short term pain relief for osteoarthritic knees.<ref>{{cite journal|last1=Bjordal|first1=J|last2=Johnson|first2=M|last3=Lopes-Martins|first3=R|last4=Bogen|first4=B|last5=Chow|first5=R|last6=Ljunggren|first6=A|title=Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials.|journal=BMC Musculoskeletal Disorders|date=2007|issue=1|pages=51|doi=10.1186/1471-2474-8-51|volume=8}}</ref>

==Epidemiology==
[[Image:Osteoarthritis world map - DALY - WHO2004.svg|thumb|[[Disability-adjusted life year]] for osteoarthritis per 100,000&nbsp;inhabitants in 2004.<ref>{{cite web |url=http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html |title=WHO Disease and injury country estimates |year=2009 |work=World Health Organization |accessdate=Nov 11, 2009}}</ref>
{{Col-begin}}
{{Col-break}}
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|≤&nbsp;200}}
{{legend|#fff200|200–220}}
{{legend|#ffdc00|220–240}}
{{legend|#ffc600|240–260}}
{{legend|#ffb000|260–280}}
{{legend|#ff9a00|280–300}}
{{Col-break}}
{{legend|#ff8400|300–320}}
{{legend|#ff6e00|320–340}}
{{legend|#ff5800|340–360}}
{{legend|#ff4200|360–380}}
{{legend|#ff2c00|380–400}}
{{legend|#cb0000|≥&nbsp;400}}
{{col-end}}]]
Globally as of 2010, approximately 250 million people had osteoarthritis of the knee (3.6% of the population).<ref name="cross2014"/><ref name=LancetEpi2012>{{cite journal |vauthors=Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, etal |title=Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 |journal=Lancet |volume=380 |issue=9859 |pages=2163–96 |date=December 2012 |pmid=23245607 |doi=10.1016/S0140-6736(12)61729-2 }}</ref> Hip osteoarthritis affects about 0.85% of the population.<ref name=cross2014/>

{{As of|2004}}, osteoarthritis globally causes moderate to severe disability in 43.4&nbsp;million people.<ref>{{cite book |title=The Global Burden of Disease: 2004 Update |year=2008 |publisher=World Health Organization |location=Geneva |isbn=978-92-4-156371-0 |page=35 |chapter=Table 9: Estimated prevalence of moderate and severe disability (millions) for leading disabling conditions by age, for high-income and low- and middle-income countries, 2004 |chapterurl=https://books.google.com/books?id=xrYYZ6Jcfv0C&pg=PA35}}</ref> Together, knee and hip osteoarthritis had a ranking for disability globally of 11th among 291 disease conditions assessed.<ref name=cross2014/>

===United States===
As of 2012, osteoarthritis affected 52.5 million people in the United States, approximately 50% of whom were 65 years and older.<ref name="cdc2016"/> It is estimated that 80% of the population have [[radiograph]]ic evidence of osteoarthritis by age 65, although only 60% of those will have [[symptom]]s.<ref name=Green2001>{{cite journal |author=Green GA |title=Understanding NSAIDs: from aspirin to COX-2 |journal=Clin Cornerstone |volume=3 |issue=5 |pages=50–60 |year=2001 |pmid=11464731 |doi=10.1016/S1098-3597(01)90069-9}}</ref> The rate of osteoarthritis in the United States is forecast to be 78 million (26%) adults by 2040.<ref name=cdc2016/>

In the United States, there were approximately 964,000 hospitalizations for osteoarthritis in 2011, a rate of 31 stays per 10,000 population.<ref>Pfuntner A., Wier L.M., Stocks C. Most Frequent Conditions in U.S. Hospitals, 2011. HCUP Statistical Brief #162. September 2013. Agency for Healthcare Research and Quality, Rockville, Maryland.[http://www.hcup-us.ahrq.gov/reports/statbriefs/sb162.jsp]</ref> With an aggregate cost of $14.8 billion ($15,400 per stay), it was the second-most expensive condition seen in U.S. hospital stays in 2011. By payer, it was the second-most costly condition billed to Medicare and private insurance.<ref>{{cite web |vauthors=Torio CM, Andrews RM |title=National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. |work=HCUP Statistical Brief #160 |publisher=Agency for Healthcare Research and Quality |location=Rockville, Maryland |date=August 2013 |url=http://hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp}}</ref><ref>{{cite journal |title=Costs for Hospital Stays in the United States, 2011: Statistical Brief #168 |date=December 2013 |pmid=24455786|author1=Pfuntner |first1=A |last2=Wier |first2=L. M. |last3=Steiner |first3=C }}</ref>

==History==
Evidence for osteoarthritis found in the fossil record is studied by [[paleopathologists]], specialists in ancient disease and injury. Osteoarthritis has been reported in fossils of the large carnivorous dinosaur ''[[Allosaurus]] fragilis''.<ref name="molnar-pathology">{{cite book |last=Molnar |first=R. E. |year=2001 |chapter=Therapod Paleopathology: A Literature Survey |title=Mesozoic Vertebrate Life |editor1-first=Darren H. |editor1-last=Tanke |editor2-first=Kenneth |editor2-last=Carpenter |editor3-first=Michael William |editor3-last=Skrepnick |publisher=Indiana University Press |pages=337–63 |chapterurl=https://books.google.com/books?id=mgc6CS4EUPsC&pg=PA337 |isbn=978-0-253-33907-2}}</ref>

===Etymology===
Osteoarthritis is derived from the Greek word part ''osteo-'', meaning "of the bone", combined with ''arthritis'': ''arthr-'', meaning "joint", and ''-itis'', the meaning of which has come to be associated with [[inflammation]].<ref>{{cite book |author =Devaraj TL |title=Nature Cure for Common Diseases |year=2011 |publisher=Arya Publication |location=New Delhi |isbn=978-8189093747 |page=368 |chapter=Chapter 41: Nature cure yoga for osteoarthritis |chapterurl=https://books.google.com.bd/books?id=PdwRBAAAQBAJ&pg=PA368}}</ref> The ''-itis'' of osteoarthritis could be considered misleading as inflammation is not a conspicuous feature. Some clinicians refer to this condition as ''osteoarthrosis'' to signify the lack of inflammatory response.{{citation needed|date=September 2014}}

==Research==
There are ongoing efforts to determine if there are agents that modify outcomes in osteoarthritis. [[Sprifermin]] is one candidate drug. There is also tentative evidence that [[strontium ranelate]] may decrease degeneration in osteoarthritis and improve outcomes.<ref>{{cite book |author=Civjan N |title=Chemical Biology: Approaches to Drug Discovery and Development to Targeting Disease|year=2012|publisher=John Wiley & Sons|isbn=9781118437674|page=313|url=https://books.google.com/books?id=ezXLFlwfJycC&pg=PA313}}</ref><ref name="pmid19087296">{{cite journal |vauthors=Bruyère O, Burlet N, Delmas PD, Rizzoli R, Cooper C, Reginster JY |title=Evaluation of symptomatic slow-acting drugs in osteoarthritis using the GRADE system |journal=BMC Musculoskelet Disord |volume=9 |page=165 |year=2008 |pmid=19087296 |pmc=2627841 |doi=10.1186/1471-2474-9-165}}</ref>

As well as attempting to find disease-modifying agents for osteoarthritis, there is emerging evidence that a system-based approach is necessary to find the causes of osteoarthritis.<ref>{{cite journal|last1=Chu|first1=CR|last2=Andriacchi|first2=TP|title=Dance between biology, mechanics, and structure: a systems-based approach to developing osteoarthritis prevention strategies|journal=J Orthop Res|date=2015|volume=33|issue=7|pages=939–947|doi=10.1002/jor.22817|pmid=25639920}}</ref> Changes may occur before clinical disease is evident due to abnormalities in [[biomechanics]], [[biology]] and/or structure of joints that predispose them to develop clinical disease. Research is thus focusing on defining these early pre-osteoarthritis changes using biological, mechanical, and imaging markers of osteoarthritis risk, emphasising multi-disciplinary approaches, and looking into personalized interventions that can reverse osteoarthritis risk in healthy joints before the disease becomes evident.

[[Gene therapy for osteoarthritis|Gene transfer strategies]] aim to target the disease process rather than the symptoms.<ref>{{cite journal|author1=T. Pap |author2=J. Schedel |author3=G. Pap |author4=U. Moller-Ladner |author5=R.E. Gay |author6=S. Gay C. Guincamp |title=Gene therapy in osteoarthritis|journal=Joint Bone Spine|year=2000|doi=10.1016/s1297-319x(00)00215-3|pmid=11195326 |volume=67|issue=6 |pages=570–571}}</ref>

===Biomarkers===
Guidelines outlining requirements for inclusion of soluble [[biomarkers]] in osteoarthritis clinical trials were published in 2015,<ref name=PMID25952342>{{cite journal|last1=Kraus|first1=VB|last2=Blanco|first2=FJ|last3=Englund|first3=M|last4=Henrotin|first4=Y|last5=Lohmander|first5=LS|last6=Losina|first6=E|last7=Onnerfjord|first7=P|last8=Persiani|first8=S|title=OARSI Clinical Trials Recommendations: Soluble biomarker assessments in clinical trials in osteoarthritis|journal=Osteoarthritis Cartilage|date=2015|volume=23|issue=5|pages=686–697|doi=10.1016/j.joca.2015.03.002|pmid=25952342|pmc=4430113}}</ref> but as yet, there are no validated [[biomarkers]] for osteoarthritis. A 2015 systematic review of [[biomarkers]] for osteoarthritis looking for molecules that could be used for risk assessments found 37 different biochemical markers of [[bone]] and [[cartilage]] turnover in 25 publications.<ref name=PMID25963100>{{cite journal|last1=Saberi Hosnijeh|first1=F|last2=Runhaar|first2=J|last3=van Meurs|first3=JB|last4=Bierma-Zeinstra|first4=SM|title=Biomarkers for osteoarthritis: Can they be used for risk assessment? A systematic review|journal=Maturitas|volume=82|issue=1|pages=36–49|date=2015|doi=10.1016/j.maturitas.2015.04.004|pmid=25963100}}</ref> The strongest evidence was for urinary C-terminal [[telopeptide]] of [[collagen type II]] (uCTX-II) as a prognostic marker for knee osteoarthritis progression and serum [[Cartilage oligomeric matrix protein|cartilage oligomeric protein]] (COMP) levels as a prognostic marker for incidence of both knee and hip osteoarthritis. A review of biomarkers in hip osteoarthritis also found associations with uCTXII.<ref name=PMID25623593>{{cite journal|last1=Nepple|first1=JJ|last2=Thomason|first2=KM|last3=An|first3=TW|last4=Harris-Hayes|first4=M|last5=Clohisy|first5=JC|title=What is the utility of biomarkers for assessing the pathophysiology of hip osteoarthritis? A systematic review|journal=Clin Orthop Relat Res|date=2015|volume=473|issue=5|pages=1683–1701|doi=10.1007/s11999-015-4148-6|pmid=25623593}}</ref>

One problem with using a specific [[collagen type II]] [[biomarker]] from the breakdown of [[articular cartilage]] is that the amount of cartilage is reduced (worn away) over time with progression of the disease so a patient can eventually have very advanced osteoarthritis with none of this [[biomarker]] detectable in their [[urine]]. Another problem with a systemic [[biomarker]] is that a patient can have osteoarthritis in multiple joints at different stages of disease at the same time, so the [[biomarker]] source cannot be determined. Some other [[collagen]] breakdown products in the [[synovial fluid]] correlated with each other after acute injuries (a known cause of secondary osteoarthritis) but did not correlate with the severity of the injury.<ref name=PMID25937025>{{cite journal|last1=Kumahashi|first1=N|last2=Swärd|first2=P|last3=Larsson|first3=S|last4=Lohmander|first4=LS|last5=Frobell|first5=R|last6=Struglics|first6=A |title=Type II collagen C2C epitope in human synovial fluid and serum after knee injury - associations with molecular and structural markers of injury|journal=Osteoarthritis Cartilage|volume=23|issue=9|pages=1506–12|date=2015|pmid=25937025|doi=10.1016/j.joca.2015.04.022}}</ref>

==References==
{{Reflist|32em}}

==External links==
{{commons category|Osteoarthritis}}
* [http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/osteoarthritis.asp American College of Rheumatology Factsheet on OA]
* [http://www.arthritis.org/ Arthritis Foundation]
* [http://niams.nih.gov/Health_Info/Arthritis/default.asp National Institute of Arthritis and Musculoskeletal and Skin Diseases]

{{Diseases of the musculoskeletal system and connective tissue}}

{{Authority control}}

[[Category:Arthritis]]
[[Category:Skeletal disorders]]
[[Category:RTT]]

Revision as of 11:09, 24 January 2017

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