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Referral and warning signs
When to refer
Referral to specialist for: Diagnostic uncertainty, Severe pain/disability unresponsive to conservative Rx, Consideration for injections or joint replacement.
Red flags
- Signs of inflammatory arthritis
- Signs of septic arthritis
- Rapidly worsening pain/deformity
- Associated systemic symptoms
- Neurological symptoms
Signs and symptoms
- Joint pain: Activity-related, worse with use, relieved by rest. May become persistent.
- Joint stiffness: After inactivity ('gelling'), usually <30 minutes. Brief morning stiffness.
- Reduced range of motion.
- Crepitus (grating/cracking sensation).
- Joint swelling (bony enlargement - osteophytes; or mild effusion).
- Joint tenderness.
- Joint deformity / instability (late).
- Common joints: Knees, Hips, Hands (DIPs - Heberden's nodes, PIPs - Bouchard's nodes, 1st CMC), Spine (spondylosis), Feet (1st MTP).
Risk factors
- Increasing age
- Obesity (esp. knee/hip)
- Female gender
- Previous joint injury
- Occupational/recreational overuse
- Genetics
- Metabolic diseases
- Joint abnormalities
Diagnosis
Clinical assessment
Primarily clinical based on age, symptoms (activity pain, brief stiffness), joint pattern, exam (bony swelling, crepitus). Differentiate from inflammatory arthritis.
Investigations
- Plain X-ray: Confirm/assess severity. Findings: Joint space narrowing (asymmetric), Osteophytes, Subchondral sclerosis, Subchondral cysts. Poor correlation with symptoms.
- Blood tests (ESR, CRP, RF, Anti-CCP): Usually normal. Rule out inflammatory arthritis.
- Synovial Fluid Analysis: Non-inflammatory fluid (low WBC). Rule out crystals/infection.
- MRI Scan: Not routine. Shows cartilage, bone marrow lesions, soft tissues.
Diagnostic criteria
Clinical diagnosis +/- supportive X-ray findings. ACR criteria exist for hand/hip/knee.
Management
Non-pharmacological management
- Core Treatments: Patient Education, Exercise (strengthening, ROM, low-impact aerobic), Weight Loss.
- Other Options: Physiotherapy, Occupational Therapy (joint protection, assistive devices), Footwear/Orthotics, Heat/Cold, TENS, Manual therapy.
- Surgical Management (Severe/refractory): Joint Replacement (Arthroplasty), Osteotomy, Arthroscopy (limited role).
Pharmacological treatment
- Analgesia:
- - Paracetamol (first-line consideration).
- - Topical NSAIDs (knee, hand).
- - Oral NSAIDs (lowest effective dose, shortest duration, consider PPI).
- - Tramadol / Weak Opioids (use cautiously).
- - Strong Opioids (AVOID chronic use).
- - Duloxetine (consider).
- Intra-articular Injections:
- - Corticosteroids (short-term relief, limit frequency).
- - Hyaluronic Acid (controversial efficacy).
- Glucosamine/Chondroitin: No proven benefit.
Monitoring
Monitor pain, function, quality of life. Monitor medication side effects. Assess need for therapy escalation/surgery referral.
Complications
- Chronic pain
- Disability
- Joint deformity / Instability
- Muscle weakness
- Sleep disturbance
- Depression / Anxiety
- Reduced quality of life
- Medication side effects
Prevention
- Maintain healthy weight.
- Avoid joint injury.
- Regular moderate exercise.
Patient education
- Explain OA as wear and tear.
- Importance of core treatments (exercise, weight loss).
- Pain management strategies.
- Role of PT/OT/assistive devices.
- Joint protection.
- Realistic expectations.
- Surgical options.
Uganda-specific notes
Very common. Diagnosis mainly clinical + X-ray. Management focuses on lifestyle, Paracetamol, NSAIDs. Access to PT, specialist injections, joint replacement very limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 10, Section 10.2.3