Clinical manifestations and diagnosis of osteoarthritis
- Michael Doherty, MA, MD, FRCP, FHEA
Michael Doherty, MA, MD, FRCP, FHEA
- Professor of Rheumatology and Head of Rheumatology, Orthopaedics and Dermatology
- School of Medicine
- University of Nottingham
- Abhishek Abhishek, MBBS, MD, MRCP, PhD
Abhishek Abhishek, MBBS, MD, MRCP, PhD
- Clinical Associate Professor of Rheumatology
- School of Medicine
- University of Nottingham
- Nottingham, UK
- Honorary Consultant Rheumatologist
- Queen's Medical Centre
- Nottingham University Hospitals NHS Trust
- Nottingham, UK
Osteoarthritis (OA) is the commonest form of arthritis and possesses marked variability of disease expression. Although most patients present with joint pain and functional limitations , the age of disease onset, sequence of joint involvement, and disease progression varies from person to person. OA ranges from an asymptomatic, incidental finding on clinical and/or radiographic examination to a rapidly progressive disabling disorder eventually culminating in “joint failure.”
The clinical features and approach to the diagnosis of OA will be reviewed here. The pathogenesis, epidemiology, and treatment of OA are discussed separately. (See "Pathogenesis of osteoarthritis" and "Risk factors for and possible causes of osteoarthritis" and "Overview of the management of osteoarthritis" and "Management of moderate to severe knee osteoarthritis".)
The primary symptoms of osteoarthritis (OA) are joint pain, stiffness, and locomotor restriction. Symptoms usually present in just one or a few joints in a middle-aged or older person. Other manifestations in patients with OA include sequelae such as muscle weakness and poor balance  and comorbidities like fibromyalgia [3-6].
Symptoms and signs — The following symptoms and signs may be observed in patients with OA:
●Pain – Pain in OA is worse with joint use (usage-related pain) and relieved by rest. It is often the most frequent symptom and generally progresses through three stages :
- Osteoarthritis: national clinical guideline for care and management in adults. In: Conditions. NCCfC (Ed), Royal College of Physicians, London 2008.
- Hurley MV, Scott DL, Rees J, Newham DJ. Sensorimotor changes and functional performance in patients with knee osteoarthritis. Ann Rheum Dis 1997; 56:641.
- Sale JE, Gignac M, Hawker G. The relationship between disease symptoms, life events, coping and treatment, and depression among older adults with osteoarthritis. J Rheumatol 2008; 35:335.
- Abad VC, Sarinas PS, Guilleminault C. Sleep and rheumatologic disorders. Sleep Med Rev 2008; 12:211.
- Imamura M, Imamura ST, Kaziyama HH, et al. Impact of nervous system hyperalgesia on pain, disability, and quality of life in patients with knee osteoarthritis: a controlled analysis. Arthritis Rheum 2008; 59:1424.
- Edwards RR, Bingham CO 3rd, Bathon J, Haythornthwaite JA. Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis Rheum 2006; 55:325.
- Hawker GA, Stewart L, French MR, et al. Understanding the pain experience in hip and knee osteoarthritis--an OARSI/OMERACT initiative. Osteoarthritis Cartilage 2008; 16:415.
- Allen KD, Coffman CJ, Golightly YM, et al. Daily pain variations among patients with hand, hip, and knee osteoarthritis. Osteoarthritis Cartilage 2009; 17:1275.
- Hill CL, Gale DR, Chaisson CE, et al. Periarticular lesions detected on magnetic resonance imaging: prevalence in knees with and without symptoms. Arthritis Rheum 2003; 48:2836.
- van Saase JL, van Romunde LK, Cats A, et al. Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Ann Rheum Dis 1989; 48:271.
- KELLGREN JH, MOORE R. Generalized osteoarthritis and Heberden's nodes. Br Med J 1952; 1:181.
- KELLGREN JH, LAWRENCE JS, BIER F. GENETIC FACTORS IN GENERALIZED OSTEO-ARTHROSIS. Ann Rheum Dis 1963; 22:237.
- Lawrence JS. Generalized osteoarthrosis in a population sample. Am J Epidemiol 1969; 90:381.
- Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986; 29:1039.
- Zhang W, Doherty M, Leeb BF, et al. EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. Ann Rheum Dis 2009; 68:8.
- Hayashi D, Roemer FW, Guermazi A. Imaging for osteoarthritis. Ann Phys Rehabil Med 2016; 59:161.
- Roemer FW, Eckstein F, Hayashi D, Guermazi A. The role of imaging in osteoarthritis. Best Pract Res Clin Rheumatol 2014; 28:31.
- Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord 2008; 9:116.
- Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ 2015; 351:h5983.
- Hannan MT, Felson DT, Pincus T. Analysis of the discordance between radiographic changes and knee pain in osteoarthritis of the knee. J Rheumatol 2000; 27:1513.
- Rosenthal AK. Crystals, inflammation, and osteoarthritis. Curr Opin Rheumatol 2011; 23:170.
- Felson DT, Anderson JJ, Naimark A, et al. The prevalence of chondrocalcinosis in the elderly and its association with knee osteoarthritis: the Framingham Study. J Rheumatol 1989; 16:1241.
- Dieppe PA, Alexander GJ, Jones HE, et al. Pyrophosphate arthropathy: a clinical and radiological study of 105 cases. Ann Rheum Dis 1982; 41:371.
- Ledingham J, Regan M, Jones A, Doherty M. Factors affecting radiographic progression of knee osteoarthritis. Ann Rheum Dis 1995; 54:53.
- Neogi T, Nevitt M, Niu J, et al. Lack of association between chondrocalcinosis and increased risk of cartilage loss in knees with osteoarthritis: results of two prospective longitudinal magnetic resonance imaging studies. Arthritis Rheum 2006; 54:1822.
- Viriyavejkul P, Wilairatana V, Tanavalee A, Jaovisidha K. Comparison of characteristics of patients with and without calcium pyrophosphate dihydrate crystal deposition disease who underwent total knee replacement surgery for osteoarthritis. Osteoarthritis Cartilage 2007; 15:232.
- Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheum 1990; 33:1601.
- Bijsterbosch J, Watt I, Meulenbelt I, et al. Clinical and radiographic disease course of hand osteoarthritis and determinants of outcome after 6 years. Ann Rheum Dis 2011; 70:68.
- Williams WV, Cope R, Gaunt WD, et al. Metacarpophalangeal arthropathy associated with manual labor (Missouri metacarpal syndrome). Clinical radiographic, and pathologic characteristics of an unusual degeneration process. Arthritis Rheum 1987; 30:1362.
- Punzi L, Ramonda R, Sfriso P. Erosive osteoarthritis. Best Pract Res Clin Rheumatol 2004; 18:739.
- Punzi L, Frigato M, Frallonardo P, Ramonda R. Inflammatory osteoarthritis of the hand. Best Pract Res Clin Rheumatol 2010; 24:301.
- Bijsterbosch J, Watt I, Meulenbelt I, et al. Clinical burden of erosive hand osteoarthritis and its relationship to nodes. Ann Rheum Dis 2010; 69:1784.
- Cavasin F, Punzi L, Ramonda R, et al. [Prevalence of erosive osteoarthritis of the hand in a population from Venetian area]. Reumatismo 2004; 56:46.
- Creamer P, Lethbridge-Cejku M, Hochberg MC. Where does it hurt? Pain localization in osteoarthritis of the knee. Osteoarthritis Cartilage 1998; 6:318.
- Wood LR, Peat G, Thomas E, Duncan R. Knee osteoarthritis in community-dwelling older adults: are there characteristic patterns of pain location? Osteoarthritis Cartilage 2007; 15:615.
- Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis 2010; 69:483.
- Slemenda C, Brandt KD, Heilman DK, et al. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med 1997; 127:97.
- Hinman RS, Hunt MA, Creaby MW, et al. Hip muscle weakness in individuals with medial knee osteoarthritis. Arthritis Care Res (Hoboken) 2010; 62:1190.
- Cibere J, Zhang H, Thorne A, et al. Association of clinical findings with pre-radiographic and radiographic knee osteoarthritis in a population-based study. Arthritis Care Res (Hoboken) 2010; 62:1691.
- Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991; 34:505.
- Gofton JP. Studies in osteoarthritis of the hip. I. Classification. Can Med Assoc J 1971; 104:679.
- Dieppe PA, Crocker P, Huskisson EC, Willoughby DA. Apatite deposition disease. A new arthropathy. Lancet 1976; 1:266.
- Dieppe PA, Doherty M, Macfarlane DG, et al. Apatite associated destructive arthritis. Br J Rheumatol 1984; 23:84.
- Nuki G. Apatite associated arthritis. Br J Rheumatol 1984; 23:81.
- McCarty DJ, Halverson PB, Carrera GF, et al. "Milwaukee shoulder"--association of microspheroids containing hydroxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects. I. Clinical aspects. Arthritis Rheum 1981; 24:464.
- Kalichman L, Hunter DJ. Lumbar facet joint osteoarthritis: a review. Semin Arthritis Rheum 2007; 37:69.
- van Eerd M, Patijn J, Lataster A, et al. 5. Cervical facet pain. Pain Pract 2010; 10:113.
- Doi K, Martel W. Monarticular erosive osteoarthritis: a possible source of confusion with infectious arthritis. J Clin Rheumatol 1995; 1:242.
- Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg 2009; 108:1662.
- Thorstensson CA, Andersson ML, Jönsson H, et al. Natural course of knee osteoarthritis in middle-aged subjects with knee pain: 12-year follow-up using clinical and radiographic criteria. Ann Rheum Dis 2009; 68:1890.
- Wolfe F, Lane NE. The longterm outcome of osteoarthritis: rates and predictors of joint space narrowing in symptomatic patients with knee osteoarthritis. J Rheumatol 2002; 29:139.
- CLINICAL MANIFESTATIONS
- Symptoms and signs
- Joint distribution
- - Single- or multiple-joint osteoarthritis
- - Generalized osteoarthritis
- Synovial fluid
- Osteoarthritis with calcium pyrophosphate deposition
- CHARACTERISTICS OF SPECIFIC JOINT INVOLVEMENT
- - Nodal osteoarthritis
- - Erosive osteoarthritis
- Facet joint
- First metatarsophalangeal joint
- DIFFERENTIAL DIAGNOSIS
- Clinical diagnosis
- When to consider additional testing
- CLASSIFICATION CRITERIA