Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Diagnosis

1.1.1 Diagnose osteoarthritis clinically without imaging in people who:

  • are 45 or over and

  • have activity-related joint pain and

  • have either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.

1.1.2 Do not routinely use imaging to diagnose osteoarthritis unless there are atypical features or features that suggest an alternative or additional diagnosis.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on diagnosis.

Full details of the evidence and the committee's discussion are in evidence review A: additional benefit of imaging in the diagnosis of osteoarthritis.

1.2 Information and support

1.2.1 When giving information to people with osteoarthritis, their families and carers, tailor it to their individual needs (such as language and culture), ensure it is in an accessible format and follow the recommendations on:

1.2.2 Explain to people with osteoarthritis that:

  • it is diagnosed clinically and usually does not need imaging to confirm the diagnosis and

  • management should be guided by symptoms and physical function and

  • the core treatments for the condition are therapeutic exercise and weight management (if appropriate), along with information and support.

1.2.3 Advise people with osteoarthritis where they can find further information on:

  • osteoarthritis and how it develops (including flares and progression over time), and information that challenges common misconceptions about the condition

  • specific types of exercise

  • managing their symptoms

  • how to access additional sources of information and support after consultations, such as peer-to-peer support and support groups

  • benefits and limitations of treatment.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and support.

Full details of the evidence and the committee's discussion are in evidence review B: post-diagnostic information on osteoarthritis for people with osteoarthritis, their family and carers.

1.3 Non-pharmacological management

Therapeutic exercise

1.3.1 For all people with osteoarthritis, offer therapeutic exercise tailored to their needs (for example, local muscle strengthening, general aerobic fitness).

1.3.2 Consider supervised therapeutic exercise sessions for people with osteoarthritis.

1.3.3 Advise people with osteoarthritis that joint pain may increase when they start therapeutic exercise. Explain that:

  • doing regular and consistent exercise, even though this may initially cause pain or discomfort, will be beneficial for their joints

  • long-term adherence to an exercise plan increases its benefits by reducing pain and increasing functioning and quality of life.

1.3.4 Consider combining therapeutic exercise with an education programme or behaviour change approaches in a structured treatment package.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on therapeutic exercise.

Full details of the evidence and the committee's discussion are in:

Weight management

1.3.5 For people with osteoarthritis who are living with overweight or obesity:

  • advise them that weight loss will improve their quality of life and physical function, and reduce pain

  • support them to choose a weight loss goal

  • explain that any amount of weight loss is likely to be beneficial, but losing 10% of their body weight is likely to be better than 5%.

    For guidance and information on weight management, including recommended interventions to support weight loss, see NICE's topic page on obesity.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on weight management.

Full details of the evidence and the committee's discussion are in evidence review D: benefit of weight loss for the management of osteoarthritis for people living with overweight or obesity.

Manual therapy

1.3.6 Only consider manual therapy (such as manipulation, mobilisation or soft tissue techniques):

  • for people with hip or knee osteoarthritis and

  • alongside therapeutic exercise.

1.3.7 If discussing manual therapy, explain to people with osteoarthritis that there is not enough evidence to support its use alone for managing osteoarthritis.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on manual therapy.

Full details of the evidence and the committee's discussion are in evidence review E: clinical and cost-effectiveness of manual therapy for the management of osteoarthritis.

Acupuncture

1.3.8 Do not offer acupuncture or dry needling to manage osteoarthritis.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on acupuncture.

Full details of the evidence and the committee's discussion are in evidence review F: clinical and cost-effectiveness of acupuncture for people with osteoarthritis.

Electrotherapy

1.3.9 Do not offer any of the following electrotherapy treatments to people with osteoarthritis because there is insufficient evidence of benefit:

  • transcutaneous electrical nerve stimulation (TENS)

  • ultrasound therapy

  • interferential therapy

  • laser therapy

  • pulsed short-wave therapy

  • neuromuscular electrical stimulation (NMES).

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on electrotherapy.

Full details of the evidence and the committee's discussion are in evidence review G: clinical and cost effectiveness of electrotherapy for the management of osteoarthritis.

Devices

For guidance on devices for knee osteoarthritis, see the NICE medical technologies guidance on AposHealth for knee osteoarthritis.

1.3.10 Consider walking aids (such as walking sticks) for people with lower limb osteoarthritis.

1.3.11 Do not routinely offer insoles, braces, tape, splints or supports to people with osteoarthritis unless:

  • there is joint instability or abnormal biomechanical loading and

  • therapeutic exercise is ineffective or unsuitable without the addition of an aid or device and

  • the addition of an aid or device is likely to improve movement and function.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on devices.

Full details of the evidence and the committee's discussion are in evidence review H: clinical and cost effectiveness of devices for the management of osteoarthritis.

1.4 Pharmacological management

Topical, oral and transdermal medicines

1.4.1 If pharmacological treatments are needed to manage osteoarthritis, use them:

  • alongside non-pharmacological treatments and to support therapeutic exercise

  • at the lowest effective dose for the shortest possible time.

1.4.2 Offer a topical non-steroidal anti-inflammatory drug (NSAID) to people with knee osteoarthritis.

1.4.3 Consider a topical NSAID for people with osteoarthritis that affects other joints.

1.4.4 If topical medicines are ineffective or unsuitable, consider an oral NSAID for people with osteoarthritis and take account of:

  • potential gastrointestinal, renal, liver and cardiovascular toxicity

  • any risk factors the person may have, including age, pregnancy, current medication and comorbidities.

    Offer a gastroprotective treatment (such as a proton pump inhibitor) for people with osteoarthritis while they are taking an NSAID.

1.4.5 Do not routinely offer paracetamol or weak opioids unless:

1.4.6 Do not offer glucosamine or strong opioids to people to manage osteoarthritis.

1.4.7 If the person with osteoarthritis asks about glucosamine or strong opioids, explain that:

  • there is no strong evidence of benefit for glucosamine

  • the risks of strong opioids outweigh the benefits.

1.4.8 Review with the person whether to continue treatment. Base the frequency of reviews on clinical need.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on topical, oral and transdermal medicines.

Full details of the evidence and the committee's discussion are in evidence review I, evidence review I: appendices A to D, evidence review I: appendices E to J: clinical and cost effectiveness of oral, topical and transdermal medicines for the management of osteoarthritis.

Intra-articular injections

1.4.9 Do not offer intra-articular hyaluronan injections to manage osteoarthritis.

1.4.10 Consider intra-articular corticosteroid injections when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise. Explain to the person that these only provide short‑term relief (2 to 10 weeks).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on intra-articular injections.

Full details of the evidence and the committee's discussion are in evidence review J: clinical and cost effectiveness of intra-articular injections for the management of osteoarthritis.

1.5 Follow-up and review

Follow-up appointments

1.5.1 Consider patient-initiated follow-up for most people with osteoarthritis.

1.5.2 Consider planned follow-up for people with osteoarthritis when their individual needs and preferences suggest that this is necessary, taking into account:

  • treatments or interventions that need monitoring

  • their ability to seek help for themselves

  • their occupation and activities

  • the severity of their symptoms or functional limitations.

    People with multiple long-term conditions are likely to benefit from a tailored approach in line with NICE's guideline on multimorbidity.

1.5.3 Advise people with osteoarthritis to seek follow-up if planned management is not working within an agreed follow-up time or they are having difficulties with the agreed approaches.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on follow-up and review.

Full details of the evidence and the committee's discussion are in evidence review L: regular follow-up and review.

Imaging for management of osteoarthritis

1.5.4 Do not routinely use imaging for follow-up or to guide non-surgical management of osteoarthritis.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on imaging for the management of osteoarthritis.

Full details of the evidence and the committee's discussion are in evidence review M: clinical and cost effectiveness of imaging during the management of osteoarthritis.

1.6 Referral for joint replacement

1.6.1 Consider referring people with hip, knee or shoulder osteoarthritis for joint replacement if:

  • their joint symptoms (such as pain, stiffness, reduced function or progressive joint deformity) are substantially impacting their quality of life and

  • non-surgical management (for example, therapeutic exercise, weight loss, pain relief) is ineffective or unsuitable.

1.6.2 Use clinical assessment when deciding to refer someone for joint replacement, instead of systems that numerically score severity of disease.

1.6.3 Do not exclude people with osteoarthritis from referral for joint replacement because of:

  • age

  • sex or gender

  • smoking

  • comorbidities

  • overweight or obesity, based on measurements such as body mass index (BMI).

1.6.4 If discussing referral for joint replacement, explain to the person with osteoarthritis that the risks of joint replacement can vary depending on the factors listed in recommendation 1.6.3.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on referral for joint replacement.

Full details of the evidence and the committee's discussion are in:

1.7 Arthroscopic procedures

1.7.1 Do not offer arthroscopic lavage or debridement to people with osteoarthritis.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on arthroscopic procedures.

Full details of the evidence and the committee's discussion are in evidence review N: clinical and cost effectiveness of arthroscopic procedures for the management of osteoarthritis.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Atypical features

Atypical features could include a history of recent trauma, prolonged morning joint‑related stiffness, rapid worsening of symptoms or deformity, the presence of a hot swollen joint, or concerns that may suggest infection or malignancy.

Flares

A temporary worsening of symptoms (pain, swelling and stiffness) that:

  • is worse than normal

  • may affect sleep, activity, function and psychological wellbeing

  • may lead to change in therapy for at least 24 hours.

Treatment package

A treatment package is defined as any treatment for osteoarthritis (this could include: exercise, manual therapy, devices and pharmacological treatments) combined with one of the following:

  • behaviour change approaches, including ways to reduce pain and straining when using joints, pain coping skills training (including spouse-assisted coping skills training), goal setting; motivational coaching; weight management counselling and workplace risk counselling

  • an education programme given by 1 or more healthcare professionals over multiple sessions, including those based on behavioural theory.

Walking aids

Walking aids include walking sticks, crutches, walking frames and rollators. They support the person with osteoarthritis to move around independently and safely by improving their walking pattern and balance or reducing weight bearing on the affected joint.