Osteoarthritis - Causes, Symptoms, Treatment and Management

What is Osteoarthritis:-

Osteoarthritis is the most common type of arthritis. It is a degenerative joint disease in which the smooth cartilage that covers the ends of bones gradually wears down over time. As the cartilage becomes thinner, bones may rub against each other, causing pain, stiffness, and reduced movement.

Causes and risk factors of osteoarthritis

OA usually develops from a combination of ageing, joint wear-and-tear, and other risk factors rather than a single cause.

Primary (age-related) osteoarthritis

This occurs without a specific injury and is associated with:

• Increasing age (common after 45–50 years)
• Natural degeneration of cartilage over time
• Reduced ability of cartilage to repair itself

Secondary osteoarthritis

This develops because of another condition or injury, such as:

• Previous joint injury (fracture, ligament tear, meniscus injury)
• Repeated stress on a joint from heavy labour, squatting, kneeling, or sports
• Obesity, especially affecting knees and hips
• Genetic/family history of OA
• Joint deformities present since birth
• Inflammatory joint diseases (e.g., rheumatoid arthritis)
• Metabolic disorders such as gout, haemochromatosis, or acromegaly
• Weak muscles around the joint, particularly the quadriceps around the knee

Joints commonly affected

• Knees
• Hips
• Spine (neck and lower back)
• Hands (fingers and thumb base)
• Feet

Symptoms of osteoarthritis

Symptoms usually develop slowly over months or years.

Simple definition

Osteoarthritis = wear-and-tear arthritis of the joints.

It mainly affects weight-bearing joints such as the knees and hips, but it can also affect the hands, spine, and feet.

What happens in osteoarthritis?

A healthy joint has smooth cartilage and lubricating joint fluid. In osteoarthritis:

• Cartilage gradually breaks down.
• The joint space becomes narrower.
• Bone may become thicker underneath the cartilage.
• Small bony outgrowths called osteophytes (bone spurs) may form.
• Mild inflammation can occur around the joint.

This process develops slowly over years.

Line of treatment of osteoarthritis with mechanism of action

Stepwise treatment approach

1. Non-drug treatment (first-line for all patients)

These measures are the foundation of treatment and should continue even when medicines are started.

2. Medicines for pain relief

A. Paracetamol (Acetaminophen)

Examples: Paracetamol 500–650 mg

Mechanism

• Acts mainly in the central nervous system.
• Inhibits central prostaglandin synthesis, reducing pain perception.

Role

• Mild OA pain when inflammation is minimal.
• Safer for the stomach than NSAIDs, but excessive doses can damage the liver.

B. Topical NSAIDs (preferred before oral NSAIDs)

Examples: Diclofenac gel, Diclofenac spray

Mechanism

• Inhibit cyclo-oxygenase (COX-1 and COX-2) enzymes locally.
• Decrease prostaglandin production in the joint and surrounding tissues.

Benefit

• Good for knee and hand OA.
• Much lower systemic side effects than oral NSAIDs.

C. Oral NSAIDs

Examples: Diclofenac, Aceclofenac, Ibuprofen, Naproxen, Etoricoxib, Celecoxib

Mechanism

• Block COX enzymes → ↓ prostaglandins → ↓ pain, inflammation, and swelling.

Important precautions

• Can cause gastritis, ulcer, bleeding, kidney injury, fluid retention, and increased blood pressure.
• Use the lowest effective dose for the shortest duration.

3. Drugs used when symptoms persist

A. Duloxetine

Class: Serotonin–norepinephrine reuptake inhibitor (SNRI)

Mechanism

• Increases serotonin and noradrenaline in descending spinal pain pathways.
• Reduces chronic pain sensitization.

Use

• Knee OA with chronic pain, especially when sleep disturbance or central pain sensitization is present.

B. Weak opioids (limited use)

Examples: Tramadol

Mechanism

• Weak µ-opioid receptor agonist and inhibitor of serotonin/noradrenaline reuptake.

Use

• Short-term rescue therapy when other medicines fail or are contraindicated.

Caution

• Drowsiness, nausea, constipation, dependence risk.

4. Intra-articular injections

A. Corticosteroid injection

Examples: Triamcinolone, Methylprednisolone

Mechanism

• Suppress inflammatory cytokines, phospholipase A2, and prostaglandin production inside the joint.

Effect

• Rapid pain relief for weeks to a few months.

Limitation

• Repeated frequent injections may accelerate cartilage damage.

B. Hyaluronic acid (viscosupplementation)

Mechanism

• Restores viscoelasticity of synovial fluid.
• Improves lubrication and shock absorption.
• May reduce inflammatory mediators.

Effect

• Modest pain relief in selected knee OA patients.

5. SYSADOA / Nutraceuticals (evidence modest)

These may help some patients but do not reliably regenerate cartilage.

6. Surgical treatment

Surgery is considered when there is severe pain, deformity, or major functional limitation despite optimal conservative therapy.

Joint replacement is the most effective treatment for end-stage knee or hip OA.

Simplified treatment flow

Step 1

Lifestyle + Exercise + Weight loss

Continue throughout treatment.

Step 2

Paracetamol or Topical NSAID

For mild localized pain.

Step 3

Oral NSAID ± gastroprotection

For persistent inflammatory pain.

Step 4

Duloxetine / short-term Tramadol

When pain remains troublesome.

Step 5

Intra-articular steroid or Hyaluronic acid

For persistent joint symptoms.

Step 6

Joint replacement surgery

For severe structural disease and disability.

Commonly used drugs in osteoarthritis

1. Paracetamol (Acetaminophen)

Common dose: 500–650 mg as needed (doctor may adjust).

Why used

• Mild osteoarthritis pain.
• Better tolerated on the stomach than NSAIDs.

Important caution

• Excessive daily doses can damage the liver.

2. Topical NSAIDs (often first choice for knee and hand OA)

Common drugs

• Diclofenac diethylamine gel
• Diclofenac sodium gel
• Ketoprofen gel

Why used

• Pain relief directly at the joint with fewer stomach and kidney side effects.

3. Oral NSAIDs (most commonly prescribed)

Common side effects

• Acidity, gastritis, ulcer, bleeding
• Kidney impairment
• Increased blood pressure or swelling

Doctors often prescribe a proton pump inhibitor (PPI) such as pantoprazole with prolonged NSAID therapy.

4. COX-2 selective NSAIDs

Examples: Etoricoxib, Celecoxib

Advantages

• Less gastric irritation than traditional NSAIDs.

Caution

• Use carefully in people with heart disease, stroke risk, uncontrolled hypertension, or kidney disease.

5. Duloxetine

Class: SNRI antidepressant used for chronic pain.

When used

• Persistent knee OA pain, especially with sleep disturbance or widespread pain sensitivity.

Common side effects

• Nausea, dry mouth, dizziness, sleepiness.

6. Tramadol (short-term rescue medicine)

When used

• Moderate to severe pain not controlled by other medicines.

Side effects

• Drowsiness, constipation, nausea, dizziness; dependence can occur with prolonged use.

7. Joint injections

Corticosteroid injections

• Triamcinolone
• Methylprednisolone

Useful during acute painful flare-ups with swelling. Relief is usually temporary (weeks to months).

Hyaluronic acid injections

Used mainly for knee osteoarthritis when pain persists despite exercise and tablets.

8. Nutraceuticals / supplements commonly used

These are supportive therapies, not proven cartilage-regenerating drugs.

Which drugs are used most commonly in India?

For a typical patient with knee osteoarthritis, doctors commonly start with:

1

Exercise + weight reduction

2

Diclofenac gel applied locally

3

Paracetamol when needed

4

Aceclofenac or Naproxen if pain persists

5

Duloxetine for chronic persistent pain

6

Steroid injection for a painful swollen flare

Medicines generally avoided or used cautiously

• Long-term daily NSAIDs without medical supervision
• Multiple NSAIDs together (for example diclofenac + ibuprofen)
• NSAIDs in patients with peptic ulcer, kidney disease, heart failure, uncontrolled hypertension, or severe liver disease
• Long-term opioid therapy

Common Indian brands used in osteoarthritis

Common nutraceutical brands used in osteoarthritis

What doctors commonly prescribe for knee osteoarthritis in India

Mild pain

Volini Gel or Voveran Emulgel

Occasional pain

Crocin / Calpol

Moderate pain

Zerodol or Hifenac

Gastric-sensitive patients

Nucoxia or Etorica (only on medical advice)

Chronic persistent pain

Duzela or Dulane

Painful swollen flare

Kenacort intra-articular injection by an orthopaedic specialist

Important safety notes

• Do not take two NSAIDs together (for example, Zerodol + Voveran) unless specifically prescribed.
• NSAIDs should be used cautiously in people with ulcer, acidity, kidney disease, heart disease, or uncontrolled hypertension.
• COX-2 inhibitors such as Nucoxia/Etorica may be easier on the stomach but are not automatically safer for the heart.
• Tramadol should be used only for short periods because of drowsiness and dependence risk.
• Steroid injections should be given by a trained doctor and not repeated frequently.

Most important lifestyle changes

1. Maintain a healthy body weight

• Excess weight puts extra stress on the knees, hips, and lower back.
• Even a 5–10% weight loss can noticeably reduce knee pain and improve walking ability.

How to do it

• Reduce sugary drinks, sweets, fried foods, and large portions.
• Increase vegetables, salads, dals, pulses, fruits, and whole grains.
• Prefer home-cooked meals.

2. Exercise regularly (the best long-term treatment)

Aim for 30 minutes most days of the week.

Best exercises for knee OA

• Walking on level ground
• Quadriceps strengthening (straight-leg raise, seated knee extension)
• Hamstring and calf stretching
• Cycling on a stationary bicycle
• Swimming or water exercise if available
• Yoga with gentle movements

Important rule

• Mild discomfort during exercise is acceptable, but sharp pain that lasts for hours means you overdid it.

Avoid long periods of complete bed rest; joints become stiffer and muscles weaker.

3. Protect the joints during daily activities

4. Use supportive footwear

• Wear soft cushioned shoes with good arch support.
• Prefer low heels.
• Avoid worn-out slippers and hard-soled footwear.

5. Heat and cold therapy

Do not apply ice directly to the skin.

6. Improve posture and ergonomics

• Sit in a chair where knees are roughly at hip level.
• Use a firm mattress.
• When standing for long periods, shift weight from one leg to the other.
• While working at a desk, keep feet flat on the floor.

7. Stay physically active throughout the day

• Break up sitting every 30–45 minutes.
• Short walks are better than sitting for many hours continuously.

8. Sleep and stress management

Poor sleep increases pain sensitivity.

• Aim for 7–8 hours of sleep.
• Practice relaxation, meditation, breathing exercises, or gentle yoga.
• Manage anxiety and depression if present.

9. Diet that may help joint health

Focus on an anti-inflammatory eating pattern.

Eat more

• Fish (if non-vegetarian), walnuts, flaxseed
• Fruits such as berries, guava, orange, apple
• Green leafy vegetables
• Turmeric in food
• Adequate protein (dal, beans, milk, curd, eggs, lean meat)

Limit

• Deep-fried foods
• Processed snacks
• Excess sugar and sweets
• Sugary beverages
• Excess alcohol

No special “arthritis diet” can cure OA, but healthy eating helps weight control and overall inflammation.

10. If you use pain medicines

• Take NSAIDs after food unless your doctor advises otherwise.
• Avoid self-medicating for long periods.
• Tell your doctor if you have ulcer, acidity, kidney disease, heart disease, asthma, or high blood pressure.
• Do not combine multiple painkillers on your own.

11. Assistive devices can reduce pain

• A walking stick held in the opposite hand can reduce knee load.
• Knee braces or sleeves may improve confidence and stability in some patients.

Ask a physiotherapist to choose the correct device.

A simple daily routine for knee osteoarthritis

Morning

Warm compress → gentle knee bending and stretching for 5–10 min

Daytime

30 min walk (can be split into 10-min sessions)

Afternoon

Quadriceps strengthening: 10 repetitions × 2 sets

Evening

Light stretching or yoga for 10 min

Throughout

Avoid prolonged squatting and take movement breaks every 30–45 min

Warning signs — seek medical advice urgently if you develop

• Sudden severe joint swelling
• Redness or warmth of the joint
• Fever with joint pain
• Inability to bear weight
• A fall with new severe pain
• Rapidly worsening deformity

The 5 habits that help osteoarthritis the most

1.      Keep weight under control

2.      Exercise daily

3.      Strengthen thigh muscles

4.      Avoid deep squatting and heavy loading

5.      Use supportive footwear and stay active

Commonly used supplements in osteoarthritis (India)

Major brands available in India

1. Glucosamine + Chondroitin combinations

Common composition: Glucosamine sulfate 1500 mg + Chondroitin sulfate 1200 mg.

2. Undenatured Type II Collagen (UC-II)

Typical dose: 40 mg once daily, often taken at bedtime.

3. Curcumin preparations

Look for formulations with enhanced bioavailability (curcumin phytosome, BCM-95, C3 complex, etc.).

4. Boswellia serrata supplements

5. Calcium + Vitamin D3

These are useful when dietary calcium is inadequate or vitamin D is low.

6. Vitamin D3 alone

7. Omega-3 fatty acids

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