Diagnostic Considerations

The initial diagnostic goal is to differentiate osteoarthritis from other arthritides, such as rheumatoid arthritis. The history and physical examination findings are usually sufficient to diagnose osteoarthritis. Radiographic findings confirm the initial impression (see Workup), and laboratory values are typically within the reference range.

Rheumatoid arthritis

Rheumatoid arthritis predominantly affects the wrists, as well as the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. It rarely, if ever, involves the distal interphalangeal (DIP) joints or the lumbosacral spine.

Rheumatoid arthritis is associated with prominent, prolonged (>1 hour) morning stiffness and overtly swollen, warm joints. Radiographic findings include bone erosion (eg, periarticular osteopenia or marginal erosions of bone) rather than formation. Laboratory findings that further differentiate rheumatoid arthritis from osteoarthritis include the following:

Systemic inflammation (elevated erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP] level)
Positive serologies (rheumatoid factor [RF] or anti–cyclic citrullinated peptide [anti-CCP] antibodies)
Inflammatory joint fluid with a predominance of polymorphonuclear leukocytes (PMNs)
Elevated white blood cell (WBC) count

Other arthritides

Back pain may result from spondyloarthropathy or from osteoarthritis with sacroiliac and lumbosacral spine involvement. Clinical history and characteristic radiographic findings can be used to differentiate these disorders.

Secondary osteoarthritis must be considered in individuals with any of the following:

Chondrocalcinosis
History of joint trauma
Metabolic bone disorders
Hypermobility syndromes
Neuropathic diseases

The following disorders should also be considered in the differential diagnosis:

Crystalline arthropathies (ie, gout and pseudogout)
Inflammatory arthritis (eg, rheumatoid arthritis)
Seronegative spondyloarthropathies (eg, psoriatic arthritis and reactive arthritis)
Septic arthritis or postinfectious arthropathy
Fibromyalgia
Tendonitis

In patients with knee pain, other disorders to consider in the differential diagnosis are patellofemoral syndrome and prepatellar bursitis.

Differential Diagnoses

Avascular Necrosis
Fibromyalgia
Gout and Pseudogout
Ankylosing Spondylitis Imaging
Imaging in Neuropathic Arthropathy (Charcot Joint)
Lyme Disease
Patellofemoral Arthritis
Psoriatic Arthritis
Rheumatoid Arthritis (RA)

Workup

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Media Gallery

Anteroposterior (AP) radiograph of the hip reveals severe superior migration of the femoral head (which reflects loss of articular cartilage), subchondral sclerosis, prominent osteophytes, and a large Egger cyst in the superior acetabulum. Mild flattening of the superior aspect of the femoral head is present.
Osteoarthritis of the elbow is not commonly seen; however, it can occur with a history of previous trauma.
Osteoarthritis of the elbow is not commonly seen; however, it can occur with a history of previous trauma.
Osteoarthritis of the elbow is not commonly seen; however, it can occur with a history of previous trauma.
This radiograph demonstrates osteoarthritis of the right hip, including the finding of sclerosis at the superior aspect of the acetabulum. Frequently, osteoarthritis at the hip is a bilateral finding, but it may occur unilaterally in an individual who has a previous history of hip trauma that was confined to that one side.
Arthroscopic view of a torn meniscus before (top) and after (bottom) removal of loose meniscal fragments.
Arthroscopic view of an arthritic knee.
Arthroscopic view of a knee after the removal of loose fragments of articular and meniscal cartilage.
Arthroscopic view of the removal of cartilaginous loose body.
Anteroposterior radiograph shows knee replacement in 1 knee and arthritis in the other, with medial joint-space narrowing and subchondral sclerosis.
Anteroposterior radiograph of the pelvis and hips shows an arthritic hip not treated surgically and a total hip replacement.
Anteroposterior radiograph obtained after knee replacement.
Lateral radiograph obtained after knee replacement (same patient as in the above image).
Oblique projection demonstrates gradual narrowing and sclerosis of the facet joints as one progresses down the lumbar spine.
Standing radiograph of the knee reveals narrowing of the medial and lateral femorotibial compartments with marginal osteophytes.
H&E stain, high power magnification showing clusters of chondrocytes (center) that is a proliferation known as "chondrocyte cloning". Image courtesy of Francis Gannon, MD.
H&E stain, medium power magnification showing numerous vertical slits (upper left) in the articular surface cartilage known as "fibrillation" with increase in eosinophilia of the remaining cartilage due to loss of proteoglycans. Image courtesy of Francis Gannon, MD.
Gross photograph of external (top) and cut surface (bottom) showing areas of complete loss of articular cartilage with peripheral osteophytes formation. Image courtesy of Francis Gannon, MD.

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Author

Carlos J Lozada, MD Director of Rheumatology Fellowship Training Program, Professor of Clinical Medicine, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine

Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Received honoraria from Pfizer for consulting; Received grant/research funds from AbbVie for other; Received honoraria from Heel for consulting.

Coauthor(s)

Schartess S Culpepper Pace, MD Assistant Professor of Medicine, Division of Rheumatology, University of Miami, Leonard M Miller School of Medicine

Schartess S Culpepper Pace, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association