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Risk factors + symptoms to diagnose knee OA (EULAR guidelines)

Clinical Question:
How should the diagnosis of knee osteoarthritis be made?

Bottom Line:
These European guidelines suggest that presence of risk factors and typical symptoms can make the diagnosis of knee osteoarthritis (OA) without radiographic changes; in fact, risk factors plus typical symptoms "overrule" a normal x-ray result. Other recommendations (see synopsis for the complete list): red flags suggest other diagnoses; MRI, ultrasound, or laboratory tests are not necessary to make the diagnosis; aspirate an effusion to rule-out other causes. (LOE = 2a)

Reference:
Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis 2010(3);69:483-489.  [PMID:19762361]

Study Design:
Practice guideline

Funding:
Foundation

Setting:
Various (guideline)

Synopsis:
These guidelines come from the European League Against Rheumatism and represent both best evidence as well as expert consensus regarding the diagnosis of knee OA in clinical practice. A committee of 17 experts assembled the best evidence and developed 10 statements regarding the diagnosis of a syndrome for which there is not a firm diagnostic standard (though the American College of Radiology has a classification scheme for research purposes, radiography is not the only marker of OA). The recommendations from the group are as follows (not all of the 10 statements were recommendations). (1) Risk factors predict knee OA: older than 50 years, female, overweight, previous knee injury, joint laxity, heavy use, family history, and presence of Heberden's nodes. (2) Typical symptoms are use-related pain, often worse at the end of the day and relieved by rest; the feeling of "giving way"; only mild morning or inactivity stiffness. Symptoms may be episodic or variable. (3) In patients older than 40 years with use-related pain, short-lived morning stiffness, functional limitation, and one or more typical examination findings: A diagnosis can be made without x-rays, and may be made even with a normal-appearing x-ray. (4) Red flags: severe local inflammation, erythema, progressive pain unrelated to usage suggest other diagnoses;. (5) MRI or ultrasound are not necessary to make the diagnosis; nor are laboratory tests, except when there is a high suspicion of other diagnoses. (6) A palpable effusion should be aspirated to exclude inflammatory disease and to identify crystals.

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