Secondary osteoarthritis: joint wear that follows another cause

In osteoarthritis the protective cartilage on the ends of the bones breaks down, causing pain, swelling and problems moving the joint, and bony growths can develop, as the NHS describes. NICE CKS describe it as a long-term disorder of synovial joints in which damage triggers repair processes leading to structural changes, with localised cartilage loss, remodelling of adjacent bone and the formation of osteophytes.

Doctors sometimes distinguish primary osteoarthritis, which has no single obvious precipitating cause, from secondary osteoarthritis, where an identifiable earlier problem has damaged the joint or altered the way it is loaded. The NHS uses the phrase secondary arthritis for osteoarthritis in joints severely damaged by a previous or existing condition, giving rheumatoid arthritis or gout as examples.

The distinction is useful because it directs attention to the original problem. A person whose knee has developed osteoarthritis after a ligament injury, or whose hip is wearing because of impingement or dysplasia, may benefit from a different assessment from someone with age-related disease.

NICE CKS group risk factors as genetic, biological and physical or biomechanical. The items below are those most relevant to secondary disease.

The symptoms are those of osteoarthritis generally. The NHS lists joint pain and stiffness and problems moving the joint, sometimes with swelling, tenderness and a grating or crackling sound. It varies from mild and intermittent to continuous and severe, and almost any joint can be affected, most often the knees, hips and small joints of the hands.

The NHS says to see your GP if you have persistent symptoms so they can confirm the diagnosis and prescribe treatment. It also notes that prolonged joint stiffness in the morning can be a sign of rheumatoid arthritis rather than osteoarthritis. NICE CKS advise a joint X-ray if there is diagnostic uncertainty, atypical features or a sudden worsening of symptoms, and referral to an orthopaedic surgeon in those circumstances too. A hot, red, very swollen joint with fever needs urgent assessment; do not wait for a routine appointment.

The NHS says a GP will ask about your symptoms and examine your joints, and may suspect osteoarthritis if you are 45 or older, have joint pain that gets worse the more you use the joints, and stiffness that is not there in the morning or lasts less than 30 minutes. Further tests such as X-rays or blood tests are not usually necessary, but may be used to rule out other causes such as rheumatoid arthritis or a fractured bone.

In secondary osteoarthritis the history is part of the diagnosis: the earlier injury, the previous inflammatory condition, or the structural problem. NICE CKS say assessment should include risk factors for OA and comorbidities, atypical features, functional limitation, psychosocial impact and treatments tried. If the cause is an inflammatory or structural problem, that problem may need its own specialist assessment.

There is no cure, but the NHS says the condition does not necessarily get worse and that treatments help relieve symptoms. It lists lifestyle measures such as maintaining a healthy weight and regular exercise, medication to relieve pain, supportive therapies to make everyday activities easier and, in a few cases, surgery to repair, strengthen or replace damaged joints.

The NHS says exercise is one of the most important treatments and should combine muscle strengthening with general fitness, ideally with a plan from a GP or physiotherapist, because doing too much too quickly or the wrong sort of exercise may damage the joints. For pain relief it lists paracetamol for short-term use, topical NSAIDs, which can be particularly effective for knees and hands, NSAID tablets with a proton pump inhibitor where suitable, short-term opioids for severe pain and capsaicin cream.

NICE CKS advise individualised therapeutic exercise, self-care including weight management and appropriate footwear, simple analgesia, psychosocial support, follow-up and referral to a local musculoskeletal team, which may provide manual therapy, assistive aids, intra-articular corticosteroid injections and structured exercise and education. Referral to an orthopaedic surgeon is offered if non-surgical management is unsuitable or ineffective after 3 months. If the cause is an ongoing inflammatory condition such as rheumatoid arthritis or gout, controlling that condition is part of protecting the joint.

The NHS says it is not possible to prevent osteoarthritis altogether but you may minimise your risk by avoiding injury and living a healthy lifestyle: aiming for at least 150 minutes of moderate aerobic activity a week plus strength exercises on 2 or more days, keeping good posture, and losing weight if overweight. NICE CKS add that physical inactivity increases the risk of developing OA.

After a joint injury or operation, follow the rehabilitation plan you are given. The NHS notes that overusing a joint that has not had enough time to heal increases risk. If you have an inflammatory arthritis, keeping the disease well controlled is the most direct way of protecting the joints from further damage, which your rheumatology team will manage.

Osteoarthritis is long term, but the NHS says it may not worsen and can sometimes gradually improve. NICE CKS note that complications may include joint deformity and chronic pain and that symptoms fluctuate, with flares lasting typically 3 to 8 days. The NHS says it is important to have support to cope with reduced mobility and advice on any financial support, and that talking to your GP or others living with osteoarthritis can help. Arthritis UK is the main charity for people with osteoarthritis.