MSK · Full case

Osteoarthritis

NICE NG226 CKS 2024

<30 minStiffness: <30 min in OA (cf. >60 min in inflammatory arthritis)

45+ yrsAge criterion for clinical OA diagnosis (NICE NG226)

10% weight10% weight loss → ~50% pain reduction in knee OA

150 min/wkExercise target for OA management

Topical firstNICE NG226: topical NSAID before oral NSAID in peripheral OA

+PPI alwaysPPI mandatory with any oral NSAID; never prescribe without

No X-rayX-ray not routinely needed for clinical OA diagnosis (NICE NG226)

No paracetamolNICE NG226 (2022): no longer recommended routinely for OA

📋 Clinical Stem — Osteoarthritis

A patient presents with joint pain, stiffness, and reduced function affecting daily life, with features consistent with osteoarthritis.

"Mr David Chen is a 62-year-old retired builder who presents with a 2-year history of progressive bilateral knee pain, worse on activity and at the end of the day. Morning stiffness lasts about 15 minutes. He has a BMI of 31. He takes amlodipine 5 mg for hypertension. He plays golf but has had to give it up over the past 6 months. He is worried the pain will only get worse and wants to know if he needs a knee replacement."

OA management pivots on two evidence-based principles: exercise and weight loss are the most effective treatments (not tablets), and topical NSAID should precede oral NSAID. In SCA, the surgical expectation conversation and the NSAID + PPI prescribing are the most commonly missed elements.

Scenario A — Clinical diagnosis, typical features Age ≥45 + activity-related pain + no morning stiffness or <30 min. Clinical diagnosis — no imaging needed. Exercise + weight loss first-line. Topical diclofenac if pharmacotherapy needed.

Scenario B — High cardiovascular risk Patient on antihypertensives or known CVD. Naproxen preferred if oral NSAID needed (lower thrombotic risk vs ibuprofen/diclofenac). Celecoxib if GI risk. PPI mandatory with all oral NSAIDs.

Scenario C — Red flags requiring investigation Young patient (<45), inflammatory features, systemic symptoms, atypical joint pattern, trauma. Bloods (CRP, ESR, RF, anti-CCP, FBC) before assuming OA.

Scenario D — Surgical consideration NRS pain ≥7 despite optimised conservative treatment, significant functional impairment, failed multiple treatment modalities. Refer to orthopaedics. Explain realistic outcomes and recovery expectations.

Key variables to adapt for Joint(s) affected (knee, hip, hand); BMI (weight loss impact); CVD risk (NSAID choice); renal function (NSAIDs); age and frailty; comorbid depression (CBT, duloxetine); surgical threshold and patient expectations.

Steps:

Step 1

History Taking — Open Question · Key Diagnostics · Red Flags · ICE

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OA history confirms the clinical diagnosis and identifies management-modifying factors. NICE NG226 clinical criteria: age ≥45 + activity-related pain + stiffness <30 min = OA until proven otherwise. Functional impact drives management. ICE must directly address the surgical expectation and establish the patient's functional goals.

🎓 SCA opener

"I can see from your notes you've been having knee pain for about 2 years and it's been affecting your golf — that sounds very limiting. Tell me in your own words what the pain is like and how it's been affecting your day-to-day life."

Reference the stem (2 years, golf). Open question inviting the patient to lead with functional impact — this surfaces the ICE naturally and allows the surgical expectation to emerge.

1A — Key targeted questions

Question	Why it matters	Changes what?
🟢 OPEN — always start here"Tell me about the pain — what is it like, when is it worst, and how is it affecting your life?"	Functional impact drives management decisions. The open answer also surfaces the ICE spontaneously — particularly the surgical expectation and the specific activity loss (golf).	ManagementPsychosocial
Morning stiffness duration"When you wake up, how long does the stiffness last before it loosens up?"	The key diagnostic discriminator. OA: stiffness <30 minutes. RA/inflammatory: stiffness >60 minutes, improving with activity (gel phenomenon). This single question separates OA from inflammatory arthritis. Stiffness >30 min → inflammatory screen (CRP, ESR, RF, anti-CCP).Classic OA: "About 10 minutes — it loosens up as I start moving." Classic RA: "An hour or more, and it's worst in the morning."	DDxInvestigations
Pain pattern — activity vs rest"Is the pain worse with movement, or does it also hurt at night when you're resting?"	Activity-related pain improving with rest = mechanical OA. Constant night pain at rest = inflammatory arthritis, infection, or malignancy. Pain consistently waking patients from sleep is not typical OA — investigate before treating.	DDxUrgency
Swelling, heat, redness"Has the joint ever become very hot, red, and swollen — especially after rich food or alcohol?"	Hot, red joint = inflammatory arthritis, septic arthritis, or crystal arthropathy (gout). Asymmetric monoarthritis with hyperuricaemia risk factors = gout. OA and gout frequently coexist — one does not exclude the other.	DDxUrgency
Weight and BMI"How much do you weigh roughly — and has that changed?"	BMI is the single most modifiable risk factor. Every 5 kg weight loss reduces knee pain by ~20% in overweight patients. 10% body weight reduction = ~50% pain reduction. Each kilogram of body weight exerts 4 kg of force through the knee joint. This is clinically more effective than most pharmacological interventions.	Management
Drug history — NSAIDs, antihypertensives, anticoagulants"Any painkillers including OTC? Blood pressure tablets? Blood thinners?"	Critical for NSAID prescribing. Patient takes amlodipine (hypertension) → naproxen preferred over diclofenac/ibuprofen (lower CVD thrombotic risk). PPI mandatory with all oral NSAIDs. NSAIDs contraindicated with anticoagulants and eGFR <30.	Management
Functional goals"What can't you do now that you used to do — what would you most like to get back to?"	Functional goals provide patient-centred targets and motivational anchors. "Getting back to golf" is more motivating than "reducing pain from 7/10 to 4/10." Connecting the treatment plan to returning to golf dramatically improves engagement with exercise and weight loss programmes.	ManagementReferral
Red flags: weight loss, night pain, systemic symptoms"Any weight loss without trying? Night sweats? Pain waking you from sleep?"	Red flags for malignancy (bone metastases), infection (septic arthritis), or systemic inflammatory disease. Night pain at rest consistently waking patients from sleep is not typical OA. Any red flag warrants investigation before managing as OA.	UrgencyInvestigations

1B — Red flags

🚨

Red Flags — investigate before managing as OA

Red flag	Why dangerous	Action
Hot, red, swollen joint + fever + systemically unwell	Septic arthritis — joint-destroying emergency; destroys joint within 24–48 hrs if untreated; mortality if missed	Same-day hospital / A&E
Stiffness >60 min + multiple small joints + symmetrical + RF positive	Rheumatoid arthritis — early DMARD treatment prevents joint destruction; do not manage as OA	Urgent 2-week rheumatology
Night pain + weight loss + known cancer + age >50	Bone metastases — X-ray + CT urgently; must be excluded	Urgent investigations + 2WW
Locked joint with acute severe pain	Loose body, meniscal tear, or avascular necrosis — do not manage as OA flare	Urgent orthopaedic assessment

1C — ICE: Ideas · Concerns · Expectations

Most OA patients believe knee or hip replacement is the only meaningful treatment. This expectation leads to disengagement from exercise and weight loss — the most effective interventions. ICE must name the surgical expectation, address fatalism ("there's nothing that can help short of surgery"), and establish the specific functional goal that will motivate engagement with the conservative programme. The patient who understands that exercise reduces pain through muscle strengthening and who has a specific functional goal (golf) will engage. The one who feels "fobbed off" will not.

💭 Ideas

"What do you think is causing the knee pain — do you have a sense of what's going on in the joint?"

Many OA patients have researched extensively. Understanding their model enables targeted education about what exercise actually does (strengthens muscles = shock absorbers) rather than generic advice.

😟 Concerns

"Is there something you're particularly worried about — about how this will progress, or about becoming more limited?"

Fatalism and fear of progressive disability are the most common concerns. Fear of pain during exercise (misbelief that it accelerates joint damage) must also be addressed. Evidence-based correction is essential.

🎯 Expectations

"What were you hoping might be possible today — were you expecting a referral to a surgeon, or were you hoping we could try something first?"

The surgical expectation must be named. Response: "Surgery is a real option — but the evidence shows that structured exercise and weight loss produce very significant benefit, often comparable to surgery, and we should give that a proper try first."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Morning stiffness under 30 minutes and pain that's worse with activity — that fits very well with osteoarthritis."

"Surgery is not off the table — but the evidence is clear that exercise and weight loss produce very significant pain reduction, often comparable to surgery. Let me explain the numbers."

"You mentioned golf — getting you back to golf is actually a very achievable goal. Let's use that as our target."

Deductions

Not asking about morning stiffness duration — the key OA vs inflammatory discriminator
Not addressing the surgical expectation — patient leaves disengaged from conservative management
Not asking about drug history for NSAID safety screening (amlodipine = CVD risk = naproxen preferred)

🔴 Red

Stiffness not asked. Surgical expectation not addressed. Drug history absent. Functional goals not explored. Jumps to prescription.

🟠 Amber

OA confirmed but surgical expectation not directly addressed with evidence. Weight loss mentioned but not quantified. Golf not used as motivational goal.

🟢 Green

Stiffness <30 min confirmed. Clinical OA explained. Surgical expectation acknowledged and reframed with evidence. Weight loss quantified. Golf as goal set. Drug history for NSAID safety taken.

Step 2

Triage Engine — Emergency · Urgent Referral · Routine

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Triage in OA: is this really OA (red flag screen), how severe is it, and is surgical threshold met?

🔴 Emergency / Urgent

Immediate Action

Act now

Hot, red joint + feverSeptic arthritis → same-day hospital; joint aspiration
Stiffness >60 min + symmetrical small jointsRA → urgent 2-week rheumatology
Night pain + weight loss + cancerBone metastases → urgent 2WW
Locked jointMeniscal tear/loose body → urgent orthopaedics

🟠 Orthopaedic Referral

Failed Conservative Tx

When indicated

NRS ≥7 + failed exercise + physio + NSAIDs + IA steroidOrthopaedics for surgical consideration
Significant functional impairment — cannot perform ADLsDocument all failed conservative interventions

🟢 Routine Primary Care

OA Management

GP practice

Typical OA (age ≥45, activity-related, stiffness <30 min)Clinical diagnosis; no imaging; exercise + weight loss first-line
Pharmacotherapy if neededTopical NSAID → oral NSAID + PPI → IA corticosteroid
Depression comorbidityPHQ-9; duloxetine (NICE NG226 evidence)

🎓 SCA Checkpoint — Step 2Tasks

Key phrase

"Based on what you've told me, this fits with osteoarthritis — the pattern is classic. I'm not referring you for surgery today, but that remains an option if the conservative programme doesn't give you sufficient benefit."

Deductions

Surgical referral at first presentation without conservative management trial
Not red-flag screening before assuming OA

Step 3

Do I Need This Examination?

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Examination confirms the diagnosis, assesses severity, and screens for inflammatory arthritis. Weight and BMI are the most clinically important measurements in OA.

Examination	Why it matters	Finding that changes management	Changes?
Weight and BMI	BMI is the most clinically important modifiable factor in OA. Documents baseline. 10% weight loss in BMI >30 = ~50% knee pain reduction. Weight is a primary treatment target — frame explicitly: "every kg lost removes 4 kg of force from your knee."Must be measured at every OA consultation to monitor the primary treatment target.	BMI >30 → weight loss is the most powerful single intervention; quantify the benefit with numbers to motivate	YES — pivotal
Joint examination — inspect, palpate, ROM	Crepitus = cartilage loss. Bony enlargement (osteophytes). Varus/valgus deformity. ROM limitation. Effusion = acute flare or crystal arthropathy. Warmth = inflammatory (not typical OA).	Hot joint + effusion → aspiration (exclude septic arthritis). Fixed deformity + severe ROM → near surgical threshold. Warm tender joint → inflammatory screen urgently	YES
Gait assessment	Antalgic gait documents functional impairment for surgical referral records. Trendelenburg = hip OA involvement. Gait abnormalities support physiotherapy prescription and surgical documentation.	Antalgic gait + NRS ≥7 → surgical documentation supported	YES — referral
Signs of inflammatory arthritis	Symmetrical small joint swelling, warmth, tenderness, deformities. OA in large joints + inflammatory small joint signs = coexisting RA not being treated — a significant clinical error.	Inflammatory signs → urgent bloods + rheumatology; do not manage as OA alone	YES — pathway change

🎓 SCA Checkpoint — Step 3Tasks

Key phrase

"I'd like to examine your knees and measure your weight today — the weight is clinically very important because it directly determines how much load is going through the joint."

Deductions

Not measuring weight/BMI — misses the most important modifiable factor
Not checking for inflammatory signs — risk of labelling RA as OA

Step 4

Do I Need This Investigation?

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NICE NG226 is explicit: X-ray and laboratory tests are NOT routinely needed for typical OA. OA is a clinical diagnosis. Investigations only when atypical features are present or NSAID safety requires checking.

Investigation	When to order (NOT routine for typical OA)	Result that changes management
Plain X-ray	NOT routine for typical OA (NICE NG226). Indicated if: atypical age (<45), inflammatory features, red flags, prior to surgical referral. X-ray findings correlate poorly with symptoms — important patient communication point.	Osteophytes + narrowed joint space = OA confirmed (but treatment unchanged). Erosions → RA. Bone destruction → malignancy screen.
FBC, CRP, ESR, RF, anti-CCP	NOT routine. Indicated when stiffness >30 min, multiple small joints, systemic symptoms, inflammatory signs, or young patient (<45).	Elevated CRP + RF + anti-CCP → RA; urgent rheumatology. Normal: supports OA diagnosis.
eGFR before NSAID	Safety check before any oral NSAID prescription. NSAIDs nephrotoxic; contraindicated if eGFR <30. In CKD eGFR 30–60: use lowest dose shortest duration with monitoring.	eGFR <30 → NSAIDs contraindicated; topical only or duloxetine. eGFR 30–60 → short-term with monitoring; warn patient.
Serum uric acid + joint aspiration (if gout suspected)	Only if acute monoarthritis with hyperuricaemia risk factors. Serum urate not diagnostic alone — can be normal during acute attack. Joint aspiration with polarised microscopy is gold standard.	Urate crystals → gout. Organisms → septic arthritis. Normal urate: does not exclude acute gout.

🎓 SCA Checkpoint — Step 4Tasks

Key phrase

"For classic osteoarthritis with your features, NICE guidance says we don't need an X-ray or blood tests to make the diagnosis — it's a clinical diagnosis. I won't be ordering imaging today."

Deductions

Ordering routine X-ray for typical OA — not indicated per NICE NG226
Not checking eGFR before prescribing oral NSAID in a patient with hypertension (CKD risk)

Step 5

Reaching a Diagnosis — Explained in Plain Language

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🗣️ Diagnosis in Plain Language

"Osteoarthritis is what we call wear and tear in the joint — the cartilage that cushions the bones gradually wears thinner, and the bones start to grind together more than they should. This causes pain, stiffness, and swelling. Despite what many people believe, there is a lot we can do before surgery. Exercise is actually the most effective treatment — not because it fixes the cartilage, but because strong muscles act as shock absorbers and take load off the joint. And weight matters enormously: every kilogram of body weight puts about 4 kilograms of force through the knee joint with each step. Losing 5 kilograms would take 20 kilograms of force off your knee — that's the kind of change that makes a real difference to the pain."

💬 Addressing the surgical expectation

"My father had a knee replacement — I assumed that's what I'd need too."
"Surgery is absolutely a real option, and I'm not dismissing it. But I want to share what the evidence actually shows. Studies comparing structured exercise and weight loss programmes against knee replacement found that a significant proportion of people waiting for surgery got equivalent benefit from the programme alone. Surgery works very well when it's needed — but it has real recovery demands, usually 3 to 6 months, and its own risks. If we can get you back to playing golf without an operation, that's a much better outcome. Let's give the programme a proper 3-month try — if you're still significantly impaired after that, I will support a surgical referral."

A — Primary care diagnosis

Osteoarthritis (NICE NG226)

Age ≥45 + activity-related pain + stiffness <30 min. Clinical diagnosis. Exercise + weight loss. Topical NSAID if pharmacotherapy needed. No routine X-ray.

Gout (crystal arthropathy)

Acute monoarthritis + hyperuricaemia risk factors. Colchicine or NSAID acutely. Allopurinol after acute attack resolved (not during). Common OA coexistence.

B — Urgent referral

Rheumatoid arthritis

Stiffness >60 min + symmetrical small joints + RF/anti-CCP positive. Urgent rheumatology. Early DMARD prevents joint destruction.

OA requiring surgery

NRS ≥7 + failed conservative management. Orthopaedic referral with full conservative management documentation.

C — Emergency

Septic arthritis

Hot, red, swollen joint + fever. Same-day hospital. Joint aspiration. Destroys joint within 24–48 hrs untreated.

Bone metastases

Night pain + weight loss + known cancer. Urgent X-ray + CT. 2WW if new suspected malignancy.

🎓 SCA Checkpoint — Step 5TasksRelating to Others

Key phrases

"The cartilage is wearing thinner — strong muscles act as shock absorbers. Exercise doesn't wear the joint out more — it protects it."

"Every kilogram you lose takes 4 kilograms of force off your knee. That's why weight loss is the most powerful thing you can do."

"Surgery is not off the table — let's give the exercise and weight programme a proper 3-month trial first."

Deductions

Not quantifying the weight loss benefit — vague "lose some weight" does not motivate
Dismissing surgery entirely — patient needs to know the pathway if conservative fails
Not checking understanding after the explanation

Step 6

If Referral Is Needed

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Most OA is managed entirely in primary care. Referral to orthopaedics requires documented failed conservative management. Urgent referral if inflammatory arthritis or septic arthritis suspected.

Indication	Urgency	GP does before referral	Must NOT do
Septic arthritis / locked joint	Same-day hospital	Direct admission; do not delay; joint aspiration urgently in hospital	Do not give antibiotics before aspiration (confounds culture)
Suspected RA (stiffness >60 min, inflammatory features)	2-week rheumatology	RF, anti-CCP, CRP, ESR, FBC, X-ray hands/feet; document symptom duration	Do not start DMARDs in primary care; do not manage as OA without inflammatory screen
OA — surgical consideration (NRS ≥7, failed conservative)	Routine orthopaedics	Document: pain NRS, functional limitations, all treatments tried (physio, weight loss attempt, topical NSAID, oral NSAID + PPI, IA steroid), duration of conservative management	Do not refer at first presentation without conservative trial; do not set expectation that surgery is the only solution
Refractory pain — specialist pain / duloxetine	Routine pain team	PHQ-9; document failed pharmacotherapy; consider duloxetine trial (NICE NG226) before referral	Do not prescribe long-term opioids for OA — evidence of harm with minimal benefit

Step 7

Management — Expectation · Goals · Exercise · Drug Cards · Follow-Up · Safety-Netting

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NICE NG226 (2022) management: (1) Exercise + weight loss — most effective. (2) Topical NSAID before oral NSAID in peripheral OA. (3) PPI MANDATORY with every oral NSAID. (4) Paracetamol NOT recommended routinely. (5) Opioids not recommended. (6) Oral diclofenac: avoid in significant CVD.

7A — Address surgical expectation: validate → explain → negotiate

🤝

Validate → Explain → Negotiate

Validate

The expectation of surgery is entirely understandable if a family member has had a replacement. Acknowledge this explicitly before presenting the evidence.

"I completely understand why you'd expect a replacement — your father had one and got excellent results. That's not an unreasonable expectation at all."

Explain

Share the evidence honestly with specific numbers. Exercise and weight loss produce significant pain reduction, often comparable to surgery.

"The research shows that a structured exercise programme and losing just 5–10% of your body weight reduces knee pain by about 50% in most people — comparable to what surgery achieves, without the 3–6 month recovery. I want to make sure you get that benefit first."

Negotiate

Always leave with a specific agreement and goal. Connect the plan to returning to golf.

"Could we agree on a 3-month structured programme — exercise, weight loss target, and a physio referral. If you're still significantly impaired after that, I'll support a surgical referral with full documentation. And let's use getting back to golf as our specific goal."

Key principle: The patient who understands that exercise reduces pain through muscle strengthening and who has a specific functional goal will engage. The patient who feels "fobbed off" will not. Address the surgical expectation directly, quantify the evidence, and set a goal that matters to the patient.

7B — Treatment goals + motivational language

Treatment goals

Return to golf — specific, patient-centred functional goal NRS pain reduction ≥3/10 from baseline 5–10% body weight reduction (BMI >30) 150 min/week exercise sustained No unnecessary imaging or investigations (clinical diagnosis) PHQ-9 completed — depression screen Surgical referral pathway understood and accessible if needed NSAID + PPI correctly prescribed and monitored

Motivational language

"Every kilogram you lose takes 4 kilograms off your knee joint with every step. Losing 5 kg takes 20 kg of force off — that's like removing a sack of potatoes your knee has been carrying."

"Getting back to golf in 3 months is genuinely achievable with this programme. Let's make that our specific goal — not just 'a bit less pain.'"

7C — Lifestyle (MOST EFFECTIVE TREATMENT — first-line)

🏃

Therapeutic Exercise

150 min/week aerobic + muscle strengthening

Mechanism

Strong muscles act as shock absorbers, reducing articular cartilage loading. Exercise also reduces central sensitisation and improves joint lubrication. Exercise does NOT accelerate cartilage loss — it protects it.

Practical

Low-impact: swimming, cycling, walking, aqua exercise. Quadriceps strengthening: straight leg raises, mini-squats, step-ups. Physio referral for supervised programme. Reassure: pain during exercise is acceptable; pain worsening after exercise should prompt review.

Exercise reduces pain ~30%, improves function ~25% — better than most medications (Cochrane)

⚖️

Weight Loss (Overweight)

Target: 5–10% body weight; quantify the benefit

Mechanism

Each kg of body weight exerts 4 kg of force through the knee joint. Weight loss reduces articular loading and has an anti-inflammatory effect through reduced adipokine secretion.

Practical

Set a specific target: "5 kg in 3 months" is more motivating than "lose some weight." Structured lifestyle programme referral. Mediterranean diet evidence for OA. Commercial weight loss programme if BMI >30.

10% body weight loss = ~50% pain reduction in overweight patients with knee OA

🧘

Physiotherapy and Education

Refer all new OA diagnoses to physiotherapy

Mechanism

Targeted muscle strengthening, biomechanical correction, pacing strategies. Patient education changes illness beliefs — particularly fatalism — the most important determinant of long-term function in OA.

Practical

Refer all new OA diagnoses. ESCAPE Pain group exercise programme. SELF-management education. Walking aids if indicated (reduces loading 15–20%).

Physio + education programme: 40% reduction in surgical referral rates in RCTs

🌡️

Heat and Cold

Heat for stiffness; ice for acute flares

Practical

Heat: warm bath, heat pack for morning stiffness and post-exercise. Cold: ice pack (wrapped in cloth) 15–20 min after activity or during flares. TENS has evidence for short-term relief.

No pharmacological side effects; evidence-based adjuncts

🧠

Mental Health Screen

PHQ-9 at every OA review

Mechanism

Depression prevalence ~20% in OA. Bidirectional: chronic pain → depression; depression → amplified pain. Depression predicts poor surgical outcomes. PHQ-9 at every review.

Practical

Duloxetine 30–60 mg OD: NICE NG226 evidence for OA pain + comorbid depression. NHS Talking Therapies referral. CBT for chronic pain.

Duloxetine reduces OA pain ~30% beyond placebo; treats depression simultaneously

👟

Footwear and Orthotics

Cushioned sports shoes; refer podiatry if appropriate

Practical

Well-fitting cushioned sports shoes. Avoid high heels. Lateral wedge insoles for medial compartment knee OA. Refer to podiatry or orthotics if appropriate.

Reduces impact loading without pharmacological side effects

7D — Prescribing guide (NICE NG226, 2022)

Critical NICE NG226 (2022) rules: (1) Paracetamol no longer recommended routinely for OA. (2) Topical NSAID before oral in peripheral OA. (3) PPI MANDATORY with every oral NSAID. (4) Naproxen preferred for CVD risk (hypertension) — not diclofenac oral. (5) Opioids: not recommended.

Step 1 — Topical NSAID (first pharmacological step)

Topical diclofenac 1% gel: apply 3–4×/day to affected joint
NICE NG226 first-line pharmacological choice for peripheral OA
Less systemic absorption — fewer GI and CVD side effects
No PPI required — key advantage over oral NSAIDs
Review at 4 weeks; if inadequate → add oral NSAID + PPI

Topical diclofenac does NOT require PPI co-prescription. Prescribing oral NSAID before trying topical for peripheral OA = NICE error.

Step 2 — Oral NSAID + PPI (always co-prescribed)

Naproxen 250–500 mg twice daily: preferred in high CVD / hypertension (lower thrombotic risk)
Ibuprofen 400 mg three times daily: lower CVD risk patients
Celecoxib 100–200 mg OD: high GI risk; caution in significant CVD
PPI MANDATORY — omeprazole 20 mg OD or lansoprazole 15 mg OD always co-prescribed
Lowest effective dose, shortest duration; review at 4 weeks

This patient takes amlodipine (hypertension): naproxen preferred. Never prescribe oral diclofenac for patients with significant cardiovascular risk factors.

Step 3 — IA Corticosteroid + Duloxetine

IA triamcinolone 40 mg: acute flare; relief 4–8 weeks; max 3×/year; not if prosthetic joint
Duloxetine 30–60 mg OD: NICE NG226 evidence for OA pain; central sensitisation or comorbid depression
NOT recommended: paracetamol routinely (NICE NG226, 2022); opioids; glucosamine; acupuncture

IA corticosteroid: max 3/year; frequent injections may accelerate cartilage loss; must exclude septic arthritis before injecting.

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE / BNF

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — Drug selector

Select characteristics — see drug cards below

Peripheral OA (knee, hand) — topical NSAID first-line, no PPI needed High CVD risk / hypertension — naproxen preferred over ibuprofen or diclofenac High GI risk (age >65, PUD, anticoagulant) — celecoxib preferred Oral NSAID prescribed — PPI mandatory (always co-prescribe) Acute flare — intra-articular corticosteroid (max 3×/year) Depression / central sensitisation — duloxetine (NICE NG226)

Prescribing approach

Topical diclofenac first (no PPI needed). If insufficient: oral NSAID + PPI mandatory. High CVD/hypertension: naproxen. GI risk: celecoxib. Acute flare: IA corticosteroid max 3/year. Depression/central sensitisation: duloxetine. Never paracetamol routinely. Never opioids for OA. Never oral NSAID without PPI.

7F — Drug reference cards

Topical Diclofenac Gel

Voltarol 1% gel; diclofenac diethylamine 1.16%

✓ NICE Step 1

Step 1 (peripheral OA)Apply 3–4× daily to joint

✓ Use when

NICE NG226 first-line pharmacological choice for peripheral joint OA (knee, hand)

Significantly less systemic absorption — fewer GI and CVD side effects than oral NSAIDs

No PPI required — key advantage; available OTC (Voltarol)

✗ Caution

Broken or infected skin; avoid mucous membranes; wash hands after application

💬 Counselling

"Apply a small amount directly over the knee joint 3 to 4 times a day — let it dry before covering. The advantage over tablets is much less gets into the bloodstream. You don't need a stomach-protecting tablet with this one."

In SCA: prescribing oral NSAID before topical for peripheral OA = NICE NG226 error. The mark: topical diclofenac first + no PPI needed. Jumping straight to oral NSAID loses this mark.

Naproxen (Oral NSAID — CVD risk)

Naprosyn; generic naproxen; 250–500 mg tablets

✓ Preferred: CVD risk

Step 2 — CVD risk250–500 mg twice daily with food + PPI

✓ Use when — always add PPI

Preferred oral NSAID in patients with cardiovascular risk factors or hypertension

Lower thrombotic cardiovascular risk than ibuprofen and diclofenac (network meta-analysis, Lancet 2013)

PPI MANDATORY — omeprazole 20 mg OD or lansoprazole 15 mg OD always co-prescribed

✗ Avoid if

eGFR <30 — nephrotoxic; AKI risk

Severe heart failure; established CVD — still lower thrombotic risk than ibuprofen/diclofenac, but not zero

⚠ Side effects

GI: dyspepsia, peptic ulcer, GI bleeding — PPI co-prescription mandatory; take with food

Cardiovascular: fluid retention, hypertension aggravation — monitor BP in this hypertensive patient

Renal: AKI risk especially in dehydration, CKD, elderly

💬 Counselling

"Take twice daily with food — never on an empty stomach. Also take the stomach-protecting tablet I'm prescribing alongside it, every day without fail. If you develop stomach pain, dark stools, or feel very unwell, stop the tablet and contact us."

In SCA: two specific marks — (1) naproxen preferred for CVD risk patients, not diclofenac or ibuprofen; (2) PPI always co-prescribed. Both must be stated explicitly. "I'll also prescribe a stomach-protecting tablet alongside this."

Ibuprofen (Oral NSAID — low CVD risk)

Brufen; Nurofen; 400 mg tablets

✓ Low CVD risk

Step 2 — low CVD risk400 mg three times daily with food + PPI

✓ Use when — always add PPI

Appropriate for patients without significant CVD risk factors

PPI MANDATORY — never prescribe oral NSAID without

✗ Avoid if

Significant CVD risk (hypertension, IHD) — use naproxen instead

eGFR <30; severe heart failure

💬 Counselling

"Three times a day with food. Always take the stomach-protecting tablet as well — that's not optional. Stop and contact us if you develop stomach pain or notice dark stools."

Intra-Articular Corticosteroid

Triamcinolone acetonide 40 mg; methylprednisolone 40 mg

✓ Flare management

Flare management40 mg IA; max 3×/year per joint

✓ Use when

Acute OA flare — significant joint effusion and pain; short-term relief 4–8 weeks

NSAIDs contraindicated or as adjunct while waiting for exercise to take effect

✗ Avoid if

Prosthetic joint — specialist procedure only; infection risk

Suspected septic arthritis — must exclude before injecting (aspiration first)

Diabetes — transient blood glucose elevation 48–72 hrs; warn patient

More than 3×/year — may accelerate cartilage loss

💬 Counselling

"This injection reduces the joint inflammation. You may have 24–48 hours of worsening pain initially — that's a normal reaction. After that, most people get significant relief for 4–8 weeks. We can repeat this up to 3 times a year."

In SCA: key knowledge points — max 3 IA injections/year; must not inject if septic arthritis suspected; warn diabetics about blood glucose; not for prosthetic joints.

Duloxetine (SNRI)

Cymbalta; generic duloxetine 30/60 mg capsules

✓ Central pain / depression

Step 330 mg OD → titrate to 60 mg OD

✓ Use when

OA pain with central sensitisation or comorbid depression (NICE NG226 evidence)

NSAIDs contraindicated or inadequate; ~30% pain reduction beyond placebo

Start 30 mg for 2 weeks then increase to 60 mg if tolerated

✗ Avoid if

MAOIs (serotonin syndrome); uncontrolled hypertension; severe hepatic impairment

⚠ Side effects

Nausea: most common; usually settles by week 2; take with food

Discontinuation syndrome: taper over 2 weeks when stopping — never stop abruptly

💬 Counselling

"This tablet works on pain pathways in the brain and spine — it's not a conventional painkiller, but it changes how pain is processed. Start at 30 mg for 2 weeks, then increase. Allow 2–4 weeks to see the pain effect. Don't stop abruptly — we'd taper it."

In SCA: duloxetine for OA is a NICE NG226 (2022) recommendation — a specific knowledge point. Knowing it is indicated for central sensitisation and comorbid depression demonstrates up-to-date guideline knowledge.

Topical Capsaicin

Axsain 0.075%; Zacin 0.025%

✓ NICE adjunct

Topical adjunctApply 3–4× daily; consistent use essential

✓ Use when

Adjunct or alternative to topical NSAID for knee and hand OA (NICE NG226)

Depletes substance P from sensory nerve terminals → reduces pain transmission

Effect builds over 4–6 weeks of regular use — must be used consistently

⚠ Side effects

Burning sensation at application site for first 2–4 weeks — this IS the mechanism; warn patient in advance or they will stop prematurely

💬 Counselling

"For the first 2–4 weeks you'll feel a burning sensation at the site — this is it working, not a problem. Stick with it; after a few weeks that reduces and the pain relief builds. Apply 3–4 times a day consistently."

7G — Psychosocial impact

🫂

OA affects identity, independence, and quality of life far beyond what the NRS pain score captures

⛳

Loss of Valued Activities

OA causes patients to give up activities central to their identity — golf, gardening, dancing, walking the dog. These losses cascade into depression, reduced activity, weight gain, and worsening OA — a vicious cycle.

Addressing the specific activity loss as a treatment goal breaks this cycle. "Getting back to golf" is more powerful than "reduce NRS by 3."

"Getting you back to golf is our goal — let's be specific about what you'd need to be able to do that."

😢

Depression and Chronic Pain

Depression prevalence in OA is ~20%. Depression amplifies pain and reduces exercise engagement — bidirectional worsening. PHQ-9 at every OA review. Duloxetine treats both simultaneously.

"How has your mood been — living with this level of pain day to day can really take a toll. I want to make sure we're not missing anything there."

🧗

Fatalism and Self-Efficacy

"There's nothing that can help short of surgery" is the most common belief barrier to OA management. Directly preventing engagement with exercise and weight loss.

Motivational interviewing, specific evidence with numbers, and connecting treatment to meaningful goals are the most effective approaches.

"I want to challenge one thing — many people believe exercise makes it worse. The research actually shows the opposite — let me explain why."

💼

Work and Productivity

Manual workers with OA (this patient: retired builder) often have occupational history as a contributing cause. OA is a leading cause of early retirement. Occupational therapy referral may be appropriate.

"Has the pain been affecting your ability to do things day-to-day — I want to make sure we factor that into the plan."

😴

Sleep Disruption

Chronic pain disrupts sleep. Poor sleep amplifies pain perception and reduces physical function — bidirectional. Evening duloxetine (if prescribed) may help sleep. Sleep hygiene advice and CBT for pain/sleep comorbidity.

"Is the pain affecting your sleep? This is something we can address specifically and it makes a real difference to how you experience the pain during the day."

👟

Exercise Fear

Many patients fear that exercise will accelerate joint damage. This misbelief must be directly addressed. Exercise does NOT wear the joint out more — it protects it through muscle strengthening and load redistribution.

"I need to address something important: exercise does not wear the joint out more. The muscles become shock absorbers — the joint actually gets more protection, not less."

7H — Follow-up schedule

4–6 weeks — Exercise and topical NSAID review

Engaging with exercise? Topical diclofenac adequate? Weight change documented. PHQ-9. If topical inadequate: add naproxen + PPI (for this patient with hypertension). Physiotherapy referral confirmed.

Medication review

3 months — Golf goal review

Have we met the golf goal or progressing? Weight change. NRS recorded. If exercise + topical insufficient: oral NSAID + PPI. Acute flare: IA corticosteroid. Begin surgical referral documentation if NRS ≥7 despite optimised management.

Goal review

6 months — Escalation or surgical referral

NRS ≥7 despite optimised conservative management → surgical referral with full documentation. PHQ-9 repeated. Duloxetine if central sensitisation or comorbid depression.

Surgical referral decision

Annual — Long-term OA review

Weight; pain NRS; functional status; NSAID safety review (BP, eGFR, GI symptoms); PHQ-9; red flag rescreen. Review whether ongoing NSAID needed or topical alone now adequate.

Annual review

Every 3–6 months — NSAID safety monitoring

Blood pressure (NSAIDs raise BP — important in this hypertensive patient), eGFR, FBC. Confirm PPI taken consistently. Reinforce lowest effective dose for shortest time.

NSAID safety

7I — Safety-netting

⚠ Three scenario-specific safety-net phrases

4–6 weeksExercise + topical NSAID review; physio confirmed; PHQ-9

3 monthsGolf goal review; escalation decision; weight change documented

6 months / AnnualSurgical referral if NRS ≥7; annual NSAID safety; red flag rescreen

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing phrases

"I'm prescribing topical diclofenac gel — 3 to 4 times a day on the knee — and I'm also prescribing naproxen and a stomach tablet to go with it for when the pain is worse. No stomach tablet, no naproxen."

"Our goal is getting you back to golf in 3 months. Let's set 5 kg weight loss as the first target — every kilo takes 4 kg of force off your knee."

"Hot joint + fever = A&E same day, not an OA flare. Always take the stomach tablet with the naproxen."

"Is there anything else on your mind before we finish?"

Deductions

Oral NSAID before topical first — NICE NG226 error
Oral NSAID without PPI — prescribing error; never omit
Diclofenac oral for hypertensive patient — naproxen preferred
Paracetamol prescribed routinely — NICE NG226 (2022) no longer recommends this
Surgical expectation not acknowledged and addressed
Functional goal (golf) not set
Closing question absent

Tasks domain — full criteria

Clinical OA diagnosis without X-ray (NICE NG226)
Topical diclofenac as Step 1 pharmacological treatment
Naproxen (not diclofenac) for hypertensive patient + CVD risk
PPI co-prescribed with oral NSAID — always
No paracetamol routinely (NICE NG226, 2022)
Physiotherapy referral made
Weight loss quantified: 5 kg = 20% pain reduction / 4 kg per 1 kg lost
Septic arthritis safety-net: hot joint + fever = A&E
NSAID GI safety-net: dark stools = stop + A&E

Relating to Others — full criteria

Surgical expectation validated then reframed with evidence
Exercise mechanism explained: muscles as shock absorbers
Weight loss mechanism: 4 kg per kg lost — specific numbers
Golf as specific functional goal committed to
Understanding checked
Closing question asked

🔴 Red

Oral NSAID without topical first. No PPI. Diclofenac for hypertensive. Paracetamol prescribed. Surgical expectation not addressed. No goal. No safety-net.

🟠 Amber

Topical NSAID tried but oral NSAID without PPI. Surgical expectation not reframed with specific evidence. Weight loss mentioned but not quantified.

🟢 Green

Topical → oral NSAID + PPI. Naproxen for CVD risk. No paracetamol. Surgical expectation reframed with evidence. 5 kg goal + golf target. Septic arthritis + NSAID GI safety-nets. Closing question.

"I've been having trouble with my knees for a couple of years now. It's been getting worse and I'm struggling with a lot of things I used to do."

Who you are

David Chen, 62 years old, retired builder. Bilateral knee pain for 2 years, worse on the right. Pain worst on walking (stairs, slopes), at the end of the day. Morning stiffness about 15 minutes — loosens up as he moves. Has tried OTC ibuprofen occasionally with partial benefit. Stopped playing golf 6 months ago — used to play weekly with friends. Takes amlodipine 5 mg for hypertension. BMI 31 (96 kg). Non-smoker. No inflammatory signs — no small joint pain, no symmetrical pattern. No cancer history. No weight loss.

Hidden agenda — surgical expectation

David's father had a knee replacement at 60 and was "back to full function" — David assumes he needs the same and is expecting a referral today. He will not be hostile about not getting a referral if the GP explains properly. He needs: (1) the surgical expectation validated before being reframed; (2) exercise mechanism explained (muscles as shock absorbers); (3) weight loss benefit quantified with specific numbers; (4) golf specifically set as the 3-month goal. If the GP says "try some exercises" without quantifying the benefit, he mentally dismisses it. If the GP says "losing 5 kg would take 20 kg of force off your knee — the research shows about 50% pain reduction," he becomes genuinely engaged.

If asked about stiffness

"About 10–15 minutes in the morning — then it loosens up as I move around"
No small joint pain (hands, wrists)
No constant night pain — pain resolves with rest
No fever, no hot/red joint

If asked about functional goals

"Golf — I used to play every week with my friends. I really miss it."
"Walking the dog is also getting hard — we used to go an hour, now 20 minutes is painful"
If golf is set as a specific target: "Do you really think I could get back to that?"

"My father had a knee replacement and it sorted him out completely — is that where I'm heading? I'd rather just get it done."

Resolution criteria: David accepts the conservative plan if: (1) surgical expectation validated ("I understand why you'd think that — your father had excellent results"); (2) exercise mechanism explained (muscles as shock absorbers — "this doesn't wear the joint out more"); (3) weight loss quantified with numbers; (4) golf set as specific 3-month goal; (5) surgical pathway not closed ("if this doesn't give sufficient benefit in 3 months, I will support a referral").

🏥

Clinic Quick Reference

Osteoarthritis — Clinical Decision Framework

NICE NG226 (2022) · CKS 2023

▼expand

🚦 1 — Triage

🔴 Emergency / Urgent

Hot joint + fever → same-day A&E (septic arthritis)

Stiffness >60 min + symmetrical small joints → 2-wk rheumatology (RA)

Night pain + weight loss + cancer → urgent 2WW

Locked joint → urgent orthopaedics

🟠 Orthopaedic Referral

NRS ≥7 + failed: exercise + physio + NSAID + IA steroid

Significant functional impairment affecting ADLs

Document all failed conservative interventions before referring

🟢 Routine Primary Care

Age ≥45 + activity pain + stiffness <30 min = OA (clinical diagnosis)

Exercise + weight loss first-line

Topical → oral NSAID + PPI → IA steroid

📊 2 — Key Numbers (NICE NG226)

No paracetamol

NICE NG226 (2022): no longer recommended routinely

Topical first

Topical NSAID before oral in peripheral OA

+PPI always

Mandatory with every oral NSAID — never omit

Naproxen

Preferred oral NSAID in CVD / hypertension

4 kg / kg

Each kg lost removes ~4 kg force from knee per step

10% weight

10% body weight loss → ~50% pain reduction (overweight OA)

No X-ray

Not routinely needed for clinical OA diagnosis

3 × IA max

Maximum 3 intra-articular steroid injections per year

💊 3 — NICE NG226 Pharmacotherapy Ladder

Pharmacotherapy Ladder

Step 1: Topical diclofenac gel — no PPI needed

Step 2: Oral NSAID + PPI (mandatory). High CVD: naproxen. GI risk: celecoxib.

Step 3: IA corticosteroid (flares, max 3/year)

Step 3: Duloxetine (central sensitisation / depression)

⚠ No paracetamol routinely · No opioids · No glucosamine

NSAID Choice by Risk

Low CVD + low GI → ibuprofen + PPI

High CVD / hypertension → naproxen + PPI

High GI risk → celecoxib + PPI

eGFR <30 → NSAIDs contraindicated; topical only

Oral diclofenac: avoid in significant CVD

⚠ 4 — Safety Netting + Follow-Up

Follow-up timeline

4–6 wks: Exercise + topical response; escalation decision

3 months: Golf goal review; weight change; surgical decision

6 months: Surgical referral if NRS ≥7 + failed conservative

Annual: Weight; NRS; NSAID safety (BP, eGFR); PHQ-9

3–6 monthly: BP + eGFR on regular oral NSAID

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Flow

0–2 min

Reference Stem + Open

"I can see you've had knee pain for 2 years and had to stop golf — that sounds very limiting. Tell me in your own words what it's like."

GSRO

✗ Not referencing stem context · ✗ Jumping straight to systematic questions

2–6 min

Stiffness + Red Flags + Drug History + ICE

"How long does morning stiffness last? Any hot/swollen joints? What medications are you on — any blood pressure tablets? Were you expecting a surgical referral today?"

TasksRO

✗ Not asking stiffness duration · ✗ Not asking drug history · ✗ Surgical expectation not explored

6–7 min

Examination

"I'd like to examine your knees and measure your weight — the weight is one of the most clinically important measurements here."

Tasks

✗ Not measuring weight · ✗ Not checking for inflammatory signs

7–10 min

Diagnosis + Reframe + Treatment

"This fits OA — clinical diagnosis, no X-ray needed. Surgery is an option, but 50% pain reduction from weight loss + exercise first. Topical diclofenac → naproxen + PPI. Goal: back to golf in 3 months."

TasksRO

✗ Oral NSAID before topical · ✗ No PPI · ✗ Paracetamol prescribed · ✗ Surgical expectation not reframed

10–12 min

Safety-Net + Follow-Up + Close

"Hot joint + fever = A&E. Dark stools = stop NSAID + A&E. Review in 4–6 weeks. Is there anything else?"

TasksRO

✗ No safety-net · ✗ No follow-up · ✗ No closing question

🔴🟠🟢 RAG Scoring

Tasks

🟢

Stiffness <30 min confirmed; clinical OA diagnosis no X-ray; topical before oral; naproxen for CVD; PPI always; no paracetamol; weight loss quantified; physio referral; safety-nets; follow-up

🟠

OA confirmed but oral NSAID before topical; no PPI; weight loss mentioned but not quantified; surgical expectation not addressed with evidence

🔴

Stiffness not asked; oral NSAID without PPI; paracetamol prescribed; no safety-net; no functional goal; surgical referral at first visit

Relating to Others

🟢

Surgical expectation validated and reframed with evidence; exercise mechanism explained; weight loss quantified; golf as goal; understanding checked; closing question

🟠

Surgical expectation acknowledged but not reframed with specific evidence; weight loss mentioned without numbers; golf not set as goal

🔴

Surgical expectation ignored; patient leaves disengaged; exercise prescribed without explanation; closing question absent

💬 Key Phrases

Surgical expectation

"I understand why you'd expect a replacement — your father had excellent results. Surgery is still an option. But the evidence shows exercise and weight loss produce comparable benefit for many people, without the 3–6 month recovery."

Exercise mechanism

"Strong muscles act as shock absorbers for the knee joint. Exercise does not wear it out more — it actually protects it by reducing the load on the cartilage."

Weight loss numbers

"Every kilogram you lose takes 4 kilograms off your knee joint with every step. Losing 5 kg would take 20 kg off — and 10% of your body weight gives about 50% pain reduction."

Goal setting

"Let's use getting back to golf as our 3-month target — that's a specific, achievable goal we can work towards."

Safety-nets

"Hot joint + fever = A&E same day. Dark stools with naproxen = stop the tablet and go to A&E."

🚫 9 Danger Zones

✗

Oral NSAID before topical for peripheral OA
→ NICE NG226: topical diclofenac is Step 1; no PPI needed for topical

✗

Oral NSAID without PPI
→ PPI is mandatory with every oral NSAID; never omit

✗

Diclofenac oral for hypertensive patient
→ Naproxen preferred in CVD risk patients (lower thrombotic risk)

✗

Paracetamol prescribed routinely
→ NICE NG226 (2022): no longer recommended for OA

✗

Surgical expectation not addressed
→ Patient leaves disengaged from conservative management

✗

Weight loss benefit not quantified with numbers
→ "Lose some weight" does not motivate; "4 kg per kg lost" does

✗

Morning stiffness duration not asked
→ The single most important OA vs inflammatory discriminator

✗

Routine X-ray ordered for typical OA
→ NICE NG226: not indicated; clinical diagnosis

✗

Closing question absent
→ Always end with "Is there anything else on your mind?"

💊 Drug Quick-Pick

Peripheral OA — Step 1

→

Topical diclofenac 1% gel

No PPI needed

Oral NSAID, high CVD/hypertension

→

Naproxen + PPI

Not diclofenac oral

Oral NSAID, low CVD risk

→

Ibuprofen + PPI

Always PPI

Acute flare

→

IA triamcinolone 40 mg

Max 3×/year

Central sensitisation / depression

→

Duloxetine 30–60 mg OD

NICE NG226

⛔ No paracetamol routinely · No opioids · Topical before oral · PPI always with oral NSAID · Naproxen for CVD risk

Osteoarthritis · GP Clinical Reasoning Framework v2 · NICE NG226 (2022) · NICE CKS Osteoarthritis (2023) · Versus Arthritis: versusarthritis.org

v3: Dual tailored summaries · NICE NG226 (2022) paracetamol removal · Topical-before-oral rule · Naproxen preferred for CVD risk · Surgical expectation reframing · Weight loss quantification (4 kg/kg)

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/SPC · Clinical judgement takes precedence · Versus Arthritis helpline: 0800 5200 520

Osteoarthritis

Red Flags — investigate before managing as OA

Immediate Action

Failed Conservative Tx

OA Management

Osteoarthritis (NICE NG226)

Gout (crystal arthropathy)

Rheumatoid arthritis

OA requiring surgery

Septic arthritis

Bone metastases

Validate

Explain

Negotiate

Select characteristics — see drug cards below

Loss of Valued Activities

Depression and Chronic Pain

Fatalism and Self-Efficacy

Work and Productivity

Sleep Disruption

Exercise Fear

4–6 weeks — Exercise and topical NSAID review

3 months — Golf goal review

6 months — Escalation or surgical referral

Annual — Long-term OA review

Every 3–6 months — NSAID safety monitoring

⚠ Three scenario-specific safety-net phrases

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda — surgical expectation

If asked about stiffness

If asked about functional goals