Osteoarthritis

Osteoarthritis Care Protocol will be implemented from January 2027 – HSG GPs may refer to updates from AIC for details on the implementation of these protocols.

Background

Osteoarthritis (OA) is characterised by focal areas of loss of articular cartilage within synovial joints, leading to pain and gradual loss of function, and typically affects older people. The diagnosis can be made clinically based on history and physical examination, with laboratory and radiological investigations selectively undertaken to exclude inflammatory arthropathy, secondary osteoarthritis, and non-articular causes of joint pain.

The true prevalence of osteoarthritis in Singapore is unknown. The local prevalence of knee osteoarthritis, one of the most common arthritides encountered in primary care, was estimated to be around 5.8% based on a local study in 2021, with an age-standardised years of life lost to disability (YLD) of 189 per 100,000 people¹. This burden is projected to increase in the coming decades due to an ageing population and rising rates of sedentary lifestyle and obesity.

This care protocol will cover the general approach to OA, with an added focus on knee OA.

Clinical Approach

Patients with OA commonly present with joint pain, stiffness, and limitation of motion. OA commonly affects the knees, hips, spine , and small joints of the hands

OA less commonly affects the elbows, wrists, shoulders, and ankles. If present in these joints, secondary causes of OA should be considered, such as trauma or other underlying inflammatory arthritis, as they are predisposing conditions that alter the joint tissues.

For Knee OA, the overall clinical approach to diagnosis and management is as such:

1. Identifying risk factors and arriving at the likely clinical diagnosis and/or differential diagnoses

a. In general, osteoarthritis may be diagnosed more confidently when the following are present:

Age of onset > 40 years of age
Persistent usage-related joint pain in one or a few joints
Morning stiffness lasting less than 60 minutes

b. Other clinical features that will add to the diagnostic certainty will include:

Absence of other constitutional symptoms
Minimal inflammatory signs outside of acute flares

Absence of warmth
Effusion if present is usually small and cool

c. Joint line or periarticular tenderness

2. Targeted physical examination for crepitus, reduced range of movement and/or weak local muscles (muscles acting over the joint) Consider and rule out red flags when patients present with joint or musculoskeletal pain

When reviewing patients presenting with joint pain, a systematic approach is useful to differentiate osteoarthritis from various differential diagnoses:

3. Selectively consider laboratory and/or radiological investigations if required

4. Anchor chronic care and management in the community

a. The main goals of osteoarthritis treatment include alleviating pain, optimising functional status, quality of life, and addressing psychosocial factors.

Prevention - reduce the risk of developing osteoarthritis by targeting modifiable risk factors such as weight loss in overweight patients
Recommend non-pharmacological treatment in patients with osteoarthritis through patient education, self-management, lifestyle modification, and refer suitable patients to physiotherapy. Referral to physiotherapy should be prioritised for patients experiencing severe pain, functional limitations, muscle weakness, restricted range of motion or difficulties with self-directed exercise programmes.
Consider referral to other allied health professionals where clinically indicated and based on individual patient needs:

Dietician - for nutritional guidance on weight management when weight directly impacts the patient's condition and outcomes
Occupational therapist - when there is a clear need for assistive devices to support functional independence and quality of life.
Psychologist - when the patient experiences significant psychosocial challenges, interventions like cognitive behavioural therapy can offer substantial benefit

Monitor disease progression through regular assessment of appropriate care components
Manage acute OA flares
Post-surgical care in the community

Management

For most patients, conservative treatment remains the cornerstone of management

For all patients

Non-Pharmacological

Pharmacological

Lifestyle modifications
Weight management (less relevant for hand OA)

Consider dietician referral if necessary. Refer to the EatWise SG Dietetic Resources Recommendation Framework for guidance on making appropriate referrals to care providers/ dietitians for nutrition/dietetic intervention.

Appropriate exercises
Self-management

Topical and oral analgesia if required

Considered first-line for most patients – refer to for details

For some patients

Non-Pharmacological

Pharmacological

Physiotherapy

Prioritise for patients experiencing severe pain, functional limitations, muscle weakness, restricted range of motion or difficulties with self-directed exercise programmes
Information about community physiotherapy programmes: Community Rehabilitation | AIC

Assistive devices, if required
Cognitive behaviour therapy, if appropriate
Acupuncture – adjunct treatment

Intra-articular injections (Hydrocortisone & Lignocaine - adjunct treatments)

May provide short-term relief for some patients
Need to balance against the risk of complications

Can be considered for some patients – refer to for details

Referral to a specialist for surgical interventions

For patients with significant pain and/or functional limitation that affects quality of life and failed appropriate conservative management (duration of symptoms lasting at least 3 to 6 months)

Consider performing the appropriate X-rays (e.g. weight bearing X-rays of the knees for knee OA) prior to referral to facilitate more informed consultation by the specialists. Ensure patients are given a copy of the report / imaging to bring on the day of the consultation if any X-rays are done.

Recommended Care Components

Table 1: Recommended care components

Recommended Care Components	Recommend minimum Frequency*	Remarks
Assessment of joint pain	Annually	Visual Analog Scale/Pain score (from 1 – 10)
Weight and BMI Assessment (if applicable e.g., OA knee)	Annually	Keep BMI 18.5-22.9 kg/m2 (For Non-Asian population, keep BMI 18.5-24.9 kg/m2)
Functional Assessment Basic Activities of Daily Living (ADLs) assessment (if appropriate) Six basic ADLs: washing, toileting, dressing, feeding, mobility and transferring *List of validated assessment tools for OA knees can be found here.	Annually	Helps to determine functional status Should be considered for patients deemed to have limitations in certain daily activities through history and/or physical examination Referral to occupational therapy for assistive devices and / or physiotherapy for mobility aids should be considered if bADLs are affected

*More frequently if clinically indicated

Considerations for Specialist Referrals

Most patients with osteoarthritis can be managed in primary care.

Referral to a specialist should be discussed with patients with unsatisfactory improvement of pain, stability, or function despite adequate conservative (non-pharmacological and pharmacological) treatment of about 3 to 6 months.

Features suggestive of instability include a history of falls, deformity such as significant genu varum/valgus and/or ligament laxity on physical examination, as well as radiological findings such as Kellgren-Lawrence Grade III and above on knee x-rays.

Click here for management of patients who require post-surgical care: .

Data Submission

The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled in their practice.

Submission of data fields marked with asterisks* is required for Healthier SG payments.

Diagnosis

Diagnosis*
CDMP condition(s)*
Diagnosis Year

Weight

BMI (kg/m²), calculated from height*, weight*
Waist circumference (in cm; mandatory to fill* if weight is not feasible. Otherwise, optional field to fill)
Weight not feasible (if applicable)*
Date*

Pain and Function

I have assessed the patient's osteoarthritis pain and the impact of osteoarthritis on the patient's daily function: Yes / No

Financing

CHAS/PG/MG cardholders who are Healthier SG enrollees can opt to use the Healthier SG Chronic Tier at their enrolled clinics, which provides percentage-based subsidies for selected chronic medications sold within the stipulated price caps.

References

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7. National University Polyclinics Clinical Practice Guidelines: Evaluation of the adult with joint pain in primary care

8. National Healthcare Group Polyclinics Clinical Practice Guidelines: Evaluation of the adult with joint pain in primary care

9. CDMP Handbook for Healthcare Professionals. 2022

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11. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee

12. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis 2019

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14. AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition - 2022

15. Agency for care effectiveness – Guidance on Acupuncture for adults with low back pain and neck pain

16. ACE Clinical Guideline Management of knee osteoarthritis – a joint effort with patients ACG | Agency for Care Effectiveness