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Osteoarthritis

Stepped care: exercise & weight loss before any drug

Field: Pain & MusculoskeletalCode: PA-03Updated: June 2026Reference: RACGP / OARSI
Exercise and weight loss outperform any single drug for OA. Build every step on this foundation. RACGP and OARSI agree that topical NSAID is commonly preferred over oral, and that opioids, intra-articular hyaluronate and arthroscopic lavage have no proven role in OA.

Stepped care — every step adds

Never skip the base — add a step only once the one below it is inadequate.

1
Foundation: education, exercise (strength, aerobic, tai chi), weight loss (5–10% of body weight if overweight).
2
Adjuncts: physiotherapy, walking aids/braces, heat or cold, TENS.
3
Topical & simple: topical NSAID commonly preferred, topical capsaicin, paracetamol PRN (mild effect only).
4
Oral NSAID (short-term): lowest dose, shortest duration, ± PPI.
5
Intra-articular / surgery: steroid injection; orthopaedic referral if conservative care fails.
Patient resources & GLA:D. MyJointPain (myjointpain.org.au) and the GLA:D Australia program (gladaustralia.com.au) — evidence-based knee/hip OA exercise and education, typically delivered through physiotherapy.

What works — evidence summary

  • Strongest evidence: exercise (strength, aerobic, tai chi), weight loss (5–10% body weight), patient education.
  • Good evidence: topical NSAIDs (knee/hand), short-course oral NSAIDs, physiotherapy, intra-articular steroid (knee).
  • Limited evidence: paracetamol (mild effect only), glucosamine/chondroitin (some patients report benefit).

Avoid — no proven benefit in OA

  • Opioids: no proven functional benefit, real harm — avoid in OA (see the PA-01B Opioid Stewardship sheet).
  • Intra-articular hyaluronate (viscosupplementation): not supported by current evidence.
  • Arthroscopic lavage/debridement: not supported for degenerative OA without a mechanical indication.
  • Long-term oral NSAIDs: cardiovascular, renal and GI harm increases with duration.

Safety

  • Exercise and weight loss outperform any single drug — build every step on this foundation before adding a drug.
  • Avoid opioids in OA — no proven functional benefit, real harm (see the PA-01B Opioid Stewardship sheet).
  • Image only if red flags or a surgical referral is being planned — incidental degenerative change is common and correlates poorly with pain.

Red flags / refer

  • Locked knee, a mechanical block, or suspected septic arthritis → urgent orthopaedic referral, same day.
  • Severe pain, night pain or functional loss despite optimal conservative treatment → orthopaedic referral.
  • Failed 3–6 months conservative treatment in a TKR/THR candidate (age- and comorbidity-adjusted) → orthopaedic referral.

PA-03 v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: RACGP Guideline for the Management of Knee and Hip Osteoarthritis, OARSI. Companion sheet: PA-03B OA Practical Care. Avoid opioids in OA — see the PA-01B Opioid Stewardship sheet.