1. A quiet revolution has transformed our understanding of OA. We still don’t know quite what it is, but we no longer believe it’s caused by “wear and tear.” That’s why exercise — both weight-bearing and not — is now highly recommended. The benefit is greatest if there’s weight loss. Losing 10% of weight can reduce OA knee pain by 25%. Assure patients that joint pain during exercise is not joint damage.

2. Try not to x-ray too much, especially not to track changes within a two-year period. There’s usually little correlation between the image and the symptoms.

3. Topical NSAIDs are making a comeback, and have always been supported by a solid evidence base. Surveyed patients have expressed a clear preference for them. Expect to see new drugs of this sort in the next few years. Topical NSAIDs should be your starting point with OA pain, at least for knee and hand.

4. Among oral NSAIDs, try to avoid giving naproxen for any prolonged period, as it has a high rate of GI events. Celecoxib 200 mg/day with a PPI is a fairly sound choice for flare-ups.

5. Glucosamine is the most widely taken supplement. But patients need to be aware that there are two kinds: glucosamine sulphate, which has good evidence backing its use in OA, and glucosamine hydrochloride, which doesn’t. Many OTC formulations contain only the latter.

6. A good dose of glucosamine sulphate is 500 mg tid. Don’t stock up on too much, it only lasts about 3 months. Patients who try it should keep a pain diary to see if it’s helping.

7. Three other “complementary” pain treatments are backed by evidence: acupuncture, capsaicin and the herbal mixture phytodolor (Populus tremula, Fraxinus excelsior and Solidago virgaurea, ratio 3:1:1). Acupuncture only works in a minority of patients, and there’s no tool to predict who will benefit. Capsaicin depletes substance P in local nerve endings. It may burn for the first few days, then start helping.

8. Chondroitin has little hard evidence to support its use. If patients want to try it, they might be steered towards an OTC product that contains both chondroitin and glucosamine sulphate. But don’t expect miracles — the largest study of this combination, GAIT, showed no significant benefit over placebo in either pain relief or cartilage loss.

9. Joint replacement is a big step, but referral should never be put off until the patient has prolonged disability. Knee replacement used to be a problem area, but the situation has reversed — today’s artificial knees are more successful than artificial hips.

10. The classic plastic-and-metal Charnley hip lasts about 10-15 years. This has led some centres to experiment with other types in younger and more active patients. But there are signs of problems with the new metal-on-metal hips, including heavy metals turning up in the brain. For now, go with ceramic if the traditional hip seems unlikely to last long enough.