Table 3 Propositions and strength of recommendation (SOR) – order according to topic (risk factors, clinical, subsets, differential diagnosis, images and laboratory tests)
No.PropositionLoESOR (95% CI)
1Risk factors for HOA include female sex, increasing age over 40, menopausal status, family history, obesity, higher bone density, greater forearm muscle strength, joint laxity, prior hand injury and occupation or recreation-related usage.Ib–IIb69 (54 to 84)
2Typical symptoms of HOA are pain on usage and only mild morning or inactivity stiffness affecting just one or a few joints at any one time; symptoms are often intermittent and target characteristic sites (DIPJs, PIPJs, thumb base, index and middle MCPJs). With such typical features, a confident clinical diagnosis can be made in adults aged over 40.IIb85 (77 to 92)
3Clinical hallmarks of HOA are Heberden and Bouchard nodes and/or bony enlargement with or without deformity (eg, lateral deviation of IPJs, subluxation and adduction of thumb base) affecting characteristic target joints (DIPJs, PIPJs, thumb base and index and middle MCPJs).Ib–IV80 (69 to 90)
4Functional impairment in hand OA may be as severe as in rheumatoid arthritis. Function should be carefully assessed and monitored using validated outcome measures.IIb57 (42 to 73)
5Patients with polyarticular HOA are at increased risk of knee OA, hip OA and OA at other common target sites (generalised OA) and should be assessed and examined accordingly.IIa–IIb77 (62 to 92)
6Recognised subsets with different risk factors, associations and outcomes (requiring different assessment and management) include IPJ OA (with or without nodes), thumb base OA and erosive OA. Each may be symptomatic or asymptomatic.IIa–IIb68 (56 to 79)
7Erosive hand OA targets IPJs and shows radiographic subchondral erosion, which may progress to marked bone and cartilage attrition, instability and bony ankylosis. Typically it has an abrupt onset, marked pain and functional impairment, inflammatory symptoms and signs (stiffness, soft tissue swelling, erythaema, paraesthesiae), mildly elevated CRP levels, and a worse outcome than non-erosive IPJ OA.IIa–IIb87 (81 to 93)
8The differential diagnosis for HOA is wide. The commonest conditions to consider are psoriatic arthritis (which may target DIPJs or affect just one ray), rheumatoid arthritis (mainly targeting MCPJs, PIPJs, wrists), gout (which may superimpose on pre-existing HOA), and haemochromatosis (mainly targeting MCPJs, wrists).Ib–IIb81 (73 to 89)
9Plain radiographs provide the gold standard for morphological assessment of HOA. A posteroanterior radiograph of both hands on a single film/field of view is adequate for diagnosis. Classical features are joint space narrowing, osteophyte, subchondral bone sclerosis and subchondral cyst, and subchondral erosion occurs in erosive hand OA. Further imaging modalities are seldom indicated for diagnosis.Ib–IIb87 (81 to 93)
10Blood tests are not required for diagnosis of HOA but may be required to exclude coexistent disease. In a patient with HOA who has marked inflammatory symptoms and/or signs, especially involving atypical sites, blood tests should be undertaken to screen for additional inflammatory arthritides.Ib–IIb78 (63 to 92)
  • CRP, C-reactive protein; DIPJ, distal IPJ; IPJ, interphalangeal joint; HOA, hand osteoarthritis; LoE, level of evidence (see table 2 for further details), presented in range upon components assessed; MCPJ, metacarpophalangeal joints; PIPJ, proximal IPJ; SOR, strength of recommendation on visual analogue scale (0–100 mm, 0 = not recommended at all, 100 =  fully recommended).