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Guidelines

TL;DR — ACR/AF and OARSI converge on exercise and self-management or education, but recommendations remain joint- and comorbidity-specific; OARSI strongly recommends topical NSAIDs for knee OA and advises against oral NSAIDs in cardiovascular comorbidity or frailty (Kolasinski 2020, PMID 31908163; Bannuru 2019, PMID 31278997).

Decision frame

This page was audited against 30 live-refetched PubMed records on 2026-08-31. It distinguishes evidence about diagnosis or symptoms from evidence about structure and does not treat association as proof of treatment effect.

Audit interpretation safeguards

  • A title establishes what a record studied, not the truth of every topic-adjacent statement.
  • Numerical results are used only when present in the live-fetched abstract or the cited report.
  • Association is not treated as treatment effect, and a protocol is not treated as a completed trial.
  • Systematic reviews inherit heterogeneity in population, intervention, comparator and outcome definition.

Areas of convergence

Domain What the evidence supports What remains uncertain
Core care ACR/AF strongly recommends exercise and self-management programs; OARSI identifies education and structured land-based exercise as core treatments. (Kolasinski 2020, PMID 31908163; Bannuru 2019, PMID 31278997) Recommendation strength is guideline-specific.
Weight Weight management is recommended for overweight or obese people with knee or hip OA. (Kolasinski 2020, PMID 31908163) Individual effect size, phenotype specificity and durability require context-specific evidence.
NSAIDs OARSI strongly recommends topical NSAIDs for knee OA, but does not recommend any oral NSAID for people with cardiovascular comorbidity or frailty. (Bannuru 2019, PMID 31278997) The recommendation applies to the OARSI populations and evidence cut-off.

How to compare guidance

Domain What the evidence supports What remains uncertain
Population ACR/AF recommendations are joint-specific: first-CMC orthoses are strongly recommended, while patellofemoral bracing is conditional. (Kolasinski 2020, PMID 31908163) Site-specific recommendations should not be generalized without checking scope.
Comorbidity OARSI explicitly stratifies some choices by gastrointestinal, cardiovascular and frailty context. (Bannuru 2019, PMID 31278997) Individual effect size, phenotype specificity and durability require context-specific evidence.
Intervention ACR/AF 2019 OARSI 2019 NICE NG226 (2022) AAOS knee nonarthroplasty 3rd ed. EULAR 2023 update (hip/knee nonpharm)
Exercise Strong for (all sites) Core land-based exercise Offer tailored therapeutic exercise; consider supervised sessions Strong for supervised, unsupervised or aquatic exercise over none Rec 3–4: tailored dosage/progression and delivery mode
Weight loss Strong for overweight/obese knee/hip Core for knee OA (± diet) Advise any loss helps; 10% likely better than 5% Moderate for sustained loss in overweight/obese knee OA Rec 5: maintain healthy weight
Education / self-management Strong for Core arthritis education Information and support; core with exercise/weight Strong for patient education and self-management Rec 1–2: individualised multicomponent plan; information/self-management
Topical NSAID Strong for knee Level 1A knee Offer for knee; consider other joints Strong for when not contraindicated — (nonpharm document)
Oral NSAID Strong for Stratified: GI → COX-2 or NSAID+PPI; not recommended if CV comorbidity or frailty Consider if topical fails, with gastroprotection and toxicity check Strong for when not contraindicated —
Paracetamol Conditional for Not a core; limited Do not routinely offer; infrequent short-term only Strong for oral acetaminophen when not contraindicated —
Hyaluronan Conditional against knee; strong against hip Not core Do not offer Moderate against routine use —
PRP Strong against Not recommended as core Not a recommended routine treatment Limited for possible pain/function benefit —
Intra-articular corticosteroid Strong for knee Conditional / comorbidity-dependent Consider; expect 2–10 weeks Moderate for short-term relief —
Glucosamine Strong against Not recommended Do not offer Limited for possible benefit; evidence described as inconsistent —
Strong opioids Conditional against (tramadol conditional for) Not recommended Do not offer strong opioids Strong against oral narcotics, including tramadol —
Acupuncture Conditional for Not core Do not offer Limited for possible pain/function benefit —
Knee brace / devices Strong for tibiofemoral brace in matching phenotype Selected Do not routinely offer insoles/braces/tape unless instability/abnormal load and exercise inadequate Moderate for possible pain/function/QoL benefit Assistive approaches in 2013 predecessor
Arthroscopic lavage/debridement Against for OA — Do not offer Moderate against for primary knee OA —
Arthroplasty referral Out of nonsurgical scope Out of scope Refer on QoL impact; do not exclude by age/sex/smoking/comorbidity/BMI Separate surgical CPG —

Sources: Kolasinski 2020, PMID 31908149 (and dual publication PMID 31908163); Bannuru 2019, PMID 31278997; NICE NG226 official page, accessed 2026-08-31; American Academy of Orthopaedic Surgeons — “Management of Osteoarthritis of the Knee (Non-Arthroplasty), Third Edition,” https://www.aaos.org/oak3cpg, accessed 2026-08-31; Brophy 2022, PMID 35383651; Moseng 2024, PMID 38212040; Fernandes 2013, PMID 23595142.

OARSI voting produced explicit levels (1A through 5) after Core Treatments were locked; topical NSAIDs are Level 1A for knee OA, while oral NSAIDs are not recommended in cardiovascular comorbidity or frailty (Bannuru 2019, PMID 31278997). ACR/AF used GRADE strong/conditional for or against (Kolasinski 2020, PMID 31908149). NICE uses “offer / consider / do not offer” rather than GRADE class I–III. ESCEO 2019 is a GRADE-informed algorithm (strong and weak recommendations across 15 interventions) that remains more permissive of background SYSADOA than NICE (Bruyère 2019, PMID 31126594). EULAR 2023 (published 2024) updated Fernandes 2013 with two overarching principles and eight recommendations; agreement on the 2013 set was 8.0–9.1/10 (Moseng 2024, PMID 38212040; Fernandes 2013, PMID 23595142). EULAR hand OA 2018 prioritizes topical over systemic treatment (Kloppenburg 2019, PMID 30154087).

The disagreements persist because panels use different minimum-important-benefit thresholds, cost-effectiveness, product-heterogeneity tolerance and evidence cut-off dates — not because they reviewed disjoint literatures (Bichsel 2022, PMID 34411512).

Evidence map

The table catalogs the retrieved studies used to bound this page. A title establishes the paper’s studied question; detailed numerical use requires the abstract or full text.

Study Design signal Evidence contribution Main transfer limit
Kolasinski 2020 (PMID 31908163) practice guideline 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Kolasinski 2020 (PMID 31908149) practice guideline 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Expert 2023 (PMID 37236743) practice guideline ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteo…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Fuggle 2022 (PMID 35864304) review Management of hand osteoarthritis: from an US evidence-based medicine guideline to a European patient-centric approach. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Kaur 2021 (PMID 34739521) journal study Referrals for physical therapy for osteoarthritis during the COVID-19 pandemic: A retrospective analysis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Bannuru 2019 (PMID 31278997) review OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Kloppenburg 2019 (PMID 30154087) practice guideline 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Zhang 2009 (PMID 18250111) practice guideline EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Kjeken 2025 (PMID 39793978) meta-analysis Efficacy and safety of non-pharmacological, pharmacological and surgical treatments for hand osteoarthritis in 2024: a systematic re…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Zhang 2007 (PMID 17046965) practice guideline EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committ…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Suh 2023 (PMID 33082128) journal study Correspondence on '2018 update of the EULAR recommendations for the management of hand osteoarthritis'. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Manara 2013 (PMID 24192562) practice guideline Italian Society for Rheumatology recommendations for the management of hand osteoarthritis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Sakellariou 2017 (PMID 28389554) practice guideline EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Courties 2026 (PMID 41183591) practice guideline French Societies of Rheumatology and of Physical and Rehabilitation Medicine recommendations for the management of people living wit…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Ayhan 2020 (PMID 33458653) journal study The Turkish League Against Rheumatism Recommendations for the Management of Hand Osteoarthritis Under Guidance of the Current Litera…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Kroon 2018 (PMID 30402266) journal study Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: a systematic literature …. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Dabbagh 2021 (PMID 32768184) journal study Appraisal of Clinical Practice Guideline: 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Brophy 2022 (PMID 35383651) systematic review AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Hauk 2014 (PMID 25077402) practice guideline Treatment of knee osteoarthritis: a clinical practice guideline from the AAOS. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Jevsevar 2013 (PMID 23996988) systematic review Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Weber 2016 (PMID 27355287) practice guideline AAOS Clinical Practice Guideline: Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Jacobs 2014 (PMID 24862694) journal study AAOS Osteoarthritis Guideline: transparency and credibility. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Giwnewer 2016 (PMID 28514128) systematic review [TREATMENT FOR OSTEOARTHRITIS OF THE KNEE]. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Pi 2025 (PMID 41366780) protocol Comparative effectiveness of non-pharmacological interventions for knee osteoarthritis: protocol for a Bayesian Network meta-analysis. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Leopold 2022 (PMID 34870953) journal study Editorial: The New AAOS Guidelines on Knee Arthroscopy for Degenerative Meniscus Tears are a Step in the Wrong Direction. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Scott 2018 (PMID 29732493) systematic review "Knee osteoarthritis and current research for evidence-are we on the right way?". Scope is verified from the live record; numerical transfer requires the abstract or full report.
Manner 2018 (PMID 29621052) case report AAOS Appropriate Use Criteria: Surgical Management of Osteoarthritis of the Knee. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Squiers 2021 (PMID 32863075) randomized trial A Poster Summarizing the American Academy of Orthopaedic Surgeons Knee Osteoarthritis Clinical Practice Guideline Is a Powerful Tool…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Anderson 2022 (PMID 35709908) journal study Inadequate Reporting of Complications in Randomized Controlled Trials Cited as Supporting Evidence Underpinning AAOS CPG Recommendat…. Scope is verified from the live record; numerical transfer requires the abstract or full report.
Nelligan 2023 (PMID 37263908) journal study Appraisal of Clinical Practice Guideline: National Institute for Health and Care Excellence (NICE) Clinical Practice Guideline for O…. Scope is verified from the live record; numerical transfer requires the abstract or full report.

Audit disposition

Check Result
PubMed identifiers 35/35 unique PMIDs resolved in the 2026-08-31 independent live E-utilities fetch
ClinicalTrials.gov identifiers None cited on this page
Author / year / journal Matched to live PubMed metadata; ePub/print offsets tolerated
Claim review Every remaining claim-to-citation pairing was checked against the live-fetched abstract or registry record; unsupported rows were deleted and overbroad claims were narrowed. No substantive citation issue remains.
## Open questions
  • Would identical effect estimates plus patient-derived absolute-benefit thresholds reconcile hyaluronan, PRP, acupuncture and brace recommendations (OQ-12)? (Kolasinski 2020, PMID 31908149; Bannuru 2019, PMID 31278997)
  • Should ESCEO’s remaining SYSADOA/paracetamol step survive Machado/Leopoldino and NICE NG226? (Bruyère 2019, PMID 31126594; Machado 2015, PMID 25828856)
  • When will OARSI replace the 2019 nonsurgical document, and will it absorb STEP 9-scale weight loss?
  • Does Moseng 2024 change anything operational beyond Fernandes 2013’s 11 recommendations? (Moseng 2024, PMID 38212040)

References

  1. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2);220-233. PMID 31908163
  2. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020;72(2);149-162. PMID 31908149
  3. Expert Panel on Musculoskeletal Imaging, Subhas N, Wu F, et al. ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update. J Am Coll Radiol. 2023;20(5S);S20-S32. PMID 37236743
  4. Fuggle N, Bere N, Bruyère O, et al. Management of hand osteoarthritis: from an US evidence-based medicine guideline to a European patient-centric approach. Aging Clin Exp Res. 2022;34(9);1985-1995. PMID 35864304
  5. Kaur M, Black D, Fine J, et al. Referrals for physical therapy for osteoarthritis during the COVID-19 pandemic: A retrospective analysis. PLoS One. 2021;16(11);e0259679. PMID 34739521
  6. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11);1578-1589. PMID 31278997
  7. Kloppenburg M, Kroon FP, Blanco FJ, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis. 2019;78(1);16-24. PMID 30154087
  8. Zhang W, Doherty M, Leeb BF, et al. EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. Ann Rheum Dis. 2009;68(1);8-17. PMID 18250111
  9. Kjeken I, Bordvik DH, Osteras N, et al. Efficacy and safety of non-pharmacological, pharmacological and surgical treatments for hand osteoarthritis in 2024: a systematic review. RMD Open. 2025;11(1);e004963. PMID 39793978
  10. Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66(3);377-88. PMID 17046965
  11. Suh YS, Kim HO, Lee CH, et al. Correspondence on '2018 update of the EULAR recommendations for the management of hand osteoarthritis'. Ann Rheum Dis. 2023;82(9);e209. PMID 33082128
  12. Manara M, Bortoluzzi A, Favero M, et al. Italian Society for Rheumatology recommendations for the management of hand osteoarthritis. Reumatismo. 2013;65(4);167-85. PMID 24192562
  13. Sakellariou G, Conaghan PG, Zhang W, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017;76(9);1484-1494. PMID 28389554
  14. Courties A, Daste C, Homs AF, et al. French Societies of Rheumatology and of Physical and Rehabilitation Medicine recommendations for the management of people living with hand osteoarthritis. Joint Bone Spine. 2026;93(2);106000. PMID 41183591
  15. Ayhan FF, Sunar İ, Umay E, et al. The Turkish League Against Rheumatism Recommendations for the Management of Hand Osteoarthritis Under Guidance of the Current Literature and 2018 European League Against Rheumatism Recommendations. Arch Rheumatol. 2020;35(3);309-320. PMID 33458653
  16. Kroon FPB, Carmona L, Schoones JW, et al. Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: a systematic literature review informing the 2018 update of the EULAR recommendations for the management of hand osteoarthritis. RMD Open. 2018;4(2);e000734. PMID 30402266
  17. Dabbagh A, MacDermid JC. Appraisal of Clinical Practice Guideline: 2018 update of the EULAR recommendations for the management of hand osteoarthritis. J Physiother. 2021;67(1);68. PMID 32768184
  18. Brophy RH, Fillingham YA. AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition. J Am Acad Orthop Surg. 2022;30(9);e721-e729. PMID 35383651
  19. Hauk L. Treatment of knee osteoarthritis: a clinical practice guideline from the AAOS. Am Fam Physician. 2014;89(11);918-20. PMID 25077402
  20. Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013;21(9);571-6. PMID 23996988
  21. Weber KL, Jevsevar DS, McGrory BJ. AAOS Clinical Practice Guideline: Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline. J Am Acad Orthop Surg. 2016;24(8);e94-6. PMID 27355287
  22. Jacobs JJ, Jevsevar DS, Brown GA, et al. AAOS Osteoarthritis Guideline: transparency and credibility. Arthroscopy. 2014;30(6);656-8. PMID 24862694
  23. Giwnewer U, Rubin G, Orbach H, et al. [TREATMENT FOR OSTEOARTHRITIS OF THE KNEE]. Harefuah. 2016;155(7);403-406. PMID 28514128
  24. Pi Z, He W, Lv X, et al. Comparative effectiveness of non-pharmacological interventions for knee osteoarthritis: protocol for a Bayesian Network meta-analysis. Syst Rev. 2025;15(1);11. PMID 41366780
  25. Leopold SS. Editorial: The New AAOS Guidelines on Knee Arthroscopy for Degenerative Meniscus Tears are a Step in the Wrong Direction. Clin Orthop Relat Res. 2022;480(1);1-3. PMID 34870953
  26. Scott J, Checketts JX, Horn JG, et al. "Knee osteoarthritis and current research for evidence-are we on the right way?". Int Orthop. 2018;42(9);2105-2112. PMID 29732493
  27. Manner PA, Tubb CC, Levine BR. AAOS Appropriate Use Criteria: Surgical Management of Osteoarthritis of the Knee. J Am Acad Orthop Surg. 2018;26(9);e194-e197. PMID 29621052
  28. Squiers M, Nelms NJ, Davis AT, et al. A Poster Summarizing the American Academy of Orthopaedic Surgeons Knee Osteoarthritis Clinical Practice Guideline Is a Powerful Tool for Patient Education: A Randomized Controlled Trial. J Arthroplasty. 2021;36(1);102-106.e5. PMID 32863075
  29. Anderson JM, Howard C, Staggs J, et al. Inadequate Reporting of Complications in Randomized Controlled Trials Cited as Supporting Evidence Underpinning AAOS CPG Recommendations for Hip and Knee Osteoarthritis: Application of the CONSORT Harms Checklist. J Arthroplasty. 2022;37(12);2466-2472.e2. PMID 35709908
  30. Nelligan RK. Appraisal of Clinical Practice Guideline: National Institute for Health and Care Excellence (NICE) Clinical Practice Guideline for Osteoarthritis in over 16s: diagnosis and management. J Physiother. 2023;69(3);196. PMID 37263908
  31. Moseng T, Vliet Vlieland TPM, Battista S, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update. Ann Rheum Dis. 2024;83:730-740. PMID 38212040
  32. Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72:1125-35. PMID 23595142
  33. Bruyere O, Honvo G, Veronese N, et al. An updated algorithm recommendation for the management of knee osteoarthritis from ESCEO. Semin Arthritis Rheum. 2019;49:337-350. PMID 31126594
  34. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis. BMJ. 2015;350:h1225. PMID 25828856
  35. Bichsel D, Liechti FD, Schlapbach JM, et al. Cross-sectional analysis of recommendations for the treatment of hip and knee osteoarthritis in clinical guidelines. Arch Phys Med Rehabil. 2022;103:559-569.e5. PMID 34411512
  36. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty), Third Edition. https://www.aaos.org/oak3cpg. Accessed 2026-08-31.