Osteoarthritis and joint health: what the guidelines say

Osteoarthritis is the most common form of arthritis, a condition in which the cartilage that cushions joints breaks down over time, leading to pain, stiffness, and reduced function, most often in the hands, hips, and knees. It becomes markedly more common from midlife onward and is a leading cause of disability in older adults. This page describes what the American College of Rheumatology (ACR), working with the Arthritis Foundation, says in its current guideline for managing hand, hip, and knee osteoarthritis, first published in 2019 and still the most recent comprehensive version as of this guideline summary. A separate international group, the Osteoarthritis Research Society International (OARSI), has published parallel non-surgical management guidelines that generally reach similar conclusions and are noted here where relevant.

What the guideline strongly recommends

Across hand, hip, and knee osteoarthritis, the ACR guideline strongly recommends several non-drug approaches as the foundation of management: exercise (including low-impact aerobic activity, and for the hip and knee, supervised exercise programs), weight loss for people with knee or hip osteoarthritis who are also overweight or living with obesity, and self-efficacy and self-management education programs that help people understand and cope with the condition. These are not framed as optional add-ons; the guideline places them at the center of its approach, ahead of most drug therapies.

For knee osteoarthritis specifically, the guideline strongly recommends topical and oral NSAIDs (nonsteroidal anti-inflammatory drugs) as drug options, and it strongly recommends intra-articular corticosteroid (glucocorticoid) injections as well. For hand osteoarthritis, it strongly recommends first carpometacarpal (thumb base) joint splinting.

What the guideline recommends against, and why that matters

The most clinically useful part of this guideline for many readers is what it recommends against, because several of these are widely sold, widely used supplements and treatments that the underlying trial evidence does not support.

• Glucosamine, with or without chondroitin, is strongly recommended against for hand, hip, and knee osteoarthritis. This is a change from the guideline’s 2012 predecessor, which only conditionally recommended against it; the 2019 update strengthened the recommendation, citing that the best available trial data do not show an important benefit. OARSI’s parallel guideline reaches the same conclusion, also citing a lack of efficacy. Both guidelines note ongoing concern about inconsistent results between industry-funded and independently funded glucosamine trials.
• Hyaluronic acid (viscosupplementation) injections, an injectable gel sometimes marketed as a joint lubricant, are strongly recommended against for hip osteoarthritis and conditionally recommended against for knee osteoarthritis, a difference in strength that reflects higher-quality evidence of no benefit in hip studies specifically.
• Opioids are recommended against as a routine option for osteoarthritis pain, reflecting both limited evidence of meaningful long-term benefit for this condition and well-established risks of dependence and other harms.

None of this means these products are dangerous for every person or illegal to use; it means the ACR guideline’s assessment of the trial evidence, at the population level, did not find them to outperform placebo by a meaningful margin, or found the risk-benefit balance unfavorable. A clinician may still have reasons specific to an individual case to discuss one of these options, but the guideline’s default position is against.

Where surgery fits

The ACR/Arthritis Foundation 2019 guideline is explicitly scoped to non-surgical management and does not issue formal recommendations on surgical procedures. Joint replacement (arthroplasty) of the hip or knee is generally understood in the broader clinical literature as a later-stage option, considered when non-surgical measures, exercise, weight management, and the medication categories above, have not adequately controlled pain and function in a person with advanced structural joint damage. Decisions about whether and when surgery is appropriate fall to an orthopedic evaluation and are outside what this guideline addresses.

The honest nuances

The strong recommendation against glucosamine is worth sitting with, because it runs directly against how heavily the supplement is marketed and how many people use it. The ACR guideline panel is explicit that this recommendation rests on trial-level evidence, not on a claim that glucosamine causes harm; it simply did not outperform placebo in the studies the panel weighed most heavily. The guideline also does not treat all injections the same: intra-articular corticosteroids carry a strong recommendation in favor for knee osteoarthritis, while hyaluronic acid, a different injectable, carries a recommendation against. Conflating the two, as informal advice sometimes does, misrepresents what the evidence shows. Finally, this guideline covers hand, hip, and knee osteoarthritis specifically; osteoarthritis at other joints, or joint pain from other causes such as rheumatoid arthritis or gout, is evaluated differently.

Questions to discuss with your clinician

• Which joints are affected, and does the pattern match osteoarthritis or another cause of joint pain that would be evaluated differently?
• What would a structured exercise or physical therapy program look like for my specific joint and level of function?
• If I am carrying excess weight, how much weight loss would be expected to meaningfully change my joint symptoms?
• Am I currently using glucosamine, chondroitin, or hyaluronic acid injections, and does the evidence behind them change how I think about continuing them?
• Which pain-management option, among the categories the guideline describes, fits my situation and any other health conditions I have?
• At what point would a referral for a surgical evaluation become appropriate for my case?

For related evidence on the lifestyle factors that affect joint health, see physical activity and body weight, or read the companion profile on strength and muscle, which supports the joints surrounding affected areas.