Joint Arthritis Diagnosis and Management

Joint arthritis is diagnosed in three steps: a clinical history, an examination that compares the painful joint with the healthy side, and a plain X-ray, which is the most informative first test. MRI is reserved for patients whose X-ray looks normal but whose symptoms persist. Management then climbs a ladder: weight loss, physiotherapy and walking aids, then medicines and joint injections, and finally joint replacement when everything else has failed.

That sequence is the backbone of the masterclass given on 2 February 2025 by Dr. Mannu Bhatia, Associate Director - Centre for Orthopaedics, BLK-Max Super Speciality Hospital, New Delhi, India, to international doctors, with live French translation for colleagues in the Democratic Republic of the Congo. His central message was practical rather than technical: much of the joint damage that ends in surgery can be slowed or avoided when the patient is diagnosed early and follows the treatment plan.

This guide covers what arthritis is, who is at risk, how it presents, and how it is diagnosed. The treatment ladder is covered in depth in two companion articles: non-surgical arthritis treatment with physiotherapy, medicines and injections, and joint replacement of the hip, knee, shoulder and elbow, which also includes the complex cases he has treated for patients who travelled from Africa.

What arthritis is: a progressive loss of movement

Arthritis is a condition of the joints that causes pain, stiffness and reduced mobility. Dr. Bhatia describes it more bluntly, as a global restriction of movement. A man of 20 walks comfortably, plays football and does whatever he likes. By the time he approaches 50, he may find his mobility restricted, his joints painful and his daily activities difficult, and he has been visiting a general practitioner and taking medicines on and off. That gradual narrowing of what a person can do is the disease in practice.

Arthritis can affect any joint: the knee, the hip, the shoulder and the small joints. The pattern differs sharply by region. Asia and Africa are the two continents from which Dr. Bhatia sees the most patients, and the two groups present differently:

• Patients from Asia: of every ten he sees with arthritis, about nine have arthritis of the knee.
• Patients from Africa: the pattern reverses. Roughly eight in ten present with arthritis of the hip, and only one or two with the knee.

For a referring doctor, that observation matters. Hip disease in an African patient is not an unusual finding to be explained away; in his practice it is the commonest presentation.

The main types of arthritis

Dr. Bhatia groups arthritis into three main types:

1. Osteoarthritis, the degenerative, age-related form, in which the joint's protective cartilage wears away over time. It is by far the most common type.
2. Autoimmune arthritis, of which rheumatoid arthritis is the leading example. Here the body's immune system attacks the lining of its own joints.
3. Post-traumatic arthritis, which follows an injury such as a fracture or a torn ligament that damages the joint surface.

He also named tuberculosis as a cause of cartilage breakdown. Tuberculosis of the joints remains an important cause of joint destruction wherever tuberculosis is common, and it needs specific treatment rather than painkillers.

The scale of the problem is large. Osteoarthritis affects around 32 million people in the United States alone. Rheumatoid arthritis affects far fewer people worldwide, but Dr. Bhatia stressed that it is a severely disabling disease.

What causes arthritis: cartilage breakdown

A healthy joint is two bone ends, each covered by a smooth layer of cartilage. As long as the cartilage is intact, the joint works perfectly. The moment the cartilage begins to break down, arthritis has started.

Around the joint lies the synovium, a thin membrane that produces synovial fluid, the joint's natural lubricant. As the cartilage thins, the space between the bones on an X-ray narrows. When the cartilage is gone and the underlying bone is exposed, the bones rub against each other, and this is the point at which, in Dr. Bhatia's words, the patient rushes to the doctor because his life is being affected.

The cartilage can break down for several reasons:

• injury
• ageing
• repetitive mechanical stress
• autoimmune disease such as rheumatoid arthritis
• other causes, such as tuberculosis

Who is at risk of osteoarthritis

The risk factors Dr. Bhatia listed are age, obesity, genetics, injury and occupation. People who use their limbs aggressively over many years are more prone to joint arthritis; his examples were soldiers, police officers, army personnel and sportsmen.

He gave particular weight to sports injuries. Meniscal tears, anterior cruciate ligament (ACL) tears and other ligament injuries are common, and in his experience they are often ignored. An untreated injury leaves the knee unstable, and an unstable knee wears out early. Recognising the disease, and the injuries that lead to it, at an early stage is important to avoid a much bigger problem later. Arthroscopic repair of these injuries is the subject of Dr. Vipin Maheshwari's guide to knee and shoulder arthroscopy, and indicative costs for international patients are on the arthroscopic ACL reconstruction cost page.

Obesity deserves its own mention because it is the risk factor a patient can change. People who are obese have a higher tendency to develop arthritis, and weight loss is the first step of treatment.

Symptoms and signs of joint arthritis

Joint arthritis presents with pain that is first linked to activity and later present at rest, together with swelling, warmth, crepitus, reduced movement and instability. The clinical picture develops in stages.

Early disease. Pain worsens with activity and is relieved by rest.

Later disease. The pain becomes continuous. It is present even when the patient is lying in bed or not walking. This is rest pain, and Dr. Bhatia treats it as a signal that the patient needs to see a specialist, either an orthopaedic surgeon or a rheumatologist.

Alongside the pain, he described six features that together make up the common presentation:

• Swelling of the joint.
• Warmth, a rise in temperature over the joint.
• Crepitus, the grating sound produced when the damaged bone surfaces rub against each other as the patient bends or straightens the knee or hip.
• Functional difficulty: trouble walking, standing up from a chair, standing for long periods and managing daily tasks such as going to the washroom. On standing, the patient needs a moment to adjust before moving.
• Reduced range of motion and a limp.
• Instability. A healthy person keeps his balance on uneven ground. A patient with knee arthritis can fall on the slightest uneven surface.

How joint arthritis is diagnosed

Joint arthritis is diagnosed from the history, an examination that compares both sides and a plain X-ray, with MRI, ultrasound and blood tests used to answer specific further questions.

History and examination

Whoever the patient sees first, whether a general practitioner, a family physician or an orthopaedic surgeon, the first steps are the same: talk to the patient, take a history and examine the joint.

Dr. Bhatia's first rule of examination is to compare the two sides. If a patient has a problem in one knee, examine the opposite limb as the reference. Then look for:

• swelling and deformity
• tenderness, how painful the joint is when touched
• range of motion, how far the patient can actually bend and straighten the joint
• gait, how the patient walks. A painful (antalgic) gait is typical, and patients often walk with a waddle, rocking from side to side like a duck
• muscle wasting: when a painful joint is used less, the surrounding muscles atrophy and weaken, which in turn makes the joint less stable

X-rays come first

Dr. Bhatia considers X-rays the most informative diagnostic test for deciding whether a patient has arthritis. He receives queries from many countries in which the patient sends an MRI. His view is clear: in a patient of around 60 with a hip or knee problem, the first investigation should be an X-ray.

On an X-ray, osteoarthritis shows three classic signs:

• joint space narrowing, which reflects lost cartilage
• osteophytes, the bony spurs that grow at the edges of a degenerating joint
• subchondral sclerosis, the hardening and whitening of the bone just beneath the worn cartilage

These findings frequently settle the management question on their own: the X-ray tells the surgeon whether the patient needs surgery or can be managed conservatively with medicines and physiotherapy. For the knee, X-rays are taken with the patient standing, so that the true joint space under body weight is visible, and the severity is commonly graded from 0 to 4 on the Kellgren-Lawrence scale.

When MRI adds value

MRI is the next step only when the X-ray is normal but the patient still has symptoms and has not responded to medication or physiotherapy. It shows what an X-ray cannot: defects in the cartilage, associated tears within the joint, and the extent of synovitis (inflammation of the joint lining). Where MRI is not available, X-rays remain sufficiently informative to guide treatment, a point of practical importance for doctors working in settings where MRI is scarce or expensive.

Ultrasound

Ultrasound is useful for detecting effusions (fluid in the joint), inflammation and tendon tears.

Blood tests

Laboratory tests help separate the types of arthritis. Dr. Bhatia's routine set includes a complete blood count, with particular attention to haemoglobin, which tends to fall in autoimmune disease such as rheumatoid arthritis, and the inflammatory markers ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein). When rheumatoid arthritis is suspected, rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) antibodies are the standard serological tests.

Joint arthritis management: the treatment ladder

Treatment follows the stage of the disease, and surgery is reserved for patients in whom conservative care has failed.

Two points from Dr. Bhatia frame the whole ladder. First, medicines and injections treat symptoms; they do not cure the disease. Second, he is not an advocate of platelet-rich plasma (PRP) injections, because they cannot regrow cartilage that has already been lost. The detail, including where his view sits against international guidelines, is in the article on non-surgical arthritis treatment.

When conservative care has failed and the patient's life is affected, the definitive treatment is joint replacement: a hip replacement for the hip, a knee replacement for the knee, and shoulder or elbow replacement for those joints. Indications, contraindications, rehabilitation and the cases he presented are covered in joint replacement of the hip, knee, shoulder and elbow.

What is the definitive treatment of osteoarthritis?

In Dr. Bhatia's view, the most effective treatment of osteoarthritis is early diagnosis followed by strict adherence to the treatment plan. Asked during the session for the definitive treatment of osteoarthritis, Dr. Bhatia answered with a pattern he sees repeatedly. A patient tears his ACL. He is advised an MRI and does not have it. He is advised ACL surgery and does not have it. He is prescribed medicines and does not take them. That patient progresses to osteoarthritis and eventually needs a knee replacement.

The same pattern spreads across joints. Patients with a problem in one knee who do not have it treated often develop the same problem in the other knee. Patients with both knees affected who delay treatment gradually develop problems in the hips and then the spine. The remedy he proposes is to see a doctor early, accept the diagnosis and follow the plan, whether that is physiotherapy or continuing treatment for rheumatoid arthritis without stopping it.

His patient-education message has three parts:

1. Do not sit at home. See a doctor at an early stage; much of the later treatment can then be avoided.
2. Change the lifestyle. A healthy diet and an active, healthy lifestyle are part of the treatment, not an optional extra.
3. Never become depressed about the condition. Even patients who are severely disabled can regain function if they stick to the treatment protocol.

The full questions from doctors on the call, including his views on PRP, contraindications to joint replacement and staged bilateral hip surgery, are on the masterclass Live Discussion page.

Related joint masterclasses

Several joint masterclasses cover neighbouring ground, each from a different angle. Dr. Ramkinkar Jha's guide to hip and knee replacement surgery focuses on the operations themselves, Dr. Rakesh Mahajan's robotic knee replacement guide on robotic technique, and Dr. Rohit Lamba's spectrum of orthopaedic disorders on the wider range of bone and joint conditions. Dr. Bhatia's session is the one built around arthritis as a disease: recognising it, diagnosing it with the simplest effective test, and treating it early enough that surgery becomes the last resort rather than the first. More orthopaedic content is collected on the orthopaedics specialty page.