There are commonly 5 stages of osteoarthritis that health professionals use to understand the progression of the condition in your joints. Knowing the stage you are in can be one of the things that can help to determine the best course of treatment for you. Stage 0 is the least severe with minimal joint changes and stage four is the most severe. While knowing the stage is important, we have to understand that the stage of your arthritis is just one piece of the puzzle. Let’s learn about the different stages, other considerations you should make in each stage, and what you can do to help pain in each one.
The purpose of the staging system for osteoarthritis, called the Kellgren-Lawrence Classification of Osteoarthritis, was originally research oriented but also could help healthcare professionals determine appropriateness for surgery. It was first created in 1957. Looking at their original published research article from 1957 (how cool!), they proposed 5 different stages primarily based on x-ray images. The descriptions of each stage were vague and include “none (0), doubtful (1), minimal (2), moderate (3), severe (4)”.
What you need to know about the classification scale:
Before we delve into more detail about this classification, I want to give you perspective on the accuracy of this scale. This is because often times if we hear that we have “stage 4- severe or even stage 3-moderate” it can be scary. We may think surgery is our only option at this point if we don’t know much about the scale itself. Turns out, this scale is not perfect, much like many other classification scales we use. There are gaps in what this scale can present, let’s briefly look at those:
- This scale is primarily based on x-ray images and findings. It has been found that the inter-rater reliability is hit or miss. This means that if 2 different physicians or imaging experts read your images they may not come to the same conclusion about what stage you are in. The accuracy was much better when the same person was interpreting the results.
- This scale does not consider other factors that contribute to osteoarthritis severity and pain. Lifestyle factors can play a huge role in pain levels. For example, obesity, comorbidities, diet, level of physical activity, and sleep patterns can significantly impact the amount of pain perceived. Each level of this classification system might meet the x-ray criteria but all may have drastically different pain levels. If an active person of appropriate weight and eating patterns is considered a stage 3 but only has mild to moderate pain she may not be ready for surgery. If an overweight person with diabetes and uncontrolled blood sugars is considered stage 3, they likely will have a completely different pain experience and may potentially need surgery.
- Changes on the x-ray may not be associated with pain. Many changes happen in our body as we age but changes on x-rays may not be the ONLY way to diagnose osteoarthritis. Consider this finding below:
This means that people up to 43% of people over 40 may have changes on their x-rays indicative of OA but are asymptomatic. More and more research is coming out stating osteoarthritis is more complex than just a "wear and tear condition". It is actually a biological process that goes beyond your x-ray findings.
This is one of the most widely used scale today but is just one piece of the puzzle to figuring out how far along your arthritis is and how appropriate you may be for surgery. This is a much more complicated decision than simply saying stages 3-4 need surgery. Here are the 3 most important considerations you should think about before getting a joint replacement surgery.
It is worth noting that understanding these stages of osteoarthritis can help you figure out the best course of treatment for you. Your x-ray images and grade on this scale can play a part in your decision for treatment but should not be the only consideration. Let’s look at these stages:
Stages of osteoarthritis:
Stage 0: Normal
This stage is often presented with no abnormal changes in the joint and likely not associated with high pain levels. In this stage, it is very important to make sure you are still taking care of your joints. Just because you don’t have pain now, doesn’t mean we can avoid all exercise and neglect the quality of our diet. Nutrition and physical activity are two of the best ways to prevent osteoarthritis and chronic joint pain.
Suggestions to take action:
- Find a type of physical activity you actually enjoy. I would highly recommend to find something other than walking. Walking is a great form of exercise but typically is not intense enough nor does it offer enough variety. You could try hiking or walking up/down hills to increase the intensity and variety. Adding in a few simple exercises before or after walking can make a huge difference, check out this video for ideas:
- Adopting a Mediterranean diet is one of the best ways to make sure what you are putting into your body is not causing a future of aches and pains. Here are are few suggestions from the Mayo clinic:
- Eat more fruits and vegetables. Aim for 7 to 10 servings a day of fruit and vegetables.
- Opt for whole grains. Switch to whole-grain bread, cereal and pasta. Experiment with other whole grains, such as bulgur and farro.
- Use healthy fats. Try olive oil as a replacement for butter when cooking. Instead of putting butter or margarine on bread, try dipping it in flavored olive oil.
- Eat more seafood. Eat fish twice a week. Fresh or water-packed tuna, salmon, trout, mackerel and herring are healthy choices. Grilled fish tastes good and requires little cleanup. Avoid deep-fried fish.
- Reduce red meat. Substitute fish, poultry or beans for meat. If you eat meat, make sure it’s lean and keep portions small.
- Enjoy some dairy. Eat low-fat Greek or plain yogurt and small amounts of a variety of cheeses.
- Spice it up. Herbs and spices boost flavor and lessen the need for salt.
Stage 1: Doubtful or Minor
In this stage, pain may not be present. Here, you will likely have slight changes in your x-ray but nothing major. You may have beginning osteophytes (bone spurs) and potential for beginning of joint space narrowing but nothing significant enough for serious intervention.
If you are controlling both your diet and exercise regiment, you will likely still be able to thrive and adventure at this stage with limited difficulty. If you find yourself in this stage but are sedentary (<60 minutes of exercise a week) or find your diet full of processed foods from boxes or cans, you may find yourself progressing to the next stage more quickly.
If osteoarthritis runs in your family, this stage is most important. You will be able to control the progression and severity of the symptoms if you take action now. Instead of thinking “it’s in my genes, there’s nothing I can do to stop the pain”, we can absolutely take action to set ourselves up for success in the future. Genetics does play a part in osteoarthritis but the symptoms can largely be dictated by lifestyle habits.
Suggestions for action:
- Understand that there are things you can do to prevent the progression of your osteoarthritis symptoms. Take a look at this video below. Recognize this is not a time to “wait and see what happens” or have longer periods of “rest” to “save your joints”. In reality inactivity is one of the leading causes of progression of osteoarthritis.
- Try to aim for at least 20-30 minutes of activity at least 5 days per week. Again, make sure this is something you enjoy and is not causing any sort of pain. The biggest thing is variety. Try to make sure you are switching things up- i.e try not to do only one activity like cycling or walking. Supplement other activities such as strength training, bodyweight exercise, kickboxing, yoga, pilates, or whatever you like!
- Continue with diet recommendations from above, including Mediterranean diet and minimizing foods that can drive up inflammation.
- This online course can be extremely beneficial in getting you on the right track to preventing the progression to further stages.
Stage 2: Mild
In this stage, you may see some joint space narrowing and definite osteophyte (bone spur) formation. You may start to notice further joint pain consistent with osteoarthritis. These symptoms can includes localized joint pain, dull/aching pain, pain that improves with mild to moderate movement, and increased pain with overactivity. You may notice that pain is off and on at this stage. You may notice more pain with certain movements that irritate the bone spurs but pain likely will not be constant. Pain typically is not debilitating or limiting at this stage but might start to become uncomfortable.
Cartilage usually isn’t negatively impacted in this stage. This is why it is important to make sure you are doing everything you can to keep it healthy. This includes continued appropriate, regular activity because exercise is actually good for cartilage. The one thing to avoid in this stage is overactivity. Exercise is great for cartilage but too much of a good thing may actually be detrimental. The most difficult part of this is learning what is “overactivity” for you. This is because it is different for almost everyone.
If you have pain that lingers after you complete a certain exercise or activity it is commonly a volume issue. This means that we likely are doing too much and we can decrease the time, frequency, or amount. If you don’t notice any pain during or after the activity, you should be okay! This even includes some high intensity exercise, as often we are told to avoid all high intensity exercise. Without pain or increasing discomfort afterwards, it is likely okay. Again, everyone’s situation is different.
Suggestions for action:
- Continue with your exercise routine but modify as necessary if you notice pain or significant discomfort afterwards. Start with decreasing frequency (how often you do the exercise or activity each week), decreasing weight (if you are strength training), or decreasing the amount (whether that’s time doing the exercise/activity, number of reps, or distance).
- Understand low impact exercise is not your only choice. There are some high intensity exercises that can still be beneficial for building muscle, power, and stronger bones! Continue to use pain as your guide and listen to your body.
- Consider including strength training. There are lots of studies that have examined how important strength training is for osteoarthritis. For example: “Strength training for 30 months, compared to range of motion exercises alone, resulted in a decreased mean rate of joint space narrowing“ which means you can help to stop the progression into the next stage! When trying strength training, I would highly recommend seeking out a physical therapist in order to make sure you are doing the right exercises and using the appropriate load.
- Focus on your balance. Keeping your balance in tip top shape is KEY to managing joint pain. If you don’t feel confident in your balance, this is an area you definitely need to focus on. Even if you do, it can always use improvements! You can read the top 5 exercises to improve your balance here.
- Keep your weight in an appropriate range. This one is extremely important. Osteoarthritis is primarily driven by inflammation. Excess adipose tissue (fat tissue) can not only increase mechanical pressure on your joints but it also keeps more inflammatory cells circling in your body. Avoiding carrying excess bodyweight can make a huge difference in the progression of your pain. A nutritionist can be extremely helpful in this situation.
Stage 3: Moderate
In this stage you likely have changes to your cartilage, more joint space narrowing, and osteophyte formation that starts to irritate the bones. I know that sounds scary but fear not! There are ways to still keep your adventure alive. In the stages of osteoarthritis, the next 2 stages are a little more difficult but there is hope.
You may notice more frequent discomfort, some potential joint swelling, and joint stiffness especially after sitting or standing in the same position for too long. If you notice pain becomes uncontrollable in certain situations and with certain movements, occasional use of NSAIDs or other anti-inflammatories may be of benefit, but definitely ask your physician first about what you should be taking. IF you are taking medications that could interact with these, it could be dangerous.
We should not have to rely solely on medications for pain relief though. Most of the time in this stage, you might notice more joint stiffness in the morning and once you move around a little bit, pain and stiffness should resolve. Climbing down stairs is a common movement that can lead to more pain. You may notice other movements that can increase pain but that means that those are the ones we need to address most.
Ice and heat may help to provide relief to irritated joints. Heat helps to promote relaxation and ice can help with pain relief- I usually don’t tend to recommend one over the other, just choose the one that typically works best for you. Compression is also helpful with joint pain relief and helps to minimize swelling. These knee compression sleeves, hand compression gloves, ankle compression socks, and hip compression sleeves can all be helpful.
I have clients who never thought they could climb stairs, bend over, or walking longer distances without pain. With the appropriate combination of movement and nutrition, they have actually found relief! In order to find relief in this stage, you have to take action.
Suggestions for action:
- Continue to modify exercise as needed for pain response. If you are having a hard time finding exercise that does not flare up pain, I highly recommend seeking out a physical therapist. In this stage, it can be harder to find exercise that doesn’t flare up pain but that doesn’t mean its not possible! We help people find relief every single day no matter what stage they are at. We just released our Knee Osteoarthritis Program, check it out here.
- Find other pain relieving options to avoid relying solely on medication. Medications an help but they are typically temporary. If we are able to find some other options like compression, ice/heat, and movement, you will have much more success with pain management.
- Find a way to manage your joint stiffness. Aside from pain, stiffness can be the net most limiting symptom. But there are easy ways to help! On my youtube channel I have tons of ideas and you can check out the most popular one here.
- Consider alternative treatments including stem cells, PRP injections, and other forms of regenerative medicine. There is lots of new evidence regarding these procedures. Meet with a regenerative medicine physician to discuss your options. This is usually a little more on the expensive side, so make sure it is the right decision for you!
- Learn how to manage joint flare-ups and overactivity. These are common in more progressive stages of arthritis but with a solid plan on how to manage them your life will be so much easier. What this video below to learn how to create a plan:
Stage 4: Severe
In this stage of osteoarthritis according to the Kellgren-Lawrence scale, you may notice larger bone spurs, increased joint space narrowing (potentially “bone on bone”), changes to your bones, and changes to cartilage make up. Your joints are most irritated in this stage. This is typically the stage that leads to surgery from the x-ray findings.
You may notice more frequent and severe pain, continued joint stiffness, and more joint swelling.
I know multiple people who are in this stage and have found effective ways to manage their pain naturally. I also know some who have been very successful with joint replacement surgery. As mentioned at the start of this article, a joint replacement is an important decision and requires considering all situations. I highly recommend reading this article which goes through the top 3 things you need to consider before getting a joint replacement.
Joint replacements are not the only option here but its a popular one. You have to decide if it is the right decision for you. With these changes in your joint, you can find ways around the pain but you don’t want to be in a constant battle with your mental health. If this pain begins to wear on you not only physically, but mentally as well- you have options.
Suggestions for action:
- Use pain medications as prescribed, but again, try not to solely rely on them for relief. Using ice, heat, regular movement in a pain-free way, and massage may be very helpful for you.
- Isometric exercises can be very helpful for pain relief. These tend to be nicer to the joints without flaring it up. Here are examples of hip isometrics, shoulder isometrics, and knee isometrics.
- Try to find an activity that can keep you moving without significant pain. Walking is a good one here and use of nordic walking poles can help reduce pain. A cane may be helpful here as well to give you some support.
- Try to find distractions or other hobbies that can take your mind off of the pain so we aren’t thinking about it all day. This can help decrease stress and frustration associated with pain.
- Meet with an orthopedic surgeon and get a few opinions for a joint replacement. Consider all of your options before going under the knife.
As you can see there are different stages of osteoarthritis and there are different considerations at each stage. It is important to focus on what we can do about pain instead of focusing on the pain itself. In order to see relief, we have to take action. There are lots of actions we can take, so start with choosing one! Don’t overwhelm yourself by trying to do all of these suggestions at once.
The biggest takeaway point is trying to avoid relying solely on what stage you are in to dictate if you need surgery or not. There are many people that are able to find relief from conservative treatments and those that do better with surgery. Understand that the decision goes deeper than what your x-ray says. Lifestyle changes can significantly impact pain levels. The stages of osteoarthritis are one piece of the puzzle.
If you would love to know the Top 5 Secrets to Getting Rid of Joint Pain Once and For All, download the FREE guide here.
Dr. Alyssa Kuhn is a physical therapist and arthritis specialist with Keep the Adventure Alive in Sandy, UT. An adventure is anything that makes you happy on the inside and her main mission is to help you keep yours alive! She has helped arthritis sufferers all over the country finally break free from their pain without surgery or more pills. She has found lots of adventures of her own including hiking, road biking, and skiing while in Utah which has inspired her to create this journey. She wants to show the world that arthritis pain doesn’t have to take our adventures away. Learn more tips and tricks on how to adventure with osteoarthritis here.
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Disclaimer: This post is for general informational purposes only. It should not be used to self-diagnose and it is not a substitute for a medical exam, cure, treatment, diagnosis, and prescription or recommendation. It does not create a doctor-patient relationship between Dr. Kuhn and you. You should not make any change in your health regimen or diet before first consulting a physician and obtaining a medical exam, diagnosis, and recommendation. Move Well Age Well, LLC and Dr. Alyssa Kuhn, PT, DPT are not liable or responsible for any advice, course of treatment, diagnosis or any conclusions drawn, services or product you obtain through this video or site.