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The 4 stages of osteoarthritis: Symptoms, treatments, and more

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Stage 1Stage 2Stage 3Stage 4TreatmentSummary
Osteoarthritis is a common form of arthritis caused by standard wear and tear of the joints. It usually presents in 4 stages, ranging from mild to severe.
Medically reviewed by Stella Bard, MD
Written by Lily Ferguson
Updated on September 11, 2023

Osteoarthritis (OA) is a condition affecting the joints, usually causing pain and swelling. It happens when the cartilage (the cushion between your joints that keeps the bones from rubbing together) wears away due to aging or sometimes because of an injury. It’s also known as degenerative arthritis.

OA is a progressive condition because your cartilage degenerates slowly over time. It’s generally divided into four stages according to a scale known as the Kellgren–Lawrence (KL) classification:

  • minor (stage 1)
  • mild (stage 2)
  • moderate (stage 3)
  • severe (stage 4)

You might also hear of stage 0, which means there’s no evidence of OA.

OA can affect any joint, but it is most common in the knees and hips. The KL classification originally referred to OA of the knees, but it is applicable to any joint.

Each stage can have its own symptoms, and usually, each one is treated differently by doctors. Knowing more about the osteoarthritis stages can help you to seek treatment and manage your condition effectively.

Stage 1: Minor or early

A person shown from the hips down walking with crutches while a healthcare professional holds their knee, representing the stages of osteoarthritis.
PER Images/Stocksy United

In stage 1 OA, your joints may be beginning to show signs of damage or wear in medical imaging scans like X-ray, MRI, or CT, but you may not notice any symptoms yet. According to the National Institutes of Health, 80% of adults older than ages 65 years would show radiographic (a kind of X-ray) signs of OA, but only 60% of them show any symptoms.

If you do notice symptoms, you’re likely to feel some mild pain in your joints, especially in your knees. The pain isn’t likely to be constant but is more likely to flare up after long periods of no activity or periods of high activity.

If you don’t notice symptoms, or if they’re mild, you might not think there’s anything wrong. In this stage, radiography helps diagnose OA, where doctors might begin to notice damage to your joints. They might do these tests if you have risk factors for OA, including old age, obesity, and family history.

According to the KL classification, radiographs aren’t likely to find narrowing of the spaces between your joints, but they might find small bony lumps in the joints known as osteophytes or bone spurs.

Stage 2: Mild

In stage 2 OA, the cartilage is breaking down further, so you’re more likely to start noticing symptoms. The pain in stage 1 will become more noticeable, likely paired with stiffness or difficulty moving the joints.

Like in stage 1, the pain might not be constant and is only likely to flare up after vigorous activity or long periods of rest. A 2018 review of hip OA found that as early as stage 2, people with hip OA walked differently from people without OA because of the affected joint.

Per the KL classification, bone spurs will be clear in imaging scans, and the joint space is more likely to have narrowed.

Stage 3: Moderate

In this stage, the number of bone spurs would increase, and the joint space would be visibly narrower in imaging scans. There may be some deformity at the end of the bones and some thickening of the bone, called sclerosis.

Understandably, this means your symptoms would be much more noticeable. They might occur when doing lower-impact exercises like walking or bending. You might also start to notice visible swelling of the joints that you hadn’t noticed before.

Stage 4: Severe

It is the final stage of OA and the most severe. According to the KL classification, bone spurs will be much larger, and there will be clear joint space narrowing. Cartilage might be entirely gone at this stage. There will also be clear sclerosis and bone deformity.

In this stage, you might find it difficult to carry out daily activities because of the joint pain and stiffness. You will also see definite swelling. The pain is likely to flare up whenever you use your joints rather than just after exercise.

Research into hip OA suggests that people with this stage of OA have less movement in their joints than people without OA or even people with milder stages of OA.

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Treatments

The treatment methods will vary according to which stage of OA you’re at.

Stage 1

For stage 1 OA, doctors don’t recommend any formal treatment. But if you’re particularly at risk, doctors might recommend prevention strategies, including certain exercises, such as knee extensions, to strengthen your joints and possibly prevent the condition from getting worse. Doctors recommend weight loss as it might help prevent OA.

Natural remedies might also be of some benefit at this stage.

Stage 2

When you start to feel symptoms in stage 2, doctors are most likely to recommend over-the-counter pain (OTC) relievers before any other treatment, including options like acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs like ibuprofen (Advil) or naproxen (Aleve).

In stage 2, continuing with the recommended prevention and lifestyle strategies will still be beneficial. Avoiding exercises that are likely to damage the joints further, like jumping and squats, may prevent faster deterioration. You can also use things like knee braces to help with symptoms and mobility.

Stage 3

Stage 3 is when doctors will begin to treat OA more intensively. The main treatment at this stage is injections into the joint of either hyaluronic acid or glucocorticoids, particularly for knee OA. The glucocorticoids include triamcinolone acetonide (Zilretta) and hydrocortisone (Cortef).

You will have to repeat the injections over time as the effects will wear off eventually.

Doctors usually reserve these injections for stage 3 and 4 knee OA with more severe symptoms. However, some evidence suggests there are benefits, both in terms of symptoms and cost effectiveness, of giving them in earlier, milder stages.

Stage 4

Alongside all the previous treatment methods, in stage 4, surgery is most likely the best treatment. The surgical options include total joint replacement, including total knee replacement or hip replacement.

According to some research into hip replacements for OA, 90% of the new joints are still functional 15 years after surgery. But, because of the risks involved, doctors usually recommend surgery only in severe cases.

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Summary

Osteoarthritis is a progressive condition, meaning it worsens with time and age. It’s generally divided into 4 stages according to the severity of the condition. Stage 1 is the mildest, while stage 4 is the most severe.

Treatments for OA depend on what stage you’re at. Milder stages focus more on OTC pain relievers and prevention methods like exercise. For more severe cases of OA, doctors administer injections into the affected joint, or you might require joint replacement surgery.

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