Add topical capsaicin cream 4 times daily, if needed, to painful joints.



If joint effusion is present, consider aspiration and intra-articular injection of a corticosteroid as initial therapy.



If more pain and symptom control is needed, add an NSAID in low dosage or a nonacetylated salicylate such as choline magnesium trisalicylate or salsalate. Tramadol may be useful as adjunctive therapy.



If more pain or symptom control is needed, useful dosage of an NSAID, plus misoprostol or a proton pump inhibitor if the patient is at risk for upper gastrointestinal tract bleeding or ulcer disease, or substitute a COX-2 specific inhibitor for the NSAID. Some patients may benefit from intra-articular injections of a hyaluronic acid product.



If response is inadequate, consicder referring the patient for joint lavage, arthroscopic debridement, osteotomy, or joint replacement.