Are We Missing Feline Osteoarthritis in 98% of Our Patients? New Study Reveals a Massive Detection Gap
Implementation of a validated screening checklist increased osteoarthritis identification from 1% to 39%—exposing how many painful cats we're sending home untreated
How many cats with osteoarthritis walked through your clinic doors today without being diagnosed? If you're like most practices relying on traditional history-taking and physical examination alone, the answer is probably "most of them." A sobering new study published in the Journal of Feline Medicine and Surgery by Margaret Gober demonstrates just how badly we're failing to identify feline osteoarthritis—and offers a straightforward solution.
The research compared two approaches to osteoarthritis (OA) detection in the same general practice setting. Using historical methods (owner conversation and physical exam), only 1% of cats were identified with orthopedic-related issues. When the same practice implemented the Feline Osteoarthritis Checklist as a systematic screening tool, that number jumped to 39%—a nearly 40-fold increase in case identification.
Let that sink in. We're potentially missing osteoarthritis in 38 out of every 39 affected cats when we rely on our traditional approach. These aren't cats with subtle, questionable signs—these are cats demonstrating behaviors consistent with painful joint disease that we're simply not detecting and therefore not treating.
The Osteoarthritis Epidemic We're Ignoring
Feline osteoarthritis isn't rare. Research using radiography, CT imaging, and post-mortem studies consistently shows that the majority of cats over 12 years old have radiographic evidence of degenerative joint disease. Some studies report prevalence rates as high as 90% in geriatric cats.
Yet despite this high disease prevalence, OA remains dramatically underdiagnosed in feline practice. Why? Several factors contribute:
Cats are masters of hiding pain. As solitary hunters evolved to conceal vulnerability, cats instinctively mask signs of discomfort. They don't limp dramatically like dogs. They don't whine or show obvious distress. Instead, they become quieter, sleep more, and gradually reduce activities—changes owners often attribute to "just getting old."
Owners normalize aging changes. When a 14-year-old cat stops jumping onto the kitchen counter, many clients assume it's normal aging rather than recognizing it as a pain-related behavior change. "He's slowing down" becomes an accepted reality rather than a red flag for treatable disease.
Physical examination has poor sensitivity. Joint palpation in cats is notoriously unreliable. Many arthritic cats don't show obvious crepitus, effusion, or pain on manipulation. The physical exam finding we rely on most in dogs—joint palpation—simply doesn't work well for feline OA detection.
We don't ask the right questions. In a busy general practice appointment, orthopedic concerns get addressed if owners volunteer them. But if clients don't spontaneously mention that Fluffy stopped using the cat tree or is now eliminating outside the litter box, we might never discover these OA-related behavioral changes.
Traditional history-taking is passive. We ask "How's Fluffy doing?" and accept whatever the owner volunteers. We're not systematically screening for specific behaviors that indicate joint pain.
This study exposes the consequences of these gaps: 98% of cats with osteoarthritis leave the clinic without diagnosis or treatment when we use traditional methods.
The Study Design: Historical vs. Systematic Screening
Gober worked with five general small animal practices—the kind of everyday clinics where most of us work—to compare two different approaches to OA detection.
Phase 1: Retrospective Review (Historical Methods)
The researcher reviewed 502 cat medical records to determine how many cats had been diagnosed with orthopedic-related issues using the practice's standard approach, which consisted of:
Routine oral history from owners
Standard physical examination including musculoskeletal palpation
Documentation of any orthopedic concerns in the medical record
This represents how most of us currently practice: we listen to what clients tell us, we perform our physical exam, and we document what we find.
Phase 2: Prospective Screening (Checklist Implementation)
The same practices then implemented systematic screening using the Feline Osteoarthritis Checklist for a different population of cats. This phase generated 437 completed screening forms.
The Feline OA Checklist is a validated, owner-completed questionnaire that asks specific questions about observable behavior changes consistent with osteoarthritis. Rather than relying on owners to spontaneously volunteer relevant information, the checklist systematically prompts them to consider specific activities and behaviors.
Questions typically cover areas like:
Jumping up or down from furniture
Climbing stairs
Grooming behavior and coat quality
Litter box use and positioning
Play behavior and activity level
Interaction with family members
Posture and mobility
By comparing the same types of practices using different screening approaches, the study could isolate the impact of systematic screening on case detection.
The Results: A 39-Fold Difference
The findings are striking and somewhat damning:
Historical methods (retrospective review):
1% of cats identified with orthopedic-related issues
Systematic checklist screening (prospective):
39% of cats identified as demonstrating at least one behavior consistent with OA
This isn't a subtle difference. This is a massive detection gap that has profound implications for feline welfare. If 39% of cats in general practice have behavioral signs consistent with osteoarthritis but only 1% are being diagnosed, we're failing to address chronic pain in 38 out of 39 affected patients.
Think about what this means in practical terms. A busy feline practice seeing 50 cats per week might have approximately 20 cats with OA-related pain walking through the door weekly. Using traditional methods, they'd diagnose perhaps one every other week. The other 19 go home suffering—not because treatment isn't available, but because we didn't recognize the problem.
Why Checklists Work When Clinical Judgment Fails
The dramatic difference between the two approaches reveals something important about human cognition and clinical decision-making. It's not that veterinarians using historical methods are incompetent or uncaring—it's that unstructured clinical encounters are vulnerable to systematic biases and oversights.
Checklists overcome availability bias. We notice and remember dramatic presentations. The cat screaming when you manipulate a hip gets diagnosed. The cat who quietly stopped jumping on the bed doesn't trigger our diagnostic algorithms.
Checklists compensate for time pressure. In a 15-minute wellness appointment, there's pressure to move efficiently. We might not take time to explore subtle behavioral changes unless prompted. A systematic checklist ensures we cover key domains regardless of time constraints.
Checklists help owners recognize significant changes. Many behavioral changes associated with OA develop gradually. Owners adapt alongside their cats, normalizing changes that seem unremarkable individually but collectively indicate painful joint disease. The act of systematically reviewing specific behaviors helps clients recognize patterns they'd overlooked.
Checklists standardize screening across clinicians and appointments. Whether Dr. Smith or Dr. Jones sees the patient, whether it's a rushed Friday afternoon or a calm Tuesday morning, the checklist ensures consistent screening coverage.
Checklists provide documentation. Screening results become part of the medical record, creating baseline data for tracking progression and treatment response over time.
The aviation industry learned decades ago that checklists save lives even when pilots are highly trained and experienced. Medicine—human and veterinary—is slowly recognizing the same principle. Complex systems prone to error benefit from standardization, and clinical medicine is nothing if not complex and error-prone.
What Counts as "At Least One Behavior Consistent with OA"?
The study reports that 39% of cats demonstrated "at least one behavior consistent with OA." This threshold is intentionally sensitive—it's designed to catch possible cases for further evaluation rather than confirm diagnosis.
A single positive response might indicate:
Decreased jumping up to elevated surfaces
Reluctance to use stairs
Reduced grooming or unkempt coat
Changes in litter box behavior (eliminating outside the box, perching on the edge rather than squatting inside)
Decreased play or hunting behavior
Increased sleep or decreased interaction
Stiffness after resting
Difficulty getting comfortable
Not every cat with one positive response has clinically significant OA requiring treatment. Some might have other explanations for behavior changes. But every cat with positive screening deserves further evaluation—at minimum, a thoughtful review of the specific behaviors, consideration of radiography if indicated, and discussion of a therapeutic trial.
The key insight is that 39% represents cats we should be evaluating further, not necessarily 39% requiring immediate treatment. But it's a vastly different—and more realistic—starting point than the 1% we're currently catching.
The 1% We Do Catch: Who Are They?
It's worth considering which cats make it into that 1% diagnosed using traditional methods. They're probably:
Cats with dramatic, obvious lameness
Cats with acute injuries or trauma
Cats with severe joint effusion, crepitus, or deformity
Younger cats where orthopedic issues seem unusual
Cats where owners specifically scheduled appointments for mobility concerns
These are the severe, unmistakable cases. The cats we're missing in the other 38% are those with more subtle presentations—the early-to-moderate OA cases where pain is present but not so overwhelming that it forces recognition.
These are exactly the cats where early intervention could prevent progression, maintain quality of life, and avoid secondary complications like obesity (from decreased activity) or litter box aversion (from pain squatting in the box).
Barriers to Implementation: Why Aren't We Already Doing This?
If screening checklists improve case detection this dramatically, why aren't they universal in feline practice? Several barriers exist:
Time constraints. Adding screening tools to already-packed appointments feels daunting. However, most validated checklists take owners just 2-3 minutes to complete in the waiting room before the appointment even starts.
Workflow integration. Implementing new protocols requires staff training, form printing or digital integration, and process changes. These logistical hurdles, while surmountable, require administrative effort.
Skepticism about owner accuracy. Some veterinarians worry that owner-reported behavior changes lack objectivity or reliability. While owners certainly have limitations as observers, research consistently shows that validated owner-completed questionnaires correlate well with objective measures of mobility and pain.
Concern about "creating" problems. There's sometimes unspoken anxiety that systematic screening will identify so many issues we'll overwhelm clients or ourselves. But undiagnosed pain doesn't cease to exist because we don't recognize it—we're just failing to address it.
Lack of treatment confidence. If we're uncertain about how to manage feline OA once we diagnose it, we might unconsciously avoid detection. This highlights the need for better education about multimodal OA management options.
Reimbursement concerns. Some practices worry that adding screening without specific client complaints won't be valued or reimbursed. However, proactive wellness care is increasingly what clients expect and appreciate, particularly when it improves their pet's quality of life.
None of these barriers are insurmountable. Practices implementing systematic screening typically find that once workflows are established, the process becomes routine and efficient.
The Welfare Imperative: Pain Recognition Is Step One
The study's conclusion emphasizes a fundamental ethical principle: pain recognition is the first step of pain management. You cannot treat pain you don't recognize.
Every cat leaving a clinic with undiagnosed osteoarthritis continues to suffer needlessly. They're less active, potentially gaining weight, possibly developing litter box aversion or behavior changes that strain the human-animal bond. Some eventually get relinquished to shelters or euthanized for "behavioral problems" that are actually pain-related.
The tools to treat feline OA exist. NSAIDs, gabapentin, adequan, multimodal analgesia, weight management, environmental modifications, physical rehabilitation—we have an expanding toolkit for managing feline joint disease. But none of these interventions happen if we don't first identify the problem.
From a welfare perspective, the 38% detection gap represents millions of cats in the United States alone living with chronic pain that could be alleviated. This isn't a rare disease affecting a few unlucky cats—it's a common condition affecting the majority of senior cats, and we're systematically failing to address it.
Practical Implementation: Making Screening Routine
So how do we actually implement systematic OA screening in practice? Here's a practical approach:
1. Choose a validated tool. The Feline Musculoskeletal Pain Index (FMPI), the Client-Specific Outcome Measures (CSOM) tool, or the Feline Osteoarthritis Checklist mentioned in this study are all validated instruments. Don't create your own from scratch—use tools with established reliability and validity.
2. Integrate into workflow. Have reception staff provide screening forms when checking in cats over a certain age (perhaps 7-8 years and older). Owners complete the form in the waiting room before the appointment.
3. Train the team. Ensure all staff understand why screening matters, how to explain it to clients, and how to score and interpret results. Front-desk staff, technicians, and veterinarians all need to be on the same page.
4. Review results systematically. Make it protocol that screening results are reviewed during every appointment for age-appropriate cats. This becomes part of the standard wellness exam, like checking weight or dental health.
5. Act on positive screens. Develop practice protocols for what happens when cats screen positive. This might include more detailed history, focused physical exam, consideration of radiography, discussion of therapeutic trials, or referral for advanced imaging.
6. Document and track. Record screening results in the medical record. Track scores over time to monitor progression or treatment response. This creates longitudinal data that's valuable for individual patient management.
7. Educate clients. Use positive screens as teaching opportunities. Help owners understand that behavior changes they've normalized ("he's just old") are actually treatable pain indicators. This reframes aging from inevitable decline to manageable disease.
8. Make it routine for all senior cats. Don't wait for clients to complain. Screen systematically at wellness visits, sick appointments, even dental cleanings or other procedures. Make OA screening as routine as parasite control or vaccination discussions.
Beyond Detection: What Happens Next?
Identifying OA is just step one. What do we do with those 39% of cats who screen positive?
Further evaluation might include:
Detailed pain-focused history exploring specific behaviors
Careful orthopedic examination (even if often unrewarding)
Radiography to document joint changes and rule out other pathology
Bloodwork before starting NSAIDs (if not recently performed)
Assessment of body condition score and weight management needs
Treatment options for feline OA include:
Pharmacological:
NSAIDs (meloxicam, robenacoxib, others where approved)
Gabapentin for neuropathic pain component
Buprenorphine for severe cases
Adequan (polysulfated glycosaminoglycan) injections
Solensia (anti-NGF monoclonal antibody) monthly injections
Non-pharmacological:
Weight management (crucial for overweight cats)
Environmental modifications (lower litter box sides, ramps to favorite perches, soft bedding)
Physical rehabilitation and therapeutic exercise
Omega-3 fatty acid supplementation
Joint supplements (glucosamine/chondroitin, though evidence is limited)
Acupuncture (some cats tolerate well)
Lifestyle:
Encourage gentle activity
Provide warmth (heated beds, warm rooms)
Make resources easily accessible
Consider multiple litter boxes with easy entry
Monitoring response:
Repeat screening tools to quantify improvement
Owner-reported behavior changes
Activity monitoring (though challenging in cats)
Quality of life assessments
The goal isn't just to diagnose OA—it's to meaningfully improve quality of life for affected cats. That requires multimodal management individualized to each patient.
Study Limitations and Strengths
Strengths:
Large sample size (502 + 437 cats across multiple practices)
General practice setting (high external validity for typical clinics)
Direct comparison of two approaches in similar populations
Use of validated screening tool
Practical, implementable intervention
Limitations:
No confirmation of OA diagnosis in screen-positive cats (screening identifies possible cases, not confirmed disease)
Different cat populations in retrospective vs. prospective phases (not the same cats)
No data on treatment initiated or outcomes
Single geographic region may limit generalizability
Doesn't address cost-effectiveness or client satisfaction
The lack of diagnostic confirmation in screen-positive cats is the most significant limitation. We know 39% had behaviors consistent with OA, but we don't know how many actually had radiographic changes, responded to treatment, or had alternative explanations for their signs. That said, the dramatic difference between 1% and 39% detection rates remains clinically meaningful even if some positives prove false.
The Economic Angle: Is Screening Good Business?
Some practices might worry that systematic OA screening without client complaints is economically questionable. But consider:
Screening creates value clients appreciate. Proactive identification of conditions that improve quality of life strengthens the veterinarian-client bond and positions the practice as thorough and caring.
Treatment of OA generates appropriate revenue. Cats diagnosed with OA may receive NSAIDs, injections, supplements, prescription diets, follow-up monitoring, and other services. These are legitimate medical needs that generate sustainable revenue.
Preventing secondary complications saves costs long-term. Cats with untreated OA may develop obesity, litter box aversion, or behavioral issues that become more expensive and difficult to manage than early OA intervention.
Screening differentiates practices. As clients become more educated about feline pain management, practices offering systematic screening stand out as progressive and evidence-based.
Compliance is likely high for OA treatment. When owners see direct quality-of-life improvements (cat jumping again, playing more, seeming happier), they're motivated to continue treatment. OA management has high visible reward.
Rather than viewing systematic screening as generating unnecessary work, consider it identifying unmet medical needs while positioning the practice as a leader in feline welfare.
The Bigger Picture: Changing Feline Medicine Culture
This study is part of a broader shift in how we think about feline medicine. For too long, cats have been treated as small dogs, their unique needs and pain expressions overlooked or misunderstood.
Recognizing that cats experience and express pain differently, that standard approaches developed for canine patients don't translate well to felines, and that we need cat-specific tools and protocols—this represents important progress in feline medicine.
Systematic OA screening is one piece of a larger cultural change toward proactive, preventive feline healthcare that recognizes subtle signs of disease rather than waiting for crisis presentations. It aligns with similar movements toward systematic screening for other common feline conditions (hypertension, hyperthyroidism, chronic kidney disease).
The message is clear: cats deserve the same thoughtful, systematic approach to disease detection and management that we provide dogs. Their stoic nature and subtle pain expression make that harder, not less important.
The Bottom Line
This study exposes a massive gap in feline osteoarthritis detection: traditional methods identify about 1% of affected cats, while systematic screening using validated checklists identifies 39%—a nearly 40-fold increase.
Key implications for practice:
Feline OA is dramatically underdiagnosed in general practice
Traditional history-taking and physical examination have poor sensitivity for OA detection
Validated screening checklists dramatically improve case identification
Implementation is straightforward and integrates into existing workflows
Pain recognition is the essential first step toward pain management
Millions of cats are living with treatable chronic pain we're failing to address
The Feline Osteoarthritis Checklist and similar validated tools give us a simple, efficient way to identify cats suffering from joint pain. Not using these tools means continuing to send home the vast majority of arthritic cats without diagnosis or treatment—a welfare failure we can no longer justify.
Implementing systematic OA screening isn't optional extra work—it's meeting the basic standard of care for feline patients. The tools exist, the validation is solid, and the impact on patient welfare is profound. It's time to make screening routine in every practice seeing cats.
Full Text Link: Implementation of a prospective in-clinic validated Feline Osteoarthritis Checklist - Journal of Feline Medicine and Surgery, PMCID: PMC12535645
