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Many of the characteristic clinical manifestations of osteoarthritis are related to the involvement of particular joints. As described before, OA has a predilection for the hand, knee, hip, and spine, and less commonly affects the shoulder, elbow, wrist, and ankle. Regarding hands Symptoms are usually bilateral, and joint involvement is usually approximately symmetrical. Typical symptoms affect just one or a few joints at a time. Symptoms can be intermittent and target characteristic sites, distal interphalangeal joints, thumb bases, proximal interphalangeal joints, and second and third metacarpophalangeal joints, in descending order of frequency . Individuals without pain may still report an "aching" or stiffness in the hands . Symptoms may worsen in approximately half of patients over the next six years, and the predictors of adverse clinical outcomes include a high level of baseline functional impairment and a greater number of painful joints, with no consistent correlation between clinical symptoms and radiographic progression . Affected people are frequently women, often with a strong familial predisposition. Symptoms usually start in middle age, typically around menopause, with a stuttering onset of pain, tenderness, and stiffness of one or a few finger interphalangeal joints. At the start, there may be intermittent or persistent warmth and soft-tissue swelling, but over a period of a few years the involved interphalangeal joints usually become less painful, and signs of inflammation subside, leaving behind firm-hard bony swellings on the posterolateral aspect of the interphalangeal joints, termed Heberden and Bouchard' nodes . Heberden nodes sometimes coalesce to form a single dorsal bar . Over a period of several years, new interphalangeal joints go through the same process in a "mono-arthritis multiplex" fashion. In addition to nodes, affected interphalangeal joints may show restriction in movement and lateral deviation (radial or ulnar, with most deviations pointing towards the middle finger). Lateral deviation of interphalangeal joints, without instability, is a characteristic feature of nodal OA. Nodes most frequently occur at the index and middle fingers. Fully evolved nodes usually are not painful but may be a cosmetic problem. Thumb-base OA generally affects older postmenopausal women. Individuals with thumb-base OA have localized deep thenar, radial wrist, or thumb-base pain, exacerbated on joint use. There may also be distal radiation into the thumb and, to a lesser extent, proximally. Activities that involve pinching (opposition of the thumb to a finger) are generally most painful. A subjective grinding sensation on movement may be present. There may be radial subluxation and adduction at the thumb base, giving it a swollen "squared" appearance. Localized tenderness may be present and passive thumb circumduction may be painful. Unlike interphalangeal joint OA, thumb-base OA sometimes associates with persistent symptoms and functional impairment. Thumb-base OA may also occur on its own without nodal interphalangeal OA.