Objective To identify risk factors for pain and functional deterioration in people with knee and hip osteoarthritis (OA) to form the basis of a future ‘stratification tool’ for OA development or progression.

Design Systematic review and meta-analysis.

Methods An electronic search of the literature databases, Medline, Embase, CINAHL, and Web of Science (1990–February 2020), was conducted. Studies that identified risk factors for pain and functional deterioration to knee and hip OA were included. Where data and study heterogeneity permitted, meta-analyses presenting mean difference (MD) and ORs with corresponding 95% CIs were undertaken. Where this was not possible, a narrative analysis was undertaken. The Downs & Black tool assessed methodological quality of selected studies before data extraction. Pooled analysis outcomes were assessed and reported using the Grading of Reccomendation, Assessment, Development and Evaluation (GRADE) approach.

Results 82 studies (41 810 participants) were included. On meta-analysis: there was moderate quality evidence that knee OA pain was associated with factors including: Kellgren and Lawrence≥2 (MD: 2.04, 95% CI 1.48 to 2.81; p<0.01), increasing age (MD: 1.46, 95% CI 0.26 to 2.66; p=0.02) and whole-organ MRI scoring method (WORMS) knee effusion score ≥1 (OR: 1.35, 95% CI 0.99 to 1.83; p=0.05). On narrative analysis: knee OA pain was associated with factors including WORMS meniscal damage ≥1 (OR: 1.83). Predictors of joint pain in hip OA were large acetabular bone marrow lesions (BML; OR: 5.23), chronic widespread pain (OR: 5.02) and large hip BMLs (OR: 4.43).

Conclusions Our study identified risk factors for clinical pain in OA by imaging measures that can assist in predicting and stratifying people with knee/hip OA. A ‘stratification tool’ combining verified risk factors that we have identified would allow selective stratification based on pain and structural outcomes in OA.

PROSPERO registration number CRD42018117643.