A 34-year-old woman comes to the physician with lateral right lower-extremity pain for a week. The pain is located just above the knee and radiates to the thigh. It is described as burning and occasionally sharp with moderate severity and an intermittent, unpredictable course. A trial of over-the-counter ibuprofen gave inconsistent improvement.
The patient was recently diagnosed with type 2 diabetes mellitus and is attempting to avoid medication with an aggressive weight loss program that includes intense exercise.
Her vital signs are normal. Body mass index is 37.8 kg/m². The knee appears grossly normal with no effusion and normal, pain-free range of motion. There is mild, poorly localized tenderness over the lateral knee especially with flexion and extension. Knee ligaments appear stable. Pedal pulses are full and there is trace edema at both ankles.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_9937_ef34_853d_3f234094834a_MD0002_00 This patient, with poorly localized lateral knee pain radiating to the thigh, shows typical features of iliotibial (IT) band syndrome. IT band syndrome is a common overuse injury seen most frequently in inexperienced runners, especially those starting a new or more strenuous training regimen. The exact pathophysiology is disputed, but it appears to arise from where the IT band passes over the lateral femoral condyle and may be due to compression of the intervening soft tissues. iliotibial (IT) band syndrome The diagnosis of IT band syndrome is based primarily on history and physical examination findings. The patient may demonstrate tenderness at the lateral femoral condyle, especially during flexion and extension of the knee. Magnetic resonance imaging may show signal intensity abnormalities in soft tissues deep to the IT band, and sensitivity is good at experienced centers. However, no studies have yet shown improved outcomes with magnetic resonance imaging and it is not recommended in uncomplicated cases (Choice C). Management of IT band syndrome is primarily biomechanical. Patients should be advised to reduce the intensity and duration of running sessions and begin a program of lower-extremity stretching and strengthening exercises. A number of specific stretches are helpful and can be easily taught in only a few physical therapy sessions or physician office visits. Refractory cases can be considered for corticosteroid injection or surgical intervention (rare). (Choice A) Meralgia paresthetica is a common cause of lateral thigh symptoms in obese patients. It is caused by compression of the lateral femoral cutaneous nerve at the waist and has been linked to tight-fitting clothing. Patients with meralgia paresthetica may demonstrate altered sensory findings in a specific region at the lateral and anterior thigh, but the knee is spared and no tenderness is noted. Meralgia paresthetica (Choice B) Anserine bursitis is a possible cause of knee pain in inexperienced runners. But unlike this patient, those with anserine bursitis will have very well-localized pain at the medial aspect of the knee. Treatment is also biomechanical, with nonsteroidal anti-inflammatory drugs and corticosteroid injection helpful as adjunctive measures. Anserine bursitis (Choice D) Patellofemoral syndrome can be differentiated from IT band syndrome by location of pain at the anterior knee, which can be reproduced by squatting. Like IT band syndrome, management of patellofemoral syndrome involves modifying the exercise regimen along with stretching and strengthening exercises. Patellofemoral bracing is often recommended but evidence for this is lacking. Patellofemoral syndrome Educational objective: Iliotibial band syndrome is a common cause of lateral knee and thigh pain and is especially common in inexperienced runners. The diagnosis is primarily clinical with lateral knee pain reproduced on palpation, especially with flexion and extension of the knee. The foundation of management is stretching and strengthening exercises for lower-extremity muscles and temporary reduction in exercise regimen. __________ References: Iliotibial band syndrome: evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/22134205)

A 34-Year-Old Woman Comes to the Physician with Lateral Right