A 67-year-old woman comes to the office due to knee pain. For the past year, she has had gradually increasing pain in the left knee that is worse with prolonged walking or climbing stairs. The patient has also had brief (5-10 min) stiffness in the knee when she first rises from bed in the morning. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. Her pain is relieved with topical diclofenac but recurs if the patient does not use it regularly. Vital signs are normal. Examination shows slightly reduced flexion at the left knee compared to the right. No joint tenderness, warmth, or palpable effusion is present. There is no laxity with varus or valgus stress or with anterior or posterior traction on the proximal tibia. X-ray of the knee is shown in the image below: Which of the following is the most appropriate next step in management of this patient's knee pain?

Question

A 67-year-old woman comes to the office due to knee pain.  For the past year, she has had gradually increasing pain in the left knee that is worse with prolonged walking or climbing stairs.  The patient has also had brief (5-10 min) stiffness in the knee when she first rises from bed in the morning.  She reports minimal pain at rest and no nocturnal pain.  There are no clicking or locking symptoms.  Her pain is relieved with topical diclofenac but recurs if the patient does not use it regularly.  Vital signs are normal.  Examination shows slightly reduced flexion at the left knee compared to the right.  No joint tenderness, warmth, or palpable effusion is present.  There is no laxity with varus or valgus stress or with anterior or posterior traction on the proximal tibia.  X-ray of the knee is shown in the image below:  Which of the following is the most appropriate next step in management of this patient's knee pain?

Quizplus · Accepted Answer

11ec25c8_d96e_6447_bc81_c983978e4842_MD0003_00 This patient has osteoarthritis (OA) of the knee, presenting with chronic joint pain that is worse with weight-bearing activity. The x-ray reveals typical findings, including narrowing of the joint space (most notable in the medial compartment) and periarticular osteophytes. Risk factors for OA include age >40, obesity, prior joint injury, and abnormal joint alignment (eg, varus deformity). Initial management includes weight loss, regular moderate activity (eg, walking), and topical or oral nonsteroidal anti-inflammatory drugs (eg, diclofenac). In addition, a dedicated exercise program to strengthen the quadriceps muscles can improve function and protect the articular cartilage from further stress. Quadriceps strength declines with age, and the pain of OA may induce patients to decrease activity, leading to disuse atrophy of the quadriceps complex. This can cause abnormal loading of the articular cartilage and accelerate degeneration of the joint. (Choice A) Arthroscopic lavage is often used for management of septic arthritis, which typically presents acutely with severe pain, erythema, effusion, and fever. However, arthroscopic lavage, with or without debridement, is not beneficial for OA. (Choice B) Intraarticular injection of hyaluronic acid derivatives (ie, viscosupplementation) is occasionally used for OA of the knee when noninvasive measures fail. However, it has significant risks (eg, acute inflammatory pain, joint infection) and likely little benefit in most cases; it is not advised for routine management. (Choice C) MRI is useful for confirming ligamentous or meniscal injury. However, this patient has no acute trauma or laxity to suggest ligamentous disruption and no clicking or locking to suggest a torn meniscus. As is commonly the case, this patient's x-ray confirms the diagnosis of OA, and advanced imaging is not needed for initial management. (Choice E) Rheumatoid arthritis can affect the knee but more commonly presents as symmetric polyarthritis affecting the small joints of the hands and wrists. Patients classically have prolonged (>30 min) morning stiffness and malaise; brief stiffness, as seen in this patient, is more consistent with OA. Educational objective: Initial management of osteoarthritis of the knee includes weight loss, regular moderate activity, and topical or oral nonsteroidal anti-inflammatory drugs. In addition, exercises to strengthen the quadriceps muscles can reduce abnormal loading on the joint and protect the articular cartilage from further stress. References: State-of-the-art management of knee osteoarthritis. (http://www.ncbi.nlm.nih.gov/pubmed/25685755)

A 67-Year-Old Woman Comes to the Office Due to Knee