A 36-year-old woman comes to the physician with knee pain that started 2 weeks earlier. The pain is localized anteriorly in both knees and is greater in the left. She moved to a new 2-story house 3 weeks ago and has used the stairs many times. Lately she has experienced severe pain when ascending or descending the stairs. The pain also increases after prolonged rest. The patient has no obvious knee trauma or swelling. When she tried to run every day 3 months ago, she developed similar symptoms and had to stop. Her only other medical problem is psoriasis on her elbows, for which she uses corticosteroid and vitamin D combination ointment.
Vital signs are normal. BMI is 34 kg/m². There is no joint line tenderness, redness, warmth, or effusion noted in either knee. Range of motion is normal with mild crepitus. Directly compressing the patella while the leg is extended elicits pain. Valgus and varus stress testing are normal. Lachman, McMurray, and anterior and posterior drawer tests are normal.
Which of the following is the best next step in management?

Question

Quizplus · Accepted Answer

This patient's anterior knee pain is most likely due to patellofemoral pain syndrome (PFPS), the most common etiology for nontraumatic knee pain. Risk factors include overuse, malalignment, and trauma, although overuse during training is probably most common. PFPS is usually diagnosed based on history and examination. Most patients complain of "achy" or "sharp" pain under or around the patella. Some patients report the affected knee as "giving way" or "buckling"; these symptoms should not be confused with those of anterior cruciate ligament injury. Some may complain of knee "locking," but the presence of true locking and joint effusions indicates intra-articular pathology (eg, meniscal injury). The knee pain typically worsens after prolonged rest and with activities such as squatting, running, or going up and down stairs. Examination shows normal range of motion, mild crepitus, and retropatellar pain with direct compression of the patella during knee extension. Obesity, weakness, and/or quadriceps atrophy may be present. Supervised physical therapy involving activity modification and quadriceps plus hip abductor strengthening for at least 6-12 months is the mainstay of treatment. NSAIDS and bracing are often tried but have not demonstrated long-term benefit in clinical studies (Choice A). However, NSAIDs can be tried for short-term pain relief while physical therapy takes effect. (Choice B) Clinical studies have not found corticosteroid injections to be an effective long-term solution for PFPS. (Choice D) MRI is indicated only when a meniscal or ligamentous injury is suspected. This patient has no knee swelling, joint instability or abnormal valgus/varus tests, so no MRI is required. (Choice E) Methotrexate is used for psoriatic arthritis, but this patient's examination findings (retropatellar pain) are most likely due to PFPS. Educational objective: Patellofemoral syndrome (PFPS) is a clinical diagnosis characterized by knee pain that worsens with squatting, moving up and down stairs, and rest. Examination shows mild crepitus and tenderness on direct compression of the patella during knee extension. Supervised physical therapy is the primary treatment for PFPS. __________ References: Patellofemoral pain syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20610028) Management of patellofemoral pain syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/17263214)

A 36-Year-Old Woman Comes to the Physician with Knee Pain