Practical PAIN MANAGEMENT, July/August 2007
51 year-old cameraman complaining of left knee pain for 6months which began after a two foot fall from an unstableriser at work. Two weeks after this injury, the patient was run-ning, as was his routine, and began to notice discomfort inhis left knee. Discontinuing running helped but, while at hisdaughter’s soccer game, he ran after a ball and a week laterbeganto have the same pain recur in his knee and has per-sisted. He feels the pain in the medial aspect of his knee when going up and down stairs, worse going up, and also when walking. NSAIDs have not helped. He has been toldhe has a torn meniscus and arthritis causing his pain.
Nomajor surgeries or medical issues.
Review of Systems:
No complaints other than seasonal al-lergies.
Left knee slightly swollen as compared toleft, but without erythema or deformity. Flexion to 110 de-grees, with restricted extension secondary to apparent Bak-ers cyst. Mild crepitus present. +1/2 drawer sign with later-al to medial motion present. Negative McMurray’s. Tender-ness present at the medial collateral ligament and pesanserius tendons.
1. Mild tricompartmental osteoarthritis with carti-lage loss most severein the lateral facet and trochlea; 2. Com-plex grade III signal in the posterior horn of the medialmeniscus and body compatible with tearing; 3. Mild anteri-or cruciate ligament sprain as well as a grade I medial col-lateral ligament sprain. Meniscocapsular separation cannotbe excluded as the edema is most intense adjacent to themeniscus; 4. Small joint effusion and small lobulatedpopliteal cyst.
After 5 prolotherapy treatmentsone month apart, the patient reported 90% improvement. At the patient’s followup visit and treatment 3 months later,he reported continued improvement, now 95%, and reportsno pain with return to regular exercise. At one year followup, the patient reports continued stability and activity.
63 year-old male, public relations executive, with 20 year his-tory of left knee pain on and off, status post 2 knee athro-scopic surgeries which gave him only short-term relief. Overthe past few years, he states the pain has worsened and re-cently exacerbated with a lifting injury. He has taken NSAIDssuch as Bextra which temporarily help, and followed theRICE protocol (rest, ice, compression, elevation), but thepain has continued. He has stiffness and difficulty gettingup from seated to standing position, and trouble going downstairs. He has been told he has cartilage degeneration andneeds a knee replacement.
Medical History and Review of Symptoms:
Tonsils outas a child and measles at age 30. No health issues except el-evated blood pressure, on medication.
Aspirin, Cozaar, Effexor, Bextra prn.
Valgus deformity,left greater than right.Flexion is restricted at 90 degrees of flexion with restrictedextension of 10 degrees from flat. There is mild swelling butno erythema. Tenderness to palpation at the medial collat-eral ligament and pes anserious tendon. +1/2 drawer signand negative McMurray.
After 10 prolotherapy treat-ments one month apart, the patient felt he was 85% im-proved and was no longer considering a knee replacement.He reported far less pain under load and resting, better flex-ibility, walking down stairs easily, and no stiffness when get-ting up from sitting or after driving. At 2-1/2 year follow-up, he had continued stability with range of motion onlymildly restricted in extension and with full range of motionin flexion.
14 year-old male with anterior knee pain for one year afterbeing active in several sports for many years, including bas-ketball, football, soccer and baseball. No prior known trau-ma. He states he was diagnosed with Osgood-Schlatter dis-ease and was told therewas nothing he could do about it.The patient wakes up in the morning with the pain and itlasts throughout the day and has prevented him from par-ticipating in his usual sports. Subsequently, he dropped outof all his athletic activities and is not currently active in anysport yet still experiences daily pain.
Medical History and Review of Systems:
Enlargement of the tibial tuberosity withtenderness to palpation at the patellar tendon insertion onthe tuberosity bilaterally. Rest of exam within normal limits.
After one treatment to the rightknee and three treatments to the left knee at 3 to 4 week in-tervals, patient states he is 95-100% better in both knees, andback to full sports activity. He reports he can now “do any-thing.” Followup at 1 and 2 years showed stable improve-ment with continued full return to all sports.
32 year-old female, former Olympic Taekwondo competitor, with history of right knee pain for three years, status post ACL reconstruction (patella technique) with partial medialmenisectomy. The patient’s pain returned 1 year later andshe underwent arthroscopic debriding which confirmeddamage to her articular cartilage. This provided only tem-porary relief. She has done rehab exercise on her own butdespite this, over the last year, medial knee pain has returnedand is now persistent and fairly constant. The pain is aggra- vated by walking and activity.
Medical History and Review of Systems:
Healthy,nohealth issues or complaints.
Right knee: patellar tracking deficit and crepitus.+2 drawer sign. Range of motion within normal limits. Neg-ative McMurray. Tender to palpation at MCL, patellar ten-don and pes anserious tendon insertion.
The patient was given six treat-ments on her right knee, approximately every 4 weeks. Shefelt immediate reduction in her pain starting with the first