MBBS V O&T – Knee pain and OA (tutorial)

Knee pain and osteoarthritis of knee (YCH tutorial)

Case example
 75 y/o lady presented with bilateral knee pain x 4 years
 Ddx
o Osteoarthritis of knee (degenerative)
o Rheumatoid arthritis
o Gout
o SLE
o Psoriatic arthritis
o Acute infection: septic arthritis
o Chronic infection (e.g. TB)
o Trauma
o Primary tumour (osteosarcoma)
o Secondary tumour (bone metastasis)
o Referred pain: hip/spine
 Approach
o Not every elderly patient present with knee pain is OA knee
 History
o Pain
 SOCRATES: site, duration, onset, radiation, inflammatory, mechanical,
aggravating/relieving
 First episode
 Episodic/progression
 Inflammatory vs mechanical pain (OA/degenerative)
 Night pain (inflammatory, infection, tumour)
 Radiation
 Any pain medication
o Associated symptoms of knee
 Stiffness (range of movement)
 Limb length discrepancy?
 Locking/give way sensation
 Numbness over calf or foot (refer pain from back)
 Hip pain usually on lateral side: C sign
o Symptoms relating to ddx
 Infection: fever, discharging sinus
 Trauma
 Malignancy: LOA, LOW, mass, hx of malignancy
 Referred pain: other sites of pain (disc prolapse), lumbar spine
(compression of nerve roots)
 Sciatica – numbness and weakness
 Cauda equina syndrome – incontinence
 RA: morning stiffness, distribution, small joint pain (hand/wrist)
 Gout: MTP joint, asymmetrical, aggravating factor (alcohol, purine)
 SLE: skin rash
 Psoriasis: well demarcated scaly extensor surface, hairline, scalp
o Functional limitation
 Exercise tolerance
 Walking distance: how long, any walking aids
 Stair case
 Activities of daily living vs instrumental activities of daily living
 Work activities
MBBS V O&T – Knee pain and OA (tutorial)

 Entertainment/leisure activities (hiking, sports)

 Religious: if need to pray
 Sexual activities
o Past medical hx
o Past surgical hx
o Drug hx and NKDA (affects management)
 Physical examination
o Look (upon standing would be more accurate)
 Lower limb alignment: varus (bent inward), valgus (bent outward)
 Scar
 Muscle atrophy
 Swelling
 Effusion
 Skin changes: discolouration, rashes, discharging sinus
 Deformity:
o Feel
 Pain: focal tenderness
 Temperature
 Swelling: bony vs soft tissue (or mass)
 Neovascular status (pulse)
o Move
 Power
 Tone
 Reflexes
 Range of motion: active and passive ROM using goniometer
 Flexion contracture
 Ligament laxity (especially elderly)
 Valgus and varus stress test for medial & lateral ligament laxity
o Specific tests
 ACL and PCL
 Medical collateral and lateral collateral ligament
o Associated tests
 Hip ROM
 Spine: straight leg raising test
 Referred pain
 LL vascular status: foot pulse (any claudication pain)
 Provisional dx: OA knee
o Mechanical pain
o Varus knee
o ROM: 10 to 100 degrees
o Affect daily living (worst on walking down stairs)
 Investigation based on hx and P/E
o X-ray (MUST for suspected OA): e.g. osteophytes
o Blood tests (e.g. RF)
o Joint aspiration (if fever)
o MRI
 X-ray of right knee (patient, date, site, supine vs standing)
o Alignment is neutral
o Narrowed joint space at medial and lateral compartment, patella-femoral joint
o Margin osteophyte and subchondral sclerosis
MBBS V O&T – Knee pain and OA (tutorial)

o Bone: other bone erosion, fracture, soft tissue swelling

 Osteophyte pathophysiology
o Cartilage erosion in OA resulting in bone-bone contact
o Varus deformity and instability
o More bone formed to stabilize
o Resulting in marginal osteophyte
 Management of OA knee
o Conservative mx
 Muscle strengthening exercise:
 Quadriceps
 Tensor fascia lata (inserts ilio-tibial band which inserts in lateral
aspect of tubercle) (lie sideways)
o Varus deformity in OA = need to train lateral tendon
 (Gluteus maximus: pelvis to greater trochanter)
 Range of movement exercise
 Lie down: and then bend knee (knee ROM to 130 degree)
 Stretching exercise
 Anaerobic exercise
 Weight loss if BMI >25
 Rest, Ice, Compression, Elevate
 Physiotherapy (knee brace? TENS? – inconclusive)
 Insole (e.g. valgus knee – no use)
 Walking aids
o Pharmacological mx
 NSAID: COX inhibitor which inhibits prostaglandin
 Oral NSAID
o Voltaren SR 100mg daily po prn x 16/52
o Ibuprofen 200mg tds po prn x 16/52
o Naproxen 250mg tds po prn x 16/52
o S/E
 GI: inhibit COX-1 result GI damage
 Renal: reduce blood flow, Na retention
 Cardiovascular: MI, stroke
MBBS V O&T – Knee pain and OA (tutorial)

 Pulmonary: bronchospasm in aspirin sensitive

asthmatic patient
o *Ulcer related complication risk factors
1. >65
2. High dose NSAID (ibuprofen >1200mg, voltaren
>100mg, naproxen >750mg)
3. Hx of complicated ulcer (GI bleed, peptic ulcer)
4. Concurrent use of aspirin, corticosteroids, anti-
coagulants
  High risk: hx of ulcer, >2 factors
 COX-2 (celecoxib, etoricoxib) + PPI
o *High cardiac risk
 Use of low dose aspirin for prevention of serious
CV event = high cardiac risk
  Naproxen + PPI (least cardio-toxic)
o *If high GI AND cardiac risk = do not prescribe
 Topical NSAID
 Tramadol (weak opioid)
 Paracetamol
 Opioid
 Mechanism of opioid:
o Mimic endogenous opioid
o Prolonged activation of opioid receptor  mu receptor
at dorsal horn of spinal cord and thalamus (pain
pathway
o G protein link to adenylate cyclase
o Open potassium channel
o Hyperpolarization
o Analgesia, sedation, euphoria
 Commonly prescribe tramadol 50mg Q6H po prn 8/52
 Growth factor
 Platelet rich plasma
 CANNOT recommend oral glucosamine, chondroitin, intra-articular
steroid, intra-articular hyaluronic acid, needle lavage (not very
convincing evidence)
o Surgical mx
 Role of surgery
 Correct alignment
 Relieve pain
 Indications
 Radiographic evidence of joint arthritis (bone-bone) AND
 Refractory to pharmacological mx
 Constant pain even at rest (or during sleep)
 Functional impairment leading to major threat to independence
or occupation/performing role
 *Survival rate 91% at 96% at 15 years follow-up
 Surgical approach
 Osteotomy
 Uni-compartmental knee replacement
o If medial compartment has pathology (more common)
 Total knee replacement
MBBS V O&T – Knee pain and OA (tutorial)

 Complications of total knee replacement

 Stiffness: 1.3-12%
o Early mobilization at day 1 (ligament need to move)
 Symptomatic instability: 1-2%
o Ligament weakness
 Infection: 1-2% (redness, swelling, may unable to walk)
 Nerve injury: 0.3%
o Popliteal nerve
o Peroneal nerve (foot drop) (at fibular neck)
 Vascular injury:
o Acute ischemia (clot)
o Potential amputation

Summary
 Underlying cause
 Standing X-ray
 Exercise and weight loss are effective
 NSAID/tramadol for pain
 Total knee replacement for end stage arthritis (aware of complications)