Case Study 3 -- Knee Pain

CASE STUDY 3 Knee Pain Dated: 4 April 2007 (edited 13 December 2007) Patient’s Name: Many Ow

NIRC: S04*****E

TABLE OF CONTENTS Page 1.

Patient Profile

1

2.

Health Assessment

1

3.

Physical Examination

2

4.

Diagnosis

3

5.

Management

5

6.

Evaluation

12

7.

Learning points

13

A 73-year-old ambulant Chinese elderly came to polyclinic with a chief compliant of left knee pain. This case study will focus on the approach to knee pain and management of knee pain in an elderly.

Elizabeth Ho Moon Liang

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PATIENT PROFILE Mdm Mandy Ow, (S04*****E) born in year 1933 is a 73-year-old fully ambulant elderly. She has DM for more than 10 years. In addition, she has IHD, hypertension and hyperlipidemia. She came to polyclinic on 9 Jan 2007 with a chief complain of left knee pain. This case study will focus of the approach to knee pain and management of knee pain in the elderly. HEALTH HISTORY Chief Complaint: Complained of left knee pain for 2 to 3 weeks. Increasing in pain intensity for 5 days. Rated pain score 8 over 10. Pain was localized on the anterior aspect of the knee joint. There was no history of trauma or sprain. Walking and climbing the stairs aggravated the pain. The pain was partially relieved by resting There was no other prior history of knee pains. The knee pain had affected her usual marketing trips. She complained of walking with a limp. No other joint pains were reported. There was no reported locking, popping or giving way of the knee. She noted that the left knee was mildly swollen in comparison to her right knee but could not recall when it started. Morning stiffness of both knees was reported. Duration of stiffness was less than 15 minutes and disappeared when she began activities. There was no fever. Mdm Ow has no history of knee injury or surgery. She also has no history of gout, pseudogout, rheumatoid arthritis or degenerative joint disease. She also has no family history of gout. Mdm Ow stays with her daughter. CURRENT MEDICATIONS a) Aspirin 100mg every morning b) Atenolol 50mg every morning c) Amlodipine Besylate 5mg every morning d) Captopril 25mg three times a day e) Tolbultamide 250mg twice a day f) Metformin 850mg three times a day g) Lovastatin 20mg every night h) Glyceryl Trinitrate 500mcg when necessary under tongue i) Calcium and vitamin D 1 tablet every morning

Elizabeth Ho Moon Liang

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DRUG ALLERGY: Nil reported. PHYSICAL EXAMINATION General appearance –. Comfortable. Has a BMI of 24.3. Afebrile. Gait – Stable Eyes – Conjunctivae not pallor. No conjunctivitis. Face – No rashes. a) CVS examination Pulse – 78 beats per minute. Regular. Blood Pressure – 140/ 90mmHg. Heart – Apex beat palpable between 4th and 5th ribs space. No thrills and heave felt. S1 and S2 sounds heard. No murmurs detected. Jugular venous pressure is not raised. No pedal edema. b) Lungs examination Lungs – Respiration rate of 12 breaths per minute. Trachea is not deviated. Chest expansion is bilaterally equal. No crepitations or wheeze heard. Vocal resonance is normal and uniform. c) Knee examination There is no erythema, bruising and discoloration of the left knee. There is also no point tenderness. Slight budging is seen on the medial aspect of the left knee joint. Popliteal bulging is seen at left knee posterior aspect. Musculature of both knees seems symmetric bilaterally. There is no bone deformity. On palpation, the left knee joint is not warm or tender. There is mild effusion felt. Range of movement of the left knee is full. Crepitus on both legs were felt. Pedal pulses were all intact. DIAGNOSES Probable diagnosis: Osteoarthritis of knees – acute exacerbation of left knee. Differential diagnoses: (1) Baker’s cyst (2) Patellofemoral knee pain (periarticular) (3) Degenerative Meniscus (intra-articular) (4) Rheumatoid arthritis / Inflammatory arthritis

Elizabeth Ho Moon Liang

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Due to the significant popliteal bulging on the posterior left knee, Baker’s cyst was placed high on the list of differentials. Other reasons to explain the politeal bulging can be due to an effusion response to the osteophytes in an osteoarthritis knee joint. Laboratory Tests Radiographs of both knee joints (AP, lateral views) The tibiofemoral and patellofemoral knee joint spaces are mildly reduced and associated with large periarticular osteophytes and subchondral sclerosis. There is spiking of the tibial spine and patellar poles. There is mild fullness of the suprapatellar region bilaterally, which may represent minimal joint effusion. There is diffuse osteopenia. Impression: Osteoartritis of both knee joints. Due to the age of the patient, clinical history and the lack of knee joint erythema and warmth, with the supporting evidence from the radiology report that this is most probably an osteoarthritis exacerbation. Unless there is evidence of suspected inflammation, ESR, CRP, rheumatoid factor and uric acid can be ordered to exclude rheumatoid arthritis and gout-related arthritis. When there is no prior history, one will suspect gout if the patient has a family history of gout, or on long-standing diuretic treatment (e.g. thiazide) and elderly in renal failure. In some elderly with gout, the presentation manifests as nodular gout or tophaceous gout on skin and Achilles tendon rather than the typical presentation of swollen and painful joints. However, if pain persists or remains undiagnosed despite symptomatic treatment and clinical follow-up, it is best to refer to rheumatology or orthopedic referral. MANAGEMENT Prevalence of Diagnoses in Primary Care Setting Sprains and strains account for 42% of the causes for knee pain. The prevalence of a diagnosis among patients presenting with acute knee pain in the adult primary care setting is osteoarthritis (34%), meniscal injuries (9%), collateral (7%), cruciate (4%) ligamentous injuries, gout (2%) and fracture (1.2%) (Jackson, O’Malley and Kroenke, 2003). Rheumatoid arthritis (0.5%), inflammatory arthritis (0.3%) and pseudogout (0.2%) are less common. Knowing the prevalence of diagnoses for knee pain helps to framework the probable diagnosis and differentials. Yet for

Elizabeth Ho Moon Liang

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those diagnoses that are not very common, it is good to keep the differentials in mind especially those which need urgent attention or different treatment e.g. fractures and septic arthritis. Approach to Knee Pain Clinical history taking for knee pain should include (1) characteristics of knee pain, (2) mechanical symptoms (3) effusion and (4) mechanism of injury and (5) any other medical history. Physical examination tests like Lachman maneuver, Anterior drawer test, Pivot shift test are tests designed for detecting ligamentous tear. For meniscal injuries, they are detected through and McMurray Test and supported by joint line tenderness tests (See Annex A). Role of APN is to elicit possible ligament or meniscal injusry through history and screening with appropriate physical examination. In some mensical tear cases, although there is no positive signs, patients still need to be promptly referred to the physician in view of the history. Thus a simple algorithm shown in Figure 1 can be used for an APN when approaching someone with a knee pain. Table 2 shows a set of clinical criteria for identifying osteoarthritis developed by American College of Rheumatology (Jackson, O’Malley and Kroenke, 2003). This tool has a sensitivity of 95% and specificity of 69%. Another tool (Table 3) that is developed which had 91% sensitivity and 86% specificity for osteoarthritis is based on clinical and radiographic findings. The decision whether to order a plain radiograph of the knee will help to make the diagnosis. Plain knee film is useful for osteoarthritis and for knee fracture. For this case study, the patient has no background of osteoarthrtitis. The pain is presented sub-acute over the past 2 to 3 weeks and increasing in intensity for the past 5 days. Although there is no presence of trauma, blow or fall, in view of her age 73 years old and the pain intensity of 8 out of 10, a radiograph of the knee joint is necessary to rule out fracture as a cause of acute knee pain. With other findings normal, chronic osteoarthritis can also give rise to exacerbation of the condition that will present with acute knee pain.

Elizabeth Ho Moon Liang

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History of trauma or injury? Suspicion of ligamentous or meniscus injury?

Yes

Order X-ray and refer Dr

Yes

Highly suggestive of inflammatory origin, refer Dr

No History: Morning stiffness >1hr, PE: Swollen, red and warm Higher Index of Suspicion: i) multiple joints involvement ii) history of gout or pseudogout iii) history of rheumatoid arthritis iv) compromised immune system: e.g. cancer, DM, HIV or on steroids No Fulfill 3 out of 5 American College of Rheumatology Clinical Criteria suggesting osteoarthritis

Yes

Highly suggestive of Osteoarthritis APN follow protocol to furnish medications

No Refer Dr for further examination. Figure 1: Proposed Algorithm Approach to Knee Pain At least 3 of the following: History a) Age more than 50 years b) Morning stiffness of 30 minutes and less Physical Examination c) Crepitus d) Bony enlargement e) No palpable warmth American College of Rheumatology (2003) Table 2: Clinical Criteria for Osteoarthritis Radiographic a) Osteophytes And at least 1 of 3: Physical Examination b) Age more than 50 years. c) Crepitus d) Morning stiffness of 30 minutes and less American College of Rheumatology (2003) Table 3: Clinical and Radiographic Criteria for Osteoarthritis

Elizabeth Ho Moon Liang

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For Baker cyst diagnosis besides clinical examination, the diagnosis needs to be confirmed by imaging e.g. arthrography, ultrasound or MRI. The prevalence of Baker cyst in rheumatoid arthritis, osteoarthritis and internal derangement is 5 to 58%, 42% and 5 to 18% respectively (Bui-Mansfield and Youngberg, 2007). According to Fam et al, 1982 (cited in Bui-Mansfield and Youngberg, 2007) the occurrence of Baker cysts relate directly to the presence of knee effusion and severity of osteoarthritis. Still it is crucial that during the physical examination to determine if the cyst is a simple Baker cyst or complicated Baker cyst. Any signs of redness, swelling or increasing in size of the cyst should be referred to the doctor for further evaluation. For this case study, Mdm Ow’s popliteal bulging is localized, and there are no signs of inflammation. Treatment and Plans Pain relief. Analgesics and NSAIDs are effective to most knee pain management. The American College of Rheumatology recommends paracetamol as the first choice of analgesic in patients with mild to moderate knee osteoarthritis. The maximum dosage for paracetamol is 4000mg/day (8 tablets of 500mg). Other analgesics with paracetamol can be tried e.g. Orphenadrine Citrate 35mg with Paracetamol 450mg and Paracetamol 500mg with Codeine 8mg. However these preparations of paracetmol needed to use with caution because of the possible addition to Orphenadrine and Codeine. It is important to remember that paracetamol dosage will lead to liver toxicity due to the saturation of toxic metabolites. For this consultation, Mdm Ow is given a week of Orphenadrine 35mg/ Paracetamol 450mg 2 tablets 3 times daily or when necessary. Due to the presence of the Baker cyst and her increased pain intensity. NSAID is given to her to reduce inflammation and pain. Ketoprofen SR capsule 100mg 1 capsule twice a day is prescribed. Addition to that, topical Piroxicam 0.5% gel is also prescribed. The side effects of NSAIDs should be a consideration before prescribing patient the NSAID treatment. Patient with the following criteria listed in Table 4 should be considered prescribing COX-2 inhibitors over the traditional NSAIDs for pain management. The differences in the rate of serious GI side effects are most pronounced in patients with a history of peptic ulcer and gastrointestinal bleeding according to University of Michigan Health System (2005).

Elizabeth Ho Moon Liang

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Patient: 1) has a history of upper GI bleeding 2) is receiving chronic, high dose systemic corticosteroids 3) has presence of a bleeding disorder 4) is receiving anticoagulants 5) has a documented intolerance to traditional NSAIDs 6) elderly patients with multiple comorbidities **Precaution: In patient with known coronary heart disease** Table 4: COX-2 Criteria and Precaution For this case although Mdm Ow is on Aspirin, she has no bleeding disorder or history of upper GI bleeding. To prevent NSAIDs-induced gastrointestinal side effects, H2 antagonist Famotidine is prescribed together. Proton pump inhibitors may also be considered to be prescribed together to prevent NSAIDs-induced side effects. According to a systematic review that compared five strategies, listed in Table 5, for the prevention of NSAIDs induced gastrointestinal toxicity, traditional NSAID plus H2 antagonist is the most cost-effective strategy for avoiding endoscopic ulcers in patients requiring long-term NSAID therapy (Health Technology Assessment, 2006). 1) Cox-1 NSAIDs plus H2 antagonists 2) Cox-1 NSAIDs plus PPIs 3) Cox-1 NSAIDs plus misoprostol 4) Cox-2 coxib NSAIDs 5) Cox-2 preferential NSAIDs Table 5: 5 Strategies to prevent NSAID-induced GI toxicity compared in Systematic Review (Health Technology Assessment, 2006) Regarding the addition of topical NSAIDs in the treatment plan, there are studies that provide evidence that topical NSAID is better than placebo. Besides the efficacy between topical NSAIDs and oral NSAIDs is comparable with not much difference in the outcomes. The side effects for topical NSAIDs are lower as topical NSAIDs do not cause the gastrointestinal harm found with oral NSAIDs, nor are they associated with increased renal failure (Bandolier 110, 2007 and Mason et al, 2004). The topical NSAIDs used for comparison in the studies are Piroxicam 0.5% gel, Diclofenac 1% gel and Eltenac 1% gel. Comparing the efficacy among the topical analgesics in chronic musculoskeletal pain management, topical NSAIDs is more effective than topical Salicylates and Capsaicin (Mason et al, 2004). The list of medications that is prescribed to Mdm Ow is as below: 1) Orphenadrine 35mg/ Paracetamol 450mg 2 tablets 3 times a day when necessary

Elizabeth Ho Moon Liang

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2) Ketoprofen SR capsule 100mg 1 capsule twice a day 3) Famotidine 20mg 1 tablet twice a day 4) Topical Piroxicam 0.5% gel 30gram Evidence for glucosamine and chondroitin in OA knee treatment. The place for glucosamine in the treatment of OA knee has been debatable. Bandolier 46’s (2007) systematic review helped to confirm the value of glucosamine and chondroitin in knee osteoarthritis. Both glucosamine and chondroitin appear to decrease pain and improve function than patients on placebo. Glucosamine also significantly reduced joint space narrowing by about 0.27mm compared with placebo over 3 years. Furthermore, they are quite safe with few side effects, particularly in comparison to NSAIDs. As many as 1 in 5 patients with knee arthritis will benefit from using oral glucosamine at 1500mg daily. The recommended doses for Chondroitin range from 800 to 2000mg daily. Non-Pharmacological Treatment. There were too few studies to draw firm conclusions to the effectiveness of non-pharmacological treatment to relieve osteoarthritis exacerbation pain (Bandolier, 2007). These studies of non-pharmacological interventions include superficial and deep heat, cold, exercise, weight loss, acupuncture, transcutaneous electrical nerve stimulation, low energy laser vibration, topically applied creams, pulsed electromagnetic fields and orthotic devices. The best evidence exists for exercise, which the trials that were conducted showed an improvement in pain and functional status. Long-term Management. The long-term management for Mdm Ow focuses on adequate calcium and vitamin D intake, exercise and prevention of falls. During consultation, it is also important to screen Mdm Ow is she has any risk factors for falling (Table 6) and other concomitant conditions that increase risk of osteoporosis deterioration. This will give an overview of the patient’s profile to see if more aggressive treatment in osteoporosis deterioration is needed. According to UMHS (2005) guidelines, the recommended dose of calcium intake for an individual, excluding food calcium, is from 1000 to 1500mg. Constipation is common for this treatment and nephrolithiasis is not a contraindication. There is evidence that vitamin D supplementation at relatively high doses 700 to 800IU/day reduces risk of hip fracture among older mean and women aged 60 and above than at lower doses of 400IU/day. Sun exposure to hands, arms and face for 10 to 30 minutes per day 2 to 3 times per week can be equivalent to

Elizabeth Ho Moon Liang

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400IU/day. The recommended tolerable upper intake level for vitamin D is 2000IU/day. Sun exposure is unlikely to result in vitamin D toxicity. · Use of any benzodiazepine or sedative/ hypnotic agent · Frailty · Environmental hazards for falls · History of falls · Impaired vision · Impaired cognition · Impaired gait, balance or transfer skills · Impaired leg or arm muscle strength or range of motion · Low physical function · Postural hypotension Table 6: Risk Factors for Falling EVALUATION The follow up visit include evaluating Mdm’s Ow response to the acute pain management and starting the long-term management plan. If the pain is persistent for more than 1-month despite treatment, referral to the orthopedic should be considered. APN RFLECTION AND LEARNING POINTS Knee pain is a very common presentation in the polyclinic setting. It is also a very common problem an APN will need to problem solve even when managing patients with chronic diseases. The approach algorithm will be a good guide for the practicing APN to be full aware of what kind of knee pain should seek doctor’s consultation.

Elizabeth Ho Moon Liang

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REFERENCES Bandolier (2007). Non-pharmacological interventions for osteoarthritis of the hip and knee. Retrieved from http://www.jr2.ox.ac.uk/bandolier/booth/painpag/Chronrev/OARA/CP011.html on 3 April 07. Bandolier 47 (2007). Glucosamine and chondroitin for knee OA. Retrieved from http://www. jr2.ox.ac.uk/bandolier/booth/Arthritis/glocOA.html on 3 April 07. Bandolier 110 (2007). Topical NSAIDs for OA: update. Retrieved from http://www.jr2.ox. ac.uk/bandolier/band129/b129-2.html on 3 April 2007. Bui-Mansfield, L.T. and Youngberg, R.A. (2007). Baker cyst. Retrieved from http://www. emedicine.com/radio/topic72.htm on 23 March 2007. Health Technology Assessment, (2006). A comparison of the cost-effectiveness of 5 strategies for the prevention of non-steroidal anti-inflammatory drug-induced gastrointestinal toxicity: a systematic review with economic modeling. Retrieved from http://www.hta.ac. uk/pdfexecs/summ1038.pdf on 3 April 07. Jackson, J.L/, O’Malley, P.G. and Kroenke, K. (2003). Evaluation of acute knee pain in primary care. Annals of Internal Medicine, 139 (7), pp. 575-588 Mason, L., Moore, R.A., Edwards, J.E., Derry, S. and McQuary, H.J. (2004). Topical NSAIDs for chronic musculoskeletal pain: systematic review and meta-analysis. BMC Musculoskeletal Disorders, 5: 28 retrieved from http://www.biomedcentral.com/content/pdf/1471-2474-528.pdfon 3 April 2007. University of Michigan Health System (2005). Guidelines for Clinical Care -- Knee pain or swelling: acute or chronic. Retrieved from http://cme.med.umich.edu/pdf/guideline/knee.pdf on 16 March 2007. University of Michigan Health System (2005). Guidelines for Clinical Care – Osteoporosis: Prevention and Treatment. Retrieved from http://cme.med.umich. edu/ipdf/guideliens/osteoporosis.pdf on 4 April 2007. READINGS Calmbach, W.L. and Hutchens, M. (2003). Evaluation of patients presenting with knee pain: part 1 – history, physical examination, radiographs and laboratory tests. American Family Physician, 68(5): 907-912. Calmbach, W.L. and Hutchens, M. (2003). Evaluation of patients presenting with knee pain: part 2 – Differential diagnosis. American Family Physician, 68(5): 917-922. Dixit, S., Difiori, J.P., Burton, M. and Mines, B. (2007). Management of patellofemoral pain syndrome. American Family Physician, 75(2): 194-202. Feng, P.H. (2003). Therapeutic agents in joint pains. The Singapore Family Physician 29(3): 1719.

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Lau, T.C. (2002). Osteoporosis. The Singapore Family Physician, 28(2): 9-16. Leong, K.H. (2003). Osteoporosis. The Singapore Family Physician. 29(3): 12-13. Satkunananthan, K. (2003). Osteoarthritis of knee and hip. The Singapore Family Physician, 29(3): 14-16. ANNEX A Physical Examination Tests for the Knee Joint Anterior drawer test Place patient supine, flex hip to 45 degrees and the knee to 90 degree. Sit on the dorsum of the foot, wrap your hands around the hamstrings (ensuring that these muscles are relaxed), then pull and push the proximal part of the leg, testing the movement of the tibia on the femur. Do these maneuvers in 3 positions of tibial rotation: neutral, 30 degrees externally, and 30 degrees internally rotated. A normal test result is no more than 6 to 8 mm of laxity. Lachman test

Place patient supine on examining table, leg at the examiner’s side, slightly externally rotated and flexed (20 to 30 degrees). Stabilize the femur with 1 hand and apply pressure to the back of the knee with the other hand with the thumb of the hand exerting pressure placed on the joint line. A positive test result is movement of the knee with a soft or mushy end point.

Pivot test

Fully extend the knee, rotate the foot internally. Apply a valgus stress while progressively flexing the knee, watching and feeling for translation of the tibia on the femur.

McMuray test

Flex the hip and knee maximally. Apply a valgus (abduction) force to the knee while externally rotating the foot and passively extending the knee. An audible or palpable snap during extension suggests a tear if the medical meniscus. For the lateral meniscus, apply a varus (adduction) stress during internal rotation of the foot and passive extension of the knee.

Joint line tenderness

Palpate medially or laterally along the knee until one comes to the joint line between the femur and tibial condyles. The presence of pain on palpation is a positive finding. Annals of Internal Medicine, 2003, 139 (7): 575-588.

Elizabeth Ho Moon Liang

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