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Bilateral Knee Osteoarthritis Case 6 : Ruth-Ann

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Faculty/Presenter Disclosurewith Faculty’s Name:

Faculty’s Name: Faculty’s Name:

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Disclosure of Commercial Support

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Mitigating potential biasN/A N/A

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N/A

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Objectives

When working with CPP, you will be able to:

Identify key elements of osteoarthritis history

List 3 assessment tools that may be useful

Identity appropriate investigations Appropriate management

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Bilateral Knee Pain

Ruth Ann is a 62 yr old retired elementary school teacher

She was touring through Europe 3 weeks ago when she tripped on some cobblestone roads and landed straight on her knee caps. She noticed some initial mild swelling the next day but had significant swelling and pain after flying home.

She is gradually improving but still complains of anterior and medial pain bilaterally especially with descending stairs, prolonged standing greater than 15 minutes and with using the elliptical machine at the gym.

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What are your Key Questions?

How do you determine if this is osteoarthritis or a structural trauma?

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Common Patient History for MSK Complaints

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History

Prior to her fall 3 weeks ago, she complained of intermittent knee pain with long walks and gardening. She had never sought medical care for this complaint but often used a menthol rub for relief of aching.

She currently describes intermittent deep aching, like a bruise, that is combined with occasional sharp pain under her knee cap especially with going down stairs.

She get relief with heat and rest.

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Joint Pain Questions

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Osteoarthritis comparison to Inflammatory Arthritis

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Brief Pain Inventory Screen

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Knee Symptoms indicating Structural Instability

Swelling

Locking

Giving Way

Clicking

Sudden, large effusion versus small delayed swelling

Knee is stuck in position, indicative of meniscal tear

Knee buckles, unexpected fall, instability from ligament tear, large meniscal tear

Common and often non-painful, often patellar related

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Functional Assessment Screening Question

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Physical Exam What physical examination techniques would

you use?We found:

Right Knee active flexion 110 degrees - pain end range, Passive flexion is 125 degrees - pain end range.

Left Knee active and passive flexion is full.

Patellar compression causes pain on right knee

Mild Joint effusion on right knee

Ligaments and mensici are intact

Gait demonstrates mild limp on right for first 5 steps then normalizes.

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Physical Exam

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Pain and Function

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Management Tools

How would you determine if investigations were appropriate ?

We used:

a) Is there poor or no response to appropriate treatment?

b)Are pain levels unmanaged with best medications?

c) Are there prolonged rheumatological symptoms greater than 6 weeks ?

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What is best Management

Ruth-Ann has mild to moderate osteoarthritis likely in the patellar and medial compartments

Her pain is improving but she is hesitant to continue with activity for fear of flaring her symptoms

Best Practice would focus on: Medications Rehabilitation and Exercise Patient Education and Self- Management

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Pain Relief

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Pain Relief

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Medication Advice

Acteominophen extended release 650mg TID, po x 7 days then prn

When to use an NSAID? When to use a Topical ? When to recommend Injection?

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Ruth-Ann wonders if this new diagnosis will lead to a knee replacement?

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Follow-Up

Monitor and Manage Swelling Pain Function

Enhance Education Promote Self-Management

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Goal Setting

Ruth-Ann is improving on her follow-up visit 3 weeks later.

She is using occasional pain medication after prolonged activity

She is back to her daily activities She would like to discuss “safe exercise” as

she has decided to join a seniors gym program and lose some weight.

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Key Resources for your patients

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Clinical Impression Bilateral Knee Osteoarthritis

Right worse than left Patellar and Medial compartments

Mild to Moderate Pre-existing mild with moderate exacerbation

after trauma

Managed with pain medications, rehabilitation exercise, education and promotion of self management

Investigations if concerned about inflammatory symptoms

Xrays if suspected fracture or for OA prognosis

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Key Clinical Information

What are the key criteria for Osteoarthritis? Morning Stiffness less than 30 min. Intermittent Pain associated with activity Recurrent episodes May lead to bony deformity and decreasing

function

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Summary

When working with Osteoarthritis, it is important to:

- Identify the differences between inflammatory and non-inflammatory joint disease

- Focus on Pain and Function in assessment and management

- Focus on patient self management for lifestyle factors

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References

Arthritis Resource Guide, Arthritis .ca

Guidelines and Protocols Advisory Committee Bcguidelines.ca