E-case #D-9

Victoria Allen, M.D.

March 31-April 4, 2003

CC: Knee pain

HPI:  A 75 year old woman presents to clinic to discuss worsening knee pain.  The pain has been present for approx. 2 years, seems to worsen slightly with activity and relieved by Tylenol or Advil.  The patient has assumed it was "a touch of arthritis" and has not sought care for this issue prior to this visit.

The reason she is interested in discussing her knee pain is related to an upcoming extended tour of Europe.  A friend told her to "come to the doctor to get a cortisone shot prior to the trip so her knee won't hurt while walking on all of those cobblestone paths and ruins".  She would like to discuss the pros and cons of cortisone injection.

Pex:

Healthy appearing, normal weight. General examination normal.

Knee examination: normal appearing, no erythema or effusion. Significant crepitus in both knees, no ligamentous instability.

Plain films weight-bearing show mild joint space narrowing, otherwise normal.

Discussion

Osteoarthritis, the most common joint disease, is characterized by progressive loss of articular cartilage, trabecular bone formation and osteophytes.  Radiographic evidence of OA can be found at some site in the majority of people older than 65 years of age.  More than 80% of those over the age of 75 are affected.  OA is a major cause of disability, and knee OA is more likely to result in disability than osteoarthritis of any other joint.  Risk factors include family history, obesity, trauma and repetitive stress.

Treatment  includes physical therapy, medications, weight reduction, and assistive devices (canes and walkers).

Use of cortisone injection is indicated in acute flares unresponsive to oral medications.  Use of injections should be infrequent especially in weight-bearing joints.

I recently attended a University of Washington CME course on Office Orthopedics and attended a workshop on knee examination and injection.  They taught the use of the superolateral approach as easiest, least painful and least side effects, especially vasovagal events.  I have enclosed their handout for your information. (For Madison providers, it is on Christopher Smith's office windowsill.)

This patient declined injection for her knees, agreed to purchase good shoes and take Tylenol on a regular schedule while traveling.

Editor's note: I have found a wonderful book written by clinicians at Tufts that I recommend to all patients like this with OA.  It is full of practical advice regarding diet and exercise, and is easily understood by a wide audience:

Strong Women and Men Beat Arthritis, by Miriam Nelson, PhD.  Putnam books.