Hey Frank what do I do with all the older patients that I’m seeing with disabling non-traumatic knee pain or dysfunction??
“My knee is giving way – hurts all the time, I have stiffness in the joint – have difficulty climbing stairs, kneeling or crawling. I have had arthroscopic surgery several years, was told I had a medial meniscal tear, surgery helped some but didn’t resolve all my symptoms. I want to be more active!!”
A healthy knee joint must respond to a variety of mechanical, cellular, and biochemical changes to maintain the health of the joint. Trauma and isolated cartilaginous lesions cause degeneration of the joint surface, resulting in osteoarthritis.
Problems with knee dysfunction can be multi-factorial; therefore, it is important to do a complete history and physical and maintain clinical vigilance of non-knee joint disease states contributing to, or causing the patients symptoms, such as degenerative lumbar or hip disease, chronic pain, vascular disease, metastatic disease, osteochondral stress fracture, etc. Remember to “OWN THE BONE” when you evaluate these patients with knee issues – think about the patient’s overall bone health.
History and Physical
The initial focus should be a thorough history followed by a complete exam of the patient’s knee/ hip/ back and sometimes ankle/foot. A complete exam must include observing the patient moving from a sitting position to standing position, stand and walking. Frequently, older patients that are complaining of knee and leg pain have radicular symptoms from the lumbar spine and are suffering from lumbar spinal stenosis which complicates their knee and or leg symptoms, or they can have concomitant ankle/foot disease which can complicate their gait and effect weight loading in their knees.
Physical Exam Knee
On knee exam, you should observe for angular deformities, effusion, loss of terminal extension/flexion, and instability, and evaluate muscle strength. Look for vascular changes in the leg/ ankle or foot.
Please also examine for a range of motion of the hip/ankle/ foot. Watch the patients ambulate, look for ankle/foot degenerative changes, midfoot collapse, tibial tendon dysfunction, and fixed deformities of the toes. Always document that protective sensation is intact in the foot especially with diabetic patients.
Initial diagnostic studies should include weight-bearing three view knee x-rays (ap/lateral/sunrise) because this is necessary to evaluate all three compartments of the knee. Consider hip, lumbar, and ankle/foot x-rays based on history and physical exam findings.
Refrain from ordering advanced diagnostic studies (MRI knee) unless suspicious for subchondral fracture, the patient is having significant mechanical issues, or you have concern for a bone lesion. Patients are frequently confused when providers order MRI knee exams and are told based on the findings that “they need knee arthroscopy or joint replacement” in order to “fix them”.
The initial focus in the treatment of all patients with degenerative joint disease of the knee should be on weight loss (if indicated) and muscle strengthening. The most important take-home points for the conservative management of degenerative knee disease is to take the time to review evidence-based treatment guidelines and educate patients on the myriad of conservative treatment options:
- American Academy of Orthopedic Surgeons: https://www.aaos.org/cc_files/aaosorg/research/guidelines/treatmentofosteoarthritisofthekneeguideline.pdf
- Committee of the Osteoarthritis Research Society International (OARSI). https://www.oarsi.org/sites/default/files/docs/2014/non_surgical_treatment_of_knee_oa_march_2014.pdf
- American College of Rheumatology (ACR) https://www.rheumatology.org/Portals/0/Files/ACR%20Recommendations%20for%20the%20Use%20of%20Nonpharmacologic%20and%20Pharmacologic%20Therapies%20in%20OA%20of%20the%20Hand,%20Hip%20and%20Knee.pdf
- National Institute of Clinical Excellence (NICE) file:///C:/Users/Frank/Downloads/musculoskeletal-conditions-bone-and-joint-conditions.pdf
In my clinical practice, I take time educating patients on why it is important to use evidence-based treatment guidelines, and focusing on comorbidities that can contribute to their joint dysfunction. I find that the appropriate use of intra-articular steroids and viscosupplementation in the knee can be helpful in alleviating symptoms and allowing greater and less painful knee joint function.
I spend a great deal of time on refocusing the patient on what is going on in their joint (or body), clarifying information that has been provided to them from providers, family, friends or internet sources and allowing them to participate in choosing a course of treatment options.
In the treatment of degenerative joint disease of the knee I have four goals:
- Do everything possible to maintain their knee joint function without surgical intervention
- Offer them a plan of treatment that includes their input
- Prepare them for joint arthroplasty if all conservative efforts fail
- Offer a palliative treatment plan for those patients that are not candidates for joint arthroplasty.
I have found this four-stage approach offers something for all patients that present with degenerative knee joint disease.
Biologics and Treatment of Degenerative Joint Disease of the Knee
Interest in the use of biologics has rapidly increased because they provide for a minimally invasive way to modify disease with relatively short recovery periods. The best advice I can give you at this time is to STAND BY………the general feeling of all the folks that develop our evidence-based treatment guidelines is the clinical use of biologics to treat OA of the knee has greatly outpaced the evidence!!!