MKSAP Quiz: progressive right knee pain
MKSAP Quiz: progressive right knee pain
A 72-year-old woman is evaluated for a 1-year history of progressive pain in the right knee. The pain is most acute along the medial aspect of the joint, worsens with activity, and is relieved with rest. She has no stiffness in the morning and has had no swelling. She also has not experienced locking or giving way of this joint.
On physical examination, vital signs are normal. There is bony enlargement of the proximal and distal interphalangeal joints. There is no evidence of a right knee effusion. Passive flexion and extension of the right knee are painful.
Laboratory studies, including complete blood count, erythrocyte sedimentation rate, and C-reactive protein, are normal. Radiograph of the right knee also is normal.
In addition to acetaminophen as needed, which of the following is the most appropriate next step in this patient's management?
A. Arthroscopy
B. Aspiration of the knee
C. MRI of the knee
D. Physical therapy
MKSAP Answer and Critique
The correct answer is D) Physical therapy. This item is available to MKSAP 15 subscribers as item 38 in the Rheumatology module.
This patient has osteoarthritis of the knee. The most appropriate next step in her management is referral for physical therapy, which is an appropriate first-line management option for patients with this condition. Quadriceps muscle training in particular has been shown to reduce pain in this population group. Use of over-the-counter acetaminophen or an NSAID on an as-needed basis also may benefit this patient.
Arthroscopy and MRI of the knee would most likely reveal abnormalities of the articular cartilage not visible on plain radiography but are not needed to establish the diagnosis of osteoarthritis. Similarly, aspiration of the knee joint would be warranted in patients with an effusion to obtain a synovial fluid leukocyte count but is not needed to establish a diagnosis; furthermore, this patient does not have an effusion.
Key Point
- Physical therapy is an appropriate first-line management option for patients with osteoarthritis of the knee, and quadriceps muscle training in particular has been shown to reduce pain in this setting.