MKSAP Quiz: Treatment for chronic knee pain
A 72-year-old man is evaluated for chronic right knee pain with morning stiffness lasting 15 minutes. He is experiencing increased difficulty walking because of knee pain. Following a physical exam and prescription for topical diclofenac, what is the most appropriate additional treatment?
A 72-year-old man is evaluated for chronic right knee pain with morning stiffness lasting 15 minutes. He is experiencing increased difficulty walking because of knee pain. He has no other medical problems other than overweight. His only medication is acetaminophen, which provides minimal pain relief.
On physical examination, BMI is 34. There is bony hypertrophy of the knee without effusion or signs of inflammation. He has moderate pain with full knee flexion but no restriction of motion. The remainder of the examination is noncontributory.
Topical diclofenac is prescribed.
Which of the following is the most appropriate additional treatment?
A. Exercise and weight loss
B. Massage therapy
C. Mobilization/manipulation and passive range of motion
D. Transcutaneous electrical nerve stimulation
MKSAP Answer and Critique
The correct answer is A. Exercise and weight loss. This content is available to MKSAP subscribers as Question 82 in the Rheumatology section. More information about MKSAP is available online.
The most appropriate additional treatment for this patient is exercise and weight loss (Option A). The 2019 American College of Rheumatology (ACR)/Arthritis Foundation (AF) guideline strongly recommends exercise for all patients with osteoarthritis (OA). The most robust evidence supports exercise in the treatment of knee and hip OA; less evidence is available for hand OA. Many helpful exercises are available for knee and hip OA, and the evidence indicates that no one exercise program is superior. However, the best program is likely the one to which the patient will adhere. Walking is the most common form of aerobic exercise evaluated in studies, either on a treadmill or as part of a supervised community program. Strengthening exercises with the use of isokinetic weight machines, resistance exercises, and isometric exercise also provide value. Aquatic exercise often encompasses aspects of aerobic fitness exercises and exercises for enhancing joint range of motion in a low-impact environment. The ACR/AF guideline notes a dose-response relationship of weight loss and resultant symptom and functional improvement in patients with OA who have overweight or obesity. Weight loss attempts coupled with an exercise program increase the benefit to the patient. Even small amounts of weight loss (5%) can have a positive effect on pain and function.
The ACR/AF recommends against the use of massage therapy (Option B) in the treatment of OA because efficacy data are lacking. Massage therapy may have other benefits, but none that pertain to outcomes specific to knee OA have yet been demonstrated.
The ACR/AF recommends against mobilization/manipulation and passive range of motion (Option C) for knee and/or hip OA. Although manual therapy can be of benefit for certain conditions, such as chronic low back pain, data show little additional benefit over exercise alone for managing OA symptoms.
Studies examining the use of transcutaneous electrical nerve stimulation (TENS) (Option D) have failed to demonstrate benefit in patients with knee OA. The ACR/AF guideline strongly recommends against the use of TENS.
Key Points
- Exercise is beneficial in hip, knee, and hand osteoarthritis; no one exercise program is superior.
- There is a dose-response relationship of weight loss and symptom and functional improvement in patients with overweight or obesity and osteoarthritis that begins with 5% loss of body weight.