As clinicians who look begin to realize is there are lots of tender spots around OA knees in patients complaining of pain. What might they be? Well, orthopedists have long considered focal joint pain tenderness at the joint line as meniscus disruption. That may not be so. They’ve examined that themselves and have found that to actually be a pretty poor predictive sign. Talk about osteophytes stretched in the capsule causing pain, all the various insertions of muscles and tendons about the joint in the capsule can be irritated and inflamed and sources of pain. There are several bursae besides the pes anserine bursa. There is on under the medial collateral ligament. Of course there is the prepatellar bursa and the infrapatellar bursa. Tender points can serve as being referred from other areas and other things such as bony problems can sometimes have focal superficial tenderness. Here’s an indication of what an orthopedist thinks of when they palpate on the joint line, thinking that may indicate meniscal disruption underneath. In several prospective studies they have found that this is sensitive but poorly specific because osteoarthritis without meniscal disruption also has a tender joint line, very commonly.
Here we see some common tender points and all the places they correspond to. This is the enthesis of the tibial fibular joint, the insertion the origin and insertion of the medial collateral ligament, later collateral ligament, insertion of the quadriceps muscle onto the superior popliteal patella, the medial synovial plica, sometimes there are lateral plica, joint line, tibial tuberosity for parapatellar insertion. In the back we have some other insertion sites, joint line and popliteus muscle. But when other cultures have addressed the tender points … well, before we get to that. Tender points have been examined fairly systematically in a recent study, a small study. When they looked at the effect of intraarticular anesthesia on patients with knee pain – simple study of 40 patients with knee pain, 10 they injected with lidocaine. They carefully examined the knees beforehand and then after. They also had patients complete questionnaires. This is actually … their main take-home point was that not everybody with a sore knee gets better after the injection, but most do and thus a lot of the pain really is mediated from intraarticular structures. Yet, if we look here at the various tender points that they found at baseline – and most of the patients had most of the tender points present – that not all of them are obliterated by intraarticular anesthesia, particularly this last one. Five centimeters before the medial joint line, or pes anserine bursa, nine had that before and seven had that later. So that’s an extraarticular source of pain that’s not modified by intraarticular treatment. The savvy old clinician will sometimes inject all these other tender points too, and I’ll confess to doing that myself, from time to time. The justification really isn’t in the form of data but in a few very old descriptions in the back of some foreign medical journals. But perhaps there are quite a few out in the audience that do the same thing.
Other cultures pay attention to tender points about the knee and modify them in different ways. Notice how Ling Lang Kwan _ corresponds quite well to the pes anserine tender point. There is growing literature on the use of acupuncture in the treatment of osteoarthritis knee pain. The latest coming out of Baltimore published earlier this year, in which they took eight of these spots – and I confess, I don’t know which eight, but these are at least four – and subjected half their group to acupuncture treatments twice a week for eight weeks, and their control group was a similar group of patients with knee OA and pain who went about their conventional therapy with the same number of follow-up visits. So they had some observational effect. Certainly the acupuncture people had quite a significant reduction in their pain scores, compared with those who went on with medical therapy. Their pain began to rise a little bit after the completion of the acupuncture treatment, but overall it was an effective way of reducing their knee pain.
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