So, move to our final case24 April of 2008
So, move to our final case. The bottom line here is that osteoarthritis is not necessarily a disease of older people. There are ways to modify it coming up. There are other ways to treat it that mimic more surgical procedures and may be preferable to use those instead of the surgical procedures.
Our last case – back to younger people – by that I mean a 22-year-old graduate student who had knee pain several weeks into the new semester. This was described as anterior knee pain, worst with prolonged sitting, climbing or descending stairs. She had occasional sense of catching, locking and giving way. (more…)
This is title irrigation in practice
This is title irrigation in practice. There’s really not much to it. Anesthetizing the joint and the skin and putting in a 14-gauge needle that’s hooked up to a device that lets you run fluid through it, a liter, and about 60 cc aliquots. In the early 90’s we tested this prospectively in 15 different centers and these are the outcome measures. The dark lines are people who underwent irrigation, the light lines are the people who had ongoing medical management, close attention only. And there’s a significant trend towards pain relief after these various activities at 12 weeks of follow-up. Trying to expand on the lavage effect, analysis of the lavage effect, and also look at what arthroscopy tells us in early knee OA. Less than a year of symptoms, less than grade II on x-ray, but satisfying ACR criteria.
The effect of arthroscopy in osteoarthritis23 April of 2008
There have been, in different forms, some prospective studies examining the effect of arthroscopy in osteoarthritis, the knee. In 1991 a couple of groups in Nottingham took advantage – there were different referral patterns in the two orthopedists in town. Some went and always got arthroscopy and some went and always got physiotherapy. So over a couple of years looked at … they ended up with 39 patients undergoing lavage and 24 undergoing physiotherapy and at the end of 6 and 12 months of follow-up there was a trend. And it reached some significance that the lavage people had a bit more pain relief. A smaller study looking at patients who underwent arthroscopic debridement versus arthroscopic lavage actually found not only no difference between the two, but no benefit really in either group after a short term follow-up. A larger, very ambitious study done years ago in Chicago by Bing Chang and Bill Arnold and others looked prospectively as arthroscopic debridement versus title irrigation; title irrigation being a wash out of the knee with a liter of fluid put through a large port cannula. After 12 months of follow-up in their study, which comprised 18 in the surgery group and 14 in the titled irrigation group, there was really no difference between the two in all various outcome measures. (more…)
I want to show you a quick example
I want to show you a quick example here of doing a quadriceps setting exercise but doing it in the functional position, so the person is standing and they are getting the motor learning they need to contract the quadriceps at the proper time and gait. We did our best, we did all we could, however after four weeks of doing his exercises there was still pain and swelling, minimal strength gains and no change in his sense of stability. So I referred him back to my favorite rheumatologist. (more…)
This is just an idea22 April of 2008
This is just an idea of why having a pronated foot can be such a problem to the knee, and I think we should look at this as maybe why women have more knee OA than men. Floor contact forces go here, body weight forces go here. You can see here that there is a discrepancy between floor contact and body weight coming down. More body weight, a greater Q-angle, more genu varus at the knee. You are going to increase this distance here and as the talus comes down you will get more stresses on the knee. So this person particularly we really need to support the foot and try to keep that from happening. Our plan is actually to put her on a home program that was reported by O’Reilley and colleagues, which I’ll show you here in a minute. But we also need to really work on stretching her plantar flexors. What you are seeing here is the regular plantar flexor stretch but using a little rolled up towel to make sure that they get supination in the foot when they stretch their plantar flexors. Stretching over a pronated foot not only is not particularly effective but it really stretches the plantar fascia and people can end up with an awful lot of foot and heel pain.
Now for this particular person21 April of 2008
Now for this particular person, we aspirated and injected her knees and also injected her pes anserine bursa but still said there were some issues which she should address with a physical therapist.
Our biomechanical findings in this person were much like some of the others that we have seen. Bilateral knee and plantar flexor weakness in this case as well as lack of ankle dorsiflexion. She has bunions as well. She also has more pronounced calcaneal valgus on weight-bearing and does have pronounced pronation. Her body mass index is over 30, which we know puts her well in the range of being obese. What we plan to do is address the foot posture and lack of dorsiflexion that contribute to her knee pain and bunions. She has problems with lower extremity alignment and strength that produces and unstable knee and poor shock absorption, which contributes to joint stress and damage, we speculate. She is sedentary, deconditioned, overweight, possibly depressed judging from her posture and her affect, and at high risk for secondary illnesses related to inactivity.
As clinicians who look begin to realize
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.
You don’t need a heart attack to change your life15 April of 2008
It just goes to show you that you don’t need a heart attack to change your life. Sometimes it may be just a sore knee. Our third case is knee pain in a 60-year-old female homemaker who has had bilateral knee pain, worsening over the past year. Constant pain, especially at night. Pain with stairs, rising from a chair. She hurts to stand for more than 30 minutes. On exam both knees were slightly warm with small effusions. She did have focal tenderness distal to the medial joint line and had tri-compartmental crepitus both knees, femoral both weight-bearing surfaces. X-rays confirmed that she had moderate OA in both knees, particularly the medial compartment.
We also have to think about this fellow in terms of his aerobic activity. Farmers and people who work with heavy equipment do a lot of lifting, do a lot of climbing, but really don’t get very much regular activity that we would consider aerobic or cardiovascular. I’m showing you this slide because this is from some data that we have that we haven’t published yet. What we are looking at here is expected cardiovascular fitness of individuals. This is a group of adults with a variety of rheumatic diseases, not just OA. This is where we would expect everybody to fit if they were normal … if they had average cardiovascular fitness for a person their age. This line here shows 120 minutes a week of some kind of aerobic activity. As you can see, most of our sample are reporting no exercise at all, but what it interesting is that they are not all down in this quadrant. They spread the line along here.