Case Study 1

Case Presentation

Mrs Jones , 55 years old, came to a musculoskeletal specialist seeking advice for a 3year history of progressively worsening pain in both knees. Her knees were stiff for about 20 minutes when she arose in the morning and for a few minutes after getting up from a chair during the day. She had difficulty walking > 30 minutes because of pain, and her symptoms were exacerbated by kneeling, squatting, or descending stairs. Although sitting, resting, and reclining relieved her pain, she became stiff if she stayed in one position for too long. Her symptoms were worse on humid or cold days, and she occasionally felt as if one of her knees would “give out.” Mrs Jones was slightly obese, and physical examination of the lower extremities revealed mild genu varum, which suggested medial compartment involvement. Her gait was mildly antalgic, and passive range of motion of both knees indicated palpable crepitus. She was unable to flex or extend her knees completely. While a physically active osteoarthritis patient commonly has a maximum flexion < 130° (compared with a normal maximum flexion of 140° to 150°), this patient’s was < 120°. In addition, in patients with severe osteoarthritis, it is not uncommon to have a partial (<'10°) loss of extension. Mrs Jones had 8° loss of extension. Patellar facet tenderness was determined by palpation. There was tenderness over the joint line and patellofemoral crepitus, which is common in patients with osteoarthritis of the knee. There was moderate warmth and soft-tissue swelling. Patellar tilt was determined clinically and, with the knee in full extension, patellar glide was measured by assessing how far the patella translated medially and laterally. Mrs Jones exhibited moderately severe decreased patellar glide both medially and laterally. Knee stability was determined in the coronal (varus/valgus) and sagittal (anteroposterior) planes. Patients with medial inflammation and a varus deformity commonly have medial pseudolaxity, which is a sensation of valgus laxity as the varus deformity is manually corrected with the patient supine and the leg extended. As expected, Mrs Jones presented with medial pseudolaxity with mild instability. In addition, patients may have increased tibial translation on both Lachman’s testing and anterior drawer testing, and a positive pivot shift maneuver, indicating a chronic anterior cruciate ligament insufficiency, which can lead to osteoarthritis. However, the examination indicated that this patient had none of these findings. Examination of Mrs Jones’s hands revealed enlargement of some of the proximal interphalangeal joints (Bouchard’s nodes) and some of the distal interphalangeal joints (Heberden’s nodes). There was a squaring at the bases of both thumbs at the carpometacarpal joints. The feet demonstrated similar deformities, with enlargement and reduced dorsiflexion of the first metatarsophalangeal joints. Upon further questioning, the patient admitted experiencing occasional pain and stiffness in these joints. Because of the prevalence of atherosclerosis in the older population, a thorough neurovascular examination was performed on this patient. Her distal pulses were intact,

as was sensation, and there was no evidence of cyanosis, clubbing, or edema. The examination showed no signs of neurovascular compromise. Had any of these findings been evident, a complete vascular workup would have been obtained, including blood work, to look for indications of a hypercoaguable state. If either neurovascular compromise or evidence of coronary artery disease had been found, then the riskbenefit ratio of prescribing a cyclooxygenase (COX)-2 inhibitor would have been weighed. Mrs Jones’s hip and back were examined thoroughly, as well, to rule out any contribution to the knee symptoms. She had full range of motion (ROM) of the lumbosacral, and all motions were pain free. Her hip examination showed decreased internal ROM, but motions were pain free and symmetric. These findings indicate that neither hips nor back was contributing to this patient’s symptoms. However, she had a leg length discrepancy, with her right leg being 0.5 cm shorter than her left. Leg length discrepancy can contribute to a patient’s symptoms and affect the treatment plan. In cases where such a discrepancy is contributing to a patient’s symptoms, both surgical and nonsurgical interventions can be considered. With Mrs Jones, the difference was < 5 cm, so correction was not necessary. Radiographs showed osteophytes, joint space narrowing, and subchondral bone sclerosis in both of her knees. Treatment: Nonpharmacologic Interventions Mrs Jones had moderate bilateral knee osteoarthritis. She was given educational material regarding her condition and informed of further resources, including the Internet and the Arthritis Foundation. The specialist discussed with Mrs Jones various pharmacologic and nonpharmacologic treatment options and lifestyle modifications that may result in better control of her osteoarthritis pain and increase her ability to function. She was advised that weight loss has been shown to decrease joint stress and pain and to improve ability to exercise.8,9 Data have shown that a 12-lb weight loss can decrease the chance of developing osteoarthritis in women by 50%. In addition, Mrs Jones was cautioned to avoid high-impact activities like running and jumping, and encouraged to take up low-impact activities such as swimming and bicycling, which have been proven most beneficial for the arthritic knee. Because she had significant patello-femoral disease, she was counseled to avoid activities that load the patellofemoral joint, such as squatting and ascending and descending stairs. The importance of maintaining a regular exercise program to maximize aerobic conditioning and increase caloric expenditure was stressed. It has been demonstrated that supervised walking programs increase functional status without increasing symptoms.10 Physical therapy. A program of physical therapy was recommended, with the goal of increasing ROM and flexibility, especially in the hamstrings. Muscle strength training for both quadriceps and hamstrings was suggested, as was proprioceptive retraining. The importance of stretching all major muscle groups that cross the joint to maintain range of motion was stressed. Tight hamstrings in particular can exacerbate knee pain, and

Mrs Jones showed evidence of this. She was advised to strengthen her quadriceps, as weak quadriceps correlate with pain severity in osteoarthritis,11 and there is evidence that quadricep strengthening improves functioning and knee pain.12-14 Quadricep sets and isometric strengthening exercise, such as straight-leg raises, were recommended as an initial program. She was advised that, as her strength improved, she should try closed-kinetic-chain strengthening of both quadriceps and hamstrings. This exercise leads to the co-contraction of the hamstrings and quadricep muscles, which results in decreases in patellofemoral joint forces, anterior cruciate ligament strain, and tibial translation. Proprioceptive retraining was prescribed as well, as this can decrease joint stress, and Mrs Jones was encouraged to use a knee sleeve during physical therapy to help her regain a sense of stability. Patellar taping was recommended as well, as this may reduce patellar facet impact on the femoral condyle. Although Mrs Jones had been active several years prior to her visit to our clinic, her symptoms had increased in both intensity and frequency in recent years, which limited her activity. Therefore, she was advised to implement this exercise program gradually, as increasing the intensity of the program too quickly can exacerbate symptoms in osteoarthritis patients. Bracing. A knee unloader brace was prescribed to relieve some of Mrs Jones’s symptoms. Knee bracing has been found to provide significant pain relief.15,16 In a trial of 20 patients with severe medial osteoarthritis of the knee, 19 experienced significant pain relief, and quadriceps muscle strength increased in 17 patients, declined in 2, and remained the same in 1.15 Another trial, in which 119 patients with varus gonarthrosis were randomized to an unloader brace, a neoprene sleeve, or standard medical treatment (control group), found that patients benefited significantly from the use of a knee brace in addition to standard medical treatment.16 At the 6-month evaluation, patients assigned to the unloader brace group had significantly less pain than those in the neoprene-sleeve group after both the 6-minute walking test and the 30-second stair-climbing test, although both the neoprene sleeve and the unloader brace were associated with significant improvement in quality of life and function compared with the control group. 16 Occupational therapy. Although Mrs Jones was retired, she enjoyed a number of recreational activities, and her osteoarthritis symptoms were interfering with her ability to participate in them. She attended occupational therapy for training in activities of daily life. Such training can help patients by providing an individual functional assessment and joint protective strategies to be used during activities of daily life.17Energy conservation and joint protection principles and stress management techniques are taught so that fatigue can be minimized and pain and stress on joints reduced, with the goal of increasing performance of activities of daily life and preventing loss of function.17 The use of adaptive equipment and alternative methods may enable patients to carry out daily tasks. For instance, simple placement of grab rails by the bathtub and raising the toilet seat may dramatically improve the home environment for patients with osteoarthritis and promote independent functioning, allowing patients to take care of

their personal hygiene.17 A raised toilet seat decreases the required range of motion and force placed on the hip and knee joints.17 The use of ice or heat before exercise may alleviate pain and thus encourage activity.17 Treatment: Pharmacologic Therapy Mrs Jones was started on 325 mg of acetaminophen three times a day, but it did not alleviate her pain. Six weeks later, she was switched to 500 mg of naproxen twice a day, which improved her symptoms by about 50%. Tramadol, one to two 50-mg tablets every 6 hours as needed, was prescribed for breakthrough pain, and a proton pump inhibitor was added to the regimen to prevent gastric discomfort. Mrs Jones’s symptoms also improved with physiotherapy. However, over the next several years her symptoms worsened, and she was given a narcotic to take for episodes of severe pain. After experiencing a severe effusion to her right knee with an inflammatory component, Mrs Jones opted to have intra-articular steroid injections. She received 3 injections spaced about 3 months apart and, each time, this provided about 3 months of relief. However, when the pain returned following the third injection, she elected to have hyaluronic acid G-F 20 injections. The first treatment was given in a series of 3 injections. Viscosupplementation with hyaluronic acid provided 18 months of relief, and the patient opted to repeat the hyaluronic acid injections when the symptoms returned. Discussion Mrs Jones responded well to the management program. She lost 15 lb initially and managed to maintain her new weight. The prescribed exercise program proved successful, and she gained strength in her quadriceps as well as functional ROM, while her overall pain decreased. Mrs Jones initially responded to the nonsteroidal antiinflammatory drugs (NSAIDs). However, because of the side effects including peptic ulcer associated with these agents, we recommend that patients be prescribed the lowest effective dose, take the drug with food, and use it for the shortest time possible. We usually start a patient on an over-the-counter agent, such as ibuprofen. Selective COX-2 inhibitors should be used only in patients with renal or gastrointestinal risk factors. As Mrs Jones’s condition deteriorated, painkillers were no longer enough to control her symptoms, and we used an intra-articular corticosteroid injection. We find this helpful for patients who no longer respond to NSAIDs and in those for whom NSAIDs are contraindicated. We do not usually aspirate the knee unless there is a tense effusion present. If aspiration is necessary, however, then the fluid is sent for the appropriate studies. If there are no signs of hemarthrosis or infection, the knee joint can be injected with corticosteroid. In patients without an effusion, a cortisone injection may be indicated if there are signs of inflammation such as synovial thickening, nocturnal or diffuse pain, or pain that is felt when the patient is at rest. Localized knee pain that is felt only with weight bearing is less likely to respond to cortisone injection. The solution — 1% lidocaine (3 mL) and triamcinolone (40 mg), or betamethasone sodium phosphate (6 mg) — is injected into the anterolateral soft spot under sterile conditions.

We have found the duration of the effects of this injection to be variable, lasting from a few days to >6 months. In Mrs Jones’s case, the effects lasted 3 months. As the injections are less effective with each successive course, we limit corticosteroid injections to 3 or 4 treatments a year. After the initial injection, we considered viscosupplementation in this patient. Although surgical interventions including a tibial osteotomy and a total knee replacement were discussed when Mrs Jones’s condition worsened, the patient elected to pursue the more conservative course with viscosupplementation. Viscosupplementation may postpone the need for surgical intervention, and studies have suggested that it may delay structural progression of the disease. Injections provide relief for 6 months to 1 year and can be repeated every 4 to 6 months. Mrs Jones is still receiving conservative care and is doing well. She is able to participate in recreational activities and continues with a strengthening program. The conservative interventions have allowed her to go back to her hobbies, including gardening, golfing, and shopping, with minimal side effects. She continues to take tramadol intermittently for breakthrough pain, but she takes an NSAID along with a proton pump inhibitor only for flareups. Her use of pain medication, including both opioids and NSAIDs, has decreased significantly since she received viscosupplementation. Conservative management. This patient’s case illustrates how a conservative management strategy can help maintain patient functioning and quality of life while minimizing side effects and avoiding major surgical trauma to the patient. Tibial osteotomy is an option for patients such as Mrs Jones, who have varus angulation < 10° and stable ligamentous support, and it can reduce symptoms and stimulate formation of a new articular surface.4 However, after discussing this intervention with the musculoskeletal specialist, Mrs Jones decided not to pursue it. With surgery there is always some risk of infection or complication from anesthesia, as well as risk of blood clots, nerve damage, or circulatory problems.4 Furthermore, it is highly probable that a total knee replacement would be needed at some time in the future, as long-term followup of patients treated in this manner indicates that clinical results deteriorate over time.4 Previous tibial osteotomy makes knee replacement more technically challenging. 4 Although surgical procedures remain an option for this patient should the situation deteriorate, by postponing or avoiding surgery in a relatively young patient such as Mrs Jones, the need for multiple knee replacements may be averted. The lifespan of a total knee replacement is not known, but it is believed that as the surgery is performed in younger people, an increasing number of these patients may live long enough to see the failure of their knee prostheses.4 Performing such surgery in middle-aged patients increases the likelihood that it will have to be repeated, with all the costs and risks inherent to major surgery. Mrs Jones’s response to viscosupplementation was excellent. She achieved 18 months of relief from her symptoms and was able to reduce the use of both NSAIDs and breakthrough medication by about 75% during this time. She still takes it, but intermittently.

Although the medical community generally considers NSAIDs safe, more than 16,500 Americans die and 103,000 are hospitalized each year as the result of anti-inflammatory drug use.18 In contrast, use of viscosupplementation is associated with a low incidence of local adverse events, which consist of local inflammation and effusion. 19 Adverse events typically occur within 48 hours of injection and rarely after the first injection of a first course of therapy, and usually resolve spontaneously or respond well to conservative symptomatic treatment.19,20 To avoid such reactions, patients are told to rest and apply an ice pack for 2 to 3 hours after the injection and avoid strenuous activities until after the course of therapy is completed.19 Mrs Jones was instructed to apply the ice pack and avoid strenuous activity and did not experience any injection reaction during either of her treatment courses. Although a first course of viscosupplementation provides relief from pain for up to 6 months in patients with osteoarthritis, a second course also has been shown to reduce pain significantly and improve physical functioning for up to 6 months.20 Mrs Jones’s experience with viscosupplementation is similar to that found in a recent clinical trial in 71 patients, where the mean interval between first- and second-course treatments was >18 months.20 Other studies have shown that deterioration in structural parameters is less in the group using viscosupplementation than in control groups.21 Conclusion The pain and disability associated with osteoarthritis have a serious impact on the lives of patients, yet conservative treatment in many patients can reduce pain, improve performance, and forestall invasive surgical procedures. A management strategy combining nonpharmacologic treatments such as strength training, appropriate exercise, weight loss, orthotics, and physical therapy with pain medication can be successful in many patients. When disease progression demands more aggressive treatment, the use of techniques such as viscosupplementation may obviate surgical procedures and achieve good clinical results, allowing patients to return to their everyday activities and more productive lives. It is essential, however, to determine treatment strategies based on individual patient characteristics such as age, comorbidities, symptoms, and risk factors for other diseases. In this way, we can maximize our patients’ quality of life while ensuring that they receive the best possible care. CASE STUDY 1: a recurring hamstring injury A 24-year-old male 100-200m sprinter presented to the clinic complaining of a recurring left hamstring injury. The first injury happened suddenly during sprinting two years ago. Since then, the injury has recurred three times but with a more gradual onset with increased intensity of sprinting. Last recurrence happened one month ago and the sprinter was still unable to resume sprinting due to pain. This athlete also complained of intermittent back pain.

A thorough physiotherapy assessment identified several factors which might precipitate the recurring hamstring problem: * Increased lumbar lordosis (low back curvature) with tight iliopsoas muscles (hip flexors) causing anterior pelvic tilt (forward tilting of pelvis). This will elongate and increase the stress on the hamstring muscles and may narrow the invertebral foramen (outlet for the nerve roots in the low back). * Palpable painful scar tissue in the hamstring muscle itself. * Decreased eccentric strength causing slight hamstring pain. * Poor trunk stabilisation control during running and increased lumbar lordosis. Decreased strength in the abdominal and deep low back muscles which put increased stress on the hamstrings to try to stabilise the pelvis during sprinting, Treatment This athlete's treatment included manual soft-tissue mobilisation to break up scar tissue in the hamstring muscles, and joint mobilisation of the lower back. The sciatic nerve was mobilised with straight leg raise and slump exercises, and the hamstring and iliopsoas muscles were stretched. He received an extensive home exercise programme including trunk stabilising exercises for the abdominal and lumbar muscles. In a functional sprinting position the hamstring muscles were strengthened eccentrically. The athlete was able to resume sprinting gradually after five weeks of treatment with improved trunk stability and no hamstring or back pain. Ulrik McCarthy CASE STUDY 2: a patello-femoral joint problem Anterior knee pain is a common complaint of many sports people, particularly those who play sports that involve high repetition of knee flexion and extension, such as cyclists, runners, rowers and so on. This case study depicts the presentation of one such athlete and the treatment which enabled him to return to sport pain-free. A 17-year-old county hockey player presented to the clinic complaining of severe aching pain behind and underneath both patellae (kneecaps) that had built up over a six-month period to the point that he was now unable to complete a hockey game or walk up and down stairs without pain. The pain tended to subside with rest over a two-day period but would return with even mild activity. His usual sporting week consisted of football two days a week, hockey three days a

week and miscellaneous other sporting participation at irregular intervals. He had no rest days. He had had a recent growth spurt and this combined with a lack of appropriate warm-up procedures had resulted in tightness of his hamstrings, calf muscles and rectus femoris (front of thigh muscle). This muscle tightness meant that he ran with a shortened stride, the knee being held in flexion during nearly all of the gait cycle. He was also unable to jog with the normal heel-toe gait pattern, thus not allowing the correct movement of the lower limb to occur. Biomechanically, he had pronated (flat) feet with tibia varum (bowing of the shin) which caused the knee joint to rotate abnormally. All of these factors contributed to a lateral maltracking of the patella in relation to the femoral joint surface, and a diagnosis of a patello-femoral joint dysfunction with associated patella tendinitis was made. Treatment This athlete's treatment consisted of mobilising the patella medially to stretch the tight lateral structures while using tape and exercise for the VMO (inner quadriceps muscles) to hold the patella medially and thus reduce the maltracking. He was taught a comprehensive stretching programme to lengthen his tight muscles. The patella tendinitis was treated with manual soft- tissue techniques to eliminate the pain and inflammation. Temporary orthotics were made to correct his foot position. Over a four-week period, the treatment eliminated his pain and allowed him to gradually get back to sport. He continued his exercises and dispensed with his orthotics after two months. With the inclusion of two rest days in his busy weekly schedule, he has stayed free of problems since.