Posted by Canadian Pharmacy
Tuesday, Apr. 15th 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.
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Now what this person has in addition to osteoarthritis is focal tenderness distal to the joint line, medial aspect. Most rheumatologists know to look for tenderness there. What resides there is the pes anserina bursa and pes anserina bursitis, if it really exists, can be a source of pain where the large bursa that sits underneath the insertion of the sartorius gracilis and the semimembranosus tendons. Although we seldom have occasions to image it, it does exist and we see the three muscles here, sartorius gracilis, semimembranosus and this descended structure on T2 is an engorged pes anserina bursa. It can cause pain by several different mechanisms, and some of the more severe pain may derive from its relationship to the saphenous nerve, which runs right next to it. In fact, the patient who complains of pain in their knee and down the shin may have it from irritation of the saphenous nerve by the bursitis. Saphenous nerve serves sensation also to the anterior two-thirds of the knee, so much of the knee pain can derive from that irritation. Does that mean we should charge our pes anserine bursitis injections as nerve blocks? I’m not sure.
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Posted by Viagra pharmacy
Tuesday, Apr. 15th 2008
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. So just asking if people exercise or not may not give you all the information you want about their cardiovascular health. Similarly, of the people who did exercise, instead of having a nice straight line up here indicating that the more you do the more fit you are, you see here we have some sort of a strange, sort of an elephant-looking thing. That’s about the most sense you can make out of it. It doesn’t really tell us anything. If we just ask people, “If you exercise, are you active” and they say yes, or they say no, that we are going to have very good indications of their cardiovascular fitness and risk for diseases.
So with this fellow we will suggest to him that he get a stationary bike or a treadmill that he can use inside the house, irrespective of weather and conditions and we will try to help him develop a program that he can do 3-5 days a week at a moderately vigorous level, 70-80% of his maximal heart rate, and at 20-60 minutes continuously. Because he has no symptoms of heart disease and no family history and is only going to participate in moderate activity, he does not require a physician-supervised treadmill test to be able to become active at that level. We also would hope that we could find good occupational therapy or a specialist to come out and do a work site assessment on his farm, but if we can’t we try to help him problem solve to do some things to reduce hip and knee bending, to reduce load lifting to 10% of his body weight if possible, to carry thing in a biomechanically good manner, to reduce stress from walking on uneven ground by paving or grading pathways and to avoid prolonged sitting or standing, which at some times of the year is hard. You can see here – this is a fairly low step for most equipment these days – look at the amount of knee and hip bending he and you can imagine the compressive forces that are going to have to be generated over that knee to get him up onto the tractor. You can modify steps and add a lower step with some equipment, but the step has to be in line with the tractor wheel because if its too low and not in line with the tire, it just gets snagged in the fields. You can tell I come from a rural background, can’t you?
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It’s also important to help people to do some problem solving to modify their workplace so that they can avoid excessive bending and stand in better positions. To help them figure out how they can modify lifting. In fact, in the literature, trying to connect occupation to osteoarthritis, probably the clearest link we have now is in farming and they think it probably comes from a lot of heavy lifting, maybe early in life. So this would be an important preventive step to take. We also might suggest to him that he use a cane when he is on uneven ground or having bad days. Proper use of the cane in the opposite hand can reduce hip forces by up to 50% and has been shown to reduce tibial strain and joint pressure in knees. So although many people resist that very often, suggesting it just to get them over the bad times and keep it in the back of the truck, is a good way to give people some extra joint protection.
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Well, that’s all done with our farmer. We’ll try to see him back in clinic and checked in with his rheumatologist to see how he’s doing.
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