And from the physicians point of view

03 April of 2008

And from the physicians point of view, aside from being grateful for a successful physical therapy intervention, it also reminds us that many of the spots that seem to be sources of pain and pathologic are in fact just merely showing the effects of disordered biomechanics, which are maybe a temporary disorder and can corrected by specific exercise interventions.


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Our next patient is a little more typical for us rheumatologists. This is knee pain in a 55-year-old farmer who is at the point of increasing pain in his right knee over the past six months. He also says it is stiff and weak. He is having trouble getting up and down on equipment, sometimes hard to put on shoes and boots and hurts worse the day after any extra activity. He’s had occasional pain in his groin and also in his back. He limps, especially in the morning or when tired. He recalls twisting his knee about a year ago. His physical exam showed a small effusion on his right knee, which was a little warm to the touch. He had crepitus, not only from the patellofemoral portion – which is fairly common – but also from the medial tibial femoral compartment from both knees. He had 10 degree flexion contracture on the right, quadriceps atrophy on the right, especially medially, and he had a little bit of restricted motion in his right hip. His x-ray confirmed our physical findings. In searching for compartment crepitus you can presume weight-bearing osteoarthritis when you find it and this confirmed it. He also had restricted motion, which suggested that he had right hip OA and the x-rays also confirmed that.
Knee replacement
Now for the rheumatologist this is maybe a no-brainer. This is a person who has a sore knee. Probably it’s osteoarthritis. He has a small effusion, he is not bad off elsewhere. Your first step might be local therapy for local disease, perhaps a corticosteroid injection. Indeed, most rheumatologists use corticosteroid injections for OA. Some quite a bit. In fact, if you get right down to it, is there data to support the use of this? It actually is a bit hard to come by, nevertheless we have, despite the lack of data, our daily practice reinforces that these are generally effective interventions for patients with knee OA, effusions and pain. We have been mulling about this for years. This is … over 40 years ago a crusty Scot named Miller decided to do a prospective study on knee OA then. Cortisone injections were rather new, only about eight years on the scene. So this study – this is the outcome, but I’ll tell you the study – they took patients with symptomatic knee OA, non-end stage, and gave each set a series of injections. A shot two weeks apart times five. Now what the shots were, number 1 was lactic acid, number 2 was Novocain, number 3 was saline, number 4 was hydrocortisone, number 5 was a mock injection which neither the patient nor the physician could realize that the syringe was not putting anything in the knee. This is the patients assessment of improvement some six weeks after completion of that series. So it looks like whatever you stick in the knee could be pretty effective for most. In fact, Kerwin did us a favor by collecting all of the prospective trials in knee OA involving corticosteroid use, and this is the results. What we see here is a portion of baseline pain score diminished by the intervention, and this is over time. In studies that had a number of different time points will have a number of different therapy. But in general, the dark lines, that is the corticosteroid treated knees tend to do a bit better over time and it can last as long as half a year.

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