A 55-year-old woman is evaluated for an 18-month history of increasingly severe knee pain with the inability to arise when seated on the floor. She does not have pain at rest or nocturnal pain. Medications are celecoxib and omeprazole.
On physical examination, vital signs are normal. Bony hypertrophy of both knees is present. There is no warmth, erythema, or swelling of the joints.
Plain anteroposterior knee radiographs show medial joint space narrowing, peaking of the tibial spines, and osteophytes; there are no erosions or osteopenia.
Which of the following is the most appropriate management?
A. Glucosamine supplements
B. Knee replacement surgery
C. Physical therapy
MKSAP Answer and Critique
The correct answer is C. Physical therapy. This content is available to MKSAP 18 subscribers as Question 8 in the Rheumatology section. More information about MKSAP is available online.
Physical therapy is appropriate for this patient whose history, physical examination, and radiographic findings are consistent with the diagnosis of osteoarthritis (OA). Physical therapy is an effective intervention for the management of pain and reduced functioning due to OA, with numerous guidelines supporting exercise as an appropriate intervention for all patients with OA. Evidence is most robust for knee OA. Many patients become sedentary due to their symptoms, and physical therapy is often a useful starting point to transition patients to participation in a regular exercise program. Physical therapy can be prescribed at any point in the course of the disease instead of medication, as a supplement to medication that does not adequately reduce pain, or prior to surgery to increase strength and potentially influence surgical outcomes.
Glucosamine supplements are the most widely used over-the-counter products worldwide for OA. Many randomized controlled trials have found that pain, function, and radiographic progression improve overall at a level equivalent to the effects of placebo in patients taking glucosamine.
Knee replacement surgery is effective for treatment of pain and disability but is not appropriate in a patient who has not been through a trial of physical therapy, particularly a patient who is not regularly exercising. Assessment of the ability to carry out activities of daily living, as well as occupational and recreational activities, will be important in the decision to seek surgery, and a physical therapist can be particularly helpful to the primary care provider in carrying out this assessment. Considerations for surgical referral include the presence of pain at rest or pain that awakens the patient in the middle of the night, both of which are less likely to respond to analgesics, exercise, or physical modalities.
Prednisone is an oral glucocorticoid that can be used as an adjunctive medication in the treatment of some forms of inflammatory arthritis. However, insufficient evidence exists to support the use of oral glucocorticoids in the treatment of OA.
- Physical therapy can be prescribed at any point in the course of osteoarthritis instead of medication, as a supplement to medication that does not adequately reduce pain, or prior to surgery to increase strength and potentially influence surgical outcomes.