A 58-year-old man is evaluated for a 3-year history of left knee stiffness, which was intermittent but has become more persistent in the past 4 months. He reports no daily pain but has knee stiffness for 10 minutes in the morning and when he sits for an extended period of time. He reports no swelling and no knee buckling or locking. History is significant for gastroesophageal reflux disease and peptic ulcer disease diagnosed 6 months ago now treated with omeprazole. He prefers not to take medications for his knee symptoms.
On physical examination, vital signs are normal. BMI is 24. Crepitus and medial joint line tenderness to palpation are noted. There is no redness, effusion, or signs of knee instability.
Left knee radiograph shows mild medial joint space narrowing and spiking of the tibial spines.
Which of the following is the most appropriate management?
B. Intra-articular glucocorticoids
C. Left knee MRI
D. Physical therapy
MKSAP Answer and Critique
The correct answer is D. Physical therapy. This content is available to MKSAP 18 subscribers as Question 73 in the Rheumatology section. More information about MKSAP is available online.
Physical therapy and a graduated leg muscle strengthening exercise program are appropriate for this patient with knee osteoarthritis. For patients with osteoarthritis, an individualized management plan includes education on osteoarthritis and joint protection, an exercise regimen, weight loss, proper footwear, and assistive devices as appropriate. Physical activity includes graduated aerobic exercise and strength training, with attention paid to bolstering strengthening periarticular structures and minimizing injury. The patient's main symptom is stiffness, not pain, and he prefers nonpharmacologic therapy at this time, which is most appropriate from a management perspective as well. Muscle weakness is common in knee osteoarthritis, possibly related to disuse, and muscle strengthening has been associated with reduced pain and improved function. All treatment guidelines agree that a muscle strengthening exercise program should be part of the patient's management plan.
Because the patient has a history of peptic ulcer disease, ibuprofen is not advisable. He also chooses not to take medication for his knee symptoms, and it is unclear whether ibuprofen would help his main symptom of stiffness.
Intra-articular glucocorticoids are useful agents in knee osteoarthritis, particularly as second-line therapies. Similar to ibuprofen, it is unclear whether this treatment would help the patient with his stiffness.
A knee MRI is not indicated in a patient without knee buckling or locking or signs of instability, all of which may indicate an unstable meniscal tear that needs surgical management. Incidental meniscal tears are common MRI findings in the middle-aged population, and especially in patients with knee osteoarthritis. Studies have shown that patients with knee osteoarthritis and meniscal tears experience similar long-term improvements in pain and function with physical therapy compared with arthroscopic surgery, and that arthroscopic surgery may even pose higher harms.
- Treatment guidelines recommend that a muscle strengthening exercise program should be part of the management plan for knee osteoarthritis.