Aging Knee/Knee Pain
Julie Adkins and Jill C. Cash
Definition
A.The knee is the largest joint of the body. The knee is not protected by layers of fat or muscle; exposure may lead to a high incidence of trauma. The articular cartilage is a firm, rubbery protein material covering the end of a bone. It acts as a cushion between the bones so that the bones do not grind together. When this articular cartilage breaks down, symptoms such as knee pain, swelling, bone spur formation, and decreased motion develop. Over a period of years, the joint slowly changes and normal activity becomes painful and difficult.
B.There is a loose relationship between knee pain and osteoarthritis of the knee. Many older people are pain free with radiological arthritis of the knee, whereas many people with knee pain have little evidence of osteoarthritis.
Incidence
A.One-fourth of people age 50 and older report chronic knee pain; for two-thirds of these, the pain is severe and disabling. Osteoarthritis of the knee is one of the five leading causes of disability among elderly men and women.
Pathogenesis
A.Patients with knee pain who do not have inflammatory arthritis may have crepitus, bony tenderness, bony enlargement, effusion, or muscle wasting. Depending on the cause of the problem, knee pain occurs because of problems such as bone rubbing bone, extra fluid in the joint space that causes pressure, irregularities of the bone, and torn cartilage.
Predisposing Factors
A.Heredity.
B.Weight gain: Increases pressure on the knee joints. One pound of weight gain equals approximately four pounds of weight pressure on the knee joint.
C.Age: The ability of the cartilage to heal itself decreases with age.
D.Gender: Occurs more frequently in women than in men.
E.Trauma history of previous injury to the knee.
F.Repetitive injuries in sports or other trauma.
G.Activity: Requires long periods of standing, poor posture/gait.
H.Chronic conditions: Metabolic disorders, muscle weakness, poor fitness, vitamin C deficiency, vitamin D deficiency.
Common Complaints
A.Knee pain at rest and with activity.
B.Inability or decreased ability to perform certain daily functions.
C.Knee gives way while walking, standing, or moving.
D.Difficulty with getting up out of a chair.
E.Need for assistive devices to ambulate.
Other Signs and Symptoms
A.Inability to stand, walk, or sit for long periods of time.
B.Pain may increase with exposure to cold or heat.
C.Pain at rest.
Potential Complications
A.Falls.
B.Fractures.
Subjective Data
A.Inquire regarding onset, duration, and frequency of knee pain.
B.Did trauma precipitate the pain, either recently or long ago?
C.Elicit a clear description of the pain and factors that aggravate or relieve it.
D.Does knee swell, feel warm to touch, or turn red at any time?
E.Does pain increase or worsen with rest/activity?
F.Ask patient to report a pain scale with rest and with activity.
G.How does pain interfere with daily living activities? Is patient unable to work? Does knee pain waken the patient at night? Does he or she have difficulty with walking, climbing steps, or getting into the car?
H.What has the patient used for pain? Over-the-counter (OTC) products and prescription products? Heat/ice/brace and so on?
I.Has the patient experienced any type of pain like this in the past?
Physical Examination
A.Inspect:
1.Gait: Observe for any abnormal movement used to compensate for the pain in the knee.
2.Note symmetry of muscles above the knee for atrophy.
3.Assess the knee for swelling, redness, or gross deformity. Swelling is classified as either localized (bursa) or generalized (intra-articular). A bursal swelling is most frequently found over the patella or over the tibial tubercle. Occasionally a bursal swelling may present in the popliteal area due to a cyst. Intra-articular swelling is usually due to an irritation of the synovium and can cause a generalized swelling of the entire knee.
B.Palpate:
1.Palpate the knee for points of tenderness, effusion, or changes in skin temperature. The knee is easier to palpate when it is flexed, making the skeletal landmarks more distinct. Palpate both the medial and lateral aspect of the knee, joint line area.
2.Test for joint stability involving the collateral ligaments and cruciate ligaments.
3.Assess range of motion (ROM) actively and passively—flexion, extension, and internal and external rotation.
4.Perform McMurray’s test to evaluate for torn meniscus.
5.Symptoms of a sprained knee:
a.Meniscus tear: Locking of knee with flexion and giving way of knee.
b.Collateral ligament tear or strain: Pain at lateral or medial sides.
c.Anterior cruciate tear: Popping sound at injury site and immediate swelling.
d.Posterior cruciate tear or strain: Pain in interior knee.
e.Patellofemoral syndrome: Popping or snapping, pain under patella with motion, and pain on stairs or hills.
f.Tendinitis: Pain over patellar tendon.
g.Prepatellar bursitis: Swelling over patella with inability to kneel due to swelling.
h.Nonspecific effusion: Effusion worse with exercise.
Diagnostic Tests
A.X-ray of affected knee or both knees for comparison. Perform knee x-rays while the patient is standing.
B.Possible MRI or CT as necessary. Consider if mechanical symptoms and effusion is present.
C.Bone scan may be considered if the patient has failed to respond to therapy after 6 to 12 weeks of therapy.
D.Laboratory values to consider: Complete blood count (CBC), erythrocyte sedimentation rate, uric acid, rheumatoid factor.
Differential Diagnoses
A.Knee pain.
B.Sepsis.
C.Gout (nontraumatic knee pain that is not associated with activity, pain with rest).
D.Malignancy/avascular necrosis.
E.Knee trauma (meniscal tears, medial or lateral collateral ligament tear, anterior cruciate ligament
tear, patella dislocation/subluxation, fracture, osteochondral defect).
F.Nontrauma acute knee pain that increases acutely with activity including cartilage injury and osteoarthritis.
G.Bursitis.
H.Fibromyalgia.
I.Arthritis (rheumatoid arthritis, psoriatic arthritis, reactive arthritis, osteoarthritis).
J.Referred pain from the hip or back.
K.Baker’s cyst (posterior knee pain not related to trauma).
Plan
A.General interventions:
1.Knee exercises and bracing, if necessary.
2.Activity modifications should be discussed with the patient to reduce pain.
3.Nonsurgical management includes appropriate footwear and assistive devices.
4.Complementary and alternative modalities include glucosamine chondroitin, acupuncture, osteopathy, and chiropractic interventions.
5.Joint aspiration, if indicated.
B.Patient teaching:
1.Weight loss education should be discussed and encouraged. Dietary management along with exercise routine should be considered. Approximately 4 to 5 pounds of pressure on the knee are relieved with every one pound of weight loss.
C.Pharmacological therapy:
1.Acetaminophen.
2.Cyclooxygenase 2 (COX-2) inhibitors (Celebrex)
3.Nonsteroidal anti-inflammatory drugs (NSAIDs) (naproxen, ibuprofen, Mobic, etc.).
4.Topical medication such as capsaicin, topical NSAIDs, or lidocaine patches may be considered.
5.Topical medication, Voltaren gel (diclofenac), may be used on large joints such as the knee four times per day as needed for joint pain.
6.Intra-articular treatments include the following:
a.Steroid injections (Depo-Medrol), which may provide short-term relief (1–4 weeks).
b.Hyaluronan injections (viscosupplementation), which may provide relief for approximately 6 to 12 months.
Follow-Up
A.Follow up in 1 to 2 weeks for evaluation of knee pain and prescribed modality effectiveness.
B.Evaluate for side effects of pharmacologic treatment.
Consultation/Referral
A.Refer to physical therapy for exercise regimens or physiotherapy. May include knee taping and water therapy.
B.Surgical consultation if there is no relief from pharmacologic or physical therapy methods. May include arthroscopy versus partial or total knee replacement, dependent on the objective findings.
Individual Considerations
A.Adults:
1.Evaluate patient individually for renal, gastrointestinal, or hepatic disorders in regards to pharmacologic preparations.
B.Geriatrics:
1.Ensure access to proper eyeglasses, hearing aids, and assistive devices such as canes, walkers, elevated toilet seats, grab bars, and shower chairs.
2.Evidence-based research conjectured: Genetic mutations and aging decrease an individual’s cartilage ability to heal itself; women over 50 years old will develop knee osteoarthritis more than men; and previous injury to the knee will lead to physical knee challenges (possibly knee replacement) after the age of 60 years.
3.Differential diagnoses specific for geriatrics with knee pain include the following:
a.Chondromalacia patellae—tenderness over the kneecap.
b.Iliotibial band syndrome—lateral knee tenderness at the fibular head and lateral femoral condyle.
c.Anserine bursitis—pain distal to knee radiating over the medial tibia.
4.Research suggested that physical therapy implemented to the elderly population will effectively reduce chronic knee pain symptoms and are considered a relevant, front-line nonpharmacological pain management.
5.Naturopathic research recommended black cumin oil to alleviate pain in geriatrics suffering with chronic knee pain. The oil is to be applied and generously massaged into the knees three times a week for one month to experience effective results. Afterwards, once a day or three times a week for maintenance pain management (patient specific).
6.Systematic reviews of clinical trials compared young adults (<65 years of age) and geriatric population (≥65 years of age) that had undergone knee arthroplasty and observed there was neither evidence of pulmonary embolism incidences nor pain/functional status differences between the two groups. However, risks and benefits must still be thoroughly discussed with geriatric patients for the patients to make an informed decision with their surgeons.
7.Take all measures to prevent falls, which adds to morbidity and functional decline.
8.Evaluate polypharmacy and other comorbidities and possible drug interactions.
9.Evaluate for medication compliance and level of alertness before starting drugs with potentially hazardous side effects.