The correct answer is A!

This question is part of the Mayo Clinic Internal Medicine Board Review course.

You are evaluating a 64-year-old farmer in the clinic with worsening right knee pain for two years. He has no history of knee injury. Pain worsens with activity. He has had intermittent swelling of the knee but has not had acute inflammation in the knee. The knee is stiff after inactivity. He takes acetaminophen 1000 mg twice daily with partial relief. He previously used ibuprofen but stopped it because of abdominal discomfort.

His past medical history is significant for coronary artery disease with previous angioplasty and stent placement. He takes metoprolol 100 mg daily and aspirin 81 mg daily.

Physical examination shows normal vital signs. BMI is 32.1 kg/m². Joint examination shows slight swelling of the right knee with tenderness over the medial joint line. There is crepitus on motion of the right knee but range of motion is maintained. The remainder of the physical examination is normal.

Laboratory studies include normal CBC, chemistry panel, and C-reactive protein.

Q: In addition to recommending weight loss, which of the following is the best recommendation for treatment of his knee pain at this time?

  A) Intra-articular triamcinolone hexacetonide injection (correct)

  B) Glucosamine sulfate 1500 mg daily

  C) Referral for total knee arthroplasty

  D) Intra-articular hyaluronic acid viscosupplement injection

Rationale

The history, physical examination, and radiographs are consistent with a diagnosis of osteoarthritis. The radiographs show joint space narrowing. Treatment of osteoarthritis is symptomatic as there is no specific therapy for the underlying problem affecting cartilage in osteoarthritis. Initial therapy should include weight loss and exercise. Pain relief including acetaminophen and NSAIDs represents primary medical therapy. Patients generally get more effects from NSAIDs than acetaminophen but his use of NSAIDS is limited by gastrointestinal side effects. It should be noted that having side effects from one NSAID does not mean that he will have similar problems from other NSAIDs.

For patients with incomplete relief from initial therapy, intra-articular corticosteroid injection is beneficial and should be used before other therapies. Glucosamine sulfate and chondroitin have been studied in controlled trials but do not show benefit over placebo. Total knee arthroplasty is beneficial for end-stage knee osteoarthritis but this patient is not at that point and has not tried injection therapy. Intra-articular hyaluronic acid injection has been promoted for the treatment of knee osteoarthritis but controlled trials do not show efficacy greater than corticosteroid injection and are more costly.

References

Bijlsma JW, Berenbaum F, Lafeber FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011;377(9783):2115-2126.

Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis: A meta-analysis. JAMA. 2003;290(23):3115-3121.

 

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