Journal of Gerontology & Geriatric Medicine Category: Medical Type: Review Article
Care of the Older Adult with Knee Pain
- Battistone MJ1*, Barker AM2, Milne CK3, Kilian A4, Johnson SA5, Eleazer GP6
- 1 Center Of Excellence Coe For Musculoskeletal Msk Care And Education, George E Wahlen Department Of Veterans Affairs Medical Center, 500 Foothill Drive, Salt Lake City, UT 84148, Utah, United States
- 2 Center Of Excellence Coe For Musculoskeletal Msk Care And Education, George E Wahlen Department Of Veterans Affairs Medical Center, Department Of Family And Preventive Medicine, University Of Utah, Salt Lake City, Utah, United States
- 3 Center Of Excellence Coe For Musculoskeletal Msk Care And Education, George E Wahlen Department Of Veterans Affairs Medical Center, Division Of General Medicine, University Of Utah, Salt Lake City, Utah, United States
- 4 Division Of Rheumatology, School Of Medicine And Health Sciences, George Washington University, Washington, DC, United States
- 5 Department Of Internal Medicine, Division Of General Internal Medicine, University Of Utah, Salt Lake City, Utah, United States
- 6 Department Of Internal Medicine, Division Of General Internal Medicine, Center Of Excellence (COE) For Musculoskeletal (MSK) Care And Education, George E Wahlen Department Of Veterans Affairs Medical Center, University Of Utah, Salt Lake City, Utah, United States
*Corresponding Author:Battistone MJ
Center Of Excellence Coe For Musculoskeletal Msk Care And Education, George E Wahlen Department Of Veterans Affairs Medical Center, 500 Foothill Drive, Salt Lake City, UT 84148, Utah, United States
Received Date: Jun 21, 2019 Accepted Date: Jul 16, 2019 Published Date: Jul 23, 2019
This paper is intended to assist clinicians caring for older adults with knee pain. The discussion is framed within the context of knee OA because this common condition typically drives management, even when other problems are superimposed. Although many clinical organizations and expert panels have produced suggestions for OA management, a recent systematic review of these guidelines has found them to be inadequately disseminated and implemented, and recommends that greater effort be made to integrate these concepts in primary care . We have written this paper in contribution to this effort and anticipate that it will be of value to those who provide primary care for older adults.
NEW CONSTRUCTS IN OSTEOARTHRITIS
It is also important for providers to be aware that not all knee pain originates from problems in the knee; arthropathies of the spine, pelvis, or hip can refer pain to the knee which may exceed symptoms elsewhere. A clear understanding of the impact of symptoms on Activities of Daily Living (ADLs) can be helpful in identifying some important clues. If there is great difficulty putting on socks and shoes, the hip should be carefully evaluated; if pain is worsened when transitioning from lying supine to sitting, the lumbar spine should be examined as a possible source of incomplete sciatica. In patients who experience chronic pain, these symptoms may be further complicated by “brain smudging”, a recent construct describing a dysregulated system of neurologic signal processing that may inhibit the ability to localize pain .
- Range of motion
- Examination to determine the presence of an effusion
- Palpation to establish the area of maximum tenderness
- In cases of recent ground-level fall or similar trauma, evaluation of the medial and lateral collateral ligaments
- Frontal (antero-posterior (AP)), weight-bearing view to evaluate the medial and lateral tibio-femoral joint spaces
- Lateral flexion view to evaluate the patellofemoral joint
- “Sunrise” or similar view to evaluate the patellofemoral articulation and possibility of medial or lateral patellar osteophytes.
Acetaminophen is first-line treatment of mild to moderate non-inflammatory pain in older adults because of its low cost and safety profile compared to other analgesics, particularly NSAIDs. In patients with intermittent symptoms, acetaminophen may be used episodically; for persistent symptoms, we recommend continuous use with doses up to 3 g/day in patients without contraindications. Acetaminophen can cause asymptomatic elevation of liver enzymes in healthy people, and although implications of this are unclear, it is recommended that acetaminophen use not exceed 2 g/day in patients with existing liver disease or increased risk of hepatotoxicity. Patients should be warned regarding use of other medications that include acetaminophen to avoid unintentional overdosing.
Non-steroidal anti-inflammatory drugs may be considered for patients with inadequate relief with acetaminophen. Topical NSAIDs are thought to be safer than oral preparations, because systemic drug concentrations are less. Without compelling evidence that one NSAID is more efficacious than another for knee OA, choices should be informed by risk factors and prescribed at the lowest dose and shortest possible duration. If one NSAID provides inadequate relief after two to four weeks, changing to a different NSAID is reasonable since individual responses vary. Some data suggest naproxen may pose a lesser cardiovascular risk than other NSAIDs, though risk can neither be entirely predicted nor eliminated . Non-acetylated salicylates and selective COX-2 inhibitors may have more favorable gastrointestinal risk profiles than other NSAIDs, but cardiovascular risks may be greater . Patients with increased risk of GI bleeding (aged 75, history of GI bleeding or peptic ulcer disease, anticoagulant use including aspirin and chronic glucocorticoid use) should have a gastroprotective agent prescribed (e.g., proton pump inhibitor or misoprostol) while taking a NSAID. Nonsteroidal anti-inflammatory drugs should be avoided or used with caution in patients with estimated glomerular filtration rate of <30 mL/min per 1.73 m2 or on dialysis.
Opioid medications should not be routinely used in treating knee pain, even if discomfort is severe [29,30]. In addition to adverse effects associated with these medications-which are particularly hazardous in older adults-opioids may also impair the effectiveness of TKA. One retrospective study found that patients who had been treated with opioids prior to TKA were 3.5 times more likely to be dissatisfied with the results than those who were opioid-naïve .
Intra-Articular (IA) injections of Corticosteroids (CS)-most frequently methylprednisolone or triamcinolone acetonide-are often used for short-term relief of pain associated with OA and meniscal derangement [22,23]. Although individual patient responses to these injections may vary, a recent randomized controlled trial comparing repeated injections (every three months for two years) with triamcinolone to those with saline demonstrated no differences in patient-reported outcomes . Short-term complications are rare, but may include infection (risk reported between 1/2600 and 1/15,000), bleeding (though is generally safe even in patients who are anticoagulated in therapeutic range), and hyperglycemia (transient increase lasting 3-5 days) [16,33,34]. Long-term local complications of repetitive CS injection may include hastening of progression of IA degeneration, though recent evidence has not produced consistent interpretations of risk [32,35].
Viscosupplementation with Hyaluronic Acid (HA) is an alternative option for patients who either have reason to avoid steroid injections or who have not responded to them, though specific recommendations and guidelines vary [22,23]. Many preparations of HA are available and no large comparison trials exist. For those who respond, benefits include less frequent injection rates (every 6 months), and avoidance of steroid side effects; risks of infection and bleeding are thought to be similar.
Finally, it is important to note that even after a technically successful procedure, a substantial number of patients-up to 20%-will have persistent knee pain . Important efforts to identify predictive variables are underway, and patients considering TKA should be informed of this possibility.
Management of meniscus and ligament injuries
These findings must prompt reconsideration of the value of MRI. The inappropriate use of this relatively high-cost imaging technique in older adults with knee pain is increasingly recognized, particularly in primary care [50,51]. For patients who are surgical candidates, we recommend referring to orthopedics in lieu of MRI. Limited data are available to guide recommendations regarding management of cruciate ligament injuries, though in OA an initial conservative approach is reasonable, even if there has been a complete rupture of either anterior or posterior ligaments. An immobilizing brace can be used following an acute injury, and if disabling instability persists despite PT, patients can be referred for orthopedic consultation regarding TKA. As with meniscal disease, MRI is not needed prior to referral, as findings would not change decisions to refer.
Management of collateral ligament injury
Management of pes anserine and pre-patellar bursitis
Portions of this work were supported by the George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.
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Citation:Battistone MJ, Barker AM, Milne CK, Kilian A, Johnson SA, et al. (2019) Care of the Older Adult with Knee Pain. J Gerontol Geriatr Med 5: 032.
Copyright: © 2019 Battistone MJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.