1. www.pspbc.ca Bilateral Knee Osteoarthritis Case 6 : Ruth-Ann

2. 2 Faculty/Presenter Disclosure with Faculty’s Name:Faculty’s Name:

3. 3 Disclosure of Commercial Support. Mitigating potential bias N/A.

4. 4 Objectives When working with CPP, you will be able to:  Identify key elements of osteoarthritis history  List 3 assessment tools that may be useful  Identity appropriate investigations  Appropriate management

5. 5 Bilateral Knee Pain Ruth Ann is a 62 yr old retired elementary school teacher She was touring through Europe 3 weeks ago when she tripped on some cobblestone roads and landed straight on her knee caps. She noticed some initial mild swelling the next day but had significant swelling and pain after flying home. She is gradually improving but still complains of anterior and medial pain bilaterally especially with descending stairs, prolonged standing greater than 15 minutes and with using the elliptical machine at the gym.

6. 6 What are your Key Questions?  How do you determine if this is osteoarthritis or a structural trauma?

7. 7 Common Patient History for MSK Complaints

8. 8 History  Prior to her fall 3 weeks ago, she complained of intermittent knee pain with long walks and gardening. She had never sought medical care for this complaint but often used a menthol rub for relief of aching.  She currently describes intermittent deep aching, like a bruise, that is combined with occasional sharp pain under her knee cap especially with going down stairs.  She get relief with heat and rest.

9. 9 Joint Pain Questions

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11. 11 Osteoarthritis comparison to Inflammatory Arthritis

12. 12 Brief Pain Inventory Screen

13. 13 Knee Symptoms indicating Structural Instability  Swelling  Locking  Giving Way  Clicking  Sudden, large effusion versus small delayed swelling  Knee is stuck in position, indicative of meniscal tear  Knee buckles, unexpected fall, instability from ligament tear, large meniscal tear  Common and often non- painful, often patellar related

14. 14 Functional Assessment Screening Question

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19. 19 Physical Exam  What physical examination techniques would you use? We found: Right Knee active flexion 110 degrees - pain end range, Passive flexion is 125 degrees - pain end range. Left Knee active and passive flexion is full. Patellar compression causes pain on right knee Mild Joint effusion on right knee Ligaments and mensici are intact Gait demonstrates mild limp on right for first 5 steps then normalizes.

20. 20 Physical Exam

21. 21 Pain and Function

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23. 23 Management Tools  How would you determine if investigations were appropriate ? We used:  Is there poor or no response to appropriate treatment?  Are pain levels unmanaged with best medications?  Are there prolonged rheumatological symptoms greater than 6 weeks ?

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25. 25 What is best Management  Ruth-Ann has mild to moderate osteoarthritis likely in the patellar and medial compartments  Her pain is improving but she is hesitant to continue with activity for fear of flaring her symptoms  Best Practice would focus on:  Medications  Rehabilitation and Exercise  Patient Education and Self- Management

26. 26 Pain Relief

27. 27 Pain Relief

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30. 30 Medication Advice  Acteominophen extended release  650mg TID, po x 7 days then prn  When to use an NSAID?  When to use a Topical ?  When to recommend Injection?

31. 31 Ruth-Ann wonders if this new diagnosis will lead to a knee replacement?

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33. 33 Follow-Up  Monitor and Manage  Swelling  Pain  Function  Enhance Education  Promote Self-Management

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36. 36 Goal Setting  Ruth-Ann is improving on her follow-up visit 3 weeks later.  She is using occasional pain medication after prolonged activity  She is back to her daily activities  She would like to discuss “safe exercise” as she has decided to join a seniors gym program and lose some weight.

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40. 40 Key Resources for your patients

41. 41 Clinical Impression  Bilateral Knee Osteoarthritis  Right worse than left  Patellar and Medial compartments  Mild to Moderate  Pre-existing mild with moderate exacerbation after trauma  Managed with pain medications, rehabilitation exercise, education and promotion of self management  Investigations if concerned about inflammatory symptoms  Xrays if suspected fracture or for OA prognosis

42. 42 Key Clinical Information  What are the key criteria for Osteoarthritis?  Morning Stiffness less than 30 min.  Intermittent Pain associated with activity  Recurrent episodes  May lead to bony deformity and decreasing function

43. 43 Summary When working with Osteoarthritis, it is important to: -Identify the differences between inflammatory and non-inflammatory joint disease -Focus on Pain and Function in assessment and management -Focus on patient self management for lifestyle factors

44. 44 References  Arthritis Resource Guide, Arthritis.ca  Guidelines and Protocols Advisory Committee  Bcguidelines.ca