Transcript Chronic Pelvic Pain

Bilateral Knee Osteoarthritis
Case 6 : Ruth-Ann
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Mitigating potential bias
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Objectives
When working with CPP, you will be able to:
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Identify key elements of osteoarthritis history
List 3 assessment tools that may be useful
Identity appropriate investigations
Appropriate management
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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.
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What are your Key Questions?
 How do you determine if
this is osteoarthritis or a
structural trauma?
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Common Patient History for MSK Complaints
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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.
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Joint Pain Questions
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Osteoarthritis comparison to Inflammatory
Arthritis
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Brief Pain Inventory Screen
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Knee Symptoms indicating Structural Instability
 Swelling
 Sudden, large effusion
versus small delayed swelling
 Locking
 Knee is stuck in position,
indicative of meniscal tear
 Giving Way
 Knee buckles, unexpected
fall, instability from ligament
tear, large meniscal tear
 Clicking
 Common and often nonpainful, often patellar related
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Functional Assessment Screening Question
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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.
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Physical Exam
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Pain and Function
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Management Tools
 How would you determine if investigations were
appropriate ?
We used:
a) Is there poor or no response to appropriate treatment?
b) Are pain levels unmanaged with best medications?
c) Are there prolonged rheumatological symptoms greater
than 6 weeks ?
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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
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Pain Relief
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Pain Relief
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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?
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Ruth-Ann wonders if this new diagnosis will lead
to a knee replacement?
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Follow-Up
 Monitor and Manage
 Swelling
 Pain
 Function
 Enhance Education
 Promote Self-Management
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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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Key Resources for your patients
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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
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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
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Summary
When working with Osteoarthritis, it is important to:
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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
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References
 Arthritis Resource Guide, Arthritis .ca
 Guidelines and Protocols Advisory Committee
 Bcguidelines.ca
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