Practice

CME
CMAJ

Decisions

A 67-year-old woman with knee pain

Alistair R. Demcoe MD, Eric R. Bohm MSc MD

What initial treatment should be Competing interests: None

A 67-year-old woman with a body mass index declared.
of 33 presents with a year-long history of recommended?
This article has been peer
worsening medial pain in both knees. Her Several evidence-based clinical practice guide- reviewed.
symptoms are aggravated by activity and reg- lines recommend the following initial interven-
Correspondence to:
ularly interfere with many of her usual act­ tions for the management of knee osteoarthritis: Eric Bohm, [email protected]
ivities. No other joints are symptomatic, and participation in a self-management program,
CMAJ 2014. DOI:10.1503​
she hasn’t experienced erythema or warmth in strengthening exercises, low-impact exercises /cmaj.141129
her knees. Examination of her knees shows ten- (aquatic or land-based), neuromuscular educa-
derness in the medial joint line, mild effusions, tion and weight management.3–6
normal range of motion with crepitus and The Arthritis Self-Management Program was
intact ligaments. Her hips and back are normal developed at Stanford University and is sup-
on examination. Her medical history includes ported by The Arthritis Society. This widely
hypertension and type 2 diabetes ­mellitus. used program is designed to help patients better
understand their diagnosis and to encourage
What is the likely diagnosis? patients to take an active role in managing their
The most likely diagnosis for this patient is osteo- arthritis and chronic pain. Meta-analyses and
arthritis of the knees. The differential diagnosis systematic reviews have shown that generalized
includes pes anserine bursitis, spontaneous osteo- strength training for the lower limbs and specific
necrosis of the knee and inflammatory arthropa- strength training for the quadriceps reduce pain
thy. Osteoarthritis is more common in women and effectively and improve physical function in
older people; in addition, obesity puts this patient osteoarthritis.4,5 A guideline from the American
at increased risk for knee osteoarthritis.1,2 Brief Academy of Orthopaedic Surgeons (AAOS) rec-
morning stiffness, persistent knee pain, a decrease ommends neuromuscular education on the basis
in function, crepitus, restricted movement and of several studies showing positive effects with
bony enlargement are clinical features and find- kinesthesia, balance and proprioception training
ings on physical examination that comprise the programs in patients with knee osteoarthritis.3
European League Against Rheumatism (EULAR) A guideline from the Osteoarthritis Research
criteria for the diagnosis of osteoarthritis.2 Society International (OARSI) recommends that
a weight loss of 5% should be achieved within a
Are any investigations necessary? 20-week period, a rate of 0.25% per week, to be
Plain radiography is the first-line imaging modal- efficacious.4 A recent randomized controlled trial
ity for the assessment of knee pain in this patient (RCT) stressed the importance of both diet and
population. The EULAR group considers plain exercise in achieving weight loss and in manag-
radiography (standing anteroposterior, standing ing knee oseteoarthritis.7
semi-flexed posteroanterior, Merchant [skyline] Patients randomly assigned to diet and exercise
and lateral views) the current gold standard for achieved more weight loss and had better physical
structural assessment of knee osteoarthritis.2 health–related quality-of-life scores than patients
Magnetic resonance imaging is not required to assigned to exercise alone. Additionally, these
make the diagnosis of osteoarthritis,2 nor is it pa­tients had superior pain and function scores than
helpful in making decisions about currently avail- patients assigned to either diet or exercise alone.7
able interventions.1 Inappropriate use of magnetic The OARSI guideline also recommends use of a
resonance imaging is costly and can result in the cane to help alleviate pain and improve function.4
detection and treatment of incidental meniscal
tears. Degenerative meniscal tears are very com- Does the patient require medication?
mon in patients with osteoarthritis and do not When nonpharmacological intervention proves
require operative treatment.1 unsatisfactory, multiple guidelines recommend

© 2014 Canadian Medical Association or its licensors CMAJ, November 18, 2014, 186(17) 1311
Practice

acetaminophen as a first-line agent for mild to Although some older systematic reviews sug-
moderate arthritis. Because of reports of gastroin- gested minor benefits for the use of physical
testinal adverse events, elevated hepatic enzymes modalities or were inconclusive,3,4 more recent
and overdose, the OARSI guideline recommends randomized trials showed no additional benefits
conservative dosing and treatment duration of to the use of these modalities.4 Manual therapy
acetaminophen.4 Although the OARSI guideline received an inconclusive rating in the AAOS
does not give exact parameters on this recom- guideline based on a lack of adequate studies
mendation, the AAOS guideline indicates it may evaluating joint mobilization, joint manipulation,
be prudent to restrict the over-the-counter dose of chiropractic therapy, patellar mobilization or
acetaminophen to 3000  mg per day and reserve myofascial release.3
the 4000 mg per day dose for prescriptions.3 In a Cochrane review, use of opioids for hip
Second-line agents include oral and topical non- and knee arthritis was found to be effective for
steroidal anti-inflammatory drugs (NSAIDs), selec- pain control and improvement in physical func-
tive cyclooxygenase-2 inhibitors and topical capsa- tion; however, because of a high rate of adverse
icin.6 Use of oral and topical NSAIDs received a events, the authors did not recommend the routine
strong recommendation in the AAOS guideline.3 use of opioids for the treatment of osteoarthritis.8
For patients with osteoarthritis localized to Most articles in this review combined data on hip
one or both knees, the OARSI guideline recom- and knee osteoarthritis. The AAOS group found
mends the use of local medications, including no studies on opioids or pain patches for the treat-
topical NSAIDs and corticosteroid injections ment of knee osteoarthritis that met its inclusion
(see below).4 This was especially emphasized in criteria, and the group was unable to recommend
patients with coexisting medical comorbidities, for or against opioid use.3 Other guideline groups
which are very common in this patient popula- were also unable to make a recommendation
tion.4 Each medication carries unique safety and regarding opioid use.4,6
adverse-effect profiles, and therapies should be Medial compartment–unloading braces
specific to each patient’s individual risk factors received an inconclusive recommendation from
and medical comorbidities. the AAOS;3 however, this intervention was sup-
ported by OARSI.4 The evidence for their use
If initial treatment fails, what other appears to be inconsistent. The AAOS recom-
options may be considered? mendation was based on inconsistent findings
Several options may be considered when initial from three moderate- to high-quality RCTs, with
treatment does not result in satisfactory symptom improvement in pain scores not always reaching
control. These include systemic medications statistical significance.3
(e.g., tramadol, duloxetine, opioids), intra-articular With inconclusive or uncertain recommenda-
corticosteroid injections, medial compartment– tions, both the AAOS and OARSI guidelines
unloading braces, physical modalities and man- stress that clinical judgment and patient prefer-
ual therapy. ence should have a substantial influencing role
For refractory symptoms, guidelines recom- when deciding to use these treatment modalities
mend tramadol3,4,6 and duloxetine.4,6 The AAOS for the management of knee osteoarthritis.3,4
recommendation for the use of tramadol is on the
basis of five  RCTs that showed outcomes in What treatments shouldn’t be offered?
favour of the treatment group.3 Duloxetine is rec- There are many other treatments that have been
ommended by OARSI on the basis of a system- used for osteoarthritis, including needle lavage
atic review and an RCT that showed that the drug for joints, lateral wedge insoles, acupuncture,
is efficacious and well tolerated for chronic pain glucosamine, chondroitin, intra-articular injec-
associated with knee osteoarthritis.4 Whereas the tions of hyaluronic acid, and arthroscopy. How-
use of intra-articular corticosteroid injections was ever, studies of these treatments have not con­
deemed inconclusive in the AAOS guideline,3 the sist­e ntly shown statistically significant or
OARSI guideline supports their use because of clinically important improvements, and their use
two systematic reviews showing significant short- is not routinely recommended in guidelines.
term decreases in pain.4 Needle lavage for joints was assessed in a
The use of physical modalities (e.g., transcu- 2010 Cochrane review, and the authors found no
taneous electrical nerve stimulation, ultrasound, benefit in terms of pain relief or improvement in
therapeutic application of musically modulated physical function.9 Neither the EULAR nor the
electromagnetic fields) and manual therapy all AAOS guidelines recommend using lateral
received an inconclusive recommendation from wedge insoles because of lack of efficacy in com-
the AAOS work group.3 These recommendations parison to neutral insoles3,5 and reports of adverse
are supported by several other guidelines.4,6 events.5 A recent meta-analysis investigating the

1312 CMAJ, November 18, 2014, 186(17)

 Practice

use of lateral wedge insoles for treatment of effects with use of hyaluronic acid injections;
medial knee osteoarthritis failed to show a statis- however, none of the improvements met the
tically significant or clinically important AAOS group’s threshold for minimal clinically
improvement in pain scores using the Western important improvement.3 The OARSI’s uncer-
Ontario and McMaster Universities Osteoarthritis tain recommendation was based on two  system-
Index (WOMAC) when compared with a neutral atic reviews and an RCT that provided inconsis-
insole.10 The Canadian Orthopaedic Association, tent conclusions and conflicting results.4
as part of the Choosing Wisely Canada cam- Over the past decade, there has been increasing
paign, does not recommend the use of either joint evidence against the use of arthroscopy in the
lavage or lateral wedge insoles for the treatment management of knee osteoarthritis. The current
of knee arthritis11 (Box 1). AAOS guideline reflects this and strongly recom-
The AAOS guideline recommends against the mends against the use of arthroscopy in the man-
use of acupuncture, glucosamine, chondroitin agement of knee osteoarthritis.3 This recommenda-
and hyaluronic acid injections for the manage- tion was based on three RCTs (two with moderate
ment of osteoarthritis of the knee.3 Other guide- strength and one with strong strength) that failed to
lines, including the 2014 OARSI guideline, are show any clinical benefit, as well as on the risk
less critical of these modalities; however, they associated with surgical intervention.3 This recom-
also do not recommend their use.4,6 mendation did not apply to patients with a primary
Acupuncture is not recommended by the diagnosis of meniscal tear and concomitant knee
AAOS based on 10  studies (five high strength osteoarthritis. In this patient population, the AAOS
and five  moderate strength), most of which did found insufficient evidence to recommend for or
not show statistically significant improvement, against arthroscopic partial meniscectomy and ren-
and if they did show improvement, it was not dered an inconclusive ­recommendation.3
clinically significant.3 The uncertain recommen-
dation in the OARSI guideline on acupuncture The case
was based on a meta-analysis that found statis­ Plain radiography confirmed the diagnosis of
tic­ally significant, but not clinically significant, moderate osteoarthritis of the knees. The patient
benefit in sham-controlled trials.4 was referred to a self-management program
Like the AAOS, the Canadian Orthopaedic through The Arthritis Society (www.arthritis.ca/
Association, as part of the Choosing Wisely asmp) for control of her knee osteoarthritis. As an
Canada campaign, recommends against the use initial management plan, a low-impact exercise
of glucosamine or chondroitin in patients with program, a weight-loss plan that included both
symptomatic osteoarthritis of the knee (Box 1). diet and exercise, and an acetaminophen dose of
The AAOS group based its recommendation on 500  mg every 6  hours as required was recom-
the analysis of 5 high-quality, 1 low-quality and mended. Should the initial management plan fail
15  moderate-quality studies, which failed to to provide sufficient symptomatic relief, a topical
show improvement in pain and function scores NSAID would be a safe and generally effective
using WOMAC and pain scores using a visual addition, taking into consideration that the patient
analogue scale.3 The OARSI guideline was less
critical than the AAOS guideline, but more spe-
cific. The OARSI guideline indicates that glu- Box 1: Choosing Wisely Canada recommendations*
cosamine and chondroitin are not appropriate for Don’t use needle lavage to treat symptomatic osteoarthritis of the knee
use in knee osteoarthritis as disease-modifying for long-term relief.
agents and, partly because of inconsistencies in • The use of needle lavage in patients with symptomatic osteoarthritis
results between industry-sponsored and indepen- of the knee does not lead to measurable improvements in pain,
dent trials, was uncertain about their role in pain function, 50-foot walking time, stiffness, tenderness or swelling.
relief.4 An older Cochrane review on the use of Don’t use glucosamine and chondroitin to treat symptomatic osteoarthritis
glucosamine in osteoarthritis showed that its use, of the knee.
when restricted to analysis of studies with ade- • Both glucosamine and chondroitin sulfate do not provide relief for
patients with symptomatic osteoarthritis of the knee.
quate allocation concealment and not using a
Don’t use lateral wedge insoles to treat symptomatic medial compartment
specific brand, failed to show a benefit in
osteoarthritis of the knee.
WOMAC pain or function scores.12
• In patients with symptomatic osteoarthritis of the knee, the use of
The AAOS group based its recommendation lateral wedge or neutral insoles does not improve pain or functional
on intra-articular hyaluronic acid injections on outcomes. In addition, the possibility exists that those who do not use
14  studies (3  high-strength and 11  moderate- them may experience fewer symptoms from osteoarthritis of the knee.
strength studies). Meta-analyses of pain, func- *Source: Canadian Orthopaedic Association: Five things physicians and patients should
tion and stiffness scores using WOMAC sub- question. Choosing Wisely Canada; 2014. Available: www.choosingwiselycanada.org/
recommendations/canadian-orthopaedic-association-2.
scales all found statistically significant treatment

CMAJ, November 18, 2014, 186(17) 1313

Practice
for osteoarthritis of the knee or hip. Cochrane Database Syst Rev
has isolated knee osteoarthritis and comorbidities 2009;(4):CD003115.
of hypertension and diabetes. Orthopedic referral   9. Reichenbach S, Rutjes AW, Nuesch E, et al. Joint lavage for
osteoarthritis of the knee. Cochrane Database Syst Rev 2010;(5):​
will be initiated for consideration of knee replace- CD007320.
ment in the future if her pain and resultant func- 10. Parkes MJ, Maricar N, Lunt M, et al. Lateral wedge insoles as a
conservative treatment for pain in patients with medial knee
tional limitations are inadequately controlled with osteoarthritis: a meta-analysis. JAMA 2013;310:722-30.
comprehensive non­operative management and 11. Canadian Orthopaedic Association. Five things physicians and
patients should question. Choosing Wisely Canada in partner-
she is willing to consider surgery. ship with the Canadian Medical Association. Available: www​
.choosingwiselycanada.org/wp-content/uploads/2014/03​/2014-03​
-28_EN​-COA-List-CLEAN.pdf (accessed 2014 Aug. 26).
References 12. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine
  1. Bennell KL, Hunter DJ, Hinman RS. Management of osteoarthritis therapy for treating osteoarthritis. Cochrane Database Syst Rev
of the knee. BMJ 2012;345:e4934. 2005;​(2):CD002946.
  2. Zhang W, Doherty M, Peat G, et al. EULAR evidence-based
recommendations for the diagnosis of knee osteoarthritis. Ann Affiliations: Concordia Hip & Knee Institute (Demcoe,
Rheum Dis 2010;69:483-9. Bohm), Winnipeg, Man.; Department of Surgery, Section of
 3. Treatment of osteoarthritis of the knee. 2nd ed. Rosemont (IL): Orthopaedic Surgery (Demcoe), University of Manitoba;
American Academy of Orthopaedic Surgeons; 2013. Section of Orthopaedic Surgery, Department of Surgery
  4. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guide-
lines for the non-surgical management of knee osteoarthritis.
(Bohm), University of Manitoba, Winnipeg, Man.
Osteoarthr Cartil 2014;22:363-88. Contributors: Alistair Demcoe selected the reference mate-
  5. Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommen-
dations for the non-pharmacological core management of hip and
rial, and drafted and revised the article. Eric Bohm conceptu-
knee osteoarthritis. Ann Rheum Dis 2013;72:1125-35. alized and revised the article. Both authors approved the final
  6. Nelson AE, Allen KD, Golightly YM, et al. A systematic review submission.
of recommendations and guidelines for the management of
osteoarthritis: The Chronic Osteoarthritis Management Initiative
of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum
CMAJ is collaborating with Choosing Wisely
2014;43:701-12. Canada, with support from Health Canada, to
  7. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet publish a series of articles describing how to
and exercise on knee joint loads, inflammation, and clinical out-
comes among overweight and obese adults with knee osteoarthri- apply the Choosing Wisely Canada recommenda-
tis: the IDEA randomized clinical trial. JAMA 2013;​310:​1263-73. tions in clinical practice.
  8. Nüesch E, Rutjes AW, Husni E, et al. Oral or transdermal opioids

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