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A 67-year-old woman with a body mass index of 33 presents with a year-long history of worsening medial pain in both knees. Her symptoms are aggravated by activity and reg- ularly interfere with many of her usual act- ivities. No other joints are symptomatic, and she hasn't experienced erythema or warmth in her knees. Examination of her knees shows ten- derness in the medial joint line, mild effusions, normal range of motion with crepitus and intact ligaments. Her hips and back are normal on examination. Her medical history includes hypertension and type 2 diabetes mellitus.
What is the likely diagnosis?
The most likely diagnosis for this patient is osteo- arthritis of the knees. The differential diagnosis includes pes anserine bursitis, spontaneous osteo- necrosis of the knee and inflammatory arthropa- thy. Osteoarthritis is more coimnon in women and older people; in addition, obesity puts this patient at increased risk for knee osteoarthritis.1,2 Brief morning stiffness, persistent knee pain, a decrease in function, crepitus, restricted movement and bony enlargement are clinical features and find- ings on physical examination that comprise the European League Against Rheumatism (EULAR) criteria for the diagnosis of osteoarthritis.2
Are any investigations necessary?
Plain radiography is the first-line imaging modal- ity for the assessment of knee pain in this patient population. The EULAR group considers plain radiography (standing anteroposterior, standing semi-flexed posteroanterior, Merchant [skyline] and lateral views) the current gold standard for structural assessment of knee osteoarthritis.2 Magnetic resonance imaging is not required to make the diagnosis of osteoarthritis,2 nor is it helpful in making decisions about currently avail- able interventions.1 Inappropriate use of magnetic resonance imaging is costly and can result in the detection and treatment of incidental meniscal tears. Degenerative meniscal tears are very com- mon in patients with osteoarthritis and do not require operative treatment.1
What initial treatment should be recommended?
Several evidence-based clinical practice guide- lines recoimnend the following initial interven- tions for the management of knee osteoarthritis: participation in a self-management program, strengthening exercises, low-impact exercises (aquatic or land-based), neuromuscular educa- tion and weight management A6
The Arthritis Self-Management Program was developed at Stanford University and is sup- ported by The Arthritis Society. This widely used program is designed to help patients better understand their diagnosis and...