Demographics
- Uncommon in young populations |
- Usually symptomatic (1/3 in >65 years of age) |
- Obesity (low grade inflammation in the joint) |
- Women more than men |
Causes
- Obesity |
- Trauma/prior surgery in the knee (within 5-15 years) |
- Occupations/activities that exposes the knee to repetitive squatting, kneeling, pivoting, stair climbing |
- Athletes in tennis, racquetball, soccer, weightlifting, dance, cycling, gymnastics, football |
- Biomechanical deficits - Varus, Valgus, glut med weakness, pes planus |
Presentation
- Mainly affects medial tibiofemoral compartment then patellofemoral and lateral compartments |
- Older adult with gradual joint pain |
- Provoked by activity , relieved by rest |
- Described as a deep ache |
- Morning stiffness that improves after >30 mins |
- Pain worse with weather changes (barometric pressure - cool/damp weather) |
- Difficulty with squatting, bending, stair climbing, prolonged walking - can acquire a limp |
- Loss of ROM (can have severe limitation) |
- Crepitus |
- SHort Stride length |
- Slower walking speed |
- Poor balance |
- May have fear avoidance behaviours |
- Joint line pain and tenderness (medial compartment) |
- +ve Valgus/Varus stress test (instablity) |
- Weak Quads |
- Assess Get up and go test |
- Assess hyperpronation of the foot and weakness of hip abductors and ext rots |
- Iliopsoas and hip flexor tightness (prevents hip from working through a full ROM - increases stress to the knee) |
- Gastrocsoleus, thigh adductors, piriformis - assess for tightness |
- Assess for posterior hip capsule tightness (inhibits normal knee mechanics - creates excessive anterior shear) |
- Assess Lx and SIJ |
- Assessed by WOMAC pain/functional assessment
ACR Criteria
At least 3 of the 6 findings: |
- Age >50 yo |
- Morning stiffness for >30 mins |
- Bony tenderness |
- Bony enlargement |
- Crepitus |
- No palpable warmth |
Imaging
- Not usually required (patients can be asymptomatic with x-ray findings) |
- If diagnosis is uncertain , x-rays can be taken |
- MRI if considering meniscal tear, ligament sprain/tear, AVN |
DDx
- Meniscus injury |
- Ligament sprain |
- Bursitis |
- Tendonitis (ITB/pes anserine tendons) |
- AVN |
- F# |
- Infection |
- Neoplasm |
- RA |
- Gout |
- Pseudogout |
- Psoriatic arthritis |
- Lyme disease |
Management
- Home exercises 2-3 times a week |
- Knee extensor/quads strengthening (Quad setting, dynamic ball wall squats, chair squats with band |
- Glut med strengthening - clam/posterior lunges |
- Hip hinges |
- Stretching of gastrosoleus, hamstring, ITB, Quads and thigh adductors |
- Yoga/taichi |
- Overweight patients - low impact aerobic exercise (biking, walking, ellipitical exercise, water walking, swimming) |
- Axial manipulation + patella glide (severe cases/pts with assistive device >25% of the day should not be manipulated) |
- Stretching of posterior hip capsule |
- Ice massage/ice |
- Myofascial release of tight musculature |
- Total knee replacement if unresponsive to conservative care |
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