Right Knee Pain

 Chief Complaint: A 60 year-old male presents to your outpatient clinic with 3 months of right knee pain.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination, and why?

Relevant History:

  • What are the pain characteristics? E.g. onset, location, duration, aggravating/alleviating factors, severity, radiation, timing, quality
  • Was there injury or trauma?
  • Was there a pop? Is there swelling? Redness?
  • Is there any locking or clicking? Does the knee give out?
  • Any constitutional symptoms? Fever/chills?
  • Has this happened before? Any history of knee problems?
  • What has the patient tried so far to help with the pain? Specifically, physical therapy, oral medications, injections, or surgery? Has the patient sought care or had a workup?
  • Is there pain anywhere else, notably back or hip pain? Is there numbness/tingling/weakness?
  • Past Medical/Past Surgical History?
  • Functional History? Is patient physically active?
  • Social History? What is the patient’s work situation? Can he work with the pain?
  • Does the patient have any allergies?

Relevant Physical Examination:

  • Vital signs
  • Inspection
  • Palpation
  • Manual muscle testing of bilateral lower extremities (myotome scan)
  • Sensory and reflex testing of bilateral lower extremities
  • Gait observation/analysis
  • Special testing: Patellar grind, patellar excursion, varus/valgus stress testing, anterior and posterior drawer, Lachman, McMurray, Bounce Home, Thessaly, Apley Grind, Pivot Shift, medial and lateral Joint Line Tenderness, Ballottement, Fulcrum, Straight Leg Raise

+ Challenge Question

  • What are you trying to assess by performing the Thessaly test?

+ Challenge Answer

  • The Thessaly test is intended to assess for a medial or lateral meniscus tear in the knee. A positive test (knee pain reproduced during the test) indicates a meniscus tear.

  • Note: Always be prepared to explain how to perform a test, why you are performing it in a particular patient, and what the test is intended to diagnose.

 

DOMAIN B: PROBLEM SOLVING

The patient has been taking acetaminophen and ibuprofen with only mild relief. Vital signs are within normal limits. There is mild swelling of the right knee. The patient exhibits normal sensation and reflexes. Knee extension strength is 4/5 on the right with pain upon testing, and 5/5 on the left. There is pain in the right knee with varus and valgus stress testing, Thessaly test, and Joint Line Tenderness. Lachman is negative.

+ What is your differential diagnosis for this patient?

  • Medial or lateral meniscus tear, medial/lateral collateral ligament sprain, patellofemoral pain syndrome, quadriceps tendonitis, patellar tendonitis, ACL/PCL tear, quadriceps muscle strain, pes anserine bursitis, primary hip joint pathology, iliotibial band syndrome (IT band syndrome), femoral stress fracture, Segond fracture, osteoarthritis, rheumatoid arthritis, lumbar radiculopathy.
 

DOMAIN C: PATIENT MANAGEMENT

+ MRI confirms a degenerative tear of the medial meniscus of the right knee. How would you proceed with treatment?

  • Offer NSAID prescription (meloxicam, celecoxib, high-dose ibuprofen) as long as renal and GI history are not prohibitive for NSAID use. Consider topical diclofenac, heat, ice, meniscus offloader brace, or patellar tracking brace. Offer physical therapy referral. Offer corticosteroid injection into the right knee. Consider orthopedic surgery referral depending on clinical response to the above interventions.
 
 

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient undergoes a course of physical therapy along with a corticosteroid injection into the knee with no significant improvement. He is referred to an orthopedic surgeon who plans to perform a knee arthroscopy with meniscus repair. The patient states, “Thanks for all your care, doctor. I also have an upcoming partial colectomy. Is it ok to go ahead with the meniscus surgery around the same time as the colectomy?”

+ What is your recommendation?

  • That is a great question. What I would like to do is personally reach out to your primary care physician as well as your colorectal surgeon and orthopedic surgeon to determine an optimal surgical plan for you. With two surgeries, we want to make sure we minimize the risks to your health while maximizing your recovery. I will also send a copy of my note today to each of these physicians, detailing my thoughts today. What other questions do you have for me today?

  • Note: If you are asked a question such as this one, it’s important to “do the work yourself”. Don’t tell the patient to ask his primary care physician himself, or to ask the surgeon himself. Take care of the patient to maximize safety, rather than push this task onto him.

 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

During your initial discussion with the patient about his treatment options, you suggest physical therapy and a meloxicam prescription. The patient states, “No, doctor. Physical therapy doesn’t work. I need something stronger for my pain. I tried one of my wife’s oxycodone pills which helped a lot. Can’t you just prescribe me that? I feel like I could actually live my life again if I had that instead of wasting my time with useless stretches.”

+ What is your response? This is the role-playing portion of our case, so please pretend that I am the patient.

  • A proper response should involve foremost compassion, followed by education and finding out how much the patient knows about his injury and disease process. A reasonable response may look like the following:

  • “I’m sorry that you are dealing with such a difficult issue. Knee pain can be very disabling. My goal is to do my best to reduce your pain and improve your function in your daily activities. Please tell me what you understand about your knee condition.” Following the patient’s response, a reasonable continuation might look something like the following: “What we want to do is address your pain using the most conservative, safest treatments at our disposal, only involving more invasive or stronger interventions if the more conservative options are not working for you. That is why I have laid out the treatment plan that we discussed. Furthermore, taking opioid medications that are not prescribed to you is against the law, and I recommend against doing so. Finally, I’m sorry that it sounds like physical therapy has not helped you in the past. The goal of physical therapy in your case is to strengthen the muscles that control the knee so that you can function better with less pain. Stretching some of the muscles around the knee can help with this process, but it is primarily strength and functional improvement that we are aiming to establish with physical therapy. Further, should the physical therapy and meloxicam not benefit you, I would be more than happy to discuss a corticosteroid injection vs. discussing your case with an orthopedic surgeon. Unfortunately, however, opioid pain medication for this condition would not be appropriate at this time, as you may find benefit from our standard treatment options without the risk for addiction. I understand that this is very disabling and painful for you, and I will be here for you every step of the way. What other questions could I help answer today?”