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Patient with knee pain
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Patient with knee pain - November 25, 2005 4:44:00 PM
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connie.pt
Posts: 76
Joined: March 28, 2005
From: Michigan
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I evaluated a 59 year old woman today whose main c/o was left knee pain. I started about two weeks ago when she woke up one morning before she got out of bed. It was so painful that she went to her primary care Dr. that day. She recieved a cortisone shot. One week later the pain was so intense that she went to the ER. No tests other than xrays were taken that she knows of. She was referred to an orthopedic Dr, who sent her for PT, to include aquatic (pool) therapy. Dx on the Rx: knee pain.
Her medical history is unremarkable except for one area: significant bowel pathology that required an ostomy, so she has an ostomy bag.
(She told the ortho doc three times that she had an ostomy bag, and he still ordered pool therapy, so I'm thinking that maybe he wasn't paying attention?) She has to sleep on her back due to the ostomy bag.
She denied any knee trauma, hx of knee pain, tingling or numbness, or feeling ill. Movement makes it feel better, as does the resting position. The pain is constant, rated 4-8 out of 10. Pain meds don't help much at all. The area of pain is superior, medial and lateral to the patella and the joint line, as well as the joint line itself. She also c/o swelling and sometimes feeling hot in this area.
She is using a rolling walker for amb. Previous to this she was working out (going to "curves") and doing Thi-Chi. She is a retired teacher.
Her gait was slow, but not as antalgic as I expected. Even though she said weight bearing was painful, she was able to balance on the affected side (left side) longer than the right in SLS.
Testing revealed hip compression was more painful than tibial-femoral compression. Patello-femoral compression was negative. The left knee was about 2.5 cm larger than the right, and it felt warmer. Distally there was no swelling. She was tender to palpation over the VMO area, and the tibial-femoral joint circumferentially.
MMT: knee ext 4, knee flex 4.
She didn't c/o pain with this.
She did c/o pain with resisted hip flex and passive hip ext. The knee in extension produced pain in supine.
In the Thomas test position, the knee pain was reproduced. In fact, she wouldn't let her hip extend down past about negative 50 degrees. I flexed her hip up just out of the painful range, then flexed her knee fully, which produced no pain. (If it was her quad, I would have expected that to reproduce the pain.)
This is where I ran out of time for the eval.
Her primary care Dr. is referring her to another ortho doc. But I'm not sure this is an orthopedic problem. As far as I know they have ruled nothing out so far.
I asked her to come back for another visit, where I will do some further testing proximally and maybe some ROM exercises in a pain-free range. Unless I find further musculoskeletal findings next visit, I plan to put her on hold until further medical testing is done.
The factors that make me hesitant to treat her:
1. no specific Dx in the presence of
2. acute onset with no trauma
3. it seems nothing has been ruled out by medical testing.
4. X-rays were of her knee only as far as I know (vs the entire femur)
5. joint warmth
6. bowel pathology; I remember reading somewhere that joint pain can be associated with this somehow.
Can anyone offer some insight here?
Connie
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Re: Patient with knee pain - November 26, 2005 2:43:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Connie,
I would like to know where this limb rests when the patient lies supine. If you find the involved limb held in internal rotation and adduction,produced at the hip, of course, and reflected in toes pointed at the ceiling, you might consider an abnormal neurodynamic as an essential diagnosis.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Patient with knee pain - November 26, 2005 2:51:00 AM
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Lukey
Posts: 180
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From: Australia
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It could be gout.
Luke
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Re: Patient with knee pain - November 26, 2005 3:00:00 AM
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connie.pt
Posts: 76
Joined: March 28, 2005
From: Michigan
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Thanks for your response, Barrett.
In supine, she held her hip in external rotation & slight abduction, with her toes pointed out. She was most comfortable with the hip & knee in the resting position.
I forgot to mention that all ligamentous tests were negative. I didn't test McMurray's because it was difficult for her to completely relax.
Connie
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Re: Patient with knee pain - November 26, 2005 3:05:00 AM
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connie.pt
Posts: 76
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From: Michigan
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Luke, yes it could be gout. It frustrates me that they didn't do a simple blood test.
Connie
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Re: Patient with knee pain - November 26, 2005 3:42:00 AM
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SJBird55
Posts: 2292
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From: Michigan
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Could be a Staphylococcus aureus infection too. (She doesn't neccessarily have to have a fever for SA.)
Barrett, does one just wake up with abnormal neurodynamics? And is there edema with abnormal neurodynamics?
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Re: Patient with knee pain - November 26, 2005 6:31:00 AM
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srcase
Posts: 551
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From: Michigan
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Hi Connie,
Good to see you back here. Interesting case. My first thought is to rule out hip joint pathology. Try Scour test and FABER's test, as well as piriformis test (crossover). See if she can do an active straight-leg raise without pain. If those are all negative, I'd try the disco test (or Thessaly?) standing pivot in slight knee flexion to rule out meniscal injury. Any pain with full knee flexion or extension with overpressure?
You may also want to check for femoral nerve entrapment or L3/L4 radic. Thomas test is a femoral nerve tension test.
Her pain with weightbearing and use of a walker is a concern, but also a clue to mechanical vs. chemical problem. Did she just start using a walker on her own?
And lastly, what does your gut tell you?? Sounds like you would like to refer her back to the physician. Follow your instincts.
Just some thoughts!
Sarah
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Re: Patient with knee pain - November 26, 2005 8:12:00 AM
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nari
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From: Australia
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I'd chase the hip a little more, testing in WB and during gait - slope, stairs?
My first instinct is that this is somehow related to her surgery/pathology, but that is probably a jump to conclusions.
I would do slump tests (gently!) and see what happens. Swelling certainly occurs with a neural "pathology", and warmth suggests infection, but the knee does not seem to be the "cause" of any pain, so I would suspect no knee pathology. Infection suggests 24/7 pain, which does not fit this lady, according to what you have told us.
Test her neurodynamics - I suspect your answer is there. If quite inconclusive, refer back or have a talk with her doctor; perhaps some more history would be helpful. Is her doctor quite sure about the lack of any new pathology?
Nari
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Re: Patient with knee pain - November 26, 2005 9:56:00 AM
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connie.pt
Posts: 76
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From: Michigan
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Thanks for all of your posts.
SJ, an infection could explain why she has pain in the knee as well as the hip. (there is 24/7 pain)
Sarah & Nari, I will definitely be looking at the hip more closely next visit.
Sarah, if it was the femoral nerve, than I would expect the Thomas test as I described above would reproduce the pain with knee flex, but it didn't.
She did begin using the walker on her own.
It's peculiar about the weight bearing factor. As I said, she c/o pain with weight bearing, and joint compression was painful. But observing her in SLS and with gait, she doesn't shift her weight to relieve the compression the (quick) way that those with ortho- or even neuro- patients do. It's more like a deep pain that feels better when she's in a different position.
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Re: Patient with knee pain - November 26, 2005 3:05:00 PM
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Randy Dixon
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I would say that you have ruled out an orthopedic problem, which is what the doctor referred her for, and it is down to either an infection, maybe septic arthritis, or neurological. I think the only safe thing to do is to refer back with a suspicion of infection and let them do some scans and bloodwork.
Even if the neurological tests resulted in positives that wouldn't rule out infection, so either way she has to have further medical tests.
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Re: Patient with knee pain - November 26, 2005 5:34:00 PM
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jma
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From: NY
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I agree. Send the patient back to the MD for further medical workup. The fact that someone has "24/7 pain" makes me suspicious. Definitely would never put anyone in a pool with an ostomy bag.
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Re: Patient with knee pain - November 27, 2005 1:22:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
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From: Kentucky
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My first thought is Gout. Unexplained, hot painful joint. Otherwise, fairly normal knee exam. I would order Uric Acid lab test and walk down the hall and talk to one of our primary care physicians.
This is actually missed quite often by physicians. I personally like the referrals that I get of "turf toe" on a 50 year old sedentary adults. Nice.
Barrett,
Is an abnormal neurodynamic first on your differential diagnosis list?
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Alex Brenner, PT, MPT, OCS
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Re: Patient with knee pain - November 27, 2005 2:06:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Alex,
Painful conditions that seem to have a mechanical component commonly have this to some extent. It seems obvious in this case we're dealing with a primary chemical problem and the contribution of neural tension to the pain is pretty much ruled out once you know how the patient is choosing to use the limb while supine. That's why I asked.
There's no way I would proceed with any significant care until the physician has done their job, and in this case it doesn't appear they have.
Thinking first about the body's most sensitive tissue being involved in the manner in which it is most vulnerable makes sense to me so I go there first. All that joint testing can wait.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Patient with knee pain - November 27, 2005 7:25:00 AM
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connie.pt
Posts: 76
Joined: March 28, 2005
From: Michigan
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Thanks, everyone.
I'll keep you posted.
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Re: Patient with knee pain - December 1, 2005 3:18:00 PM
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connie.pt
Posts: 76
Joined: March 28, 2005
From: Michigan
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I talked with the patient on the phone; she's going to another ortho doc.
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Re: Patient with knee pain - December 1, 2005 8:33:00 PM
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Randy Dixon
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Ortho. again?
I heard about a patient today, similar symptoms, turns out she had a tumor and ovarian cancer. It was causing a type of neurovascular compression. First doctor missed it completely.
If it wasn't for the warmness of the knee I would have suspected something like that in this case. I wouldn't have gone back to an ortho. I realize this isn't your call though, hope you keep us posted if you hear anything.
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Re: Patient with knee pain - December 4, 2005 11:20:00 AM
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Dr.Wagner
Posts: 1237
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From: Indianapolis
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Ok, I volunteered to help moderate the forum named "medical complexity"...to help clarify "medical issues". Got no response.
Anyway. As I cannot see the patient, do an exam, or read the chart; I can only comment on certain pathologies which have been mentioned.
1. Gout. Sure, but a 54 year old with 24/7 pain that goes on for weeks? Negative films for lesions. Test of choice, joint aspiration. Likely negative. Gout has exacerbations, usually not weeks and weeks of pain. But, it could be, certainly worth a tap if it continues.
2. Staph Aureus. Well, this would be a sorry soul with a staph aureus/toxic joint. By this point she would be in a bad way. No fever, no constant swollen, hot, angry knee makes me think otherwise.
Joint aspiration is test of choice.
3. Tumor. If you see a hoofprint think a horse not a zebra. If the KNEE hurts and it feels swollen, the pathology is likely there. Get an MRI or CT if one still has concerns, the scout film will contain a hip xray.
4. Neurodynamics etc...can't comment, that is part of the art of therapy.
Questions I would have...1. as the therapist, you are extremely intelligent, if this doesn't seem right...perhaps it isn't. Does it seem logical a patient with knee pain at 59 is using a walker?
2. Why the colostomy?
3. What meds is she on?
4. Where does she work? Who is the primary source of reimbursement (insurance, workers comp, lawsuit).
5. Are there any systemic signs of illness?
6. "Why are joint aspirations NOT done commonly in the office" may be your question, clinics often times do not have the facilities to handle joint fluid and many FP's don't feel comfortable tapping joints. Orthopods don't have the time because they have 30 patients to see before lunch/surgery/golf. In other words, a joint tap is very very helpful.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Patient with knee pain - December 4, 2005 1:13:00 PM
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Sean_Collins
Posts: 74
Joined: October 20, 2005
From: Massachusetts
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Hi Dr. Wagner -
Who did you ask? Did you send a message to Dave? I think it is a great idea for you to be a moderator of this forum to help with the medical issues. I can also send a message to Dave regarding this -
Best -
SC
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: Patient with knee pain - December 4, 2005 2:33:00 PM
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connie.pt
Posts: 76
Joined: March 28, 2005
From: Michigan
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Dr. Wagner,
I appreciate your insight and contributions to this forum. I especially appreciate the "extremely intelligent" comment.
I don't remember why the colostomy, just that it wasn't cancerous.
Without the chart, I don't remember what meds she was on, either.
She is a retired schoolteacher with insurance.
I didn't get the feeling that this was a psycho-social issue for her, or that she was getting any other kind of benefit from having this problem.
There were no other red flags or signs of systemic pathology.
Randy, I agree that it would be better for her to see her primary care doc again, but as you said it wasn't my call.
The warmness of the knee was located at the knee joint, but there very little swelling there. The swelling that was palpable was over the VMO area. This didn't make sense to me in the absence of trauma. If it was synovitis or even hemarthrosis, I would expect the majority of the swelling to be at the joint itself, and even distal if there was a lot of fluid.
Hope to hear from her soon.
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Re: Patient with knee pain - December 4, 2005 2:52:00 PM
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David Adamczyk
Posts: 292
Joined: March 14, 1999
From: Cleveland
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Dr. Wagner,
I apologize for the non-response to your message. My SBC global spam software recently decided that all mail from the dave@rehabedge server was spam, and it permanently deleted all mail from that server starting sometime before Thanksgiving.
I concur that your insight as a co-moderator would be an excellent and valuable addition to the Medical Complexity Forum. I hope that this Forum becomes a resource for all therapists, including those who practice in a direct access setting.
The dave@rehabedge.com email address is functioning again. I will contact you this week about getting you set up as a Forum Moderator. Thank you again for your contributions to RehabEdge.
Dave
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