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Right Knee Pain

Short summary

41-year-old male that in the past decade had suffered 2-3 times a year from bilateral knee pain which resolved spontaneously. Last year he had episodes of thumb pain that had lasted for several weeks and had affected grasp movements. The patient had responded to NSAID treatment for 2 weeks. MRI of the right knee showed Mild endoarticular effusion in the sub-quadriceps recess, chondropathy of the femoropatellar joint and lesion of the medial meniscus. The diagnosis of the first orthopedic specialist was lesion of the right medial meniscus, but the second diagnosed bilateral femoropatellar chondropathy.

Patient's questions

On account of the opposing views provided by the two orthopedic specialists, we ask :

1. What do you infer is the main diagnosis?

2. What therapy would you suggest? In particular, is arthroscopy advisable? Please, suggest the best medical therapy in order to prevent chondropathy.

3. What would the possible clinical evolution be after seeing the current radiology studies of the knee?

Medical Background

Diagnosis : Right Knee Pain
Age : 41 years old

Past History:
No significant past medical history.

Current Illness:
Episodes of bilateral knee pain, especially in the right knee, over the past decade at 2-3 years intervals which always resolved spontaneously and without clinical investigation. In 2008 pain in both thumbs, prevailingly on the right side, persisted for about 2 months also impeding hand grasp movements. The patient took nimesulide for about 2 weeks but without benefit; eventually, pain resolved spontaneously.

Following a new and more intense episode of right knee pain, the patient had an X-ray of the right knee on 11/18/2008 which revealed no skeletal alterations.
On 09/2008 an MRI of the right knee was performed and the report reads:
Mild endoarticular effusion in the sub-quadriceps recess.
for Evidence of arthrosis. Grade 2 chondropathy of the femoropatellar joint.
No significant alterations nor signs of alteration of the cruciate ligaments.
Grade 3 lesion of the medial meniscus.
Collateral ligaments, quadriceps and patellar tendons are normal.
No alteration of Hoffa’s fat pad”.
During an orthopaedic visit on 12/2008 the following diagnosis emerged: “lesion of the right medial meniscus”. Hospitalization for surgery was advised and the following symptomatic medical therapy recommended:
Indoxen 25 mg. 1 tablet twice daily 7 days;
Toradol 10-15 drops when needed.
On 01/2009 the patient was referred to another orthopedic specialist whose report states:
- Physical examination: no effusion
Bilateral cracking sounds of femoropatellar joints
Knee flexion is preserved
Pain during squats
Initial appearance of Heberden nodes involving both hands’ digits
- Diagnosis: bilateral femoropatellar chondropathy
- Therapy: Dona granules 1 daily for 3-month cycles
Magnetic therapy
Swimming but only freestyle
Avoid climbing stairs
Follow-up visit in one year
Therefore, there was no indication for surgery for the time being.

Medical opinion

Apparently in the past few months the patient had a more severe episode of right knee pain. No significant trauma has been mentioned. No events of knee locking or giveaways are reported.

In such a young patient the clinical story suggests the possibility of generalized Arthritic disease (RA, Psoriatic Arthritis and others and also Osteoarthritis). I suggest such an investigation should be performed by the patients GP (General practitioner or family doctor).

Reviewing the X-RAYS:
• There is good bone quality
• The joint space is preserved.
Early mild arthritic changes can be noticed, especially in the intercondylar eminence and peripheral edges of the femoral condyles and tibial plateau.

On MRI: there is mild amount of effusion. Evidence of mild chondral changes, mostly in the patelofemoral joint is evident. The cruciate ligaments and the medial and lateral collateral lig are normal. The medial meniscus has intra meniscal changes but not a large tear. The lateral meniscus is normal.

On the basis of the data presented it seems to me that the most relevant and probable

For the time being I would defer arthroscopy. I do not recommend surgical procedures unless there are significant and specific clinical findings that correlates well with the imaging findings.

In this particular case no particular clinical findings of medial meniscus pathology has been mentioned or presented.

I would suggest the following Recommendations:
Physical therapy to preserve muscle and joint stability and range of motion.
• The use of patellar soft knee brace at times of symptoms.
Repeated course of NSAID - (rofeoxib, etodalac or others) in short ( 5-7 days) course
• treatment to be repeated as needed.
Supplement of diet with glucoseamines and chondroitin sulfate for the next 3 – 6 moths, and review the clinical status in 3- 6 months.
Only if symptoms do not pass or clinical signs of meniscal pathology are significant, an arthroscopy should be considered.