Rose Williams: A 72-Year-Old Female With Right Knee Pain

Learning Objectives

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Learn the common causes of knee pain.
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Develop an understanding of the unique anatomy of the knee joint.
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Develop an understanding of the causes of arthritis of the knee.
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Learn the clinical presentation of osteoarthritis of the knee.
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Learn how to use physical examination to identify pathology of the knee joint.
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Develop an understanding of the treatment options for osteoarthritis of the knee joint.
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Learn the appropriate testing options to help diagnose osteoarthritis of the knee joint.
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Learn to identify red flags in patients who present with knee pain.
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Develop an understanding of the role in interventional pain management in the treatment of knee pain.

Rose Williams

Rose Williams is a 72-year-old seamstress with the chief complaint of, “I can’t walk up the stairs to my house because of my knee.” Rose went on to say that she wouldn’t have bothered me, but it was becoming harder and harder to make it up her front steps after coming home from work. Rose said that 50 years of pinning hems and cuffs had finally caught up with her. “Doc, I don’t know what I would do if I didn’t go to work every day, but the getting down on my knees and getting up again is getting harder and harder. The pain at work is bad enough, but the last few weeks, when I get home, I have to use my arms to help pull me up my front stairs.”

I asked Rose if anything like this has happened before. She shook her head and said, “I’m in pretty good shape for 72 years old, but my right knee is giving me a fit. I have never been a sound sleeper, but this knee must wake me up 20 times a night. I have been using my heating pad, but you know I live alone and I am afraid to leave it on at night.”

I asked Rose about any antecedent trauma to the right knee. She thought about it for a minute and said that she really couldn’t remember any injuries, but she did tend to get down on her right knee when she was marking cuffs and hems.

I asked Rose to point with one finger to show me where it hurts the most. Rose didn’t point, but instead cupped the front of her right knee in her palm and rubbed it, responding, “The whole knee hurts. Doc, the other thing is, sometimes I feel this grating sensation, especially when I first get up in the morning.” She denied popping or catching with flexion and extension. I asked if she had any fever or chills and she shook her head no. “What about steroids?” I asked. “Did you ever take any cortisone or drugs like that?” Rose again shook her head no and said, “Doc, you know me. I’m a tough old bird and I wouldn’t bother you if it didn’t really hurt. I love my job—it’s my life! But this knee has really got me worried. I have to be able to get into my house or what will become of me?”

On physical examination, Rose was afebrile. Her respirations were 18 and her pulse was 74 and regular. Her blood pressure (BP) was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. I did a rectal exam and pelvic, which were both normal. Visual inspection of the knee revealed no cutaneous lesions or obvious hernia or other abnormal mass. The area overlying the right knee was warm to touch. Palpation of the right knee revealed mild diffuse tenderness, with no obvious synovitis or point tenderness. On ballottement of the right knee, there was a suggestion of mild effusion. There was mild crepitus, but I did not appreciate any popping or catching. Range of motion was decreased, with pain exacerbated with active and passive range of motion. The left knee examination was normal, as was examination of her other major joints, other than some mild osteoarthritis in the fingers. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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No history of acute knee trauma
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No fever or chills
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Gradual onset of right knee pain over the last several weeks with exacerbation of pain with knee use
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Grating sensation in the right knee
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Sleep disturbance
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Difficulty walking up stairs due to pain
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Pain on kneeling

The Physical Examination

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The patient is afebrile
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Normal visual inspection of knee
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Palpation of right knee reveals diffuse tenderness
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No point tenderness
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Mild warmth of right knee
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Crepitus and pain with range of motion
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No evidence of infection
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Suggestion of a mild effusion
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No active synovitis

Other Findings of Note

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Normal BP
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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No groin mass or inguinal hernia
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No CVA tenderness
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Normal pelvic exam
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Normal rectal exam
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Normal upper extremity neurologic examination, motor and sensory examination
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Examination of joints other than the right knee were normal other than some mild osteoarthritis of the hands

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiograph of the right knee

Test Results

The plain radiographs of the right knee revealed significant joint space narrowing and osteophyte formation consistent with severe osteoarthritis ( Fig. 1.1 ).