The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults

Ultrasound-Guided Pes Anserine Bursitis Injection Choices: Prolotherapy or Oxygen-Ozone or Corticosteroid: A Randomized Multicenter Clinical Trial

OBJECTIVE

Pes anserine bursitis is the most common cause of periarticular knee pain. The aim of the study was to evaluate the efficacy of local injection-based therapies with different materials.

DESIGN

The enrolled patients were randomly allocated to three groups to receive different interventions. Outcome measures included pain severity using the visual analog scale and the Western Ontario and McMaster Universities osteoarthritis index that was evaluated before the intervention, 1 and 8 wks after that.

RESULTS

This trial was performed on 72 participants, with male-to-female ratio of 0.14 and with a mean age of 61.49 ± 9.35 yrs. Corticosteroids in the first group, oxygen-ozone in the second group, and dextrose 20% in the third group, were injected into the pes anserine bursa under ultrasound guidance. Interaction between time and group showed a statistically significant improvement in visual analog scale and Western Ontario and McMaster Universities Arthritis Index ( P ≤ 0.05) in favor of corticosteroids and oxygen-ozone groups after 1 wk and in favor of oxygen-ozone and prolotherapy groups after 8 wks.

CONCLUSIONS

All three treatment options are effective for patients with pes anserine bursitis. This study showed that the effects of oxygen-ozone injection and prolotherapy last longer than those of corticosteroid injection.

Osgood-Schlatter Disease Unveiled Under High-frequency Ultrasonogram

Osgood-Schlatter disease is a painful condition, affecting the tibial tuberosity of physically active children with a painful bump that aggravates with repetitive impacts over the affected area during exercise, sports, or even usual daily activities. The condition is usually unilateral; however, bilateral presentation is not unlikely. In addition to clinical features, a unique radiological finding appears worthy in terms of accurate diagnosis. Moreover, ultrasonogram-based pathological changes could appear not only in the tibial tuberosity but also in the patellar tendon. In this study subject, I approached the condition with a high-frequency musculoskeletal ultrasonogram in order to add further information about the ailment in medical literature. The conservative approach was found effective to relieve the patient's problems.

Knee Pain and Structural Damage as Risk Factors for Incident Widespread Pain: Data From the Multicenter Osteoarthritis Study

OBJECTIVE

To examine the longitudinal relationship of knee pain, radiographic osteoarthritis (OA), symptomatic knee OA, and knee pain severity to incident widespread pain.

METHODS

The Multicenter Osteoarthritis Study is a longitudinal cohort of persons with or at risk of knee OA. Participants were characterized as having consistent frequent knee pain, radiographic OA (Kellgren/Lawrence scale grade ≥2), symptomatic OA, and knee pain severity at the 60-month visit (baseline). Widespread pain was categorized as pain above and below the waist, on both sides of the body and axially, using a standard homunculus, excluding knee pain. Incident widespread pain was defined as the presence of widespread pain at 84 months in those who were free of widespread pain at baseline. We assessed the relationship of baseline radiographic OA, symptomatic OA, consistent frequent knee pain, and knee pain severity, respectively, with incident widespread pain using logistic regression, adjusting for potential confounders, including models with and without pain severity.

RESULTS

At baseline, 1,129 subjects were eligible for analysis (mean ± SD age 66.7 ± 7.8 years; mean ± SD body mass index 30.1 ± 5.8 kg/m² ; 52% women). Radiographic OA in either knee (adjusted odds ratio [OR_adj ] 0.90 [95% confidence interval (95% CI) 0.63-1.30]; P = 0.587) was not associated with incident widespread pain. Baseline bilateral consistent frequent knee pain (OR_adj 2.35 [95% CI 1.37-4.03]), bilateral symptomatic OA (OR_adj 2.11 [95% CI 1.04-4.24]), and knee pain severity (worst knee) (OR_adj 1.11 [95% CI 1.05-1.17]; P < 0.001) were significantly associated with incident widespread pain.

CONCLUSION

Consistent frequent knee pain, symptomatic OA, and knee pain severity increased the risk of developing widespread pain, independently of structural pathology. These results suggest that knee pain, and not structural pathology, contributes to the onset of widespread pain.

Pes Anserine Bursitis in Symptomatic Osteoarthritis Patients: A Mesotherapy Treatment Study

Background: Pes anserine bursitis strongly affects quality of life in patients with osteoarthritis. Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, and injections of corticosteroid, with highly variable responses; recovery can take 10 days to 36 months. Mesotherapy is a minimally invasive technique consisting of subcutaneous injections of bioactive substances. The goal is to modulate the pharmacokinetics of the injected substance and prolong the effects at a local level.

Objective: To evaluate the effects of mesotherapy with diclofenac for anserine bursitis associated with knee osteoarthritis.

Methods: One hundred and seventeen patients with anserine bursitis associated with grade II Kellgren-Lawrence knee osteoarthritis, assessed by clinical, radiographic, and ultrasonographic examination, were evaluated and treated. They were randomly divided into two groups (A, mesotherapy; B, control). Group A completed nine sessions of mesotherapy with sodium diclofenac (25 mg/1 mL; Akis®, IBSA, Lugano, Switzerland), 1 mL for each session, three times per week. Group B received 21 oral administrations of sodium diclofenac (50 mg; Voltaren®, Novartis, Parsippany, NJ), once a day for 3 weeks. Primary outcome measures were pain intensity assessed by visual analogue scale (VAS), along with ability to perform activities of daily living, ability to participate in sports, level of pain, symptoms, and quality of life, as assessed by the Knee injury and Osteoarthritis Outcome Score. These measures were performed before and after the treatment period and at 30 and 90 days' follow up.

Results: In both groups pain level decreased significantly after the treatment period. Ultrasonography showed a reduction of the hypoechoic area related to anserine bursitis only in group A.

Conclusion: Administration of conventional NSAIDs (diclofenac) by mesotherapy is effective in managing anserine bursitis in knee osteoarthritis in the short term and mid-term. These observations could be of interest for efforts to reduce the adverse effects of oral administration of anti-inflammatory drugs.

Association between the severity of femoral condylar cartilage erosion related to knee osteoarthritis by ultrasonographic evaluation and the clinical symptoms and functions

OBJECTIVE

To determine the association between the severity of femoral condylar cartilage erosion resulting from knee osteoarthritis (OA) by an ultrasonographic grading system and the clinical symptoms and functions.

DESIGN

Cross-sectional study.

SETTING

A tertiary center.

PARTICIPANTS

Participants (N=101) with and without subjective complaints of knee discomfort were consecutively enrolled. Patients who had ever received knee arthroplasty, who had inflammatory arthritis, and whose knee flexion range of motion was <90° were excluded. A total of 194 knees were evaluated.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A semiquantitative ultrasonographic grading system was used to evaluate the severity of femoral condylar cartilage erosion. The clinical symptoms and functions were evaluated with the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lequesne index. The association of the VAS/WOMAC/Lequesne index with the ultrasonographic grading was assessed.

RESULTS

Positive linear associations were found between the ultrasonographic grading and the following: the VAS and the total scores and pain subscales of both the Lequesne index and WOMAC. Multivariate logistic regression analysis revealed grade-dependent association between VAS and ultrasonographic grading after adjusting for age, sex, and body mass index. The WOMAC and Lequesne index scores were associated with the ultrasonographic grading in more severe degrees, particularly in the pain subscales.

CONCLUSIONS

This semiquantitative ultrasonographic grading system may well reflect the clinical symptoms and functions related to knee OA as evaluated by the VAS, WOMAC, and Lequesne index. This method provides a more comprehensive description and measurement of knee OA.

Safety and efficacy of methylprednisolone infiltration in anserine syndrome treatment

OBJECTIVE

The anserine syndrome is a common cause of knee pain. Infiltration with glucocorticoids has been evaluated in studies with low level of evidence and there are no published clinical trials to determine its usefulness. The objective of this study was to determine the efficacy and safety of the infiltration of methylprednisolone in the treatment of Anserin Syndrome.

METHODS

We conducted a clinical trial in 58 adult patients with anserin syndrome, which presented intra-articular pathology ruled that reflected pain in the medial aspect of the knee. The WOMAC scale was assessed at baseline and patients were randomized to receive an infiltration of lidocaine plus 40 mg methylprednisolone acetate (group 1) versus xylocaine plus distilled water (group 2). Both groups received 100mg of diclofenac sodium for 10 days. The WOMAC scale was applied at 4 weeks and adverse events were recorded.

RESULTS

Equivalence was demonstrated in both groups for demographic variables and initial clinical evaluation. There was no statistical difference in the three domains of assessment of the baseline WOMAC score. The median baseline WOMAC in group 1 was 32 and in group 2 was 25.5 points. At 4 weeks it was 8 and 6.5 points, which corresponded to an improvement of 61.6 and 62.8% respectively.

CONCLUSION

The infiltration with methylprednisolone in anserin syndrome is not superior to placebo in patients taking diclofenac measured by the WOMAC scale at 4 weeks. The incidence of adverse events did not show any differences either.

Reasons for functional decline despite reductions in knee pain: the Multicenter Osteoarthritis Study

BACKGROUND

The majority of interventions for knee osteoarthritis aim to reduce knee pain with the assumption that improvements in function will automatically follow. However, this assumption is not universally true, and a paradoxical decline in function is not uncommon following reduction in knee pain.

OBJECTIVE

The purpose of this study was to examine what factors beyond knee pain are important for functional decline among people with reductions in knee pain.

DESIGN

This was an observational cohort study.

METHODS

The Multicenter Osteoarthritis Study (MOST) is a National Institutes of Health-funded longitudinal study of people who have or are at high risk for knee osteoarthritis. This study included individuals who had a meaningful reduction in pain in either knee over 30 months, defined as a 41% decrease in visual analog scale pain score with an absolute decrease of ≥20/100. Meaningful decline in walking speed was defined as a decrease of 0.1 m/s during a 20-m walk. To examine the association of risk factors with meaningful decline in walking speed, risk ratios were calculated and adjusted for potential confounders.

RESULTS

Of the 465 people with a meaningful reduction in knee pain (mean [SD] age=63.3 [7.8] years, 67% female, 82% Caucasian, mean [SD] body mass index=31.3 [6.3] kg/m(2)), 20% had a meaningful decline in walking speed. Adjusting for confounders, participants with new comorbidity and those with widespread pain had 1.8 and 1.7 times the risk of decline compared with their counterparts with no comorbidity or widespread pain (adjusted risk ratio=1.8 [95% confidence interval=1.1-3.0] and 1.7 [95% confidence interval=1.1-2.8], respectively).

LIMITATIONS

Generalizability is limited to people with a reduction in knee pain.

CONCLUSIONS

Reductions in knee pain are not always accompanied by improvements in walking speed. Health providers should consider that the onset of new comorbidity and presence of widespread pain may increase the risk of functional decline despite a reduction in knee pain.

Low back pain and other musculoskeletal pain comorbidities in individuals with symptomatic osteoarthritis of the knee: data from the osteoarthritis initiative

OBJECTIVE

To examine the association of concurrent low back pain (LBP), and other musculoskeletal pain comorbidity, with knee pain severity in symptomatic knee osteoarthritis (OA).

METHODS

Individuals from the Progression Cohort of the Osteoarthritis Initiative (n=1,389, ages 45-79 years) with symptomatic tibiofemoral knee OA were studied. Participants identified pain in the low back, neck, shoulder, elbow, wrist, hand, hip, knee, ankle, or foot. The primary outcome was the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) applied to the more symptomatic knee. We examined WOMAC pain score in persons with and without LBP, before and after adjusting for other musculoskeletal symptoms.

RESULTS

Of the participants, 57.4% reported LBP. The mean±SD WOMAC pain score (possible range 0-20) was 6.5±4.1 in participants with and 5.2±3.4 in participants without LBP (P<0.0001). In multivariate analyses, LBP was significantly associated with increased WOMAC knee pain score (β [SE]=1.00 [0.21], P<0.0001). However, pain in all other individual musculoskeletal locations demonstrated similar associations with knee pain score. In models including all pain locations simultaneously, only LBP (β [SE]=0.65 [0.21], P=0.002), ipsilateral elbow pain (β [SE]=0.98 [0.40], P=0.02), and ipsilateral foot pain (β [SE]=1.03 [0.45], P=0.02) were significantly associated with knee pain score. Having >1 pain location was associated with greater WOMAC knee pain; this relationship was strongest for individuals having 4 (β [SE]=1.83 [0.42], P<0.0001) or ≥5 pain locations (β [SE]=1.86 [0.36], P<0.0001).

CONCLUSION

LBP, foot pain, and elbow pain are significantly associated with WOMAC knee pain score, as are a higher total number of pain locations. This may have implications for clinical trial planning.

A Review of Topical Diclofenac Use in Musculoskeletal Disease

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed medications for the treatment of musculoskeletal disorders. Osteoarthritis is the most common form of arthritis in humans and its prevalence rises with age. Oral NSAIDs have potential associated toxicities that must be monitored for and can limit the use of these drugs in certain populations including people of older age. Topical NSAIDs are now being recognized as an option for the treatment strategy of osteoarthritis. We review the efficacy and safety of one of the most common topical NSAIDS, topical diclofenac, for the treatment of osteoarthritis.

Pain reporting at different body sites is explained by a single underlying genetic factor

OBJECTIVES

Musculoskeletal pain is reported commonly; however, the extent to which pain in individual body areas reflects the severity of site-specific pathology or a more generalized propensity to feel pain is uncertain. We used a classical twin design to examine the pattern of pain reporting at different body sites among monozygotic (MZ) and dizygotic (DZ) twins to assess its heritability and to examine evidence for a common underlying propensity to report musculoskeletal pain.

METHODS

A well-characterized sample of female twins (TwinsUK cohort) was sent a questionnaire to determine their experience of pain in the neck and back, elbow, knee, thigh, hands or feet. The genetic contribution to pain reporting was assessed through univariate and multivariate analyses.

RESULTS

Pain was reported with a prevalence of 17-46%, depending on the anatomical site. Univariate analysis indicated an underlying heritability for pain reporting at all sites of 28-71%. Pain reporting at different sites was modestly but uniformly correlated; a single factor accounted for 95% of the overall variance in pain reporting. The correlation for scores on this factor was 0.46 in MZ twins and 0.23 in DZ twins, corresponding to a 'pain reporting factor' heritability of 46% (95% CI 40%, 52%).

CONCLUSIONS

A single genetic factor underlies the propensity to report body pain at different musculoskeletal sites. These findings, which contrast with those for radiographic OA that is determined by genetic factors specific to each anatomical site, will inform the future search for therapeutic targets to treat pain in chronic degenerative diseases.

Knee extensor strength does not protect against incident knee symptoms at 30 months in the multicenter knee osteoarthritis (MOST) cohort

OBJECTIVE

Knee extensor weakness has not been associated consistently with the risk for incident knee pain. Additionally, the balance of hamstring-to-quadriceps strength (H:Q ratio) may affect risk and has not been studied. The authors determined whether knee extensor weakness or muscle imbalance is a risk factor for development of frequent knee pain or stiffness and whether the effect is modified by lower limb alignment.

DESIGN

Observational study.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ages 50-79 years with or at risk of knee osteoarthritis based on obesity, knee injury, or surgery. A total of 1269 knees from women and 1006 knees from men without frequent knee symptoms at baseline and with 15- or 30- month follow-up outcome data were included.

ASSESSMENT OF RISK FACTORS

Isokinetic knee extensor and flexor strength as well as radiographic hip-knee-ankle alignment were measured at baseline. H:Q ratio was dichotomized, with normal being considered to be >/=0.6.

MAIN OUTCOME MEASUREMENTS

Frequent knee symptoms at 15- or 30-month follow-up (frequent knee pain, aching, or stiffness on most days of the past month reported at both telephone contact just before and at visit).

RESULTS

Mean +/- SD age was 62.2 +/- 8.0 years and mean body mass index (BMI) was 30.1 +/- 5.4 kg/m(2). Mean peak knee extensor strength (KES) was 132.6 +/- 42.4 and 76.9 +/- 25.3 N.m in men and women, respectively. Approximately 50% of knees in men and 59% of knees in women had an H:Q ratio <0.6. A total of 307 of 2275 eligible knees developed frequent knee symptoms at follow-up. Logistic regression controlling for age, BMI, femoral neck bone mineral density, activity score, and baseline Kellgren Lawrence grade revealed that neither KES nor H:Q ratio predicted the development of knee symptoms in gender-stratified or combined analyses. These results were unaffected by adjusting for lower limb alignment.

CONCLUSIONS

Neither concentric quadriceps strength nor H:Q ratios predicted the development of frequent knee symptoms at 15- or 30-month follow-up in this cohort.

Imaging the painful osteoarthritic knee joint: what have we learned?

Pain in the peripheral joints is an increasingly common problem, resulting in significant patient disability and health-care expenditure. Osteoarthritis (OA), a syndrome of joint pain with associated structural changes, is the most prevalent joint disease, yet the etiology of pain in OA is not entirely clear. Traditional assessment of the structure-pain relationship in knee OA has relied on conventional radiography, which has several limitations, not least the discrepancy between symptoms and radiographic findings. MRI has the capability to visualize all the structures within the knee joint, and there is a growing body of work using MRI to examine the correlation between structural findings and symptoms. In large cohort studies, synovial hypertrophy, synovial effusions, and abnormalities in the subchondral bone have been associated with knee pain. Advances in our understanding of the etiology of pain in OA will assist in the identification of further targets for treatment of this common and painful disease.

Gender difference in symptomatic radiographic knee osteoarthritis in the Knee Clinical Assessment--CAS(K): a prospective study in the general population

Background

A recent study of adults aged ≥50 years reporting knee pain found an excess of radiographic knee osteoarthritis (knee ROA) in symptomatic males compared to females. This was independent of age, BMI and other clinical signs and symptoms. Since this finding contradicts many previous studies, our objective was to explore four possible explanations for this gender difference: X-ray views, selection, occupation and non-articular conditions.

Methods

A community-based prospective study. 819 adults aged ≥50 years reporting knee pain in the previous 12 months were recruited by postal questionnaires to a research clinic involving plain radiography (weight-bearing posteroanterior semiflexed, supine skyline and lateral views), clinical interview and physical examination. Any knee ROA, ROA severity, tibiofemoral joint osteoarthritis (TJOA) and patellofemoral joint osteoarthritis (PJOA) were defined using all three radiographic views. Occupational class was derived from current or last job title. Proportions of each gender with symptomatic knee ROA were expressed as percentages, stratified by age; differences between genders were expressed as percentage differences with 95% confidence intervals.

Results

745 symptomatic participants were eligible and had complete X-ray data. Males had a higher occurrence (77%) of any knee ROA than females (61%). In 50–64 year olds, the excess in men was mild knee OA (particularly PJOA); in ≥65 year olds, the excess was both mild and moderate/severe knee OA (particularly combined TJOA/PJOA). This male excess persisted when using the posteroanterior view only (64% vs. 52%). The lowest level of participation in the clinic was symptomatic females aged 65+. Within each occupational class there were more males with symptomatic knee ROA than females. In those aged 50–64 years, non-articular conditions were equally common in both genders although, in those aged 65+, they occurred more frequently in symptomatic females (41%) than males (31%).

Conclusion

The excess of knee ROA among symptomatic males in this study seems unlikely to be attributable to the use of comprehensive X-ray views. Although prior occupational exposures and the presence of non-articular conditions cannot be fully excluded, selective non-participation bias seems the most likely explanation. This has implications for future study design.