Topics in PAIN MANAGEMENT Vol. 34, No. 7 Current Concepts and Treatment Strategies February 2019 CONTINUING EDUCATION ACTIVITY Assessment and Management of Knee Pain Angela Starkweather, PhD, ACNP-BC, FAAN The purpose of this article is to review evidence about the assessment and management of knee pain. Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to: 1. Describe 3 of the most common causes of knee pain in adult patients. 2. Explain the various physical examination maneuvers that can be performed to detect mechanical knee injuries. 3. Compare treatment approaches for the common causes of knee pain, including active and passive therapies. Key Words: Knee pain, Meniscal injuries, Osteoarthritis, Patellofemoral pain syndrome nee pain is one of the top 10 most common reasons for adjustments for age and body mass index.2 Athletes with pre- K outpatient visits.1 Data from the National Health and vious knee injuries are at significantly higher risk of suffering Nutrition Examination Survey and Framingham Osteoarthritis from chronic knee pain than the general population.3 Overall, Study found that knee pain and symptomatic knee osteoarthri- people with knee pain report worse physical functioning and tis have risen 10% to 25% over the past several decades, after quality of life, compared with those without knee pain, which emphasizes the need for effective management of pain in affected individuals.4 Because knee pain can be caused by a Inside This Issue wide range of bone or soft tissue injuries, infections, or chronic Assessment and Management of Knee Pain . 1 diseases (gout, osteoarthritis), identifying the most efficient Walking the Line: FDA Warns Against Any Off-Label Dr. Starkweather is Professor and Director, Center for Advancement in Managing Pain, University of Connecticut School of Nursing, 231 or Compounded Drugs for Intrathecal Pumps . 8 Glenbrook Rd, Storrs, CT 06269; E-mail: angela.starkweather@ ICYMI: In Case You Missed It . 9 uconn.edu. The author, faculty, and staff in a position to control the content of this CE Quiz . 11 CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial organizations relevant to this educational activity. CME Accreditation Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on January 31, 2021. CNE Accreditation Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Lippincott Professional Development will award 1.0 contact hours for this continuing nursing education activity. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This CNE activity expires on December 4, 2020. 1 TTPMv34n7.inddPMv34n7.indd 1 008/01/198/01/19 77:39:39 PPMM Topics in Pain Management February 2019 CO-EDITORS process for diagnosis and treatment is a priority for clinicians across different settings. Elizabeth A.M. Frost, MD Professor of Anesthesiology Icahn School of Medicine at Mount Sinai New York, NY Knee pain and symptomatic knee osteoarthritis have risen 10% to 25% Angela Starkweather, PhD, ACNP-BC, CNRN, FAAN Professor of Nursing over the past several decades. University of Connecticut School of Nursing Storrs, CT Initial Assessment of Knee Pain ASSOCIATE EDITOR With presentation of acute knee pain, initial assessment should focus on history-taking with determination of mecha- Anne Haddad nism of injury, precise location and characteristics of symp- Baltimore, MD toms, and function.5 The clinician should elicit the patient’s description of the pain and its characteristics, such as timing (acute or insidious), EDITORIAL BOARD location, duration, intensity, quality, radiation, and alleviating Jennifer Bolen, JD or aggravating factors. The clinician should also ask about The Legal Side of Pain, Knoxville, TN other symptoms that may not seem to be related, and which either precede or accompany the presence of knee pain. These C. Alan Lyles, ScD, MPH, RPh symptoms might include fever, chills, pharyngitis or sore University of Baltimore, Baltimore, MD throat, or skin rash. Examination of the knee includes observa- tion and palpation for joint tenderness, range of motion, weight-bearing ability, and specific tests to identify joint insta- Stephen Silberstein, MD 6 Jefferson Headache Center, Philadelphia, PA bility (Table 1). During the physical examination, compare findings to the contralateral uninjured knee and assess adja- cent joints for referral pain, including the hip and ankle.7 Steven Silverman, MD Michigan Head Pain and Neurological Institute, Ann Arbor, MI The continuing education activity in Topics in Pain Management is intended for clinical and academic physicians from the specialties of anesthesiology, neurology, psychiatry, physical and rehabilitative medicine, and neurosurgery, as well as residents in those fields Sahar Swidan, PharmD, BCPS and other practitioners interested in pain management. 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Topics in Pain Management is independent and not affiliated with any organization, vendor Lonnie Zeltzer, MD or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does not constitute endorsement. All com- UCLA School of Medicine, Los Angeles, CA ments are for general guidance only; professional counsel should be sought for specific situa- tions. Editorial matters should be addressed to Anne Haddad, Associate Editor, Topics in Pain Management, 204 E. Lake Avenue, Baltimore, MD, 21212; E-mail: [email protected]. Topics in Pain Management is indexed by SIIC HINARI and Google Scholar. 2 ©2019 Wolters Kluwer Health, Inc. All rights reserved. TTPMv34n7.inddPMv34n7.indd 2 008/01/198/01/19 77:39:39 PPMM Topics in Pain Management February 2019 Table 1. Components of the Initial Evaluation of Knee Pain History Physical Examination Specific Mechanical Injuries History of knee pain, injury, or joint disease Observation of color, swelling, alignment, Integrity of the ACL: Lachman test, Medical history, comorbidities, and present medications deformity, gait, weight-bearing, wounds, pivot shift test Travel, exposures (eg, tick bite), and sexual contacts inflammation (calor, rubor, tumor, dolor) Involvement of other organ systems Occupation, sports, and functional abilities or Palpation for temperature and to detect Integrity of the MCL and LCL: varus limitations swelling, tenderness, joint effusion (patellar and valgus stress tests ballottement), masses, or tendon defects Mechanism of injury Range of motion (active and passive) Meniscal injury: combination of joint- Position of knee at time of injury and amount of Hypermobility line tenderness and results of Apley force/direction, and torsion test, McMurray test, Thessaly test, Onset of pain and swelling and Ege’s test Acuity of injury Neurovascular