Health Care Guideline:
Diagnosis and Treatment of Adult
Degenerative Joint Disease of the Knee
Copyright © 1998 by Institute for Clinical Systems Integration
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Work Group Leader
James Lee, MD, MPH, Mork Clinic
Family Practice
Dave Thorson, MD, Family HealthServices Minnesota
James Lee, MD, MPH, Mork Clinic
Health Education
Renee Bergstrom, Mayo Clinic
Internal Medicine
Margaret Stein, MD, HealthPartners
Rheumatology
Thomas Harkcom, MD, HealthPartners
Orthopedic Surgery
Mark Thomas, MD, HealthSystems Minnesota
Pharmacy
John Condon, RPh, HealthSystem Minnesota
Physical Medicine and Rehabilitation
Mary Jurisson, MD, Mayo Clinic
Buyers' Health Care Action Group
Wendy Anderson, General Mills
Measurement Advisor
Jane Gendron, ICSI
Facilitator
Julie Persoon, RN, ICSI
This guideline is intended for use with "established" patients who are 18 years of age or older who complain of a painful knee which may be due to degenerative joint disease. An "established" patient is one who has been seen at his or her primary clinic or medical group at least once.
Priority Aims for Medical Groups When Using This Guideline
1. Improve the efficacy of diagnostic imaging.
Possible measures of accomplishing this aim:
a. Percent of patients with knee x-ray panels that include a standing view of the knee.
b. Percent of patients diagnosed with DJD who did not receive MRIs during the diagnostic process.
2. Increase the use of recommended conservative approach as first-line treatment.
Possible measures of accomplishing this aim:
a. Percent of patients receiving non-pharmacologic pain management as part of the first-line treatment.
b. Percent of patients receiving acetaminophen or analgesic dose nonsteroidal medications as the first-line medication.
3. Increase patient education.
Possible measures of accomplishing this aim:
a. Percent of patients with documented education in four comprehensive areas: protecting the joint, exercise, pain relief, healthy living habits.
b. Percent of patients receiving patient education on medications and their uses.
Clinical Algorithms & Annotations
Diagnosis
and Treatment Algorithm
Algorithm Annotation List 2-9
Definition of Degenerative
Joint Disease
2. Provider Visit
3. Does the History and Physical Examination
Indicate DJD?
4. Further Diagnostic Testing?
5. Referral to Speciality Providers
8. Treatment of Degenerative Joint Disease of
the Knee
9. Follow-up Provider Visit
Discussion and
References: Download PDF Version of This Guideline
Definition of Degenerative
Joint Disorder
1c. Does the Patient Need to Be Seen Today?
1d. Schedule Visit According to Urgency
1e. Provide Appropriate Patient Education
Diagnosis
and Treatment Quick Reference Sheet
| 2 Provider Visit History Components
Physical Examination Components
Symptoms/Signs Consistent with DJD of the Knee
Symptoms/Signs Inconsistent with DJD of the Knee
|
8 Treatment of DJD
|
| 4 X-Ray Views If the physician chooses to obtain an x-ray, standing AP (weight bearing), lateral (possibly weight bearing) and notch view (PAIC) or tangential patellar are recommended |
Definition of Degenerative Joint Disorder
Degenerative joint disease is a heterogenous class of joint disorders characterized by degeneration and loss of cartilage, alteration of subchondral bone, and associated soft tissue changes that may be due to a variety of causes. These changes, which are the result of cartilage injury exceeding the rate of cartilage repair, occur gradually over time. Clinical criteria for the definitive diagnosis of degenerative joint disease of the knee are based on history, physical examination, and roentgenologic findings that may occur late after the onset of pathologic findings. Degenerative joint disease, for the purposes of this guideline, includes patients in whom cartilage injury may exceed the rate of repair, resulting in the potential for progressive joint destruction.
1c. Does the Patient Need to Be Seen Today?
The time frame in which a patient may be seen can be determined by asking a series of triage questions. The questions are intended to determine which symptoms require more urgent treatment by a physician and which ones can be managed through phone advice.
One way to prevent "no shows" is to do phone follow-up. Phone follow-ups can be beneficial in two ways. For capitated products, they provide additional "slots" for appointments. For fee for service products, they increase revenue generation. However, some clinics may not have the staff to support this activity.
The patient should receive an immediate (UC/ER/Clinic) provider visit if he or she meets any of the following criteria:
a. atypical bacterial infection
b. atraumatic fracture
c. traumatic fracture or derangement
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1d. Schedule Visit According to Urgency
The patient should receive an appointment within the next 3 days if he or she meets any of the following criteria:
Patients with other types of knee pain should be scheduled for a routine visit.
The patient should be seen at the next available visit for all other types of knee pain.
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1e. Provide Appropriate Patient Education
When a patient is scheduled for an appointment within 3 days or several weeks, recommendations for home self care should be given by the medical information nurse or other appropriate personnel. This pre appointment education does not take the place of a provider visit, but is only interim advice.
Education should include advice on basic techniques to reduce pain and inflammation in the affected joint. Such techniques include rest, ice, compression, elevation, and the use of appropriate over-the-counter analgesics as follows:
Rest: Reduce or avoid of activities that aggravate the pain. Alternate work with rest throughout your day.
Ice: Ice pack applied to the affected joint for 10-15 minutes several times a day. Protect the skin with clothing or a towel.
Compression: If swelling is present, a compression such as AceTM wrap dressing or sleeve may be used. It should be unwrapped and rewrapped three to four times per day.
Elevation: Elevate the affected extremity above the level of your heart to help reduce swelling.
Analgesics: Recommend acetaminophen (TylenolTM) in standard over-the-counter doses for pain. Over-the-counter anti-inflammatories (NSAIDs) such as ibuprofen (AdvilTM, MotrinTM, etc.), naproxen sodium (AleveTM), or acetylsalicylic acid (aspirin, EcotrinTM, etc.) may be used if the patient has no history of ulcer disease, diabetes, renal disease, liver disease, or bleeding diathesis; is not currently using anticoagulants such as warfarin (Coumadin¨) or heparin and has no sensitivity to these medications; and is under the age of 65 and not pregnant.
The following over-the-counter medications may be recommended by the triage person at the clinic. These medications and dosages will provide analgesic and/or anti-inflammatory effects.
These medications need to be taken on a full stomach and on a PRN basis. Should a patient choose to take the highest dosage, he or she may achieve an antiinflammatory effect from ibuprofen, aspirin, or naproxen sodium. Acetaminophen has only analgesic effects.
Since there is no data that one NSAID is more efficacious than another, the use of ibuprofen or naproxin sodium would be most cost effective. It is suggested that NSAID use should be prioritized on the basis of cost.
A patient education brochure or other written information to reinforce home self care instruction may be offered to the patient. This information may be given over the phone, or the patient may be able to pick it up at the clinic if the clinic has the information available in a handout or brochure.
In certain systems, telephone follow-up may be used to confirm appointments or to allow patients to cancel appointments if home self care has resolved the initial problem.
Strength of the evidence in support of these recommendations: A.
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The provider visit should focus on diagnosis of degenerative joint disease of the knee rather than the differential diagnosis of knee pain. History should include the following components:
Physical Examination
Typical physical examination findings in degenerative arthritis of the knee include:
The physical examination may include some or all of the following components as appropriate:
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3. Does the History and Physical Examination Indicate DJD?
A history and physical examination may produce a nonspecific result. The practitioner may wish to get laboratory tests, x-rays, etc. to help him or her diagnose the patient's condition. It is possible that a patient has both DJD and another diagnosis.
In general, the following are consistent with the diagnosis of degenerative joint disease of the knee:
The following are inconsistent with DJD of the knee:
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4. Further Diagnostic Testing?
If history and physical examination are not conclusive for DJD alone, further diagnostic testing is indicated. For the purposes of this guideline, "diagnostic testing" will include x-rays, joint taps, MRI, bone scan, CT, lab work, etc.
X-Rays
With a diagnosis of degenerative joint disease of the knee, it is usually not necessary to obtain an x-ray on the first visit. Indications for x-rays in the evaluation of joint pain may include:
If the physician chooses to obtain an x-ray, standing AP (weight bearing), lateral (possibly weight bearing) and notch view (PAIC) or tangential patellar are recommended.
Special views such as the PAIC view may reveal joint space narrowing when the standing AP view looks normal. The major indication for follow-up x-rays is to identify new pathology or to plan surgery. Follow-up x-rays are not indicated to simply log the progression of the disease. The x-rays should have clinical significance.
When a diagnosis of degenerative joint disease of the knee is made, CTÕs, bone scans and MRIÕs are not recommended.
Indications for laboratory testing in DJD
1. Non-traumatic monarticular effusions with swelling generally require aspiration with the following tests performed on the fluid (if the fluid is not straw colored and clear):
The synovial fluid in OA should be non-inflammatory, i.e., < 200 wbc/mm3, but in a flare could go up to 1-2,000 wbc/mm3. Fluid should be clear to only faintly turbid.
Consider a Lyme test in the presence of monarticular arthritis with joint swelling if the patient gives a history of deer tick bite, ECM rash or possible exposure to ticks.
2. If suspecting monarticular inflammatory arthritis, consider serum rheumatoid factor, Lyme serology, and uric acid in addition to synovial fluid analysis.
3. If a patient has osteoarthritis by x-ray that is not due to past trauma or known process and if the patient is younger than 50, the following may be considered:
Strength of the evidence in support of these recommendations: B.
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5. Referral to Specialty Providers
When specialty referral is indicated, coordinated management by the primary care provider and a musculoskeletal specialty provider is desirable. On the initial visit, the provider may reach a diagnosis that requires further evaluation or treatment by a specialty provider. Referral to Rheumatology, Orthopedic Surgery, Physical Medicine and Rehabilitation, or another musculoskeletal specialist may be recommended for:
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8. Treatment of Degenerative Joint Disease of the Knee
The overall goals of treatment are:
Treatment at the first provider visit should include the following:
1. Patient Education
Treatment at the initial visit begins with education. A discussion of the disease and its natural history will allow realistic goals for treatment to be established. The patient should be instructed in methods of proper body mechanics and joint protection. Lifestyle or environment changes should be suggested to eliminate excessive and recurrent trauma. Weight reduction should be recommended for overweight individuals. Moderate exercise should be encouraged. Vigorous activities that produce prolonged pain and inflammation should be avoided.
Some providers may wish to use the patient education outline found in the implementation section as a checkoff sheet to allow quick documentation of educational components and simultaneously provide the patient with a written summary of recommendations. Other brochures or handouts to reinforce education about the disease, exercise, or medications are listed in the implementation section under educational resources. The provider may wish to consider a referral to education classes for self-management of arthritis. There are some computer-based education programs which may be appropriate. If the patient seems to need more help in problem solving to implement self-care, consider referral to a nurse for medication instruction, physical therapy for exercise instruction, or an occupational therapist for joint protection instruction.
Patient education should, in general, be reinforced with further written or verbal instruction.
A sample patient education handout explaining joint protection, exercise, pain relief and basic healthy living habits can be found in the implementation section.
2. Pain Management
a. Joint protection. The patient should be instructed to avoid prolonged standing, kneeling, squatting, and stair climbing.
If obese, the patient should lose weight through modification of diet and a consistent low impact aerobic conditioning program such as walking 45 minutes to one hour daily. If a patient with DJD of the knee is unable to walk, consider referral to a physiatrist or physical therapist to assist in identifying appropriate alternative aerobic conditioning exercises.
If work or home activities seem to aggravate the problem, consider an outside evaluation by an appropriate health care professional.
b. Physical modalities - see the patient education implementation tool under pain relief using heat and cold.
c. Medications
The patient may be started on a course of acetaminophen or a nonsteroidal anti-inflammatory drug in appropriate analgesic doses if there are no contraindications to those medications. Since there is no proven efficacy of one NSAID over another, a less expensive one should be tried initially. Narcotic medications are not advised. Systemic administration of adrenocorticosteroids is of no value. The American College of Rheumatology advocates the use of nonpharmacologic methods first and addition of medication only when additional analgesia is necessary.
d. Miscellaneous pain relievers
When heat, cold, or medications are contraindicated or ineffective, the following may also be considered:
e. Cognitive restructuring, stress management, relaxation
These are covered in pain management classes and support groups, the Arthritis Self-Help Course, and stress management classes. Consider referral to one of these classes if they are available. Some of these are covered in the Arthritis Foundation brochure "Coping with Pain."
f. Ensure adequate restorative sleep Provide instruction in basic sleep hygiene measures. Assess causes of non-restorative sleep (pain, nocturia, depression, psychosocial stress, poor sleep hygiene, sleep disorder, CHF, etc.) and treat appropriately (relaxation before bed, instruct in use of sleep hygiene amitriptyline, etc.)
3. Exercise - Exercise should include the following:
a. Active range of motion for the hip, knee and ankle for maintaining and regaining range of motion and for promoting joint health and nutrition.
b. Progressive walking. Begin walking for a duration that is well tolerated as a baseline such that it does not produce accelerating knee pain over successive days. Gradually increase the walk duration to a goal of 45-60 minutes five to seven days per week for closed chain strengthening and endurance training of the legs and for management of obesity. It may also contribute to a sense of well-being and pain control.
c. Quad sets with VMO (vastus medialis obliques) activation at full knee extension.
If the patient is unable to walk, has contractures or severe exercise intolerance, has fallen, or has other reasons for being unable to carry out this exercise program, consider referral to a physiatrist or physical therapist for a supervised program 2 or 3 times a week until the patient can perform in an independent program. A physical therapist may focus on the use of other modalities and more specific exercises to regain range of motion, strengthen the lower extremities, and improve endurance. If there is severe loss of function, a physiatrist may be helpful in supervising treatment for complex loss of function.
4. Assistive Devices
In some cases an assistive device such as a splint, brace, cane, crutch or walker may be an appropriate component of initial treatment. Although anyone with appropriate training may instruct in the use of assistive devices, it may be most efficient to refer to a physical therapist, OT, ergonomist, or other professional who is trained to select and instruct in the use of these devices. A physical therapist can teach most patients to use a knee sleeve, cane or walker in 1-2 visits. Other assistive devices such as reachers, bath benches, raised toilet seats, grab bars, etc. may be suggested by an OT, sometimes in a visit to the home, where other safety issues may also be addressed. In the workplace, an OT, PT, or ergonomist may suggest modifications. Sport specific trainers may provide the best advice in athletic activities.
5. Injection with Corticosteroid or Hyaluronan Preparation
6. Follow-up
A follow-up appointment should be scheduled in 3-6 weeks.
Strength of the evidence in support of the recommendation: A.
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The goals of the follow-up provider visit are similar to those of the initial treatment visit. The response to the initial treatment should be assessed. If the patient is responding well to the initial treatment, key points of the treatment plan should be reviewed and reinforced and the following pain rating question should be repeated: How would you rate your average pain over the past month (0-10)? If the patient has had little improvement in symptoms or function or has had complications the provider may consider the following approaches:
1. Medication change
Trial of a different antiinflammatory medication.
2. Physical Therapy
Some patients may benefit from a supervised exercise program or from specific therapeutic modalities the therapist can provide.
3. Injections
Local intra-articular corticosteroid injections or hyaluronan preparation may provide temporary relief of pain and may be appropriate at this point in some patients.
4. Referral
In the patient who is not responding, consideration may be given to referral to an arthritis specialist - Rheumatology, Physical Medicine and Rehabilitation, or Orthopedic Surgery.
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Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.
Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):
Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):
Guidelines obtained from the Agency for Health Care Policy and Research (AHCPR) or other sources, position statements, panel consensus statements from the National Institutes of Health (NIH) or elsewhere, review articles, and textbook chapters that cite primary evidence are not assigned a grade because they are not primary evidence. The individual studies cited in such secondary sources can be graded according to the categories presented above.
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