Writing with the hindsight’s benefit in “What I Wish I’d Known About My Knees” in the New York Times, Jane Brody laments the cost, pain, and effort she expended to avoid knee replacement.

“Many of the procedures people undergo to counter chronic knee pain in the hopes of avoiding a knee replacement have limited or no evidence to support them. Some enrich the pockets of medical practitioners while rarely benefiting patients for more than a few months,” she writes. “I wish I had known that before I had succumbed to wishful thinking and tried them all.”

A Medscape slideshow, titled “Evaluating Knee Pain: The Latest in Diagnosis and Management,” sheds more light on the subject of knee pain. “The evaluation of knee pain can be challenging,” the authors write. “In part, this stems from the fact that knee pain may arise secondary to disease within the joint, around the joint … and distant to the joint.”

Pinpointing the precise location of the problem is “critical in order to separate true articular disease from periarticular or referred pain,” they add.

Patients may report that swollen knees feel larger than normal, although that can be a difficult thing for a physician to identify visually if both knees are swollen. The knees might also feel tighter or stiffer than they typically do. One they confirm swelling, physicians then identify whether it is inflammatory or noninflammatory, the authors write.

“Determining the underlying etiology of knee swelling often requires close examination of other joints; a detailed nonmusculoskeletal exam; and, as always, a good history,” they add. “Because the knee is an isolated joint, there are no pathognomonic patterns of disease, as seen in the hands; thus, the astute clinician needs to garner important clues from the history and exam.”

Some of those clues can come from medical histories. “Many diseases may be associated with joint pathology,” the authors write. “A detailed review of the patient’s medical history and review of systems, as well as travel history and exposures — e.g. tick bites — may provide clues to the knee pathology, especially if the cause of knee swelling is not otherwise readily apparent.”

The Medscape slideshow includes several cases. About one, a 62-year-old woman with right knee swelling, which developed four or five weeks prior, the authors note, “Defining the location of abnormality is critical in differentiating disease within the joint from periarticular conditions, such as patellofemoral syndrome, prepatellar bursitis, and pes anserine bursitis.”

In recent years, new rheumatoid arthritis treatments have “employed mechanisms of action biosimilar to already FDA-approved agents.” They add:

The lack of novel treatment concepts has led some to question whether the field was in a rut. Nonetheless, important new data have recently appeared that allow rheumatologists to refine their use of existing RA therapies. One of the most promising new developments is in identifying which patients with RA may be able to taper their therapy. Ideal candidates for tapering include those who have had sustained remission for ≥ 6 months on stable disease-modifying antirheumatic drugs (DMARDs), low disease activity scores, negative autoantibody tests, and other factors. Other recent data from the ongoing Dutch PRAIRI trial have shown that RA can be targeted preclinically with a single infusion of the anti-CD20 antibody rituximab, which can delay its onset by up to a year in high-risk individuals. This approach may be of particular value, in light of results from a recent study showing that early intervention leads to lesser disability rates than later treatment.

Readers can view the entire slideshow here. CreakyJoints reader may be particularly interested in the sections on arthritis and the skin, gout, and comorbid arthritides, as well as the conclusion.

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