Am Fam Physician. 2016 Feb 1;93(3):170.
to the editor: An increasing number of overweight middle-aged and older individuals are presenting to health care professionals with knee pain. This problem has proven difficult to treat, which places into question the pathogenesis of knee pain in this population.`
Although the cause of pain may be clear in cases of severe osteoarthritis with knee swelling and limited range of motion, studies have shown that in cases of mild to moderate arthritis, there is poor correlation between radiographic findings and severity of knee pain.1 Magnetic resonance imaging (MRI) is unreliable in establishing a diagnosis, as studies in older adults found a high rate of false-positive results and incidental MRI changes in the contralateral, asymptomatic knee.2 Thus, imaging findings may have little correlation with the actual cause of the knee pain.
A number of treatments targeting pathology inside the knee joint have not been proven to be effective or only provide short-term benefit. These include oral glucosamine, injections with viscosupplementation or steroids, and arthroscopic debridement.3
Given that conservative treatments targeting intra-articular pathology in degenerative knees fail to provide consistent, enduring relief, it becomes important to focus on other etiologies of knee pain.
One condition that causes knee pain in older, overweight women is pes anserine bursitis. A few clinical studies have shown that this condition can be treated successfully with physiotherapy as well as a steroid injection into the pes bursa, which can be performed safely in the office setting.4,5
I encounter these cases routinely in older, overweight women referred for knee arthritis or meniscus tear identified on an imaging study. These individuals demonstrate maximal tenderness over the pes bursa, not on the joint line, and characteristically have quadriceps weakness. Many women who have been referred to me as candidates for knee replacement have avoided surgery with treatment of pes bursitis, which includes a self-directed strengthening program for the hip and knee, and occasionally an injection into the pes bursa. Diagnosing and treating pes anserine bursitis can potentially decrease the amount of knee arthroplasty, especially in women who undergo about 50% more knee replacements than men.6
Physicians should place pes anserine bursitis in the differential diagnosis when assessing overweight middle-aged and elderly women with knee pain. A careful history and physical examination may lead to the correct diagnosis and successful conservative treatment, thus avoiding unnecessary surgical procedures based primarily on the findings of imaging studies.
Author disclosure: No relevant financial affiliations.
REFERENCESshow all references
1. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systemic search and summary of the literature. BMC Musculoskeletal Disord. 2008;9:116....
2. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108–1115.
3. Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013;21(9):571–576.
4. Kang I, Han SW. Anserine bursitis in patients with osteoarthritis of the knee. South Med J. 2000;93(2):207–209.
5. Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the hip and knee. Am Fam Physician. 2003;67(10):2147–2152.
6. Williams SN, Wolford ML, Bercovitz A. Hospitalization for total knee replacement among inpatients aged 45 and over: United States, 2000–2010. NCHS Data Brief. 2015;(210):1–8.
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