Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 52-year-old man with gradually progressive left knee pain

mksap
Conditions
May 4, 2013
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 52-year-old man is evaluated for a 5-year history of gradually progressive left knee pain. He has 20 minutes of morning stiffness, which returns after prolonged inactivity. He has minimal to no pain at rest. He reports no clicking or locking of the knee. Over the past several months, the pain has limited his ambulation to no more than a few blocks.

On physical examination, vital signs are normal. BMI is 25. The left knee has a small effusion and some fullness at the back of the knee; the knee is not erythematous or warm. Range of motion of the knee elicits crepitus. There is medial joint line tenderness to palpation, bony hypertrophy, and a moderate varus deformity. There is no evidence of joint instability on stress testing.

Radiographs of the knee reveal bone-on-bone joint-space loss and numerous osteophytes.

Which of the following is the most appropriate next diagnostic step for this patient?

A: CT of the knee
B: Joint aspiration
C: MRI of the knee
D: No diagnostic testing

MKSAP Answer and Critique

The correct answer is D: No diagnostic testing. This item is available to MKSAP 16 subscribers as item 3 in the Rheumatology section.

No additional diagnostic testing is indicated for this patient who has osteoarthritis, which is a clinical diagnosis. According to the American College of Rheumatology’s clinical criteria, knee osteoarthritis can be diagnosed if knee pain is accompanied by at least three of the following features: age greater than 50 years, stiffness lasting less than 30 minutes, crepitus, bony tenderness, bony enlargement, and no palpable warmth. These criteria are 95% sensitive and 69% specific but have not been validated for clinical practice. Additional diagnostic testing is not appropriate, because it has no impact on the management of advanced disease.

CT of the knee is very sensitive for pathologic findings in bone and can be used to look for evidence of an occult fracture, osteomyelitis, or bone erosions. However, none of these are suspected in this patient.

Small- to moderate-sized effusions can occur in patients with osteoarthritis, and the fluid is typically noninflammatory. Joint aspiration in this patient without evidence of joint inflammation and evident osteoarthritis is not useful diagnostically but is often done in the context of intra-articular corticosteroid injection or viscosupplementation.

MRI is useful to evaluate soft-tissue structures in the knee such as meniscal tears. Patients with meniscal tears may report a clicking or locking of the knee secondary to loose cartilage but often have pain only on walking, particularly going up or down stairs. Patients with degenerative arthritis often have MRI findings that indicate meniscus tears. These tears are part of the degenerative process but do not impact management; arthroscopic knee surgery for patients with osteoarthritis provides no clinical benefit. The one exception may be in patients with meniscal tears that result in a free flap or loose body, producing painful locking of the joint. These symptoms are not present in this patient.

Key Point

  • Osteoarthritis is diagnosed clinically and does not require advanced imaging to establish the diagnosis.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

The Affordable Care Act: Spinning reform without real reform

May 3, 2013 Kevin 12
…
Next

Watching my grandfather pass away changed my life

May 4, 2013 Kevin 21
…

ADVERTISEMENT

Tagged as: Orthopedics

Post navigation

< Previous Post
The Affordable Care Act: Spinning reform without real reform
Next Post >
Watching my grandfather pass away changed my life

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • What if medicine had an exit interview?

    Lynn McComas, DNP, ANP-C
  • Finding healing in narrative medicine: When words replace silence

    Michele Luckenbaugh
  • Why coaching is not a substitute for psychotherapy

    Maire Daugharty, MD
  • Why doctors stay silent about preventable harm

    Jenny Shields, PhD
  • Why gambling addiction is America’s next health crisis

    Safina Adatia, MD
  • How robotics are reshaping the future of vascular procedures

    David Fischel
  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • Mastering medical presentations: Elevating your impact

      Harvey Castro, MD, MBA | Physician
    • Why the fear of being forgotten is stronger than the fear of death [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why what doctors say matters more than you think [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden incentives driving frivolous malpractice lawsuits

      Howard Smith, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • Why the fear of being forgotten is stronger than the fear of death [PODCAST]

      The Podcast by KevinMD | Podcast
    • How a rainy walk helped an oncologist rediscover joy and bravery

      Dr. Damane Zehra | Physician
    • How inspiration and family stories shape our most meaningful moments

      Arthur Lazarus, MD, MBA | Physician
    • A day in the life of a WHO public health professional in Meghalaya, India

      Dr. Poulami Mazumder | Physician
    • Why women doctors are still mistaken for nurses

      Emma Fenske, DO | Physician
    • How home-based AI can reduce health inequities in underserved communities [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • Mastering medical presentations: Elevating your impact

      Harvey Castro, MD, MBA | Physician
    • Why the fear of being forgotten is stronger than the fear of death [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why what doctors say matters more than you think [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden incentives driving frivolous malpractice lawsuits

      Howard Smith, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • Why the fear of being forgotten is stronger than the fear of death [PODCAST]

      The Podcast by KevinMD | Podcast
    • How a rainy walk helped an oncologist rediscover joy and bravery

      Dr. Damane Zehra | Physician
    • How inspiration and family stories shape our most meaningful moments

      Arthur Lazarus, MD, MBA | Physician
    • A day in the life of a WHO public health professional in Meghalaya, India

      Dr. Poulami Mazumder | Physician
    • Why women doctors are still mistaken for nurses

      Emma Fenske, DO | Physician
    • How home-based AI can reduce health inequities in underserved communities [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

MKSAP: 52-year-old man with gradually progressive left knee pain
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...