Please generate a case study report for non-pharmacological interventions designed to assist Mrs. Jones in her rehabilitation. This case study should not be more than two pages.
Case Presentation
Mrs. Jones (not her real name), 55 years old, came to a musculoskeletal specialist seeking advice for a 3-year history of progressively worsening pain in both knees. Her knees were stiff for about 20 minutes when she arose in the morning and for a few minutes after getting up from a chair during the day. She had difficulty walking > 30 minutes because of pain, and her symptoms were exacerbated by kneeling, squatting, or descending stairs. Although sitting, resting, and reclining relieved her pain, she became stiff if she stayed in one position for too long. Her symptoms were worse on humid or cold days, and she occasionally felt as if one of her knees would “give out.”
Mrs. Jones was slightly obese, and physical examination of the lower extremities revealed mild genu varum, which suggested medial compartment involvement. Her gait was mildly antalgic, and passive range of motion of both knees indicated palpable crepitus. She was unable to flex or extend her knees completely. While a physically active osteoarthritis patient commonly has a maximum flexion < 130°(compare with normal maximum flexion of 140° to 150°), this patient’s was>< 120°. in addition, in patients with severe osteoarthritis, it is not uncommon to have a partial><’10°) loss of extension. Mrs. jones had 8° loss of>
Patellar facet tenderness was determined by palpation. There was tenderness over the joint line and patellofemoral crepitus, which is common in patients with osteoarthritis of the knee. There was moderate warmth and soft-tissue swelling. Patellar tilt was determined clinically and, with the knee in full extension, patellar glide was measured by assessing how far the patella translated medially and laterally. Mrs. Jones exhibited moderately severe decreased patellar glide both medially and laterally.
Knee stability was determined in the coronal (varus/valgus) and sagittal (anteroposterior) planes. Patients with medial inflammation and a varus deformity commonly have medial pseudolaxity, which is a sensation of valgus laxity as the varus deformity is manually corrected with the patient supine and the leg extended. As expected, Mrs. Jones presented with medial pseudolaxity with mild instability. In addition, patients may have increased tibial translation on both Lachman’s testing and anterior drawer testing, and a positive pivot shift maneuver, indicating a chronic anterior cruciate ligament insufficiency, which can lead to osteoarthritis. However, the examination indicated that this patient had none of these findings.
Examination of Mrs. Jones’s hands revealed enlargement of some of the proximal interphalangeal joints (Bouchard’s nodes) and some of the distal interphalangeal joints (Heberden’s nodes). There was a squaring at the bases of both thumbs at the carpometacarpal joints. The feet demonstrated similar deformities, with enlargement and reduced dorsiflexion of the first metatarsophalangeal joints. Upon further questioning, the patient admitted experiencing occasional pain and stiffness in these joints.
Because of the prevalence of atherosclerosis in the older population, a thorough neurovascular examination was performed on this patient. Her distal pulses were intact, as was sensation, and there was no evidence of cyanosis, clubbing, or edema. The examination showed no signs of neurovascular compromise. Had any of these findings been evident, a complete vascular workup would have been obtained, including blood work, to look for indications of a hypercoaguable state. If either neurovascular compromise or evidence of coronary artery disease had been found, then the risk-benefit ratio of prescribing a cyclooxygenase (COX)-2 inhibitor would have been weighed.
Mrs. Jones’s hip and back were examined thoroughly, as well, to rule out any contribution to the knee symptoms. She had full range of motion (ROM) of the lumbosacral, and all motions were pain free. Her hip examination showed decreased internal ROM, but motions were pain free and symmetric. These findings indicate that neither hips nor back was contributing to this patient’s symptoms. However, she had a leg length discrepancy, with her right leg being 0.5 cm shorter than her left. Leg length discrepancy can contribute to a patient’s symptoms and affect the treatment plan.
In cases where such a discrepancy is contributing to a patient’s symptoms, both surgical and nonsurgical interventions can be considered. With Mrs. Jones, the difference was < 5 cm, so correction was not necessary. radiographs showed osteophytes, joint space narrowing, and subchondral bone sclerosis in both of her joints.
