Case of the Month #15: Chronic Knee Pain by Dr Kerry Bosworth

Published: 05/05/2022


Osteoarthritis (OA) is the most common form of arthritis. It is a leading cause of pain and disability worldwide. The knees, hips and small hand joints are most commonly affected. Patients often believe it is an inevitable part of ageing but this is not true and OA does not necessarily deteriorate.

There is a localised loss of cartilage, remodelling of adjacent bone and associated inflammation, synovial hypertrophy, inflammatory changes within the synovium and intermittent effusions. Therefore, it is inaccurate to call OA a non-inflammatory arthritis. Various traumas may trigger a joint to repair itself. This slow but efficient process results in a structurally altered but symptom-free joint. This process may not be able to compensate if the trauma is too great or the repair is compromised and symptomatic OA may eventually occur.

Risk factors include joint injury, other joint conditions (e.g. rheumatoid arthritis or gout), age, a family history of OA, obesity and female gender.

The NICE guideline, CG177 Osteoarthritis: care and management, was published in 2014 and updated in 2020. It states that osteoarthritis should be diagnosed clinically without investigations if a patient is 45 or over and has activity-related joint pain and has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.

The 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip and Knee differs in some of its recommendations with conditional recommendations for duloxetine and acupuncture, strong recommendations against TENS and conditional recommendations against modified shoes and lateral and medial wedged insoles.