Monday, June 27, 2011

Knee Pain in the Elderly: Common symptoms, varied causes

Knee pain in the elderly is a very common occurrence. The knee is the largest and most complex joint in the body. Injuries and diseases of the knee are frequent sources of disability, pain, and lost days from work.  Discomfort may be associated with many different diseases. The pain can affect the ability to ambulate, participate in daily activities and sleep comfortably.    The causes of pain usually originate in the knee joint.  Occasionally, a problem elsewhere can trigger pain that is referred to the vicinity of the knee.  Problems that originate in the knee joint itself are generally easy to diagnose and can be treated by your primary care physician, rheumatologist, or orthopedic surgeon.  Referred pain to the knee usually comes from either the hip or the spine and can be more difficult to diagnose.

Statistically, Americans are nearly 100% likely to have an episode of knee pain at least once in their lifetime. The incidence of knee pain is higher with increasing age and therefore is very common in the elderly. Initial attacks of knee pain, may respond to home remedies such as the use of rest, ice or heat, anti-inflammatory medications, weight loss, and a low impact exercise program.  Knee pain that lasts more than 10 days and is associated with swelling in the joint or inability to weight bear generally requires a visit to your physician.  Physical exam x-rays and occasionally blood testing are included in the diagnostic evaluation. 

Common causes of knee pain

            Inside the knee joint
a.       Osteoarthritis
b.      A torn meniscus
c.       Rheumatoid or Inflammatory Arthritis
d.      Gout
e.       Knee joint infection
f.        Tendonitis or Bursitis

Outside of the knee joint
a.       Hip arthritis
b.      Sciatica
Osteoarthritis (OA) is the most common cause of knee pain in the elderly.  OA is the wear and tear type of arthritis that we are all subject to.  The incidence is slightly higher in women than men.  Increasing rates of obesity and decreased rates of exercise have resulted in an epidemic of OA in our society.  Most patients experience a slow gradual increase in pain and swelling.  Physically, there is often a bow legged appearance especially with weight bearing.  Inside the knee, a patch like loss of covering cartilage on the end of the bones allows the bones to rub together. Commonly the arthritis is also associated with a longstanding meniscus tear.   Initial treatment consists of rest, ice, anti-inflammatory medicines, weight loss and a low impact exercise program.  Injectable lubricates are available for arthritic knees and can temporarily diminish symptoms in moderate cases.  Dietary supplements are commonly advocated (glucosamine and chondroitin) but have never been shown effective in scientific studies. For severe arthritis, knee replacement surgery has extremely high success and patient satisfaction rates.

The meniscus is a structure in the knee shaped much like a washer. It is rubbery in nature and acts to help increase the contact area between the thigh and shinbone as they meet in the joint. Twisting and squatting activities are known to facilitate tears of the meniscus and can be the inciting event to bring on pain. A torn meniscus or cartilage can occur at any age.  Although this condition is common in young athletes, it can occur in the elderly as well.  In the elderly, the tear usually occurs incrementally and gradually over a period of months or years.  As a result, the appearance of a problem can be sudden or insidious.  Most torn menisci are on the medial or inside joint line of the knee and are associated with swelling, intermittent locking, difficulty with squatting or rising from a chair. When the tear catches, the patient will have a snapping or a grinding sensation. This problem can turn on and off like a light switch. With large tears the ability to ambulate is limited. A physical exam can establish the diagnosis.  Initial treatment includes rest, ice, and anti-inflammatory medications.  A steroid injection into the joint may help dramatically. Occasionally arthroscopic surgery is necessary to resolve the symptoms.

Rheumatoid arthritis is less common overall than osteoarthritis and presents more in women by a ratio of 8 to 1. Rheumatoid arthritis is an autoimmune disease in which the immune system of the patient begins attacking the synovial lining and covering cartilage within the joint.  Hallmarks of the disease include: at least an hour of morning stiffness, rashes, symmetrical involvement, and joint deformity especially in the hands. The disease process eventually destroys the joint surface. Laboratory data frequently can confirm the presence of rheumatoid arthritis. Over the last decade the use of disease-modifying medications have become prevalent and for the first time in modern history, the disease can actually be slowed dramatically by the appropriate use of these medications. Generally after the diagnosis of rheumatoid arthritis is made the patient should come under the care of a family doctor or rheumatologist who can administer and monitor the use of these medications appropriately. If and when rheumatoid arthritis causes significant destruction of the cartilage covering the end of the bone, knee replacement surgery is an appropriate next step.

Gout is more common in elderly men.  It occurs in genetically sensitive patients when uric acid levels in their blood exceed the saturation point and they crystallize in synovial joints.  The crystals cause sudden intense pain, swelling and redness. The big toe knuckle is most commonly involved, followed by the ankle and the knee joint.  Attacks can be triggered by diet (foods high in urates), alcohol and aggravation.  Some diuretics are known to trigger an attack.  The diagnosis requires a reasonable suspicion and can be confirmed by the finding the presence of gout crystals in fluid from the knee joint.  An attack will subside rapidly after the administration of the right medications.  Prevention of further attacks is accomplished by diet, and prophylactic medicine.  Although infection of the knee joint is unusual, it closely mimics gout with the main difference being the presence of fever and malaise. Infection can occur after a penetrating injury, or in immuno-compromised patients. 

Tendonitis and bursitis of the knee are common in patients of all ages. They can occur as a result of injury, repetitive activities, arthritic conditions or even gout. Generally the location of the pain is specific to the presence of a tendon or a bursal sack and treatment is supportive with anti-inflammatory medications and rest. The conditions usually resolve promptly.

Osteoarthritis(OA) of the hip joint can cause pain radiating to the knee. Patients sometimes arrive convinced that the knee is the source of the problem, only to find out that x-rays of the knee are normal and x-rays of the hip on the same side show severe arthritis. Generally the type of limp caused by a bad hip has a characteristic John Wayne waddle while the knee limp is more stiff-legged.
Sciatic pain emanating from the low back commonly results in pain radiating across the knee. Nerves exit the spine and coalesce into the sciatic nerve. Pressure on these nerves from arthritis or disk problems can produce pain down the back of the leg and the posterior aspect of the knee.  Cramping, spasms, and numbness often accompany pain from sciatica. 


There are many causes of knee pain in the elderly; most conditions are not serious and can be treated using anti-inflammatory medications, rest, ice, and activity modification. If the symptoms don’t resolve over 10 days to 2 weeks a visit to your doctor is advised.  A diagnosis will likely be made quickly and appropriate treatment begun.  Longstanding and increasing knee pain in the elderly is most likely arthritis related.  Arthritis is the loss of the cartilage covering on the end of the bones that meet in the knee joint.  If this becomes severe, and medication, physical therapy, exercise and weight loss do not resolve the problem, knee replacement surgery results in extremely high success and satisfaction rates in appropriately selected patients.

Sunday, June 12, 2011

Musings on Nepal

Namaste.  (nah-mah-stay).  This simple Hindu greeting is expressed by pressing the palms of the hands together in front of the heart.  The head is bowed slightly as the word is spoken.  It literally means “the spirit or light within me recognizes and honors the spirit or light within you.”

We very recently returned from a journey to Kathmandu, Nepal, a valley burrowed deep in the recess of the Himalayas, the highest mountains on earth.  Our primary purpose—to assess the medical facilities and prepare for Operation Walk Syracuse’s November trip to Nepal to perform desperately needed hip and knee replacement surgery.

The stark contrasts of reality that we witnessed are staggering and pervasive in both city and village life.  The region and the people are primordial, yet caught in the throes of modernization.  It is a place of breath-taking beauty and unspeakable poverty.  Sanitation is more than a pervasive issue.

Kathmandu lies deeply isolated in a valley surrounded by mountains.  City roads are dangerously crowded, unguided due to the lack of traffic signs and signals.  Travel by car, bus, or motorbike is a treacherous, grueling affair.  Most mountain villages are reachable only by dirt roads and footpaths.

The pollution is pervasive.  Noxious fumes hang low over the city and we observed many people struggling to protect their airways through the use of masks or scarves placed over their mouths and noses.

The hospital environment will be challenging.  The medical facility falls far short of those we comfortably use in the U.S.  The challenges in providing effective medical and surgical care are very apparent.  Paucity of resources, a hospital physical plant that is lacking hot water, adequate toileting facilities, and up-to-date equipment and supplies add to the already challenging care environment.

By contrast, the physicians and orthopedic clinical staff areknowledgeable, enthusiastic, motivated, and committed to meet the needs of their patients.  We were warmly greeted and welcomed to the Medical College.  Our hosts were extraordinarily gracious.  We collaboratively planned for our November surgical joint replacement marathon which will include our team of nearly 40 health care providers who will travel with us to Nepal.  In addition to the cordial welcome from the medical staff, hospital administration, and the Minister of Health, we were warmly greeted by twenty of the prospective patients.  We left the hospital bearing the x-rays for fifty (50) patients who are hoping to receive ninety-three (93) joint replacement procedures during our abbreviated visit in November.  A daunting and overwhelming task is at hand.

We saw so very little during our short visit but more than enough to make us appreciate what we have here, and how much we take that for granted each and every day.

It was all about the people.  We were struck by the extremes of everything they experience, yet are sincerely welcoming and positive.  Ox-drawn carts and cows share the roads with taxis and other motorized vehicles.  T-shirt clad teenagers sell roadside wares next to sari-clad women washing clothes at a public well.  As we wandered through the narrow brick streets of Bhaktapur, an ancient city with Hindu and Buddhist temples that seem unchanged for centuries, or gazed across the terraced-fields that lie at the gateway to Everest after hiking to the highest point of Nagarkot, we remained most in awe of the remarkable inhabitants of this country. 

As we departed Kathmandu dreading the long, jet-lag filled return to Syracuse, we were energized by what we had seen and what promises to lie ahead.  We eagerly look forward to the next time that we will be met with the greeting we received from everyone in Nepal, rich or poor:  Namaste.  This humbling gesture is meant to recognize that we essentially are all on equal standings.  We are one with these people as we prepare to travel more than 7,500 miles to the other side of the world on this life-altering trip.  Until then, we will hold on to the people of Nepal and so many of the lessons learned.


In the Streets of Bhaktapur

Wednesday, June 1, 2011

Granting the Wish to Walk

Greetings from Nepal.  I have embarked on our "pre-trip" to Nepal a few days early to spend some "adventure-time" with two of my sons.  We will enjoy exploring and trekking for a week and will then meet up with Kim Murray and Mike O'Hara in Kathmandu to begin the exciting process of planning for our surgery visit in November.

Should you be wondering what a trekk in Nepal might involve, our approximate itinerary is as follows:

31 May’2011: Fly Pokhara to Jomsom [15-20 minutes] and trek to Kagbeni [approx 04 hours walk]:
It will be a sunny and windy day and the temperature will be approx 20 – 28 degree Celsius.  On the way to Kagbeni they have to cross Kali Gandaki River via wooden bridge and Lubra River. Enroute you will pass through small village.

01 June’2011: Trek Kagbeni to Muktinath (3800m) – 03 hours
Usually the weather and climate will be the same as Kagbeni. On the way we will pass through small villages called Khing and Jarkot and reach to Muktinath for overnight stay.

02 June’2011: Trek back visit Lubra village and Jomsom – 4 hours
After breakfast we descent to Lubra river. We are high above the river again and must cross two bigger side-valleys on the way downstream. Eventually we come to some fenced-in fields and a garden with apple trees, near Lubra’s village school.
After Lubra, the trail leads to the Kali Gandaki and we have to leap across the river Panga a couple of times! At the confluence of the two rivers we join the caravan of tourists going to Jomsom The climate will be similar to Muktinath and in the afternoon it will be a windy day.

03 June’2011: Trek to Tukche village (2590m): 3 hours
The climate will be similar to Muktinath. On the way we will pass small village called Syang and then to Marpha which is very famous for Apple wine and there is big agriculture farm and this area is very famous for apple and then to Tukche village.

04 June’2011: Trek to Gasa (1080m) 5-6 hours:
Day will be warmer but possibility of rainfall.  This day we have to cross Kali Gandaki river couple of times and we will reach Kalapani, from here we have to walk through pine forest and descent to Lete village and after crossing the river, level walk to through forest to Gasa village for overnight stay.

05 June’2011: Drive from Gasa by local jeep to Beni and to Pokhara:

Today after breakfast we will drive from Gasa by local jeep to Beni via tatopani and from Beni we will have a private transfer from to Pokhara. Total driving hours will be approx 06 hours. From Gasa to Beni off road and from Beni to Pokhara is black topped.

Once back in Kathmandu we will tour all relevant portions of the hospital, spend time with a representative from the Ministry of Health, meet several of our prospective patients, and most importantly, assess the environment in which we will be performing surgery this fall.

Look forward to reading many exciting observations and stories upcoming blogs after we return.  Stay tuned for photos as well.