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18 Articles in Volume 11, Issue #9
Pain and Sleep: A Delicate Balance
Management of Insomnia: Considerations For Patients With Chronic Pain
PPM Editorial Board Outlines Management Strategies for Chronic Pain Patients With Insomnia
Attention Deficit Hyperactivity Disorder And Patients With Pain
Dry Needling Offers Relief From Chronic Low Back Pain
Etiology of Chronic Pain and Mental Illness: How To Assess Both
Temporomandibular Disorder: Examining the Cause And Treatments
Highlights From PAINWeek 2011
Is Your Patient Using Heroin?
Medications For Low Back Pain
Nonpharmacologic Treatments for Patients With Sleep Disorders and Pain
Man With Constant, Daily Headache Pain, Photophobia, Phonophobia, and Nausea
Successful Nonoperative Treatment of Persistently Painful Knees Following Total Knee Arthroplasty—A Case Series
Insomnia in Chronic Pain Patients
What Is Going Wrong With Research? Finding the Right Answer
Testing Positive for Marijuana in Urine
Hydrocodone, Carisoprodol, and Alprazolam—A Most Lethal Combination
Pro-inflammatory Diet

Successful Nonoperative Treatment of Persistently Painful Knees Following Total Knee Arthroplasty—A Case Series

An estimated 20% of patients with total knee arthroplasty will report pain following the procedure. Careful examination of the structures around the knee can reveal tendonitis, bursitis, and soft tissue pain that respond to usual care.

Case 1—Complex Regional Pain Syndrome?

History
A 63-year-old woman presented to our office 15 months after undergoing bilateral total knee arthroplasties (TKA). The patient reported that the initial surgeries were uncomplicated, with no adverse events. However, with time, the patient suffered from continued pain and, more recently, from a gradual loss of range of motion. She was treated with manipulation under anesthesia (MUA), which successfully restored some of the range of motion, but she continued to have diffuse, debilitating pain that significantly limited her daily function. The pain was mostly intense in the distal quadriceps, and was more prominent in the right knee than in the left knee.

Physical Examination
The patient’s right knee showed no skin discoloration, erythema, or hyperalgesia to light touch. The patient had a well-healed surgical incision. There was some typical periarticular warmth, but no erythema. Range-of-motion examination revealed that the patient lacked 20 degrees of extension and had flexion to only 75 degrees. Functional testing demonstrated decreased strength activation of the quadriceps on the right side, with considerable extensor lag of approximately 15 degrees. Palpation of the periarticular soft tissues revealed mild tenderness in the pes bursa. The patient was extremely sensitive at the insertion of the quadriceps tendon. She would withdraw from light to moderate pressure in this area. There was a small joint effusion, and distally the neurovascular exam was intact. There was some decrease in sensation around the incision.

Examination of the left knee demonstrated relatively poor range of motion as well, but better than that of the right knee. The patient lacked 10 degrees of extension, with flexion to 85 degrees. The surgical incision of this knee also was well healed. There were no significant skin changes identified. The distal neurovascular exam was intact. Again, there was considerable tenderness at the insertion of the quadriceps tendon. Activation of the quadriceps muscle was near normal.

Prior Treatment
Treatment had consisted of physical therapy and aggressive pain management, which included hydromorphone (Dilaudid), pregabalin (Lyrica), and amitriptyline (Elavil). This regimen would help her sleep, but her days remained difficult, with considerable pain upon ambulation and limited range of motion. The patient presented with a working diagnosis from a consulting orthopedic surgeon of complex regional pain syndrome (CRPS). The surgery was deemed technically sound and the implants properly positioned (Figure 1).

Figure 1. Postoperative radiographs of successful bilateral total knee arthroplasty. The implant position and operative technique were deemed technically sound.  (Image courtesy of Joseph J. Ruane, DO.)

Differential Diagnosis

  • CRPS
  • Failed total knee arthroplasty
  • Lumbar radiculopathy
  • Multifocal soft tissue pain

Final Diagnosis
Quadriceps tendonitis and periarticular soft tissue pain with muscle inhibition

Treatment
Based on this diagnosis, a conservative treatment plan was initiated. A physical therapist with extensive experience in treating patients who have undergone TKA also participated in the patient’s evaluation. This combined medical and physical therapy evaluation concluded the quadriceps tendonitis with resultant muscle inhibition was the primary influence in this patient’s disability.

The quadriceps tissue tendonitis was treated with iontophoresis to the distal quadriceps tendon using dexamethasone 4 mg/mL solution. Light local soft tissue effleurage and muscle activation techniques also were included. She was also given a prescription for diclofenac patches (Flector) to use daily over the distal quadriceps.

Medication treatment included increasing the dosage of pregabalin to a maximum of 300 mg per day, with careful titration, to aid with the generalized hyperalgesia that had developed. She was encouraged to take hydromorphone prior to each physical therapy visit to maximize her ability to work aggressively on range of motion.

Outcome
The addition of physical therapy modalities and local treatments to the extensor mechanism resulted in a pain reduction of 50% (based on a Numeric Pain Intensity Scale [NPIS]) in the first 3 weeks. This facilitated a more aggressive approach to achieving the therapy goals. Once her pain inhibition was removed, her motion improved rapidly. Her gait pattern also normalized. After 6 weeks of treatment, the patient was discharged with an average NPIS rating of 1 to 2 out of 10 and full extension in both knees with flexion beyond 110 degrees bilaterally.

Case 2—“Failed Total Knee Arthroplasty”

History
A 63-year-old woman presented 2 years after undergoing an uncomplicated right TKA. The surgery and immediate postoperative period were uneventful. Approximately 6 weeks after surgery, the patient began to experience daily, lateral, and anterior knee pain. The pain was worse when she climbed stairs and decreased with prolonged periods of non–weight bearing. She reported no significant night pain.

The surgeon who performed the index TKA informed the patient that the implant appeared radiographically sound and that the surgery had been performed with appropriate technique. The patient was then informed that post-surgical pain of uncertain etiology is an unfortunate risk of the procedure and that she would have to live with her current symptoms. The contralateral knee had mild medial compartment osteoarthritis that did not interfere with activity.

Physical Examination
Examination of the right knee revealed minimal effusion. The patient had full range of motion, but had pain when passing into full extension. The incision was well healed with no dehiscence or defects. The pesancerine bursa, patellar tendon, and quadriceps tendon were unremarkable to palpation. The patient was tender to palpation in the area of the lateral retinaculum and the lateral femoral condyle. A musculoskeletal ultrasound obtained in the office with demonstrated no significant tissue changes (Figure 2).

Figure 2. Longitudinal musculoskeletal ultrasound of distal iliotibial band. The tendon displays normal, homogeneous fibrillar architecture, and normal bony contour is also seen. It is not unusual for there to be a lack of significant tissue changes in patients who present with a convincing clinical diagnosis. (Image courtesy of Joseph J. Ruane, DO.)

Prior Treatment
The patient had tried multiple oral nonsteroidal anti-inflammatory drugs (NSAIDs) with only minimal benefit. A trial of opioid therapy was discontinued because of undesirable side effects. She also had tried several over-the-counter topical analgesics without benefit.

Differential Diagnosis

  • Lumbar radiculopathy
  • Osteoarthritis of the hip radiating to the knee
  • Distal iliotibial band syndrome (ITBS)
  • Persistent synovitis
  • Mechanical failure of the implant

Final Diagnosis
Distal ITBS

Selected Treatment
We discussed options including physical therapy, topical NSAIDs, and local corticosteroid injection. Because of the level of discomfort and relative degree of frustration with her daily pain, the patient requested to start with local injection.

Under ultrasound guidance, the iliotibial band was superficially infiltrated with 2 mL (4 mg/mL) of dexamethasone and 2 mL of 1% lidocaine. With this injection, the patient experienced immediate and significant improvement of her local lateral knee discomfort (lidocaine effect). This injection was accompanied by the commencement of a home program of icing and stretching of the ITB. Of note, most clinical presentations of ITBS do not demonstrate any characteristic abnormalities on ultrasound.

Outcome
Three weeks after the initial injection and adherence to the home program, the patient reported nearly 60% to 70% relief of her pain symptoms, with her average NPIS rating dropping from 7.5 to 3 out of 10. She was unable to undergo outpatient physical therapy because of occupational and financial constraints.

Oral NSAID treatment was continued for another month, at which time she returned for her second follow-up visit. At this time, she reported stable but continued pain, and was therefore treated with a second corticosteroid/lidocaine injection, which provided 90% improvement in her pain symptoms. At her 12-week follow-up, she reported regaining normal daily function.

Three years post-treatment, the patient reports good knee function with occasional bouts of lateral knee pain that are managed with topical diclofenac gel, ice, and stretching.

Case 3—Medial Knee Pain

History
A 56-year-old obese woman presented with burning, aching pain throughout the front of her knee. The patient reported that she had undergone left TKA 2 years ago. She enjoyed a full year of good pain control and functional outcome before developing a slow progression of symptoms. She reported falling onto the pavement, and believes the pain started shortly thereafter. At no point did she return to her surgeon for follow-up.

Physical Examination
Standing evaluation demonstrated bilateral pesplanus of the feet (flat feet). The left knee had adequate range of motion from 0 to 120 degrees. The patient had vague pain symptoms when the knee was both flexed and extended. There was no palpable effusion identified, although this was difficult to assess secondary to the patient’s soft tissue girth.

Further examination of the knee revealed minimal tenderness and no obvious pathology within the patellar tendon, quadriceps tendon, or distal iliotibial band. Local tenderness and soft tissue fullness were noted at the proximal medial tibia at the level of the tibial tubercle. On weight bearing, she experienced pain with every step. Stair climbing and descent caused similar pain symptoms that were not more severe than with ambulation on level ground.

Prior Treatment
The patient had been on prescription NSAIDs and had undergone a trial of opioids, but discontinued these agents secondary to side effects. The patient also had tried a variety of over-the-counter topical analgesic agents without benefit.

Differential Diagnosis

  • Tibial stress fracture
  • Pesanserine bursitis
  • Mechanical failure or loosening of total knee arthroplasty implant
  • Hoffa’s fat pad impingement

Final Diagnosis
Pesanserine bursitis (Figure 3)

Figure 3. Longitudinal oblique view of pesanserine bursitis. Ultrasound image over the tibial insertion of the pesanserine complex demonstrating distention of the anserine bursa (arrow). Note that the bursa separates the pesanserine tendons from the distal insertion of the underlying medial collateral ligament.  (Image courtesy of Jeffrey Strakowski, MD.)

Selected Treatment
The patient was treated with an injection of dexamethasone 1 mL (4 mg/mL) and 1% lidocaine 1 mL to the pesanserine bursa. The injection did not penetrate the joint space, as it was delivered distally and medially into the pesanserine bursa. She was prescribed physical therapy for lower extremity strengthening. Additionally, the patient was fitted for custom shoe orthotics, as the literature has suggested a strong association between pesplanus and pesancerine bursitis. The patient also was extensively counseled with regards to weight loss. Because of her comorbid diabetes and hypertension, it was decided not to use NSAIDs.

Outcome
The patient reported 90% pain relief 1 month after the injection; and symptom relief was persistent at 3-month follow-up. Eight months after initial treatment, the patient presented with recurrence of significant pain and requested a second injection. She did not wish to undergo any additional physical therapy. She received a second injection, and at her 4-week follow-up after the second treatment, she reported 90% improvement in pain, and all her functional goals were achieved.

Conclusion
Pain after TKA is reported to be a problem in an estimated 20% of cases.1 It is described as a surgical risk and is often accepted as an unfortunate outcome of the procedure. However, careful physical examination of the diagnostic evaluation can reveal soft tissue pathologies that can be successfully managed. Careful examination of the soft tissues around the knee can reveal tendonitis, bursitis, and soft tissue impingement that may respond to local modalities.2,3Local injection to the periarticular soft tissues, if performed with meticulous aseptic technique, should pose no threat to the implant and can be considered when soft tissue pathology is severe enough to impair daily activities.4,5 Patients who have persistent pain in the absence of mechanical dysfunction of the prosthesis may enjoy significant improvements in pain and function through such localized soft tissue treatments.

Last updated on: February 9, 2012
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