Family Medicine 11: 74-year-old woman with knee pain User: Lauren Harasymiw Email: [email protected] Date: October 17, 2018 00:37 GMT/UTC Learning Objectives The student should be able to: Elicit a thorough history for the chief complaint of knee pain. Discuss the components of a thorough knee exam. Formulate differential diagnosis for knee pain in an adult. Develop an appropriate treatment plan for osteoarthritis, including medications and lifestyle modifications. Recognize when imaging and referral to specialists are appropriate for knee pain. Describe the different classes of medications useful for the treatment of chronic pain, and recognize their common side effects. Discuss the USPSTF recommendations for appropriate screenings and immunizations in adults. Knowledge Effects of Nonsteroidal Anti-Inflammatory Medications on Symptoms of Gastroesophageal Reflux Disease Nonsteroidal anti-inflammatory medications, like ibuprofen (Advil, Motrin), can worsen the symptoms of GERD, especially if taken on an empty stomach. Key History for Knee Pain Patient’s age Age can help narrow your differential diagnosis, as certain conditions are classically seen in certain age groups. Children and adolescents who present with knee pain are likely to have patellar subluxation, tibial apophysitis (Osgood-Schlatter), or patellar tendonitis). Adults are more prone to patellofemoral syndrome (a clinical diagnosis of exclusion for anterior knee pain), overuse syndromes (such as pes anserine bursitis), traumatic injuries (ligamentous sprains – anterior cruciate, medial collateral, lateral collateral – and meniscal tears) and inflammatory arthropaties, such as rheumatoid arthritis, septic arthritis, and reactive arthritis (formerly known as Reiter syndrome). Any previous history of trauma / injury to knee Without a history of trauma, ligament injuries and meniscal tears are less likely. These conditions often present with acute onset of pain following trauma. Treatments that make it better Analgesics can often help pain, regardless of the etiology. This is less helpful in narrowing the differential diagnosis since it is so non-specific. Actions that worsen the symptoms Actions that worsen the symptoms are not typically helpful to narrow the differential diagnosis. However, asking the patient to perform certain maneuvers can help to assess the functioning of certain aspects of the knee as well as the extent the patient’s pain interferes with mobility. For example, the ability to squat is influenced by supporting musculature, ligaments, and the knee joint. Impaired squatting ability could be caused by effusion, knee arthritis, injury to the ligaments, etc., whereas the ability to perform the duck waddle assesses the stability of the knee and effectively rules out significant ligament instability, joint effusion, and significant damage to the meniscal cartilage. Acute versus insidious onset of pain The time frame of the onset of pain does not usually help narrow the differential significantly, although it can suggest whether to focus on acute (potentially traumatic) injury as a possible cause in contrast to a chronic, systemic etiology of the condition. © 2018 Aquifer 1/11 Monoarticular joint involvement Knowing which joint(s) are involved can be helpful, as certain conditions have an affinity for particular joints. Gout (uric acid crystal deposition in the joint that causes severe pain) often presents in the great toe, whereas rheumatoid arthritis typically affects three or more joints, often including the hands and feet. Osteoarthritis often affects the knees, hips, and back. Evaluation of Knee Pain Suspected infectious process causing knee pain If concerned about septic arthritis or an acute inflammatory arthropathy, check a Complete Blood Count (CBC) with differential and erythrocyte sedimentation rate (ESR), though this test is non-specific. Perform an arthrocentesis and send the fluid for cell count with differential, glucose and protein, bacterial culture and sensitivity, and polarized light microscopy for crystals. An arthrocentesis can also help differentiate between simple effusion and hemarthrosis or occult osteochondral fracture. A simple joint effusion produces clear, straw-colored transudative fluid. This can happen with osteoarthritis and degenerative meniscal injuries. Hemarthrosis is typically caused by a tear of the anterior cruciate ligament or a fracture. A bloody knee aspirate can be associated with a knee sprain (i.e. ACL, PCL) or acute meniscal tear. An osteochondral fracture causes hemarthrosis with fat globules. Suspected rheumatoid arthritis causing knee pain If considering RA, check rheumatoid factor (RF) on blood work. This test is not very sensitive and only moderately specific for rheumatoid arthritis. It would be more helpful to as a test to rule out RF (if the test is negative), than to rule it in (if the test is positive). Trauma causing knee pain To evaluate knee pain following trauma, apply the Ottawa Knee Rules to decide whether or not to order an x-ray. Osteoarthritis Epidemiology Epidemiology Osteoarthritis is very common among U.S. adults, and the leading cause of disability. In fact, arthritis is expected to affect an estimated 67 million adults in the United States by 2030. Findings from a National Health Interview Survey several years ago indicated that an estimated 21.6% of the adult U.S. population (46.4 million persons) had doctor-diagnosed arthritis. Both white and black races are at equal risk for the disease. Initial management Exercise has been shown to improve function and decrease pain in OA. Current guidelines strongly recommend that patients with symptomatic knee OA participate in an exercise program commensurate with their ability to participate; they do not preferentially recommend aquatic or land-based exercise. Personal Health Questionnaire (PHQ) – 2 for Depression “During the past month:” 1. “Have you often been bothered by feeling down, depressed or hopeless?” 2. “Have you often been bothered by little interest or pleasure in doing things?” Side Effects of NonSteroidal Anti-Inflammatory Drugs (NSAIDs) gastrointestinal upset decreasing the effectiveness of hypertension medications increasing the effect of sulfonylureas Patients who use NSAIDs chronically – taking 5,000 or more pills in a lifetime – are at an increased risk of developing end-stage renal disease. Elderly patients are at an increased risk of developing gastric ulcers when using NSAIDs chronically. NSAIDs, aspirin, and acetaminophen can all cause hepatotoxicity, and contribute to coagulopathy. Recommended Preventive Screening for a 74-Year-Old Woman Recommended Screening Colorectal cancer screening by fecal occult blood test (FOBT), flexible sigmoidoscopy, or colonoscopy is recommended for patients ages 50 to 75 years old. The US Preventive Services Task Force (USPSTF) recommends against screening for colorectal cancer after the age of 75 years. The USPSTF recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup. Patients 18 years old and older should be screened for elevated blood pressure. The USPSTF recommends biennial screening mammography for women ages 50 to 74. They state that evidence is insufficient to make any recommendation for screening over the age of 75. © 2018 Aquifer 2/11 Screening Not Recommended A one-time ultrasound to screen for an abdominal aortic aneurysm (AAA) is recommended in men 65 to 75 years old who have any history of smoking, but the USPSTF recommends against routine screening for AAA in women. Evidence is insufficient to make recommendations about the routine use of interventions to prevent low back pain in adults in the primary care setting. The USPSTF strongly recommends screening women over 45 years old for lipid disorders if they are at increased risk of coronary heart disease. The USPSTF makes no recommendation about screening women over the age of 20 who do not have an increased risk of coronary heart disease. The USPSTF recommends against screening for carotid artery stenosis in asymptomatic patients. There is not sufficient evidence to recommend for or against routine screening for thyroid disease. Based on USPSTF recommendations, women over the age of 65 should not be screened for cervical cancer if they have had adequate recent screening with normal Pap smears, and are not otherwise at high risk for developing the disease. Annual Visit Preventive Medicine 1. Screening tests 2. Update adult immunizations Tetanus – Sustitute one-time dose of Tdap for Td booster, then boost with Td every 10 years Pneumococcal Polysaccharide – If > 65 years, one dose Flu – One dose annually Zoster – If > 60 years, one dose Clinical Skills Performing a Knee Exam Have the patient put on a gown, as it is important to be able to fully examine and compare the painful knee and the non-painful knee. Observe the patient walking and climbing onto the examination table. Inspect both legs for erythema, edema, bruising, or atrophy of the quadriceps. Palpate the knee joints, feeling for warmth, effusion, and point tenderness. P ay particular attention to the patella, tibial tubercle, patellar tendon, quadriceps tendon, anterolateral and anteromedial joint line, medial joint line, and lateral joint line. Check knee range of motion by flexing and extending the knees (normal is 0 degrees extension, and 135 degrees flexion). Assess for tenderness and range of motion on hip exam. Common knee exam maneuvers: Instructional video on knee exam maneuvers. Review a diagram of the knee and specific exam maneuvers. Specific Knee Exam Maneuvers Lachman’s test Assesses the stability of the anterior cruciate ligament (and not the posterior cruciate ligament) This test is performed with the patient lying supine with the injured knee raised and slightly flexed to 30 degrees. The distal femur is stabilized by the physician with one hand, while the proximal tibia is held by the other hand. Force is applied to move the tibia anteriorly. The test is considered positive if there is excessive motion of the tibia. Anterior and posterior drawer signs Assess the anterior cruciate and posterior cruciate ligaments, respectively They are performed with the patient laying supine, knee bent to 90 degrees, and the foot stabilized, most easily done by the physician sitting on the foot. The physician’s thumbs are placed on the tibial tubercle, while the fingers are placed on the posterior calf. The physician then attempts to displace the tibia, either anteriorly or posteriorly. Too much motion of the tibia, or lack of a clear end-point, especially as compared to the non-painful or non-affected side, constitutes an abnormal finding. Valgus and varus stress tests Assess functioning of the medial and lateral collateral ligaments These test are performed with the patient’s leg in full extension with the knee flexed to about 30 degrees. The physician places his/her hand on the lateral knee joint to apply a valgus stress to the distal tibia, or on the medial knee joint to apply a varus stress to the distal fibula. Excessive motion of the knee signifies instability of the corresponding ligament. McMurray Can assess the medial and lateral menisci, though it has low sensitivity and The physician holds the patient’s heel with one hand and grasps the knee over the medial and lateral joint lines with the other hand. The patient’s knee is flexed as much as possible. The tibia is rotated either internally (tests lateral meniscus) or externally (tests medial meniscus) as the knee is extended to about 90 degrees. A varus © 2018 Aquifer 3/11 test specificity for diagnosing meniscal tears stress (lateral meniscus) or valgus stress (medial meniscus) is applied across the knee joint while the knee is being extended. The test is positive if a clunk or click is felt, or if testing causes reproducible knee pain. Carpal Tunnel Exam Examine the wrist for swelling, warmth, tenderness, deformity, and discoloration. Atrophy of the thenar eminence (the raised fleshy area on the palm of the hand near the base of the thumb) may be evident with longstanding, untreated carpal tunnel syndrome. Tinel’s sign: Tap over the median nerve at the wrist to reproduce symptoms. Phalen’s test: Flex wrist by having patient place dorsal surfaces of hands together in front of her for 30 to 60 seconds to reproduce symptoms. Management Management of Pain Related to Osteoarthritis Treatment Results for Knee OA Evidence Exercise Specifically water- or land-based exercise, aerobic walking, quadriceps strengthening, resistance exercise, tai chi Reduce pain and disability A Acetaminophen First choice analgesic for both short and long-term treatment of mild to moderate pain related to osteoarthritis because of its tolerability and low side-effect profile. Dosing is up to 4 gm per day in divided doses, though some recommend lower doses (2-3 gm/day in divided doses) if long-term use is desired. Caution patients to be aware of coincident use of other over-the-counter or prescription medications that may contain acetaminophen so that the maximum combined daily dose does not exceed 4 gm. Little risk of nephrotoxicity, and hepatotoxicity is a rare side effect if taken appropriately. Reduce pain A NSAIDS Second choice to acetaminophen because of their association with gastrointestinal side-effects, including gastritis. Especially true in the geriatric population because of their increased risk of acute gastrointestinal bleeding, even when used in conjunction with antacids or proton pump inhibitors. Risk of prolonged bleeding times, a potential problem if the patient is at risk for falling. Reduce pain A Intra-articular corticosteroid injections Should be considered if the knee joint is inflamed, as evidenced by swelling and pain. No more than three injections per year, and no more frequent than one injection per month. Long-acting triamcinolone is typically preferred over methylprednisolone, and 1 ml of steroid should be combined with 3-4 ml local anesthetic. 24 hours of immobilization following the injection helps maximize the effects, but prolonged rest should be avoided. Can reduce pain, limit the need for other medications, and improve function. Fewer associated side effects than NSAIDs or opiates. Short-term benefit with few adverse effects A Acupuncture A 2006 systematic review showed that acupuncture is better than sham-control interventions for peripheral joint osteoarthritis. Also shown to reduce pain and improve function in patients with OA of the knee when used as an adjunct treatment. May provide some benefit B A randomized controlled trial (RCT), followed by a meta-analysis failed to show a decrease in pain or slowed progression of joint space narrowing related to © 2018 Aquifer 4/11 Glucosamine glucosamine use. A small subset of participants in the GAIT study with moderate-to-severe pain did show statistically significant pain relief when glucosamine was combined with chondroitin sulfate as compared to placebo, but more investigation was recommended to confirm this finding because of the small sample size. The same was not true of the mild pain subset which showed no improvement over placebo. May provide some benefit for persons with moderate to severe pain B Chondroitin Does not decrease pain B Sadenosylmethionine (SAM-e) As effective as NSAIDs in reducing pain and disability B Tramadol (Ultram) Older patients with moderate to severe pain may experience modest benefit; use is limited by side effects B Dietary or supplemental omega-3 fatty acids appear to have some anti-inflammatory benefits that could help decrease joint pain. Non-Pharmacologic Recommendations for the Management of Knee Osteoarthritis Strongly recommend that patients with knee OA: Participate in cardiovascular (aerobic) and/or resistance exercise – either aquatic or land-based Lose weight (for persons who are overweight) Conditionally recommend that patients with knee OA: Participate in self-management programs Receive manual therapy in combination with supervised exercise Receive psychosocial interventions Use medially directed patellar taping Wear medially wedged insoles if they have lateral compartment OA Wear laterally wedged subtalar strapped insoles if they have medial compartment OA Be instructed in the use of thermal agents Receive walking aids, as needed Participate in tai chi programs Be instructed in the use of transcutaneous electrical stimulation* No recommendations regarding the following: Participation in balance exercises, either alone or in combination with strengthening exercises Wearing laterally wedged insoles Receiving manual therapy alone Wearing knee braces Using laterally directed patellar taping Be treated with traditional Chinese acupuncture * These modalities are conditionally recommended only when the patient with knee osteoarthritis (OA) has chronic moderate to severe pain and is a candidate for total knee arthroplasty but either is unwilling to undergo the procedure, has comorbid medical conditions, or is taking concomitant medications that lead to a relative or absolute contraindication to surgery or a decision by the surgeon not to recommend the procedure. When to Refer to a Patient with Osteoarthritis to an Orthopedic Surgeon Arthroscopic debridement hasn’t been proven to help pain or functioning in osteoarthritis. Generally, a knee replacement is not considered for osteoarthritis until other non-operative treatments have failed to relieve symptoms to an adequate degree. Chronic Pain Medications Opioids A meta-analysis showed that strong opioids (oxycodone and morphine) were more effective than naproxen or nortriptyline for treating chronic noncancer pain, but not the weaker opioids (propoxyphene, codeine). The most common side effect of long-acting opioids is constipation. This side effect can usually be treated with a bowel regimen that may include laxatives, stool softeners, exercise, and a high water and fiber diet. Short-acting opioids act on several different receptors, including mu receptors in the central nervous system. Their side effects are similar to the long-acting opioids, and include euphoria, bradycardia, sedation, physical dependence, nausea, vomiting, and respiratory depression. Short-acting opioids actually carry more risk of tolerance than long-acting ones (C) because of their short half-life of three to four hours. © 2018 Aquifer 5/11 Patients need to use them more frequently to control their pain adequately. Short-acting opioids tend to be helpful for flares of acute pain, but if daily use is needed, long-acting opioids should be considered. Tricyclic antidepressants Tricyclic antidepressants have anticholinergic side effects, including dry mouth, constipation, urinary retention, blurred vision and paralytic ileus. They also have many gastrointestinal side effects, are sedating, and can have neurologic side effects like ataxia, tremors, paresthesias, and mental clouding. They are relatively contraindicated in patients with severe cardiovascular disease or conduction problems because they can contribute to tachycardia, arrhythmias, hyper- or hypotension, heart block, and myocardial infarctions. Anticonvulsants Anticonvulsants have been shown to be helpful for pain related to trigeminal neuralgia, but evidence is lacking for other chronic pain syndromes. Lamotrigine (Lamictal) was shown to be ineffective for treating chronic neuropathic pain in a meta-analysis. Some anticonvulsants require blood level monitoring and have severe side effects like megaloblastic anemia. Carbamazepine (Tegretol) can interfere with other medications because it is a cytochrome P-450 inducer, including decreasing the effectiveness of hormonal contraception. Several anticonvulsants are also known teratogens. Patients need to be educated about expectations for their pain control, and attainable goals should be set. Recommended Chronic Pain Control When Initial Conservative Treatment Fails Tramadol, a centrally acting analgesic with effects on the µ-opioid receptor that also stimulates release of serotonin and inhibits reuptake of norepinephrine, may be a good choice, given its effectiveness in alleviating moderate to severe pain and its lower abuse potential than other more potent opiod agonists, though it still carries some risk. A long-acting opioid might also be a good option. Often a short-acting opioid is given first to see how much is needed to control pain adequately over a 24-hour period, and then is converted to a long-acting alternative. If the long-acting opioid alone is not sufficient, then use either acetaminophen or a short-acting opioid for breakthrough pain. The goal should always be to use the smallest sufficient dose for the shortest period of time to achieve adequate pain control. Tricyclic antidepressants can be effective for chronic pain treatment and may be considered. Studies Imaging to Evaluate Osteoarthritis Indications Imaging for knee pain in a patient with no preceding trauma may not be necessary when the history and physical exam are consistent with osteoarthritis. However, if there is any question as to the diagnosis, or you are interested in assessing the severity/location of disease, an x-ray would not be unreasonable. An x-ray would also be warranted if there is no improvement with initial conservative treatment. Magnetic resonance imaging (MRI) MRI would be preferred if locking, popping, or joint instability were of concern, to detect meniscal or ligament damage. However, if an x-ray shows significant joint space narrowing, an MRI would likely not be needed even if there were mechanical symptoms, unless the patient fails to improve with conservative management. Views If a knee x-ray is desired to evaluate for osteoarthritis (OA), anteroposterior, lateral, and standing weight-bearing views should be obtained. A Merchant’s View can help evaluate the patellofemoral joint. The Merchant’s view is a “top” view of the knee obtained with the knee bent at a 45- degree angle, showing the alignment of the patella in the groove of the femur (throchlear groove). Major radiographic features of OA Joint space narrowing Subchondral sclerosis (Hardening of tissue beneath the cartilage. In osteoarthritis, there is increased periarticular bone density.) Osteophytes (Also known as bone spurs; bony projections arising from the joint.) Subchondral cysts (Fluid-filled sacs in the bone marrow.) Interpretation Knee x-rays are insensitive for detecting early OA and do not correlate well with the degree of symptoms. When findings are present, patellofemoral and tibiofemoral joint osteophytes correlate best with pain, and joint space narrowing best predicts disease progression. Carpal Tunnel Syndrome Diagnosis Both Tinel’s and Phalen’s have fairly low sensitivity and specificity for diagnosing carpal tunnel syndrome. Tinel’s sign is about 36% sensitive and 75% specific for carpal tunnel syndrome. Phalen’s is a little more sensitive at 57%, but less specific at 58% if the test is positive. © 2018 Aquifer 6/11 The diagnostic test of choice for carpal tunnel syndrome is an electrodiagnostic test (a nerve conduction velocity study) which has a sensitivity of 48- 84% and specificity of 95-99%. One review found that the three most helpful findings in predicting the electrodiagnosis of Carpal Tunnel Syndrome are: 1. Hand symptom diagrams (patient indicates symptoms in at least 2 of digits 1, (thumb) 2, and 3 (“classic” pattern), or with palmar symptoms as long as not confined only to ulnar aspect of palm (“probable” pattern)) 2. Hypalgesia (decreased sensitivity to pain) 3. Weak thumb abduction strength testing Electrodiagnosis of Carpal Tunnel Syndrome An electrodiagnostic test, or nerve conduction velocity study, is not typically necessary to make the diagnosis of carpal tunnel syndrome if the history and physical suggest the diagnosis. It is an expensive and somewhat uncomfortable test, and should only be done when necessary if symptoms fail to improve with conservative treatment, motor dysfunction is present, or thenar atrophy is seen on physical exam. Clinical Reasoning Differential Diagnosis for Knee Pain Diagnosis Location of pain History of trauma Fever Systemic symptoms Special notes Patellofemoral Pain Syndrome (chondromalacia patellae) Anterior knee pain No; overuse injury more likely No Typically presents in women as “theater sign”- mild to moderate anterior knee pain, worse after prolonged sitting Iliotibial Band Tendonitis Lateral knee pain No; overuse injury more likely (repetitive knee flexion) No No effusion Pain aggravated with activity Anterior Cruciate Ligament Sprain General knee pain Yes; noncontact deceleration forces No Moderate to severe joint effusion Swelling within two hours of “pop” Medial Collateral Ligament Sprain Medial joint line pain Yes; misstep or collision No Immediate onset of pain/swelling after trauma Lateral Collateral Ligament Sprain Lateral joint line pain Yes; varus stress No Immediate onset of lateral knee pain Less common than medial collateral ligament sprain Meniscal Tear Medial or lateral joint line Yes; sudden twisting injury No Can occur with chronic degenerative process Mild effusion Possible atrophy of the vastus medialis obliquus portion of the quadriceps Catching/locking of the knee Can have positive McMurray test Septic arthritis Generalized extreme pain with any movement No Yes Elevated WBC Elevated ESR (usually >50 mm/hr) Abrupt onset of pain and swelling Arthrocentesis with turbid synovial fluid © 2018 Aquifer 7/11 Osteoarthritis Generalized or joint line tenderness; pain aggrevated by weight-bearing activities, relieved by rest Not acute trauma. Past history of trauma can predispose to developing osteoarthritis No Chronic joint stiffness and pain Crepitus on exam Mild or no joint effusion Gout / pseudogout Extreme pain with any movement; also painful to touch No No Acute pain and swelling without prior trauma Arthrocentesis with clear or slightly cloudy synovial fluid Negatively birefringent rods in gout Positively birefringent rhomboids in pseudogout Popliteal (Baker’s) Cyst Posterior popliteal area No No Insidious onset of mild to moderate pain in the popliteal area of the knee Most common synnovial cyst of the knee Differential for Chronic Knee Pain Top Five Diagnoses knee sprain osteoarthritis rheumatoid arthritis gout/pseudogout psoriatic arthritis Knee sprain Can be associated with a small effusion, and with pain that worsens with weight-bearing and activity. Unlikely without history of trauma or change in activities that would be expected with sprain. Osteoarthritis Usually the large joints are asymmetrically involved. Can be monoarticular in young adults if due to trauma or a congenital defect, but more commonly presents as polyarticular or generalized arthritis. Joint stiffness , if present, is typically worse after effort. Rheumatoid arthritis Can have associated subcutaneous nodules that are firm and nontender, and are located at pressure points. Joint stiffnessfor more than thirty minutes in the morning is common . Typically bilateral joint pain, involving three or more joints (in particular the hands or feet). Gout Can be associated with tophi which are visible or palpable nodules often located on the ears or in the soft tissue. Tophi can also form in the bones, joints, and cartilage. They are typically not painful, and take years to develop. Psoriatic arthritis Common clinical manifestations may include peripheral arthritis, nail and skin disease, dactylitis, enthesitis and axial disease. Clinical pattern is variable, and arthritis may precede skin changes Skin findings precede joint symptoms in about 85 percent of patients Less Likely Diagnoses Lyme disease Caused by Borrelia burgdorferi. Typically presents with acute monoarticular joint pain. More likely to occur in endemic areas, such as the northeastern region of the United States. Usually a history of possible exposure to a tick bite. Typically a history of a rash, this does not rule out the possibility of Lyme disease, as some patients with Lyme disease do not develop a rash. Typically presents with a single painful joint. Exam is usually remarkable for swelling and warmth. © 2018 Aquifer 8/11 Septic arthritis Patients are typically febrile, though sometimes elderly patients will be afebrile with this diagnosis. Risk factors include diabetes, rheumatoid arthritis, prosthetic joints, recent surgery, preceding skin infection or trauma, and being over the age of 80. Often resembles gout or pseudogout, but can be differentiated from these by joint aspiration. In septic arthritis, the fluid appears very turbid (opaque) and has an abundance of inflammatory cells (white blood cell count 15K to > 200K; the lower part of this range (< 35K) may be associated with infections caused by low virulence or partially treated organisms, and the synovial white blood cell count may be elevated in inflammatory causes of arthritis, though usually not as markedly as in septic arthritis.) In gout or pseudogout, the fluid is usually slightly turbid with a moderate amount of white blood cells (3K – 50K), and the presence of crystals (calcium pyrophosphate or monosodium urate) is diagnostic. Popliteal or Baker’s cysts Arise in association with underlying disease, including rheumatoid arthritis or osteoarthritis. Posterior knee painif the cyst is large, and can also have difficulty fully flexing the knee . Symptomatic cysts can often be palpated on exam in the posterior fossa. Ankylosing spondylitis A form of spondyloarthritis commonly associated with the HLA-B27 genotype that typically occurs in young adults. It is a chronic inflammatory process of the axial skeleton, resulting in chronic back pain and progressive loss of motion of the spine. Hips are sometimes affected as well. Systemic Lupus Erythematosis Unlikely without other signs and symptoms accompanying the joint pain, including fever, skin rashes, Raynaud’s phenomenon, pleuritis, or chest pain. The typical rash of SLE is a malar “butterfly” rash, which appears as an erythematous maculopapular rash over the nose and cheeks that spares the nasolabial folds, and typically occurs or worsens with sun exposure. Discoid lesions can also be present, which look like discrete erythematous placques with scaling. SLE arthritis is also typically migratory. References Aertgeerts B, Buntinx F, Kester A. 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