Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010;69:483-489.
Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29:1039-1049.
Cubukcu D, Sarsan A, Alkan H. Relationships between pain, function and radiographic findings in osteoarthritis of the knee: A cross-sectional study. Arthritis. 2012;2012:984060.
Creamer P, Hochberg M. Why does osteoarthritis of the knee hurt--sometimes? Br J Rheumatol. 1997;37:726-728.
Richmond J, Hunter D, Irrgang J, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of osteoarthritis (OA) of the knee. J Bone Joint Surg Am. 2013;92:990-993.
Cooper, Kassim Javaid M, Arden N. Epidemiology of osteoarthritis. In: Arden N, Blanco FJ, Bruyere O, et al. Atlas of Osteoarthritis. 2nd ed. London: Springer Healthcare, 2018:18-33.
Centers for Disease Control and Prevention. Osteoarthritis (OA) Fact Sheet. https://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Updated January 19, 2019. Accessed March 11, 2019.
Kotlarz H, Gunnarsson CL, Fang H, et al. Insurer and out-of-pocket costs of osteoarthritis in the US: evidence from national survey data. Arthritis Rheum. 2009;60:3546-3553.
Wallace IJ, Worthington S, Felson DT, et al. Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proc Natl Acad Sci U S A. 2017;114:9332-9336.
Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician. 2003;68:917-922.
Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, et al. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016;59:134-138.
Aletaha D, Neogi T, Silman AJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2010;69:1580-1588.
Chaisson CE, Gale DR, Gale E, Kazis L, Skinner K, Felson DT. Detecting radiographic knee osteoarthritis: what combination of views is optimal? Rheumatology (Oxford). 2000;39:1218-1221.
McAlindon TE, Snow S, Cooper C, Dieppe PA. Radiographic patterns of osteoarthritis of the knee joint in the community: the importance of the patellofemoral joint. Ann Rheum Dis. 1992;51:844-849.
Duddy J, Kirwan JR, Szebenyi B, Clarke S, Granell R, et al. A comparison of the semiflexed (MTP) view with the standing extended view (SEV) in the radiographic assessment of knee osteoarthritis in a busy routine X-ray department. Rheumatology (Oxford). 2005;44:349-351.
Boegard T, Rudling O, Petersson IF, Jonsson K. Correlation between radiographically diagnosed osteophytes and magnetic resonance detected cartilage defects in the tibiofemoral joint. Ann Rheum Dis. 1998;57:401-407.
Javaid MK, Kiran A, Guermazi A, et al. Individual magnetic resonance imaging and radiographic features of knee osteoarthritis in subjects with unilateral knee pain: the health, aging, and body composition study. Arthritis Rheum. 2012;64:3246-3255.
Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64:465-474.
Jordan KM, Arden NK, Doherty M, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62:1145-1155.
McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22:363-388.
Ong CK, Lirk P, Tan CH, et al. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med Res. 2007;5:19-34.
Bruyere O, Cooper C, Pelletier JP, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum. 2014;44:253-263.
Biederman RE. Pharmacology in rehabilitation: nonsteroidal anti-inflammatory agents. J Orthop Sports Phys Ther. 2005;35:356-367.
Bruno R, Iliadis A, Jullien I, et al. Naproxen kinetics in synovial fluid of patients with osteoarthritis. Br J Clin Pharmacol. 1988;26:41-44.
US Food and Drug Administration. Naprelan Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020353s031s032lbl.pdf. Accessed March 13, 2019.
FDA Acetaminophen Dosage Announcement. https://www.medicaid.nv.gov/Downloads/provider/web_announcement_468_20120425.pdf. Accessed March 13, 2019.
US Food and Drug Administration. FDA Drug Safety Communication: Prescription Acetaminophen Products to be Limited to 325 mg Per Dosage Unit; Boxed Warning Will Highlight Potential for Severe Liver Failure. https://www.fda.gov/Drugs/DrugSafety/ucm239821.htm. Accessed March 12, 2019.
American Association of Hip and Knee Surgeons. American Association of Hip and Knee Surgeons Position Statement on Opioid Use for the Treatment of Osteoarthritis of the Hip and Knee. http://www.aahks.org/position-statements/opioid-use-for-the-treatment-of-osteoarthritis-of-the-hip-and-knee/. Accessed March 11, 2019.
Ayhan E, Kesmezacar H, Akgun I. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop. 2014;5:351-361.
Hepper CT, Halvorson JJ, Duncan ST, et al. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies. J Am Acad Orthop Surg. 2009;17:638-646.
Bannuru RR, Natov NS, Obadan IE, et al. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Rheum. 2009;61:1704-1711.
Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48:370-377.
Jones A, Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response. Ann Rheum Dis. 1996;55:829-832.
Frank E, Hung H-H, Krishnan Y, et al. Dose-Dependent Chondroprotective Effects of Triamcinolone Acetonide on Inflamed and Injured Cartilage Using an In Vitro Model. Austin, TX: Orthopaedic Research Society; 2019..
Sakellariou G, Conaghan PG, Zhang W, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017;76:1484-1494.
Fukui N, Yamane S, Ishida S, et al. Relationship between radiographic changes and symptoms or physical examination findings in subjects with symptomatic medial knee osteoarthritis: a three-year prospective study. BMC Musculoskeletal Disorders. 2010;11:269.
Neogi T, Felson D, Niu J, et al. Association between radiographic features of knee osteoarthritis and pain: results from two cohort studies. BMJ. 2009;339:b2844.
Heidari B. Knee osteoarthritis diagnosis, treatment and associated factors of progression: part II. Caspian J Intern Med. 2011;2:249-255.
Bellamy N, Campbell J, Robinson V, et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006:CD005328.
Bodick N, Williamson T, Strand V, et al. Local effects following single and repeat intra-articular injections of triamcinolone acetonide extended-release: Results from three nonclinical toxicity studies in dogs. Rheumatol Ther. 2018;5:475-498.
Kraus VB, Conaghan PG, Aazami HA, et al. Synovial and systemic pharmacokinetics (PK) of triamcinolone acetonide (TA) following intra-articular (IA) injection of an extended-release microsphere-based formulation (FX006) or standard crystalline suspension in patients with knee osteoarthritis (OA). Osteoarthritis Cartilage. 2018;26:34-42.
US Food and Drug Administration. Drug Approval Package: ZILRETTA (triamcinolone acetonide). https://www.accessdata.fda.gov/drugsatfda_docs/nda/2017/208845Orig1s000TOC.cfm. Accessed March 13, 2019.
Conaghan PG, Hunter DJ, Cohen SB, et al. Effects of a single intra-articular injection of a microsphere formulation of triamcinolone acetonide on knee osteoarthritis pain: A double-blinded, randomized, placebo-controlled, multinational study. J Bone Joint Surg Am. 2018;100:666-677.
Spitzer AI, Richmond JC, Kraus VB, et al. Safety and efficacy of repeat administration of triamcinolone acetonide extended-release in osteoarthritis of the knee: A phase 3b, open-label study. Rheumatol Ther. 2019.
Pham PC, Khaing K, Sievers TM, et al. 2017 update on pain management in patients with chronic kidney disease. Clin Kidney J. 2017;10:688-697.
Bodick N, Lufkin J, Willwerth C, et al. An intra-articular, extended-release formulation of triamcinolone acetonide prolongs and amplifies analgesic effect in patients with osteoarthritis of the knee: a randomized clinical trial. J Bone Joint Surg Am. 2015;97:877-888.
Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ. 1993;307:1329-1330.
Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interv Aging. 2012;7:89-95.
Maricar N, Parkes MJ, Callaghan MJ, et al. Where and how to inject the knee--a systematic review. Semin Arthritis Rheum. 2013;43:195-203.

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Faculty

John C. Richmond, MD

Professor of Orthopedic Surgery
New England Baptist Hospital
Tufts University School of Medicine
Boston, Massachusetts

Disclosures

Disclosure: John C. Richmond, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Flexion Therapeutics; Histogenics
Served as a speaker or a member of a speakers bureau for: Flexion Therapeutics

Editors

Pakinam Aboulsaoud, PharmD

Medical Education Director, Medscape, LLC

Disclosures

Disclosure: Pakinam Aboulsaoud, PharmD, has disclosed no relevant financial relationships.

Megan Whitney, DMD

Medical Writer

Disclosures

Disclosure: Megan Whitney, DMD, has disclosed the following relevant financial relationships:
Medical writing for Conformis, Inc.

CME Reviewer

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

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Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

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This activity has been peer reviewed and the reviewer has disclosed the following relevant financial relationships:
Received grants for educational activities from: Medacta
Owns stock, stock options, or bonds from: Risalto Healthcare
Served as an advisor or consultant for: Medacta

CME

Clinical Challenges in the Diagnosis and Management of Knee Osteoarthritis

Authors: John C. Richmond, MD
CME Released: 4/26/2019
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 4/26/2020, 11:59 PM EST

Start Activity

Target Audience and Goal Statement

This activity is intended for orthopedists and orthopedic surgeons, rheumatologists, and primary care physicians.

The goal of this activity is to improve physicians' knowledge of assessing patients and selecting a treatment for the management of knee OA, as well as selecting patients appropriate for intra-articular steroid treatment of knee OA.

Upon completion of this activity, participants will:

Have greater competence related to
- Selecting patients appropriate for intra-articular steroid treatment of knee OA
- Assessing patients for knee OA
- Selecting a treatment for the management of knee OA

Disclosures

Faculty

John C. Richmond, MD

Professor of Orthopedic Surgery
New England Baptist Hospital
Tufts University School of Medicine
Boston, Massachusetts

Disclosures

Disclosure: John C. Richmond, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Flexion Therapeutics; Histogenics
Served as a speaker or a member of a speakers bureau for: Flexion Therapeutics

Editors

Pakinam Aboulsaoud, PharmD

Medical Education Director, Medscape, LLC

Disclosures

Disclosure: Pakinam Aboulsaoud, PharmD, has disclosed no relevant financial relationships.

Megan Whitney, DMD

Medical Writer

Disclosures

Disclosure: Megan Whitney, DMD, has disclosed the following relevant financial relationships:
Medical writing for Conformis, Inc.

CME Reviewer

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Peer Reviewer

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From Medscape Education Orthopaedics

CME

Clinical Challenges in the Diagnosis and Management of Knee Osteoarthritis

Authors: John C. Richmond, MDFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME Released: 4/26/2019

Valid for credit through: 4/26/2020, 11:59 PM EST

processing....

The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

Case 1: Patient History

Michael is a 52-year-old accountant with an active lifestyle. Until recently, he played tennis 3 days per week. He reports pain in his left knee when climbing stairs and playing tennis. He recalls that he injured his knee 2 years ago and his primary care physician (PCP) "took an x-ray and said there were a few bone spurs." His PCP recommended physical therapy (PT) and naproxen sodium, taken as needed. Michael states that PT is helpful, but his pain has increased in the past 3 months and the naproxen is no longer effective.

Table 1. History and Physical Examination Findings

History	Findings
Systemic	No history of systemic disease
Surgical	Appendectomy 1977
Current medications	Naproxen sodium 220 mg as needed for pain; daily multivitamin

Physical Examination	Findings
Vital signs	BP = 122/72 mm Hg; HR = 80 bpm; RR = 16 breaths/min; oral temperature = 36.7°C
Height	183 cm
Weight	82.3 kg
General impression	Well-nourished and hydrated; cognitively intact
Skin	Normal
Head and neck	Normal
Chest and lungs	Normal
Abdomen	Normal
Upper and lower extremities	Normal at rest

BP = blood pressure; HR = heart rate; RR = respiratory rate.

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The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient is intended or should be inferred.

The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on medscape.org. These materials may include therapeutic products that have not been approved by the US Food and Drug Administration, off-label uses of approved products, or data that were presented in abstract form. These data should be considered preliminary until published in a peer review journal. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity. A qualified healthcare professional should be consulted before using any therapeutic product discussed.

References

Faculty and Disclosures

Faculty

John C. Richmond, MD

Editors

Pakinam Aboulsaoud, PharmD

Megan Whitney, DMD

CME Reviewer

Nafeez Zawahir, MD

Peer Reviewer

CME

Clinical Challenges in the Diagnosis and Management of Knee Osteoarthritis

Target Audience and Goal Statement

Disclosures

Faculty

John C. Richmond, MD

Editors

Pakinam Aboulsaoud, PharmD

Megan Whitney, DMD

CME Reviewer

Nafeez Zawahir, MD

Peer Reviewer

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Clinical Challenges in the Diagnosis and Management of Knee Osteoarthritis

Case 1: Patient History

Table 1. History and Physical Examination Findings