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Five-minute Practitioner: November

Knee injuries

In an acute anterior cruciate ligament injury there is always an acute injury with a pop, instability, immediate swelling, generalised pain and inability to continue the activity. Knee instability is common particularly when twisting or on rough ground. The pain is felt generally deep within the knee unless a meniscus is also torn.

Acute meniscal injuries commonly present as a squatting, kneeling or twisting injury, localised pain and overnight swelling. Pain is usually located on the medial or lateral aspect of the knee and is exacerbated when twisting, squatting or on stair climbing. Characteristically, patients with meniscal injuries may also have pain when lying on their side at night, commonly they say it is painful when their knees touch together. Age does not exclude the possibility of meniscal injuries for which arthroscopy may be curative.

Patients with anterior knee pain commonly experience pain while going down hills or stairs, sitting for prolonged periods with the knee bent or when driving. The pain is usually relieved by

rest and at night. Often, patients with symptoms of synovial plicae within their knee (a common cause of anterior knee pain) present with episodic painful

clicking or momentary catching in

the knee when descending stairs or jumping.

MRI is an invaluable tool in diagnosing and managing knee problems. However, the costs are considerable. MRI is overly sensitive in demonstrating meniscal tears. Indeed, 50 per cent of active, asymptomatic men of 45 years will have a positive scan for a meniscal tear. Synovial folds or plicae are not well shown on standard MRI. Some other conditions

such as articular cartilage defects or patellar tendonitis are not well demonstrated on conventional MRI,

which may be negative. More »4

Growing pains

A typical picture suggestive of benign growing pains is the child aged between four and eight,

who has an active day and then wakes in the night crying with cramp-like pain, typically affecting both legs, localised in the skin, calf, foot or knee, but not involving the joints. The pains ease in 10 to 20 minutes, the child returns to sleep and wakes the following morning as if nothing has happened. There are no daytime symptoms, no limp and no reduction in the child's functional level.

The frequency of the episodes is widely variable, but they generally resolve over a period of six to 24 months from onset. Even the most prolonged cases have stopped

by 11 years in girls or 13 years in boys.

If any of the following are present, a diagnosis of growing pains should not be made without further investigation: systemic symptoms, night or day; pain during the day, even if caused by activity; limp or restriction of functional level; localising signs – tenderness, swelling, wasting, redness or warmth; reduction in the range of motion at adjacent joints. More »28

Recognising PMR

polymyalgia rheumatica affects the elderly, rarely occurring in those aged 50–59 years, but increasing in each decade over 60 years.

It presents with proximal girdle pain and early morning stiffness, often acutely and usually bilaterally; tenderness may also occur. Power may be restricted by pain, but true weakness is not apparent. Systemic features such as fatigue, fever, loss of appetite and weight loss are common and may be the dominant features.

PMR is linked with giant cell arteritis (GCA), an inflammatory process affecting the temporal and other extracranial arteries. GCA causes headaches, scalp tenderness, jaw claudication, visual symptoms and systemic upset. Around

25 per cent of PMR patients have features of GCA.

An inflammatory response is almost always present, with raised ESR, PV or CRP. A normochromic anaemia and raised alkaline phosphatase are common.

PMR is treated primarily with glucocorticoids. An initial dose of 15mg of prednisolone daily appears effective. Lower doses are associated with relapse, and higher doses with side-effects. There should be around 80 per cent improvement within a few days. More »40

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