Thursday, November 22, 2012

A State Patrolman


I was working in an out-patient medicine clinic when I went into to see my next scheduled patient.  He was a 50ish year old cop who worked for the State Patrol.  As such, he had ended up chasing more than enough suspects through the open fields, as well as in and out of old buildings.  But he loved his work so much he didn’t want to stop doing it, even though he had received several offers over the years for promotion.  Being a street cop was what got his juices going, he told me. 

I knocked on the door, and then opened it to find Stan sitting on the exam table.  I had known Stan for a while, He was always enjoyable to talk to, as he usually told me of his latest escapade catching yet another suspect. 

“Morning, Stan, what brings you in today?”
“My knee.  I think I really did it in this last time chasing a suspect up and down one of the rocky hillsides.”
“Okay, which knee and what day was this?”
“It’s my left knee, and it was three days ago.  My knee hasn’t quit hurting since.”
“Okay, what were you doing, exactly, like did you feel your knee give out on you, or did you fall down on it, what exactly happened?”
“I don’t remember much about my knee that day, I was trying to nab this suspect with the help of another patrolman.  He took off running and before I knew it, he was trying to climb up a rocky incline that had a lot of loose dirt.  I started climbing the rocky incline and my partner took off running up the grassy side of the incline to get to the top of the hill before the suspect.  The suspect didn’t make it up the incline, he kept sliding back down, so I was finally able to nab him and pull him down.  My partner immediately slid down the incline on his butt and grabbed his cuffs to put on the suspect.  We were standing him up as I was reading him his Miranda rights.  It wasn’t until after we got the suspect back in my partner’s patrol car that I started noticing my knee was hurting.”
“Well, you know as well as I do, that you have had a couple of injuries to both knees over the years.  You also played sports as a kid for many, many years.  So you knees are not what they used to be.”
“I know.  I talked to my supervisor yesterday and he re-offered me the permanent desk job I was offered six months ago.  The department still wants me to do it.  I’ll be heading up the drug smuggling operations in the state, which is what I’ve basically been doing out in the field for too many years.  I told him I would do it.  I know my knees can’t handle anymore running, climbing and wrestling suspects out in the field.”
“Good choice, Stan.  Now, let me take a look at that knee.”

His left knee was a little swollen over the medial side (inner side) of his knee, right next to his kneecap.  He did have some increased heat felt there and it was tender to palpation.  There was also a small amount of fluid felt. 
“Stan, I think you have patellar bursitis going on.”
“What’s that?”
“It’s a condition where the bursa, or fluid sac between your knee cap and your knee has become inflamed or swollen.  It therefore hurts to walk.  I’ll start you on some anti-inflammatory medication called motrin and have you take it three times a day for the next two weeks.  I also want you to put either an ice pack or a heating pad on the inside part of your knee here where it hurts.  Then I want to see you back in two weeks.”
“Okay, but why do I need to come back in and see you?”
“Well, take a look at your knees, don’t they look a little like door knobs to you?”
“Yeah, now that you mention it, they do.”
“Well, remember what the orthopedic surgeon told you a few years back when you injured your left knee and he went in and repaired your ACL (anterior cruciate ligament which helps stabilize the knee joint)?”
“Yeah, he said something along the line that I was going to end up with arthritis in my knee before too long because he saw several bony growths in my knee with his scope, which he proceeded to remove.”
“That’s right.  I think in two weeks you’re going to come back in here, the bursa is going to be healed, but you’re still going to be in pain due to the presence of osteoarthritis.  Those ‘knobby knees’ tells me that you now most likely have osteoarthritis, so you took a desk job in time, thank goodness.”
“Oh, brother.  I was hoping that wasn’t going to happen for a while.”
“Well, let’s see how you’re doing in two weeks and take it from there.”
“Okay.”

Risk factors for acquiring osteoarthritis include:
--age (the older you are the more likely you are to have it)
--female sex
--obesity (the more weight your joints carry on the more likely they are to breakdown)
--lack of osteoporosis (the higher the bone density in women, the more likely they were to  have osteoarthritis)
--occupation: those who do a lot of bending, squatting, stair climbing have a higher risk
--previous injury to the joint from playing sports, etc.
--weakness of the quadriceps muscle (the major muscle that goes the length of the upper portion of the leg, on the front side)
--gout:  crystal deposition from gout eventually destroys the cartilage
--gene inheritance

Stan returned in two weeks for his follow-up exam.  His bursitis was almost gone, but I had been right, his knee pain was still present. 
“So, tell me Stan, what’s going on with your knee now?”
“It still hurts, mostly on the inner side of the knee.  I’ve also noticed that it occasionally makes a ‘cracking sound.’”
“Well, the cracking sound is what we call, crepitus.  That’s a sign of osteoarthritis.  Let me take a look at your knee and then we’ll take it from there.”
“Okay.”
Stan had what I thought I would find.  His tests for any lateral or medial (basically side to side) movement which is called a varus and valgus stress tests were negative.  His anterior drawer test was negative (a movement where you try to pull the knee out towards you while it is in a 90 degree angle).  His increased heat I had felt was gone. 
“Stan, the orthopedic surgeon was correct.  You now have osteoarthritis in this knee.  It’s not going to get much better, it’s a chronic condition that typically slowly progresses and some patients end up having to receive a total knee replacement due to their pain and limited mobility.  What I want to do is send you to the physical therapist and let them help you with daily exercises you can do for your knee which will help with all of the pain.  I also want you walking at least 30 minutes a day on it.  If you can find a swimming program, in other words water aerobics class nearby sign up for that.  You don’t need to lose any weight, which most people do, so that doesn’t affect you.  I want you to continue with your daily motrin which will help with your pain.  I’ll see you back in two months after you’re done with the physical therapist, okay?”
“Okay.”

To diagnose osteoarthritis of the knee, the following must be present:
--knee pain (not related to acute trauma)  AND
Within the following scenario: (3 of the following 6 signs must be present):
--age > 50 yrs
--morning stiffness for less than 30 minutes
--crepitus (crunching sound) upon active motion of the knee
--bone tenderness
--bone enlargement (patient generally looks like the have ‘knobby knees’)
--no increased heat felt over the joint

Most patients should have the following done prior to their receiving a diagnosis of osteoarthritis:
--a sed rate (to make sure that the arthritis is not related to any auto-immune disorder)
--rheumatoid factor titers (to rule out any auto-immune disorder)
--withdrawal of some joint synovial fluid (to assess it for any presence of crystal formation which would lead you to believe it is gout)
--x-rays of the patient weight bearing which should show decrease in the cartilage space as well as osteophytes (excess bony growth)

Treatment of osteoarthritis includes:
--weight loss (if the patient is obese)
--exercise program (water aerobics is especially good seeing that it gives buoyancy to the body and helps to support the joint)
--wedged shoe insole
--over the counter medication: glucosamine and chondroitin
--acupuncture

If the above does not deal with the patient’s pain then full dose Tylenol is generally put in the mix (at 3,000 mg a day).  If patients have failed Tylenol then they can be tried on a NSAID (non-steroidal anti-imflammatory drug).  An NSAID can be either motrin (ibuprofen) , naprosyn (aleve),  celebrex or other forms of NSAIDs.

If NSAIDs don’t work then patients can have their knee injected with steroids, which generally gives relief for several weeks up to 3 months.  Narcotics can be used intermittently, if at all.  If the symptoms persist beyond this and the patient has significant functional impairment then they are seen by an orthopedic surgeon for a total knee replacement. 

Stan returned in two months.  His knee felt better, he had stayed with the physical therapy program and was doing daily knee exercises at home.  He was also walking every day after work.  He was glad that he had switched over to the desk job, he noticed his knee wasn’t so swollen and painful due to him resting it at work during the day. 

Due to his age, I could assume, down the road that he would need steroid injections from the orthopedic surgeon and then eventually a knee replacement, He had just done too much damage to it over the years.  But at least the State Patrol now has someone in charge behind his desk who really knows the ins and outs of drug smuggling along the state’s highways and interstates. 

3 comments:

  1. Knee surgery is done to people with advanced osteoarthritis. Physical therapy shows good results and is an alternative to knee replacement.

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  2. Susan you are correct that total knee replacements are not done until the patient has advanced osteoarthritis and is or has become functionally disabled due to it. In reference to my patient I was referring to the fact that he will most likely need a knee replacement (10-20 yrs down the road) due to all of the cartilage damage he had already suffered.
    Physical therapy is a great benefit for patients and a definite help! PT can probably also prolong the life of a natural knee, but I'm not aware of any med literature showing that it is a permanent replacement to TKR. Thanks for your comments. --sharon

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  3. It is good that Stan decided to go back to doing desk work for his health. It is not only because he had a knee replacement surgery due to osteoarthritis but because of his ageing. I think that he has already served well and can do less strenuous work.

    Sienna Christie

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