Duong Vicky, Oo Win Min, Ding Changhai, Culvenor Adam G, Hunter David J
Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
Department of Physical Medicine and Rehabilitation, Mandalay General Hospital, University of Medicine, Mandalay, Mandalay, Myanmar.
JAMA. 2023 Oct 24;330(16):1568-1580. doi: 10.1001/jama.2023.19675.
Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain.
Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise therapy is first-line treatment; surgery is not indicated even in the presence of mechanical symptoms (eg, locking, catching).
Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management.
在成人的所有初级保健就诊中，约5%与膝关节疼痛有关。骨关节炎（OA）、髌股关节疼痛和半月板撕裂是膝关节疼痛最常见的原因。
膝关节OA估计影响全球6.54亿人，是45岁及以上出现与活动相关的膝关节疼痛且晨僵时间不超过30分钟或无晨僵的患者膝关节疼痛最可能的诊断（敏感性95%；特异性69%）。髌股关节疼痛通常影响40岁以下身体活跃的人群，终生患病率约为25%。蹲位时膝前疼痛对髌股关节疼痛的敏感性约为91%，特异性为50%。半月板撕裂估计影响12%的成年人口，可发生在40岁以下人群的急性创伤（如扭伤）后。或者，半月板撕裂可能是40岁及以上膝关节OA患者存在的一种退行性病变。麦克马瑞试验包括同时进行膝关节旋转（分别向内或向外旋转以检查外侧或内侧半月板）和伸展（敏感性61%；特异性84%）以及关节线压痛（敏感性83%；特异性83%）有助于半月板撕裂的诊断。不建议对所有可能患有膝关节OA的患者进行影像学检查。OA的一线治疗包括运动疗法、减重（如果超重）、教育和自我管理项目，以使患者能够更好地管理自身病情。对于终末期OA（即关节间隙消失或极小且无法耐受疼痛）患者，在采用所有适当的保守治疗方法后，可考虑手术转诊进行膝关节置换。对于髌股关节疼痛，建议进行髋部和膝部强化锻炼，并结合足部矫形器或髌骨贴扎，无需手术治疗。大多数半月板撕裂采用保守治疗（运动疗法4 - 6周）也合适。对于严重的创伤性（如桶柄状）撕裂，即半月板组织移位，可能需要手术治疗。对于退行性半月板撕裂，运动疗法是一线治疗方法；即使存在机械症状（如卡顿、交锁）也不建议手术治疗。
膝关节OA、髌股关节疼痛和半月板撕裂是膝关节疼痛的常见原因，可通过临床诊断，且可能导致严重残疾。每种情况的一线治疗包括保守治疗，重点是运动、教育和自我管理。
