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Notfall & Hausarztmedizin 2007; 33(4): 204-210
DOI: 10.1055/s-2007-982781
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© Georg Thieme Verlag Stuttgart · New York

Knieschmerzen in der Hausarztpraxis - Epidemiologie, Differenzialdiagnose und Präsentation in der Praxis

Knee pain in GP practice - epidemiology, differential diagnosis and presentation in medical practiceHagen Sandholzer1
  • 1Abteilung Allgemeinmedizin, Universität Leipzig
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Publication History

Publication Date:
29 May 2007 (online)

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Knieschmerzen in der Allgemeinpraxis beruhen zu zwei Drittel aller Fälle auf Muskel-Skelett-Erkrankungen. Für den Hausarzt ist die Diagnostik einfacher als für den Orthopäden oder Chirurgen, da er lediglich abwendbar gefährliche Verläufe heraussieben muss und weder diagnostisch (Röntgen, MRT) noch therapeutisch (Operation) Bandläsionen, Meniskusrisse oder Frakturen weiterversorgen kann. Bei der Untersuchung werden immer beide Knie vergleichend untersucht, orientierend auch die anderen Gelenke. Bei steigendem Alter ist die arterielle Verschlusskrankheit eine immer wichtiger werdende Differenzialdiagnose. Bei Einleitung einer symptomatischen Therapie ist die Ulcusanamnese bedeutsam, sowie Allergien oder sonstige Kontraindikationen gegen Nicht-Steroidale Antirheumatika (NSAR). Bei akuten Beschwerden kommt eine „RICE”-Therapie in Betracht: Ruhigstellung, Kaltkompressen und für 24 Stunden Hochlagerung bei aktivierter Arthrose, daneben medikamentöse Entzündungshemmung. In jüngeren Studien und Meta-Analysen hat sich regelmäßiges Gehtraining als effektiv, kostengünstig und umsetzbar in der Hausarztpraxis erwiesen.

Knee pain in GP patients is mostly due to musculoskeletal disorders and acute injuries. A simple algorithmic approach for the management of knee pain works well. After anamnesis and physical examination have excluded serious pathology such as fractures, menisci and ligamental lesions or infections, the GP should consider the age of the patient. In young patients, who often suffer from functional knee pain, a wait-and-see strategy is advisable. The older the patient, the more likely is arthritic pain. Before initiating symptomatic treatment the GP should consider contraindications for anti-inflammatory drugs such as ulcers, heart failure or renal impairment. In such cases a brief treatment with diclofenac is appropriate. Evidence-based non-pharmacological treatment includes regular physical activity (walking) and surgery in severe cases.

Key words

knee pain - GP - differential diagnosis - RICE therapy - training the patient to walk

Literatur

  • 1 Aggarwal A, Sempowski IP. Hyaluronic acid injections for knee osteoarthritis. Systematic review of the literature.  Can Fam Physician. 2004;  50 249-256
    PubMedSearch in Google Scholar
  • 2 Arrich J, Piribauer F, Mad P. et al. . Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis.  CMAJ. 2005;  172 1039-1043
    CrossrefPubMedSearch in Google Scholar
  • 3 Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis.  BMJ. 2004;  328 869
    CrossrefPubMedSearch in Google Scholar
  • 4 Arzneimittelkommission der Bundesärztekammer: Therapieempfehlungen Degenerative Gelenkerkrankungen.  www.akdae.de/35/index.html
  • 5 Leitlinien Orthopädie/Gonarthrose. AWMF online
  • 6 Battisti WP, Katz NP, Weaver AL. et al. . Pain management in osteoarthritis: a focus on onset of efficacy - a comparison of rofecoxib, celecoxib, acetaminophen, and nabumetone across four clinical trials.  J Pain. 2004;  5 511-520
    CrossrefPubMedSearch in Google Scholar
  • 7 Bellamy N, Campbell J, Robinson V. et al. . Intraarticular corticosteroid for treatment of osteoarthritis of the knee.  Cochrane Database Syst Rev. 2006;  2
    PubMedSearch in Google Scholar
  • 8 Bellamy N, Campbell J, Robinson V. et al. . Intraarticular corticosteroid for treatment of osteoarthritis of the knee.  Cochrane Database Syst Rev. 2005;  2
    PubMedSearch in Google Scholar
  • 9 Bellamy N, Campbell J, Robinson V. et al. . Viscosupplementation for the treatment of osteoarthritis of the knee.  Cochrane Database Syst Rev. 2006;  2
    PubMedSearch in Google Scholar
  • 10 Bellamy N, Campbell J, Robinson V. et al. . Viscosupplementation for the treatment of osteoarthritis of the knee.  Cochrane Database Syst Rev. 2005;  2
    PubMedSearch in Google Scholar
  • 11 Biswal S, Medhi B, Pandhi P. Longterm efficacy of topical nonsteroidal antiinflammatory drugs in knee osteoarthritis: metaanalysis of randomized placebo controlled clinical trials.  J Rheumatol. 2006;  33 1841-1844
    PubMedSearch in Google Scholar
  • 12 Bjordal JM, Ljunggren AE, Klovning A, Slordal L. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials.  BMJ. 2004;  329 1317
    CrossrefPubMedSearch in Google Scholar
  • 13 Clinical evidence - the international source of the best available evidence for effective health care.  www.clinical evidence.com, BMJ
  • 14 Boutron I, Tubach F, Giraudeau B, Ravaud P. Methodological differences in clinical trials evaluating nonpharmacological and pharmacological treatments of hip and knee osteoarthritis.  JAMA. 2003;  290 1062-1070
    CrossrefPubMedSearch in Google Scholar
  • 15 Brand C, Cox S. Systems for implementing best practice for a chronic disease: management of osteoarthritis of the hip and knee.  Intern Med J. 2006;  36 170-179
    CrossrefPubMedSearch in Google Scholar
  • 16 Brosseau L, MacLeay L, Robinson V. et al. . Intensity of exercise for the treatment of osteoarthritis.  Cochrane Database Syst Rev. 2003;  2
    PubMedSearch in Google Scholar
  • 17 Brosseau L, Milne S, Wells G. et al. . Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis.  J Rheumatol. 2004;  31 2251-2264
    PubMedSearch in Google Scholar
  • 18 Brosseau L, Robinson V, Wells G. et al. . Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis.  Cochrane Database Syst Rev. 2005;  4
    PubMedSearch in Google Scholar
  • 19 Brosseau L, Welch V, Wells G. et al. . Low level laser therapy (Classes I, II and III) for treating osteoarthritis.  Cochrane Database Syst Rev. 2004;  3
    PubMedSearch in Google Scholar
  • 20 Brouwer RW, Jakma TS, Bierma-Zeinstra SM. et al. . Osteotomy for treating knee osteoarthritis.  Cochrane Database Syst Rev. 2005;  1
    PubMedSearch in Google Scholar
  • 21 Brouwer RW, Jakma TS, Verhagen AP. et al. . Braces and orthoses for treating osteoarthritis of the knee.  Cochrane Database Syst Rev. 2005;  1
    PubMedSearch in Google Scholar
  • 22 Chevalier X, Marre JP, de J Butler, Hercek A. Questionnaire survey of management and prescription of general practitioners in knee osteoarthritis: a comparison with 2000 EULAR recommendations.  Clin Exp Rheumatol. 2004;  22 205-212
    PubMedSearch in Google Scholar
  • 23 Cochrane T, Davey RC, Matthes SM Edwards. Randomised controlled trial of the cost-effectiveness of water-based therapy for lower limb osteoarthritis.  Health Technol Assess. 2005;  9 1-114
    PubMedSearch in Google Scholar
  • 24 Combe B, Landewe R, Lukas C. et al. . EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).  Ann Rheum Dis. 2007;  66 34-45
    CrossrefPubMedSearch in Google Scholar
  • 25 D'hondt NE, Struijs PA, Kerkhoffs GM. et al. . Orthotic devices for treating patellofemoral pain syndrome.  Cochrane Database Syst Rev. 2002;  2
    PubMedSearch in Google Scholar
  • 26 Ethgen M, Boutron I, Baron G. et al. . Reporting of harm in randomized, controlled trials of nonpharmacologic treatment for rheumatic disease.  Ann Intern Med. 2005;  143 20-25
    PubMedSearch in Google Scholar
  • 27 Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee.  Cochrane Database Syst Rev. 2003;  3
    PubMedSearch in Google Scholar
  • 28 Garner SE, Fidan DD, Frankish R, Maxwell L. Rofecoxib for osteoarthritis.  Cochrane Database Syst Rev. 2005;  1
    PubMedSearch in Google Scholar
  • 29 Godwin M, Dawes M. Intra-articular steroid injections for painful knees. Systematic review with meta-analysis.  Can Fam Physician. 2004;  50 241-248
    PubMedSearch in Google Scholar
  • 30 Gotzsche PC. Do patients with osteoarthritis get the clinical research they need?.  Ann Rheum Dis. 2000;  59 407-408
    CrossrefPubMedSearch in Google Scholar
  • 31 Hubbard TJ, Denegar CR. Does Cryotherapy Improve Outcomes With Soft Tissue Injury?.  J Athl Train. 2004;  39 278-279
    PubMedSearch in Google Scholar
  • 32 Jacobs WC, Clement DJ, Wymenga AB. Retention versus removal of the posterior cruciate ligament in total knee replacement: a systematic literature review within the Cochrane framework.  Acta Orthop. 2005;  76 757-768
    CrossrefPubMedSearch in Google Scholar
  • 33 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
    CrossrefPubMedSearch in Google Scholar
  • 34 Langford R, McKenna F, Ratcliffe S. et al. . Transdermal fentanyl for improvement of pain and functioning in osteoarthritis: a randomized, placebo-controlled trial.  Arthritis Rheum. 2006;  54 1829-1837
    CrossrefPubMedSearch in Google Scholar
  • 35 Lee C, Straus WL, Balshaw R. et al. . A comparison of the efficacy and safety of nonsteroidal antiinflammatory agents versus acetaminophen in the treatment of osteoarthritis: a meta-analysis.  Arthritis Rheum. 2004;  51 746-754
    CrossrefPubMedSearch in Google Scholar
  • 36 Lin J, Zhang W, Jones A, Doherty M. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised controlled trials.  BMJ. 2004;  329 324
    CrossrefPubMedSearch in Google Scholar
  • 37 Lin YC, Davey RC, Cochrane T. Tests for physical function of the elderly with knee and hip osteoarthritis.  Scand J Med Sci Sports. 2001;  11 280-286
    CrossrefPubMedSearch in Google Scholar
  • 38 Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis: a meta-analysis.  JAMA. 2003;  290 3115-3121
    CrossrefPubMedSearch in Google Scholar
  • 39 Mason L, Moore RA, Edwards JE, Derry S, McQuay HJ. Topical NSAIDs for acute pain: a meta-analysis.  BMC Fam Pract. 2004;  5 10
    CrossrefPubMedSearch in Google Scholar
  • 40 Mason L, Moore RA, Edwards JE. et al. . Topical NSAIDs for chronic musculoskeletal pain: systematic review and meta-analysis.  BMC Musculoskelet Disord. 2004;  5 28
    CrossrefPubMedSearch in Google Scholar
  • 41 Modawal A, Ferrer M, Choi HK, Castle JA. Hyaluronic acid injections relieve knee pain.  J Fam Pract. 2005;  54 758-767
    PubMedSearch in Google Scholar
  • 42 Ofman JJ, MacLean CH, Straus WL. et al. . A metaanalysis of severe upper gastrointestinal complications of nonsteroidal antiinflammatory drugs.  J Rheumatol. 2002;  29 804-812
    PubMedSearch in Google Scholar
  • 43 Osiri M, Welch V, Brosseau L. et al. . Transcutaneous electrical nerve stimulation for knee osteoarthritis.  Cochrane Database Syst Rev. 2000;  4
    PubMedSearch in Google Scholar
  • 44 Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain.  Phys Ther. 2001;  81 1675-1700
    PubMedSearch in Google Scholar
  • 45 Poolsup N, Suthisisang C, Channark P, Kittikulsuth W. Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials.  Ann Pharmacother. 2005;  39 1080-1087
    PubMedSearch in Google Scholar
  • 46 Reilly KA, Barker KL, Shamley D. A systematic review of lateral wedge orthotics - how useful are they in the management of medial compartment osteoarthritis?.  Knee. 2006;  13 177-183
    CrossrefPubMedSearch in Google Scholar
  • 47 Rendenbach U, Lipp Th. Knieschmerzen.  In: Sandholzer H. Praxistrainer Allgemeinmedizin.  Stuttgart: Schattauer. 2007;  157
    PubMedSearch in Google Scholar
  • 48 Richy F, Bruyere O, Ethgen O. et al. . Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis.  Arch Intern Med. 2003;  163 1514-1522
    CrossrefPubMedSearch in Google Scholar
  • 49 Rintelen B, Neumann K, Leeb BF. A meta-analysis of controlled clinical studies with diacerein in the treatment of osteoarthritis.  Arch Intern Med. 2006;  166 1899-1906
    CrossrefPubMedSearch in Google Scholar
  • 50 Roddy E, Zhang W, Doherty M. et al. . Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee - the MOVE consensus.  Rheumatology (Oxford). 2005;  44 67-73
    CrossrefPubMedSearch in Google Scholar
  • 51 Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review.  Ann Rheum Dis. 2005;  64 544-548
    CrossrefPubMedSearch in Google Scholar
  • 52 Sandholzer. Orthopädischer Untersuchungskurs-Skipt. Unpubl. Leipzig 2005
    Search in Google Scholar
  • 53 Superio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment.  Arthritis Care Res. 1996;  9 292-301
    CrossrefPubMedSearch in Google Scholar
  • 54 Towheed TE, Hochberg MC. A systematic review of randomized controlled trials of pharmacological therapy in osteoarthritis of the hip.  J Rheumatol. 1997;  24 349-357
    PubMedSearch in Google Scholar
  • 55 Towheed TE, Maxwell L, Anastassiades TP. et al. . Glucosamine therapy for treating osteoarthritis.  Cochrane Database Syst Rev. 2005;  2
    PubMedSearch in Google Scholar
  • 56 Towheed TE, Maxwell L, Judd MG. et al. . Acetaminophen for osteoarthritis.  Cochrane Database Syst Rev. 2006;  1
    PubMedSearch in Google Scholar
  • 57 Tugwell P. Economic evaluation of the management of pain in osteoarthritis.  Drugs. 1996;  52 48-58
    PubMedSearch in Google Scholar
  • 58 Verbrugge LM, Gates DM, Ike RW. Risk factors for disability among U.S. adults with arthritis.  J Clin Epidemiol. 1991;  44 167-182
    PubMedSearch in Google Scholar
  • 59 Vetter NJ, Charny M, Lewis PA, Farrow S. Prevalence and treatment of symptoms of rheumatism and arthritis among over 65 year olds: a community profile.  Br J Gen Pract. 1990;  40 69-71
    PubMedSearch in Google Scholar
  • 60 Vignon E, Valat JP, Rossignol M. et al. . Osteoarthritis of the knee and hip and activity: a systematic international review and synthesis (OASIS).  Joint Bone Spine. 2006;  73 442-455
    CrossrefPubMedSearch in Google Scholar
  • 61 Watson MC, Brookes ST, Kirwan JR, Faulkner A. Non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the knee.  Cochrane Database Syst Rev. 2000;  2
    PubMedSearch in Google Scholar
  • 62 Weaver AL, Messner RP, Storms WW. et al. . Treatment of patients with osteoarthritis with rofecoxib compared with nabumetone.  J Clin Rheumatol. 2006;  12 17-25
    CrossrefPubMedSearch in Google Scholar
  • 63 Wegman A, Windt D van der, Tulder M van. et al. . Nonsteroidal antiinflammatory drugs or acetaminophen for osteoarthritis of the hip or knee? A systematic review of evidence and guidelines.  J Rheumatol. 2004;  31 344-354
    PubMedSearch in Google Scholar
  • 64 Welch V, Brosseau L, Peterson J. et al. . Therapeutic ultrasound for osteoarthritis of the knee.  Cochrane Database Syst Rev. 2001;  3
    PubMedSearch in Google Scholar
  • 65 Zhang W, Doherty M, Bardin T. et al. . EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).  Ann Rheum Dis. 2006;  65 1312-1324
    CrossrefPubMedSearch in Google Scholar

Korrespondenz

Prof. Dr. med. Hagen Sandholzer

Selbstständige Abteilung für Allgemeinmedizin, Universität Leipzig

Philipp-Rosenthal-Straße 55

04103 Leipzig