Workup for Chronic Bilateral Knee Pain with History of Steroid Joint Injections
The standard workup for a 56-year-old patient with chronic bilateral knee pain and history of steroid joint injections should include radiography of the knees as the initial imaging study, followed by appropriate laboratory tests to rule out inflammatory conditions, and consideration of more advanced imaging based on clinical findings. 1
Initial Evaluation
- Plain radiographs (X-rays) should be the first imaging study performed, including weight-bearing anteroposterior, lateral, and patellofemoral views to assess for osteoarthritis severity, joint space narrowing, osteophytes, and other structural abnormalities 1
- Comprehensive pain assessment including location, quality, severity (using a 0-10 scale), duration, and exacerbating/alleviating factors 1
- Functional assessment to determine limitations in activities of daily living and instrumental activities 1
- Physical examination focusing on:
- Joint effusion, warmth, erythema (signs of inflammation)
- Range of motion limitations
- Crepitus
- Joint stability testing
- Specific provocation tests (e.g., McMurray's test for meniscal pathology) 1
Laboratory Testing
- Inflammatory markers: ESR and CRP to assess for inflammatory component, particularly important given history of steroid injections 1
- Consider autoimmune panel if inflammatory arthritis is suspected based on clinical presentation (morning stiffness >30 minutes, multiple joint involvement) 1
- Synovial fluid analysis via joint aspiration if effusion is present to rule out infection, crystal arthropathy, or inflammatory arthritis 1
Advanced Imaging
MRI without contrast is indicated when:
- Radiographs are normal or show minimal changes despite significant symptoms
- Suspicion of meniscal pathology, ligamentous injury, or cartilage damage
- History of prior patellar dislocation or instability
- Need to evaluate extent of cartilage damage 1
Ultrasound may be useful to:
- Detect synovial pathology, effusions, and cortical erosive changes
- Evaluate for meniscal extrusion
- Guide joint aspiration or injection if needed 1
CT scan without contrast may be considered if:
- Patellofemoral issues are suspected
- Evaluation of prior osseous injury is needed 1
Special Considerations for Patients with History of Steroid Injections
Document injection history: frequency, timing, duration of relief, and any adverse effects 1
Assess for possible steroid-related complications:
Evaluate for possible infection: particularly important in patients with history of intra-articular injections, check for fever, severe pain, warmth, erythema 1
Treatment Response Assessment
- Document response to previous treatments including steroid injections, NSAIDs, physical therapy, and other interventions 1
- Assess pain relief duration after previous steroid injections to determine efficacy 3
- Consider alternative diagnoses if poor response to appropriate treatments 1
Additional Considerations
- Rule out referred pain from hip pathology (consider hip radiograph if clinical suspicion exists) 1
- Evaluate for mechanical symptoms such as locking, catching, or giving way that might indicate meniscal pathology or loose bodies 1
- Consider bone scan only if there is concern for occult fracture, infection, or complex regional pain syndrome that cannot be diagnosed by other means 1
Common Pitfalls to Avoid
- Overreliance on imaging findings: Radiographic severity often does not correlate with pain severity, especially in bilateral disease 1
- Repeated steroid injections without adequate evaluation: Recent evidence suggests increased risk of requiring knee arthroplasty with multiple corticosteroid injections 2
- Failure to consider non-knee sources of pain: Hip pathology or spine issues can refer pain to the knee 1
- Inadequate assessment of inflammatory versus mechanical pain patterns: This distinction helps guide appropriate treatment 1