MKSAP 12 Rheumatology Board Review Cases

1
MKSAP-12 RHEUMATOLOGY BOARD REVIEW INSTRUCTIONS

• The MKSAP-12 Board Review for Rheumatology
  includes
• a printed copy of 70 case presentations and
  questions, entitled MKSAP-12 Rheumatology page
  57-75, available from the Olive View-UCLA Medical
  Center Department of Medicine or Library AND
• this Powerpoint presentation by Dr. Philip
  Clements and Dr. Andrew Wong, which supplements
  the MKSAP-12 Rheumatology question and answer
  section, page 103-128.
• Open the powerpoint file (double click). The
  opening screen will show the menu bar on top.
  Select SLIDE SHOW on the menu bar, then choose
  the first command View Show (one click).
• To advance, use your left mouse button, or your
  DOWN arrow key. To go back, use your UP arrow
  key.
• To QUIT the presentation, hit ESC (escape).
  You will return to the opening screen, then hit
  Exit to quit Powerpoint. You will then return to
  the website.

2
Case 1

• Radiologic hallmarks of OA
• Joint space narrowing
• Osteophytes
• Subchondral bony sclerosis
• Subchondral cysts
• PE shows marked loss of motion (cannot fully
  extend hip by 30o 10o total rotation)
• Joint replacement is indicated when all other
  measures no longer control pain.
• Often it is pain at night that convinces the
  patient to have surgery.

3
Case 2

• Bimodal distribution of deaths in SLE
• Early SLE complications and infection
• Late Accelerated atherosclerotic CV disease
• Pertinent findings or lack of them
• Substernal chest pain in 39 y/o F with SLE
• Pain not positional nor pleuritic
• Lack of antiphospholipid antibodies
• T-wave changes

4
Case 3

• Sjogrens is an autoimmune inflammatory disease
  which destroys the exocrine glands (eyes, mouth,
  bronchial, vaginal).
• It is associated with multiple autoantibodies
• ANA 80
• Rheumatoid factor 90
• SSA / SSB 60-70
• Elevated Ig levels 80
• Elevated sed rate 80-90

5
Parotid gland biopsy
Inflammatory lymphocytes
Damaged gland
6
Case 4

• Sudden onset of low back pain after activity
  pain radiating down right leg. Straight leg
  raising positive (raising leg makes pain go down
  the leg). Neuro intact.
• Dx most likely acute low back (disc) or facet
  joint strain with radicular pain.
• Rx Pain meds, corset (maybe), encourage activity
  as tolerated.
• Imaging has high false positive rate.
• Image if suspect CA, osteoporotic fracture

7
Case 5

• Suspect limited Wegeners (a chronic
  granulomatous vasculitis), which can present as
  an inflammatory process of larynx (producing
  subglottic stenosis), ears and/or eyes.
• Chances of finding Wegeners (granulomatous
  vasculitis) by tissue bx
• Upper airway bx may show inflammation, necrosis,
  granulomasrarely vasculitis.
• Renal bx focal GN, no Ig depositis
  (pauci-immune)
• Open lung granulomatous inflammation AND
  vasculitis
• ANCA (esp Proteinase 3) strongly supports
  Wegeners
• Other rheum serologies negative (ANA, RF, SSA,
  SSB)

8
Case 6

• L/S spine degenerative disease can affect the
  disc and facet joints.
• Painful syndromes can occur in soft tissues
  downstream, in a Christmas-like affect
  (paraspinal muscles, troch bursa, ant thighs)

9
Case 7

• Hip pain often refers to groin, buttock and
  anterior thigh ( L3, L4).
• Acute or subacute hip pain in SLE patients on
  steroids should suggest possibility of AVN.
• MRI diagnostic procedure of choice for AVN.
• Disease process
• Ischemia infarcts medullary bone .
• Cartilage and thin layer of bone fed by synovial
  fluid.
• Dead bone and cartilage eventually collapse.
• Then OA takes over.

10
AVN
Early
Late
11
Case 8Enteropathic arthropathies

• Inflammatory bowel disease
• Enterogenic reactive arthritis
• Whipples
• Celiac disease
• Intestinal bypass surgery

12
Case 8Celiac disease

• Arthralgias/arthritis occur in 28 of Celiac pts.
• Patterns of arthritis
• Polyarthritis
• Oligoarthritis
• Spondylitis
• Onset of arthritis may precede or follow GI Sxs
• A gluten-free diet reverses the arthritis.

13
Case 9

• Hypertrophic pulmonary osteoarthropathy
• Diffuse bilateral upper and lower extremity pain
• COPD in older smoker
• Clubbing
• Tender, painful distal ulna and radius, tibia
• Non-inflammatory joint fluid
• High sed rate
• Look for lung CA with chest x-ray.
• Document HPO with radioactive bone scan or
  periosteal elevation in long bone x-rays.

14
HPO
15
Case 10

• Inflammatory polyarthritis of short duration
  think viral illness.
• Characteristics of Parvovirus B19 infection
• Women who care for sick children
• Transient generalized rash can occur
• Usually small joint swelling, and pain is usually
  symmetrical
• Arthritis usually resolves in 2-4 weeks
• IgM parvovirus titers positive
• Occasionally RF and ANA may be positive
  evanescently
• Non-erosive arthritis

16
Parvovirus hands
17
Case 11

• CPPD secondary to hemochromatosis
• OA like changes in MCPs unusual in OAusually
  means CPPD
• OA changes in knee may be from CPPDsupported by
  chondrocalcinosis (cartilage calcifications) of
  menisci
• Liver biopsy to assess iron load in
  hemochromatosis.
• Treating hemochromatosis changes patients
  livesdoesnt help the joint disease.

18
CPPD
OA-like changes of MCP joints
Chondrocalcinosis
19
Case 12

• Polyarthritis, diarrhea, pleuritic chest pain and
  weight loss (from malabsorption) in middle-aged
  maleconsider Whipples in Diff Dx.
• Small intestine biopsy looking for PCR sequence
  of Tropheryma whippelii, which is essential to
  making the diagnosis.
• Lymph node biopsy looking for PAS-positive
  macrophages supports Dx.

20
Case 13

• Amyloid (?2-microglobulin) suggested by
• 13 years of ESRD on hemodialysis (50 p 13 yrs).
• Numbness tingling in thumb and index finger
  suggests CTS (median nerve distribution).
• Pain on motion and LOM of shoulders.
• Treatment of choicerenal transplant and get off
  hemodialysis.

21
Case 14

• Antiphospholipid syndrome suggested by
• Blood clots
• 2 or more miscarriages or abortions (esp 1st
  trimester)
• 2 or 3 of these lab abnormalities for APS
• Anticardiolipin Abs (IgG or IgM)
• Lupus anticoagulant (DRVVT)
• ?2-glycoprotein
• This patient had no lab abnormalities of APS and
  only one miscarriage

22
Case 15

• Young male with 2 DVTs (17 y/o and now at 24
  y/o).
• Family history of DVTs.
• Most frequent inherited cause of DVT in white pts
  is Factor V Leiden deficiency.
• Work up for APS and other inherited causes of
  hypercoaguability (i.e., deficiencies of protein
  C or S and antithrombin 3).

23
Case 16

• Pt had some improvement, but is still weak and
  has high CPKs while on high doses of steroidsnot
  adequately controlled. As such at high-risk of
  steroid AEs.
• Add DMARD
• Methotrexate most widely use
• RCT showed benefit from Imuran (azathioprine)

24
Case 17

• Amyotrophic dermatomyositis (skin rash without
  muscle weakness).
• Without muscle weakness there is no
  myositisparaphase from Carl Pearson, MD
• Dermatomyositis in older person (gt60 y/o) may
  mean cancercheck the usual suspects (breast,
  cervix, ovaries, chest)

25
DM rashes
26
Case 18

• Henoch-Schonlein purpura (HSP)
• Antecedent viral infection (esp URI)
• Arthralgias and/or arthritis
• Abdominal pain frequent
• Palpable purpura, esp lower extremities
  (leukocytoclastic vasculitis and IgA deposits on
  punch biopsy)
• Some renal involvement (esp GN) commonIgA
  positive immunofluroescence on biopsy
• Usually treat conservatively.
• Severe GI or renal involvement may require
  steroids.

27
HSP purpura
28
Case 19Polymyalgia rheumatic

• Shoulder and pelvic girdle pain/stiffness, esp AM
• Fatigue, anorexia, mild weight loss
• Occasionally mild synovitis
• Mild anemia
• Over 55 years old
• Sed rate usually elevatedoccasionally not by
  much
• Increased alkaline phosphatase in 1/3 of patients
• Dramatic response to therapeutic trial of low
  dose prednisone (20 mg/d), usually within 24-72
  hours.

29
Case 20

• Transverse myelitis of spinal cord in SLE
• Sudden onset of symptoms
• Neurologic deficit of lower extremities with
  urinary and/or fecal incontinence suggest cord
  disease
• Weakness of both legs (subjective and objective)
• Difficulty urinating, fecal incontinence
• Upper and lower motor neuron findings
• Rectal exam shows weak anal sphincter
• MRI most sensitive test for finding edema of the
  spinal cord
• Check for antiphospholipid antibodies

30
Case 21

• This part of the clinical picture suggests
  Reactive Arthritis (AKA Reiters)
• 4 week hx diarrhea
• 3 week hx asymmetric polyarthritis, predominantly
  affecting lower extremities, with enthesopathy
  and skin lesions on bottom of feet.
• The 3 month hx of temp to 101o F, fatigue, 22 lb
  weight loss suggests something in addition.
• Anyone with new onset Reactive Arthritis
  (Reiters) deserves an HIV test.

31
Reiters
32
Anyone with new onset reactive arthritis deserves
and needs to be tested for HIV.
33
Case 22

• 0 1 2 3 4 5 6 5 4 3 2 1 0
• Palindrome It leaves as it came.
• After one or two weeks of arthritic complaints,
  the patient and her/his joints return to their
  previous conditionwithout a trace. The episodes
  recur and leave without a trace.
• Madam, Im Adam (madam im adam)

34
Case 23
35
Hepatitis C associated syndromes

• Vasculitis (essential mixed cryoglobulinemia)
• Digit gangrene
• Nephritis
• Mononeuritis multiplex (foot drop, wrist drop)
• Arthritis
• Inflammatory polyarthritis (clinically can look
  like RA but is usually nonerosive)
• Rheumatoid factor positive

36
Case 24Adult Stills

• High spiking fevers
• Arthralgias, arthritis
• Maculopapular rash
• Lymphadenopathy
• Serositis
• Sore throat (90), cultures negative
• Negative RF and ANA
• Leukocytosis
• Hepatosplenomegaly

37
Case 25

• CPPD
• Short stubby crystal
• Weakly positively birefringent under polarized
  compensated light
• Verboten meds
• Colchicine Q2h is in-humane
• No NSAIDs with renal insuff
• Allopurinol doesnt work here
• Intra-articular steroid best Rx in renal or GI
  disease

Regular light
Polarized
Compensated light
38
Case 26

• Five factors differentiate inflammatory back
  pain
• Onset before 40 y/o
• Insidious onset
• Persistence for at least 3 months
• Associated morning stiffness
• Improvement with exercise
• Only 10-20 of male first-degree relatives who
  inherit B-27 actually develop AS.

39
Lumbar strain

• Mechanical back pain
• Sudden onset (only half remember an inciting
  incident)
• Minimal stiffness
• Hurts more with exercise
• Gets better lying down
• Pain may accentuate with cough or straining
• Motion may be limited but Schober usually OK

40
Case 27

• Chemotherapeutic agents mask the inflammatory
  aspects of hepatitis. Hepatitis may flare when
  pt taken off MTX. Better in NOT to give MTX in
  the face of Hep C.
• HIV pts may convert to full-blown AIDS if given
  MTX. AVOID MTX in HIV potential pts (new
  Reactive Arthritis) until their HIV tests are
  negative.

41
Case 28

• Polymyalgia Rheumatica
• Profound limb girdle stiff
• Anemia
• Elevated sed rate
• Very responsive to 15-20 mg
• prednisone QDRx trial
• Vascular symptoms may indicate concomitant
  temporal arteritis
• Headache
• Jaw claudication
• Visual changes (amaurosis)
• Scalp tenderness
• Cough

42
Case 29

• 1st CMC joint frequent site for OA.
• Tenderness on the joint.
• Crepitus, pain on motion of 1st CMC
• Extensor tendons of thumb not tenderand
  Finkelsteins negative (for de Quervains).

43
Case 30

• Trochanteric bursitis is often a sign of
  something else (hip OA, sore feet, new shoes).
• Patients say hip hurts but point to lateral
  hip.
• Tender lateral femur, about 4-6 inches below
  tuberosity.
• Injection best choicedirect Rx without systemic
  toxicity.

Troch bursa
44
Case 31

• Wait 2 wks after attack to start uricosuric
  agent.
• Benemid is first choice uricosuric agent.
• Allopurinol first choice if
• Creatinine gt2.0 mg/dl
• Tophi
• Urine uric acid gt800mg per 24 hours
• Chemotherapy
• Hx of renal stones
• Allergy to Benemid

45
Case 32
46
Case 32

• By history and exam, his RA has burned out.
  Some patients may reactivate when they become
  more active physically.
• Probably doesnt need 7.5 mg prednisonereduce to
  5 or less mg daily, a dose which preserves bone.
• Pts on long term steroids need prophylactic
  bisphosphonates or calcitonin started when
  steroids are started.

47
Case 33Lupus-like syndrome Drugs implicated

• Common
• Procainamide
• Hydralazine

• Uncommon
• Minocycline
• ?-blockers
• D-penicillamine
• Isoniazid
• Quinidine
• PTU
• Hydantoins
• Trimethodione
• Chlorpromazine

48
Case 34
Peau dorange

• Rule of thumb
• No sclerodactyly
• No Raynauds/nailfold changes
• No ANA
• Equals NO SCLERODERMA!
• Think of some other entity, like eosinophilic
  fasciitis (EF).
• EF usually has high percent eosinophils on WBC
  diff.
• Bx for EF requires open, deep fascial biopsynot
  punch.

49
Case 35

• Diabetic neuroarthropathy
• Affecting intertarsal tarsometatarsall joints
  here.
• Marked destruction and erratic calcifications.

Normal

• In spite of marked erosions, may have little
  pain, unless infected.
• Sensation and proprioception usually impaired.

Diabetic
50
Case 36

• Five factors differentiate inflammatory back pain
  (spondyloarthropathies or SAs)
• Onset before 40 y/o
• Insidious onset
• Persistence for at least 3 months
• Associated morning stiffness
• Improvement with exercise
• NSAIDs are for pain in SAs.
• Patient probably has a spondyloarthropathy
  (undifferentiated) and needs to learn stretching
  exercises and posture training.

51
Case 37

• ELISA testing for Borrelia burgdorferi
  notoriously gives false positive results (3-7
  normals).
• Needs confirmation by Western blot.

• Absence of IgG Ab at 3 years (in pt not Rxd with
  Abx) is against active or ongoing Lyme.
• Pts knee problem probably OARx with
  acetaminophen.

E. Chronicum migrans
52
Case 38

• RCTs have shown Omega-3 fatty acids and high
  salmon/halibut diets to be anti-inflammatory.
• Lose 8 strength per week by immobilizing.
• Temperature in joint increases with applied heat.
• Glucosamine/chondroitin are mildly
  anti-inflammatory and reduce the pain of OA.
  Acupuncture reduces pain, not inflammation.

53
Case 39

• SSc is associated with esophageal hypomotility,
  leading to dysphagia and dyspepsia.
• SSc pt with increasing dysphagia and wt loss
  needs evaluation of esophagus for stricture or
  obstruction (not an UGI).

54
Case 40Remitting, Seronegative Symmetrical
Synovitis with Pitting Edema (RS3PE)

• Usually in older persons.
• Pitting edema of hands.
• Swelling reduces the ability to make a fist.
• May be related to polymyalgia rheumatica.
• Very responsive to prednisone and not to standard
  NSAIDs. Remember to start bisphosphonate or
  calcitonin to prevent bone loss.

55
Case 41

• Patient quotes
• I hurt all over.
• I feel like a truck hit me.
• This fatigue is the worst.
• I dont sleep worth a damn.

d
d
56
Case 42

• The history and physical findings suggest an
  ankle strain, caused by putting her weight down
  on her left foot in a particularly uneven area.
• Adequate exam and evaluation of range of motion
  is hindered by acute swelling.

• Treatment plan
• Follow-up exam
• Apply ice
• Use brace to promote early ambulation

57
Case 43

• Migratory polyarthritis.
• Skin pustules.
• Joint effusions are often inflammatory (wbcgt2.0)
  but usually sterile.

• Culture portals of entry (pharynx, anus,
  urethra). Culture pustule also.
• Discount a sexual history which is negative.

58
Disseminated Gonococcal Infection

• In subjects lt40 years old, GC is the biggest
  cause of joint infection.
• Since STDs tend to occur together, test for
  chlamydia, syphilis and HIV.
• Also Rx blind for chlamydia.
• Dx by clinical suspicion and culturing portals of
  entry (throat, anus and urethra).
• Best culture is directly onto Thayer-Martin
  medium at bedside.

59
Case 44
Ruptured Bakers Cysts
Crescent sign
60
Pseudo-phlebitis of ruptured popliteal (Bakers)
cyst

• Some signs of ruptured cyst may resemble
  phlebitisAbrupt onset of calf swelling,
  tenderness, positive Homans sign.
• Other characteristics of ruptured cyst differ
• Knee effusions common.
• Best lab test is ultrasonographylooking for
  Bakers cyst and/or phlebitis of calf and thigh.
• Best Rx is steroid injection into suprapatellar
  bursa or medial knee jointknee hydraulics will
  pump it into posterior knee.

61
Case 45

• Pulmonary hypertension
• occurs in 30-40 of SSc on echo.
• severe PHT seen in 10.
• often as isolated PHT without significant ILD.
• Isolated PHT occurs predominantly in limited SSc
  of long duration.
• Low DLCO is the clue (often lt50-55 predicted).

Prominent Pulmonary Artery
62
Case 46

• Synovial fluid essential for Rx of acute
  inflammatory synovitis
• Hemarthrosis
• Crystal-induced
• Septic arthritis
• Reactive arthritis
• Traumatic arthritis
• Overuse from traveling
• When INR in Rx range (2-3), it is safe to do
  arthrocentesis.

63
Case 47

• X-ray shows flattening of head and joint
  incongruity later it will show OA.
• 2-5 of alcoholics affected.
• Steroids other major riskespecially in SLE or
  vasculitis.
• If suspect AVN and plain x-ray normal, get
  MRIbest technique for showing early AVN.

64
Case 48

• In the NIH trials, the probability of avoiding
  renal failure at 10-12 years in SLE DPGN was
• 90 with cyclophosphamide treatment
• 60 with azathioprine (this was not significantly
  different than cyclophosphamide
• only 20 with prednisone

65
CTX Rx of SLE DPGN
Short course 6 monthly infusions Long course 6
monthly infusions, followed by quarterly infusions
for 2 more years.
66
Case 49

• Lumbar Stenosis

67
Tip-offs to lumbar stenosis Body maneuvers which
extend the L/S spine narrow the canal (and
compress the nerve roots), while spine flexion
opens the canal).

• Increases symptoms
• Walking (pseudoclaudication)
• Walking down hill
• Leaning backwards
• Lying prone in bed
• Pulses should be intact and ankle-arm index ?
  1.0

• Decreases symptoms
• Sitting still
• Bending forward while walking (shopping cart)
• Walking with cane
• Walking uphill
• Lying supine in bed

68
Case 50

• Cheiroarthropathy
• Sclerodactyly
• No Raynauds
• Capillary loops normal
• ANA negative
• Flexion contractures of fingers give prayer
  sign
• Usually type I Diabetes

69
Diabetes mellitus

• Other MSK complications of diabetes
• Dupuytrens
• Trigger fingers
• Adhesive capsulitis (frozen) of shoulder

70
Case 51

• Enzyme profile in PM
• (with or without SLE)
• CPK 95
• Aldolase most cases
• ALT most cases
• AST most cases
• LDH most cases

71
Case 52

• In RF patient with inflammatory polyarthritis
  of the rheumatoid type (RA-like), check for Hep C
  first.
• If Hep C test is negative, can use MTX.
• Therapeutic progression (first year of RA)-- keep
  adding therapies until RA controlled
• NSAID and/or low dose prednisone.
• Add hydroxychloroquine and/or sulfasalazine.
• Add methotrexate (7.5 to 25 mg weekly) with folic
  acid QD.
• If max doses of MTX dont control, add anti-TNF-?
  inhibitor or leflunomide.

72
Case 53

• Scleroderma ?BP ? Creatinine

Renal Crisis
Until proven otherwise
73
Case 53
74
Case 54

• Two FDA-approved saliva stimulators
• Pilocarpine (Salagen) 5 mg qid
• Cevimeline (Evoxac) 30 mg tid

75
Case 55

• Hypothyroidism
• Carpal tunnel syndrome
• Non-inflammatory synovial fluid
• Elevated CPKs
• Fibromyalgia

Numb areas in CTS
76
Case 56

• Ig proliferative GN
• Proteinuria (gt500 mg/d)
• Often pedal edema
• RBCs and WBCs in RUA
• ANA
• Often anti-dsDNA Ab
• Normal-low C3, C4
• Creatinine nl or up

77
Case 57

• Mild osteoarthritis
• Crepitus OA
• Good exercises
• Walking
• Isometric quad strengthening
• Consider acetaminophen also

Normal knee x-ray
78
Case 58Lupus-like syndrome Drugs implicated

• Common
• Procainamide
• Hydralazine

• Uncommon
• Minocycline
• ?-blockers
• D-penicillamine
• Isoniazid
• Quinidine
• PTU
• Hydantoins
• Trimethodione
• Chlorpromazine

79
Case 59
80
Case 60

• Total protein albumin globulin
• (which in this case is elevated).
• Anemic
• High ESR, CRP, SAA, ?-glob,
• fibrinogen, haptoglobin, etc.
• Dx multiple myeloma
• ESR in female

D
Age 10 2
81
Case 61

• On too much steroid!
• Hydroxychloroquine is good for SLE rash and
  arthritis.
• SLE arthritis is usually NON-erosive.

82
Case 62
83
PolychondritisEpisodic inflammation of hyaline
cartilage

• Ears and/or nose common
• Larynx and tracheal cartilage most
  life-threatening
• Non-erosive arthritis
• Eyes (scleritis)
• Aortic regurgitation
• Panniculitis of skin

84
Case 63

• Antiphospholipid syndrome suggested by
• Blood clots
• 2 or more miscarriages or abortions
• 2 or 3 of these lab abnormalities for APS
• Anticardiolipin Abs (IgG or IgM)moderate to high
  level
• Lupus anticoagulant (DRVVT)
• ?2-glycoprotein
• Lupus anticoagulant cannot be assessed when the
  patient is being treated with heparinwarfarin
  yes.

85
Case 64

• Chondrocalcinosis on x-ray suggests CPPD.
• OA-like changes of 2nd and 3rd MCP suggest CPPD.
• Diff dx of CPPD includes
• Hemochromatosis
• Hyperparathyroidism
• Acromegaly
• Diabetes mellitus
• Rx of 2 diagnoses changes lives
• Hemochomatosis (Fe, transferrin/ IBC, ferritin)
• Hyperparathryoidism (Ca, Ph, PTH)

86
Case 65
87
Case 65

• Reflex Sympathetic Dystrophy (RSD)
• Follows injury (sometimes minor)usually
  extremity.
• Constant dysesthesia, often disproportionate to
  injury.
• Vasomotor changes are frequent
• Early hyperemia and swelling of skin, exquisite
  tenderness
• Late cold, hyperhidrotic skin atrophy of skin
  and muscle contractures osteopenia
• Lab and path studies usually negative.
• Three-phase radioactive bone scan often positive.

88
Case 66
Mitral valve vegetations

• APS often affects veins and arteries.
• TIAs and strokes in SLE are often emoblic from
  valve vegetations.

89
Case 67

• Differential dx of E.Nodosum
• TB, Fungal
• Strept, Yersinia
• Birth control pills, Sulfa
• Behcets, IBD
• Sarcoid

90
Hilar adenopathy
91
Case 68

• FMF characterized by two phenotypes
• Brief attacks of fever, recurring at irregular
  intervals accompanied by peritonitis, arthritis
  or pleuritis.
• Insidious development of systemic AA amyloidosis
  (nephropathy) and renal failure.
• Chronic colchicine treatment prevents both
  clinical attacks and amyloidosis.

92
(No Transcript)
93
Case 69
94
Behcets Syndrome

• Recurrent oral ulcers (3x/yr)
• And 2 of the following
• Recurrent genital ulcers
• Eye lesions
• Skin lesions
• E. nodosum
• Pseudofolliculitis
• Papular pustular lesions
• Acneiform lesions
• Pathergy

95
Case 70

• OA of knee
• Joint space narrowing often occurs first in the
  medial compartment.
• Quad strengthening first line of therapy.
• Acetaminophen first choice for drug therapy.