今日の臨床サポート

中高年者の膝関節痛(診察手順含む)

著者: 眞島任史 日本医科大学付属病院 整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2020/02/14
参考ガイドライン:
  1. 変形性膝関節症の管理に関するOARSI勧告OARSIによるエビデンスに基づくエキスパートコンセンサスガイドライン(日本整形外科学会変形性膝関節症診療ガイドライン策定委員会による適合化終了版)
患者向け説明資料

概要・推奨   

  1. 既存ガイドラインの批判的評価、調査エビデンスの体系的レビュー、および諸専門分野からなる国際的な専門委員会のコンセンサスが得られた見解に基づき、慎重に文言を選んだ25件の推奨事項のうち24件が適合化された。推奨度Aの項目を以下に示す。
  1. OAの至適な管理には、非薬物療法と薬物療法の併用が必要である日本整形外科学会SOR97%[95%CI94~99] 推奨度A)。
  1. すべての膝関節OA患者に対して、治療の目的と生活様式の変更、運動療法、歩調、歩行速度の調整、減量、および損傷した関節への負担を軽減する方法に関する情報を提供し、教育を行う。最初は医療従事者により提供される受動的な治療ではなく、自己管理と患者主体の治療に重点をおき、その後、非薬物療法の積極的な順守を奨励する日本整形外科学会SOR97%[95%CI94~99] 推奨度A)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必 要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が 必要となりま
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
眞島任史 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 定期レビューを行い、概要・推奨を追記した。 

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 日本における膝関節痛の有訴率は15%程度である[1]
  1. 55歳以上の人口の25%は膝痛を持っているという海外の調査もある[2]
  1. 疼痛を有する症候性変形性膝関節症は1000万人に上ると推定されている[3]
  1. 50歳以上の内側半月板の症状を呈する患者の3.4%が特発性膝関節骨壊死であったとの報告がある[4]
  1. 化膿性関節炎や結核性関節炎の頻度は少ないが、診断が遅れると治療に難渋するので必ず否定しなければならない。
  1. 関連痛や動脈病変は見落とされることが多いので、注意を要する。
 
関連画像:
  1. 中高年の膝痛の原因は、主なものに変形性膝関節症、関節リウマチ、化膿性関節炎、結晶沈着性関節炎(痛風、偽通風)、膝関節骨壊死(特発性膝関節顆部骨壊死[5])、結核性関節炎、半月板損傷、関節遊離体、神経病性関節症、脆弱性骨折 、腱・靭帯付着部炎、骨腫瘍、転移性骨腫瘍、閉塞性動脈硬化症、股関節・腰椎疾患による関連痛などがある。
 
変形性膝関節症の分類(Kellgren-Lawrence分類[20]
画像[20])'>

Gradeが進んでいる症例で、ADLの障害が強ければ手術治療を考慮する。
a:Grade 0
b:Grade 1
c:Grade 2
d:Grade 3
e:Grade 4

出典

img1:  著者提供
 
 
 
変形性膝関節症の分類(Kellgren-Lawrence分類[20]
画像[20])'>

Gradeが進んでいる症例で、ADLの障害が強ければ手術治療を考慮する。

出典

img1:  著者提供
 
 
 
関節リウマチの膝の典型的X線写真

変形性関節症は骨増殖性変化が主体で、内側もしくは外側どちらか一方の関節裂隙の狭小化である。関節リウマチは骨萎縮が主体であり、内側・外側両方の関節裂隙が狭小化する。

出典

img1:  著者提供
 
 
 
偽痛風のX線写真

半月板の石灰化を伴うことがある

出典

img1:  著者提供
 
 
 
内側半月板後節の断裂

MRI画像(a)と関節鏡視下縫合術の内視鏡写真(b)。MRI画像の矢印は断裂部位を示す。

出典

img1:  著者提供
 
 
 
  1. 神経病性関節症:図<図表>
  1. 脛骨近位の脆弱性骨折:図<図表>
  1. 骨巨細胞腫:図<図表>
  1. 骨巨細胞腫(Giant Cell Tumor)のCT画像:図<図表>
 
  1. 特発性膝関節骨壊死
  1. 病歴:75歳女性
    誘因なく2週間前から右膝痛出現。強い夜間痛を訴える。
  1. 診察:膝屈曲位で大腿骨内側顆に圧痛を認めた。
  1. 診断のためのテストとその結果:単純X線写真では内側関節裂隙の狭小化を認め軽度の変形性膝関節症である。
  1. 治療:NSAIDsを投与し、MRIの予約を行った。
  1. 転帰:MRIでは大腿骨内側顆の骨壊死であった。足底挿板を装用させ、NSAIDsで保存加療した。
  1. 追記:若く活動性が高ければ高位脛骨骨切り術の適応になる。変形性関節症が強い場合には人工膝関節置換術の適応になる。
 
特発性膝関節骨壊死

a:膝関節単純X線写真正面像。骨壊死ははっきりしない。
b:膝関節単純X線写真側面像
c:上図a, bのMRI前額断。壊死の範囲が明らかである。
d:上図a, bのMRI矢状断。壊死の範囲が明らかである。

出典

img1:  著者提供
 
 
問診・診察のポイント  
問診:
  1. 以下の確認を行う。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

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文献 

著者: H Sakakibara, S K Zhu, M Furuta, T Kondo, M Miyao, S Yamada, T Hideaki
雑誌名: Environ Health Prev Med. 1996 Oct;1(3):114-8. doi: 10.1007/BF02931201.
Abstract/Text Factors associated with knee pain were investigated using 871 self-administered questionnaires (405 men and 466 women) from residents aged over 30 years in a rural area of Japan. The prevalence of knee pain increased with age, particularly in women over 50. It was significantly higher in women than in men. Body mass index (BMI) was significantly related to knee pain in women, though not in men. With reference to occupational factors, frequent heavy lifting on the job was significantly associated with knee pain in both men and women, whereas job-related standing and walking showed no such relationship. As for living conditions, residence on rather steep mountain slopes and the habit of sitting on Japanese tatami mats were significant factors related to knee pain in men, but not in women. There was no association of knee pain with the style of toilet (Japanese or Western). After controlling for all significant factors by multiple logistic regression analysis, age, heavy lifting, and residence on steep slopes were found to be independent factors related to knee pain in men; and age, BMI, and heavy lifting were the factors in women.

PMID 21432433  Environ Health Prev Med. 1996 Oct;1(3):114-8. doi: 10.1・・・
著者: T E McAlindon, C Cooper, J R Kirwan, P A Dieppe
雑誌名: Br J Rheumatol. 1992 Mar;31(3):189-92.
Abstract/Text In order to investigate the strength of any relationship between knee pain and disability, a postal questionnaire was sent to 2102 men and women aged over 55 registered at a general practice in Bristol. A response rate of 80.6% was achieved at second reminder. Knee pain was common particularly in women (27.6% overall). Disability was also more frequently reported in women (P less than 0.05) and rose with increasing age. Respondents with knee pain had significantly more disability relating to upper as well as lower limb activities (P less than 0.05).

PMID 1540789  Br J Rheumatol. 1992 Mar;31(3):189-92.
著者: Shigeyuki Muraki, Toru Akune, Hiroyuki Oka, Yuyu Ishimoto, Keiji Nagata, Munehito Yoshida, Fumiaki Tokimura, Kozo Nakamura, Hiroshi Kawaguchi, Noriko Yoshimura
雑誌名: Arthritis Rheum. 2012 May;64(5):1447-56. doi: 10.1002/art.33508.
Abstract/Text OBJECTIVE: To examine the incidence and progression of radiographic knee osteoarthritis (OA) and the incidence of knee pain, and their risk factors in Japan, using the large-scale population of the nationwide cohort study ROAD (Research on Osteoarthritis/osteoporosis Against Disability).
METHODS: Subjects from the ROAD study who had been recruited in 2005-2007 were followed up with knee radiography 3 years later. A total of 2,262 paired radiographs (74.4% of the original sample) were scored using the Kellgren/Lawrence (K/L) grading system, and the incidence and progression rate of knee OA was examined. The incidence rate of knee pain was also examined. In addition, risk factors were tested for their association with incident and progressive radiographic knee OA and incident knee pain.
RESULTS: Given the ∼3.3-year followup, the rate of incident K/L grade ≥2 radiographic knee OA was 6.9% and 11.9% in men and women, respectively, while that of K/L grade ≥3 knee OA was 8.4% and 13.9% in men and women, respectively. The rate of progressive knee OA was 17.8% and 22.3% in men and women, respectively. The incident rate of knee pain was 21.2% and 27.3% in men and women, respectively. Female sex was a risk factor for incident K/L grade ≥2 knee OA, but was not associated with incident K/L grade ≥3 knee OA or progressive knee OA. Knee pain was a risk factor for incident and progressive knee OA. Previous knee injury was a risk factor for knee pain but not for radiographic knee OA.
CONCLUSION: The present longitudinal study revealed a high incidence of radiographic knee OA in Japan.

Copyright © 2012 by the American College of Rheumatology.
PMID 22135156  Arthritis Rheum. 2012 May;64(5):1447-56. doi: 10.1002/a・・・
著者: Dietrich Pape, Romain Seil, Ekkehard Fritsch, Stefan Rupp, Dieter Kohn
雑誌名: Knee Surg Sports Traumatol Arthrosc. 2002 Jul;10(4):233-40. doi: 10.1007/s00167-002-0285-z. Epub 2002 Apr 9.
Abstract/Text Aseptic osteonecrosis of the medial femoral condyle has recently been reported as a complication of arthroscopic surgery. The time interval between the onset of symptoms and pathognomonic MRI changes (diagnostic window) is not known for osteonecrosis of the knee. To determine the prevalence of early-stage spontaneous osteonecrosis of the knee (SONK) we prospectively examined 176 patients by MRI between May 1998 and December 1999. In six patients MRI revealed a bone marrow edema pattern and subtle subchondral bone changes in the medial condyle consistent with early-stage SONK (prevalence of 3.4%); in the 53 patients older than 65 years the prevalence was 9.4%. In 10 patients (5.7%) the bone and marrow changes on MRI imaging either resolved on follow-up MRI and were regarded as transient epiphyseal lesions or were considered to be reactive changes due to underlying degenerative articular disease. Including MRI in the preoperative diagnostic procedures could avoid missing the diagnosis of avascular necrosis before planning an operative treatment of suspected meniscal tears in elderly patients.

PMID 12172718  Knee Surg Sports Traumatol Arthrosc. 2002 Jul;10(4):233・・・
著者: S Ahlbäck, G C Bauer, W H Bohne
雑誌名: Arthritis Rheum. 1968 Dec;11(6):705-33.
Abstract/Text
PMID 5700639  Arthritis Rheum. 1968 Dec;11(6):705-33.
著者: Rinie Geenen, Cécile L Overman, Robin Christensen, Pernilla Åsenlöf, Susana Capela, Karen L Huisinga, Mai Elin P Husebø, Albère J A Köke, Zoe Paskins, Irene A Pitsillidou, Carine Savel, Judith Austin, Afton L Hassett, Guy Severijns, Michaela Stoffer-Marx, Johan W S Vlaeyen, César Fernández-de-Las-Peñas, Sarah J Ryan, Stefan Bergman
雑誌名: Ann Rheum Dis. 2018 Jun;77(6):797-807. doi: 10.1136/annrheumdis-2017-212662. Epub 2018 May 3.
Abstract/Text Pain is the predominant symptom for people with inflammatory arthritis (IA) and osteoarthritis (OA) mandating the development of evidence-based recommendations for the health professional's approach to pain management. A multidisciplinary task force including professionals and patient representatives conducted a systematic literature review of systematic reviews to evaluate evidence regarding effects on pain of multiple treatment modalities. Overarching principles and recommendations regarding assessment and pain treatment were specified on the basis of reviewed evidence and expert opinion. From 2914 review studies initially identified, 186 met inclusion criteria. The task force emphasised the importance for the health professional to adopt a patient-centred framework within a biopsychosocial perspective, to have sufficient knowledge of IA and OA pathogenesis, and to be able to differentiate localised and generalised pain. Treatment is guided by scientific evidence and the assessment of patient needs, preferences and priorities; pain characteristics; previous and ongoing pain treatments; inflammation and joint damage; and psychological and other pain-related factors. Pain treatment options typically include education complemented by physical activity and exercise, orthotics, psychological and social interventions, sleep hygiene education, weight management, pharmacological and joint-specific treatment options, or interdisciplinary pain management. Effects on pain were most uniformly positive for physical activity and exercise interventions, and for psychological interventions. Effects on pain for educational interventions, orthotics, weight management and multidisciplinary treatment were shown for particular disease groups. Underpinned by available systematic reviews and meta-analyses, these recommendations enable health professionals to provide knowledgeable pain-management support for people with IA and OA.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
PMID 29724726  Ann Rheum Dis. 2018 Jun;77(6):797-807. doi: 10.1136/ann・・・
著者: Kusum Sharma, Aman Sharma, Shiv Kumar Sharma, Ramesh Kumar Sen, Mandeep Singh Dhillon, Meera Sharma
雑誌名: Int Orthop. 2012 Feb;36(2):255-9. doi: 10.1007/s00264-011-1241-7. Epub 2011 Mar 26.
Abstract/Text PURPOSE: Multiplex Polymerase Chain Reaction (MPCR) is a technique in which two or more gene targets are amplified in a single reaction. This has increased sensitivity of diagnosis as a single gene target may be absent in some Mycobacterium tuberculosis strains.
METHODS: MPCR using two target genes specific for Mycobacterium tuberculosis, that is, IS6110 and MPB 64, ZN staining and Mycobacterial culture were performed on synovial fluid/pus samples of 80 (three confirmed, 77 suspected) patients of osteoarticular tuberculosis and 25 non tuberculosis patients.
RESULTS: MPCR had a sensitivity of 100% in confirmed cases and 81.8% in clinically suspected cases. AFB was positive in one patient and Mycobacterial culture was positive in three patients. MPCR also had 100% specificity; MPB64 was positive in five patients in which IS6110 was negative whereas IS6110 was positive in two patients in which MPB64 was negative.
CONCLUSIONS: MPCR is a sensitive and specific method for diagnosis of paucibacilliary conditions such as osteoarticular tuberculosis.

PMID 21442201  Int Orthop. 2012 Feb;36(2):255-9. doi: 10.1007/s00264-0・・・
著者: David S Jevsevar, Peter B Shores, Kyle Mullen, Danielle M Schulte, Gregory A Brown, Deborah S Cummins
雑誌名: J Am Acad Orthop Surg. 2018 May 1;26(9):325-336. doi: 10.5435/JAAOS-D-17-00318.
Abstract/Text INTRODUCTION: Knee osteoarthritis (KOA) is a significant health problem with lifetime risk of development estimated to be 45%. Effective nonsurgical treatments are needed for the management of symptoms.
METHODS: We designed a network meta-analysis to determine clinically relevant effectiveness of nonsteroidal anti-inflammatory drugs, acetaminophen, intra-articular (IA) corticosteroids, IA platelet-rich plasma, and IA hyaluronic acid compared with each other as well as with oral and IA placebos. We used PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to perform a systematic search of KOA treatments with no date limits and last search on October 7, 2015. Article inclusion criteria considered the following: target population, randomized controlled study design, English language, human subjects, treatments and outcomes of interest, ≥30 patients per group, and consistent follow-up. Using the best available evidence, two abstractors independently extracted pain and function data at or near the most common follow-up time.
RESULTS: For pain, all active treatments showed significance over oral placebo, with IA corticosteroids having the largest magnitude of effect and significant difference only over IA placebo. For function, no IA treatments showed significance compared with either placebo, and naproxen was the only treatment showing clinical significance compared with oral placebo. Cumulative probabilities showed naproxen to be the most effective individual treatment, and when combined with IA corticosteroids, it is the most probable to improve pain and function.
DISCUSSION: Naproxen ranked most effective among conservative treatments of KOA and should be considered when treating pain and function because of its relative safety and low cost. The best available evidence was analyzed, but there were instances of inconsistency in the design and duration among articles, potentially affecting uniform data inclusion.

PMID 29688920  J Am Acad Orthop Surg. 2018 May 1;26(9):325-336. doi: 1・・・
著者: D Rhon
雑誌名: Osteoarthritis Cartilage. 2008 Dec;16(12):1585; author reply 1589. doi: 10.1016/j.joca.2008.04.019. Epub 2008 Jun 2.
Abstract/Text
PMID 18515155  Osteoarthritis Cartilage. 2008 Dec;16(12):1585; author ・・・
著者: American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines
雑誌名: Arthritis Rheum. 2002 Feb;46(2):328-46.
Abstract/Text
PMID 11840435  Arthritis Rheum. 2002 Feb;46(2):328-46.
著者: F A van Gaalen, S P Linn-Rasker, W J van Venrooij, B A de Jong, F C Breedveld, C L Verweij, R E M Toes, T W J Huizinga
雑誌名: Arthritis Rheum. 2004 Mar;50(3):709-15. doi: 10.1002/art.20044.
Abstract/Text OBJECTIVE: Rheumatoid arthritis (RA) is a common, severe, chronic inflammatory joint disease. Since the disease may initially be indistinguishable from other forms of arthritis, early diagnosis can be difficult. Autoantibodies seen in RA can be detected years before clinical symptoms develop. In an inception cohort of patients with recent-onset arthritis, we undertook this study to assess the predictive value of RA-specific autoantibodies to cyclic citrullinated peptides (CCPs) in patients with undifferentiated arthritis (UA).
METHODS: Anti-CCP2 antibody tests were performed at baseline in 936 consecutive, newly referred patients with recent-onset arthritis. Patients who could not be properly classified 2 weeks after inclusion were categorized as having UA. Patients with UA were followed up for 3 years and evaluated for progression of their disease to RA as defined by the American College of Rheumatology (ACR) 1987 revised criteria.
RESULTS: Three hundred eighteen of 936 patients with recent-onset arthritis were classified as having UA and were available for analysis. After 3 years of followup, 127 of 318 UA patients (40%) had been classified as having RA. RA had developed in 63 of 249 patients (25%) with a negative anti-CCP test and in 64 of 69 patients (93%) with a positive anti-CCP test (odds ratio 37.8 [95% confidence interval 13.8-111.9]). Multivariate analysis of the presence of anti-CCP antibodies and parameters from the ACR criteria identified polyarthritis, symmetric arthritis, erosions on radiographs, and anti-CCP antibodies as significant predictors of RA.
CONCLUSION: Testing for anti-CCP antibodies in UA allows accurate prediction of a substantial number of patients who will fulfill the ACR criteria for RA.

PMID 15022309  Arthritis Rheum. 2004 Mar;50(3):709-15. doi: 10.1002/ar・・・
著者: S L Wallace, H Robinson, A T Masi, J L Decker, D J McCarty, T F Yü
雑誌名: Arthritis Rheum. 1977 Apr;20(3):895-900.
Abstract/Text The American Rheumatism Association sub-committe on classification criteria for gout analyzed data from more than 700 patients with gout, pseudogout, rheumatoid arthritis, or septic arthritis. Criteria for classifying a patient as having gout were a) the presence of characteristic urate crystals in the joint fluid, and/or b) a topus proved to contain urate crystals by chemical or polarized light microscopic means, and/or c) the presence of six of the twelve clinical, laboratory, and X-ray phenomena listed in Table 5.

PMID 856219  Arthritis Rheum. 1977 Apr;20(3):895-900.
著者: Michael A Mont, David R Marker, Michael G Zywiel, John A Carrino
雑誌名: J Am Acad Orthop Surg. 2011 Aug;19(8):482-94.
Abstract/Text Osteonecrosis (ON) of the knee is a progressive disease that often leads to subchondral collapse and disabling arthritis. Recent studies have identified three distinct pathologic entities, all of which were previously described as knee ON: secondary ON, spontaneous ON of the knee, and postarthroscopic ON. Radiographic and clinical assessment is useful for differentiating these conditions, predicting disease progression, and distinguishing these conditions from other knee pathologies. The etiology, pathology, and pathogenesis of secondary ON of the knee are similar to those found at other sites (eg, hip, shoulder). Spontaneous ON is a disorder of unknown etiology. Postarthroscopic ON has been described as an infrequent but potentially destructive complication. Various treatment modalities (eg, core decompression, bone grafting, high tibial osteotomy, arthroplasty), have been used with varying degrees of success for each type of ON. Secondary ON frequently progresses to end-stage disease, and early surgical intervention is recommended. Initial management of spontaneous ON of the knee and postarthroscopic ON is typically nonsurgical, with observation for clinical or radiographic progression.

PMID 21807916  J Am Acad Orthop Surg. 2011 Aug;19(8):482-94.
著者: P R Krey, D A Bailen
雑誌名: Am J Med. 1979 Sep;67(3):436-42.
Abstract/Text
PMID 474588  Am J Med. 1979 Sep;67(3):436-42.
著者: J H KELLGREN, J S LAWRENCE
雑誌名: Ann Rheum Dis. 1957 Dec;16(4):494-502.
Abstract/Text
PMID 13498604  Ann Rheum Dis. 1957 Dec;16(4):494-502.

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