a case report - knee

8/12/2019 A Case Report - Knee

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A Case ReportKnee Pain


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History Sometimes she notices some relief with massage and

ice, but mostly the pain is relieved with rest.

The pain bothers her mostly when she walks or

stands for more than 10 minutes at a time. It used tobe 30 minutes but recently she notices the paincoming on more often than it used to. She finds ithard to go up or down stairs.

She is a machinist and has to stand at her job,although recently, she has been given a stool to siton during some of the aspects of her job.


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History She had an MRI and x-rays of her knee when

the injury first occurred.

At that time she was diagnosed with asprained medial collateral ligament and

anterior cruciate ligament. No meniscus tears

were seen on the MRI.


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Provide your Differential Diagnosis Minimum of 2

Examinations for DDx

What examinations would you

perform on your patient?


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About the knee

www.medterms.com/.../art.asp

?articlekey=8857


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About the knee examWhat should we ask the patient?Is there any locking, popping, or giving way of the knee?

A history of locking episodes suggests a meniscal tear.

A sensation of popping at the time of injury suggests ligamentousinjury, probably complete rupture of a ligament. (third-degree tear)

Episodes of giving way are consistent with some degree of knee instability andmay indicate patellar subluxation or ligamentous rupture.

Joint Swelling?

Rapid onset (within two hours) of a large, tense effusion suggests rupture of theanterior cruciate ligament or fracture of the tibial plateau.

Slower onset (24 to 36 hours) of a mild to moderate effusion is consistent withmeniscal injury or ligamentous sprain.

Recurrent knee effusion immediately after activity is consistent with meniscalinjury.


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Examination

(comparing the good knee to the bad knee)Inspection:

The right knee has mild swelling around themedial patella and popliteal fossa.

The musculature of both thighs and legs are

symmetric bilaterally. (VMO)The quadriceps angle (Q angle) is withinnormal limits(A Q angle greater than 15 degrees is apredisposing factor for patellar subluxation).

Palpation:Check for pain, warmth, and effusion.

Point tenderness at the medial knee and in thepopliteal fossa.

No pain on the left knee.

CALMBACH W and HUTCHENS M. Evaluation of

Patients Presenting with Knee Pain: Part I. Am Fam

Physician 2003; 68:907-12. Copyright 2003 American

Academy of Family Physicians.


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Examination Tissues?

Bone

Ligament Meniscus

Muscle


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Examination

Bone:

Fracture? Arthritis?

After the initial trauma, she was evaluated by x-rayand MRI.

No fractures at that time, no trauma since.


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Examination

Muscle:

Muscle testing was normal for both the

quadriceps and biceps famous (5/5)

Meniscus and ligaments:


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Examination

Orthopedics: Patella:

patellar apprehension test, Ballottement Test, Clarke's

Sign (Patellar Scrape test)

Cruciates:

Drawer Test, Lachman's Test

Collaterals:

Varus, Valgus, Apley's Distraction Test

Meniscus:

Apley's Compression Test, Bounce Home Test,

McMurray Sign


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Examination: Patella:

Patellar apprehension test = negative

Ballottement Test = Positive

Clarke's Sign (Patellar Scrape test) = Positive Bilateral

Cruciates: Drawer Test = negative

Collaterals: Varus = negative (no movement or pain at 0 and 30 degrees)

Valgus = no pain with slight movement at o degrees and pain at 30degrees

Apley's Distraction Test = positive for pain at the MCL Meniscus:

Apley's Compression Test = negative

McMurray Sign = negative


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Modified Thomas Test

Tests for flexibility for the ITB, iliopsoas,

Quadriceps

SLR: hamstrings

Our patient had tight hamstrings and ITBs


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What do the test results mean?

Positive tests?

Negative tests?

What else should we test?


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Evidence Based Clinical Evaluation

Koos Knee Survey:

Knee and Osteoarthritis Outcome Score

Symptoms, Pain, ADLs, Sports and recreation, Quality

of life42 QuestionsNever Rarely Sometimes Often Always

(0) (1) (2) (3) (4)

Add it up and divide by 168Her score was 67

VAS was a 5 out of 10


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X-rays


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X-ray report

A mild decrease in joint space involving the medial

compartment. The lateral and retropatellar

compartments are within normal limits.

There is no unusual soft tissue calcification

visualized. The articular surfaces are within normal

limits.

Impressions: Mild reduction of joint space involving themedial compartmentdegenerative joint disease.


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Final Dx

726.61 Pes anserinus tendinitis or

bursitisPes anserinus is the anatomic term used to identify the

insertion of the conjoined tendons into theanteromedial proximal tibia. From anterior to

posterior, pes anserinus is made up of the tendons

of the sartorius (F), gracilis (A), and

semitendinosus (C) muscles. The term literally

means "goose's foot," describing the webbedfootlike structure. The conjoined tendon lies

superficial to the tibial insertion of the medial

collateral ligament (MCL) of the knee.


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pes anserine bursitis The bursa can become inflamed as a result of overuse or a direct contusion. Pes

anserine bursitis can be confused easily with a medial collateral ligament sprain or,less commonly, osteoarthritis of the medial compartment of the knee.

The patient with pes anserine bursitis reports pain at the medial aspect of the knee.This pain may be worsened by repetitive flexion and extension. On physicalexamination, tenderness is present at the medial aspect of the knee, just posteriorand distal to the medial joint line.

No knee joint effusion is present, but there may be slight swelling at the insertionof the medial hamstring muscles. Valgus stress testing in the supine position orresisted knee flexion in the prone position may reproduce the pain. Patient mayreport pain when walking up or down stairs.

CALMBACH W and HUTCHENS M. Evaluation of Patients Presenting with Knee Pain: Part I. Am Fam Physician 2003;68:907-12. Copyright 2003 American Academy of Family Physicians.


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Final Dx:

726.61 Pes anserinus tendinitis or bursitis

739.6 Lower extremities, Nonallopathic

lesions, not elsewhere classified


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Patient Management Plan

3 times per week for 2 weeks followed by 2

times per week for 2 weeks.

To reduce the pain in the right knee (lowering theKOOS score by 20 points)

Allow for mild limitation of ALDs.

Adjust the knee (posterior medial Tibia) Give stabilizing exercises and stretches

Instruct use of supports


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Daily Visits

The patient returned 2 days later with a VAS rating of a 0

No pain in the knee. She was able to go up and down steps

without pain.

She was not using a brace or the tape.She did ice and was stretching.

No adjustment was indicated, she was put on resisted

quadriceps and hamstring exercises.

The patient was told to come back in 1 week or if the pain

came back, which ever came first.


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Daily Visits

She returned a week later with complaints ofright knee pain.

A mild pain started the night before ourappointment due to walking around at hergrandsons baseball game.

Her knee was evaluated and adjusted for a

posterior medial tibia.She was scheduled to return in a week or if the

pain returned.


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Daily Visits

1 week later she returned with no pain.

She was doing the exercises and stretching, but

no longer icingShe was walking 2 miles a day with her husband

for the last 4 days without pain.

Her knee was evaluated and no adjustment wasindicated.

A re-evaluation of the KOOS was taken.


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Patient Management

The patient was released from active care andtold to return in 6 weeks for a follow up visit.

She has continued with chiropractic care forher knee and occasional low back pain for thepast 3 years. She is now see once every 5 to 6months.

She has referred at least 6 patients to theclinic for their knee complaints. She calls usthe knee clinic


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Questions?

Comments?

Concerns?

a case report - knee

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