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Case History 1 – Knee

Robert Long is a 32 year old solicitor who plays football twice per week in his spare time. 10 days ago, while playing football, he was tackled and fell. He continued for 5 minutes, but was unable to continue due to pain and giving way in the left knee when he twisted. He now complains of pain over the medial aspect. He has a lot of swelling over the knee and walks with a limp. His likely diagnosis is that he has sustained a partial tear of the medial meniscus and collateral ligament but the anterior cruciate ligament is OK. He lives with his wife and 2 sons in a 3-bed house and is not currently taking any medication other than anti-inflammatories.



PMC (Present Medical Condition);
• Robert long was playing football when he was tackled and fell over. He continued to play for 5 mins but was unable to continue due to pain and giving way of the left knee when he twisted.
• Complaints of pain on the medial aspect of the left knee
• Swelling over the knee and he now walks with a limp
PMH (Past Medical History); Nil
Drug History; taking anti-inflammatories
Social History; lives with wife and 2 sons in a 3 bedroom house
Possible diagnosis; partial tear of the medial meniscus and collateral ligament.

Collateral ligament;
These ligaments supply stability to your knee for side to side movement and even during normal walking. Injury to these areas usually occurs after a strike from the side such as a football tackle. There are two collateral ligaments in the knee. The medial collateral ligament (MCL) is located on the inside of the knee. It is the most frequently injured collateral ligament. Usually, the mechanism of injury is a blow to the outside of the knee, while the foot is planted firmly on the ground. The good news, however, is that it often can heal on its own, if properly protected with a hinged knee brace. Sometimes, an MCL tear is associated with a tear of the ACL and a meniscus tear. This is known as the "unhappy triad". The lateral collateral ligament (LCL) is located on the outside of the knee. It is much more rarely injured.

Symptoms;
• Pain over the side of the knee joint
• Swelling which can be mild to quite significant
• Knee being unstable

Treatment of collateral ligament tears;
• Cryotherapy
• Pain medicated drugs such as anti-inflammatories
• Physiotherapy
• Braces to support and strengthen the knee
• Surgery ( this is usually a last resort most orthopaedic surgeons agree that tears of the MCL or LCL should first be treated conservatively)

Diagnosis;
• A good history and physical examination will usually be enough to make a diagnosis. However, x-rays and MRI scans may be carried out to confirm diagnosis.

Medial meniscus tears;
The medial meniscus on the inside of your knee rests between the femur and the tibia. It is made up of tough cartilage and conforms to the surfaces of the bones upon which they rest. Together with the lateral meniscus. The meniscus function to distribute your body weight across the knee joint and improve stability of the knee joint. The two most common causes of tears in the meniscus are traumatic injury (most commonly seen in athletes) and degenerative processes. The most common mechanism of a traumatic meniscus tear occurs when the knee joint is bent and the knee is then twisted.

Symptoms of meniscus tears;
• Knee pain
• Swelling of the knee
• Tenderness when pressing on meniscus
• Popping or clicking within the knee
• Limited motion of the knee

Treatment;
• Cryotherapy
• Injections of cortisone (type of steroid)
• Surgery (meniscal repair or meniscectomy)

Diagnosis;

• A good history and physical examination will usually be enough to make a diagnosis. However, x-rays and MRI scans may be carried out to confirm diagnosis. An x-ray can be used to determine if there is evidence of degenerative or arthritic changes to the knee joint. The MRI is helpful at actually visualising the meniscus. However, simply ‘seeing’ a torn meniscus on MRI does not mean a specific treatment is needed. Many people can live with meniscus tears. It is only when the meniscus tear becomes symptomatic and interferes with activities that surgery to treat the meniscus tear should be considered.


What would you be expecting to get from subjective assessment;
• How the injury happened- from a traumatic injury occurring from the side i.e. tackle in football as stated in the case study
• Pain gets worse during any type of activity but eases with rest
• Some difficulty in walking - the knee feels like it is going to ‘give out’

Objective assessment;
Looking for any swelling, bruising, deformity or posture
Check ROM at knee joint expecting some limitation
ROM that occurs at the knee joint is;
 Flexion
 Extension
These may be checked with active, passive or resisted tests.

Special tests;
• McMurray Test; patient supine with test knee completely flexed. To test the medial meniscus, laterally rotate knee and passively extend to 90 degrees while palpating joint line. To test the laterally meniscus, repeat test with the knee in medial rotation. Positive sign; a snap or click.
• Apley's Test; patient prone with knee flexed to 90 degrees. Medially and laterally rotate tibia- first with distraction and then compression. Positive sign; pain
• Anterior drawer test; patient supine with hips flexed to 45 degrees and knees flexed to 90 degrees. Stabilize foot. Apply posterior force to tibia. Positive sign; tibia moves more than 6mm on the femur
Other Tests; you might want to observe your patient during walking or on the stairs