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B-68
Clinical Case Slide - Knee II
Wednesday, June 1, 2016, 3:15 PM - 5:15 PM
Room: 202
1162
Chair: Daniel C. Herman. University of Florida, Gainesville, FL.
(No relationships reported)
1163
Discussant: Jim Swenson, FACSM. University of Rochester, Penfield, NY.
(No relationships reported)
1164
Discussant: Karl B. Fields. Sports Medicine Center, Greensboro, NC.
(No relationships reported)
1165
June 1, 3:15 PM - 3:35 PM
Recurrent Knee Pain in a Teenage Dancer
Sean C. Engel1, Holly J. Benjamin, FACSM2. 1University of Chicago-NorthShore, Glenview, IL. 2University of Chicago, Chicago, IL. (Sponsor:
Holly Benjamin, FACSM)
(No relationships reported)
HISTORY: A 13 y/o female was pivoting while playing with her friends and felt her right kneecap shift after a noncontact valgus stress. She had pain and swelling shortly after
the injury, but was able to ambulate at that time with a limp. Anterior knee pain was minimal but persistent for several days. Use of a knee sleeve lessened the pain. At her
initial clinic visit 5 days post-injury, she had a large joint effusion. She demonstrated full extension but flexion was limited to 95°. Tenderness was present at the medial patellar
facet and over the retinaculum. Ligamentous and meniscal testing was negative. Radiographs obtained in the ED and clinic demonstrated a chronic appearing well corticated
loose body suggestive of synovial osteochondromatosis. She was given a presumptive diagnosis of patellar subluxation, told to continue with brace use, and referred to
physical therapy. PT gave her an HEP after one visit as her stability, strength, and range of motion were within normal limits. The athlete was lost to follow up for four months,
but presented again to clinic after an instability event left her with a painful, swollen, right knee, with limited ROM and an inability to ambulate without crutches. Further history
revealed that she had been experiencing “shifting” in her knee once or twice monthly while playing sports with minimal pain.
PHYSICAL EXAMINATION:
Examination of knee revealed a 2+ effusion. No focal tenderness to palpation. ROM was painful ranging from -10° extension to 110° flexion. Negative valgus/varus stress
tests, McMurray’s, apprehension and grind tests were noted. Lachman’s testing was asymmetric with 1-2+ on the injured side but significant guarding and discomfort was
noted by the patient who was somewhat uncooperative.
DIFFERENTIAL DIAGNOSIS:
1) Recurrent Patellar Subluxation
2) Loose Body
3) ACL Injury
TESTS AND RESULTS:
MRI demonstrated:
1) Ossified loose body in the anterior compartment
2) Complete rupture of ACL
3) Diminutive medial meniscus, possible chronic tearing
FINAL DIAGNOSIS:
1) ACL rupture with avulsion fx/loose body adherent to the ACL stump
2) Large bucket handle medial meniscus tear
TREATMENT AND OUTCOMES:
1)ACL reconstruction with hamstring autograft with allograft augmentation
2)Repair of medial meniscus
3)Removal of loose body with ACL debridement
1166
June 1, 3:35 PM - 3:55 PM
Bilateral Knee Pain—Soccer
Eze Uzosike. Kaiser Permanente Fontana, Fontana, CA.
Email: Eze222@gmail.com
(No relationships reported)
HISTORY: A 16-year-old high school female soccer player presented with bilateral knee pain and swelling three weeks after initial injury to her left knee. During soccer camp,
she sustained a varus load of her left knee while attempting to pivot with her leg in a planted position. This injury was re-aggravated the next day by a kick to the lateral aspect
of the left knee during practice, with considerable afterwards. Her right knee had been bothersome for about six weeks prior to her left knee injury. She had tried to kick a
soccer ball against an opposing player attempting to do the same thing. She developed inferior-posterior knee pain and low-grade effusion afterwards. Both knees felt
unstable to ambulation
PHYSICAL EXAMINATION:
Inspection: Skin Changes (-), + Genu Valgum of both knees, 2+ bilateral knee effusion, restricted range of motion bilaterally due to pain
R Knee
Palpation, Tenderness: Lateral joint facet, lateral joint line, and posterior knee,
Special Test: Lachman (-), A/P Drawer test (-), Bounce test (+), Valgus / Vagus laxity (-), Patellar Apprehension (+), Ober (+), Tenderness along insertion of IT band: positive
L Knee
Palpation, Tenderness: Medial & lateral joint facet, lateral joint line, and insertion of IT band
Special Test: Lachman (-), A/P Drawer test (-), Bounce test (+), Valgus / Vagus laxity (-), Patellar Apprehension (+), Ober (+)
DIFFERENTIAL DIAGNOSIS:
Bilateral Osteochondral Lesion
Bilateral Discoid Meniscus
318
Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Rheumatoid Arthritis
Pigmented Villonodular Synovitis
TEST AND RESULTS:
Bilateral Knee X-ray: No underlying bone abnormality, misalignment or acute fracture is noted. Bilateral joint effusion present.
MRI Bilateral Knee: No high-grade chondrosis, intra-articular bodies or Baker’s cysts noted. Ligaments and tendons are intact. Menisci are normal.
LAB: Elevated ESR and CRP, 1+ Proteinuria, High ANA Titer
Synovial Fluid Evaluation: Notable for high PMN’s
FINAL/WORKING DIAGNOSIS:
Chronic Arthritis, Rheumatoid Arthritis
TREATMENT AND OUTCOME:
--NSAIDS course
--Ultrasound guided aspiration of knees with Cortisone injection
--Improvement in pain and knee swelling
--Care transferred to Rheumatology for further workup
--Patient has yet to return to active soccer
1167
June 1, 3:55 PM - 4:15 PM
Noncontact Knee Injury-Football
Francis P. Foti, II. LECOM, Erie, PA. (Sponsor: Patrick Leary, FACSM)
Email: frankfoti11@gmail.com
(No relationships reported)
HISTORY: 18-year-old Division-II football defensive back who sustained an injury after jumping into the air to catch a ball and then reportedly hyperextended his knee when
he landed. He developed immediate onset of left knee pain and inability to bear weight. He had complaints of paresthesias along the dorsal aspect of his left foot and was
unable to dorsiflex his left foot. He was sent to the emergency room by ambulance after brief evaluation by athletic training staff for further evaluation.
PHYSICAL EXAMINATION: Initial exam revealed positive Lachman test and Varus stress test at 0° and 30°. Evaluation in the emergency room revealed moderate effusion,
tenderness to palpation over lateral joint line and tibial plateau, decreased sensation to light touch over dorsum of foot and inability to dorsiflex foot. Sensation was otherwise
intact. Dorsalis pedis and posterior tibial pulses were 2+. Thigh and leg compartments were soft.
DIFFERENTIAL DIAGNOSIS:
1. Single or Multi Ligamentous Injury
2. Fracture (Femur, Patella Tibia, Fibula)
3. Dislocation (knee or patella)
4. Neurovascular Injury
TESTS AND RESULTS:
Xray
-Suprapatellar effusion; no acute fracture
Computerized Tomography Angiography of Lower Extremities
- normal three vessel run-off
Magnetic Resonance -Tear of ACL, PCL and LCL
-nondisplaced fracture tibial plateau
FINAL DIAGNOSES:
Knee Disclocation III L (ACL, PCL, LCL, PLC, Lateral Meniscus)
Biceps Tendon Disruption
Tibial Plateau Fracture
Fibular Nerve Contusion
TREATMENT AND OUTCOMES:
1. Imaging performed (Xray, CTA, MRI).
2. Placed in a Knee immobilizer.
3. Admitted for observation of neurovascular status and pain control.
4. Heparin was used for thrombosis prophylaxis during admission.
5. Transitioned to a Total Range of Motion brace locked at 20°, fitted for an Ankle Foot Orthosis and ordered a wheel chair.
6. Discharged on Xarelto and Percocet with plans for further evaluation at Allegheny General Hospital in Pittsburgh for surgical repair.
7. Arthroscopically assisted ACL reconstruction with allograft, PCL reconstruction, LCL reconstruction with hamstring tendon autograft, left biceps tendon repair, lateral
meniscus open repair and major synovectomy.
8. Physical therapy was initiated 2 weeks postoperatively.
9. Discussion in regards to possible return to sports is pending.
1168
June 1, 4:15 PM - 4:35 PM
Knee Injury – Recreational Runner
Brenda E. Castillo, MD, Isabel Rutzen, MD, Irma Valentin-Salgado, MD, Liza Hernandez-Gonzalez, MD. VA Caribbean Healthcare System,
San Juan, PR. (Sponsor: William Micheo, MD, FACSM)
Email: brendi00@yahoo.com
(No relationships reported)
HISTORY: Case of a 41 year-old army soldier who had an acute bilateral knee giveaway weakness while jogging. After running for a mile, his left knee gaveway and he fell to
the floor. He stood up without difficulties and ambulated for a short distance when he fell again due to right knee weakness. He had difficulty ambulating, although he felt no
pain. During his ER visit, he had a third fall resulting in a right lateral malleolus fracture. Orthopedics was consulted and performed bilateral patellar tendon repair and right
lateral malleolus ORIF. He was discharged home with bilateral hinged knee braces locked at full extension and weight-bearing precautions. Two months post-op, he was
admitted to the acute inpatient rehabilitation ward of the VA Caribbean Healthcare. No past medical history of systemic conditions or regular medications.
PHYSICAL EXAMINATION: Examination revealed bilateral knee valgus deformity, mild soft tissue swelling and bilateral pes planus. He had full knee extension and limited
knee flexion to 90 degrees. Knee special tests were negative for meniscal, cruciate ligament or collateral ligament injury. Neurovascular exam was unremarkable.
DIFFERENTIAL DIAGNOSIS:
1. Patellar tendon rupture
2. Quadriceps tendon rupture
3. Anterior cruciate ligament sprain
4. Meniscal injury
5. Collateral ligament sprain
319
Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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