42 year old male with knee pain (Science (Evidence Based Practice…
42 year old male with knee pain
Evidence Based Practice
A feature of non-contact ACL injuries is the involvement of multiple vectors or multiplanar loading of the knee, sagittal and coronal loads, in combination with imbalanced muscle contraction forces of the quads and HS, leading to significant stresses on the ACL.
The swelling/effusion of an ACL injury is caused by injured blood vessels. Localized lateral swelling in this case was Caused by the grade 2 LCL sprain.
The swelling/effusion of an ACL injury is caused by injured blood vessels. Localised lateral swelling in this case was Caused by the grade 2 LCL sprain.
Bone bruise was caused by high impact of fall
: This method is often suggested in pts over 40 due to complications of surgery such as stiffness, arthrofibrosis, infections, wound healing problems, or thromboembolic disease, degenerative knee osteoarthritis.
Return to golf
is suggested in pts with demeanding activities such as cutting and pivoting (Golf).
Some studies have found no change in knee function and return to sport 2 years post surgery. Early phase degree of instability and function were a good predictor on success non-surgical interventions. suggesting that the current pt will have good prognostic factors for a return to sport (golf) with conservative management. This choice will be given to the pt
As pt wants to play golf once he retires it looks possible to manage conservatively with successful return to sport.
Surgery suggested if multiple structures involved.
Pt only tore acl with MCL sprain.
Traumatic injury where a noise was heard with minimal swelling and limited pain with the feeling of "instability" only symptom. this is suggestive of injury within the knee
Landing from jump with the knee in valgus. LCL injury often seen with other structures such as ACL
I have seen these features in prac exams and case studies. I was surprised how functional someone with a recent full ACL rupture could be.
Hypo -thetico-deductive Reasoning
Fell off 1-2m scaffold. heard crunch, felt twist and pain and slight swelling in L knee.
Next day felt unstable with not much pain. went to work .
: MOI indicates acute knee injury and symptoms of feeling unstable indicate damage to internal structures e.g ACL, MCL, LCL, PCL, meniscus
: Crouch = pain at EOR with difficulty getting up. Walking = feels pinch at end of stance. walking was easier on toes with no pinch
: Knee ROM: R) Ext = 3 Flex = 130
L) Ext 2 Flex = 215
Strength and ROM are good, indicating that a conservative approach to ACL rehab is possible. Will talk with surgeon
Session 2: Subjective:
: Doing well. has been walking around more and planning on returning to work on Monday.
1 more item...
: 3 x 10 calf raises DL- BW // ADD 149
: progression - 3 x 12 calf raise DL10kg Jones machine.
: HHD - Hip - ADD = R 209 L 136 (P2) ABD R 236 L 211 EXT R 444 L 400
: LCL tape // ADD 171
: MRI conforms full ACL rupture and grade 2 LCL sprain. no damage to meniscus or PCL. Bone bruise of lateral corner also found :check:
this is pt preference This is pt preference due to work commitments
: has been suggested by surgeon.
: Pt shows fear with taking time off work due to being self employed. He seems worried about money and time off work. It was important to remind him that surgery may be needed but we'll do all we can to get him back as son as possible if he has good with compliance with treatment.
Pt is far less fearful now as he is back to work as feeling good
: Communication about the injury was done with housing analogy - ACL = internal structures and need a strong surrounding structure or it wont work well. He was also worried about seeing atrophy in the first week. this was used as motivation for strength training by saying it can come back quickly if he trains his legs.
Further education on mm strength programs given
Narrative Based Reasoning
Work on Monday
Back to playing golf and kicking football with daughter (12 y/o). Key goal is to play golf once retired (10 years away)
Increased LL strength and stability. long term management
increase muscle activation. measure HHD to see strength levels before return. Decreased swelling.
2 daughters (12,14) - wife
: Roofer - gutters & fascia
: Golf 1-2 x a week
. Possible need for pain management. Possible psychological referral if time off work is too difficult.
Pt doesn't want to take pain medications
: Read MRI report. Possible need for future imaging depending on management approach taken.
: Has suggested surgery. Will give details that pt is progressing well and a conservative approach is possible.
Pt is progressing well so conservative approach seems as though it will be successful
Possibly needed in later management
Pt seems aware that conservative approach will be a long term program and has talked about getting back in the gym. EP referral?