Knee Follow-Up Exam

KNEE FOLLOW-UP EXAMINATION NAME: Sarah Elizabeth Jenkins DATE: 1 November 2024 FILE: SEJ-K-007 TITLE: Mrs. SIDE: Right The patient is 6 months post-operative from an ACL reconstruction on the right knee. --- History: = Medical diseases: Mrs. Jenkins has a history of well-controlled essential hypertension, managed with daily medication. She also has a history of seasonal allergies, which are managed with over-the-counter antihistamines as needed. = Medication used: Amlodipine 5mg daily for hypertension. Loratadine as needed for allergies. She also takes a daily multivitamin and a glucosamine supplement for joint health, which she started approximately 3 months ago. = Allergies: Penicillin (rash), environmental allergens (seasonal). = Complications: Mrs. Jenkins experienced mild post-operative swelling for the first 4 weeks, which resolved with RICE therapy and physiotherapy. There were no surgical site infections or deep vein thromboses. Previous Treatment Right Knee: Mrs. Jenkins underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with a hamstring autograft on 1 May 2024. Prior to surgery, she completed 8 weeks of pre-operative physiotherapy to improve quadriceps strength and range of motion. Post-operatively, she has been diligent with her physiotherapy regimen, focusing on strengthening, proprioception, and gait training. Her previous treatments included RICE (rest, ice, compression, elevation) immediately post-injury and NSAIDs for pain management. Right Knee: Mrs. Jenkins reports persistent occasional stiffness, particularly in the mornings and after prolonged sitting, rated 2/10 on a pain scale. She also notes some mild clicking with deep knee flexion but denies locking or instability. She has been able to return to light jogging and cycling, but still experiences some apprehension with pivoting movements. No new swelling or redness. She feels her quadriceps strength is improving but still not at pre-injury levels. Orthopaedic complaints not related to the knees: Patient denies any other orthopaedic complaints at this time. --- Examination: Right knee examination – Tibio-femoral joint: * Alignment: Neutral mechanical axis. No obvious valgus or varus deformity. * Gait: Mild antalgic gait noted, favoring the right leg slightly. Ambulated without assistive devices. * Scarring: Well-healed surgical incisions, non-tender, non-erythematous. * Swelling: No significant effusion palpated. * Atrophy: Mild quadriceps atrophy noted compared to the left, approximately 1cm circumference difference. * Tenderness: Mild tenderness along the medial joint line with deep palpation. * Range of motion: Full extension (0 degrees). Flexion to 135 degrees. Pain occurs at end-range flexion. * Meniscus findings: Negative for medial and lateral meniscal tears on McMurray's test. * Collateral ligament findings: Medial collateral ligament (MCL) stable, no laxity. Lateral collateral ligament (LCL) stable, no laxity. Right knee examination – Patella: * Alignment: Patella centrally aligned. * Tracking: Smooth tracking throughout range of motion. * Apprehension sign: Negative. * Tenderness: No patellar tenderness. * Crepitus: Mild crepitus with patellar mobilisation. Other orthopaedic examination findings: No other orthopaedic examination findings were performed at this visit. --- Special investigations: Right knee X-rays: Recent X-rays (dated 25 October 2024) show good hardware placement for ACL reconstruction with no signs of osteolysis. Joint spaces are preserved, and no acute bony pathology is identified. Right knee MRI: Not indicated at this time. Right knee other special investigations: Not indicated at this time. --- Diagnosis: Right knee: * Status post ACL reconstruction (6 months). Mild quadriceps weakness and persistent stiffness. Apprehension with pivoting activities. Other general diagnosis: * Essential hypertension (well-controlled). * Seasonal allergies. --- Treatment plan: Right knee: Further investigations: No further investigations planned at this time. Conservative: Continue current physiotherapy regimen with increased focus on quadriceps strengthening, plyometrics, and agility drills. Introduce sport-specific training. Emphasize proprioceptive exercises. Continue glucosamine supplement. Prescribe a topical NSAID gel for localized stiffness as needed. General measures: Advised patient to continue regular exercise, maintain a healthy weight, and follow up with her GP for blood pressure management. Patient advised to gradually increase activity levels and avoid high-impact pivoting sports until cleared by the surgeon or physiotherapist. Follow-up plan including timing and what is planned for the follow-up: Return for review in 3 months to assess progress and readiness for full return to sport. Medication prescribed: Diclofenac 1% gel, apply to right knee up to three times daily as needed for pain/stiffness.