Sport Medicine Consult

Sports Physician's Consult APPOINTMENT DATE: 1 November 2024 REASON FOR REFERRAL Referral for right knee pain, exacerbated by running and sports activities. The primary symptom is sharp, intermittent pain localized to the anterior aspect of the right knee. HISTORY OF PRESENTING ILLNESS The primary complaint is right anterior knee pain, which began insidiously approximately 3 months ago after increasing running mileage. The pain is described as a sharp, stabbing sensation, occasionally radiating to the medial aspect of the knee. Severity is rated 6/10 during activity, 2/10 at rest. Associated symptoms include occasional clicking but no locking or giving way. Aggravating factors include running, jumping, and squatting. Relieving factors include rest, ice, and over-the-counter NSAIDs (ibuprofen). Previous treatments include RICE (rest, ice, compression, elevation) and stretching, which provided temporary relief. Patient has no relevant surgical history. Current functional limitations include inability to participate in weekly football matches and difficulty with stair climbing. The patient perceives the condition to be gradually worsening despite attempts at self-management. Current status is that he is unable to perform his usual athletic activities without significant pain. His goal for this appointment is to return to playing football without pain. MEDICAL HISTORY - Mild exercise-induced asthma, well-controlled with salbutamol as needed. - No other significant past medical conditions. MEDICATIONS - Salbutamol inhaler (100mcg/dose) prn for exercise-induced asthma. - Ibuprofen (400mg) prn for knee pain, up to twice daily. ALLERGIES - Penicillin (rash) SOCIAL HISTORY Patient is a 32-year-old male, working as an accountant. He is an avid amateur footballer, playing twice a week, and also enjoys recreational running. Non-smoker, occasional alcohol use (2-3 units per week). PHYSICAL EXAMINATION Right knee: Mild effusion noted. Palpation revealed tenderness over the patellar tendon insertion and inferior pole of the patella. Range of motion was full but painful at end-range flexion. Patellar apprehension test was negative. Quadriceps strength was 4/5 on the right compared to 5/5 on the left. Mild crepitus with patellar tracking. McMurray's, Lachman's, and anterior/posterior drawer tests were negative. Collateral ligaments stable. Gait was antalgic on the right. No significant oedema or erythema. IMAGING Right knee X-ray (dated 25/10/2024): No acute fracture or dislocation. Mild degenerative changes noted in the patellofemoral joint. No significant joint space narrowing. IMPRESSION 1. Patellar Tendinopathy, right knee. 2. Patellofemoral Pain Syndrome, right knee (differential diagnosis). PLAN - Advise relative rest from aggravating activities (running, jumping, football) for 2-4 weeks. - Commence quadriceps and hamstring strengthening exercises, focusing on eccentric loading for patellar tendon. - Prescription for Naproxen 500mg BID for 10 days to manage inflammation and pain. - Referral to physiotherapy for guided rehabilitation and activity modification advice. - Review in 4 weeks to assess progress and consider further imaging (MRI) if symptoms persist. - Short-term goal: Reduce pain to 0/10 at rest and <3/10 with daily activities. Long-term goal: Return to full sports participation without pain. I have explained to the patient that an AI-assisted scribe will be used for note-taking during the assessment. Verbal consent was obtained, and this note was generated using this technology to ensure accuracy and efficiency in documenting the assessment. Time Spent with Patient: 00:25:30 Start Time: 10:15 End Time: 10:40