Sport Medicine Follow-Up

FOLLOW-UP NOTE APPOINTMENT DATE: 01 November 2024 SUBJECTIVE Chief complaint and reason for follow-up: Patient returns for follow-up regarding persistent left knee pain, specifically anterior knee pain exacerbated by running and stair climbing. Reason for follow-up is to assess response to previous physiotherapy and consider further interventions. Duration, timing, location, quality, and severity of symptoms: Symptoms have been ongoing for 6 months, intermittent at first but now more consistent, especially after activity. Pain is a dull ache, occasionally sharp, located around the patella. Severity is 6/10 with activity, 2/10 at rest. Response to previous treatments or interventions since the last visit: Patient completed 8 weeks of physiotherapy focusing on quadriceps strengthening and gluteal activation. Initially reported mild improvement, but pain has plateaued over the last two weeks despite adherence to exercises. No new medications or injections since last visit. Progression of symptoms since last visit — unchanged. Aggravating or relieving factors: Aggravated by running, jumping, and prolonged sitting. Relieved by rest and ice. Self-management strategies include stretching and foam rolling, which provide temporary relief. Previous episodes or recurring issues: Patient reports similar, less severe knee pain episode approximately two years ago after increasing running mileage, which resolved with rest. Impact on current daily function, work, or physical activity: Unable to participate in weekly recreational football games. Difficulty with daily walks exceeding 30 minutes. Work as a software engineer is largely sedentary, but prolonged sitting can aggravate pain. Associated symptoms: No swelling, locking, giving way, or systemic symptoms. OBJECTIVE Vital signs: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Physical examination findings: Left Knee: Inspection: No effusion, erythema, or gross deformity. Mild quadriceps atrophy noted compared to the right. Palpation: Tenderness noted at the inferior pole of the patella and patellar facets. Range of Motion: Full active and passive range of motion. Pain elicited with deep knee flexion. Strength: 4/5 quadriceps strength on the left, 5/5 on the right. Hamstring and gluteal strength 5/5 bilaterally. Special Tests: Patellar grind test positive on the left, indicating patellofemoral pain. Negative for meniscal tears (McMurray's) or ligamentous laxity (ACL/PCL Lachman, anterior/posterior drawer, MCL/LCL valgus/varus stress tests). Gait: Antalgic gait noted during heel strike on the left, especially with faster walking. Completed investigations and their results: Plain X-ray Left Knee (dated 15 October 2024): No bony abnormalities, joint space narrowing, or signs of arthritis. Patella alta not evident. ASSESSMENT Most likely diagnosis based on clinical findings: Patellofemoral Pain Syndrome (PFPS) of the left knee. Differential diagnoses considered: Patellar tendinopathy, chondromalacia patellae, meniscal tear (ruled out by examination). PLAN Planned investigations: None at this time. Will consider MRI if symptoms persist despite further conservative management. Planned treatment or interventions: 1. Continue with current physiotherapy exercises, focusing on eccentric quadriceps loading and VMO strengthening. 2. Implement activity modification: Advise patient to reduce running intensity and duration, avoid aggravating activities like jumping and deep squats for 4-6 weeks. 3. Recommend use of a patellar tracking brace during aggravating activities. 4. Prescribe a short course of topical NSAID (diclofenac gel) for pain management. 5. Discuss the option of a corticosteroid injection if symptoms do not improve significantly in the next 4-6 weeks. Additional actions: Provide patient education on proper warm-up/cool-down, footwear assessment, and gradual return to activity principles. PROCEDURE NOTE Injection type, side, and substance administered, and whether ultrasound guidance was used: Left knee infrapatellar fat pad corticosteroid injection (20mg Triamcinolone) under ultrasound guidance. "The risks, benefits, and alternatives of the procedure were explained to the patient, and informed consent was obtained. The fees for the non-insured services were reviewed prior to the procedure." Specific site, side, needle details, medication details, ultrasound usage, patient positioning, and technique used, including approach if relevant: Site: Left knee, infrapatellar fat pad. Needle: 25-gauge, 1.5-inch needle. Medication: 1ml (20mg) Triamcinolone acetonide mixed with 1ml (1%) Lidocaine. Ultrasound guidance used for precise needle placement and medication delivery. Patient positioned supine with knee slightly flexed. Technique: In-plane approach, needle advanced to the infrapatellar fat pad, confirmed by real-time ultrasound visualisation. "The skin overlying the injection site was cleaned with chlorhexidine and alcohol swabs, and a no-touch aseptic technique was used." "After completion of the injection, the needle was withdrawn, and gentle pressure was applied to the injection site to minimize bleeding. A bandage was applied to cover the injection site. The procedure was well tolerated without any immediate complications. Post-injection care was reviewed. They were advised to monitor for any signs of infection, bleeding, or adverse reactions and to report any concerns promptly." Immediate pain relief reported following local anesthetic, if applicable: Patient reported significant (80%) immediate pain relief in the left knee after the local anaesthetic injection. I have documented the assessment using an AI-assisted scribe to ensure accuracy and efficiency in note-taking. Time Spent with Patient: 35 minutes Start Time: 10:00 End Time: 10:35