Knee Exam

KNEE EXAMINATION NAME: Mrs. Eleanor Vance DATE: 01 November 2024 FILE: EV-00789-2024 TITLE: Mrs. SIDE: Both REFERRING PRACTITIONER: Dr. Thomas Kelly --- History: Medical diseases: Mrs. Vance has a history of well-controlled hypertension, diagnosed 5 years ago, managed with medication. She also has osteoarthritis, diagnosed 2 years ago, affecting both knees, which she manages with over-the-counter pain relievers. Medication used: She is currently taking Ramipril 5mg once daily for hypertension and occasionally uses Ibuprofen 400mg as needed for knee pain. She also takes a daily multivitamin. Allergies: Mrs. Vance reports no known drug allergies. She has a seasonal allergy to pollen, which causes mild rhinitis. Other operations: She underwent an appendectomy at age 25 with no reported complications. No other previous surgical procedures are noted. Operative adverse reactions: No adverse reactions or complications were noted during or after her appendectomy. Complaint Right Knee: Patient complains of chronic dull ache in her right knee, exacerbated by walking stairs and prolonged standing. The pain has been present for approximately 2 years, gradually worsening. It is relieved by rest and applying a heat pack. She reports occasional clicking but no locking or instability. Pain Right Knee: The pain is located diffusely across the anterior aspect of the right knee, described as a dull ache. On a scale of 0-10, her pain is typically 4/10, increasing to 7/10 with activity. There is no radiation of the pain. Previous Treatment Right Knee: Previously, Mrs. Vance has tried physiotherapy for 6 months, which provided temporary relief. She also received a corticosteroid injection 8 months ago, which offered relief for approximately 3 months. She currently uses topical anti-inflammatory creams. Complaint Left Knee: Patient complains of intermittent sharp pain in her left knee, particularly with twisting movements and kneeling. The pain started approximately 18 months ago, also gradually worsening. It is relieved by rest. She reports occasional stiffness, especially in the mornings, lasting about 15-20 minutes. Pain Left Knee: The pain is localised to the medial joint line of the left knee, described as sharp. On a scale of 0-10, her pain is typically 3/10, increasing to 6/10 with specific movements. There is no radiation of the pain. Previous Treatment Left Knee: She has not undergone any specific treatment for her left knee pain, apart from using over-the-counter pain relief when symptoms are severe. Other orthopaedic complaints not related to the knees: Mrs. Vance occasionally experiences lower back stiffness, particularly after prolonged sitting, but states it is manageable and not her primary concern today. --- Examination: Weight: 75 kg Height: 165 cm BMI: 27.5 kg/m^2 Right knee examination – Tibio-femoral joint: * Mild valgus alignment noted. * Minimal effusion present. * Tenderness to palpation along the medial joint line. * Range of motion: Full extension (0 degrees), Flexion to 120 degrees with mild pain at end range. * Meniscal assessment: McMurray's test negative. Apley's grind test negative. * Ligament assessment: Lachman's test negative, Anterior/Posterior drawer tests negative, Varus/Valgus stress tests negative at 0 and 30 degrees. * Special tests: Nil significant. Right knee examination – Patella: * Good patellar tracking, no apprehension. * Mild retropatellar crepitus on movement. * No significant tenderness. Left knee examination – Tibio-femoral joint: * Normal alignment. * No effusion. * Tenderness to palpation along the medial joint line. * Range of motion: Full extension (0 degrees), Flexion to 115 degrees with moderate pain at end range. * Meniscal assessment: Medial McMurray's test elicits pain with a subtle click. Apley's grind test positive for medial meniscus. * Ligament assessment: Lachman's test negative, Anterior/Posterior drawer tests negative, Varus/Valgus stress tests negative at 0 and 30 degrees. * Special tests: Nil significant. Left knee examination – Patella: * Patellar tracking appears normal. * No apprehension or crepitus. * No significant tenderness. Other orthopaedic examination findings: Spine examination revealed mild tenderness in the lumbar paraspinal muscles with full range of motion. No neurological deficits were noted in the lower extremities. --- Special investigations: Right knee X-rays: Anteroposterior (AP) and lateral views demonstrate mild to moderate joint space narrowing in the medial compartment, with osteophyte formation. Patellofemoral joint space appears preserved. Right knee MRI: MRI shows full-thickness cartilage loss in the medial tibiofemoral compartment with subchondral bone oedema. No significant meniscal tears or ligamentous injuries are observed. Right knee other investigations: Nil other investigations performed. Left knee X-rays: AP and lateral views show mild joint space narrowing in the medial compartment. No significant osteophytes or subchondral changes are noted. Left knee MRI: MRI reveals a horizontal tear of the posterior horn of the medial meniscus, extending to the inferior articular surface. Mild chondromalacia of the medial femoral condyle. Ligaments are intact. Left knee other investigations: Nil other investigations performed. --- Diagnosis: Right knee: Osteoarthritis, right knee, Kellgren-Lawrence Grade 2-3. Left knee: Medial meniscal tear, left knee, and early osteoarthritis, left knee. Other orthopaedic diagnosis: Lumbar spondylosis (mild). Other general diagnosis: Essential hypertension, controlled. --- Treatment plan: Right knee – Further investigations: Consider bone scan if conservative measures fail to assess for ongoing inflammatory activity. Right knee – Conservative: Continue with regular low-impact exercise (e.g., swimming, cycling). Initiate a structured physiotherapy programme focusing on quadriceps strengthening and gait training. Consider viscosupplementation if oral pain relief is insufficient. Right knee – Theatre: Discuss options for unicompartmental knee arthroplasty if conservative management fails and symptoms significantly impact quality of life. Left knee – Further investigations: No further investigations are immediately planned. Left knee – Conservative: Referral to physiotherapy for targeted rehabilitation, including strengthening exercises and activity modification. Advise on R.I.C.E. (Rest, Ice, Compression, Elevation) for acute exacerbations. Consider a trial of a knee brace for support during activity. Left knee – Theatre: Discuss possibility of arthroscopic meniscectomy if symptoms persist despite conservative management and pain significantly impacts daily activities. General measures: Patient advised on weight management and healthy lifestyle choices. Follow-up appointment scheduled in 6 weeks to review progress and discuss treatment options. Medication prescribed: N/A (patient to continue current medications; Ibuprofen use as needed for breakthrough pain). Other orthopaedic conditions: Advised to continue with core strengthening exercises for lumbar stiffness and consider referral to a chiropractor if back pain worsens.