Initial Appointment

HOPC: * Patient reports acute onset of right knee pain after an awkward twist during a netball game on 25 October 2024. * Initial pain was sharp, 7/10, with immediate swelling and difficulty weight-bearing. * Managed with RICE (rest, ice, compression, elevation) and over-the-counter paracetamol since onset, providing minimal relief. * Pain has progressed to a constant dull ache, exacerbated by movement, 4/10 at rest. * Aggravating factors: Walking, going up/down stairs, pivoting movements, prolonged standing. * Easing factors: Rest, ice, elevation. * 24-hour behaviour: Stiff and painful in the mornings, gradually improving with gentle movement, worsening again in the late afternoon/evening after activity. Night pain is minimal unless patient moves awkwardly in sleep. Radiology: * X-ray Right Knee (26 October 2024): No fractures or bony abnormalities identified. * MRI Right Knee (30 October 2024): Indication of meniscal tear (medial meniscus posterior horn) and Grade 1 MCL sprain. Past Medical History: * Asthma: Managed with Salbutamol inhaler as needed (1-2 puffs, as required). No recent exacerbations. * No known allergies. Social History: * Lives with partner in a two-story house. Good support network from partner and family. * Social drinker (1-2 units/week). Non-smoker. No illicit drug use. * No significant family history of musculoskeletal conditions. Mother has Type 2 Diabetes. * Employed full-time as a primary school teacher. Works 8am-4pm, Monday-Friday. Role involves prolonged standing, some lifting of children, and frequent movement around the classroom. Currently on sick leave due to injury. Goals: * Short-term physiotherapy goals: * Reduce right knee pain to 2/10 at rest within 2 weeks. * Restore full knee extension and flexion active range of motion (AROM) within 3 weeks. * Be able to walk for 15 minutes without significant pain within 4 weeks. * Long-term physiotherapy goals: * Return to playing netball at pre-injury level within 6 months. * Be able to comfortably climb a full flight of stairs without pain within 3 months. * Resume all work duties without limitation within 2 months. Objective: * Observation: * Mild swelling noted around the medial aspect of the right knee. * Antalgic gait present, patient guarding right knee. * Palpation: * Tenderness over medial joint line and medial collateral ligament. * Active Range of Motion (AROM) Right Knee: * Flexion: 0-110 degrees (limited by pain and stiffness). * Extension: -5 degrees (extension lag). * Strength (Manual Muscle Test) Right Lower Limb: * Quadriceps: 4/5 (right) vs 5/5 (left) * Hamstrings: 4/5 (right) vs 5/5 (left) * Calf: 5/5 bilateral * Special Orthopaedic Tests: * Lachman's Test: Negative * Anterior Drawer Test: Negative * Valgus Stress Test (0 and 30 degrees): Mild laxity with pain at 30 degrees, consistent with MCL sprain. * McMurray's Test: Positive for pain and click with internal rotation during flexion/extension, suggestive of medial meniscal involvement. Treatment: * Education: * Nature of meniscal tear and MCL sprain, expected healing times, importance of graded activity. * Pain management strategies, including RICE and gentle movement. * Importance of adhering to home exercise programme for optimal recovery. * Manual and Hands-on Treatment: * Soft tissue release: Quadriceps and hamstrings, right thigh (5 minutes each, moderate pressure). * Mobilisation: Patellofemoral joint glides (3 sets of 30 seconds, Grade II). * Active Therapeutic Exercises: * Quadriceps isometric contractions: Right leg, 3 sets of 10 repetitions, hold 5 seconds. * Glute bridge: 3 sets of 12 repetitions. * Heel slides: Right leg, 3 sets of 15 repetitions. * Home Exercises Prescribed: * Quadriceps isometric contractions: 3 sets of 10 repetitions, hold 5 seconds, 3 times/day. * Heel slides: 3 sets of 15 repetitions, 3 times/day. * Gentle knee extension stretches: Hold 30 seconds, 3 repetitions, 3 times/day. Assessment: * Primary Diagnosis: Right knee medial meniscal tear with Grade 1 medial collateral ligament sprain, likely a result of the twisting injury sustained during netball. Clinical reasoning is supported by the mechanism of injury, localised pain and swelling, positive McMurray's and Valgus stress tests, and MRI findings. The patient presents with acute pain and significant functional limitations in ambulation and daily activities. * Differential Diagnoses: Anterior cruciate ligament injury (ruled out by negative Lachman's and Anterior Drawer tests), patellofemoral pain syndrome (less likely given acute trauma and localised tenderness). * Progress towards goals: Patient is currently in the acute phase of injury. Pain levels are high, and range of motion is limited. Baseline measurements have been established to track progress. Initial goals focus on pain reduction and restoring basic mobility. * Barriers to progress: Patient's occupation as a primary school teacher requires prolonged standing and movement, which may be a barrier to rest and recovery initially. Fear of re-injury may also impact adherence to exercise. Plan: * Continue with RICE protocol, pain management, and a progressive home exercise programme focused on pain-free range of motion and muscle activation. * Next review appointment: 1 November 2024 (in one week). * Treatment for next appointment: * Re-assessment of pain and range of motion. * Progression of strengthening exercises. * Further education on injury management and return-to-sport guidelines. * Referrals: No immediate referrals planned, but orthopaedic review will be considered if conservative management does not yield satisfactory progress. * Communications: Physiotherapist to provide a brief update to the patient's GP regarding the initial assessment and management plan.