Sports Medicine Phone Follow-Up

Sports Physician's Phone Follow-Up Note TELEPHONE FOLLOW-UP NOTE APPOINTMENT DATE: 1 November 2024 SUBJECTIVE Patient, a 32-year-old semi-professional football player, called for follow-up regarding persistent right knee pain. He reports the pain started approximately 3 weeks ago after a particularly intense training session, describing it as a dull ache located around the patella, worse with squatting, climbing stairs, and running. The pain is rated 6/10 at its worst. He notes an improvement with rest and ice, but symptoms return with activity. He has continued to experience the same pain despite reducing training intensity and consistently icing the knee since the last visit. He has been taking over-the-counter ibuprofen (400mg three times daily) with minimal relief. There has been no significant progression of symptoms, but no notable improvement either. He finds relief with rest, elevation, and cold compresses. He attempted a short jog yesterday, which aggravated the pain significantly. No specific self-management strategies have provided lasting relief. This is the first significant knee issue he has reported in the last 5 years. The pain is impacting his ability to participate in football training and matches, affecting his performance and mood. He denies any locking, clicking, giving way, or swelling, and no systemic symptoms such as fever or weight loss. OBJECTIVE Physical exam deferred due to telephone assessment. Relevant results from the MRI of the right knee performed on 28 October 2024 were reviewed. MRI findings indicated patellar tendinopathy with mild signal changes at the inferior pole of the patella, consistent with early degenerative changes, and no meniscal tears or ligamentous injury. ASSESSMENT Right patellar tendinopathy (jumper's knee). Differential diagnoses considered include patellofemoral pain syndrome, early osteoarthritis, and prepatellar bursitis. PLAN Planned investigations: None at this stage, as recent MRI provides sufficient diagnostic information. Planned treatment or interventions: Patient advised to continue relative rest from aggravating activities. Prescribed topical diclofenac gel to be applied twice daily. Referred for a course of physiotherapy focusing on eccentric quadriceps strengthening exercises and patellar tendon loading protocols. Emphasised importance of gradual return to sport protocol under physiotherapist guidance. Additional actions such as referrals, counselling, or follow-up: Referral sent to 'Optimal Performance Physiotherapy'. Patient counselled on activity modification and the chronic nature of tendinopathy, stressing patience and adherence to the rehabilitation program. Scheduled for a follow-up telephone consultation in 4 weeks to assess progress. I have documented the assessment using an AI-assisted scribe to ensure accuracy and efficiency in note-taking. Time Spent with Patient: 00:15:20 Start Time: 10:30 End Time: 10:45