Patient Summary Email (Sport Medicine)

CONFIDENTIAL REPORT VIA Email Dear Mr. Davies This email summarises the findings and treatment plan from your recent consultation regarding your knee injury. We discussed your symptoms, conducted a physical examination, and reviewed your imaging results to formulate a comprehensive approach to your recovery. History of Present Illness: Mr. Davies is a 38-year-old amateur footballer who presented with a chief complaint of left knee pain and instability following an injury sustained during a football match approximately 3 weeks ago. He describes a twisting mechanism where his foot was planted, and his body rotated. He experienced immediate sharp pain and a 'pop' sensation. He has had difficulty bearing weight since and reports intermittent locking and giving way of the knee. SUMMARY: Current Condition/Complaint: - Detailed description of primary injury, problem, complaint or symptom: Left knee pain and instability, particularly during weight-bearing and twisting movements. Reports intermittent locking and giving way. - Date of onset or date of surgery (mention only if applicable and available): 12 October 2024 - Description of how the injury occurred or complaint began (mention only if applicable and available): Sustained during an amateur football match while attempting a pivot; experienced a twisting injury to the left knee with a reported 'pop'. - Details of any prior therapy, interventions, and/or surgery (mention only if applicable and available): Initially rested, applied ice, and took over-the-counter pain relievers. No formal physiotherapy initiated prior to this visit. - Describe progression of complaint and nature of symptoms (mention only if applicable and available): Initial swelling has subsided, but pain persists, especially medially. Locking episodes occur randomly, leading to giving way. Pain is rated 6/10 on exertion, 2/10 at rest. - Imaging (if available) (List and summarize in detail in pay terms any MRI or X-ray reports or other radiology imaging findings noted in reports found in the context that are included as context or discussed. if it has been explicitly mentioned in the transcript, contextual notes or clinical note, also add them. Include the date of the imaging, the important findings and any other relevant information in detail. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.): MRI Left Knee performed on 25 October 2024: Revealed a complete tear of the medial meniscus posterior horn, a high-grade sprain of the anterior cruciate ligament (ACL) with near-complete disruption, and bone bruising on the lateral femoral condyle and lateral tibial plateau. No significant meniscal extrusion or other major ligamentous injuries noted. Patient's current diagnosis and treatment plan: Based on clinical examination and MRI findings, the patient has a left knee anterior cruciate ligament rupture and a medial meniscal tear. The treatment plan involves initial conservative management followed by surgical reconstruction and comprehensive rehabilitation. IMPRESSION: - Therapist's professional opinion based on subjective and objective findings (if applicable and available): Mr. Davies presents with classic symptoms and signs consistent with a significant internal derangement of the left knee, specifically an ACL rupture and medial meniscal tear. His instability and locking symptoms are directly attributable to these injuries. He is highly motivated to return to football. - Prioritized problems list (mention only if applicable and available): 1. Left knee instability and giving way. 2. Left knee pain. 3. Medial meniscal tear causing mechanical symptoms. 4. Impaired function and inability to return to sport. - Progress towards stated goals (if applicable): Not applicable at this initial consultation stage; goals to be established. - Factors affecting progress and any need for modification in the plan (if applicable): Patient's high activity level and desire to return to sport necessitate a robust rehabilitation plan. Surgical intervention is likely required for optimal long-term stability and function given the complete ACL tear. DIAGNOSIS: - ICD-10 Code - Description of Diagnosis 1: S83.512A - Sprain of anterior cruciate ligament of left knee, initial encounter - ICD-10 Code - Description of Diagnosis 2: S83.212A - Bucket handle tear of medial meniscus, current injury, left knee, initial encounter PLAN: Treatment Plan: The immediate plan is to manage pain and swelling, followed by pre-operative strengthening, and then surgical intervention for ACL reconstruction and meniscal repair. Post-operatively, a structured physiotherapy program will be implemented. - Detailed treatment plan including interventions, frequency, and duration (if available): Initial phase (2 weeks): RICE (Rest, Ice, Compression, Elevation), NSAIDs, gentle range of motion exercises. Pre-operative physiotherapy (4-6 weeks): Focus on quadriceps and hamstring strengthening, proprioception, and knee extension. Surgical phase: Left knee arthroscopy with ACL reconstruction (hamstring autograft) and medial meniscal repair. Post-operative physiotherapy (6-9 months): Phased rehabilitation focusing on pain control, range of motion, strength, balance, agility, and sport-specific drills. Follow-up appointments will be scheduled bi-weekly initially, then monthly. - Anticipated goals and expected outcomes (mention only if applicable and available): Restore full knee stability and range of motion. Achieve quadriceps and hamstring strength comparable to the uninjured leg. Return to pre-injury level of amateur football within 9-12 months. Alleviate pain and mechanical symptoms. - Equipment required and its usage (mention only if applicable and available): Post-operative knee brace (hinged) for 4-6 weeks for stability and controlled range of motion. Crutches for initial weight-bearing restriction post-surgery. - Education strategies for the patient (mention only if applicable and available): Provided information on the nature of ACL and meniscal injuries, the surgical procedure, and the importance of adherence to the rehabilitation protocol. Emphasised gradual progression and avoidance of pivoting activities. Dietary advice for healing. - Referrals to other professionals (mention only if applicable and available): Referral to Orthopaedic Surgeon for surgical consultation. Referral to specialist Physiotherapist for pre- and post-operative rehabilitation. 1. Left Knee Instability - Impression, likely diagnosis for Issue 1 (condition name only): Anterior Cruciate Ligament (ACL) rupture - Differential diagnosis for Issue 1 (only if applicable): Other ligamentous injuries (e.g., PCL, collateral ligaments), patellar instability. - Investigations planned for Issue 1 (only if applicable): Not applicable, MRI confirmed diagnosis. - Treatment planned for Issue 1 (only if applicable): ACL reconstruction. - Relevant referrals for Issue 1 (only if applicable): Orthopaedic surgeon. 2. Left Knee Pain and Locking - Impression, likely diagnosis for Issue 2 (condition name only): Medial Meniscal Tear - Differential diagnosis for Issue 2 (only if applicable): Chondral injury, loose body. - Investigations planned for Issue 2 (only if applicable): Not applicable, MRI confirmed diagnosis. - Treatment planned for Issue 2 (only if applicable): Meniscal repair during arthroscopy. - Relevant referrals for Issue 2 (only if applicable): Orthopaedic surgeon. Please do not hesitate to contact our office if you have any questions or require further clarification regarding your diagnosis or treatment plan.