Case Presentation
A 25-year-old patient presents to the ER with left knee pain
Patellar soft tissue injuries
Prepatellar Bursitis (Housemaid's Knee)Patient will present as → a 40-year-old carpet installer who spends his working day on his knees, fitting carpets. In the past few months, he had been aware of a dull ache over his right knee, which had seemed to be aggravated by pressure and flexion of the knee. He had been wearing kneepads, using a soft mat, and trying to avoid kneeling on that knee. However, he was alarmed to wake one morning with a large, tender, fluctuant swelling over the kneecap. |
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Prepatellar bursitis is an inflammation of the bursa in the front of the kneecap (patella)
DX: Concern for septic bursitis in wrestlers - aspiration with gram stain and culture
TX: compressive wrap, NSAIDs, +/- aspiration, and immobilization for 1 week. Corticosteroid use is controversial
References: Merck Manual · UpToDate |
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Picmonic
Prepatellar bursitis is an inflammation of the prepatellar bursa in front of the kneecap that can be caused by repeated trauma on the flexed knee (e.g., sports injuries, pressure from excessive kneeling). It is also known as Housemaid’s knee. Manifestations include pain and erythema. A minority of the cases can be complicated by septic bursitis from staphylococcus aureus. Aspiration can be done in patients with acute bursitis to rule out infectious causes of gout. NSAIDs are used to manage symptoms, and antibiotics should be added if an infectious etiology is suspected. Play Video + Quiz |
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Patellar TendinitisPatient will present as → a 22-year-old college basketball player with chronic anterior pain of her right knee. The patient has had over 6 months of physical therapy without improvement. It initially only bothered her during training, but she is now no longer able to compete and has pain with daily activities. Physical exam reveals swelling of the anterior knee and tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at distal pole of the patella in full flexion. Her MRI is shown here. |
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An injury to the tissue connecting the kneecap to the shin bone (patellar tendon)
DX: Radiographs - AP, lateral, skyline views of the knee - usually normal -may show inferior traction spur (enthesophyte) in chronic cases
TX: Ice, rest, activity modification, followed by physical therapy. Surgical excision and suture repair as needed
References: Merck Manual · UpToDate |
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Patellofemoral Pain (PFP)Patient will present as → a 27-year-old female presents with knee pain. Her pain worsens when she is running downhill or climbing up the stairs. She describes the pain as “achy” and being behind the knee. When sitting for long periods of time, she reports her knees feeling stiff. She denies any recent history of trauma and has never had surgery. She has tried multiple over-the-counter analgesics but were not effective. She is a registered dietician and an avid runner who is preparing for a marathon. A full knee examination is performed. |
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 "The term chondromalacia patella is used to describe pathologic changes in the articular cartilage of the patella, such as softening, erosion, and fragmentation. While frequently confused with PFP, chondromalacia patella is a pathologic diagnosis and constitutes a distinct cause of knee pain. - UpToDate" DX: Although PFP is a clinical diagnosis, the diagnosis can be supported by the patellofemoral compression test (reproduction of the pain with compression of the patella during knee extension) TX: Treatment is usually conservative with the use of physical therapy, weight loss, NSAIDs, and support braces References: Merck Manual · UpToDate |
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Picmonic Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome, or PFPS, is an overuse injury of the knee, commonly seen in young athletic women. Pain in this syndrome is primarily poorly localized anterior knee pain, that worsens with squatting, running, prolonged sitting, and climbing stairs. Although PFPS is a clinical diagnosis, the diagnosis can be supported by the patellofemoral compression test and the apprehension sign. Treatment is usually conservative with the use of physical therapy, weight loss, NSAIDs, and support braces. Play Video + Quiz |
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Ligament/Meniscal injuries
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Anterior Cruciate Ligament (ACL) TearPatient will present as → a 24-year-old male with severe pain in the right knee. He is a professional football player and a few hours prior to presentation, an opposing player hit his leg from his left side. Afterward, he felt a “popping” sound that was followed by severe knee pain and a sensation of knee instability. On physical exam, there is an anterior translation of the proximal tibia when pulled as the patient has the knee flexed at 90° and supine. Ice is applied to the knee and ibuprofen is prescribed. An MRI is ordered. Orthopedic surgery is consulted to evaluate if ligament reconstruction is needed. |
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Testing:
DX: Magnetic resonance imaging (MRI) can confirm the diagnosis
References: Merck Manual · UpToDate |
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A 33-year-old male presents to your office with a complaint of right knee injury associated with pain and swelling. He states he was running after his loose dog and suddenly stopped, hyperextended his knee, heard a pop and noticed immediate swelling. On physical examination, the Lachman test and anterior drawer test demonstrates joint laxity. Which of the following ligaments is most likely injured?
Question 1 Explanation: Anterior cruciate ligament injuries occur with sudden deceleration injuries. Patients often hear a pop and the diagnosis is aided by assessing the anterior drawer test and Lachman test. The immediate swelling as well as laxity with anterior drawer test and Lachman test should raise suspicion of anterior cruciate ligament injury.
There is 1 question to complete.
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Picmonic Anterior cruciate ligament (ACL) tear
The ACL stabilizes the knee by resisting hyperextension and anterior dislocation of the tibia during flexion. Injuries typically occur during non-contact sports such as basketball and soccer, but can also occur from trauma. Play Video + Quiz |
Medial Collateral Ligament (MCL) TearPatient will present as → a 26-year-old college football player is brought to the emergency department after being hit on the lateral side of the left knee. He reports hearing a pop and then his knee buckled. He is now in severe pain and is having difficulty walking. On examination, there is swelling over the medial aspect of the left knee. There is laxity when a valgus stress test is performed on the knee. The results of the Lachman and McMurray tests are negative. You order an MRI of the knee with results seen here. |
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Patient will present → after sustaining a valgus stress injury (from the outside) such as a hit in football
DX: MRI definitive study TX: Conservative treatment with bracing and physical therapy is typically effective
References: Merck Manual · UpToDate |
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Picmonic Medial collateral ligament (MCL) tear
 A medial collateral ligament (MCL) tear is an injury of the ligament that connects the femur to the tibia on the medial aspect of the knee. It occurs in patients that have experienced high-energy trauma. It is typically treated conservatively and can be clinically observed with the valgus stress test. Play Video + Quiz |
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Lateral Collateral Ligament (LCL) TearPatient will present as → a 25-year-old soccer player injures his knee after colliding with an opposing player during a game. On physical exam, his Lachman is weakly positive. He has laxity to varus stress with the knee flexed to 30 degrees. Dial test of the tibia shows increased external rotation at 30 degrees, but not at 90 degrees in comparison to the contralateral leg. |
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DX: Radiographs - AP, lateral, and varus stress radiographs
TX: Conservative treatment with bracing and therapy is typically effective
References: Merck Manual · UpToDate |
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Posterior Cruciate Ligament (PCL) TearPatient will present as → a 22-year-old recreational soccer player who sustained a right knee injury 6 months ago. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee “giving way.” Physical exam reveals 10° varus alignment when standing and a varus thrust with walking. Strength is full compared to the other side. Ligamentous exam reveals a stable ACL and MCL but opens to a varus stress and a 3+ posterior drawer and positive dial test at both 30° and 90° degrees of flexion. |
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DX: MRI is the confirmatory study for the diagnosis of PCL injury TX: Protected weight bearing and rehab indicated for isolated Grade I (partial) and II (complete isolated) injuries
References: Merck Manual · UpToDate |
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Meniscal TearPatient will present as → a 35-year-old man with complaints of swelling and pain in the left knee. The patient states that he sustained a twisting injury in a football game 3 days ago. The injury did not take him out of the game; he was able to continue participating with minimal difficulty. Over the last 2 days, the pain has progressed. He notes a catching sensation and pain that is more medially located. On physical examination, the patient is found to have tenderness over the medial joint line and limited range of motion. Forced flexion and circumduction of the joint cause a painful click. |
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Testing
DX: Radiographs of the knee, possibly including sunrise, tunnel, posteroanterior, weight-bearing anteroposterior, and lateral views
TX: If the tear is not serious, physical therapy, compression, elevation, and icing of the knee can heal the meniscus
References: Merck Manual · UpToDate |
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Picmonic Meniscal Tear
The menisci are fibrocartilage semicircular bands that serve to stabilize the knee and absorb forces between the distal femoral condyles and the proximal tibial plateau of the knee. Injury can be sustained from trauma or in a degenerative manner. Symptoms include locking and clicking, as well as a positive McMurray test. Meniscus tears are typically managed conservatively, or in serious cases, surgery. Play Video + Quiz |
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