Acute Knee Injury in a Soccer Player

Abstract

HISTORY: A fifteen year old female high school soccer player presented to a sports medicine clinic with a 2 day history of right knee pain. During a soccer game, she was tripped up over another player's feet going for the ball suffering a valgus injury to her right knee. Patient reported feeling a pop with immediate pain. She limped off of the field but had been using crutches and knee immobilizer at time of presentation. She complained of swelling and worsening pain with weight-bearing or knee flexion. She denied radiation of her pain, numbness or tingling. Medical HISTORY: Negative for previous knee injury or surgery. Positive for ankle sprain PHYSICAL EXAM: Right knee: Small joint effusion with tenderness to palpation over course of MCL primarily proximal and midportion as well as over lateral femoral condyle. Negative patellar apprehension test. Range of motion limited in flexion to 90 degrees. Patient able to achieve full extension. There was no laxity with valgus and varus stress at 0 degrees. At 30 degrees had guarding and laxity (1+) with valgus stress. stable to varus stress. Guarded with lachman exam without firm endpoint. Negative posterior drawer. Pain with McMurray's test without catch or clunk, localized deep in knee. Full range of motion at ankle, 2+ distal pulses, sensation intact to light touch in LE. DIFFERENTIAL DIAGNOSIS: 1. ACL injury 2. Patellar Dislocation 3. Bone Bruise 4. Occult Fracture 5. Meniscus Injury 6. MCL sprain TESTS AND RESULTS: Plain films: 3 views right knee: no acute fracture MRI right knee: non- displaced Salter-Harris IV fracture of the distal femur. Grade 2 sprain of the superficial medial collateral ligament and patellofemoral ligament at the femoral attachment. Bone marrow contusion pattern suggesting a pivot shift injury with intact ACL. Working Diagnosis: MCL sprain with non-displaced Salter IV femur fracture Treatment: 1. 6 weeks nonweightbearing in TROM with progressive return to weightbearing activities. 2.Locked in extension for 4 weeks, unlocked TROM for 2 weeks 3. Physical therapy: Initially comprised of straight leg raises, quadriceps sets and range of motion modalities. At 4 weeks, therapy was advanced to progressive weightbearing activities. At 6 weeks, patient was transitioned to sport specific modalities and agility training. Outcome: Gradual return to soccer play in 10 weeks