Knee Pain - Acute on Chronic - Football Player

Abstract

HISTORY A 14 year-old male presented to sports clinic with a complaint of left knee pain for five days. The patient is an offensive guard for his high school freshman football team. He stated that his injury occurred when he stepped on another player's foot while walking backwards which caused him to hyperextend his knee. At that point, he was unable to continue playing secondary to pain. He later felt the pain localized laterally across the knee. He also experienced swelling the following day, along with a sensation of locking or clicking. He had increased pain with stair climbing. The patient did report a previous hyperextension injury of the left knee six months prior to presenting to clinic with residual pain and swelling. These symptoms resolved and he had played without any problems. PMH/PSH: Negative Medications: Ibuprofen prn pain. No supplements, herbs, vitamins or prescription drugs Allergies: NKDA PHYSICAL EXAMINATION The patient was in no acute distress, walking with a nonantalgic gait. Vitals: Temp= 98.7 Pulse = 70 RR = 16 BP = 130/70 Weight = 260 Height =6′2″ Examination of lower extremities: Active ROM full at the hip and ankle bilaterally. The left knee was lacking full extension while prone with a heel height difference of 4cm. A mild effusion was present at the knee joint. The Patella was non-tender. Negative patellar apprehension and grind tests. Normal patellar tracking and good VMO strength. Mild anterolateral joint line tenderness. No tenderness at fibular head or IT Band. McMurray's, Anterior and Posterior drawer and Lachman's tests were negative. Negative valgus and varus laxity at 0 and 30 degrees. Positive pain at lateral joint line with varus stress. Negative external rotation recurvatum test. Negative Ober's. Positive difficulty with squatting. Differential Diagnosis Meniscal Injury Lateral Collateral Ligament Injury Posterolateral Corner Injury Osteochondral Defect (OCD) Patellar Subluxation TESTS AND RESULTS Xrays Left knee plain films read by Radiology as normal. However, in clinic reviewed and found to have a cortical disruption with OCD in the anterior lateral aspect of femoral condyle MRI left Knee Large OCD involving the anterior aspect of the lateral femoral condyle with a loose body noted anterior to the insertion site of the ACL most likely arising from the site of the OCD. ACL, PCL, LCL, MCL and menisci intact. FINAL WORKING DIAGNOSIS OCD of lateral femoral condyle with loose body TREATMENT AND OUTCOMES Nonweightbearing and orthopedic referral Scheduled arthroscopy with loose body removal. Possible microfracture, possible cartilage biopsy, possible internal fixation.