Case 1 - Knee Pain Post Workout

Case History

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Knee pain (left) for 10 months in a 25 year old fit man, who has been doing workouts for several years. Post gap of 15 days, he returned to Gym and started with 100 Kilo barbell squat. He has lifted this weight before, but this time it was after a gap of 15 days. He felt sudden pain in the knee and had to stop. There was no "POP" sound when this happened. Next few days he noticed swelling of the knee and took rest for 2 weeks. Post that, on doing weighted squats he has been getting pain and swelling. MRI scan of the knee and the whole thigh has been done which has been reported as completely normal. 

 

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Working Diagnosis

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Based on clinical findings so far what would be your working diagnosis?

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Quads tendinopathy?

Patellar tendinopathy?

Quads tendon tear?

Patellar tendon tear?

Patellar chondromalacia?

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Mental Math (History)

 

Quads tendinopathy or patellar tendinopathy can be considered, however these conditions are typically Repetitive strain injuries (RSI) and not acute injuries. 

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Quads tendon tear is possible, but that is commonly seen in people typically of the age above 40 years. 

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Patellar tendon tear is possible, however if that was the case he would have had symptoms with other activites as well and not just on doing barbell squats further to the initial eposide.

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Patellar cartilage tear can be considered. But this is commonly a repetitive strain injury as well and not a result of an acute injury. But, it cannot be ruled out at this point of time.

 

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Clinical Examination

 

On examination, we notice that there is a mild effusion. Knee range of movement is full. There is no tenderness of the quads tendon, patellar tendon and joint line. Patellar grind test is negative for pain and for grittiness. Meniscal tests are negative. On testing the ACL laxity present. Compared to other knee, there is more play however the definite end point was felt. Rest of the ligaments are stable. 

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Working Diagnosis

 

Based on the clinical history and examination what is your working diagnosis now?

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Patellar chondromalacia?

Tendinopathy?

ACL Partial tear?

 

Mental Math (History + Clinical Examination)

Patellar condromlacia can now be ruled out as our clinical examination has not revealed any pain or grittiness on examination. Tendinopathies are unlikely to be the prime reason as there is no tenderness of the tendons. ACL complete tear is unlikely as the end point is felt on examination of his knee. 

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Investigations

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X-ray did not reveal any bone abnormailities. MRI scan images reveal a stretch in the ACL appearing like a sail. Although there was no proper tear, but MR scan images showed an ACL grade 1 injury. 

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Mental Math (History + Clinical Examination+ Investigations)

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Putting all these things together in a nutshell, let us try to solve the problem. The nature of injury may not typical of the ACL injury. However, while doing barbell squatswhen he had a jerky movement there was a twisting moment with the foot being planted firm. The effusion doesn't happen without an injury of a structure inside the knee joint. MRI scan reports may be suggestive of lots of things or may even omit certain things, however only when you clinically correlate and look for the right things, the diagnosis can become evident. 

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