Clinical Reasoning Case

Rockie is a 20-year-old college soccer player who states that she twisted her left knee while descending a hill during soccer practice 3 days ago. She did not fall, and was able to limp and hop back to campus with the assistance of a teammate. The team physician ordered imaging and referred her to PT at the time of the injury. She will be re-examined by an orthopedic surgeon in two weeks if she has not been able to return to full play by that time.

Subjective History

Name: Rockie Martin Date: February 16, 2018

Age: 20 y/0 Height: 5’7” Weight: 135# Occupation: College Student, Soccer Player

PMH: Right Ankle Sprain in 2017, Otherwise unremarkable BP:112/76 HR:68

Medications: Advil q4h

Diagnostic Imaging: X-ray negative, MRI ordered but not yet scheduled

Currently Working: Not Playing Soccer since injury Date of Injury: February 13, 2018

Mechanism of Injury: Twisted left knee while descending a hill during am soccer practice 3 days ago

Type of Complaint: Constant Dull Ache medial knee; Occasional buckling with descending stairs; Moderate Swelling began a couple hours after the injury.

Location/Spread: Medial Knee – no spread.

Constant or Intermittent: Constant

NPRS: Present/Best/Worst: 3/10; 1/10; 8/10 NPRS

Aggravating Factors: Descending stairs, running after 5 minutes, standing 30 minutes, sitting 30 minutes

Easing Factors: Rest, Ice, Elevation, Dangling the leg off the edge of the bed

24 Hour History: Stiff in sore in am which eases, then pain is dependent on activity, sleep is not affected in pm

Condition Improving, Static, Worsening: Slight Improvement since initial injury

New Injury/Old Injury/Episodic Injury: New Injury

Functional Loss: Obligate or Non-Obligate: Antalgic Gait with limp. Unable to run or play soccer

Recreational Hobbies and Activities: Dancing, Cycling

Functional Questionnaire: KOS ADLS: 54%; KOS Sport: 29%

Previous Treatment: Not Applicable

Patient Goals: Return to soccer ASAP. Participate in upcoming tournament

FUP’s: No catching or locking, no back, hip, or thigh symptoms. No bowel or bladder dysfunction

Physical Examination Findings

Posture: Left hip and knee held in slight flexion. Decreased WB left LE. No atrophy with good muscle bulk and contour. Visible suprapatellar swelling. Bilateral foot pronation and genu valgum.

Gait: Antalgic. Decreased WB Left with Short and quick step right LE.

Lumbar and Hip Screening: Negative with no impact on symptoms

Standing Exam

Squat: Decreased depth (70%) limited by avoidance of knee flexion.

Step Down: Antalgic with increased genu valgum and decreased knee flexion. Step up increase in left knee pain

SLS: Right: 30 seconds EC, Left: 10 Seconds

Sitting

Reflexes: 2+ Bilateral

MMT: Right LE: 5/5 MMT. Left Knee Flexion: 4+, Extension: 4/5 with pain. Other hip and Ankle MMT: 5/5 Bilateral

Special Tests: Positive McConnell Test

Lying

ROM: Right: 5 degrees of hyperextension to 135 AROM, 140 PROM

Left: 0-130 AROM with pain reproduced with overpressure flexion> Extension

Girth: Mid Patella: Left 3cm > Right; Left = Right 5 cm above patella

Palpation: Crepitus with AROM, tender medial patella

Special Tests: Positive Ober Test Bilateral, Q-Angle 20 degrees bilateral, Positive Balottment Test, Modified Stroke Test 1 left, Negative Anterior Drawer Bilateral. Slight positive on Lachman Left.