Knee Pain

Matthew A. Close, DOSteadman-Hawkins Sports MedicineGreenville Hospital System University Medical Center

Chief Complaint and HistoryCC:16-year-old offensive lineman who presented to the training room with left knee pain after a football game HPI:No specific injury during the gameSwelling and moderate pain afterwards No giving way, locking or catchingMild numbness over the top of his kneeNo previous injury

Physical ExamInspection: Moderate soft tissue edema antero-medially. Antalgic gait. Palpation: Trace effusion, TTP at anterior medial joint line, and distal medial quadriceps with deep palpation. ROM: Active 5/0/115, Passive produced pain with flexion past 120 degrees.

Physical ExamStrength: 5/5 strength in knee flexion/extension. Stability: Stable in varus/valgus at 0 and 30 degrees. Negative Lachman. Stable ant/post drawers. Special Tests: Discomfort with McMurray, but no click.Neurovascular: Numbness over top of knee. Pulses 2/4 at DP and PT.

Differential Diagnosis

Differential DiagnosisACL tearMedial meniscal tearPatella contusionPartial quadriceps tearThigh contusionPrepatellar bursitisMCL sprain

Tests and Results

Tests and Results

5 Days Post-Injury

MRI

MRI ResultsExtensive subcutaneous edema anteriorly with mild fluid collection between subQ fat and underlying fascia. Increased signal in posterior medial meniscus, no tear. Grade 1 chondromalacia of patella. Cruciate and collateral ligaments without injury.

Final Working Diagnosis

Final Working Diagnosis

Historical PerspectiveMaurice Morel-Lavallee (1853)Tejwani SG, et al. Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the National Football League. Am J Sports Med. 2007; 35(7):1162-1167.24 patients (27 knees)14 (52%) conservative13 (48%) aspiration (mean 2.7 times)3 (11%) doxycycline sclerodesisTime to full resolution 16.3 days

Treatment and OutcomeTreatmentNeoprene compression sleeve, cryotherapy, rest. Rehabilitation coordinated with schools athletic trainer, emphasizing ROM exercises and quadriceps strengthening. Swelling and ecchymosis eventually resolved.OutcomePt returned to football practice after 2 weeks, and resumed starting position 3 weeks after injury.

Prepatellar Bursitis

*Axial section at femoral metaphysis. Confluent fluid collection between vastus musculature and subQ fat*