A 34-Year-Old Man

and Iain McNamara¹

(1)

Trauma & Orthopaedics, Norfolk & Norwich University Hospital, Norwich, United Kingdom

A 34-year-old man presented to the clinic with a 7-year history of right anterior knee pain.

Question 1

Is it likely that he has a serious condition?

He was not working because of mental health problems: agoraphobia and anxiety.

Question 2

Are these mental health problems likely to be part of the problem or irrelevant?

Seven years previously his symptoms started suddenly when he developed a sharp pain just above the patella after planting his left foot on the ground twisting on it. The problem has occurred more and more frequently, but over time he has been left with medial-sided suprapatellar pain that stops him from exercising significantly, reducing him to walking for about 30 min with his dog. The knee has never swollen or locked. He has difficulty on the stairs but not specifically up or down.

Question 3

What is the differential diagnosis?

He has tried foot orthotics, as well as an ultrasound-guided steroid injection into his knee, without benefit.

Question 4

What in the history predicted failure of an intra-articular steroid injection?

Current Medication

Drugs for mental health problems; no analgesics

Question 5

What is the significance of no analgesics being taken?

Question 6

What are the crucial examination findings that will help you come to a proper management plan?

On Examination

His BMI was 25, the Beighton score 1 out of 9.

He had a normal rotational profile to his lower limb with straight knees.

He had no effusion in either knee, and the VMO was of normal bulk and power. He had no marked tenderness in the quadriceps.

He did not relax when testing his patellar mediolateral glide. The patella tracked straight without crepitus. The knees had a full range of motion. The tibiofemoral joint was normal.

He had poor balance on each leg and during a single-leg squat on the left, he internally rotated his femur. On the right leg he could only manage to get about a quarter of the way down because of inhibition by pain.

Question 7

What images do you need and what do you expect them to show?

X-rays

The MRI scan was reported as:

There is mild/moderate distal quadriceps insertional tendinopathy with mild intra-substance myxoid degeneration and peritendinous oedema along the deep surface of the tendon. Normal appearances of the menisci with no meniscal tear identified. Normal appearances of the cruciate ligaments and collateral ligament complexes. The articular cartilage surfaces are preserved with no significant focal chondral or osteochondral defect identified. The subchondral marrow signal is normal throughout. No significant joint effusion. No sign of intra-articular loose bodies.

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