A 30-year-old woman comes to the physician with knee swelling and pain after twisting her knee while playing soccer 2 days ago. She is an avid soccer player and has increased her game time over the last couple of weeks. The patient was initially unable to bear weight on the knee but was able to walk later that day. She has iced the knee and taken ibuprofen, with some relief.
Physical examination shows a small effusion with medial joint line tenderness to palpation. Passive flexion and extension of the knee result in a painful click in mid-extension. The patient is unable to squat due to significant pain as she attempts the maneuver. Valgus and varus stress tests are normal. Anterior drawer test shows no signs of knee instability.
Plain radiographs of the knee are normal.
Which of the following is the most likely diagnosis?

Question

A 30-year-old woman comes to the physician with knee swelling and pain after twisting her knee while playing soccer 2 days ago.  She is an avid soccer player and has increased her game time over the last couple of weeks.  The patient was initially unable to bear weight on the knee but was able to walk later that day.  She has iced the knee and taken ibuprofen, with some relief.
Physical examination shows a small effusion with medial joint line tenderness to palpation.  Passive flexion and extension of the knee result in a painful click in mid-extension.  The patient is unable to squat due to significant pain as she attempts the maneuver.  Valgus and varus stress tests are normal.  Anterior drawer test shows no signs of knee instability.
Plain radiographs of the knee are normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_992c_2f49_853d_6fe798e6b316_MD0002_00 This patient's presentation of twisting injury with medial joint line tenderness, click during mid-extension, and negative instability testing is consistent with likely medial meniscal injury. Acute meniscal injuries usually occur after sudden twisting with a fixed foot during sudden deceleration and direction change. Chronic degenerative tears usually occur in older patients with repeated minimal twisting or stress. Meniscal tears can occur in isolation or with concomitant anterior cruciate ligament (ACL) injury. (Choice A) ACL injury can occur after a twisting injury but usually presents with joint instability and a positive anterior drawer test. This patient's normal joint stability and negative anterior drawer test make ACL injury unlikely. (Choice B) Medial collateral ligament injury usually presents with abnormal valgus stress testing, which is normal in this patient. (Choice D) Patellofemoral syndrome (PFS) is a diagnosis of exclusion that commonly occurs with overuse injuries but without pathognomic signs and symptoms. Although the medial joint line tenderness is worrisome for ligamentous disruption in this patient, PFS should be diagnosed only if all ligament evaluations are normal. (Choice E) Although stress fractures are common in sports activities with significant running (eg, soccer), patients usually have gradual symptom onset without range-of-motion abnormalities. Educational objective: Medial meniscal injuries typically present with pain, locking, and swelling. Ligament testing for instability is negative, but joint line tenderness is often present. __________ References: Clinical examination of the knee: know your tools for diagnosis of knee injuries. (http://www.ncbi.nlm.nih.gov/pubmed/22035381)

A 30-Year-Old Woman Comes to the Physician with Knee Swelling