A 22-year-old man comes to the office due to intermittent right knee pain that has been increasing for the past 8 weeks. The pain began after the patient participated in a recreational soccer tournament, but he does not recall any significant injuries. He has intermittent, moderate pain associated with a sensation of "catching" in the knee while walking. At times he is unable to completely extend the knee. The patient also had swelling at the joint several days after the pain began, but the swelling slowly resolved. The symptoms affect his daily routine, especially outdoor activities, which he has not done since the injury. He has taken over-the-counter acetaminophen with inconsistent relief. On examination, his gait is grossly normal. There is full, pain-free range of motion of the knee with no erythema, warmth, or swelling. No ligamentous laxity is found with varus or valgus stress, or with anterior or posterior traction on the lower leg. With the knee held in internal and external rotation, flexion and extension at the knee elicits moderate pain and crepitus. X-ray of the knee is normal. Which of the following is the best next step in management of this patient?

Question

A 22-year-old man comes to the office due to intermittent right knee pain that has been increasing for the past 8 weeks.  The pain began after the patient participated in a recreational soccer tournament, but he does not recall any significant injuries.  He has intermittent, moderate pain associated with a sensation of "catching" in the knee while walking.  At times he is unable to completely extend the knee.  The patient also had swelling at the joint several days after the pain began, but the swelling slowly resolved.  The symptoms affect his daily routine, especially outdoor activities, which he has not done since the injury.  He has taken over-the-counter acetaminophen with inconsistent relief.   On examination, his gait is grossly normal.  There is full, pain-free range of motion of the knee with no erythema, warmth, or swelling.  No ligamentous laxity is found with varus or valgus stress, or with anterior or posterior traction on the lower leg.  With the knee held in internal and external rotation, flexion and extension at the knee elicits moderate pain and crepitus.  X-ray of the knee is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d96b_7e0f_bc81_d13b2d5d49b7_MD0003_00 This patient has intermittent knee pain associated with catching of the joint and limitation in range of motion. This suggests a tear of the meniscus, which is commonly caused by a twisting injury while the foot is in a fixed position. Patients may also have an associated effusion and a sensation of instability. Examination findings can include medial joint line tenderness and palpable locking or catching when the joint is rotated or extended while under load (eg, Thessaly test, McMurray test [as in this patient]). However, although these tests have high specificity for meniscal injury, sensitivity is variable, and patients may have normal findings at the time of examination. Thessaly test McMurray test Patients with short-term symptoms and minimal limitations in activity, or older patients with chronic tears due to degeneration of the cartilage, can be managed conservatively with rest and nonsteroidal anti-inflammatory drugs (Choice C). However, young patients who have mechanical limitations or recurrent effusions lasting >3-4 weeks should be considered for confirmatory MRI, which can clearly visualize the soft tissues of the knee. If a significant tear is found, surgical consultation is recommended. (Choice A) Arthrocentesis is recommended to evaluate unexplained joint effusions. This patient's effusion has resolved, and arthrocentesis is unlikely to be useful. (Choice B) Intraarticular glucocorticoid injections are recommended only in patients with degenerative meniscal injury due to underlying osteoarthritis. (Choice E) Radionuclide bone scans are used to evaluate malignant, infectious, or inflammatory bone diseases. These scans can also identify occult fractures, but MRI is superior for imaging the soft tissues of the knee and would identify an occult fracture as well. Educational objective: Acute knee pain associated with catching or reduced range of motion suggests a meniscal tear. Persistent symptoms in patients with suspected meniscal injury should be evaluated by MRI, and surgical consultation is advised for significant tears.

A 22-Year-Old Man Comes to the Office Due to Intermittent