Below is a case I saw recently that challenged me. You be the doc and tell me what you would do. In a few days I’ll describe the plan I settled on with my patient:
The Story: Young man, approximately 30 years old. Exercises regularly, in very good shape. Recently was skiing and tried to swerve. His left ski continued in the same line but his body and the other ski turned more than 90 degrees to the right. Before he could right himself, he heard an audible “pop” in his left knee, and then he crashed (I asked if the wipe out was at least cool…he said no, it was slow and goofy. He was barely moving). When he tried to get up, he felt excruciating pain in his knee and throughout his whole leg. He was barely able to get down the hill and could hardly walk to the car. Conveniently, someone else was driving home.
He came to see me on crutches, nearly incapable of putting weight on the knee. The accident happened approximately 24 hours prior to seeing me. He said the knee did not swell dramatically and that some motions hurt intensely and others weren’t so bad.
The Exam: The knee looked almost totally normal compared to the right one. I couldn’t see any swelling and couldn’t make fluid waves by bunching up the skin and tapping on it. The lateral (outside) and medial (inside) edges of the joint were not painful to pushing. The patella (kneecap) and the ligament that holds it in place were aligned well and not tender. There was no laxity in the tendons and I couldn’t push the lower leg in and out (called the drawer sign).
However, determined to cause him massive pain in some way, I succeeded by holding his foot at the sole with his leg extended and twisting like I was turning a faucet. The pain was so bad he broke into a sweat, got out of breath, and gave me a seriously murderous look. The pain was equally bad rotating the other direction. Most other motions of the joint did not cause pain but there was some stiffness.
The Choices: Here are some of the things I considered for a plan:
B.) R-I-C-E. This is the acronym for Rest, Ice, Compression, Elevation
C.) Knee immobilizer
E.) Referral to orthopedics for eval and probable surgery
F.) Narcotic pain meds + B
G.) Non-narcotic pain meds + B
H.) All of the above
I.) Tell him to learn to ski better and not be such a clutz (KIDDING, kidding, didn’t really think this about the guy…I’ve bailed like an idiot more times that I can count on my surfboard)