You Be The Doc – Twisted Knee

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:

ski.jpgThe 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.

ski3.jpgThe 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:

knee-mri.jpgA.) MRI
B.) R-I-C-E. This is the acronym for Rest, Ice, Compression, Elevation
C.) Knee immobilizer
D.) Xray
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)

20 thoughts on “You Be The Doc – Twisted Knee

  1. Would not an X-ray be a good Idea? and if something weird shows up then an orthopaedic referral would be appropriate. In the mean time, I would always apply the magic RICE and start with anti-inflammatory analgesia treatment (unless he’s allergic…so which ever med would be suitable)
    How did I do , doc? =]
    And tell him to stick to cross-country skiing. Its much safer, if not boring.

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  2. Pingback: Twisted Knee - What I Did «

  3. batguano101

    The pop gave it away as surgical.
    Your physical exam indicated a posterior cruciate ligament and on your MRI there it is and probably screamed at you when you looked at the series.
    I would go H and rib him a little with I out loud.
    You did a great workup and sent him off to the orthopod on a silver plater, so all he has to do is schedule and tidy up the tendon.
    You are too good doctor.

    Here is my only real issue but granted it is a personal one.
    I studied and am licensed abroad, and the issue there is narcotics cannot be kept due to theft so we use Ketorolac.
    I still do not know the limits exactly on pain, but it is suppose to be equivalent to Morphine sulphate for the ER.

    The point is here in the USA these non addictive NSAIDS are available, but the addictive, highly addictive, PO opiates are ALWAYS used instead.
    So what is your view doctor? Am I just an FMG who does not count, or is it harmful to patients to load them with opiates when diclofenac would work among others?

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    1. NotaDoctor

      I agree. I tore my ACL and all I needed was advil, on a regular schedule. After the first few days I needed no pain meds. The point is to safely get rid of the pain so you can function.

      P.S. I am not a fan of the pivot shift test either. 🙂

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  4. hopeless101

    i twist my knee all the time and after a lot of rest and doing R-I-C-E it should start to feel better. however do not try to do sport for a few weeks after as there is a very high risk of doing it again.

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  5. I had an enormous swelling from my knee. My doctor told me to do swat thrusts, I had never heard of R I C E . I was in a lot of pain and the joints burnt as I walked. The second time my doctor told me it was normal and to do excersise. I now believe I twisted my knee at work. I am going back to the “doctor” soon.

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  6. SueLynn

    Xrays to make sure there isn’t a fracture. Then a MRI to check for torn cartilage. Then surgery depending on the severity of the injury as seen on the MRI films. Thats my plan of action.

    Have a great day.

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  7. greg

    I’ve been an MD for 30 years. 20mg/kg of morphine and 50 cc prilosec, followed by ATK amputation. Better to be safe than sorry. And a bottle of single malt whisky (for you).

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  8. Tamee

    my son did something called a leg bar to me about a week ago we were just playing around and he grabbed my leg and somehow twisted and pulled til it popped I was supposed to say tap out well i didn’t know that it still hurts i can walk on it for about 30 minutes and then it just aches inside it hurts if i touch the right side of the knee it shoots up my leg and down and it wakes me up at night should I see a doctor or will it go away?

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    1. Yep. And what I recommended, if I remember.

      But, truth be told, I’m of the persuasion that RICE is a food, not a medical therapy (or a verb). IMHO, RICE is the modern equivalent of home-calling country doc telling the most fretful person in the room to boil water just to give them something to do.

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  9. B. Anderson

    About 8 months ago I injured my knee, both in fact. I can still walk, and all that good stuff, but it hurts quite a lot, and I end up having sit down after about 10 minutes. I had to visit a clinic 7 times before they would send me for an Xray, and on the 8th visit they finally scheduled me in for an MRI (still waiting for that to happen actually).

    I’m just a little ‘ole BLS EMS provider, and my experience currently consists of dealing with gunshots drawn on with sharpies in a classroom, and my most significant trauma event was when I cut my face shaving. Nevertheless, I can take a good guess saying it’s a torn cartilage of some sort, perhaps the meniscus. Medial pain, locking of the joint, the squeaking sound it makes can’t be good either, but I was told it would go away and to come back if it persisted.

    Canada could use some physicians like yourself, and maybe then people here wouldn’t be forced to infiltrate the emergency department when nothing gets done outside of it.

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