Physical Examination and a Provisional Clinical Diagnosis
It is crucial that the knee examination should be approached in a systematic manner, and compared with the unaffected knee, in order to obtain a baseline.
On asking the patient to indicate the most painful area or areas of his knee, he pointed to both the lateral and medial joint line. It is very important to identify the precise location as knee injuries represent some of the most clinically challenging musculoskeletal disorders (Hoyt et al 2007). The areas indicated suggested a meniscul injury. Other clinical tests would follow to get a provisional diagnosis.
Physical examination manoeuvres of the Appley and Mc Murray tests were performed on the injured knee. These two tests are clinically proven to provide a definite diagnosis of a meniscus injury (Brunker et al 2009, Hernandez et al 2006, Choi et al 2009) .Both tests proved positive indicating a potential meniscus injury. Other clinical signs and symptoms of the injured knee observed were:
- Joint line tenderness (palpated with the knee flexed at 45-90 degrees.
- Joint effusion – this is usually present, although absence of an effusion does not necessarily rule out meniscal damage.
- Pain – usually present on squatting, especially with posterior horn tears.
- Restricted range of motion of the knee joint – this may be due to the torn meniscal flap or the effusion .
- A positive Mc Murrays – this is positive when one can hear a “clunk” and pain is reproduced on flexion and rotation (Brunker et al 2009).
On the evidence of the physical examination it was decided to send the patient for an orthopedic review to one of the local surgeons. The patient was subsequently seen very quickly by an orthopedic surgeon it was agreed that the provisional diagnostic findings were accurate in this particular case. The “Ottawa Knee Rules “(OKR) applied that a magnetic resonance imaging (MRI) was not indicated. This rule states that 65.5% of MRI’s are unnecessary (O’Sullivan et al 2006). However, in conflict to the OKR an MRI scan was ordered and the results revealed a Grade 1, 1mm tear to the peripheral rim. This was also shown to be true in that the vascularity of the meniscus is poor beyond 1-2mm from the meniscosynovial junction, yet 22% of tears occur with a > 3mm of the peripheral white rim. Henning in 1987 stated that it is possible to obtain healing with a 5mm peripheral white rim without resection of any portion of this rim, thus maintaining the full size of the meniscus. However the study in quiet old and possible out of date. The purpose of taking the MRI was to determine the precise location, tear and type to the meniscus. In this case the surgeon felt justified in providing this service. Nevertheless an MRI will provide more information to the surgeon in choosing the appropriate treatment methods with the help of arthroscopic findings (Ahn et al 2009).In contrast (Johnson 2000) stated in his research that it is often necessary to assess a swollen knee by providing the patient with a radiograph image. The patients in this study all underwent anterior cruciate ligament (ACL) reconstruction as opposed to meniscal repair.
The surgeon recommended to the patient, to repair the meniscal tear rather than perform an arthroscopic procedure. A menisectomy is not an innocuous procedure and it seems reasonable to suggest that if an injured meniscus could be salvaged rather than excised, the outcome in meniscal surgery might improve (Wirth 1981).
Although meniscus tears suitable for repair are infrequent, meniscal repair is preferable to meniscectomy (Barber 1987).The knee was immobilized for a period of 6 weeks as a form of repair. The results show that there was greater healing, tissue strength, compared to suturing the meniscus with immobilization (Zhang 1987). The interpretation of this study, however, must be made with caution as the tissue used was animal (rabbits), rather than human. Further research is indicated in this area to ascertain clinical significance. The main advantage of meniscal repair can prevent the onset of osteoarthritis (OA) (Saxon et al 1999).Research has shown that to be true, however the downside for the sports person is that rehabilitation time is much longer for recovery and therefore perhaps not an option, possibly selecting an meniscectomy instead (Barber 1987). As a quick return to their sport in the athletes mind, is paramount.
After further consultation with his surgeon, who went through the advantages and disadvantages of surgery the patient decided on receiving a partial meniscectomy. His decision was purely based on a quicker return to his sport. Anecdotal evidence would suggest 5 weeks post op, as opposed to 10 weeks after a meniscal repair (Boyd 2002).He was also advised that any further damage to the same meniscus could lead to developing early OA of the knee (Saxon et al 1999). After listening to all the advice from his consultant surgeon, the patient in this study upheld his decision to go ahead with a partial meniscectomy.