Elbow Case Study 1 : Partial Tear of

medial meniscus and collateral ligament

Case History 1 – Knee

Robert Long is a 32 year old solicitor who plays football twice per week in his spare
time. 10 days ago, while playing football, he was tackled and fell. He continued for 5
minutes, but was unable to continue due to pain and giving way in the left knee when
he twisted. He now complains of pain over the medial aspect. He has a lot of
swelling over the knee and walks with a limp. His likely diagnosis is that he has
sustained a partial tear of the medial meniscus and collateral ligament but the anterior
cruciate ligament is OK. He lives with his wife and 2 sons in a 3-bed house and is not
currently taking any medication other than anti-inflammatories.

Anatomy & Pathology

Medial Meniscus – tough cartlidge confirms to surfaces of the tibia and fibula
(femoral plateau and tibial condyles) distributes body weight trauma if knee bent or
twisted.

Lateral Collateral Ligament – rarely injured

Medial Collateral Ligament – can heal on its own with knee brace

The anterior cruciate ligament the MCL and meniscus are known as the “unhappy
triad” of injuries – they can occur together.

The knee has limited inherent stability – ACL & pcl stabilise against posterior and
anterior force – LCL & MCL – varus and valgus force

Subjective Examination
Where\What : medial aspect of left knee - with MCL expect pain medial swelling
and instability – with meniscal tear expect pain stiffness swelling and or popping

When: 10 days ago

How: trauma football – with MCL we can expect instability to be part of the trauma
we can expect impact and we can expect limited motion over 6-8 hours – with
Meniscal tear we can expect a twist and swelling to come on after 2/3 days.

0-10 rating: mid range

24-hour cycle: ask

Better for: activity

Worse for: rest

Type of pain: ask

Past Medical History/ General History: one

Red Flags and general concerns: is ACL ok

SH: age of sons? Does he go up and down stairs?

DH: only NSAID’s

Patient’s main outcome: perhaps reduce pain – or play football

Objective Examination

Working Hypothesis: confirm diagnosis and rule out ACL damage

Advice & Consent: ask and obtain

General Observations: confidence in walking – any signs of instability –

especially when turning

Acute Observations:
Skin colour – bruising – especially if traumatic
Swelling – from both MCL and Meniscal tear
Posture – observe
Muscle bulk – unlikely observe
Deformity – examine, unlikely

Active Tests: position patient in flexion for prone

Extension – have patient sitting on side of bed
Rotations – have patient on side of bed with feet on ground

Flexion Extension
Medial rotation
Lateral Rotation

– Meniscal injury expect limited motion in flexion & extension some popping o
clicking

Passive Tests:
Flexion extension
Medial rotation
Lateral rotation

With meniscal tears expect limited ROM , and change in end feel due to swelling

Resisted Tests:
Flexion Extension
Medial Rotation
Lateral Rotation

Should still be OK insider range – perhaps small weakness but the injury is only 10
days old

Special Tests:
Position patient in supine

Mcmurrays test – knee flexed , rotate knee and passively extend to 90 degrees while
palpating the joint line – with lateral rotation a click and or pain will be reported if
there is a medial tear

Valgus/Varus – collateral ligament test – if it gives excessively sign of damage – for

varus (hand pushes out distal limb moves in) => lateral damage – for valgus (hand
push in distal out) =>-medial damage

Functional Tests: walking up stairs -> meniscal

Problem turning -> ligament damage
ACL (rule out damage by asking patient to hop if possible)

Palpation: tenderness on pressing => meniscus

MCL -> palpate with knee in flexion (figure of 4) along course of
MCL (medial femoral condyle to tibial insertion) – positive sign is pain on pressing
Measurements:
Record any limited motion in active flexion or extension

Advice & Possible Treatment:

MCL – cryotherapy, NSAID’s, braces, and physiotherapy – surgery is last resort – mcl
damage is treated conservatively.

Meniscal – cryotherapy steroid injections & surgery -> no sports till better! – Carries
a predisposition to degenerative arthritis