Medial Meniscus

[SportRehab]

Hi Guys

I have a client (18 years old footy player) who twisted his knee 5 weeks ago.

Mechanism: lateral knee rotation on a flexed knee (twisting out on a fixed foot)

He is now much better, however he still experiences pain on kicking the ball with the inner side of the foot. He also complains on a feeling of "instability" in the knee

Facts about his current status:

- positive medial Mc'murrays & negative prone and standing Appley's compression
- no pain on medial joint line (firm) palpation
- all ligament provocation tests are OK (MCL, LCL, ACL, PCL)
- pain on passive knee flexion and extension (especially with overpressure)
- feels fine with CKC exercises (SL deadlifts, lateral squats, rotational lunge) and nordic curls
- good proprioception and knee appears stable whilst performing excursion exercises

My questions:

1.) is it possible anyhow that he has got stage III medial meniscus rupture, which contraindicates aggressive CKC strengthening? (he does not have locking, crepitations or pain during active and passive knee motion)....ROM is also near full. Does such a clinical observation rule out stage III lesion?
2.) is it more likely that deep coronary ligament is affected?
3.) is there any chance that the knee cartilage is damaged (althoug clinically appears to be fine?)

4.) And most importantly any other suggestions in terms of follow up treatment? (Continuing with CKC, Foamrolling,...)?

Thanks in advance

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[mnovikov]

Hi,
How is his ROM, end feel, and quadrants? If he is just a bit restricted in end of flexion or extension, try some repetitive movements to end range, even it there is pain. If it produces pain but it does not last after, recheck your baselines: ROM, squats, jumps whatever reproduces his pain. You may also have to play in the internal/external rotations combined with flexion or extension. If it gets worse after repeated movements in one direction, try the other if to see if it eases.

[SportRehab]

As i said in the previous post, his ROM is near full (maybe loss of 5 degrees in extension and flexion) ... the passive overpressure however brings some pain in both directions (quite indicative for meniscal lesion). Ultrasound examination also confirmed no MCL or LCL rupture (as i previously diagnosed)

Rotation and extension is combined with Mc'Murray's if that is what you mean? And yes medial Mc'murrays still reproduces deep joint pain, but there is no locking, crepitation.

he is able to perform lateral lunges, nordic hamstring curls, SL deadlifts and normal squats until 45 degrees of flexion (i have also added some weights and he is totally happy about it).... furthermore, his proprioception remains quite solid, he has good control on one leg (excursion exercises), also knee appears stable as he is not shaking nor valgus-collapsing during exercises. And most importantly - no pain at all. Pain is sometimes reproduced on football pitch (kicking the ball) and twisting and cutting.

Just wanted to ask you guys - based on your experience do you think is it anyhow possible for this patient to have a stage III meniscus lesion?
(I am almost 95% that he does not, based on my assessment and his level of fitness)... we would like rule this out and continue with conservative approach as this is desirable for stage I,II lesion anyways.

[Yarok]

hi

ultrasound examination should show any damge to menisci.

As i said in the previous post, his ROM is near full (maybe loss of 5 degrees in extension and flexion) ... the passive overpressure however brings some pain in both directions (quite indicative for meniscal lesion). Ultrasound examination also confirmed no MCL or LCL rupture (as i previously diagnosed)

Rotation and extension is combined with Mc'Murray's if that is what you mean? And yes medial Mc'murrays still reproduces deep joint pain, but there is no locking, crepitation.

he is able to perform lateral lunges, nordic hamstring curls, SL deadlifts and normal squats until 45 degrees of flexion (i have also added some weights and he is totally happy about it).... furthermore, his proprioception remains quite solid, he has good control on one leg (excursion exercises), also knee appears stable as he is not shaking nor valgus-collapsing during exercises. And most importantly - no pain at all. Pain is sometimes reproduced on football pitch (kicking the ball) and twisting and cutting.

Just wanted to ask you guys - based on your experience do you think is it anyhow possible for this patient to have a stage III meniscus lesion?
(I am almost 95% that he does not, based on my assessment and his level of fitness)... we would like rule this out and continue with conservative approach as this is desirable for stage I,II lesion anyways.

- - - Updated - - -

hi

ultrasound examination should show any damge to menisci.

As i said in the previous post, his ROM is near full (maybe loss of 5 degrees in extension and flexion) ... the passive overpressure however brings some pain in both directions (quite indicative for meniscal lesion). Ultrasound examination also confirmed no MCL or LCL rupture (as i previously diagnosed)

Rotation and extension is combined with Mc'Murray's if that is what you mean? And yes medial Mc'murrays still reproduces deep joint pain, but there is no locking, crepitation.

he is able to perform lateral lunges, nordic hamstring curls, SL deadlifts and normal squats until 45 degrees of flexion (i have also added some weights and he is totally happy about it).... furthermore, his proprioception remains quite solid, he has good control on one leg (excursion exercises), also knee appears stable as he is not shaking nor valgus-collapsing during exercises. And most importantly - no pain at all. Pain is sometimes reproduced on football pitch (kicking the ball) and twisting and cutting.

Just wanted to ask you guys - based on your experience do you think is it anyhow possible for this patient to have a stage III meniscus lesion?
(I am almost 95% that he does not, based on my assessment and his level of fitness)... we would like rule this out and continue with conservative approach as this is desirable for stage I,II lesion anyways.

[SportRehab]

Unfortunately not my friend. Ultrasound is really poor tool for diagnosing intra-articular lesions (MRI would be much better as it is 90-95 % accurate for torn meniscus). But at least the ligament integrity was double checked with this.

Still would welcome any suggestions,...