[0:00]Hey everyone, we've got another super case study for you today. Our patient has had a knee injury and is getting ongoing pain following this injury.
[0:09]So can you work out what's going on with this patient? We're going to guide you through the assessment, the diagnosis and all the clinical reasoning, so if you're ready, let's dive in.
[0:20]Hey everyone, Khalida here. Welcome back to Clinical Physio. Thank you so much for joining us for another case study, and today's patient has had a knee trauma.
[0:28]Now, if you like this video, please help us by smashing that like button. It's the best way you can support our channel. And otherwise, let's dive into this case study.
[0:36]So, our patient is a 44-year-old lady, and she's had a significant knee injury, but this isn't her first knee injury.
[0:45]We can see that in 2012, she tore her ACL in her left knee.
[0:52]This was surgically repaired. Then in 2020, she injured her left medial meniscus, which was also surgically repaired.
[1:01]So, this patient has had a history of left knee injuries, but also a history of left knee surgeries.
[1:07]Then, five weeks ago, the patient had an injury whilst skiing.
[1:12]This was done abroad, and she had all the right investigations following her injury, and it was seen that she experienced a tibial plateau fracture.
[1:25]She had reruptured her left ACL that was previously surgically repaired, and she had a medial meniscal root tear.
[1:34]And a root tear is a tear of where the meniscus actually joins on to the bone at the most central point, and therefore it almost moves the meniscus out of place because it's lost that anchor to the bone.
[1:49]So, a major knee injury. However, thankfully, it seems to have been managed well.
[1:54]She was seen by orthopaedics abroad and she was given a knee brace that she had to move in with a specific protocol.
[2:04]She had to spend three weeks non-weight bearing with the knee brace locked at 0 degrees, so full extension.
[2:11]And then she had to spend two weeks where she could put a little bit of weight on it, partial weight bearing, but once again, with the knee brace locked at 0 degrees full extension.
[2:21]So she hasn't flexed her knee for the last five weeks because she's had to maintain this full extension position.
[2:29]However, as you can imagine that has led to some complications. She's now presenting with significant pain, particularly around the posterior knee, and we can see that this patient has effectively had a really challenging five weeks on a knee that is already vulnerable because of the previous injuries and surgeries that she's already had.
[2:50]So next, let's move on to the objective examination. So, we can see that this knee is clearly still very, very swollen.
[2:58]It's swollen all over, but particularly it seems to be more swollen posteriorly. And the skin seems to have a shiny appearance to it, particularly around the posterior aspect of the knee.
[3:10]There doesn't seem to be any redness in the area, but it is clearly very irritable and clearly very, very swollen.
[3:18]So we palpate around the knee, and there's pain on the medial joint line.
[3:22]We know that she's got this medial meniscal root tear, so that would make sense, and also there's a lot of swelling there, but it is also very painful to palpate once again around her posterior knee.
[3:35]We then have a look at her range of movement. Now, we know that she has full extension of her knee.
[3:40]She's been keeping her knee in the locked brace since the injury occurred, and she does present with full extension, which would make sense because she spent so much time in that position.
[3:51]However, she's unable to flex her knee more than 20 degrees, and that's quite a significant restriction, given that it's five weeks post injury. Yes, of course, we know that she's been in the brace, but 20 degrees is very, very small, and she presents with a lot of again, posterior knee pain when we try and do this movement.
[4:13]So then at the end of the assessment, we just start to ask a little bit more questions about what's been going on.
[4:19]And there's two key things that we find out that add to the picture.
[4:23]Number one is that she spent the first four weeks abroad on holiday in the ski resort where she was seen by orthopaedics and managed for her knee injury, and she only flew back to the United Kingdom one week ago.
[4:38]Secondly, she reports that she hasn't been very mobile. She hasn't been on her feet very much with the crutches, simply because of the amount of pain that she's in.
[4:48]So, not only has she been not very active because of the fact that she's been abroad and she only flew home one week ago, she hasn't been very active overall with her knee injury.
[5:00]So this prompted us to think to ourselves, is there anything else serious going on other than the knee injury?!
[5:14]But why is this pain that she's experiencing getting worse, particularly around the posterior knee that has led to this really challenging position that she finds herself in now?
[5:23]So that's the key question that we'd like to pose to you all watching. So, pause the video, have a think about the whole case, is there anything else serious that you think might be going on?
[5:33]Pause the video, write down your thoughts, and join us in a second.
[5:44]Okay everyone, time's up. Let's get back to the case study.
[5:47]So indeed, there was something else serious going on for this patient because unfortunately, with all these posterior symptoms, what do we know that can sometimes happen following a knee injury or a knee surgery in the posterior leg? Of course it is a DVT, a deep vein thrombosis.
[6:07]And this patient did indeed have a 6cm DVT running from the posterior thigh all the way down to the mid-calf, so a really clearly sizeable DVT, and that was clearly what was causing all of these posterior symptoms.
[6:25]So if we go through the key points and the different things that highlighted this potential DVT to us.
[6:31]First of all, we know that swelling and injury and inflammation can be all risk factors for a DVT.
[6:39]Particularly the significance and the amount of damage that this patient has suffered in this injury.
[6:46]The fracture is going to cause swelling. The meniscal root tear might cause some swelling, but we also know that ACL will also cause a lot of swelling, all through bleeding in the area following these injuries.
[7:01]So, a lot of fluid in the area is one thing and a lot of blood in the area of course is one thing.
[7:06]The second thing is that she hasn't been very active. We can see that she hasn't been moving her knee because she's been keeping it in a 0 degree extension position for five weeks now, and she explained to us that she hasn't been very active on her feet most recently because of the pain that she's been experiencing.
[7:34]So, not only has she been not very active because of the fact that she's been abroad and she only flew home one week ago, she hasn't been very active overall with her knee injury. So this prompted us to think to ourselves, is there anything else serious going on other than the knee injury?!
[5:14]But why is this pain that she's experiencing getting worse, particularly around the posterior knee that has led to this really challenging position that she finds herself in now?
[5:23]So that's the key question that we'd like to pose to you all watching. So, pause the video, have a think about the whole case, is there anything else serious that you think might be going on?
[5:33]Pause the video, write down your thoughts, and join us in a second.
[5:44]Okay everyone, time's up. Let's get back to the case study.
[5:47]So indeed, there was something else serious going on for this patient because unfortunately, with all these posterior symptoms, what do we know that can sometimes happen following a knee injury or a knee surgery in the posterior leg? Of course it is a DVT, a deep vein thrombosis.
[6:07]And this patient did indeed have a 6cm DVT running from the posterior thigh all the way down to the mid-calf, so a really clearly sizeable DVT, and that was clearly what was causing all of these posterior symptoms.
[6:25]So if we go through the key points and the different things that highlighted this potential DVT to us.
[6:31]First of all, we know that swelling and injury and inflammation can be all risk factors for a DVT.
[6:39]Particularly the significance and the amount of damage that this patient has suffered in this injury.
[6:46]The fracture is going to cause swelling. The meniscal root tear might cause some swelling, but we also know that ACL will also cause a lot of swelling, all through bleeding in the area following these injuries.
[7:01]So, a lot of fluid in the area is one thing and a lot of blood in the area of course is one thing.
[7:06]The second thing is that she hasn't been very active. We can see that she hasn't been moving her knee because she's been keeping it in a 0 degree extension position for five weeks now, and she explained to us that she hasn't been very active on her feet most recently because of the pain that she's been experiencing.
[7:34]So, not only has she been not very active because of the fact that she's been abroad and she only flew home one week ago, she hasn't been very active overall with her knee injury. So this prompted us to think to ourselves, is there anything else serious going on other than the knee injury?!
[5:14]But why is this pain that she's experiencing getting worse, particularly around the posterior knee that has led to this really challenging position that she finds herself in now?
[5:23]So that's the key question that we'd like to pose to you all watching. So, pause the video, have a think about the whole case, is there anything else serious that you think might be going on?
[5:33]Pause the video, write down your thoughts, and join us in a second.
[5:44]Okay everyone, time's up. Let's get back to the case study.
[5:47]So indeed, there was something else serious going on for this patient because unfortunately, with all these posterior symptoms, what do we know that can sometimes happen following a knee injury or a knee surgery in the posterior leg? Of course it is a DVT, a deep vein thrombosis.
[6:07]And this patient did indeed have a 6cm DVT running from the posterior thigh all the way down to the mid-calf, so a really clearly sizeable DVT, and that was clearly what was causing all of these posterior symptoms.
[6:25]So if we go through the key points and the different things that highlighted this potential DVT to us.
[6:31]First of all, we know that swelling and injury and inflammation can be all risk factors for a DVT.
[6:39]Particularly the significance and the amount of damage that this patient has suffered in this injury.
[6:46]The fracture is going to cause swelling. The meniscal root tear might cause some swelling, but we also know that ACL will also cause a lot of swelling, all through bleeding in the area following these injuries.
[7:01]So, a lot of fluid in the area is one thing and a lot of blood in the area of course is one thing.
[7:06]The second thing is that she hasn't been very active. We can see that she hasn't been moving her knee because she's been keeping it in a 0 degree extension position for five weeks now, and she explained to us that she hasn't been very active on her feet most recently because of the pain that she's been experiencing.
[7:34]So, not only has she been not very active because of the fact that she's been abroad and she only flew home one week ago, she hasn't been very active overall with her knee injury. So this prompted us to think to ourselves, is there anything else serious going on other than the knee injury?!
[5:14]But why is this pain that she's experiencing getting worse, particularly around the posterior knee that has led to this really challenging position that she finds herself in now?
[5:23]So that's the key question that we'd like to pose to you all watching. So, pause the video, have a think about the whole case, is there anything else serious that you think might be going on?
[5:33]Pause the video, write down your thoughts, and join us in a second.
[5:44]Okay everyone, time's up. Let's get back to the case study.
[5:47]So indeed, there was something else serious going on for this patient because unfortunately, with all these posterior symptoms, what do we know that can sometimes happen following a knee injury or a knee surgery in the posterior leg? Of course it is a DVT, a deep vein thrombosis.
[6:07]And this patient did indeed have a 6cm DVT running from the posterior thigh all the way down to the mid-calf, so a really clearly sizeable DVT, and that was clearly what was causing all of these posterior symptoms.
[6:25]So if we go through the key points and the different things that highlighted this potential DVT to us.
[6:31]First of all, we know that swelling and injury and inflammation can be all risk factors for a DVT.
[6:39]Particularly the significance and the amount of damage that this patient has suffered in this injury.
[6:46]The fracture is going to cause swelling. The meniscal root tear might cause some swelling, but we also know that ACL will also cause a lot of swelling, all through bleeding in the area following these injuries.
[7:01]So, a lot of fluid in the area is one thing and a lot of blood in the area of course is one thing.
[7:06]The second thing is that she hasn't been very active. We can see that she hasn't been moving her knee because she's been keeping it in a 0 degree extension position for five weeks now, and she explained to us that she hasn't been very active on her feet most recently because of the pain that she's been experiencing.
[7:23]We know that blood needs to circulate, and one thing that is important for that is us actually moving.
[7:29]With the lack of movement going on, this increases the risk of the DVT.
[7:34]Then we have the other key piece of information that we found towards the end of the objective assessment that she has been on a recent long-haul flight because she's only come back from the trip one week ago.
[7:46]And we know that this position of immobility being on a flight for a long period of time, this stasis of the blood where it's not moving, as well as dehydration, which we know happens through flying, also increases the risk of DVT.
[7:59]And then the fact that she's got so much posterior pain, so much posterior swelling, and the skin changes where they've got this shiny appearance to them, also all highlighted to us the potential of this DVT.
[8:12]So, a really important case. What are the take home messages?
[8:17]Number one, remember that not all DVT signs may be in place when your patient has a DVT.
[8:26]It doesn't always present precisely in a textbook with pain and swelling and warmth and redness.
[8:33]It may not always present like that, but if there are some present, then we should always increase our suspicion.
[8:39]And the second point is, always think DVT for the knee.
[8:44]We know that following any major injury or any major surgery for the knee, that increase of risk is high for a DVT.
[8:52]And as it was for this particular patient, we always need to be on the lookout for that, particularly with these posterior symptoms.
[9:00]So everyone, I really hope you enjoyed this video. If you have, please support us by smashing that like button.
[9:05]It's the number one way that you can help our channel and show us your support. If you want more resources for us, make sure to check out our Instagram account @clinicalphysio.
[9:16]We've got loads of brilliant resources there for physiotherapists. And if you like learning by case studies, be sure to check out our membership platform, member.clinicalphysio.com.
[9:25]On membership we have the case study club, a brilliant resource where we go through lots of different clinical conditions with MSK experts to show us their clinical reasoning, how they came to the diagnosis with their patient that will really help you if case studies is the way you like learning.
[9:40]So everyone, thank you so much for watching. My name's Khalid. See you soon here on Clinical Physio.
