Brendan Beckham: A 32-Year-Old Male With Acute Left Medial Knee Pain Following a Soccer Injury





Learning Objectives





  • Learn the common causes of knee pain.



  • Develop an understanding of the unique anatomy of the knee joint.



  • Develop an understanding of the anatomy of the medial meniscus.



  • Understand the function of the muscles of the medial meniscus.



  • Develop an understanding of the causes of medial meniscus tear.



  • Develop an understanding of the various types of medial meniscus injury.



  • Learn the clinical presentation of medial meniscus tear.



  • Learn how to examine the knee.



  • Learn how to use physical examination to identify pathology of the medial meniscus.



  • Develop an understanding of the treatment options for medial meniscus tear.



Brendan Beckham







“Call me Brendan,” my new patient said as I introduced myself. Brendan was a 28-year-old professional soccer player with our local farm team with the chief complaint of, “I blew out my right knee.” Brendan stated that about a week ago, he was taking the ball down to the goal and pivoted to avoid a defender to move in for the score when he felt like “something popped in my left knee. Doc, it really hurt, but I went ahead and made the kick, scored, and then headed off to the locker room to ice my knee. I took a quick shower, but the inside of my knee was killing me. I didn’t immediately say anything to anybody because, you know, at my age…” as his voiced just trailed off. “But I figured with ice, Tylenol, and a couple of days off, I would be right as rain. But here I am,” he said with a weak smile. I asked if he had ever had anything like this before and he shook his head and said, “Just the usual aches and pains. I never miss a game. I love playing soccer. I hope to play for a long time yet, so I need you to give me a shot or something. No hard drugs, because the league is always doing drug screens.”


I told Brendan I would do all I could for him, and the first step was to figure out exactly what was going on with his knee. I asked Brendan how he was sleeping and he said, “Pretty well, but every time I roll onto my left knee, I wake up.” Brendan denied any fever or chills.


On physical examination, Brendan was afebrile. His respirations were 16 and his pulse was 64 and regular. His blood pressure was 118/82. His head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was a left lower quadrant scar that Brendan said was from an appendectomy when he was a kid. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the left knee revealed a small area of ecchymosis over the medial joint space. I asked Brendan about it and he said, “Oh, that’s nothing, just a little bruising from the acupuncture.” I asked if the acupuncture helped and he gave me a wry smile and said if it did, he would be at practice rather than sitting on my exam table.


I asked Brendan to point with one finger to show me where it hurt the most, and he pointed to the area over the medial joint space. He said, “Doc, it feels like it’s down in the knee; not on the outside.” He volunteered, “Sometimes after a squat, when I get up, it feels like my knee is going to catch or lock up.” I gently flexed and extended the knee and he said that reproduced the pain. The left knee was a little warm medially but did not appear to be infected. I felt like Brendan had a large joint effusion, so I performed the bulge sign test for knee joint effusions, which was positive, as was his ballottement test ( Figs. 2.1–2.3 ). Brendan exhibited a positive McMurray test as well as a positive squat test ( Figs. 2.4 and 2.5 ). Brendan’s right knee examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. I told Brendan I was pretty sure I knew what was going on and we were going to get some tests to confirm it.




Fig. 2.1


Eliciting the bulge sign for small knee joint effusions.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016: Fig. 202-1.



Fig. 2.2


Eliciting the ballottement sign for large knee joint effusions. (A) The examiner displaces synovial fluid from the suprapatellar pouch into the joint. (B) The examiner ballottes the patella.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016: Fig. 203.1A,B.



Fig. 2.3


The ballottement test. (A) The examiner displaces synovial fluid from the suprapatellar pouch into the joint. (B) The examiner performs ballottement on the patella.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016: Fig. 203.2A,B.



Fig. 2.4


The McMurray test for torn meniscus.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016: Fig. 219-1.



Fig. 2.5


The squat test for torn meniscus. (A) The squat test for meniscal tear. The patient is asked first to perform a full squat with the feet and legs fully externally rotated. (B) The squat test for meniscal tear. The patient is then asked to perform a full squat with the feet and legs fully internally rotated.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016 [Figs. 221-3 and 221-4].


Key Clinical Points—What’s Important and What’s Not


The History





  • A history of sudden onset left medial joint pain following a soccer injury



  • A history of a sudden pop in the knee at the time of the acute injury



  • A history of continued pain in spite of conservative therapy, including acupuncture



  • No history of previous significant knee pain



  • No fever or chills



  • Sleep disturbance



The Physical Examination





  • The patient is afebrile



  • Palpation of left knee reveals tenderness over the medial joint space



  • An effusion of the left knee joint as indicated by a positive bulge and ballottement test



  • The presence of mild ecchymosis over the medial right knee joint space



  • Pain on flexion and extension of the left knee



  • A positive drop McMurray test



  • A positive squat test



Other Findings of Note





  • Normal HEENT examination



  • Normal cardiovascular examination



  • Normal pulmonary examination



  • Normal abdominal examination with a well-healed appendectomy scar noted



  • No peripheral edema



  • Normal upper extremity neurologic examination, motor and sensory examination



  • Examination of other joints was normal



What Tests Would You Like to Order?


The following tests were ordered:




  • Plain radiographs of the left knee



  • Magnetic resonance imaging (MRI) of the left knee



  • Ultrasound of the left knee with special attention to the medial meniscus



Test Results


The plain radiographs of the left knee revealed no evidence of bony abnormality or fracture, but showed patellar tilting due to the large effusion behind and around the patellar tendon ( Fig. 2.6 ). The MRI revealed a bucket handle tear of the medial meniscus ( Fig. 2.7 ). The ultrasound of the left medial meniscus reveals complex tearing of the meniscus ( Fig. 2.8 ).


Aug 9, 2021 | Posted by in PAIN MEDICINE | Comments Off on Brendan Beckham: A 32-Year-Old Male With Acute Left Medial Knee Pain Following a Soccer Injury
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