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Knee pain is one of the most common musculoskeletal problems that patients present within clinical settings. According to Bunt et al. (2018), knee pain affects approximately 25% of adults, and its prevalence has increased by almost 65% over the past 20 years. Evaluation of knee pain requires the collection of significant patient history, including location, onset, duration, and quality of pain; associated mechanical or systemic symptoms; history of swelling; description of precipitating trauma; and pertinent medical or surgical history. Examination procedures for patients with knee pain include inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and unique (provocative) tests (Bunt et al., 2018). Accurate diagnosis of the etiology of a patients knee pain depends on the effectiveness of history-taking and physical examination. The possible diagnostic considerations for the patient in the case study include anterior cruciate ligament (ACL) tear and meniscus tear. The lesser options are Patellofemoral syndrome, gout, and Pes anserine bursitis. ACL tear is a type of knee injury involving tearing the anterior cruciate ligament, one of two cruciate ligaments that aid in stabilizing the knee joint (Evans & Nielson, 2022). Meniscus tear is a condition associated with tearing the knee cartilage that cushions the shinbone from the thighbone.
Various factors play critical roles in diagnosing the causes of a patients knee pain, and nurse practitioners should be attentive to such factors during the assessment. The first factor is the location of the knee pain. Anterior pain, as in the case study, suggests that the patella, patellar tendon, or its attachments are involved in developing the pain (Bunt et al., 2018). Attention to the mechanical symptoms associated with knee pain is also essential. Bunt et al. (2018) state that a pop sound suggests meniscal or ligamentous tears. Swelling, mechanism of injury, and medical or surgical history also help diagnose knee pain. Such factors are combined with the results of physical examinations and tests to determine the accurate diagnosis.
The diagnostic considerations, in their order of importance, include ACL tear and meniscus tear are to be considered as the final diagnosis. The ACL is the principal stabilizer of the knee. Patients with ACL tears usually present with an acute injury, an associated pop, a sensation of tearing, and the immediate onset of effusion (Musahl & Karlsson, 2019). The patient presents with all three typical symptoms of ACL, including sudden left medial knee pain, giveaway weakness, and an audible pop. The patients positive anterior drawer sign and Lachman test confirmed the diagnosis. Lachman, anterior drawer, and pivot shift tests are significant provocative tests for ACL injury (Bunt et al., 2018). Therefore, the patient is most likely to be affected by ACL tears. The meniscus tear is the next diagnostic consideration based on the patients history and physical examination. Meniscal tears can cause various symptoms, including pain localizing to the joint line, swelling, clicking, catching, locking, and the knees classic giving away (Bhan, 2020). Meniscal tears arise from sudden twisting injuries of the knee or trauma. The patient has tenderness on the medial meniscus, a small effusion, and a positive McMurray test suggesting a combination of ACL and medial meniscus tear. Meniscus tear typically accompanies ACL tears.
A diagnostic workup is essential to guide the practitioner on the appropriate treatment plan for the patient. Based on the final diagnosis in the case study, the recommendations are as follows. First, an X-ray of the knee-AP lateral and tunnel view to rule out fractures of the femur, tibia, and fibula and detect osteoarthritis and joint pathology. Second, a knee MRI is necessary for soft tissue pathology, including ACL tear, meniscal tear, collateral ligament injury, and effusions. Third, rest, ice, compression (with taping), and elevation (RICE) are standard measures for joint injury to reduce soft tissue swelling and pain. Next are non-steroidal anti-inflammatory agents, which reduce pain and swelling in common injuries and arthritis when prescribed as a scheduled interval for a specific time. Lastly, rehabilitation exercises include physical therapy to improve muscle strength and range of motion.
References
Bhan, K. (2020). Meniscal tears: Current understanding, diagnosis, and management. Cureus, 12(6). https://doi.org/10.7759/cureus.8590Links to an external site.
Bunt, C. W., Jonas, C. E., & Chang, J. G. (2018). Knee pain in adults and adolescents: The initial evaluation. American Family Physician, 98(9), 576-585. https://www.aafp.org/pubs/afp/issues/2018/1101/p576.htmlLinks to an external site.
Evans, J., & Nielson, Jl. (2022). Anterior cruciate ligament knee injuries. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499848/Links to an external site.
Musahl, V., & Karlsson, J. (2019). Anterior cruciate ligament tear. New England Journal of Medicine, 380(24), 2341-2348. https://doi.org/10.1056/NEJMcp1805931Links to an external site.
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