Diagnosis of Medial Knee Pain: Atypical Stress Fracture About the Knee Joint

Abstract

Study Design: Resident's case problem. Background: A 19-year-old female, currently enrolled in a military training program, sought medical care for a twisting injury to her right knee. The patient reported her symptoms as similar to an injury she incurred 1 year previously while enrolled in the same military program. The patient's past medical history included a nondepressed fracture of the medial tibial plateau and complete tear of the deep fibers of the medial collateral ligament. Diagnosis: Physical exam revealed nonlocalized anterior and medial knee pain without evidence of internal derangement. Initial knee and tibia radiographs were unremarkable. Referral for orthopedic physician evaluation resulted in concurrence with the therapist's diagnosis and plan of care, and the patient was allowed to continue with limited physical training demands. Despite periods of rest, the patient's symptoms progressively worsened upon attempts to resume running. The examining therapist referred the patient for magnetic resonance imaging (MRI) due to the patient's worsening symptoms, normal radiographs, and concern for a proximal tibia stress fracture. MRI revealed a severe proximal tibial metaphysis stress fracture. Discussion: Stress fractures are commonly encountered injuries in individuals subjected to increased physical training demands. Early evaluation may not yield well-localized findings and may mimic other conditions. Nonmusculoskeletal conditions should be considered in the management of patients with stress fractures. This resident's case problem illustrates the importance of serial physical examinations and collaboration with other healthcare practitioners in the comprehensive assessment and management of a patient with a severe stress fracture.

Effectiveness of neuromuscular electrical stimulation in the functional knee rehabilitation in soldiers

“…After a thorough analysis of the scientific literature over the past 10 years, the parameters used in NMES should be: table 3. Hierarchy of levels of evidence based on the types of research design (Moore et al, 2013) 6 .…”

“…The impact of physical therapists on improving the health and military readiness of service members has garnered the support of the military's medical leadership to such a degree that they are regularly credentialed by local military hospitals and health care facilities with clinical privileges to: safely examine patients with and without physician referral; order diagnostic imaging; order laboratory tests; refer patients to other practitioners; initiate duty limitations; and perform electromyographic and nerve conduction studies [1][2][3][4][5][6] . Military physical therapists are often the first credentialed health care provider in the process of care to diagnose and treat patients with musculoskeletal injuries.…”

“…The musculoskeletal injury rates are not unique to stateside assignments and occur in higher frequency in combat environments 8 . In a deployed setting (combat zone), nonbattle musculoskeletal injuries account for 87% of all injuries [6]. The rate of musculoskeletal injuries in deployed settings is estimated to occur 6.5 to 7 times more frequently than combat-related injuries 6 .…”

Bones

“…The stress injuries may be classifi ed into fi ve grades as follows: grade I, endosteal marrow edema; grade II, periosteal edema and endosteal marrow edema; grade III, muscle edema, periosteal edema, and endosteal marrow edema; grade IV, fracture line; and grade V, callus in cortical bone [ 34 ]. Even in the cases in which the stress fracture is located at the weightbearing surfaces, depression of the articular surface of the bone might not be present, and radiography does not enable the diagnosis [ 36 ]. MR imaging is the method of choice, being able to identify all the abovementioned pathological changes.…”

Physical Therapists Referring Patients to Physicians: A Review of Case Reports and Series

“…In some of these publications, multiple patients were described, providing a total of 71 individual patient cases for review. 1,[4][5][6][7][8][12][13][14][15][16]17,18,[20][21][22][23][24][25][26][27][28][29][30][31][32]34,35,[37][38][39]41,42,44,[46][47][48][49][50][51][52][53][54][55]58,[60][61][62][63][64][65][66][67][68][69][70]…”