CASE 4 – STRESSED OUT
June 25, 2017
CASE 6 – IN A JAM
June 25, 2017

CASE 5 – HMMM?CL

64 year old presents with medial sided knee pain following a valgus injury to his right knee playing hockey.    You assess him and his knee has no effusion, his MCL is tender at it’s proximal insertion and he experiences pain when you apply a valgus force to gap his MCL.  The remainder of his examination was benign.
He is treated with a stabilizing brace, physiotherapy and you ask him to follow up in 6 weeks.

6 months later he re-presents to the clinic.  He was unable to follow up earlier due to work committments and is complaining of persistent medial knee pain over his medial femoral condyle.

Examination:
There is no sign of any effusion in his knee.
His knee is warm to touch medially over his femoral condyle.
Still experiences pain with valgus stress of his MCL.
The remainder of his knee examination including ligamentous, patellofemoral, hamstrings is completely normal.

Xray – There is a boney lesion over the medial femoral condyle with no evidence of any significant Osteoarthritis.
Figure 1 AP Xray of Knees
PelligriniStiedaLesionRightkneeAPweb
Figure 2 Tunnel View of Knees
PelligriniStiedaLesionRightkneeTunnelweb
Figure 3 Hilighted area of Interest
PelligriniStiedaLesionRightkneeTunnelhilightweb

US – Shows a partial tear of his MCL with thickening, edema and a boney avulsion within the torn ligament.
Figure 4 – US of proximal MCL insertion – with affected area of edema
PelligriniStiedaLesionRightkneeUSweb

Assessment:  Pelligrini-Stieda Lesion

Plan:
Initial treatment options for a Pelligrini-Stieda Lesion may include NSAIDs and icing.  However, it is likely that an US-guided cortisone injection is required.   If the cortisone injection is unsuccessful then excision of the avulsed fragment can be considered.   In this case, the patient ended up having an Ultrasound-guided injection.  He reported a complete resolve in his symptoms within 1 week and reported no pain or irritation with full return to his prior activities two months post injection.

Dr. Neil Dilworth (Sept 22, 2014)