I wanted to share a quick story about a new patient I had at my clinic a few weeks back. This 34 year old male came in as a new patient with a complaint of some “minor knee pain” after falling at work. He walked into my treatment room with what seemed like good control of his knee. I didn’t see a limp nor was his gait antalgic in the least. I figured it was a muscle strain or something of that nature. I get him on the bed to do stability testing and this is what I find:
At fist I thought it was an ACL tear but upon further investigation it was a PCL tear. I didn’t show it in the video, but his sag sign was very positive.
I then did another stability test and this is what I found:
This maybe a little harder to see but he also have extreme laxity of his MCL!!
So let’s review: This patients calmly walks into my clinic with very little pain after falling at work and hearing a pop. He looks stable in gait yet these orthopaedic tests tell us a very different picture…not sure I’m able to explain this clinically
I had him go back to his GP to get an MRI to confirm my diagnosis and it was in fact shown to be a full PCL and MCL tear. His surgeon does not want to do surgery as the PCL has a very poor recovery rate as her his words ( I didn’t know that at the time).
Any suggestions on how to treat this? Just curious to see what others might do?
Pretty interesting case, right?!
Thanks for readng
jessephysio 
I would try to get him a brace for external support with medial ad lateral struts to reduce varies/valgus loads. Since he’s non-operable apparently, I would go over proprioception exercises and investigate is joint position sense. Since the MCL was damaged, I’d work the hip abductors and external rotators to reduce the femoral adduction and IR that would cause stress to the MCL. Secondly, I would work the quads as a check reign to posterior translation of the tibia (I’d start out in minimal degrees of flexion given his positive sag sign – probably with SLR type movements in supine, standing, TKE maybe as well). Given this happened at work, I would investigate what type of movement patterns are needed for his job and address them accordingly to make sure his mechanics are faulty and may put him at risk for either worsening or exacerbation of symptoms. Good case
Thanks for sharing this case!
I completely agree with Steve in regards to the addition of some type of external support. This is paramount early on to promote optimal healing. Outside of relative contraindications during initial stages of rehab such as adduction SLR (MCL integrity) and hamstring training (PCL integrity), just ensure you are working in the 0-60 deg range during OKC knee extension exercises to reduce strain on the PCL. As Steve also stated, base your treatment on the physical impairments and progress your patient within their tolerance and symptom exacerbation.
Steve, Jason
Thanks for the feedback..I have worked with him al ot of glute med/max strengthening using mainly CKC exercises, as open OKC work places more stress on the tibia in a posterior direction which he is already hurting in.
His pain is minimal so it makes it a lot easier to get the exercises we need in. He was fitted for a custom made hinge brace a few weeks ago and enjoys wearing it (for the most part). A lot of the exercises we do are functional due to their similarity to what he has to do as a manual labour worker at work. Just breaking down the patterns to their component parts and getting them more stable.
Thanks for the tips and for reading!
More blogs coming soon.