HISTORY:
Anthony is a 55 year old, white male who comes In today at the referral of Dr. Richard Delany for evaluation of Injury to his left knee. Anthony states that one month ago he was playing basketball when-he came down from a rebound hit the floor and experienced acute discomfort In his left knee. He had immediate onset of pain and swelling. He was seen In follow up at Atrius Health. He was referred by Dr. Kyle John for MRI scan of his left knee at Weymouth MRI on 8/2/18. Testing showed evidence of a complete tear of the ACL in association with posterolateral corner injury involving the LCL complex as well as the lateral meniscus. There was also evidence of a medial posterior meniscal capsular separation associated with MCL sprain. Anthony was seen by Dr. Delany who gave him three BIO protocols which helped significantly. He states that the swelling is down and the knee Is not bothersome at this point. He has had no episodes of instability since his Injury. He Is here today for some guidance regarding future protocol.
PAST MEDICAL HISTORY:
Anthony Is status post right ACL reconstruction 25+ years ago. Surgery was done by Dr. Fred Heller and Dr. Charles DiCecca. He apparently had good result from that surgery although he has had some chronic achy discomfort in the knee ever since. Otherwise Anthony states that he is basically very healthy.
MEDICATIONS:
He takes medication for hypertension.
PHYSICAL EXAMINATION:
On examination today, Anthony is a pleasant, healthy appearing, white male. He walks in the office without obvious antalgia. He has evidence of a very small effusion present in the left knee. He has no sensitivity at the medial or lateral joint lines. He has full ROM of the left knee. He opens up just very slightly on valgus stress testing at 30 degrees although it Is not uncomfortable for him. He has negative Lachman, anterior drawer, and pivot shift testing. He does have 1/2 inch of quadriceps atrophy left thigh at five inches above the superior pole of the patella.
DIAGNOSTIC TESTING:
I reviewed Anthony’s MRI report left knee from Weymouth MRI dated 8/2/18.
IMPRESSION:
Anthony has evidence of torn ACL left knee in association with torn lateral meniscus and MCL sprain.
PLAN:
He is doing extremely well at this time. He has a very small residual effusion which is probably on the basis of residual quad atrophy. I think he should continue on a conservative course In light of his age. I do not feet we should be aggressive in terms of advising ACL reconstruction in light of how well he is doing at this point. I gave him a script for PT at Furnace Brook to work on quad and hamstring strengthening and flexibility exercises. I will see back in five weeks. At that time, we may want to get him fitted with CTI II brace to utilize with hiking activities. He states that he no longer really plans on playing basketball or any other jumping or cutting sports.