There is pain in the knee which has progressed to the point that it limits activity and sleep. It is affecting daily activities. There has not been improvement with conservative care.
Xray series of the knee including weight bearing A/P and flexion views as well as lateral and sunrise views was personally evaluated by me and demonstrates the following: Fracture (s) and/or Dislocation(s): None . Alignment: Normal . Joint space(s): Normal . Soft tissues: Normal .
General Appearance: well-nourished, well developed in no acute distress. Orientation: oriented to person, place and time. Mood / Affect: calm. Gait: antalgic Coordination: normal. Knee Exam. Skin and lymph appears normal in the affected extremity. Inspection / Palpation LE (R/L): medial joint line tenderness, +Mcmurray. Knee ROM (R/L): 0-120 / 0-120. Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+). Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+). Strength LE: 5/5 EHL, tibialis anterior, plantar flexion. Sensation: Subjective normal distal sensation bilaterally. Vasculature: <2 second capillary bilaterally
Contusion of left knee
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.