In a 58‑year‑old male with a 6‑month history of left knee pain, a horizontal tear of the posterior horn of the medial meniscus, a slight strain of the medial collateral ligament, possible compromise of the medial patellofemoral ligament, moderate patellofemoral osteoarthritis, and mild lateral patellar subluxation, how are the clinical findings from onset to the present the same or different?

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Clinical Progression Analysis: Left Knee Pathology from Onset to Present

The clinical findings have remained essentially stable from onset to present, with the patient demonstrating persistent structural pathology (meniscal tear, MCL strain, MPFL compromise, patellofemoral osteoarthritis) but showing symptomatic improvement following viscosupplementation injection, reducing pain from 4-6/10 to 1/10 currently.

Structural Findings: Unchanged

The MRI findings documented at initial presentation have remained constant throughout the clinical course:

  • Horizontal tear of posterior horn medial meniscus - This degenerative tear pattern is associated with increased medial tibial slope and posterior tibial osteophytes 1, representing a structural lesion that does not spontaneously heal
  • Slight MCL strain without complete tear - Partial ligamentous injury that typically stabilizes with conservative management
  • Questionable MPFL integrity - The MPFL injury pattern (47% occur at patellar attachment, 26% at femoral attachment 2) remains structurally compromised
  • Moderate patellofemoral osteoarthritis - Degenerative changes that are progressive and irreversible
  • Slight lateral patellar subluxation - Biomechanical malalignment persisting due to MPFL insufficiency

Clinical Presentation: Improved Symptoms

Initial Presentation (6 months ago):

  • Pain level: 4/10 baseline, 5-6/10 at worst
  • Constant pain with increased pain on walking
  • Locking episodes present
  • Stiffness present
  • Instability with buckling
  • Pain with walking >1 mile and standing >30 minutes

Current Presentation (Physical Therapy Evaluation):

  • Pain level: 1/10 currently, 5-6/10 at worst, 0/10 at best
  • Tender to palpation at medial joint line
  • ROM: Left knee flexion 128° (right 134°), extension 0° (right 2° hyperextension)
  • Mild girth increase: mid-patella 40mm left vs 39mm right
  • Strength deficits: Hip flexion 4+/5, knee flexion 4-/5, knee extension 4/5 on left
  • Positive McMurray, Thessaly, and joint line palpation tests (confirming meniscal pathology 3)
  • Positive LCL varus test in partial flexion (laxity)
  • LEFS score: 49/80 (moderate functional limitation)

Key Changes Over Time

What Has Improved:

  • Pain reduction from 4/10 baseline to 1/10 currently following Durolane (hyaluronic acid) injection
  • Functional tolerance of hobbies and ADLs improved post-injection
  • Acute inflammation resolved (initial Kenalog injection provided temporary relief)

What Remains Unchanged:

  • Structural pathology on MRI (meniscal tear, ligament injuries, osteoarthritis)
  • Mechanical symptoms (crepitus, positive meniscal tests)
  • Strength deficits (quadriceps weakness 4/5, hamstring weakness 4-/5)
  • ROM limitations (6° flexion deficit compared to contralateral side)
  • Patellar instability (lateral subluxation, MPFL compromise)

Clinical Implications

The patient demonstrates a typical pattern for degenerative meniscal pathology with concurrent patellofemoral dysfunction: structural lesions remain static while symptoms fluctuate based on inflammation control and activity modification. The horizontal meniscal tear pattern in a 58-year-old represents degenerative pathology rather than acute traumatic injury 1, explaining why conservative management with injections provides symptomatic relief without structural healing.

The MPFL injury (occurring in 87-93% of patellar dislocations 2, 4) contributes to ongoing lateral patellar subluxation and patellofemoral pain. The positive McMurray and Thessaly tests confirm persistent meniscal pathology 3.

Current management with physical therapy targeting quadriceps strengthening (currently 4/5, goal ≥4+/5) and patellar stabilization is appropriate 5, as exercise therapy forms the cornerstone of patellofemoral pain management. The patient's functional improvement with viscosupplementation and bracing indicates successful symptom control despite persistent structural pathology.

Critical Pitfall to Avoid:

Do not interpret symptomatic improvement as structural healing. The meniscal tear, MPFL compromise, and osteoarthritis remain unchanged and may require surgical intervention if conservative management fails to maintain functional improvement. The goal is meniscal preservation when possible 3, but this patient's degenerative horizontal tear pattern may ultimately require partial meniscectomy if mechanical symptoms persist despite therapy.

References

2
Research

Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study.

Sports medicine, arthroscopy, rehabilitation, therapy & technology : SMARTT, 2009

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