Degenerative Seizure: A Case Study

DOI: 1/16/2015. Patient is a 66-year old female assembler who sustained injury when she slipped on ice, caught herself and hurt her knee. Per OMNI, she was initially diagnosed with right knee strain.

MRI of the right knee obtained on 07/07/15 demonstrated a tear of the anterior horn of the lateral meniscus. The root of the posterior horn of the lateral meniscus is attenuated as well which may represent a degenerative tear, although the ligament of Humphrey is relatively prominent and this may represent a normal variant. There is a Grade 2-3 degenerative cartilage loss involving the apex of the trochlear cartilage. There is a grade 2 cartilage loss involving the lateral compartment of the knee. There is a joint effusion and Baker’s cyst.

She describes her pain as burning, sharp, sore, stabbing, and throbbing. She rates her pain as a 2/10. She notes that she has had physical therapy for the past 3 months with no relief. She just started using a topical anti-inflammatory has had no relief yet. She is afraid of needles and therefore does not want to try a steroid injection. She would like to proceed with surgery. She was given prescription for Pennsaid 2% 2 pumps twice daily.

Per medical report dated 07/16/15, she rates her right knee pain as 2/10, described as burning, clubbing, sharp, sore, and stabbing. It is worse with all activity and better with anti-inflammatories, ice and rest. She uses Motrin which did not really help her. Pennsaid is not working. She does use a brace. On examination, she can fully extend the knee but can only flex to about 95 degrees. She is very tender in the lateral joint line but not medially. Meniscal grind testing increases her pain laterally. She has a small effusion.

As of this report, x-rays from her last visit reveal a normal lateral compartment of the right knee with perhaps a little medial compartment