Michael Miller
35 years old, Male
Left knee grade 3 anterior cruciate ligament (ACL) sprain
Initial diagnosis Left knee grade 3 anterior cruciate ligament (ACL) sprain.
Diagnosis made by physical exam, MRI, CT
Chief complaint I am a active individual. About a third of the time I play, my knee will buckle, causing severe pain. Within minutes, the pain lapses and I am then able to continue playing. I can run, walk, and cycle with no pain at all. I even trail run for about 20 miles a week in the mountains. I would prefer to avoid surgery, but am worried about causing permanent damage to my knee.
HPI Mr. Miller is a 35 year-old male with a history of left knee pain and instability for the last 2 months secondary to left ACL tear diagnosed by MRI. The pain has been persistent since January. He describes moderate pain, looseness, and instability around the left knee. The pain increases with activity. On 9/24/13, the patient’s treating physician noted the presence of a grade 3 ACL sprain, mild left knee effusion, and pain at the end of flexion. MRI of the left knee revealed an ACL tear. He recommended range of motion and strengthening exercises, and surgical ACL reconstruction.

Proposed treatment Left ACL reconstruction with autograft vs. allograft.
Goal of consultation The patient seeks a second opinion to define the optimal course of treatment. Specifically, he seeks to gain the following information:
  1. In your opinion, how severe is the injury to my knee?
  2. Do you believe surgery is required? If so, what is the optimal procedure, and what are the associated risks?
  3. If reconstruction is recommended, do you recommend autograft or allograft?
  4. Do you recommend any alternatives to surgery? If yes, what are the risks and benefits of these treatments?
  5. Will avoiding surgical treatment result in permanent damage to the knee?
  6. Would there be any activity restrictions with and without surgery?
  7. Would you recommend physical therapy before or after surgery? If so, what is the recommended intensity and duration of physical therapy?
  8. What can I do to prevent recurrence of this or similar injuries?
ROS Pain localized diffusely around the left knee. See page 5 of Medical Records.
Medications None
Allergies NKDA
Family history No relevant history
Social history Software developer. Enjoys running, tennis, travel, and time with family.

Tobacco: none

Alcohol: moderate use

Notable physical exam findings

6’1”, 190 lbs

No pain on patellofemoral compression, no atrophy or crepitus. Mild effusion is present.

Imaging reports Please see included.
Opinion
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